Medical Authorization

Medical Director Authorization

 

 

Please Print or Type:

 

Facility Name:________________________________________________________________ Account #__________________________

 

Contact Name:__________________________________________ E-mail address:___________________________________________

 

Company Shipping Address: ______________________________________________________________________________________

 

City: ___________________________________ State: _____________ Zip: ______________ Telephone: ________________________
Does customer have multiple shipping addresses?
*If there is more than one shipping address, please
include an attachment with additional addresses.

 

___________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

PHYSICIAN LICENSE INFORMATION

 

I, the undersigned, am the Medical Director  for the above-named facility at the above-specified shipping address. In this capacity, I hereby authorize the facility to authorize the below-indicated category(ies) of products and submit the following referenced license(s) with respect to such orders, with a copy of such license(s) attached to this form.

 

I wish to order Prescription Drugs and/or Medical Devices. License authorizing these items is as follows:

 

Physician’s License or State Board of Pharmacy License #_______________________ Expiration Date: ____________________

 

I hereby swear under penalty of perjury that (i) I am the (check one): Medical Director Pharmacist-in-Charge with responsibility for the facility identified above in Part A with respect to the specified address; (ii) that the license information provided is current and accurate and I am, therefore, licensed to authorize shipment of the substances indicated on this form to the facility designated.

 

Signature: _____________________________________________ Date: _________________

 

Print Name: ____________________________________________ Print Title: _______________________________________________

 

 

 

Address _____________________________________________________________________

 

 

 

Phone: ____________________________  Email: ____________________________________

 

Note:
This Authorization is only valid if accompanied by a copy of the license specified above. This Authorization will expire at the time of the expiration of the above-specified license (as applicable to the product ordered). Upon expiration, a new Authorization must be submitted for orders to be processed. If there is a change in Medical Director, this Authorization will immediately become invalid and a new Authorization, including applicable license(s), must be submitted for orders to be processed.