E-Prescribe Agreement

1

Practice NameName of the practice for which the provider will be sending prescriptions

2

Practice Contact's Name

First Name

Last Name

3

Practice Contact's Phone

4

Practice Contact's Email

example@example.com

5

Provider's Name

6

{ProviderName1}'s NPI Number

7

{ProviderName1} has a DEA Number?

YESNO

8

{ProviderName1}'s DEA Number

9

Enroll Another Provider?

YesNo

10

Provider's Name

11

{ProviderName2}'s NPI Number

12

{ProviderName2} has a DEA Number?

YESNO

13

{ProviderName2}'s DEA Number

14

Enroll Another Provider?

YesNo

15

Provider's Name

16

{ProviderName3}'s NPI Number

17

{ProviderName3} has a DEA Number?

YESNO

18

{ProviderName3}'s DEA Number

19

Enroll Another Provider?

YesNo

20

Provider's Name

21

{ProviderName4}'s NPI Number

22

{ProviderName4} has a DEA Number?

YESNO

23

{ProviderName4}'s DEA Number

24

Enroll Another Provider?

YesNo

25

Provider's Name

26

{ProviderName5}'s NPI Number

27

{ProviderName5} has a DEA Number?

YESNO

28

{ProviderName5}'s DEA Number

29

Surescripts Electronic Prescription Service Terms* This field is required.Click 'I Agree' to accept the service terms

30

Date of Submission

Date

31

Form Sender Name

32

Form Sender Email

example@example.com

33

Criterions E-Prescribe Subscription Agreement* This field is required.Click 'I Agree' to accept this agreement