T-REX-COR: New Integration Setup Form

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T-Rex Change Order Request Form New Integration Setup
Form Type: Generic Pharmacy Information System

Summary: This change order request form is required to set up new integrations between a Transportation Management System, T-Rex, and a Pharmacy Information System (SuiteRx, PrimeRx, Liberty Software, etc.). This completed form will be added to your existing T-Rex Platform-as-a-Service (PaaS) Agreement. All setup fees must be remitted in full before set up is scheduled. All transaction fees incurred during your onboarding month will be billed on the first of the following month. Please complete and e-sign this form to start the integration setup process.

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?
Pharmacy & Pharmacy Information System
Please note that the LTHQ/T-Rex Support Team will not contact your pharmacy customer directly without your consent. However, we may need to contact your pharmacy information systems provider to initiate a new setup.

Setup Timeframe Expectations: Below are the reasonable timeframes for setting up integrations. Please note that these are to be used as guidelines. The T-Rex support team will provide you with a more accurate timeframe once we complete our review.

New PIS or TMS Setup: 2 - 4 Weeks
What is the pharmacy's name?*
Requested T-Rex Go Live Date

MonthDayYear
Date
Pharmacy Contact Name*

First NameLast Name
Pharmacy Contact Phone Number*
Pharmacy Contact Title*
Pharmacy Contact Email Address*
example@example.com
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Pharmacy Information System are we integrating via T-Rex? *
Who are we connecting T-Rex too?
What is the estimated total delivery stops per scheduled release?*
Which level will you pickup and deliver scan packages in your TMS for this pharmacy? Pick 1 of the following options.*

Tote Level (i.e TOT1234)Manifest Level (i.e PAK1234, AWAS241202110900212070, etc.)Script (Rx) Level (Rarely Used!)
What Data Retention option is required for this pharmacy location? (90-Days is included on all transaction. Options above 90-Day retention will incur an additional add-on fee).*

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)
Is there an incumbent Courier/Delivery Service provider to this pharmacy?*

YesNo
If yes, what is the name of the current Courier/Delivery Service provider?*
Put N/A if you answered No to the previous queston.
Has the current Courier/Delivery Service provider been notified of the planned transition?*

YesNo
Please use this section to document any additional information you would like to communicate with our team.
Disclosures and Fees
- Non Refundable Setup Fee: $1,500
- The setup fee is due upfront and must be paid in full to begin the integration process.
- 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.
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T-Rex Change Order Request Form New Integration Setup

Your Company Information

Pharmacy & Pharmacy Information System