New Customer Application

"*" indicates required fields

Has an OurPharma Account Manager been assigned?*

Yes

OurPharma Account Manager*

Facility Information

Company Name*

Primary Pharmacy GPO Affiliation*

GPO Name*

Is this company a member of an IDN?*

Yes

Is this company affiliated with a Health System?*

Yes

IDN*

Health System Affiliation*

Shipping Address (must match DEA license if purchasing controlled substances)*

Street Address Address Line 2 City State ZIP Code

Billing Address*

Same as Shipping Address

Street Address Address Line 2 City State ZIP Code

Company Phone Number*

Fax Number

Company Email Address

Company Website

Does your facility have a DEA number?*

Yes

Does your facility have a State Pharmacy License Number?*

Yes

Does your facility have a State Controlled Substance Registration Number (CDS, CSR, BNDD)?*

Yes

Required for the following states: IA, IL, IN, LA, MD, MI, MS, MO, NJ, NM, NC, OK, OR, SC

Does your facility intend to use CSOS?*

Yes

No (There is a $100 processing fee for paper 222 submissions)

N/A - We do not intend to order DEA Schedule II products

DEA Number*

Please enter the DEA Number

DEA Registration Upload*

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Please upload a copy of your current DEA Registration.

State Pharmacy License Number*

Please enter the State Pharmacy License Number

State Pharmacy License Upload*

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Please upload a copy of your current State Pharmacy License.

State Controlled Substance Registration Number (CDS, CSR, BNDD)*

Please enter the State Controlled Substance Registration Number

State Controlled Substance Registration Upload*

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Please upload a copy of your current State Controlled Substance Registration.

Contact Information

Shipment Notification Email Group or Distribution List Address

It is recommended that a group inbox or distribution list be provided by your organization for shipment notifications.

Recall Notification Email Group or Distribution List Address

It is recommended that a group inbox or distribution list be provided by your organization for recall notifications.

Purchasing Agent/Buyer Name*

First Last

Purchasing Agent/Buyer Phone Number/Ext*

Authorized CSOS Signer (Purchasing Agent/Buyer)*

Yes

Purchasing Agent/Buyer Email*

Purchasing Agent/Buyer Reports (sent via email)

QA Report

Monthly Usage Report

Shipment Notifications

Director of Pharmacy*

First Last

Director of Pharmacy Phone Number/Ext*

Authorized CSOS Signer (Director of Pharmacy)*

Yes

Director of Pharmacy Email*

Director of Pharmacy Reports (sent via email)

QA Report

Monthly Usage Report

Shipment Notifications

Would you like to add additional contacts?

Yes

Additional Pharmacy Contact 1 Name

First Last Title

Additional Pharmacy Contact 1 Number/Ext

Authorized CSOS Signer (Additional Pharmacy Contact 1)

Yes

Additional Pharmacy Contact 1 Email

Additional Pharmacy Contact 1 Reports (sent via email)

QA Report

Monthly Usage Report

Shipment Notifications

Additional Pharmacy Contact 2 Name

First Last Title

Additional Pharmacy Contact 2 Number/Ext

Authorized CSOS Signer (Additional Pharmacy Contact 2)

Yes

Additional Pharmacy Contact 2 Email

Additional Pharmacy Contact 2 Reports (sent via email)

QA Report

Monthly Usage Report

Shipment Notifications

Additional Pharmacy Contact 3 Name

First Last Title

Additional Pharmacy Contact 3 Number/Ext

Authorized CSOS Signer (Additional Pharmacy Contact 3)

Yes

Additional Pharmacy Contact 3 Email

Additional Pharmacy Contact 3 Reports (sent via email)

QA Report

Monthly Usage Report

Shipment Notifications

Invoicing

Pharmacy Billing Contact Name and Title

Pharmacy Billing Contact Phone

Pharmacy Billing Contact Email*

Accounts Payable Contact Name and Title

Accounts Payable Contact Phone

Accounts Payable Contact Email*

Email Address For Invoice Receipt*

Additional Information Needed for Billing

All invoices will be sent via email unless otherwise specified here

Purchase Order Submission & Correspondence

Primary option: Online Portal via GraphiteRx e-commerce Platform. Secondary option: via mail that may incur order processing fees

Payment Terms:*

Default (OurPharma Net 15 Payment Terms)

GPO Contract Terms (applies to HealthTrust and Premier accounts)

Other (A representative from OurPharma will contact you to discuss)

TAX EXEMPTION*

Non-Tax Exempt

Tax Exempt (Documentation is required, please upload below)

FREIGHT TERMS*

Pre-Pay (Invoiced)

Collect (Charged to customer's account)

All shipments currently sent via FedEx

FedEx Account Number

Please enter your FedEx account number here.

UPS Account Number

Please enter your UPS account number here. (Note: UPS shipment availability is still in development.)

Please upload any addition files as needed.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.