Become a Partner

Organization Information

Organization/Clinic Name *
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Address *
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City *
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State/Province *
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Zip Code *
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Provider Information

First Name *
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Last Name *
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What type of Provider are you? *
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NPI *
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Provider's Personal Email Address *
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Important: Our provider portal is a regulated e-prescribing system. Eden Pharmacy is required to use the provider’s personal email address, accessible only by the provider, to complete enrollment. Once the account is established, the provider can add authorized users for support.
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Business Phone Number *
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Contact Phone Number (if different than Business Number)
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Additional Email Addresses

Email Address for Account Notifications (if different than Provider Email above)
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Email Address for Shipment Notifications (if different than Provider Email above)
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Operations Information

How will billing be handled?*
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Important: Compounded medications paid for by the provider or organization must be administered or dispensed only to the individual patient for whom they are prescribed. Any unused portion remaining in the container that is not intended to be sent home with the patient must be properly discarded.

Organizations paying for medications must not mark up or otherwise up-charge for drugs, and must comply with all applicable federal and state laws and regulations governing the billing and charging of medications.
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How will medication hand-off be handled?*
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Questions/Requests

Do you have a specific question or request?
Other:

Accuracy Confirmation

Your Name *
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Your Email Address *
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Thank You!

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