EPCS Order Form
AccountInformatio n
KareoID:
Account:
ContactName:
Practice/ProviderInformation
Practice:
Provider:
Description Price Quantity Total
ePrescribeControlledSubstancesetupforEHRprovider 75.00$ 75.00$
SecurityToken
Doesthisproviderneedahardwaresecuritytoken?
Yes,pleasemailonehardtokentothephysicaladdresslistedbelow.
Name
Address
City State ZipCode
WillthistokenbesenttoaResidentialorBusinessaddress?
No,theaboveprovideralreadyhasahardwaresecuritytoken.
PaymentMethod
IdeclarethatIhaveauthoritytosignthisorderformontheaccount'sbehalf.IhearbyauthorizeKareoto
chargethepaymentmethodonfileforthisaccountforthetotalamountabove.
AuthorizedName Date
Please return this form to Kareo by fax at (800) 7982310.
1
AuthorizedSignature
EPCS End-User Agreement
By signing this agreement, prescribing provider acknowledges and agrees that:
1. In accordance with the EPCS regulations set by the DEA,
i. Any token (soft or hard) cannot be on the same device used to prescribe.
Each Customer and administrative level users are responsible for informing end
users of the prohibition.
ii. Any identified security incidents must be filed with the DEA and the filed report must be
retained a minimum of 2 years. A copy of the filed report must also be forwarded to
security@kareo.com.
iii. Any person designated to set logical access controls must determine whether any
identified auditable event represents a security incident that compromised or could have
compromised the integrity of the prescription records.
iv. Any such incidents must be reported to the electronic prescription application provider
(Kareo) and the Drug Enforcement Administration within 1 business day.
2. I understand that by choosing this e-prescribing “add-on” service, I am authorizing Kareo’s
subcontractor to retain individual prescription transactions for purposes of financial reporting,
insurance claims and other legal and business purposes and that the Kareo Term, Termination
and Return of Data Policy is amended accordingly for users of the “add-on” service.
Provider Name:
Provider Signature:
Date:
Please return this form to Kareo by fax at (800) 7982310.