T-REX-COR: Change Order Request

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T-Rex Change Order Request Form Existing Integration
Form Type: Generic Change Order Request

Summary: This change order request form is required to make changes to a current integration. This completed form will be added to your existing T-Rex Platform-as-a-Service (PaaS) Agreement. Any changes that impact billing will take effect on the first of the following month. Please complete and e-sign this form.

Instructions:
1. Enter All Required Fields.
2. Click on the Adobe Sign button and E-Sign your request to complete your request.
3. Our support team will review your request to verify your submission and identity. Once verified, our team will e-sign the document and then will reach out to you to schedule the next steps for your request.
Please contact us with any questions at 908-900-4720 or by emailing us at help@t-rex.technology.
Your Company Information
What is your Company Name?*
Enter the same name as entered on your PAAS Agreement.
Your Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requestor Name*

First NameLast Name
Requestor Phone Number*
Requestor Title?*
Requestor Email*
example@example.com
Select your TMS System*
Who are we connecting T-Rex too?
What I Need Changed
Please indicate what you would like changed below.

Disclosures:
- Change Requests for switching PIS or TMS systems may incur a new setup fee based on the complexity of the change. The T-Rex support team will contact you if a charge is to be applied.
- Change Requests to switch your data retention will be applied and completed on the first of the month. (i.e New Billing Cycle)
Which Integration requires a change?*
Enter the same name as entered on your PAAS Agreement.
I would like to make the following change/s.*

Update my company information.Update my pharmacy information.Update my accounting information.Update Authorized UsersChange the scanning level being sent to the TMS.I am changing my TMS for my integrated locations.I am changing my PIS for integrated locations.I want to change my data retention.Other
Which Pharmacy Information System are you switching too?
Who are we connecting T-Rex too?
Which Transportation System are you switching too?
Who are we connecting T-Rex too?
Select the new scanning level being sent to the TMS.

Tote Level (i.e TOT1234)Manifest Level (i.e PAK1234, AWAS241202110900212070, etc.)Script (Rx) Level (Rarely Used!)
I want to change my Data Retention Period.

90-Days (Included)180-Days ($0.03)365-Days ($0.09)730-Days ($0.21)1095-Days ($0.29)1460-Days ($0.32)1825-Days ($0.35)3,650-Days ($0.50)
Please use this section to document any changes for the first four options and/or to provide any further details for this change request.
Disclosures and Fees
- Your E-Pod Transaction Fee will be based on your PAAS agreement Rate Matrix.
- Client will be charged on the first of each month for the total number of completed electronic proof of deliveries (E-Pod’s) for the prior month for all integrated locations.
- E-POD Charge: An E-POD charge will be incurred when a driver completes proof of delivery at a delivery stop or nursing station. A driver performing a consolidated stop delivery will only incur 1 E-POD charge.
- Data Retention is based on a per Business Unit Basis. Client must select this method at the beginning of the implementation process. Any future change request will not take effect until the next billing cycle.
- Client cannot change the data retention options after an E-POD has been completed. In addition, these change requests can only be performed at the start of the next billing cycle.
- Client agrees and absolves Company of any liability for Data Quality.
- Company will provide Client with a secret key to access stored data in the event of an audit. The lookback period for available data will be based on the client's selected retention period. Company will also provide a secret key to the client to access stored data.
- By signing this form, you agree to all terms, conditions, and billing requirements as stated in your current PAAS agreement and this change order request.
Should be Empty:

T-Rex Change Order Request Form Existing Integration

Your Company Information

What I Need Changed