Practice Demographics

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Practice Name:

Practice Owner Name:

Practice Physical Address:

City:

State:

Zip:

Phone:	Fax:
Practice Type:	Practice DEA # (if applicable):

For 503B, Days and Hours for Delivery:

Practitioner Demographics

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Practice Name:

Practitioner Name: Degree/Title: State License Number: State CS License/Registration Number (if applicable): DEA Registration Number: NPI Number: Practitioner Email:

Belmar Pharma Solutions (BPS) is committed to continuous compliance within state and federal laws. To ensure that all orders received are written for a legitimate medical purpose within the usual scope and practice of the practitioner within a valid patient-practitioner relationship, BPS requires that the prescribing practitioner agrees that the following standards are met before sending in an order:

1) A documented patient evaluation, which includes history and physical exam, to establish diagnosis for any prescribed drug.
2) Adequate and sufficient dialogue between the prescribing practitioner and patient about the options, benefits, and risks associated with the treatment.
3) Current and complete medical records are maintained by the practitioner.
4) Only medications from 503B outsourcing facilities may be used, or stocked, for office use.
5) Compounded medications will not be relabeled or resold by your clinic.

By signing this form, you agree that all orders sent to the Belmar Pharma Solutions organization have met the standards above and you are in full compliance with state and federal laws regarding a valid patient-practitioner relationship.

Authorized Agents & LifeFile User Profiles

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LifeFile is the cloud-based, Protected Health Information (PHI) compliant, prescription software used by Belmar Pharma Solutions. There is an ordering portal for the 503B outsourcing facility for office use ordering.

Online Ordering

Practitioner Name:

DEA #:

Practice Name:

Address:

City:	State:	Zip:
Practitioner Email:	Phone:

Authorized Agents

Each listed agent will need a unique email address to receive their personal login information.

Agent 1 Name: Title: Email:  Full Privileges: Authorized to submit Rx/orders as allowed under law; select corresponding attestation statements based off of my medical directives; view Rx/orders status and tracking.  Limited Privileges: View only Rx/orders status and tracking.

 

Agent 2 Name: Title: Email:  Full Privileges: Authorized to submit Rx/orders as allowed under law; select corresponding attestation statements based off of my medical directives; view Rx/orders status and tracking.  Limited Privileges: View only Rx/orders status and tracking.

 

Agent 3 Name: Title: Email:  Full Privileges: Authorized to submit Rx/orders as allowed under law; select corresponding attestation statements based off of my medical directives; view Rx/orders status and tracking.  Limited Privileges: View only Rx/orders status and tracking.

*If no privilege option is selected, agent will be set up with view only access.

Please be sure to notify Belmar Pharma Solutions of any DEA registration, address, or staff access changes. Belmar Pharma Solutions is not liable if you fail to notify us, as these changes may compromise the integrity of your practice's patient information, and/or your personal licensing/registration. You can do this by emailing welcome@belmarpharma.com

I, (print name) the Practitioner, am granting access to the above individuals (Authorized Agents) to the privileges selected.

Annual CS Ordering Estimates

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503B Outsourcing Facility: Belmar Select Outsourcing

If you do not intend to order office-use testosterone pellets or testosterone cypionate blends, please check the box below and continue to the next section.

Ordering for Office Use
Belmar Select Outsourcing (BSO) is Belmar Pharma Solutions' 503B outsourcing facility that ships compound manufactured medications directly to your office for office use only. Please note: BSO medications and supplies must ship to the address on the practitioner's/account holder's DEA registration.

Anticipated Ordering
The DEA requires that we track controlled substance ordering trends. To meet compliance requirements, please list the quantity of each dosage form you plan on ordering on an annual basis.

Annual Quantity of Testosterone Pellets (any dose):

Annual Quantity of Testosterone Cypionate Liquid Vials (any dose):

Practitioner Name (DEA Registration Holder):

DEA #:

Practitioner Acknowledgment

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If you are NOT an MD or DO, you must complete this section.

Practitioner Name:

Title:

Do you have a collaborative or practice agreement?
Please select the option below that applies to you.

NO I am not required to have a collaborative or practice agreement because I have completed the necessary requirements as determined by my state of licensure, and/or have independent authority. I am permitted under state and federal law to: Procure controlled and non-controlled medications. (503B Outsourcing Facility – Office use medications shipped to office.)  Yes  No  N/A Please list the states in which you hold licensure and have Independent Authority:

YES I am required to have a collaborative or practice agreement with a supervising/collaborating practitioner or with my site of practice, and am compliant with practitioner laws in my state. My existing agreement permits me to: Procure controlled and non-controlled medications. (503B Outsourcing Facility – Office use medications shipped to office.)  Yes  No  N/A Please list the states in which you hold licensure and have a Collaborative or Practice Agreement:

Collaborating/Supervising Practitioner's Information

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(Complete only if applicable)

Name:

Professional Designation:

Address (Registered Under State Medical License):

City:	State:	Zip:
Phone:	DEA Registration #:
State Medical License #:	State CS # (if applicable):
NPI #:

Signature & Attestation

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By signing below, I certify that all information provided in this application is accurate and complete, that I am in full compliance with state and federal laws regarding a valid patient-practitioner relationship, and that I authorize the individuals listed as Authorized Agents to access the LifeFile privileges selected above.

Practitioner Name:

Degree/Title:

Date:

Please provide current and valid copies of your Medical License for each state and/or country.