New Provider Account Form

Practitioner / Practice Information:

Prescriber Name (Required)

Credentials (Required)

NPI# (Required)

DEA#

Prescriber Name

Credentials

NPI#

DEA#

Prescriber Name

Credentials

NPI#

DEA#

Clinic Name (Required)

Clinic Address (Required)

Street Address

Address Line 2

City

State

Days & Hours of operation

Clinic Phone (Required)

Clinic Fax(Required)

Clinic Website

Primary Order Contact(Required)

Primary Order Email(Required)

Order Direct Phone(Required)

Primary Billing Contact

Billing Direct Phone

Primary Billing Email

Billing Information

Billing Credit Card #:(Required)

EXP(Required)

CVV(Required)

Billing Address(Required)

Street Address

Address Line 2

City

State

Authorized Credit Card Signature(Required)

* By typing your full name, you authorize the secure storage of your credit card and automatic charges with the same legal effect as a handwritten signature.

* For your convenience, credit cards are securely stored on file for all office orders and bill clinic prescriptions. All invoices are sent via email upon order completion and due upon receipt. Credit cards will automatically be charged prior to delivery and/or pick-up.

As the (Title/Practitioner) (Required)

Of (Name of Clinic) (Required)

I hereby authorize the following individual(s) to execute for on behalf of the named entity/organization and physician, any actions necessary for the purpose of procuring prescription drugs.

These actions include placing new orders either by phone, e-scripts, fax, picking up office orders, and allowing the authorized agent to engage in dialogue with the pharmacy about patient specific prescription products. If there is ever a change in the authorized agents, the physician must submit a new form.

This form is required even when the authorized agent is the executive authority themselves.

A copy of the physician’s license is a requirement for the above agreement. Controlled substance ordering requires a copy of a DEA license.

Name of authorized agent(Required)

Title(Required)

Name of authorized agent

Title

Name of authorized agent

Title

Applicant Name(Required)

Title(Required)

Date

In order to process your account application, we require a copy of your valid practitioner's license and DEA license (if dispensing controls).

Upload your Credentials(Required)

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New Provider Form

Practitioner / Practice Information:

Billing Information