OBP Integration Request

OBP Account Integration Request

Thank you for partnering with Optimal Balance Pharmacy. OBP uses this form to complete initial request for account integrations. Please provide the following answers and details.

Account and Direct Contact Demographics

This section collects your clinic’s physical address and practice details along with the current direct contact for clarifications.
Clinic or Business Name
Please enter the name of your clinic or business
Address for Clinic or Business

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number for your clinicFormat: (000) 000-0000.
Direct Point of Contact for Integration

Enter the main, direct point of contact during the integration process.
Direct Point of Contact Full Name

First NameLast Name
Role or Title
Please provide the title or role of the individual who will be responsible for prescription clarifications.
Phone Number
Direct phone number that Optimal Balance can call to reach point of contact for prescription clarifications.Format: (000) 000-0000.
Email
Email address for the best point of contact

Account Qualifying Questions

Please answer the following questions in preparation of account set up.
When is your anticipated Go Live Date for the integration

MonthDayYear
Please enter a date to target for Go-Live
How will Billing Orders Occur?
Are we Shipping to Clinic, Patient or Both?
Will you be allowing prescribing of Controlled Substances shipped outside of the state of Texas?
Will you have a list of your Providers ready to Upload into a CSV template?
Please download and complete the Provider CSV Template before uploading your completed file below.

Download Provider CSV Template
Please upload Provider list. This list will be used for uploading into your account once integrated. Please include:

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OBP Account Integration Request