Upload File

electronic prescription of controlled substance(s) form*name on card: *cardholder’s billing...

  • Home
  • Documents
  • Electronic Prescription of Controlled Substance(s) Form*Name on Card: *Cardholder’s Billing Address: Practice Information *Practice Name: *Practice Address: *Practice City,State,
1
*Name on Card: *Cardholder’s Billing Address: Practice Information *Practice Name: *Practice Address: *Practice City,State, Zip Replacing a lost or damaged token will incur a $50 replacement Non-refundable fee. *Provider’s Signature: *Date: Credit Card Information Email completed form to: [email protected] *First Name: _______________________ Middle Initial __ Last Name: ________________________ *Provider’s Home Address___________________________________________________________________ *Provider’s Personal E-mail: _________________________________________________________________ *Provider’s Individual NPI: ___________________ *Provider’s DEA:____________________________ *Provide a copy of your DEA License By signing below, (1) you are certifying that the above information is accurate and complete and that you have the legal authority and are licensed to prescribe controlled and non-controlled substance(s) in the state where you practice; (2) you consent to Comtron’s use of the above information to verify your identity, your authority to prescribe medication, your licensure in the state you practice and your ability to e-prescribe controlled and non-controlled substance(s)in Medgen EHR, including the right to disclose the information to third parties, if necessary, and (3) you authorize Comtron to charge the credit card below an initial implementation fee of $195 and an annual reoccurring charge of $195 thereafter (4) you agree to retain a copy of any and all security incident reports created by you or Comtron. Any security incident that is discovered must be filed with the DEA and all security incident reports must be retained for a minimum of 2 years. Any security incident reports generated by your practice must also be forwarded to Comtron Corp. (5) you agree to the prohibition in which the DEA prohibits all users from using a hard/soft token that is on the same computer or device they are using to transmit a prescription. **The NPI provided below must match the name provided on this form on the NPI Registry ** If there is a security freeze with Experian, it needs to be unfrozen. as Dr. First verifies identity based on Experian profile The e-mail provided below is where you will receive correspondence in regards to your EPCS enrollment process as well as your invitation from DrFirst EPCS Gold to start the onboarding process. Please fill out all mandatory fields Information with an asterisk* is required (please print) Electronic Prescription of Controlled Substance(s) Request Form *Card #: *Verification Code on back of card: *Expiration Date: **Pre-paid credit cards are not acceptable. ** Note: An Annual Fee of $195.00 (non-refundable) will be charged to the credit card below. This chargeincludes our processing fee as well as fulfills the mandatory requirement for providerverification with Dr. First. Provider Information (Circle One) Visa MasterCard Amex Discover

Upload: others

Post on 23-Jul-2021

2 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: Electronic Prescription of Controlled Substance(s) Form*Name on Card: *Cardholder’s Billing Address: Practice Information *Practice Name: *Practice Address: *Practice City,State,

*Name on Card:

*Cardholder’s Billing Address:

Practice Information*Practice Name:

*Practice Address:

*Practice City,State, Zip

Replacing a lost or damaged token will incur a $50 replacement Non-refundable fee.

*Provider’s Signature: *Date:

Credit Card Information

Email completed form to: [email protected]

*First Name: _______________________ Middle Initial __ Last Name: ________________________

*Provider’s Home Address___________________________________________________________________

*Provider’s Personal E-mail: _________________________________________________________________

*Provider’s Individual NPI: ___________________

*Provider’s DEA:____________________________ *Provide a copy of your DEA License

By signing below, (1) you are certifying that the above information is accurate and complete and that you have the legal authority and are licensed to prescribecontrolled and non-controlled substance(s) in the state where you practice; (2) you consent to Comtron’s use of the above information to verify your identity, yourauthority to prescribe medication, your licensure in the state you practice and your ability to e-prescribe controlled and non-controlled substance(s)in Medgen EHR,including the right to disclose the information to third parties, if necessary, and (3) you authorize Comtron to charge the credit card below an initial implementationfee of $195 and an annual reoccurring charge of $195 thereafter (4) you agree to retain a copy of any and all security incident reports created by you or Comtron.Any security incident that is discovered must be filed with the DEA and all security incident reports must be retained for a minimum of 2 years. Any security incidentreports generated by your practice must also be forwarded to Comtron Corp. (5) you agree to the prohibition in which the DEA prohibits all users from using ahard/soft token that is on the same computer or device they are using to transmit a prescription.

**The NPI provided belowmustmatch the name provided on this form on the NPI Registry** If there is a security freeze with Experian, it needs to be unfrozen. as Dr. First verifies identity based on Experian profileThee-mail provided below is where you will receive correspondence in regards to your EPCS enrollment process as well as yourinvitation from DrFirst EPCS Gold to start the onboarding process.

Please fill out all mandatory fields Information with an asterisk* is required (please print)Electronic Prescription of Controlled Substance(s) Request Form

*Card #:

*Verification Code on back of card:

*Expiration Date:

**Pre-paid credit cards are not acceptable. **Note: An Annual Fee of $195.00 (non-refundable) will be charged to the credit cardbelow. This chargeincludes our processing fee as well as fulfills the mandatoryrequirement for providerverification with Dr. First.

Provider Information

(Circle One) Visa MasterCard Amex Discover

SERVING YOU - Address · cardholder’s individual habits and fraud risk. Falcon uses real-time scoring for maximum fraud-fighting power. The technology analyzes and scores each transaction

International Travel Insurance Purchase Cover Insurance Terms …€¦ · International Travel Insurance Purchase Cover Insurance Terms and Conditions Gold Cardholder’s Policy April

Practice Number Practice Name/ Dr Name Telephone …bazil-vlachos-j5d6.squarespace.com/s/Dentists.pdf · Practice Number Practice Name/ Dr Name Telephone Number Street Address Postal

Practice account application · ALL PRICES phone 0800 0304169 EXCLUDE VAT infohenryscheinmedical.co.uk 423 Practice name Senior partners name GMC number Practice address Postcode

PRACTICE PRACTICE NAME PHYSICAL ADDRESS 1 ......PRACTICE_NAME PHYSICAL ADDRESS 1 SUBURB TOWN PROVINCE PHONE_NUMBER 0005568 Dr ARIVAN MOODLEY C M A Centre Croftdene Chatsworth Kwazulu-Natal

Best practice guide - Address Management 19 September 2014 Issue 1.4

OPTICAL NETWORK LIST GAUTENG20180905081928 AM... · optical network list gauteng practice number practice name address 1 address 2 address 3 address 4 post code tel fax cell email

33 == =TIMMM !#$%&'&()*'+, … · Credit card ( American ... Bank autopay=( !"#$% Authorization form will be sent to you.)!"#$% Cardholder’s signature ... els and invest in wind

UCLA Health FPG Holiday Closures - UCLA …fpg.uclahealth.org/workfiles/documents/FPGHolidays1.pdfUCLA Health FPG Holiday Closures Practice Name Location & Mailing Address Practice

Attention Applicants - AZ Regulatory Board of Physician ......Practice Address: This is the practice/principal place of your business. The address and phone number provided will appear

Retirement villages: good practice to address key issues · Retirement villages: good practice to address key issues consumer.vic.gov.au Page 6 of 29 The residents’ role If a resident

Clear Aligner Laboratory Form v1.pdfPatients name: Date of Birth: Gender: M F Case type: Full Limited Retainer Only Doctors name: Practice name: Practice address: Address Tele Post

NIPEC CONFERENCE FIT FOR LIFE FIT FOR PRACTICE CNO ADDRESS

CODE OF PRACTICE REVIEW - PMCPA · 2 Code of Practice Review November 2017 Our address is: Prescription Medicines Code of Practice Authority 7th Floor, Southside, 105 Victoria Street,

Address Munging - Logansport Savings Bank...e 1 Address Munging: the practice of disguising, or munging, an e-mail address to prevent it being automatically collected and used as a

Practice Number Practice Name/ Dr Name Telephone … Number Practice Name/ Dr Name Telephone Number Street Address Postal Town Province Fax number Email Address 7024487 Dr M C Buchanan

(Facility Name Here) (Physicians Name Here) (Practice Name Here) (Practice Address Here) (Practice Phone Number Here) (Practice Website Here)

Practice Location City State Zip Code Provider Last Name ... · Street Address Line 1 Practice Location Street Address Line 2 City State Zip Code Aaron Carrie 75 Francis St. Boston

· Web viewDeepen their instructional practice by learning to identify and address specific learning needs

Code of Practice to Address - Ontario · This Code of Practice to address Workplace Harassment (“Code of Practice”) is approved . by the Minister of Labour under Part III.1 of

alvasayurveda.comalvasayurveda.com/brochure.pdfTOPIC 'Key Note Address ' 'Key Note Address' Application of 'Charakokta Chatushka' in the Clinical Practice A view on 'Shastrasahith

Executive MBA Application Formhome.intekom.com/gsbuct/emba/downloads/apply.doc  · Web viewCARD HOLDER’S NAME (Please print) Cardholder’s signature . Executive MBA Application

How Physical Therapists Address Obesity in Clinical Practice for Obesity Part II conference.pdfHow Physical Therapists Address Obesity in Clinical Practice Audioconference Susan Scherer,

Educational Design Research: appropriate to address problems in educational practice

Physician Practice (& ASC) Consolidation · Physician Practice (& ASC) Consolidation Henry Bloom President [email protected] ... “The mergers reveal attempts to address market

Where students go for Deep Practice. Application of FIM Features: Assess fluency levels Address fluency needs Assess problem solving Practice problem

THE ANATOMY OF A TRANSACTION - Valued Merchant ......Merchant’s bank pays merchant for cardholder’s purchase Cardholder’s bank bills cardholder A U T H O R I Z AT I O N TIME

Advanced Social Work Practice Behaviors to Address

PRACTICE AND - aptqs.co.za · PRACTICE AND CONTACT DETAILS APT Quantity Surveyors CC CK:2007/180745/23 Practice #F1687 Physical address: 463 Main Road Lakeside 7945 Postal address:

bhcic.co.uk  · Web viewPractice Name. Address. Tel: Fax: Practice Logo. Practice Name. Service Continuity Plan & Risk Assessment. Document Control. A.Confidentiality Notice. This

Sharing information - Bletchley Dental Practice · Web viewDr Renuka Arun (Birm 1998) and Assosciates Practice name and address : Bletchley Dental Practice 295 Whaddon Way Milton

TRUE or FALSE? A debit card is electronically connected to the cardholder’s bank account

OBSERVATIONAL ASSESSMENT: CONNECTING THE DOTS...What is developmentally appropriate practice? NAEYC Guidelines address instructional decisions in five key practice areas: •Creating

Page2 AGC MemberApplication nw2 - Microsoft · Bill credit card for $ Exp CVV (Visa, MC, Discover, AMEX) Credit card # Billing Zip Code Cardholder’s Name Cardholder’s Signature

Practice-Based Education Practice-Based Education · share their practice knowledge, report research into strategies that address these ... interpretation and narrative. ... in practice-based