PPI Due Diligence Form

Patient Health First

PPI Due Diligence Form

Section 1

To ensure compliance with DEA and FDA regulations we are requesting you respond to the following questionnaire in order to use Preferred Pharmaceuticals, Inc. (PPI) as your vendor for dispensing medication:

1. Please state the official business name and mailing address you would like the medication to be shipped to (this cannot be a PO Box):

2. Please list your office’s main provider’s DEA and State License. If your office intends on ordering controlled medications, please make sure the address associated with the following DEA license matches the mailing address:

* All medications purchased from Preferred Pharmaceuticals will be purchased under the provider’s license information listed above. All controlled medications will be dispensed under the provider listed above. If another provider wants to order and dispense controlled medication at this site, they must fill out an additional Due Diligence Form.

Section 2

If your office plans on dispensing controlled medication (C-II, C-III, C-IV, C-V), please answer the following questions.

If you will only be dispensing non-controlled medication, please disregard this section and proceed to Section 3.

Section 3

The following questions are to evaluate the software that would best suit your office. If you only plan on dispensing non-controlled medication, and/or only want to manually dispense, disregard the following questions.

When would be the preferred time for us to set up and train your office on the web-based software? Keep in mind training and setup will be after your office has received medication and takes about an hour to hour and a half.
What is your local time zone?

* To receive the barcode scanner for the dispensing software, your initial order (and only the initial order) must to reach the minimum of $500. However, if you do not reach the $500 minimum on your initial order, then the cost of the barcode scanner ($150) will be charged to your office. You may also purchase a barcode scanner on your own as any standard barcode scanner should work.

Shipping information:

Orders over $100 will not be charged for shipping. Backordered shipments will not be charged a shipping fee. All orders automatically ship ground through Fedex. Orders placed before 2pm (PST) will ship out on the same business day. Expedited shipping requests must be submitted before 1:00pm (PST). The shipping cost on expedited orders shall be the responsibility of the order recipient and is calculated by weight, size, and distance of the shipment.

Sign This Form

I have carefully and thoroughly read the information provided in this form with clear comprehension. I certify that all statements and information provided herein are true and accurate. I certify that my entire staff and I understand that, should we choose to dispense controlled medication (C-II, C-III, C-IV, C-V), we must comply with all the state and federal regulations. This includes, but is not limited to reporting controlled medication to the state, complying with the double lock requirement, and maintaining an accurate and detailed report of all controlled substances. I understand that all medications purchased from Preferred Pharmaceuticals will be purchased under the provider’s license information listed in Section I. All controlled medications will be dispensed under the same provider listed in Section I. If another provider wants to order and dispense controlled medication at this site, they will fill out an additional Due Diligence Form.

Practice Contact Information

(We will contact this person with any questions in regards to medication orders):