Agent Authorization

Agent authorization to transmit prescriptions on behalf of the prescriber

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Prescriber Information

The licensed prescriber granting this authorization.

First name *

Last name *

Email *

Phone *

NPI Number *

Controlled Substances

Required only if you will authorize transmission of controlled-substance prescriptions.

DEA Number

Upload DEA License

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Authorized Agents

Individuals you authorize to transmit prescriptions on your behalf.

Agent 1

First name *

Last name *

Email *

Role *

e.g. Medical Assistant, RN, Office Manager

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.

Prescriber Signature *

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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.