LFG Clinic Account Onboarding Package

Partner With Us!
Thank you for choosing LFG Compounding. We are dedicated to providing the highest quality of pharmacy services at competitive prices. In order for LFG Compounding to service your practice, we need the following forms completed. They will be sent to our inbox and we will reach out if we require anything further!

Thank you!
Below are the following documents that will require completion:

- Account Setup Form

- Recurring Credit Card Authorization Form

- Acknowledgment of Accounts Payable Upon Services

- Prescription Profile Agreement

- Not for Resale Agreement

- Return or Damaged Goods Policy

- Dispensing Authority, only if applicable

- E-Prescribe Implementation Forms
Please include the following along with your account setup package

A current copy of State Medical License Certificate(s) for each prescribing StateA current copy of DEA License
Connect and Experience

To learn more about our services or our team, we encourage you to visit our website at www.lfgcompounding.com and we look forward to our partnership.

Account Setup Form (Required For Each Location)
Practice/Clinic Name
Prescriber Legal Name as identified on the license
NPI #
State License #
DEA #
Additional State License for Prescribing to patients in other States
Primary Address
City
State
Zip
Phone Number
Fax Number
Office Contact If Other Than Physician
Contact Phone
Contact Email
example@example.com
Email for order tracking
example@example.com
Email for billing and invoices
example@example.com
Where did you hear about us?

Internet SearchFacebookInstagramReferralTradeshowOther
Were you contacted by one of our representatives?

YesNo
If yes, provide name of representative
LFG Account Manager
Signature of Approval

Clear

Recurring Credit Card Charge Authorization Form

This document confirms your request for payment by credit card or debit card.

I (we) hereby authorize LFG Compounding to make recurring charges to my credit card listed below, and if necessary, initiate adjustments for any transactions credited/debited in error.

This authority will remain in effect until LFG Compounding is notified by me (us) in writing to cancel it in such time as to afford LFG Compounding and/or credit card company a reasonable opportunity to act on it.

All receipts are sent directly to the cardholder within 24 hours of processing. All records are kept in a secure file electronically password protected and accessible to authorized personnel only.
Billing Address
Billing Zip Code
Phone Number
Email
example@example.com
I authorize LFG Compounding to charge the credit card indicated in this authorization form according to the terms outlined above. I certify that I am an authorized user of this credit card and I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

If I am not the card holder but have been authorized to use the card on file, please ensure to print your name and contact information below:
Printed Name
Signature

Clear
Date

MonthDayYear
Date

Acknowledgement of Accounts Payable Upon Services

LFG Compounding will provide the prescribing provider or their designated representative a weekly invoice for prescriptions filled each week no later than Monday evening of the following week. The prescriber or their designated representative shall review the invoice for any discrepancies and report back to LFG Compounding (info@lfgcompounding.com) before that Thursday morning at 10:00 am CST. Payments will be processed in full in the event that LFG Compounding does not receive any feedback from the previous week's orders.

Failure to pay the weekly invoice by Friday morning will result in administrative holds placed on the account. LFG Compounding reserves the right to also charge the card on file once the weekly orders surpasses $5,000.00.

Printed Name of cardholder or designated representative authorized to make business decisions on behalf of the organization:
Printed Name
Signature

Clear
Date

MonthDayYear
Date
I, Dr. / Practitioner blanks have received consent from the patients of my practice to receive medications on their behalf. I acknowledge the receipt of these medications are to facilitate training/counseling and/or patient specific office administration for custom compounds and other prescription medications. These medications are not intended to be used for any other patients in the practice and are not intended for resale.
Physician/Practitioner Name
Physician/Practitioner Signature

Clear
Date

MonthDayYear
Date

Prescriber Profile Agreement (Must Be Completed By All Prescribers)

LFG Compounding is committed to compliance with state and federal laws.

Many States allow advanced practice nurses or physician assistants to prescribe medications. LFG Compounding is delighted to partner with all prescribers, to achieve optimum outcomes for our patients. If your state requires a written agreement between a designated prescriber, working under the authority of a physician, we require a copy of the document that provides that authority for our records.

If you have independent prescribing authority. Then no document is needed. Some states with independent prescribing authority have limitations on prescribing controlled substances in the law, and we will adhere to those limitations. If you are required to have a dispensing authorization agreement, please ensure the authority extends to controlled substances, if you are prescribing any controlled substance.

We are aware in some instances a patient's residence may differ from the state their prescribing physician is located. To ensure all prescriptions received by LFG Compounding are pursuant to a valid patient/doctor relationship, we require our prescribing physicians agree the following elements are satisfied prior to sending us a prescription. For the purposes of state law, many state authorities, with the endorsement of medical societies consider the existence of the following elements as an indication a legitimate doctor/patient relationship has been established:

1. A physical examination is performed.
2. A medical history has been obtained.
3. A patient has a medical complaint.
4. Some logical connection exists between the medical complaint, the medical history, the physical examination and the drug prescribed.
I, Dr./Prescriber blanks agree all prescriptions sent to LFG Compounding have met the criteria above, and a valid patient/doctor relationship exists applicable to state and federal laws.
Physician Name / Prescriber
Physician Signature

Clear
Date

MonthDayYear
Date

Return Or Damaged Goods Policy

LFG Compounding is committed to providing prompt and efficient service. LFG Compounding carefully packs and inspects each order. We hope you are pleased with the items you have ordered. Please check the contents of your package immediately.

We require that you report any missing items or product damage within 24 hours of receiving the package. No exchanges or refunds will be honored unless we are notified within 24 hours, no exceptions.

LFG Compounding must report all damages immediately to the delivery service for inspection, therefore, we ask you to keep all products and packaging in the condition as it was received. Lost packages are usually located and delivered by the carrier. To avoid duplicate shipments, replacements will be sent after a claims process is complete.

Backordered Of Out Of Stock Items: Our inventory levels are kept as current as possible, however, from time to time an item may become back ordered or temporarily out of stock. In these cases, we shall notify you by a notice in the package, by telephone or email to apprise you of this.

Missing, Shorted Or Damaged Items: LFG Compounding is responsible for return shipping costs in the following circumstances only.
- The item is defective
- The item was damaged during shipment
- An item was received not listed on the prescription

Delivery Failures: You will be responsible for the return shipping costs and any other costs that occur during the delivery process for delivery failures including but not limited to package refusals or if required signature is unavailable. We are not responsible for delivery failures due to the result of a declined signature.

Returns: The FDA prohibits a pharmacist from returning drug products back to stock once they have been out of his or her possession. Therefore, no returns are permitted.

Refunds: All sales are final, there are no refunds on prescription medications. Please contact us with any questions or concerns at 512-994-0008.

I agree and understand the terms outlined above:
Physician Name / Prescriber
Date

MonthDayYear
Date
Signature

Clear

E-Prescribe Implementation Forms

Spend more time with your patients by utilizing our prescriber platform to e-prescribe, manage and track orders, access custom reports and access real time data.

We offer our healthcare partners the ability to e-prescribe using our online software.

- HIPAA Compliant
- It's Secure
- Electronic Prescription Ordering System
- Reduced errors, paper, & unnecessary phone calls
- Track prescriptions from start to finish
- Increase accountability by assigning privileges

Prescription Ordering Implementation Credentials:

The information provided below, will be used to create your HIPAA compliant provider log in credentials for our prescription ordering platform.
Practice Name
Specialty
Provider Name
Primary Address
City
State
Zip
Phone Number
Email Address
example@example.com
State License Number (of authorized prescriber)
DEA # (of authorized to prescribe controls)
(Repeat the Implementation Credentials form as needed for additional providers
Practice Name
Specialty
Provider Name
Primary Address
City
State
Zip
Phone Number
Email Address
example@example.com
State License Number (of authorized prescriber)
DEA # (of authorized to prescribe controls)
(Repeat the Implementation Credentials form as needed for additional providers
Practice Name
Specialty
Provider Name
Primary Address
City
State
Zip
Phone Number
Email Address
example@example.com
State License Number (of authorized prescriber)
DEA # (of authorized to prescribe controls)
11614 BEE CAVES RD #130, AUSTIN, TEXAS 78738
11614 Bee Caves Road #130
Austin, TX 78738

EMAIL: info@LFGcompounding.com

PHONE: (512) 994-0008
PHONE: (512) 994-0008
Should be Empty:

Partner With Us!

11614 BEE CAVES RD #130, AUSTIN, TEXAS 78738

PHONE: (512) 994-0008