Prescriber Agreement Form - Community Clinical

Prescriber's Agreement

Office Administration of Compounded Preparations - Acknowlegment of Pharmacy and Prescriber Requirements
Practice Name *
Practice Location *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescriber Name *

First NameLast Name
Professional Credentials (MD, PA-C, NP-C, etc.)*
Prescriber Email (Must be a unique email address. We do not accept - info@doctorsoffice.com)*
example@example.com
Prescriber Phone Number*
Please enter a valid phone number.
Prescriptive Authority Information
State(s) Licensed to Practice Medicine *
Primary State License #*
Primary State License Expiration Date*

MonthDayYear
Date
DEA #
DEA Expiration Date

MonthDayYear
Date
NPI #*
Do you have prescriptive authority by your state of licensure?*

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

YesNo
Collaborating Physician Name (If applicable)

First NameLast Name
Collaborating Physician's Email (If Applicable)
example@example.com
Collaborating Physician Phone Number (If Applicable)
Please enter a valid phone number.
Acknowledgements

Please select all that you acknowledge and agree to adhere to the following statements.
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.
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 prescriptions 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 substance is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills that 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 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.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.
Pharmacy Requirement

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 Arizona 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 for office use 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 Arizona State Board of Pharmacy, the Board of Pharmacy where the patient resides, and the FDA.
By signing this form, l declare under penalty of perjury (under the laws of the United States of America) that:*

I am a licensed practitioner with prescriptive authority.This agreement may be electronically signed only by licensed prescribers that are in good standing with their overseeing state and federal agencies.The electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.Any false or misleading e-signatures will carry the same level of criminal prosecution as forgery using handwritten signatures.
Prescriber Signature *

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Prescriber's Agreement

Prescriptive Authority Information

Acknowledgements