PRESCRIBER'S AGREEMENT
Office Administration of Compounded Preparations and Designation of ePrescribing Agents
Part 1: PRESCRIBER INFORMATION
Business Name
*
Business Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prescriber Name
*
First Name
Last Name
Prescriber Email
*
example@example.com
Collaborating Physician's Name(if applicable)
First Name
Last Name
Collaborating Physician's email (if applicable)
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NPI Number
*
DEA Number
*
DEA Expiration Date
-
Month
-
Day
Year
Date
State License Number
*
State License Number
*
State License Expiration Date
*
-
Month
-
Day
Year
Date
Are you allowed prescriptive authority by your state of licensure?
*
Yes
No
Have you met the eligibility requirements of your state for full prescriptive authority?
*
Yes
No
If applicable, do you have an active collaboration protocol and/or agreement?
*
Yes
No
Not Applicable
Mississippi GLP-1/GIP Prescribing Acknowledgements
*
I have reviewed and understand the supplemental guidance on the compounding and prescribing of GLP-1/GIP medications as provided by the Mississippi State Board of Medical Licensure (MSBML) dated August 6, 2024. This can be found online: www.msbml.ms.gov/node/466 or by contacting the MSBML office directly at 601-987-3079.
Prescribing of GLP/GIP Compounded Medications: By accepting this agreement, you agree not to prescribe GLP/GIPs solely based on an indication for weight loss, as set forth by the MSBML.
Compounded Products and FDA Approval: All compounded products are not FDA approved or indicated for any specific medical condition.
Use of FDA-Registered Facilities: Lee Silsby Compounding Pharmacy and all Revelation Pharma pharmacies use only FDA-registered facilities for all Active Pharmaceutical Ingredients (APIs), excipients, and bases in their compounded products.
Compliance with USP Standards: Lee Silsby Compounding Pharmacy and all Revelation Pharma pharmacies adhere to the highest standards set forth in USP <797> guidelines for sterile compounding. Certificate of Analysis (COA), Active Pharmaceutical Ingredient (API) specifications, and all pertinent testing and verification documents are available upon request.
Prescriber Acknowledgements
*
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 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.
DEA regulations permit a pharmacist to dispense a controlled substance in Schedules III, IV, and V pursuant to a signed paper prescription, a facsimile of a signed paper prescription, an electronic prescription, or an oral prescription made by an individual practitioner. Prescriptions for controlled substances in Schedules III and IV may not be filled or refilled more than six months after the date of issuance or be refilled more than five times.
Submit
Should be Empty: