Get Pharmacy User Access Authorization Form

The Pharmacy User Access Authorization Form is crucial for managing access to pharmacy services on the MirixaPro platform. This guide provides you with a clear, step-by-step approach to ensure accurate completion of the form online.

Follow the steps to effectively complete your authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the pharmacy information. Fill in the pharmacy name, mailing address, any chain or PSAO details if applicable, and provide the phone and fax numbers, along with the NCPDP and NPI numbers.
3. Next, identify the individuals who will perform services on behalf of the pharmacy. Fill in the names, titles, and email addresses for each Authorized User. Ensure accuracy as they will have access to sensitive patient data.
4. Indicate whether each Authorized User has additional privileges. Answer ‘Yes’ or ‘No’ for whether the user can authorize billing and if they can add or manage user accounts on behalf of the pharmacy.
5. An owner or manager must sign the form to approve the Authorized Users. If you are not the pharmacy owner or top executive, you cannot sign this form as an Authorized User.
6. Date the form and print your name, indicating your official title. This verifies your legal authority to sign on behalf of the pharmacy.
7. Finally, fax the completed form to Mirixa Corporation at the provided fax number. Ensure you retain a copy of the submitted form for your records.

Take prompt action to complete your Pharmacy User Access Authorization Form online to ensure timely access to the necessary pharmacy services.