Agent Authorization

Designate the staff members you authorize to transmit prescriptions to the pharmacy on your behalf.

Prescriber Information

The licensed prescriber granting this authorization.

First name *

Last name *

Email *

Phone *

NPI Number *

DEA Number

Authorized Agents

Individuals you authorize to transmit prescriptions on your behalf. (A provider can add multiple authorized agents, but an authorized agent can only be tied to one provider.)

Agent 1

First name *

Last name *

Email *

Role *

e.g. Medical Assistant, RN, Office Manager

Not the prescriber?

This form must be signed by the prescriber. Send them a secure link and everything you've filled in will be ready for their review and signature.

Prescriber email *

Your name

So the prescriber knows who sent it

Your email

Optional — we'll copy you on the email to the prescriber and again when they sign

Provider Authorization & Signature

I hereby designate the following individual(s) as my authorized agent(s) for the limited purpose of transmitting prescription orders I have authored to pharmacies on my behalf. This includes electronic transmission (e-prescribing), facsimile, and communication of prescription status between my practice and the dispensing pharmacy.

This authorization is limited to transmission only. The agent may not exercise clinical judgment or represent itself as a prescriber. All prescriptions transmitted under this authorization originate from my clinical decision, issued in the usual course of my professional practice for a legitimate medical purpose. I remain the practitioner of record.

I represent that I have reviewed and am in compliance with the laws and regulations of my state(s) of licensure governing the use of authorized agents for prescription transmission. I accept full responsibility for ensuring this designation is permitted under applicable state law.

If there is a change in authorized agent(s), I will notify the pharmacy and AutoPilot Technologies immediately. I will notify AutoPilot and the pharmacy within 48 hours of any change to my licensure, DEA registration, or prescriptive authority.

I confirm I am the licensed prescriber named above, that the state(s) in which I practice permit prescriptions to be transmitted by an authorized agent, and I authorize the individuals listed as my agents to transmit prescriptions on my behalf as described.

Prescriber Signature *

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Signing as

Enter prescriber name above

NPI: Enter NPI above