New Provider/Clinic SignUp LB

NEW PROVIDER & CLINIC SIGNUP

WELCOME!
Thank you for choosing AGErite Pharmacy & Wellness Center as your specialty pharmacy provider. We are thrilled to have the opportunity to work with you! At AGErite, we are committed to offering you unparalleled service, advanced medication management, and the most competitive pricing. At AGErite Pharmacy & Wellness Center, the principles of partnership, collaboration, integrity, commitment, and customer focus are the foundation of everything we do. Whether working with healthcare facilities or individual patients, these values guide our approach to ensuring the highest level of care and service. Please take a moment to complete the forms in this packet, which include our Provider Information sheet, Agreement for Services, and Convenient Payment Options. Once completed, return the forms to us, and we will get started on providing you with the highest level of pharmacy care. We look forward to supporting your patient needs. If you have any questions or need assistance, don't hesitate to contact us. We're here to help! Welcome and thank you for choosing AGErite Pharmacy!

Sincerely,

AGErite Pharmacy Team
BILLING CONTACT INFORMATION
AGErite Pharmacy & Wellness Center

phone: (281) 654-8417

email: Compounding@AGEritePharmacy.com

HOURS OF OPERATION (subject to change)

Monday: 10:00 am - 3:00 pm (CST)

Tuesday: 11:00 am - 4:00 pm (CST)

Wednesday: 10:00 am - 3:00 pm (CST)

Thursday: 10:00 am - 3:00 pm (CST)

Friday: 10:00 am - 3:00 pm (CST)

Saturday: CLOSED

Sunday: CLOSED

For most up to date business hours, check our Google page: https://g.co/kgs/1d161Sv
CLINIC INFORMATION
Clinic Name*
Primary Physician's Name*
Primary Physician's NPI*
Primary Physician's DEA*
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
Format: (000) 000-0000.
Alternative Phone
Format: (000) 000-0000.
Email*
example@example.com
<2020-5051-100>100
Please list other Physician / NP below with their NPI's & DEA (if applicable) who are authorized to call/email/fax prescriptions to pharmacy on

Agents who can order medication on behalf of providers
Agent Name #1*
Provider Name*
Agent Name #2
Provider Name
Agent Name #3
Provider Name
ClinicPatientBoth
Responsible Party/Bill to Information

(this is where the bill will be sent via email)
Name*
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
Format: (000) 000-0000.
Alternative Phone
Format: (000) 000-0000.
Email*
example@example.com
Invoice will be automatically billed upon ordering. If you would like to cancel your medication order, please call us at 281-654-8417 or you will get billed the full amount.
Agreement for AGErite Pharmacy Services
The Clinic agrees to pay all co-pays, over-the-counter, medications, or non-covered charges.

The Clinic authorizes AGErite Pharmacy access to its patients' medical records for proper medication assessment. For large volume clinic-use orders, payment is due prior to fulfillment regardless of selected billing option. In the event any balance is not paid as agreed, the undersigned agrees to pay a collection fee up to 35% of the unpaid balance. In the event of a lawsuit to collect the unpaid balance, the undersigned further agrees to pay court costs and reasonable attorney's fees. Automatic Payments will be charged when medications are sent out.
Responsible Party*

First NameLast Name
Responsible Party Signature*

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Date*

MonthDayYear
Date
Billing Options

PLEASE CHOOSE ONE OF THE BILLING OPTIONS LISTED BELOW
OPTION 1: AUTO WITHDRAWAL FROM CREDIT CARD ON DISPENSE - DAILY BILLINGOPTION 2: AUTO WITHDRAWAL FROM CREDIT CARD EVERY MONDAY - WEEKLY BILLING
Option 1: The card on file will be charged in real time when an order is placed.

Option 2: The card on file will be charged upon issuance of the invoice every Monday for all orders dispensed the week prior.
I authorize AGErite Pharmacy LLC dba AGErite Pharmacy & Wellness Center to charge my credit card on file monthly. This authorization will remain in effect until I cancel it. I may cancel this authorization any time by contacting AGErite Pharmacy at (281) 654-8417 or emailing info@AGEritePharmacy.com.
ORDERING PROCESS
1. Ensure your clinic packet has been received and processed by the pharmacy.
2. You will receive a confirmation email from info@AGEritePharmacy.com
3. Ways to submit orders
  - Using our convenient order forms via Jotforms
  - Escribe new orders to:
    
    AGErite Pharmacy & Wellness Center, 12827 Telge Road Ste 160 Cypress, TX 77429
  - Fax scripts to (281) 605-1912
  - Email scripts to compounding@AGEritePharmacy.com
Please note:

From receipt of the prescription to delivery to the patient, you can expect 2-4 business days for available medications. Our normal processing time is up to 2 business days with 1- or 2-day shipping unless otherwise requested.
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NEW PROVIDER & CLINIC SIGNUP

BILLING CONTACT INFORMATION

CLINIC INFORMATION

Responsible Party/Bill to Information

Agreement for AGErite Pharmacy Services

Billing Options

ORDERING PROCESS