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
Chain A46 - Third Party Assistance (for Puerto Rico pharmacies only)

Affiliate *

NCPDP (NABP) *

(7 digits)

Pharmacy NPI #

(10 digits) Your Pharmacy's NPI number

Federal Tax ID # *

(9 digits) ex: 121234567 No Formating Characters

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)
All communications will be sent to pharmacy by way of email (i.e. deposits/broadcast communications).

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 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.