Facility Information Form

Welcome to RemedyRepack! We are eager to begin providing you with a level of service far above our competition. For us to effectively meet this standard, we ask that you please provide the following information.

Please complete the below form for each unique facility. If you require assistance completing this form please contact our Customer & Contract Liaison, Lauren Stout at 1.866.845.3791 or by email at lsstout@remedyrepack.com

Full Facility Name

Requested Start Date

Full Address (No PO Boxes)

Primary Contact Information

Secondary Contact Information

Packaging Type (Select All That Apply)

HDPE White Bottles
Blister Cards
U/D Solid
U/D Liquid

Additional Services (Select All That Apply)

Relabeling
Wholesale
Medical Device Kitting

Does your facility currently utilize a drug formulary?

Yes
No

Formulary (If Applicable)

Electronic Pedigree Papers

Electronic pedigree papers are transaction history data, showing where medication has previously been transferred, beginning with the original manufacturer.

The FDA requires us to send pedigree papers with stock prescription medication that must remain on file. We will provide these by request via electronic access through a website to eliminate filing unless your facility does not have internet service.

Pedigree Contact Information

Delivery

We will utilize FedEx ground shipping Monday-Friday where available. If shipping address is different from listed above, please provide address below.

Same
Different

FedEx/UPS Shipping Address (No PO Boxes)

Is there staff available on weekends or holidays to receive shipment of medications if FedEx Next Day Air if needed?

Yes
No

We have the capability to send electronic order confirmations and delivery confirmations via email. The purpose of this confirmation is to inform you of the exact contents that shipped in your order. These items will also be listed on your delivery sheet accompanying your delivery.

Email Address for Confirmations

Billing

Purchasing

Please select the providing vendor for your medications

RemedyRepack
An outside authorized wholesaler

Only complete if you checked authorized wholesaler.

Invoicing

If medications for repackaging are drop-shipped through your preferred wholesaler/distributor vendor

Which method do you prefer?

Monthly
Per Order

Invoiced Through

RemedyRepack
An outside authorized wholesaler

If preference is invoiced through RemedyRepack, please continue to answer questions 1. – 4.

If preference is invoiced through authorized wholesaler vendor, please contact your authorized wholesaler representative for invoice setup.

1. Would you like to receive your invoices electronically via a secure email or fax number instead of a hard copy?

Yes
No

2. Is your facility exempt from state and/or local tax? If yes, please provide all applicable tax exemption certificates for all states in whichRemedyRepack would be shipping goods.

Yes
No

3. Do you require a purchase order to process payment?

Yes
No

4. Which payment method do you prefer?

We do not process automatic payments for customers. We can process a credit transaction once your billing department provides us with the approval via email/phone after they receive the invoice.

Licensing Records

RemedyRepack is required by Federal Law to maintain the proper licensing records to provide any (non-patient specific prescription) medications to your facility. For RemedyRepack to provide this service, please complete the below section. Please provide a copy of the current physician/facility license allowing your facility to purchase these medications.

If your facility currently has a physician/facility license and/or DEA license, please complete the following information.

Physician/Facility License Number

License Expiration Date

Upload License

Physician/Facility License permits facility to receive non-control stock medication. A copy of license must be provided.

DEA License Number

License Expiration Date

Upload License

Pharmacy DEA License permits facility to receive both control and non-control stock medication. A copy of license must be provided.

For Compliance with DEA Regulations

Will you be purchasing controlled substances?

Yes
No

This process is part of our due diligence obligations under the Controlled Substances Act (CSA) and DEA regulations, ensuring that we do not inadvertently engage in unlawful activities related to the distribution, sale, or handling of controlled substances. Your timely response to this request will help us continue to provide our products and services in full compliance with federal law.

  • Controlled Substance Forms should be filled out in their entirety.
  • Controlled Substance Forms should include all controlled substances you intend to order including estimated quantities.

The information you provide will be used solely for compliance purposes to ensure that your company complies with federal, state, and local regulations. All responses will be handled confidentially in accordance with applicable privacy laws. RemedyRepack appreciates your partnership and support of our Regulatory Compliance Program. Your cooperation with this DEA requirement is appreciated, and we are here to answer any questions you may have throughout the customer due diligence review process.

Company Information

Nature of Business

Please briefly describe your business operations and any involvement with controlled substances

Authorized Personnel for Ordering, Receiving, and Handling Controlled Substances

Controlled Substance Handling Policies

Does your company have formal written policies for the handling of controlled substances?

Yes
No

If yes, please provide a brief summary or attach relevant documents

Employee Training Program

Does your company provide training to employees involved with controlled substances on legal and regulatory requirements?

Yes
No

If yes, please provide details on your training program

Storage and Security Measures

Describe the security measures in place for storing controlled substances, including physical security, inventory controls, and access restrictions

DEA Compliance

Have there ever been any DEA inspections or investigations involving your company?

Yes
No

If yes, please provide details and any actions taken to address the findings:

Regulatory Violations or Enforcement Actions

Has your company ever been subject to any regulatory violations, fines, or enforcement actions related to controlled substances?

Yes
No

If yes, please provide details

By signing below, you certify that the information provided in this questionnaire is accurate and complete to the best of your knowledge. You also acknowledge that your company is committed to complying with all applicable DEA and regulatory requirements concerning controlled substances.

Signature of Power of Attorney Name on license taking responsibility for stock medication

Date