Telehealth Affiliate Initial Inquiry

Telehealth Affiliate Initial Inquiry

A minimum of 50 prescriptions per week is required for contract set-up. We can service patients directly if you are just getting started.
Name of the Submitter*

First NameLast Name
Title*
I would like to receive emails containing marketing, education, promotions, and/or information from Valor Compounding Pharmacy.*

YesNo
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)?*
A MSO is a business organization that provides the necessary administrative (telehealth) infrastructure, scale and technology for contracted covered entities to function successfully. A MSO is not a "Covered Entity" under HIPAA and must sign Valor's MNDA and BAA as a requirement of this process.
What is the URL of your telehealth company?*
Is your company active or in development?*
Congratulations on starting your new company! We are happy to provide you with information about compounds and how we work.

To help you get started, you may have your providers order prescriptions for their patients and will dispense and collect payment directly from the patients. Providers can order prescriptions through e-prescribe (we are listed as "Valor Compounding Pharmacy", by secure online form on our website under "For Providers", by fax at 510-548-0305, or by calling 510-548-8777.

Once you reach a consistent volume of 50 prescriptions a week, we can discuss setting up a MSO contract and process at that 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.
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?*

FacebookTV InterviewLinkedInGoogle/Internet SearchInstagramPress Release/NewsTwitterPhysician ReferralFamily/FriendOther
Please verify that you are human*
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