Copy of Account Agreement

Bill Office

Date

Please check this box if you have multiple providers in your practice. We will contact you for their information.

Physicians Name:

Clinic Name:

DEA Number:

License Number:

NPI Number:

Street Address

City

State

Zip code

Phone

Fax:

Email:

Card Holder Name:

Credit Card Number:

Exp.

Billing Email:

Billing Street Address

City

State

Zip code

Under this agreement:

The provider agrees to not resell medication at more than the retail cost.
University Compounding Pharmacy has full retail-price transparency if requested by the patient.
Legally the patient has the right to fill their prescription at any pharmacy they choose.
Controlled medications cannot be shipped to the provider's office.
No refills will be processed for prescriptions paid by the provider.

Thank You!