IPD Customer Setup Form V2

IPD Customer Setup Form
GENERAL INFORMATION
Enter IPD Sales Representative ID, if known
How did you hear about IPD?
If other, please explain:

Existing Customers, Enter IPD Account Number

If existing, is this a change in ownership?

YesNo

Legal Business Name:*
Doing Business As:

Business Physical Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Business Phone Number*
Please enter a valid phone number.

Business Fax Number
Please enter a valid phone number.

Business Email*
example@example.com

Business Owner Name*

First NameLast Name

Business Owner Phone*
Please enter a valid phone number.

Business Owner Email*
example@example.com

Hours of Operation*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Open
Close

Customer Type*

PharmacyDistributorMedical Facility

NPI*

DEA Registration Number*

Please upload a copy of the DEA Registration

Cancelof

State Board License Number (Facility)*

Please upload a copy of the state board license (facility)

Cancelof

Pharmacist In Charge*

First NameLast Name

Pharmacist In Charge License Number*

Please upload a copy of the Pharmacist in Charge license

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Dispensing Physician*

First NameLast Name

Dispensing Physician License Number*

Dispensing Physician NPI:*

Please upload a copy of the Dispensing Physician license

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When do you start your daily order process?*

Purchaser Contact *

First NameLast Name

Purchaser Contact Email*
example@example.com

Purchaser Contact Phone*
Please enter a valid phone number.

Accounting
Billing Address is the same as Physical Business Address?*

YesNo

Bill To Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Will you be purchasing Controlled Substances from Independent Pharmacy Distributor?*

YesNo

CONTROLLED SUBSTANCE QUESTIONNAIRE

PHARMACY
GENERAL INFORMATION
Number of Employees*

Has your pharmacy been open LESS THAN 90 day?*

YesNo

Number of Years in Business*

Additional Pharmacies Owned*

Please Check who you fill scripts for. List the percentages for each. Percentages must equal 100%.*

	Check if you fill scripts for the following:	Enter the Percentage Filled (Total must equal 100%)
Doctor's Office
Rehab Center
Hospitals
Diet Clinics
Nursing Homes
Hospice
Pain Clinics
Total

Are you a closed-door pharmacy (no retail business)?*

YesNo

What process is used to validate a prescription before it is dispensed to the patient?*

ON-SITE INSPECTION INFORMATION
On-site Inspection Contact*

First NameLast Name

On-Site Inspection Contact Phone Number*
Please enter a valid phone number.

CONTROLLED SUBSTANCES
Select the schedule(s) that you will be purchasing*

CIICIIICIVCV

What percentage of controls are paid for on a Cash & Carry basis? (Include only prescriptions paid in cash, please do not include co-pays)*

If greater than 20% are paid for on a Cash & Carry basis, explain:*

Has your pharmacy ever refused to dispense a prescription to a customer?*

YesNo

If pharmacy has never refused to dispense a prescription to a customer, explain:*

Do you have a Security System that monitors the controlled substances in your facility?*

YesNo

Describe your security system:*

Mandatory Dispensing Report in Excel Format: Pharmacy Software generated 90 day dispensing report for all products dispensed. MUST include: Product Names, NDC, Qty Dispensed*

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How many total scripts do you fill monthly?*

What percentage of these scripts are controlled substances?*

List in descending order the Top 3 physicians writing prescriptions for CONTROLLED SUBSTANCES that your pharmacy is dispensing*

	First Name	Last Name	DEA Number
Physician
Physician
Physician

Name of Registrant*

First NameLast Name

Will you purchase controlled substances through CSOS?*

YesNo

Other than the registrant, will other staff member(s) in the facility be authorized to sign a DEA 222 Form?*

YesNo

DEA 222 Authorized Signers (other than Registrant)*

	First Name	Last Name	Title	License Number
Authorized Signer
Authorized Signer
Authorized Signer

Who is your Primary Wholesaler?*

If other, please specify:*

Who are your Secondary Wholesalers, do you purchase controls from them?*

	Wholesaler Name	Non-Control Purchases	Control Purchases
Wholesaler 1
Wholesaler 2
Wholesaler 3

Has another vendor ever terminated your ability to purchase controlled substances?*

YesNo

Explain why another vendor has terminated your ability to purchase controlled substances:*

MAIL AND INTERNET ORDERS
Do you have any mail order sales*

YesNo

What is the total percentage of sales through mail order?*

What total percentage is out-of-state?*

How is the prescription sent to your pharmacy?*

E-mailMailFaxother

If other, please explain:

How is the customer and/or physician directed to your pharmacy?*

Does your pharmacy participate in any form of Internet Sales of Controlled Substances?*

YesNo

Is your pharmacy VIPPS certified?*

YesNo

What is the percentage of sales through the internet?*

How is the prescription sent to your pharmacy?*

E-mailMailFaxOther

If other, please explain:

How is the customer and/or physician directed to your pharmacy?*

Please list your website address and/or internet site that your pharmacy is associated with:

LICENSING AND REGULATIONS
What was the date of your last state inspection?

MonthDayYear
Date

Please upload a copy of your last state inspection

Cancelof

If you cannot upload a copy of the last state inspection, please explain:

What was the date of your last federal inspection?

MonthDayYear
Date

Upload a copy of the last federal inspection

Cancelof

If you cannot attach a copy of the last federal inspection, please explain:

Has there been any disciplinary action taken against the pharmacy or a member of the staff?*

YesNo

Please explain disciplinary action(s) taken against the pharmacy or a member of the staff:*

Has your federal controlled substance registration ever been revoked, suspended, restricted, or denied?*

YesNo

Explain why your federal controlled substance registration has been revoked suspended, restricted or denied:*

Has your state professional license or controlled substance registration ever been revoked, suspended, denied, restricted or placed on probation?*

YesNo

Please explain why your state professional license or controlled substance registration ever been revoked, suspended, denied, restricted or placed on probation:*

Do you dispense controlled substances into multiple states?*

YesNo
Select ALL state(s) where you dispense Controlled Substances, except your domicile state, and provide your license number(s):*
Please upload a copy of your State Control Substance License(s)

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Are you following all controlled substance rules and regulations within the states you serve, including all reporting requirements?*

YesNo

Additional Comments:

Signature (Full Name)*

Clear

Title of Signer*

Date*

MonthDayYear
Date

Controlled Substances Questionnaire

DISTRIBUTOR
GENERAL
Briefly describe the nature of your business:*

Provide copies of public relations materials (i.e. brochures, catalogs, pamphlets)*

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Name of Registrant*

First NameLast Name

Will you submit orders for controlled substances using CSOS?*

YesNo

Other than the registrant, will other staff member(s) in the facility be authorized to sign a DEA 222 Form?*

YesNo

Other than the registrant, identify the specific staff member(s) in the facility that are authorized to sign a DEA 222 Form:

	First Name	Last Name	Title
Authorized Signer
Authorized Signer
Authorized Signer

Provide the date on which your company began controlled substance distribution activities:*

MonthDayYear
Date

Do you sell controlled substances or other pharmaceuticals to any customers who distribute or dispense over the internet?*

YesNo

Are any of your customers internet-based pharmacies?*

YesNo

What product categories do you anticipate purchasing from IPD?*

	Select Product
Non Controls
CII
CIII-V

Provide the mix of your primary customer categories (to total 100%)*

	Percentage
Distributors
Retail Pharmacies
Physicians
Hospitals
Urgent Care Centers
Wellness Centers
Pain Clinics
Other

Define customer types in "other" category:

List any fines, license suspensions or other actions relating to controlled substances in the past 5 years.*

Upload relevant documents pertaining to: any fines, license suspensions or other actions relating to controlled substances in the past 5 years

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Has your firm been cited for any violations?*

YesNo

If Yes, please provide an explanation why your firm has been cited for any violations: *

Upload relevant documentation

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Do you have a specific individual who manages compliance with controlled substance recordkeeping, security and other DEA regulations?*

YesNo

Name of individual who manages compliance with controlled substance recordkeeping, security and other DEA regulations*

First NameLast Name

Phone Number of individual who manages compliance with controlled substance recordkeeping, security and other DEA regulations*
Please enter a valid phone number.

Email of individual who manages compliance with controlled substance recordkeeping; security and other DEA regulations*
example@example.com

Do you have a system in place to monitor large or questionable controlled substance purchases from your downstream customers*

YesNo

Describe your Suspicious Order Monitoring (SOM) system:*

Upload SOM written protocol:*

Cancelof

Provide a brief overview of your due diligence program pertaining to new customer accounts for those customers that purchase controlled substances.*

Upload a copy of the form*

Cancelof

Provide an updated copy of your Controlled Substance Policies and Procedures*

Cancelof

Provide the last 12 months of ARCOS data submissions in Excel format*

Cancelof

Have you had any controlled substance thefts during the past 24 months?*

YesNo

If yes, how many?*

Explain the controlled substance thefts during the past 24 months?*

Was the U.S. DEA notified?*

YesNo
If Yes, what office?

What database or verification method do you utilize to ensure that customer DEA registration numbers are not expired and current at the specific address to which you ship controlled substances?*

Do you periodically obtain an updated copy of the customer's DEA registration certificate?*

YesNo

Security System
List the name of the security company which provides central station alarm monitoring service and maintenance. *

List the address of the security company which provides central station alarm monitoring service and maintenance. *

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number of the security company which provides central station alarm monitoring service and maintenance *
Please enter a valid phone number.

Does the facility have a Card Access Control System?*

YesNo

Does the facility have a CCTV Surveillance of sensitive areas including those where controlled substances are received, stored and processed for distribution?*

YesNo

Does the facility have an On-site guard force?*

YesNo

Where are controlled substances stored?*

CageSafesWalk-in Vault

Provide the approximate size of your facility in sq.ft*

Provide the number of employees*

Do you have a facility security manager?*

YesNo

Facility Security Manager Name*

First NameLast Name

Facility Security Manager Phone*
Please enter a valid phone number.

Facility Security Manager Email*
example@example.com

Signature (Full Name)*

Clear

Date*

MonthDayYear
Date

Title of Signer*

Pharmacy Customer Affidavit
Legal Business Name*

Legal Business Address*

Street Address

Street Address Line 2

CityState

Zip Code

Pharmacist In Charge*

First NameLast Name

This is to affirm that the above-named pharmacy and the pharmacist and pharmacy technicians employed by the pharmacy understand the obligation to exercise "corresponding responsibility" when dispensing prescriptions for controlled substances. Specifically, the pharmacy represents that it will only dispense prescriptions for controlled substances in situations where the prescriptions were written for a legitimate medical purpose by a practitioner acting within the scope of their professional practice. The pharmacy further represents that it is aware of common "red flags" associated with prescriptions for controlled substances, that the pharmacy has policies and procedures for detecting and resolving red flags, and that pharmacist have unfettered authority to refuse to fill any controlled substance prescription, if the pharmacist cannot resolve a red flag or otherwise believes that the prescription is not legitimate.
This the Date* .

Signature (Full Name)*

Clear

Signer's Name*

First NameLast Name

Signer's Title*

CONTROLLED SUBSTANCE QUESTIONNAIRE

MEDICAL FACILITY
GENERAL INFORMATION
Number of Employees*

Has your facility been open LESS THAN 90-days?*

YesNo

Number of Years in Business*

Additional Practices Owned:*

Please estimate the number of patients that live outside a 10 mile radius of your facility:*

Please check how controlled substances will be utilized. List the percentages for each. Percentages must equal 100%*

	Check if control substances are utilized	Enter the percentage
Dispensing by Physician (Prescriptions)
Consumption During Procedure
Other
Total

If other, please explain

Are patients given physical exams when determining need for controlled substances?*

YesNo

What pain scale is used to determine patients need for controlled substance?*

ON-SITE INSPECTION INFORMATION
On-site Inspection Contact Name:*

First NameLast Name

On-site Inspection Contact Phone:*
Please enter a valid phone number.

CONTROLLED SUBSTANCES
Select the schedule(s) that you will be purchasing*

CIICIIICIVCV

What percentage of controls are paid for on a Cash & Carry basis? (Include only prescriptions paid in cash, please do not include co-pays)*

If greater than 20% are paid for on a Cash & Carry basis, explain:*

Has your practice ever refused to dispense a prescription to a patient?*

YesNo

Explain why your practice has never refused to dispense a prescription to a customer.*

Do you have a Security System that monitors the controlled substances in your facility?*

YesNo

Describe your Security System:*

Mandatory Dispensing Report (in Excel Format): Software generated 90-day dispensing report for all products dispensed*

Cancelof

How many total scripts do you fill monthly?*

What percentage of these scripts are controlled substances?*

List in descending order the Top 3 physicians writing prescriptions for CONTROLLED SUBSTANCES that your facility is dispensing:*

	First Name	Last Name	DEA Number
Physician
Physician
Physician

If you cannot provide 3 providers, please explain:

Name of Registrant*

First NameLast Name

Will you purchase controlled substances through CSOS?*

YesNo

Other than the registrant, will other staff member(s) in the facility be authorized to sign a DEA 222 Form?*

YesNo

DEA 222 Authorized Signers (other than Registrant):

	First Name	Last Name	Title	License Number
Authorized Signer
Authorized Signer

Who is your Primary Wholesaler?*

If other, please specify:*

Who are your Secondary Wholesalers? Do you purchase controls from them?*

	Wholesaler Name	Purchase Non-Controls	Purchase Controls
Wholesaler 1
Wholesaler 2
Wholesaler 3

Has another vendor ever terminated your ability to purchase controlled substances?*

YesNo

If yes, explain:*

MAIL AND INTERNET ORDERS
Do you have any mail order sales?*

YesNo

What is the total percentage of sales through mail order?*

What total percentage is out-of-state?*

How is the prescription sent to your practice?*

EmailMailFaxOther

If other, please explain:

How is the patient directed to your practice?*

Does your practice participate in any form of Internet Sales of Controlled Substances?*

YesNo

Is your practice VIPPS certified?*

YesNo

What is the percentage of sales through the internet?*

How is the prescription sent to your practice?*

EmailFaxMailOther

If other, please explain:

How is the patient directed to your practice?*

Please list your website address and/or internet site that your practice is associated with:

LICENSING AND REGULATIONS
What was the date of your last state inspection?

MonthDayYear
Date

Please upload a copy of your last state inspection:

Cancelof

If you cannot upload a copy of the last state inspection, please explain:

What was the date of your last federal inspection?

MonthDayYear
Date

Please upload a copy of the last federal inspection:

Cancelof

If you cannot upload a copy of the last federal inspection, please explain:

Has there been any disciplinary action taken against the practice of a member of the staff?*

YesNo

Please explain disciplinary action(s) taken against the practice or a member of the staff:*

Has your federal controlled substance registration ever been revoked, suspended, restricted, or denied?*

YesNo

Please explain why your federal controlled substance registration has been revoked, suspended, restricted or denied:*

Has your state professional license or controlled substance registration every been revoked, suspended, denied, restricted or placed on probation?*

YesNo

Please explain why your state professional license or controlled substance registration has ever been revoked, suspended, denied, restricted or placed on probation:*

Are you following all controlled substance rules and regulations within the state(s) you serve, including all reporting requirements?*

YesNo

Additional Comments:

Signature (Full Name)*

Clear

Signer's Title*

Date*

MonthDayYear
Date

DEA Power of Attorney
Name of Registrant*

First NameLast Name

Address of Registrant*

Street Address

Street Address Line 2

CityState

Zip Code

DEA Registration Number*

I, First Name Last Name (name of person granting power), the undersigned, who am authorized to sign the current application for registration of the above0named registrant under the Controlled Substances Act of Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint First Name Last Name (name of attorney-in-fact), my true and lawful attorney for me in my name, place, and stead, to execute applications for Forms 222 and to sign orders for Schedule I and II controlled substances, whether these orders be on Form 222 or electronic, in accordance with 21 U.S.C. 828 and Part 1305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney must lawfully do or cause to be done by virtue hereof.
Signature of Person Granting Power

Clear

I, First Name Last Name (name of attorney-in-fact), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.
Signature of Attorney-In-Fact

Clear

Witnesses
Signature of Witness

Clear

Signature of Witness

Clear

Signed and Dated on: (current date)

MonthDayYear
Date

Notice of Revocation

To be completed only when Power of Attorney is revoked
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or the Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact Date this same day.
Signature of Person Revoking Power

Clear

Witnesses
Signature of Witness

Clear

Signature of Witness

Clear

Signed and dated on: (current date)

MonthDayYear
Date

Credit Application
Select Payment Option*

Credit/ACHPrepayMail Check
Mail checks to:

Independent Pharmacy Distributor

P.O. Box 896827

Charlotte, NC 28289-6827

*Checks received after the 10th of each month will be considered late*
To finalize setup:

Credit Card/ACH Authorization forms must be completed.
Select the link on the Thank You Page

Legal Business Name*
Doing Business As:

Ownership Type:*

Class of Trade*

PharmacyWholesalerOther

Federal Tax ID*

DEA Registration Number*

State License Number*

Accounts Payable Contact *

First NameLast Name

Accounts Payable Contact Phone Number*
Please enter a valid phone number.

Accounts Payable Contact Email*
example@example.com

Trade Reference:

Trade Reference Account Number:

Select Credit Limit
If other, enter requested Credit Limit*

The undersigned entity ("Company"), in consideration of the credit being extended to Company both now and in the future (the "Obligations") as described in this Credit Application & Agreement (this "Agreement"), hereby pledges, assigns, transfers, delivers and grants INDEPENDENT PHARMACY DISTRIBUTOR, LLC ("IPD") a security interest in, a lein upon, and a right of set off and/or recoupment against, any and all of its existing and future right, title and interest in Company's accounts receivable, proceeds thereof, and all other real and person property of the Company. Company agrees to execute any documents required by IPD to provide for such security interest, including but not limited to a separate financing statement or security agreement in the form acceptable to IPD. This security interest is granted to IPD to secure the payment of the Obligations as well as any default interest, attorneys' fees and cost as set forth herein as well as any other indebtedness Company owes IPD as well as any future advances of credit including all renewals, extensions, and modifications of this Agreement. All invoices from IPD shall be paid by Company by the 10th day of the following month. Statements not timely paid shall accrue interest at the rate of one and one-half percent (1.5%) per month. In addition, the Company agrees to pay attorneys' fees actually incurred, court costs, and/or collection agency fees in the event that IPD hires an attorney or collection agency to collect any amounts past due. In consideration of credit being extended to Company by IPD, the receipt and sufficiency of which is hereby acknowledged, and to induce IPD to extend the credit herein, each individual below (each, a "Guarantor" and collectively "Guarantors"), jointly and severally, personally guaranties the full, prompt and complete payment and performance of Company under this Agreement. If IPD elects to enforce its rights against less than all Guarantors, that election shall not release any Guarantor from his or her obligations under this Agreement. The compromise or release of any of the obligations of any of the other Guarantors or Company shall not serve to waive, alter, or release any Guarantor's obligation under this Agreement. Each Guarantor agrees that this guaranty is an absolute, complete and continuing guaranty of performance and payment, and not of collection. Thus, IPD may insist that any or all of the Guarantors pay immediately, and IPD is not required to attempt to collect first from Company or any other party liable for the obligations under this Agreement. Each Guarantor waives presentation for payment, notice of non-payment, protest and notice of protest, demand for payments and diligence in bringing suit against any party hereto. No notice of indebtedness or of any extension of credit by IPD to Company needs to be given. The terms of credit may be rearranged, extended and/or renewed without notice to any of the Guarantors. Each Guarantor represents, with Company, that all of the information submitted is true, complete and accurate. Each Guarantor agrees that should any payments to IPD relating to this Agreement, in whole or in part, be invalidated, declared to be fradulent or preferential, set aside and/or required to be repaid to a trustee, receiver or any other party under any bankruptcy act or code, state, or federal law, common law or equitable doctrine, this guaranty shall remain in full force and effect (or be reinstated, as the case may be) until payment in full of any such amounts, which payment shall be due on demand. This guaranty, as well as all other provisions of this Agreement, shall be governed by North Carolina law. Each Guarantor agrees that any legal action of proceeding against him or her with respect to any of his of her obligations under this Agreement or guaranty must be brought exclusively in District or Superior Court in Davidson County, North Carolina. By the execution and delivery of this guaranty, each Guarantor submits to and accepts the jurisdiction of those courts. Each Guarantor waives any claim that Davidson County is not a convenient forum or the proper venue for any such suit, action or proceeding. COMPANY AND EACH GUARANTOR HEREBY MUTUALLY, VOLUNTARILY, IRREVOCABLY AND UNCONDITIONALLY WAIVE FOR THE BENEFIT OF THE OTHER ANY RIGHT TO HAVE A JURY PARTICIPATE IN RESOLVING ANY DISPUTE, WHETHER SOUNDING IN CONTRACT, TORT, OR OTHERWISE, IN ANY WAY RELATED TO THIS AGREEMENT. THE TRANSACTIONS RELATED THERETO OR THE RELATIONSHIP ESTABLISHED THEREBY. THIS PROVISION IS A MATERIAL INDUCEMENT TO INDEPENDENT PHARMACY DISTRIBUTOR LLC TO ENTER INTO THIS TRANSACTION.

Name of Owner*

First NameLast Name

Driver's License Number*

Please upload a copy of Owner's Drivers License*

Cancelof

Home Address of Owner*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number of Owner*
Please enter a valid phone number.

Signature of Owner (Full Name)*

Clear

Date*

MonthDayYear
Date

Math Challenge*
Should be Empty:

IPD Customer Setup Form

GENERAL INFORMATION

Accounting

CONTROLLED SUBSTANCE QUESTIONNAIRE

GENERAL INFORMATION

ON-SITE INSPECTION INFORMATION

CONTROLLED SUBSTANCES

MAIL AND INTERNET ORDERS

LICENSING AND REGULATIONS

Controlled Substances Questionnaire

GENERAL

Security System

Pharmacy Customer Affidavit

CONTROLLED SUBSTANCE QUESTIONNAIRE

GENERAL INFORMATION

ON-SITE INSPECTION INFORMATION

CONTROLLED SUBSTANCES

MAIL AND INTERNET ORDERS

LICENSING AND REGULATIONS

DEA Power of Attorney

Witnesses

Notice of Revocation

Witnesses

Credit Application