PRESCRIBER'S AGREEMENT
Office Administration of Compounded Preparations and Designation of ePrescribing Agents
Part 1: PRESCRIBER INFORMATION
Business Name
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Business Phone Number
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Please enter a valid phone number.
Prescriber Name
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First Name
Last Name
Prescriber Email
*
example@example.com
Collaborating Physician's Name(if applicable)
First Name
Last Name
Collaborating Physician's email (if applicable)
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NPI Number
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DEA Number
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DEA Expiration Date
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Month
-
Day
Year
Date
State License Number
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State License Expiration Date
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Month
-
Day
Year
Date
Are you allowed prescriptive authority by your state of licensure?
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Yes
No
If applicable, do you have an active collaboration protocol and/or agreement?
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Yes
No
Not Applicable
Prescriber Requirements
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These compounded preparations may only be administered to the patient for which the medication was prescribed, and may not be sold to any other person or entity. when the compounded preparation is administered, physician agrees to indicate on the patient's medical chart the lot number and beyond-use date(BUD) of the preparation used.
Prescriber is actively monitoring the care of patients, either through direct patient-care or oversight of appropriately trained personnel.
If the prescriber terminates relationship with the practice, the prescriber will immediately notify the pharmacy the date of termination.
For any compounded medications that the prescriber intends to administer or provide the patient, the prescriber will personally offer to discuss matters which will enhance or optimize drug therapy with each patient or caregiver of such patient. Such discussion shall be in person, whenever practicable, or by telephone and shall include appropriate elements of patient counseling, based on the professional judgement of the prescriber.
I Acknowledge
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The state, Medical, and Pharmacy Board requirements located in your state, as well as the Drug Enforcement Agency (DEA), regulate the legal requirements for generating prescriptions for a legitimate medical purpose. DEA rules also explicitly define the use of agents to help facilitate the transmission of controlled substance prescriptions orders. The summary of the DEA rule is noted below, and the language in that rue serves as the foundation for terms of using our e-prescription portal.
For a prescription for a controlled substance to be effective, the prescription must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his/her professional practice. This determination is the sole responsibility of the practitioner and may not be delegated. The responsibility for the proper prescribing and dispensing of controlled substance is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills that prescription.
A prescription may be prepared by the secretary or agent for the signature of a practitioner. Accordingly, an authorized agent may prepare a controlled substance prescription only based on the authorized agent may prepare a controlled substance prescription only based on the instructions of the prescribing practitioner as to the required elements of a valid prescription and then provide the prescription to the practitioner to review. The authorized agent does not have the authority to make medical determinations. For a controlled substance, the practitioner must personally sign the prescription, whether manually or electronically. The prescribing practitioner cannot delegate his or her signature authority. (21 CFR 1306.05(f))
As noted above, the practitioner remains responsible for ensuring that the prescription conforms to State and Federal Laws and Regulations, and the practitioner cannot delegate to an agent the authority to make a medical determination of need for a controlled substance prescription. However, the prescriber may delegate the transmission of the prescription drug order to an authorized agent.
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