2204 FM 1960 W
Suite F
Houston, TX 77090

Phone: (281) 919-2964
Fax: 1-833-702-1164
www.obprx.com

New Account Form

Account Demographics

Clinic
Name:

Address:

State

Zip Code

Phone:

Fax

Check if the above address is a residential address (Check box if, Yes)

Practice Type

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 state in which I practice telemedicine.)

Hybrid in person and telemedicine patient care

Direct Contact for Clarifications

First Name

Last Name

Title

Phone

Email Address

Check if the above address is a residential address (Check box if, Yes)

Will this person require privileges to LifeFile Account?

Yes No

If yes, please select the level of privileges:

Full Privileges – authorized to submit Rx Orders as allowed under law; select corresponding attestation statement based off my medical directives; view Rx orders, status tracking, and reporting.

2204 FM 1960 W
Suite F
Houston, TX 77090

Phone: (281) 919-2964
Fax: 1-833-702-1164
www.obprx.com

Limited Privileges – authorized to only view Rx orders status, tracking, and reporting.

Administrative Contacts (Optional)

First Name

Last Name

Title

Phone

Email Address

Check if the above address is a residential address (Check box if, Yes)

Will this person require privileges to LifeFile Account?

Yes No

If yes, please select the level of privileges:

Limited Privileges – authorized to only view Rx orders status, tracking, and reporting.

Billing Information

(If we are billing your patients, please leave area below blank)

Visa Mastercard American Express Discover

Cardholder Name

Cardholder Email

Card Number

Exp Date:

CVV

ZIP

Address

State

City

2204 FM 1960 W
Suite F
Houston, TX 77090

Phone: (281) 919-2964
Fax: 1-833-702-1164
www.obprx.com

Select Signature Type

Clinic Shipping Information (If different from above)

Address:

Clinic's City:

State

Zip Code

Shipping Availability (Use the check box to indicate the days you can receive shipments.)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Mid-Level Partitioner Demographics

2204 FM 1960 W
Suite F
Houston, TX 77090

Phone: (281) 919-2964
Fax: 1-833-702-1164
www.obprx.com

Need to add more Providers? Please use table below

First Name	Last Name	Phone	NPI	State Licensed In	State License Number	DEA

Supervising Physician Demographics

2204 FM 1960 W
Suite F
Houston, TX 77090

Phone: (281) 919-2964
Fax: 1-833-702-1164
www.obprx.com

Need to add more Supervising Physicians? Please use table below.

First Name	Last Name	Phone	NPI	State Licensed In	State License Number	DEA

Sales Rep:

Phone:

I have reviewed and verified the information in this document.

Signature:

New Account Form

Account Demographics

Practice Type

Direct Contact for Clarifications

Administrative Contacts (Optional)

Billing Information

Shipping Availability (Use the check box to indicate the days you can receive shipments.)

Mid-Level Partitioner Demographics

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Supervising Physician Demographics

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