Medical Provider Intake Form – Millers Pharmacy

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📞 201-891-3333 | ✉ contactus@millerspharmacy.com

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NEW MEDICAL PROVIDER INTAKE FORM

Practice / Company

Name

Email

Telephone

Address

City

State

Zip Code

Website URL

Provider 1

Provider

Phone

NPI #

DEA #

Office Manager

Phone

Office Fax

Office Email

Provider 2

Provider

Phone

NPI #

DEA #

Office Manager

Phone

Office Fax

Office Email

Questions

Are the medications ordered going to be paid by?

Company Patient

We are shipping the order to?

Company Patient

Is MILLERS permitted to contact Patient?

Only Provider MILLERS may contact

Do You require signature of patient for shipments of controlled substances (Charges Apply)?

Yes No

Did you approve the pricing sheet provided?

Yes No

On controlled substances, You agree that you will do PMP and other appropriate backround checks?

Yes No

You agree that you have represented to MILLERS that it can rely on such information?

Yes No

Payment Information

Name

Billing Address

Payment Type

American Express Mastercard Visa Other

Card #

Expiration Date

Security Code

Notes

Type here...

Provider

Prescriber Name

Phone

Email

Signature

Date

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Email: contactus@millerspharmacy.com
Phone: 201-891-3333
Fax: 201-275-1256
678 Wyckoff Avenue, Wyckoff, NJ 07481

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