Assure IV

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Assure® Infusions New Account Information Form

Please include a copy of your DEA License, State Pharmacy License, and CDS License (if applicable). MO and OK, please provide BNDD License.

* Indicates a required field.

Section 1 – Facility Information

Facility Name *

Facility Type *

Primary Pharmacy GPO Affiliation

IDN or Health System Affiliation *

FACILITY SHIPPING ADDRESS

Street Address Name *

Department, Suite, or Other Shipping Information

City *

State *

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Zip Code *

Country *

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FACILITY BILLING ADDRESS

Street Address Name *

Department, Suite, or Other Shipping Information

City *

State *

▼

Zip Code *

Country *

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Pharmacy Main Phone Number

State Pharmacy License Number

*Not required for VA Hospitals

DEA Number *

Does your facility utilize a Drug Database?

First Data Bank Cerner-Multum Redbook Other

Section 2 – Users

Director of Pharmacy

Email Address

Phone Number

Pharmacy Buyer

Email Address

Phone Number

Additional Pharmacy Contact

Title

Email Address

Phone Number

Additional Pharmacy Contact

Title

Email Address

Phone Number

Additional Pharmacy Contact

Title

Email Address

Phone Number

Section 3 – Invoicing

Pharmacy Billing Contact Name

Title

Email Address

Phone Number

Accounts Payable Contact Name

Title

Email Address

Phone Number

ALL INVOICES WILL BE SENT VIA EMAIL UNLESS OTHERWISE SPECIFIED BELOW

Additional Information Needed for Billing

The person signing this New Account Information Form agrees that the above information is accurate and that they are an authorized signatory for this facility.

Title *

First Name *

Last Name *

Email Address *

Phone Number *