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By signing below you are attesting that you have the legal authority to sign on behalf of your pharmacy and to identify Authorized Users of the MirixaPro platform. Signature Title Print Name Date Please fax this completed form to Mirixa Corporation at 703. Note that if any Authorized User stops performing services on behalf of your pharmacy e.g. if the user is no longer employed at the pharmacy you must notify Mirixa Support immediately so that the user s account may be deactivated. Mirixa will create a MirixaPro account for each user listed below. PHARMACY USER ACCESS AUTHORIZATION FORM Pharmacy Information Pharmacy Name Mailing Address Name of Chain or PSAO if applicable Phone Number Fax Number NCPDP Number NPI Number User Information Please identify the individual s who will perform services on the MirixaProSM platform on behalf of your pharmacy. These Authorized User s will have access to your pharmacy s cases and patient data* Your pharmacy assumes responsibility for the actions of all Authorized Users. Typically Authorized Users are licensed pharmacists pharmacy students or pharmacy technicians assisting with patient care services. Additional Privileges Is this user a service provider entitled to authorize billing for health care services Yes/No Should this user be able to Does this user have the add or manage user power to sign contracts accounts on behalf of on behalf of pharmacy pharmacy Name Title Email Address Saying yes in these boxes provides a user with privileges that do not exist for a basic account. Generally pharmacists are entitled to authorize billing for health care services. Most pharmacies appoint one senior staff member to manage all user accounts on behalf of the pharmacy. Other users including technicians and students maintain basic accounts to allow them to assist with case scheduling data entry and other important functions. An owner or manager should sign this form to approve other pharmacy staff to become Authorized User s. You cannot identify yourself as an Authorized User unless you are the pharmacy owner or highest executive. 865. 2198. For additional assistance contact Mirixa Support at 866. 218. 6649. 2014 Mirixa Corporation* All rights reserved*. PHARMACY USER ACCESS AUTHORIZATION FORM Pharmacy Information Pharmacy Name Mailing Address Name of Chain or PSAO if applicable Phone Number Fax Number NCPDP Number NPI Number User Information Please identify the individual s who will perform services on the MirixaProSM platform on behalf of your pharmacy. These Authorized User s will have access to your pharmacy s cases and patient data* Your pharmacy assumes responsibility for the actions of all Authorized Users. Typically Authorized Users are licensed pharmacists pharmacy students or pharmacy technicians assisting with patient care services. Additional Privileges Is this user a service provider entitled to authorize billing for health care services Yes/No Should this user be able to Does this user have the add or manage user power to sign contracts accounts on behalf of on behalf of pharmacy pharmacy Name Title Email Address Saying yes in these boxes provides a user with privileges that do not exist for a basic account.