Optimal Balance Pharmacy Account Setup

  • Optimal Balance Pharmacy Account Setup

    Thank you for partnering with Optimal Balance Pharmacy. This form collects essential account demographics, licensure, and DEA information required to verify prescriptive authority and ensure compliance with all State Boards of Pharmacy and federal regulations. Accurate and complete information helps us activate your account efficiently and prevent delays in processing prescriptions.We appreciate the opportunity to support you and the patients you serve.

  • Account Demographics

    This section collects your clinic’s physical address and practice details to properly establish your account within our system.
  • Format: (000) 000-0000.

  • Practice Type

    You will identify whether your practice operates as a physical location, telemedicine only, or a hybrid model. This information ensures accurate records, proper state licensure alignment, and compliance with applicable regulatory requirements.
  • Please indicate below how the clinic provider patient services*

  • Contacts for Prescription Clarifications

    This section collects key information for clinic staff who will interact with Optimal Balance Pharmacy, including name, title, phone number, and email address. You will also designate the appropriate access level and privileges needed within our LifeFile Pharmacy system. Providing accurate details ensures secure system access, proper role alignment, and protection of patient information.
  • Format: (000) 000-0000.
  • Will this person require privileges to LifeFile Account*
  • If yes, please select the level of privileges
  • Would you like to add Optional Staff/Clinician to your Account*
    • Additional Contact to Add to Account  
    • Format: (000) 000-0000.
    • Will this person require privileges to LifeFile Account*
    • If yes, please select the level of privileges*
    • Billing Information 

    • Billing Information

      This form is hosted on a HIPAA-compliant enterprise platform and secured with encrypted SSL technology. Payment information is processed through a PCI-compliant payment gateway to maintain strict confidentiality and industry-standard data protection. Please note, all credit card details are PHI protected and will be masked during form submission.
    • Please select card type
    • Rows
  • Is your Shipping Address for your Clinic different than from the Account Demographics section?*

  • Shipping Information

    In this section we will collect your shipping information and also collect the days of the week your clinic accepts shipments.
  • Shipping Availability - Use the checkboxes below to indicate the day you can receive shipments.*
  • Do you have Mid-Level Practitioners that will be prescribing*
    • Mid-Level Practitioner Demographics 

    • Mid-Level Practitioner Demographics

      Please provide the required licensure and credentialing details for any Nurse Practitioner, Physician Assistant, or other Mid-Level Practitioner who will be prescribing through your clinic. This information is necessary to verify state licensure, prescribing authority, and DEA registration when applicable, and ensures compliance with all applicable State Board of Pharmacy and federal regulations. If your state requires a supervising physician for mid-level prescribers, please ensure that information is also provided in the appropriate section of this form.
    • Format: (000) 000-0000.
    • Would you like to add Additional Mid-Level Practitioners to your account?*
    • Does your State Require a Supervising Physician or Collaborating Physician for you to Prescribe medications? (Note-if you selected MD or DO as the professional license type in the above section, AND you do NOT need to add any other supervising or collaborating physicians, select No)*

  • Supervising & Collaborating Physicians

    Please provide the supervising physician’s demographic and licensure information, including contact details, NPI, state license, and DEA registration if applicable. This information is required to verify prescriptive authority and ensure compliance with applicable state regulations governing mid-level practitioners. Accurate and complete details will help prevent delays in account approval and prescription processing.
  • Format: (000) 000-0000.
  • Either now or in the future will the Supervising or Collaborative Physician intend on prescribing Schedule III or Schedule IV substances such as Testosterone or Phentermine?*
  • Would you like to add Additional Supervising/Collaborative Physicians to your account?*

  • Ready to Submit your Form

    Please click submit to submit your New Account Form. If you need to revisit, you can also click the save button.
    • OBP Sales Representative Information 
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