Lee Silsby - Prescriber Agreement

Business Name*

Business Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Prescriber's Name*

First NameLast Name

Prescriber's Email*

example@example.com

Collaborating Physician's Name (If Applicable)

First NameLast Name

Collaborating Physician's Email (If Applicable)

example@example.com

Business Address*

Street Address

Street Address Line 2

CityState

Zip Code

NPI Number*

DEA Number

DEA Expiration Date

Date

State License Number*

State License Expiration Date*

Date

Are you allowed prescriptive authority by your state of licensure?*

YesNo

Have you met the eligibility requirements of your state for full prescriptive authority?*

YesNo

If applicable, do you have an active collaboration protocol and/or agreement?*

YesNoNot Applicable

Prescriber Requirements*

Repackaging, Relabeling, and Reselling Prohibition: I acknowledge that the current FDA guidance prohibits the Repackaging (e.g. drawing up syringes), Relabeling (e.g. removing or covering any part of the original prescription label), and Reselling of 503A compounded medications.Patient Specific Requirement: 503A compounded preparations may only be administered or dispensed to the patient for whom the medication was prescribed and may not be sold to any other person or entity.Documentation Requirement: When administering or dispensing the compounded preparation, the physician agrees to record the lot number and beyond-use date (BUD) of the preparation used on the patient's medical chart.Patient Provider Relationship Requirement: The prescriber must actively monitor the care of patients, either through direct patient care or by overseeing appropriately trained personnel.Patient Counseling Requirement: For any compounded medications that the prescriber intends to administer or provide to the patient, the prescriber will personally offer to discuss matters that will enhance or optimize drug therapy with each patient or the patient's caregiver. Such discussions shall be in person, whenever practicable, or by telephone, and shall include appropriate elements of patient counseling based on the professional judgment of the prescriber.Provider Practice Relationship: If the prescriber terminates their relationship with the practice, they will promptly notify the pharmacy of the termination date.Prescriptions must be shipped to an address within the jurisdiction where the provider is licensed and cannot be forwarded or transferred to any other location.

I Acknowledge*

Violations of any prescriber requirement could result in the termination of this agreement and account.The State, Medical, and Pharmacy Board requirements located in your state, as well as the Drug Enforcement Agency (DEA), regulate the legal requirements for generating prescriptions for a legitimate medical purpose. DEA rules also explicitly define the use of agents to help facilitate the transmission of controlled substance prescription orders. The summary of the DEA rule is noted below, and the language in that rule serves as the foundation for terms of using our e-prescription portal.For a prescription for a controlled substance to be effective, the prescription must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his/her professional practice. This determination is the sole responsibility of the practitioner and may not be delegated. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription.A prescription may be prepared by the secretary or agent for the signature of a practitioner. Accordingly, an authorized agent may prepare a controlled substance prescription only based on the instructions of the prescribing practitioner as to the required elements of a valid prescription and then provide the prescription to the practitioner to review. The authorized agent does not have the authority to make medical determinations. For a controlled substance, the practitioner must personally sign the prescription, whether manually or electronically. The prescribing practitioner cannot delegate his or her signature authority. (21 CFR 1306.05(f))As noted above, the practitioner remains responsible for ensuring that the prescription conforms to State and Federal Laws and Regulations, and the practitioner cannot delegate to an agent the authority to make a medical determination of need for a controlled substance prescription. However, the prescriber may delegate the transmission of the prescription drug order to an authorized agent.Delivery of Filled Prescriptions to Prescriber: For filled prescriptions delivered to the prescriber's practice in accordance with the pharmacy's standard policies and procedures, the prescriber must ensure the proper storage of the prescription medication until picked up by the patient. The medication must be stored in accordance with the storage requirements on the prescription label and must be stored in a lockable room or lockable cabinet, cart, or other device that cannot be easily moved and shall remain locked at all times when not in use, with access limited to the licensed practitioner or designee.

Rows	Full Name of Agent	Title	Agent's Email Address (Must be Unique)
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PRESCRIBER'S AGREEMENT

Part I: PRESCRIBER INFORMATION

Part II: DESIGNATING AGENTS TO COMMUNICATE PRESCRIPTION DRUG ORDERS

Part III: PHARMACY REQUIREMENTS AND REQUIRED SIGNATURE BY A LICENSED PRACTITIONER