Provider Onboarding

Provider Onboarding Form

Thank you for choosing Helping HandsRX as your compounding pharmacy partner. Please complete all sections below. Our team will review your application and contact you within 1–2 business days.

This onboarding form is not required to order, but is helpful to pharmacy staff to understand your needs.

Section 1 — Practice / Clinic Information

Practice / Clinic Name *

Street Address *

City *

State *

ZIP Code *

Country

Office Phone *

Office Fax

Practice Website (optional)

Section 2 — Prescriber Information

First Name *

Last Name *

Credentials (MD, DO, NP, PA, etc.) *

Specialty

State Medical License Number

License State

DEA Number

NPI Number *

Additional Prescribers at this Location (name, credential)

Section 3 — Preferred Contact Person

Contact Name *

Title / Role

Direct Phone *

Email Address *

Best Method of Contact *

PhoneEmailFaxText

Section 5 — Agreement & Signature

By signing below, I confirm that all information provided is accurate and complete. I authorize Helping HandsRX to verify my credentials and agree to comply with all applicable state and federal compounding pharmacy regulations. I understand that prescriptions must be patient-specific and that Helping HandsRX operates as a licensed 503A compounding pharmacy.

Prescriber Signature *

Date *

Printed Name *

Title *

Provider Onboarding Form

Section 1 — Practice / Clinic Information

Section 2 — Prescriber Information

Section 3 — Preferred Contact Person

Section 4 — Specialty & Patient Volume

Section 5 — Agreement & Signature