E-Prescribing Registration Form

With the electronic prescribing feature of the program, you will be able to do all of the following over the Internet:
  • Receive NEW prescriptions from prescribers
  • Send Refill Requests to prescribers
  • Receive responses to the Refill Requests

To sign up for electronic prescribing, you must have a high-speed Internet connection at your pharmacy.  You cannot send or receive messages through dialup or over the phone line.

Also, you can only send and receive messages to/from prescribers that are also signed up with SureScripts. The pharmacy program will automatically know whether or not a prescriber is able to receive electronic prescribing messages.

The fees associated with electronic prescribing are as follows:
  • One-time fee of $250.00 for the initial setup of the program. There will be no yearly maintenance fees.
  • A fee of $0.18 for each New Rx you receive and each Refill Request you send. There is no fee for receiving a Response to a Refill Requests. You will receive a monthly bill for these charges with the bill for your regular transmission charges.
If you would like to sign up for electronic prescribing, please fill out this form to submit your pharmacy's information.
* Denotes a mandatory field.
* NCPDP# :
* NPI# :
* Pharmacy Name :
* Address Line 1 :
Address Line 2 :
Cross Street :
* City :
* State :
* Zip :
* Primary Phone :
* Fax :
Alt Phone 1 :    Type: 
Alt Phone 2 :    Type: 
Alt Phone 3 :    Type: 
Alt Phone 4 :    Type: 
Alt Phone 5 :    Type: 
Email Address :