Specialty Medication Prescriber Enrollment Template

Specialty pharmacies need the prescriber on file before the first dispense. This enrollment form collects the clinic, the specialty, and a signature.

Great for

• Specialty pharmacies enrolling a new prescriber
• Clinics opening an account for limited-distribution drugs
• Hub teams that need the same details from every office

Collect the identifiers your pharmacy requires. Do not ask patients to fill this in.

This form starts enrollment. It does not submit a prescription or a prior authorization.

Questions in this template

1. Prescriber name *
   Name
2. NPI or license number *
   Short text
3. Clinic name *
   Short text
4. Email *
   Email
5. Phone *
   Phone
6. Specialty *
   Dropdown Oncology, Rheumatology, Gastroenterology, Dermatology, Other
7. This clinic can receive medication deliveries *
   Yes or no
8. Prescriber signature *
   Signature