BRP Service Agreement

Patient Health First

BRP Service Agreement

Clinic & Shipping Information

Must match DEA license info if ordering controls

License Information

Please provide all current State and DEA license numbers for where you hold licenses:


Practice Information

(If Yes, please attach the Final Order, agreement, or similar material issued by the agency concluding the matter.)

Additional Contact Information

(orders, clinic info, etc)
(if different from clinic)

Authorized Agents

(Please fill out if you would like others to order medication on behalf of the doctor)

Bryant Ranch Prepack is hereby authorized to provided pharmaceutical products as ordered by myself or one of my authorized agents. I assume responsibility for the storage and use of drug products (including controlled substances) received pursuant to my orders. Should I leave this facility, or otherwise discontinue ordering, I shall notify in writing to rescind this authorization.

Payment Options (Optional)

Credit Card Information: Please complete if you would like to convert to credit card terms after initial order. You may cancel this automatic billing authorization at anytime by contacting us by email only: accounting@brppharma.com

8. TERMS, CONDITIONS, AND ACCEPTANCE

  1. RETURN POLICY: Healthcare provider has 72 hours from the date of received invoice to question the invoice or the product for any damage/unwanted products. NO returns are permitted unless the provider has prior written authorization from BRP Pharmaceuticals. On very rare occasions returns may be permitted within 30 days of date of invoice with a 25% restocking fee which are on a case-by-case basis. Expired medications purchased from BRP may be returned for disposal only Free of Charge. NO CREDIT will be given for expired medications.
  2. TERMS: Net 30 days from the date of invoice, 2% late fee will be applied to case of collection. The clinic, doctor, and/or mgmt. company will be responsible to pay all the legal & collection fees.
  3. AUTHORIZED AGENTS: It is understood that only duly authorized, licensed and registered individuals may purchase, store, administer, dispense or possess dangerous drugs and controlled substances. If Payor is not the authorized Healthcare Provider, then the Payor may NOT possess these restricted products provided by BRP.
  4. Each party shall abide by all applicable statues, laws, regulations, rules, policies, standards, guidelines and procedures now in effect or hereinafter enacted, including but not limited to (i) laws regarding the provision of insurance or healthcare services, including, but not limited to, Medicare and Medicaid; (ii) the Prescription Drug Marketing Act; (iii) the Federal Controlled Substances Act; (iv) the Federal Food, Drug and Cosmetics Act; and (v) any state laws relating to the sale of pharmaceutical products being purchased by Healthcare Provider pursuant to this Agreement.

* Important: It will be the clinic’s responsibility to inform BRP immediately of any changes with physician in charge, licensures and/or change of address.

Signatures

I state, under penalty of perjury of the laws of the state in which I practice, that the information I have provided on this form is true and correct.