Join the National Health Rx Provider Network

1. Parties

This Account & Prescriber Service Agreement (“Agreement”) is entered into between: National Health Rx, a licensed 503A compounding pharmacy (“Pharmacy”), and [Clinic Name] (“Prescriber”). Both parties agree to the terms below as a condition for establishing and maintaining an account for prescription fulfillment.

2. Compliance Requirement

Prescriber agrees that:

• All prescriptions submitted to Pharmacy are patient-specific, pursuant to Section 503A of the Federal Food, Drug, and Cosmetic Act.
• Prescriber will provide valid patient identifiers and clinical justification upon request.
• Prescriber will not request office-use compounded medications.
• Prescriber will only prescribe within the scope of their license.

3. Prescription Submission Requirements

Prescriber agrees to:

• Submit accurate, complete patient information for each prescription.
• Provide clinical details needed to ensure safe compounding and dispensing.
• Submit prescriptions via fax, phone, EMR, secure email, or e-prescribe, as approved by Pharmacy.
• Pharmacy may place prescriptions on hold pending clarification or compliance review.

4. Payment Terms

4.1 Payment Prior to Fulfillment. Prescriber acknowledges and agrees: All prescriptions must be paid in full prior to fulfillment and shipment. No prescription will be compounded or dispensed until payment is received. This applies to patient-pay and clinic-pay prescriptions.

4.2 Accepted Payment Methods. As authorized in the New Account Form.

4.3 Non-Payment / Declined Charges. If payment is declined or outstanding: the order will remain in Financial Hold status until resolved. Any repeated failures may lead to account suspension.

5. Shipping, Handling & Returns

• Prescriber acknowledges that compounded medications generally cannot be returned or refunded once dispensed, except as required by law.
• Pharmacy follows appropriate shipping and handling protocols.

6. Recordkeeping

Both parties agree to retain records in compliance with: State board of pharmacy regulations; HIPAA; FDA 503A requirements. Prescriber will promptly respond to Pharmacy requests for missing information needed for compliance.

7. Clinical & Professional Obligations

Prescriber agrees:

• To provide appropriate follow-up care for patients receiving compounded medications.
• To promptly report adverse events or suspected quality issues to the Pharmacy.
• Not to market or distribute compounded medications in violation of law.

8. Indemnification & Liability

Prescriber agrees to indemnify Pharmacy for:

• Prescribing outside scope
• Providing incomplete or inaccurate patient information
• Misuse or redistribution of compounded medications

Pharmacy maintains liability in accordance with state law and its compounding license.

9. Termination

Pharmacy may terminate this Agreement for: Non-payment; Repeated compliance issues; License changes; Evidence of improper prescribing. Prescriber may terminate at any time with written notice, except that all outstanding balances must be paid.

10. Signatures

By typing your full legal name below and clicking Submit Registration, you are electronically signing this Agreement on behalf of [Clinic Name]. Your signature has the same legal effect as a handwritten signature.