New Customer Application

"*" indicates required fields

Has an OurPharma Account Manager been assigned?*

Yes

OurPharma Account Manager*

Facility Information

Facility Name*

Primary Pharmacy GPO Affiliation*

GPO Name*

Is this facility a member of an IDN?*

Yes

Is this facility affiliated with a Health System?*

Yes

IDN*

Health System Affiliation*

Does your facility plan on purchasing the EnduraKT formulation?*

Yes

Select all days of the week that your facility can receive product deliveries*

Tuesday

Wednesday

Thursday

Friday

Is this facility part of a medical group? (Doctor/Medical/Dentist practice)*

Yes

For hospital customers, please select “No”

Are there multiple site addresses associated with this application?

Yes

If so, an OurPharma Customer Service Representative will reach out to collect the additional address information.

This field is hidden when viewing the form

Has your facility purchased the EnduraKT formulation in the past?*

Yes

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

Facility Phone Number*

Facility Fax Number

Facility Email Address

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.

Provider in Charge License Number*

Please enter the Provider in Charge License Number

Provider in Charge License Upload*

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

Please upload a copy of your current Provider in Charge License

Facility License Number (if applicable)

Please enter the Facility License Number

Facility License Upload (if applicable)

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

Please upload a copy of your current Facility License

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 Email*

Purchasing Agent/Buyer Phone Number/Ext*

Authorized CSOS Signer (Purchasing Agent/Buyer)*

Yes

Purchasing Agent/Buyer Reports (sent via email)

Monthly Usage Report

Shipment Notifications

Director of Pharmacy or Medical Provider-in-Charge*

First Last

Director of Pharmacy or Medical Provider-in-Charge Email*

Authorized CSOS Signer (Director of Pharmacy or Medical Provider-in-Charge)*

Yes

Director of Pharmacy or Medical Provider-in-Charge Reports (sent via email)

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)

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)

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)

Monthly Usage Report

Shipment Notifications

Invoicing

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)

FedEx Account Number

Please enter your FedEx account number here.

UPS Account Number

Please enter your UPS account number here.

Please upload any addition files as needed.

Drop files here or

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