MediBridge - Prescriber Agreement

Business Name*

Business Phone Number*

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email for Shipping Notifications to Clinic (Orders shipping to the patient will use the patient's email, if one is provided)

example@example.com

Prescriber's Name*

First NameLast Name

Prescriber's Email*

example@example.com

NPI Number*

Are you allowed prescriptive authority by your state of licensure?*

YesNo

Resident State License Number (please note: number, not state)*

Resident State License Expiration Date*

Date

DEA Number

DEA Expiration Date

Date

If applicable, do you have an active collaboration protocol and/or agreement?*

YesNot Required (Either for my License or in for my State)

Collaborating Physician's Name (If Applicable)

First NameLast Name

Collaborating Physician NPI Number

Collaborating Physician's Email (If Applicable)

example@example.com

Prescriber Requirements*

I acknowledge federal pharmacy law strictly prohibits the relabeling, repackaging, and reselling of any of our compounded preparations.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, I agree to indicate on the patient's medical chart the lot number and beyond-use date (BUD) of the preparation used.I am actively monitoring the care of patients, either through direct patient-care or oversight of appropriately trained personnel.If I terminate my relationship with the practice, I will immediately notify the pharmacy the date of termination.For any compounded medications that I intend to administer or provide the patient, I will personally offer to discuss matters that 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 in accordance with law and the prescriber's professional judgment.Any violations of these policies may result in all prescriptive authority to be removed from the pharmacy system and immediate termination of our account relationship without prior notification.

Prescription Requirements*

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 prescription orders. The summary of the DEA rule is noted below, and the language in that rule 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 substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the 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 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.

Provider Authorization for PHI Disclosure and Prescription Processing

By signing below, the undersigned Provider acknowledges and agrees that The Medibridge is acting as a Business Associate and/or Covered Entity, as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In this capacity, The Medibridge is authorized to receive, use, disclose, and discuss Protected Health Information (PHI) as necessary to carry out its services. This includes, but is not limited to, the receipt, processing, and submission of prescriptions on behalf of the Provider, in accordance with all applicable federal and state laws. All such activities will be conducted in full compliance with HIPAA and/or other relevant privacy regulations.

If any documentation is needed for auditing or review purposes, or if the Provider wishes to revoke this authorization, please contact b2bsupport@revelationpharma.com.

Pharmacy Requirements
The compounding of preparations will include the following activities by the Pharmacy: verification of the source of raw materials to be used; compliance with applicable United States Pharmacopoeia guidelines (including testing requirements), the Health Insurance Portability and Accountability Act of 1996, and all applicable competency and accrediting standards as determined by the Georgia State Board of Pharmacy as well as the Board of Pharmacy in the Practice's state residence. Pharmacy agrees to record the lot numbers of compounded preparation supplied for office use so that, in the event a recall of the preparation is required, Pharmacy shall notify Physician of the recall and can facilitate contacting any patients who received the product. In such an event, Pharmacy’s existing protocols for notifying patients, quarantine of the product (if applicable), and/or recall will be followed.

Any adverse reactions or complaints may be submitted by the patient to either Pharmacy or Physician; in the event a report is made, the entity receiving the report will forward a copy to the other entity. If patient harm is suspected or confirmed to be due to a preparation compounded by Pharmacy, Pharmacy will notify the Georgia State Board of Pharmacy, the Board of Pharmacy where the patient resides, and the FDA.

By signing this form, l declare under penalty of perjury (under the laws of the United States of America) that:*

I am a licensed practitioner with prescriptive authority.This agreement may be electronically signed only by licensed prescribers that are in good standing with their overseeing state and federal agencies.The electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity,enforceability and admissibility.Any false or misleading e-signatures will carry the same level of criminal prosecution as forgery using handwritten signatures.

Signature*

Professional Credentials*

Prescriber's Name*

First NameLast Name

Date

Please verify that you are human*

THE MEDIBRIDGE PRESCRIBER AGREEMENT

Part I: Prescriber Information

Part II: Pharmacy Requirements and Required Signature by a Licensed Practitioner