IPD Setup Form

* = Required Information

Submission Date

Unique ID

Enter IPD Sales Representative ID, if known

Existing Customers, Enter IPD Account Number

Legal Business Name*

Doing Business As

Business Physical Address

Street Address*

Street Address Line 2

City *

State *

Zip Code *

Business Email*

Business Phone Number*

Business Fax Number

Business Owner Name

First Name*

Last Name*

Business Owner Phone*

Business Owner Email*

Hours of Operation*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Open
Close

Customer Type*

Pharmacy

Distributor

Medical Facility

When do you start your daily order process? *

If the answer is Distributor, please answer the following:

NPI *

DEA Registration Number*

State Board License Number (Facility)*

Will you be purchasing Controlled Substances from Independent Pharmacy Distributor? *

Yes

Control Substance License Number*

Accounting

Billing Address is the same as Physical Business Address?*

Yes

If the answer is No, please answer the following:

Bill To Address

Street Address*

Street Address Line 2

City*

State*

Zip Code*

If the answer is Pharmacy, please answer the following:

NPI *

DEA Registration Number*

State Board License Number (Facility)*

Pharmacist In Charge

First Name*

Last Name*

Pharmacist In Charge License Number*

Will you be purchasing Controlled Substances from Independent Pharmacy Distributor? *

Yes

Control Substance License Number*

Accounting

Billing Address is the same as Physical Business Address?*

Yes

If the answer is No, please answer the following:

Bill To Address

Street Address*

Street Address Line 2

City*

State*

Zip Code*

If the answer is Medical Facility, please answer the following:

NPI *

DEA Registration Number *

State Board License Number (Facility) *

Dispensing Physician

First Name*

Last Name*

Dispensing Physician License Number*

Dispensing Physician NPI*

Will you be purchasing Controlled Substances from Independent Pharmacy Distributor? *

Yes

Control Substance License Number*

Accounting

Billing Address is the same as Physical Business Address?*

Yes

If the answer is No, please answer the following:

Bill To Address

Street Address*

Street Address Line 2

City*

State*

Zip Code*

Purchaser Contact*

First Name*

Last Name*

Purchaser Contact Email*

Purchaser Contact Phone*

GENERAL INFORMATION

Number of Employees*

Has your pharmacy been open LESS THAN 90 day?*

Yes

Number of Years in Business*

Additional Practices Owned*

Please estimate the number of patients that live outside a 10 mile radius of your facility *

Please check how controlled substances will be utilized. List the percentages of each. Percentages must equal 100%.

	Check if control substances are utilized	Enter the Percentage
Dispensing by Physician (Prescriptions) *
Consumption During Procedure *
Other *
Total *

If other, please explain

Are patients given physical exams when determining need for controlled substances?*

Yes

What pain scale is used to determine patients need for controlled substances?*

On-site Inspection Contact Name

First Name *

Last Name *

On-site Inspection Contact Phone

Contact Phone *

Select the schedule(s) that you will be purchasing *

CII

CIII

CIV

What percentage of controls are paid for on a Cash & Carry basis?(Include only prescriptions paid in cash,please do not include co-pays) *

If greater than 20% are paid for on a Cash & Carry basis, explain *

Has your practice ever refused to dispense a prescription to a patient? *

Yes

Explain why your practice has never refused to dispense a prescription to a customer *

Do you have a Security System that monitors the controlled substances in your facility? *

Yes

Describe your Security System *

Mandatory Dispensing Report (in Excel Format): Software generated 90-day dispensing report for all products dispensed *

How many total scripts do you fill monthly? *

What percentage of these scripts are controlled substances? *

Physician

First Name

Last Name

DEA Number

Physician

First Name

Last Name

DEA Number

Physician

First Name

Last Name

DEA Number

If you cannot provide 3 providers, please explain

Name of Registrant *

Last Name *

Will you purchase controlled substances through CSOS? *

Yes

Other than the registrant, will other staff member(s) in the facility be authorized to sign a DEA 222 Form? *

Yes

DEA 222 Authorized Signers (other than Registrant)

	First Name	Last Name	Title	License Number
Authorized Signer
Authorized Signer
Authorized Signer

I, (name of person granting power *), the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint (name of attorney-in-fact *), my true and lawful attorney for me in my name, place, and stead, to execute applications for books of official order forms and to sign such order forms in requisition for Schedule I and II controlled substances, in accordance with section 308 of the Controlled Substances Act (21 U.S.C. 828) and part 305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by virtue hereof.

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or the Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact this same day.

Signature of Person Revoking Power

Clear

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Who is your Primary Wholesaler? *

If other, please explain *

Who are your Secondary Wholesalers, do you purchase controls from them?

	Wholesaler Name	Non-Control Purchases	Control Purchases
Wholesaler 1
Wholesaler 2
Wholesaler 3

Has another vendor ever terminated your ability to purchase controlled substances? *

Yes

If yes, explain *

Do you have any mail order sales *

Yes

If the answer is YES, please answer the following: *

What is the total percentage of sales through mail order? *

What total percentage is out-of-state? *

How is the prescription sent to your pharmacy? *

E-Mail

Mail

Fax

Other

Other Prescription *

How is the customer and/or physician directed to your pharmacy? *

Does your pharmacy participate in any form of Internet Sales of Controlled Substances? *

Yes

If the answer is YES, please answer the following: *

Is your pharmacy VIPPS certified?*

Yes

What is the percentage of sales through the internet?*

How is the prescription sent to your pharmacy?*

E-Mail

Mail

Fax

Other

Other Prescription *

How is the customer and/or physician directed to your pharmacy? *

Please list your website address and/or internet site that your pharmacy is associated with

What was the date of your last state inspection?

Please Upload a copy of the last state inspection

If you cannot upload a copy of the last state inspection, please explain

What was the date of your last federal inspection?

Please Upload a copy of the last federal inspection

If you cannot upload a copy of the last federal inspection, please explain

Has there been any disciplinary action taken against the practice or a member of the staff? *

Yes

Please explain disciplinary action(s) taken against the practice or a member of the staff *

Has your federal controlled substance registration ever been revoked, suspended, restricted, or denied? *

Yes

Please explain why your federal controlled substance registration has been revoked, suspended, restricted or denied *

Has your state professional license or controlled substance registration every been revoked, suspended, denied, restricted or placed on probation? *

Yes

Please explain why your state professional license or controlled substance registration has ever been revoked, suspended, denied, restricted or placed on probation *

Select ALL state(s) where you dispense Controlled Substances, except your domicile state, and provide your license number(s)

State

License Number

Control License Number, if applicable

Add more States...

Are you following all controlled substance rules and regulations within the state(s) you serve, including all reporting requirements? *

Yes

Additional Comments

Signature *

Clear

Signer's Title *

Date *

GENERAL INFORMATION--

Number of Employees*

Has your pharmacy been open LESS THAN 90 day?*

Yes

Number of Years in Business*

Additional Pharmacies Owned*

Please Check who you fill scripts for. List the percentages for each. Percentages must equal 100%. *

	Check if you fill scripts for the following	Enter the Percentage Filled (Total must equal 100%)
Doctor's Office
Rehab Center
Hospitals
Diet Clinics
Nursing Homes
Hospice
Pain Clinics
Total

Are you a closed-door pharmacy (no retail business)?*

Yes

What process is used to validate a prescription before it is dispensed to the patient?*

On-site Inspection Contact

First Name*

Last Name*

On-Site Inspection Contact Phone Number*

Select the schedule(s) that you will be purchasing *

CII

CIII

CIV

What percentage of controls are paid for on a Cash & Carry basis? (Include only prescriptions paid in cash, please do not include co-pays)*

If greater than 20% are paid for on a Cash & Carry basis, explain *

Has your pharmacy ever refused to dispense a prescription to a customer?*

Yes

If pharmacy has never refused to dispense a prescription to a customer, explain *

Do you have a Security System that monitors the controlled substances in your facility?*

Yes

Describe your security system *

Dispensing Report in Excel Format: Pharmacy Software generated 90- day dispensing report for all products dispensed

Click here to upload the dispensing report

Note: Account cannot be fully reviewed until dispensing report is submitted

How many total scripts do you fill monthly? *

What percentage of these scripts are controlled substances? *

List in descending order the Top 3 physicians writing prescriptions for CONTROLLED SUBSTANCES that your pharmacy is dispensing *

	First Name	Last Name	DEA Number
Physician
Physician
Physician

Name of Registrant

First Name*

Last Name*

Will you purchase controlled substances through CSOS?*

Yes

Other than the registrant, will other staff member(s) in the facility be authorized to sign a DEA 222 Form?*

Yes

DEA 222 Authorized Signers (other than Registrant)

	First Name	Last Name	Title	License Number
Authorized Signer
Authorized Signer
Authorized Signer

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Who is your Primary Wholesaler? *

If other, please specify *

Who are your Secondary Wholesalers, do you purchase controls from them?

	Wholesaler Name	Non-Control Purchases	Control Purchases
Wholesaler 1
Wholesaler 2
Wholesaler 3

Has another vendor ever terminated your ability to purchase controlled substances? *

Yes

Explain why another vendor has terminated your ability to purchase controlled substances *

What was the date of your last state inspection?

Please Upload a copy of your last state inspection

If you cannot upload a copy of the last state inspection, please explain

What was the date of your last federal inspection?

Please Upload a copy of your last state inspection

If you cannot upload a copy of the last state inspection, please explain

Has there been any disciplinary action taken against the pharmacy or a member of the staff? *

Yes

Please explain disciplinary action(s) taken against the pharmacy or a member of the staff *

Has your federal controlled substance registration ever been revoked, suspended, restricted, or denied? *

Yes

Explain why your federal controlled substance registration has been revoked, suspended, restricted or denied *

Has your state professional license or controlled substance registration ever been revoked, suspended, denied, restricted or placed on probation?*

Yes

Please explain why your state professional license or controlled substance registration ever been revoked, suspended, denied, restricted or placed on probation *

Do you dispense controlled substances into multiple states?*

Yes

Select ALL state(s) where you dispense Controlled Substances, except your domicile state, and provide your license number(s)

State

License Number

Control License Number, if applicable

Add more state...

Are you following all controlled substance rules and regulations within the states you serve, including all reporting requirements? *

Yes

Additional Comments

Signature (Full Name) *

Clear

Date*

Legal Business Name *

Doing Business As

Business Physical Address

Street Address *

Street Address 2

City *

State *

Zip Code *

This is to affirm that the above-named pharmacy and the pharmacist and pharmacy technicians employed by the pharmacy understand the obligation to exercise "corresponding responsibility" when dispensing prescriptions for controlled substances. Specifically, the pharmacy represents that it will only dispense prescriptions for controlled substances in situations where the prescriptions were written for a legitimate medical purpose by a practitioner acting within the scope of their professional practice. The pharmacy further represents that it is aware of common "red flags" associated with prescriptions for controlled substances, that the pharmacy has policies and procedures for detecting and resolving red flags, and that pharmacist have unfettered authority to refuse to fill any controlled substance prescription, if the pharmacist cannot resolve a red flag or otherwise believes that the prescription is not legitimate.

This the date *

Signature (Full Name) *

Clear

Signer's First Name *

Signer's Last Name *

Signer's Title *

GENERAL

Briefly describe the nature of your business *

Provide copies of public relations materials (i.e. brochures, catalogs, pamphlets, etc.) *

Name of Registrant

First Name *

Last Name *

Will you submit orders for controlled substances using CSOS?*

Yes

Other than the registrant, will other staff member(s) in the facility be authorized to sign a DEA 222 Form?

Yes

DEA 222 Authorized Signers (other than Registrant)

	First Name	Last Name	Title	License Number
Authorized Signer 1
Authorized Signer 2
Authorized Signer 3

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Signature of Person Granting Power *

Clear

I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-In-Fact *

Clear

Witnesses

1. Witnesses Signature *

Clear

2.Witnesses Signature *

Clear

To be completed only when Power of Attorney is revoked

Signature of Person Revoking Power

Clear

Select ALL state(s) where you dispense Controlled Substances, except your domicile state, and provide your license number(s)

State

License Number

Control License Number, if applicable

Add more state...

Provide the date on which your company began controlled substance distribution activities*

Do you sell controlled substances or other pharmaceuticals to any customers who distribute or dispense over the internet?*

Yes

Are any of your customers internet-based pharmacies?*

Yes

What product categories do you anticipate purchasing from IPD?*

Non Controls

CII

CIII-V

Make provide the mix of your primary customer categories (to total 100%) *

	Percentage
Distributors
Retail Pharmacies
Physicians
Hospitals
Urgent Care Centers
Wellness Centers Pain
Clinics
Other
Total

List any fines, license suspensions or other actions relating to controlled substances in the past 5 years

Upload relevant documents pertaining to: any fines, license suspensions or other actions relating to controlled substances in the past 5 years

Has your firm been cited for any violations?*

Yes

If Yes, please provide an explanation why your firm has been cited for any violations and upload relevant documentation *

Upload relevant documentation *

Do you have a specific individual who manages compliance with controlled substance recordkeeping, security and other DEA regulations?*

Yes

First Name *

Last Name *

Phone Number of individual who manages compliance with controlled substance recordkeeping, security and other DEA regulations *

Email of individual who manages compliance with controlled substance recordkeeping; security and other DEA regulations *

Do you have a system in place to monitor large or questionable controlled substance purchases from your downstream customers *

Yes

Describe your Suspicious Order Monitoring (SOM) system *

Upload SOM written protocol *

Provide a brief overview of your due diligence program pertaining to new customer accounts for those customers that purchase controlled substances. *

Provide an updated copy of your Controlled Substance Policies and Procedures
Provide the last 12 months of ARCOS data submissions in Excel format

Upload a copy of the form *

Have you had any controlled substance thefts during the past 24 months?*

Yes

If yes, how many? *

Explain the controlled substance thefts during the past 24 months?*

Was the U.S. DEA notified?*

Yes

If Yes, what office? *

Do you periodically obtain an updated copy of the customer's DEA registration certificate?*

Yes

What database or verification method do you utilize to ensure that customer DEA registration numbers are not expired and current at the specific address to which you ship controlled substances *

Credit Card	ACH Manual	ACH Auto	Prepay
Mail Check