Telehealth Affiliate Initial Inquiry

Telehealth Affiliate Initial Inquiry

As an NABP-accredited pharmacy and LegitScript-certified partner, we conduct thoughtful due diligence to ensure aligned, compliant telehealth partnerships. To maintain a consistent patient experience, we generally collect payment directly from patients, while selectively supporting alternative billing structures for telehealth organizations with established operations and proven care delivery models.
Name of the Submitter*

First NameLast Name
Title*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you an Authorized Signer for the Company?*

YesNo
Name of Authorized Signer

First NameLast Name
Title of Authorized Signer
Email of Authorized Signer
example@example.com
Company Name*
What is the corporation status of the company?*
What is the state of incorporation for the company? (hidden)*
What is the State of Incorporation for the company?*
Is this a Managed Services Organization (MSO)?*
What is the URL of your telehealth company?*
Is your company active or in development?*
Congratulations on launching your new company—we’re excited to support you as you get started.

We’re happy to share information on available formulations and how we work with telehealth partners. In the early stages, providers can begin prescribing directly, and we will dispense medications and coordinate payment with patients to ensure a smooth and consistent experience.

Prescriptions can be submitted via ePrescribe (listed as Valor Compounding Pharmacy), through our secure online provider forms, by fax at 510-548-0305, or by phone at 510-548-8777.

As your operations grow and prescribing activity becomes more established, we’re happy to revisit partnership structures, including MSO arrangements, at the appropriate time.
How many scripts do you anticipate sending over to Valor each week?*
Please note: For prescription volumes less than 50 per week, please have your licensed providers send us patient-specific prescriptions electronically and we will dispense and collect payment directly from the patients.
How many scripts do you anticipate sending over to Valor each week?*
Please note: For prescription volumes less than 50 per week, please have your licensed providers send us patient-specific prescriptions electronically and we will dispense and collect payment directly from the patients.
Please indicate the states you would like us to serve.*
You can see the states we are licensed in at: https://valorcompounding.com/states-we-serve/.
Who will collect payment for the compounded medication from the patient?*
Please note: For less than 50 prescriptions per week, Valor will collect payment directly from the patient. Collecting payment directly from the patient is the preferred process, including in contracts, but accounts receivable for patient pass-through payments set-up can be discussed if the volume is over 50 prescriptions per week.
Please describe your telehealth program.*
Describe the medical disciplinary focus, goals for the patient, how the appointment works, etc.
Please list the compound(s) needed. Include strengths, quantity, dosage.*
Please note: We do NOT make peptides, IV nutrients or vitamins, growth hormones, nor semiglutide and other weight loss compounds.
Anything else you would like us to know?
How did you hear about us?*

Family/FriendPhysician ReferralPatient ReferralAI ChatbotOnline SearchSocial MediaAdvertisementConferenceValor WebsiteValor RepOther
I would like to receive emails containing marketing, education, promotions, and/or information from Valor Compounding Pharmacy.*

YesNo
Please verify that you are human*
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