Account Onboarding Form

  • Account Onboarding Form

  • For questions please call 404.815.1610 or email pharmacists@mixwithintegrity.com

  • Format: (000) 000-0000.
  • Practice Type
  • Indicate services you provide or are interested in providing:*
  • Who is the payer of the prescription? (Account Pay, Patient Pay or both?) NOTE: If both, the payment method will need to be specified on the prescription by the clinic to prevent billing errors*
  • Preferred Shipping Method: Ship to office (no controlled substances), ship to patient, or both ? NOTE: If both, the shipping method will need to be specified on the prescription by the clinic to prevent delays.*
  • Preferred Rx Transmission Method
  • Would you like to utilize our Provider Portal to submit and track prescription orders?*
  • How would you like to notify the pharmacy of a patient's refill?*
  • How did you hear about us?

  • Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method of Contact

  • Provider Information

  • Certification and Acknowledgment

  • Certification and Acknowledgment

    By signing this Agreement, the undersigned certifies, acknowledges, and agrees as follows:

    1. Pharmacy Status and Compliance: Integrity Compounding Pharmacy operates as a 503A compounding pharmacy in accordance with all applicable federal and state laws and regulations.
    2. Patient-Specific Prescriptions: All prescriptions dispensed by Integrity Compounding Pharmacy are prepared and dispensed solely pursuant to valid, patient-specific prescriptions.
    3. Prescription Use: Prescriptions shall not be issued for office use, resale, or any purpose other than treatment of the identified patient
    4. Legal and Professional Standards: The undersigned agrees to comply with all applicable federal and state laws, regulations, and applicable professional standards governing the prescribing, handling, and use of compounded medications.
    5. Legitimate Medical Purpose: All prescriptions issued by or on behalf of the undersigned shall be issued for a legitimate medical purpose and in the usual course of professional practice.
    6. Pricing Transparency and Compliance: Integrity Compounding Pharmacy is committed to operating in full compliance with all applicable federal and state laws, including the Federal Anti-Kickback Statute and all related regulations. 
      • Integrity’s prescription pricing is not considered confidential information and may be communicated at the pharmacy's discretion when appropriate and permissible. Integrity will take into account any established provider billing relationships when determining how pricing communication is handled. 
    7. Provider Billing Responsibilities: If a provider elects to purchase prescriptions directly from Integrity (i.e “office-pay” or pass through model), the provider agrees to structure patient billing in a compliant and transparent manner. This includes:
      • Charging patients no more than the amount paid to the pharmacy, plus any reasonable, fixed fees for services rendered. This includes but is not limited to an administrative fee, processing fee, inclusion in a legitimate bundled care model (e.g, per-visit, package-based, or programmatic pricing)
      • Prohibiting percentage-based markups to prescription costs or structuring fees in a manner that could be interpreted as generating profit from the prescription itself. 
    8. Clinic Communication and No-Contact Models: In the event the clinic operates under a no-contact or limited-contact care model, the undersigned acknowledges and agrees that Integrity Compounding Pharmacy shall not be responsible for delays, non-delivery, or patient dissatisfaction resulting from the clinic’s failure to:
      • Provide accurate and complete patient information, including but not limited to shipping address, contact information, or prescription details;
      • Communicate to the patient expected timelines, delivery status, or prescription availability; or
      • Ensure the patient is aware that Integrity Compounding Pharmacy may contact the patient as required by applicable state law to provide mandatory patient counseling.
      • Integrity Compounding Pharmacy shall not be responsible for replacement costs, remakes, refunds, or reshipment fees arising from inaccurate information provided by the clinic or failure of the clinic to adequately communicate with the patient.
      • This section shall not apply to care models in which Integrity Compounding Pharmacy directly contacts the patient to obtain demographic information, confirm details, provide counseling, or coordinate fulfillment.

  • Integrity
    COMPOUNDING PHARMACY

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