Become a Provider

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.

I certify that the email address above is the provider’s personal, secure email address and is not accessible by other parties.

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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?*

Patients will pay for all of their own medications.Our organization will pay for all medications.Billing will vary and we will document on every prescription who is paying.

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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.

I certify that I will adhere to the above dispensing, disposal, and billing requirements and all applicable federal and state laws.

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How will medication hand-off be handled?*

Please deliver all medications to our organization.Please ship all medications to our organization.Patient choice: Pharmacy will contact patient to determine if patient wants pick-up, delivery, or shipping.We will document special instructions on the hardcopy.

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Questions/Requests

Do you have a specific question or request?

A patient specific order formSet up an accountCustomized intake formConsultation with pharmacist

Other:

Accuracy Confirmation

Your Name *

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Your Email Address *

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I affirm that the information provided above is complete and correct to the best of my knowledge and understanding. I am aware that any false or misleading information may result in administrative, civil, or criminal consequences.

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Become a Partner

Organization Information

Provider Information

Additional Email Addresses

Operations Information

Questions/Requests

Accuracy Confirmation

Thank You!