Home Products Acyclonine MUM Credentials Prescriber Information (Required only once for first time orders) "*" indicates required fields Office Administration of Compounded Preparations and Designation of ePrescribing AgentsPart 1: Prescriber InformationBusiness Name* Business Phone* Please enter a vaild phone numberPrescriber's Name* First Last Prescriber's Email* Business Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code NPI Number* State License Number* License State* AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State State License Expiration Date:* MM slash DD slash YYYY Prescriber Requirements:* These compounded preparations may only be administered to the patient for which the medication was prescribed, and may not be sold to any other person or entity. When the compounded preparation is administered, physician agrees to indicate on the patient’s medical chart the lot number and beyond-use date (BUD) of the preparation used. Prescriber is actively monitoring the care of patients, either through direct patient-care or oversight of appropriately trained personnel. If the prescriber terminates relationship with the practice, the prescriber will immediately notify the pharmacy the date of termination. For any compounded medications that the prescriber intends to administer or provide the patient, the prescriber will personally offer to discuss matters which will enhance or optimize drug therapy with each patient or caregiver of such patient. Such discussion 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 prescription 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 substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the 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 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. Part II: Pharmacy Requirements and Required Signature by a Licensed PractitionerThe 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 Georgia 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 Georgia 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. Date* MM slash DD slash YYYY Signature*Professional Credentials* MD / DO OD / DDS / DMD / DPM PA / NP ND Other Professional Credentials: Other* Full Name as signed (on Signature)*
