Specialty Medication Prescriber Enrollment

Specialty Medication Prescriber Enrollment
Complete this form to enroll as a prescriber for specialty medications. Please provide accurate and up-to-date information.
Prescriber's Full Name
First NameLast Name
Professional Credentials (MD, DO, NP, PA, etc.)
Medical License Number
NPI Number
DEA Number
Practice/Clinic Name
Practice Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Practice Email Address
example@example.com
Specialty Area(s)
Other
Please list specialty medications you have experience prescribing
Preferred Method of Communication
Prescriber's Signature
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