EPrescribing Portal Prescribers Agreement

Business Name

Business Phone Number

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

Prescriber Name

First NameLast Name

Prescriber 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 / Province

Postal / 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?

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

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

Terms of ePrescribing Portal Use - Checking the box confirms your agreement to the following:

Prescriber Requirements

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.

I Acknowledge

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))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.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.

Provider Reference - Medication Storage & Handling Requirements for Prescriptions Delivered to Prescriber Locations

Signature

EPRESCRIBING PORTAL PRESCRIBERS AGREEMENT

Part 1: PRESCRIBER INFORMATION