EPRESCRIBING PORTAL PRESCRIBERS AGREEMENT
Agreement to use of Prescribing Portal and Designation of ePrescribing Agents at Everwell Specialty Pharmacy
Part 1: PRESCRIBER INFORMATION
Business Name
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Business Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Prescriber Name
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First Name
Last Name
Prescriber Email
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example@example.com
Collaborating Physician's Name(if applicable)
First Name
Last Name
Collaborating Physician's email (if applicable)
example@example.com
Business Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NPI Number
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NPI Number
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DEA Number
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DEA Expiration Date
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Month
-
Day
Year
Date
State License Number
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State License Number
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State License Expiration Date
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Month
-
Day
Year
Date
Are you allowed prescriptive authority by your state of licensure?
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Yes
No
Have you met the eligibility requirements of your state for full prescriptive authority?
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Yes
No
If applicable, do you have an active collaboration protocol and/or agreement?
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Yes
No
Not Applicable
Terms of ePrescribing Portal Use - Checking the box confirms your agreement to the following:
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Prescribing Compliance with 503A Patient Specific Prescriptions: All prescriptions for compounded medications must be issued only for specific patients after proper evaluation and in compliance with all state and federal regulations. These prescriptions cannot be issued for office or clinic stock.
Prescriber Responsibility for Accuracy: The prescriber is responsible for the accuracy and legality of prescriptions sent through the pharmacy’s portal. The prescriber agrees that they will ensure all prescriptions are written in accordance with applicable laws and are intended only for the patient specified.
Access Delegation: The prescriber may assign authorized agents (e.g., nurses, office staff) their own portal access for the purpose of entering prescriptions on the prescribers behalf. The prescriber remains fully responsible for any actions taken by the designated agents on the portal and agrees to notify the pharmacy promptly if access is compromised or if the agent no longer requires access.
Credential Security: The prescriber and any designated agents agree to maintain the confidentiality of their login credentials and ensure that they are used appropriately. Should these credentials become compromised, the prescriber is responsible for taking immediate action to secure the account and will notify the pharmacy.
HIPAA Compliance: The prescriber ensures that all prescribed medications and patient information are handled in accordance with HIPAA regulations. This includes safeguarding the privacy and security of patient data, particularly when using the pharmacy’s portal.
Indemnification: The prescriber agrees to indemnify and hold the pharmacy harmless for any losses, claims, or legal consequences resulting from compromised access or unauthorized agent actions under the prescribers authority.
Audit Rights: The pharmacy reserves the right to audit prescribers account and agent actions on the pharmacy's portal to ensure compliance.
Termination for Non-Compliance: The pharmacy reserves the right to terminate access to the prescribers portal if there is evidence of non-compliance, including failure to secure access credentials, failure to safeguard patient data, or improper handling of prescriptions.
Prescriber Requirements
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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
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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.
Everwell is located in the state of Florida, where a pharmacist may not dispense more than a 30-day supply of a controlled substance listed in Schedule III (e.g., Testosterone) based on an oral prescription. However, if the prescription is transmitted electronically through an approved EPCS (Electronic Prescriptions for Controlled Substances) system or via fax with a wet signature, the pharmacy is authorized to dispense up to a 90-day supply, provided it does not exceed six months from the original date written on the hard copy.
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.
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