Account Setup FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Office Name *Shipping Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDifferent Billing Address ?NoYes Business info Name Billing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness infoPhoneFaxEmail *Primary ContactSecondary Contact Prescribers Writing Rx: (Name / NPI / DEA) RX NameNPIDEA Supervising Physician Name / NPI / DEA & Phone #: RX NameNPIDEAPhoneAcceptanceI AcceptI/we acknowledge and agree that all prescriptions submitted to US Compounding Factory (USCF) will comply with all federal and state laws, regulations, and rules governing prescription medications and 503A compounding. I/we shall maintain appropriate documentation for each prescription and agree to the terms of billing as described above.Office BillingAccounting Contact *Accounting Phone *Accounting Email *NotesACCOUNT VALIDATION: Please supply the following information with your completed form. USCF will be verifying the information provided. Supplying incomplete or incorrect information will delay USCF ’s approval of your account.Attach a Copy of Current Business License Drag & Drop Files, Choose Files to Upload Attach Copy of Each Prescriber ’s and Medical Director / Supervising Physician ’s Current License, Registration, and DEA Registration If Applicable Drag & Drop Files, Choose Files to Upload Submit
