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Indiana Professional Licensing Agency

PLA > Professions > INDIANA BOARD OF PHARMACY > INSPECT > Pharmacy Change Order Request Form Pharmacy Change Order Request Form

Indiana Scheduled Prescription Electronic Collection & Tracking
Protecting Hoosiers One Prescription At A Time

Required Field Required Field

Pharmacy Change Order Request

Change Order Number:
Pharmacist DOB: (mm/dd/yyyy format)
Pharmacy Name:
Pharmacist Name:
Pharmacy NABP:
Pharmacist Professional License Number:

Pharmacy Contact Information

Address Line 1:
Email Address:
Address Line 2:
City:
Address Line 3:
State/Province:
Telephone Number:
Zip/Postal Code:
Fax Number:
Country/Region:

DISCLAIMER

I (the Dispenser/Practitioner) attest that I am not submitting a change order request under false pretense in an effort to alter or fabricate patient information. I understand that all valid or invalid data modifications are solely my responsibility as the dispenser/practitioner.

I understand that INSPECT is under no obligation to investigate the validity of my Pharmacy Change Order Request and Digital Signature (Notwithstanding my pharmacy NABP number, professional license number, DEA number, my date of birth and name). I am duty-bound to abide by all applicable Federal and State guidelines including, but not limited to, IC-35-48-7 and The Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Misuse of INSPECT's data constitutes a criminal offense and may result in the suspension/revocation of access privileges, or, in some cases, action against offending accountholder's and/or agent's professional license.

Required Field I acknowledge/agree to the Electronic Signature Agreement

Reason for Change

Changes Requested

The Following Areas Can Be Modified:

PRESCRIBER INFO:

  • DEA Number (If the prescription reported has been attributed to the wrong prescriber)

DATE INFORMATION:

  • Rx Written (If the written date reported for the prescription is incorrect)
  • Rx Filled (If the filled date reported for the prescription is incorrect)

PRESCRIPTION SPECIFIC INFO:

  • Rx Number (If the prescription number reported is incorrect)
  • Refill Code (If the code indicating whether the prescription is new or a refill is incorrect)
  • Days Supply (If the estimated number of days the prescription will last is incorrect)
  • Quantity (If the metric units of drug being dispensed is incorrect)

PATIENT NAME PATIENT DOB

Signatures

In order to modify existing records within the prescription management program system, you, or your authorized reprensentive, will be required to use an electronic signature. Please be aware that an electronic signature is as legally binding as a handwritten signature. Click here to read the full Electronic Signature Agreement   www.in.gov/inspect

Required Field Requested By:
Required Field Date:
Modified By: (INSPECT Staff Person)
Date: