• PRESCRIBER'S AGREEMENT - STANLEY

    Office Administration of Compounded Preparations and Designation of ePrescribing Agents

  • Part I: BUSINESS INFORMATION

  • Format: (000) 000-0000.

  • Part II: PRESCRIBER INFORMATION & ACKNOWLEDGMENTS

  • State License Number Expiration Date*
     - -
  • DEA Number Expiration Date
     - -
  • If applicable, do you have an active collaboration protocol and/or agreement?*
  • Do you intend to prescribe Controlled Substances for your patients?
  • DEA Number Expiration Date
     - -
  • Collaborating Physician's State License Number Expiration Date
     - -
  • Prescriber Requirements*
  • I Acknowledge the following:*

  • Part III: DESIGNATING AGENTS TO COMMUNICATE PRESCRIPTION DRUG ORDERS

    (OPTIONAL AGENT USE OF PRESCRIBER'S PORTAL)
  • Is the diagnosis, assessment of symptoms, and recommendation for treatment completed by a licensed prescriber?*
  • Does the prescriber issue "standing orders" for the RN or other medical personnel to follow that do not satisfy the prescriber's legal duties to the patient?*
  • Would you like to designate an agent to communicate prescription drug orders?*
  • Rows

  • Part IV: PHARMACY REQUIREMENTS AND REQUIRED SIGNATURE BY A LICENSED PRACTITIONER

  • Pharmacy Requirements

    The compounding of preparations will include the following activities by the Pharmacy: verification of the source of raw materials to be used; compliance with applicable United States Pharmacopoeia guidelines (including testing requirements), the Health Insurance Portability and Accountability Act of 1996, and all applicable competency and accrediting standards as determined by the North Carolina State Board of Pharmacy as well as the Board of Pharmacy in the Practice's state residence. Pharmacy agrees to record the lot numbers of compounded preparation supplied so that, in the event a recall of the preparation is required, Pharmacy shall notify Physician of the recall and can facilitate contacting any patients who received the product. In such an event, Pharmacy's existing protocols for notifying patients, quarantine of the product (if applicable), and/or recall will be followed.

    Any adverse reactions or complaints may be submitted by the patient to either Pharmacy or Physician; in the event a report is made, the entity receiving the report will forward a copy to the other entity. If patient harm is suspected or confirmed to be due to a preparation compounded by Pharmacy, Pharmacy will notify the North Carolina State Board of Pharmacy, the Board of Pharmacy where the patient resides, and the FDA.

  • By signing this form, I declare under penalty of perjury (under the laws of the United States of America) that:*
  • Date*
     - -
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  • Should be Empty: