New Medical Practice: Account Information

PRESCRIBER AGREEMENT

OFFICE ADMINISTRATION OF COMPOUNDED PREPARATIONS AND DESIGNATING E-PRESCRIBING AGENTS
A SEPARATE FORM MUST BE COMPLETED FOR EACH PRESCRIBER
Date: {todaysDate}

This agreement indicates that Innovation Compounding LLC, located in Kennesaw, GA 30152, hereafter known as "Pharmacy," will provide compounded preparations for administration to patients in the medical office, hereafter known as "Practice," either by the Physician personally or by an authorized person under the Physician's direct and immediate supervision, hereafter known as "Physician" at the address:
Practice Name *
Physician Name *

First Name Last Name Prescribing Credentials
Physician Email *
Required for Agent Authorization
Supervising Physician (if applicable)

First Name Last Name
Physician Telephone *
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address
Street Name, Suite, City, State & Zip Code (US only)

PART I:
OFFICE ADMINISTRATION OF COMPOUNDED PREPARATIONS

PHYSICIAN REQUIREMENTS

1.) These compounded preparations may only be administered to the patient for which the medication was prescribed, and may not be sold to any other.) 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.

2.) Physician is licensed in the same state as Practice.

3.) Physician is actively monitoring the care of patients, either through direct patient-care or oversight of appropriately trained personnel.

4.) If Physician terminates relationship with Practice, Physician will immediately notify Pharmacy the date of termination.

PHARMACY REQUIREMENTS

The 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 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.

PART II:
DESIGNATING AGENTS TO COMMUNICATE PRESCRIPTION DRUG ORDERS

TERMS OF USE

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.

Prescriber’s Authorizing Agent Information

Authorized Agent: JOI Partners, LLC, DBA The JOI Group

Title: Management Services Organization (MSO)

Agent's Email Address: rxharmony@thejoigroup.com
ADDITIONAL AUTHORIZED AGENTS (Optional)

Full Legal Name: First name Last name
Title:
Agent Email Address:
This cannot be a shared email. Must be unique email for authorized agent.

PART III:

REQUIRED SIGNATURE BY A LICENSED PRACTITIONER

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. I also agree that this agent authority agreement may be electronically signed only by a licensed prescriber who is in good standing with their overseeing state and federal agencies. I agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. Specifically, any false or misleading e-signatures will carry the same level of criminal prosecution as forgery using handwritten signatures.

AGREED UPON BY:
Physician Name *
Enter First and Last Name
DEA # *
9-digit alpha numeric number
NPI # *
10-digit number
State License # *
Physician Signature *

Clear
Shawn Hodges, PharmD (for Pharmacy)
1. An individual practitioner means a physician, dentist, veterinarian, or other individual licensed, registered, or otherwise permitted, by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice, but does not include a pharmacist, a pharmacy, or an institutional practitioner. A mid-level practitioner means an individual practitioner, other than an individual practitioner, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Mid-level practitioners are authorized to dispense controlled substances by the State in which they practice. 21 U.S.C. §1300.012. The CSA definition that an agent is "an authorized person who acts on behalf of or at the direction of" the prescribing individual practitioner. 21 U.S.C. 802(3).
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PRESCRIBER AGREEMENT