New NCPDP Application

Patient Health First

New NCPDP Application

Please provide all documents listed below and complete the following form. The Fee is $375.00.

  1. Doctor's Medical License or Clinic License if a clinic.
  2. DEA License. The DEA license MUST reflect the same address that is on the application if there are controlled substances being dispensed.
  3. NPI Confirmation Email. Please use the organizational NPI number, and NOT the individual NPI. The NPI Business Practice Location MUST match the address on the application. You may go to the national registry on the CMS website https://nppes.cms.hhs.gov and obtain a copy.
  4. EIN (Employer Identification Number) Document. This MUST be a Federal Tax ID (EIN) letter sent by the IRS.
    • Form cannot be a W-9 or State Tax ID form.
    • If you don't have a copy of your EIN/Federal Tax Id confirmation letter, you may contact the IRS Business Tax Line at 1-800-829-4933 to request a copy.

Payment Information

For Invoice Receipt

Affiliation Agreement

This Affidavit is to affirm my affiliation relationship as documented below.

I understand my relationship will be updated on the National Council for Prescription Drug Programs (NCPDP) Database if received by NCPDP within 30 days of the signature date on this form and will be based on the Effective Date indicated below. This Affidavit must be received by NCPDP before 15th of the month to assure inclusion in the following month’s NCPDP v2.x file distribution.

Section 1 - NON PHARMACY DISPENSING SITE INFORMATION

Section 2 - ADDITION/ACTIVE RELATIONSHIP AFFILIATIONS

Please list the active third party relationships in the following table. The addition of an exclusive Type 5 – Third Party Contracting Relationship will automatically terminate any existing Type 5 Third Party Contracting Relationships as of the new start date.

Section 3 - TERMINATION (ENDING) RELATIONSHIP AFFILIATIONS

Please end any and all relationships that are no longer active or will be ending in the near future. If you are adding an exclusive relationship, please use this section to end all other relationships.

* This affidavit cannot be processed by NCPDP if the relationship codes are not provided.

* Relationship Codes are 3-digits. Payment Center Codes are 6-digits. If you are uncertain of your Relationship or Payment Center Codes, please contact your relationship provider (PSAO) or NCPDP Provider Services Department at (480) 477-1000.

Section 4 - AUTHORIZATION TO PROCESS