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.
Clinic Name*
Please enter the name of your clinic or business
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number for your clinicFormat: (000) 000-0000.
Is the Clinic Address Listed Above a Residential Address?*
Please indicate whether the address provided is a private residence rather than a commercial or medical office location
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.
Physical location - is the actual place where patients receive care.Telemedicine Only - (I confirm that I have a collaborative agreement, or appropriate supervision in all states that require it, and am compliant with mid-level practitioner laws in all states in which I practice telemedicine.Hybrid - in person and telemedicine patient care.

Do you intend to have Optimal Balance Bill-the-Patient Directly?*
If you would like for Optimal Balance to Bill-Clinic instead, select No.

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.
Card Holder: Full Name

First NameLast Name
VisaMastercardAmerican ExpressDiscover
Card: Expiration Month
Select the month that your card expires.
Card: Expiration Year
Please select the year your card expires.
Please Enter your Card Details Below. Enter your card number in four separate boxes. Ex- if your card number is 1234 5678 9012 3456, enter 1234 in the first box, 5678 in the second, 9012 in the third, and 3456 in the fourth. If you do not wish to enter your card details, simply put all 0's.*

Please Enter your Card Details Below - Enter your card number in four separate boxes. Ex- if your card number is 1234 5678 9012 3456, enter 1234 in the first box, 5678 in the second, 9012 in the third, and 3456 in the fourth.

Rows	Digits 1-4	Digits 5-8	Digits 9-12	Digits 13-16 (Amex user will have 15 digits)
CC #

Card: CVV Code
Please enter credit card CVV code.
Card: Billing Zip Code
Please enter the credit card number billing 5 digit zip code.
Payment Signature

Powered by Jotform SignClear

YesNo
Shipping Information

In this section we will collect your shipping information and also collect the days of the week your clinic accepts shipments.
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
MondayTuesdayWednesdayThursdayFridaySaturday

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.
Name*

First NameLast Name
Please select your license type/credentials from the drop down list below*
If other, please specify below
Other*
Please enter the license type/credentials
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please select the state in which you currently hold an active professional license.*
Please select the state in the drop down above
What is that state license number?*
Please enter your state license number in the above field
What is your NPI number *
Enter the NPI the 10 digit number under which you are registered with the National Plan and Provider Enumeration System (NPPES), administered by the Centers for Medicare & Medicaid Services (CMS)
Will This Mid-Level Prescriber be Prescribing Schedule III or Schedule IV Controlled Substances such as Testosterone or Phentermine?
Please enter your Drug Enforcement Administration (DEA) registration number.*
Enter the active DEA registration number issued by the United States Department of Justice, Drug Enforcement Administration (DEA) under which you are authorized to prescribe controlled substances, if applicable
YesNo
Additional Mid-Level Practitioner Demographics
YesNo

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.
Name*

First NameLast Name
Please select your license type/credentials from the drop down list below*
If other, please specify below
Other License Type/Credentials*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Please select the state in which you currently hold an active professional license.*
Please select the state in the drop down above
What is that state license number?*
Please enter your state license number in the above field
What is your NPI number *
Enter the 10 digit NPI number under which you are registered with the National Plan and Provider Enumeration System (NPPES), administered by the Centers for Medicare & Medicaid Services (CMS)
YesNo
Please enter the Supervising/Collaborating Physician's Drug Enforcement Administration (DEA) registration number.*
Enter the active DEA registration number issued by the United States Department of Justice, Drug Enforcement Administration (DEA) under which you are authorized to prescribe controlled substances, if applicable
YesNo
Additional Supervising/Collaborative Physician Demographics
- aecode
- aename
- aeemail
- tbcode
- tbname
- tbemail
- Should be Empty:

Optimal Balance Pharmacy Account Setup

Account Demographics

Practice Type

Contacts for Prescription Clarifications

Billing Information

Shipping Information

Mid-Level Practitioner Demographics

Supervising & Collaborating Physicians