Third Party Station Enrollment Application Form

PHARMACY INFORMATION

Pharmacy Name *

Type of
Relationship *

Chain 866 - Third Party Assistance with Reconciliation
Chain 854 - Third Party Assistance only

Affiliate *

NCPDP (NABP) *

(7 digits)

Pharmacy NPI #

(10 digits) Your Pharmacy's NPI number

Federal Tax ID # *

(9 digits) ex: 12-1234567

DEA # *

Renewal Date * (YYYY-MM-DD) ex: 2008-03-15

State License # *

Renewal Date * (YYYY-MM-DD) ex: 2008-03-15

Medicaid #

Medicare B #

BNDD #

DPS #

(Texas Pharmacies only)

Primary Switch *

Backup Switch

(if you have a backup switch)

Software Vendor *

Pharmacy Address *
(Physical Address)

Line1
Line2
City State Zip
County

Mailing Address *

Line1
Line2
City State Zip

Contact
Information *
Enter phone numbers with Area Code.
example:
913-123-4567

* First Name * Last Name
* Main Phone # Ext
Alt Phone # Ext
Mobile Phone #
* Pharmacy FAX # (main FAX number)
Reconciliation FAX # (ex: your accounting dept. FAX)
Email Address (ex: name@domain.com)

Authorized
Signature *
as will be signed on
documents

* First Name
* Last Name
Title

GENERAL CREDENTIALING INFORMATION

Insurance
Coverage *
Enter Limits in whole dollars.

Examples:
1000000 or 1,000,000

Name of Primary Carrier
Address of Carrier
Expiration Date (YYYY-MM-DD) ex: 2008-03-15
Limits - Per Occurence $ Aggregate $
Most PBM's require pharmacies to carry insurance with minimums of $1 million per occurrence and $3 million aggregate.

General *
Answer these four
questions by checking
Yes or No to each one.

If you check Yes on
questions 1, 2, or 3
you must provide a brief
explanation.

1) Have any of your pharmacy's state license or DEA registrations been limited, suspended
or revoked in the last 3 years?
No Yes - If Yes, please explain

2) Have any of your current pharmacists had their state license limited, suspended or revoked
within the last 3 years?
No Yes - If Yes, please explain

3) Has Medicaid or Medicare ever excluded, suspended or sanctioned participation for you
or your pharmacists’ license and/or your pharmacy license?
No Yes - If Yes, please explain

4) Will your pharmacy retain current copies of all pharmacy’s state permit, DEA certificate,
BNDD certificate, liability insurance and all staff pharmacists’ license?
No Yes* (Must select Yes in order to participate)

Pharmacy Practice
(check all that apply)

Retail (open to public)	Mail Service	Clinic/Hospital Outpatient (closed to public)
Closed Door	Long-Term Care	Other ->

Patient Services *
(hours of operation)

24 Hour Pharmacy (Pharmacist available on location)
Open Specific Hours - enter normal hours of operation below (ex: 8:00am, 9:30pm, etc.)

	SUN	MON	TUE	WED	THU	FRI	SAT
OPEN
CLOSE

Available for After Hours Emergency Calls.
After Hours Phone #

Description of
Services
(check all that apply)

Patient Counseling	Compunding capability	Patient Ref/Resource Ctr
Prescription Literature	Handicap Access	BP Monitoring
Durable Equipment	On-line Claim Submission	Generate Patient Profiles
Drive-up Window	NCPDP Standard Compliant	Accept E-Prescriptions
Bi-Lingual Staff -> Languages

Pharmacy Operations *
Two selections are required. Check any others that apply.

Maintain a Patient Signature Log	* Medication error identification and reduction system in place (required)
Have Prescription Error Procedures	* Maintain professional and general liability insurance with coverage of not less than $1 million per occurrence and $3 million in aggregate for death and personal injury (required by third party payers)
HIPAA Compliant	In good standing with all state and federal licensing agencies

TAXONOMY

1. Primary *

(REQUIRED)

2. Secondary

(Optional)

3. Tertiary

(Optional)

4. Quaternary

(Optional)

5. Quinary

(Optional)

SUBMIT ENROLLMENT APPLICATION FORM

After filling out, selecting, or checking all required (*) and optional fields, please double check all fields and the information that you have provided. This will save time when your application is processed, saving a telephone call to obtain missing or incomplete information.
Upon acceptance of your application, a pre-populated agreement will be mailed to you for you to sign and return to Third Party Station.

(Click the Validate button to check your input before printing or submitting your application)

(Click the Print button to keep a copy for your records)

(Click Submit button to send your enrollment application)

If you have problems or questions about this form, please call Third Party Station, at: 800-460-1575 Option #2.