3.Prescriber DEA: 4.Board Registration Number: 5.Business Tel:

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1 Commonwealth of Massachusetts Department of Public Health, Office of Prescription Monitoring and Drug Control 99 Chauncy Street, Boston, MA Tel: MA ONLINE PMP DELEGATE ENROLLMENT FORM (This form is not for medical resident or intern delegates) PRIMARY ACCOUNT HOLDER INFORMATION 1.Practitioner Type: (Select one) Physician Dentist Advanced Practice Nurse Podiatrist Nurse Midwife Physician Assistant Prescribing Pharmacist Dispensing Pharmacist 2.Name: First Middle Last Suffix 3.Prescriber DEA: 4.Board Registration Number: 5.Business Tel: You (not the delegate) will receive notifications about the delegate and that the delegate is now assigned to you. 6.CERTIFICATION BY REQUESTING PRIMARY ACCOUNT HOLDER: I delegate access authority and permission to the individual whose information appears below. I hereby certify that the information on this application is true to the best of my knowledge, and that I will comply with the laws of the Commonwealth of Massachusetts and all applicable rules and regulations promulgated by the Department of Public Health. I also certify, in accordance with M.G.L. c. 62C, section 49A, that I have to the best of my knowledge and belief complied with all laws of the commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting of child support. I also certify that I have read and agree to the TERMS AND CONDITIONS FOR SUPERVISION OF A DELEGATE USING THE MA ONLINE PRESCRIPTION MONITORING PROGRAM. I understand that the Terms and Conditions may be revised from time to time, that I will be notified of any change and that my continued use of the MA Online PMP after such notice shall constitute my acceptance of the new Terms and Conditions. Signed under the pains and penalties of perjury. Signature (no initials): Date DELEGATE INFORMATION 1.Name: First Middle Last Suffix 2.Board and Registration /Certificate Number 3.Title: RN LPN PhIntern CPhT DT DH LP (if possessed) Other (secretary, med assistant etc.) 4.Business Address (If different from primary account holder, please include a letter of explanation): Practice or Facility Name (and Department if applicable): Street: City: State: ZIP: 5. Business Tel.: 6. Four digit Birth Month and Day (MMDD): 7. Choose a four digit PIN for MA Online PMP: 8.CERTIFICATION BY PERSON REQUESTING ENROLLMENT AS DELEGATE : I hereby certify that the information on this application is true to the best of my knowledge, and that I will comply with the laws of the Commonwealth of Massachusetts and all applicable rules and regulations promulgated by the Department of Public Health. I also certify, in accordance with M.G.L. c. 62C, section 49A, that I have to the best of my knowledge and belief complied with all laws of the commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting of child support. I also certify that I have read and agree to the TERMS AND CONDITIONS FOR SUPERVISION OF A DELEGATE USING THE MA ONLINE PRESCRIPTION MONITORING PROGRAM. I understand that the Terms and Conditions may be revised from time to time, that I will be notified of any change and that my continued use of the MA Online PMP after such notice shall constitute my acceptance of the new Terms and Conditions. Signed under the pains and penalties of perjury. Notarized Signature of the Delegate: Date NOTARY SECTION On this day of, 20, before me, the undersigned notary public, personally appeared (name of document signer), proved to me through satisfactory evidence of identification, which were, to be the person This space for seal. whose name is signed on this document in my presence. Signature of Notary: Date: My Commission Expires: Delegate Enrollment Pagket V

2 Terms and Conditions for a Primary Account Holder, Authorization of and Responsibility for a Sub-Account Holder (Delegate) User of the Massachusetts Online Prescription Monitoring Program By electing to become a Primary Account Holder in the Massachusetts Online Prescription Monitoring Program (MA Online PMP), you agree to abide by the requirements governing the Prescription Monitoring Program at 105 CMR and any other applicable requirements, including, but not necessarily limited to: 1) You attest to the following: i. You are a duly licensed health care professional authorized to prescribe or dispense controlled substances in the Commonwealth of Massachusetts (physician, dentist, physician assistant, advanced practice nurse, or pharmacist); As an individual authorized to prescribe, you are duly registered with the Massachusetts Department of Public Health, Drug Control Program, to prescribe controlled substances. You also agree to promptly notify the Department of any change or proposed change in your licensure or registration status; You are duly enrolled to use the MA Online PMP You have not provided nor will provide your login credentials (i.e., username, password, Personal Identification Number or any other security information) to anyone else. You are responsible for promptly notifying the Drug Control Program of any compromise of your login credentials or changes to your enrollment information (e.g., changes to name, business or address, license or registration number) or prescriptive privileges; and v. Your use of the MA Online PMP is for the purpose of providing medical or pharmaceutical care for your patient.. You may not request the prescription history for anyone other than your patient or for a patient encounter. You have elected to become a primary account holder and supervise a delegate who can access patient prescription histories from the MA Online PMP on your behalf. 2) You acknowledge that you understand the following: i. You are responsible for the delegate s competence to utilize the MA Online PMP. This includes the delegate s knowledge of and compliance with the Massachusetts Online Prescription Monitoring Program Terms and Conditions for a Delegate, knowledge of and compliance with the proper use of the MA Online PMP and applicable state and federal laws governing confidentiality and security of personal/patient information, including, if applicable, the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). The delegate s account is associated with your MA Online PMP account. The primary account holder is responsible for all delegate use of the prescription monitoring program and the primary account holder may be referred to the appropriate licensing authority if delegate use is inconsistent with all laws, regulations and terms and conditions for use of the MA Online PMP. When accessing patient prescription histories from the MA Online PMP on your behalf, the delegate is required to use their log-in credentials associated with your MA Online PMP account. v. The role of the delegate is limited to accessing patient prescription histories from the MA Online PMP on your behalf. A delegate user of the MA Online PMP cannot monitor, review or interpret prescription history reports. You must monitor delegate use of the prescription monitoring program and inform the Department when a delegate has violated the Delegate User Terms and Conditions or is no longer authorized by you, the primary account holder, to be a delegate within one business day of such violation or loss of authorization. Usage of the MA Online PMP is recorded and monitored and that your right to use the system may be revoked at any time at the discretion of the Department. v Your controlled substances registration may be suspended or terminated pursuant to the procedures outlines in 105 CMR through , and a referral may be made to law enforcement or the appropriate licensing board if appropriate, pursuant to 105 CMR (c). v Data is being provided for the purpose of safe prescribing and dispensing, including assessing or preventing the possibility of drug abuse or diversion, but does not require you to take action that you believe to be contrary to the best interests of your patient; and ix. The Department may revise these Terms and Conditions from time to time. You will be notified of any change and your continued use of the MA Online PMP after such notice shall constitute your acceptance of the new Terms and Conditions.

3 Terms and Conditions for a Sub-Account Holder (Delegate) User of the Massachusetts Online Prescription Monitoring Program By electing to become a Delegate User of the Massachusetts Online Prescription Monitoring Program (MA Online PMP), you agree to abide by the requirements governing the Prescription Monitoring Program at 105 CMR and any other applicable requirements, including, but not necessarily limited to: 1) You attest to the following: i. You have a professional work relationship with the health care professional who is the Primary Account Holder for whom you will be accessing patient prescription reports from the MA Online PMP. You have provided accurate information regarding any registration or license to practice you hold from a MA Board of Registration. You also agree to promptly notify the Department of any change or proposed change in any licensure or registration status you hold. You will not provide your login credentials (i.e., username, password, Personal Identification Number or any other security information) to anyone else. You are responsible for promptly notifying the Drug Control Program of any changes to your enrollment information (e.g., changes to name, address, license or registration number). v. You are responsible for promptly notifying the Primary Account Holder and the Drug Control Program of any compromise of your login credentials. Your use of the MA Online PMP is on behalf of the Primary Account Holder. If you have more than one Primary Account Holder, you will login to the MA Online PMP with the credentials associated with the Primary Account Holder for whom you are accessing patient prescription reports. You may not request the prescription history for anyone other than the patient (or patients in files for a batch look-up) as directed by the Primary Account Holder. 2) You acknowledge that you understand the following: i. You are responsible for proper utilization of the MA Online PMP. This includes knowledge of and compliance with the proper use of the MA Online PMP and applicable state and federal laws governing confidentiality and security of personal/patient information, including, if applicable, the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). Your delegate account is associated with the Primary Account Holder s MA Online PMP account. When accessing patient prescription histories from the MA Online PMP on behalf of the Primary Account Holder, you are required to use your log-in credentials associated with that Primary Account Holder. The role of the delegate is limited to accessing patient prescription histories from the MA Online PMP on behalf of the Primary Account Holder. A delegate user of the MA Online PMP, cannot monitor, review or interpret prescription history reports. v. You must promptly notify the Department of any potential violation of confidentiality or use of the data in a manner contrary to laws, regulations or applicable professional standards; v v ix. Usage of the MA Online PMP is recorded and the Primary Account Holder will monitor your activity in the MA Online PMP. Usage of the MA Online PMP is recorded and monitored by the Drug Control Program and your right to use the system may be revoked at any time at the discretion of the Department. Data is being provided for use by the Primary Account Holder for the purpose of safe prescribing and dispensing, including assessing or preventing the possibility of drug abuse or diversion; and The Department may revise these Terms and Conditions from time to time. You will be notified of any change and your continued use of the MA Online PMP after such notice shall constitute your acceptance of the new Terms and Conditions.

4 MA Online PMP Delegate Enrollment Form Instructions There are two information sections on this application. These instructions follow the numbered questions in each section sequentially. If you need additional guidance contact the Drug Control Program at Incomplete forms will be returned to the person requesting enrollment and the primary account holder will be informed. Practitioner Information for Primary Account Holder: 1) Check appropriate practitioner type. 2) Print name. 3) For prescribers, provide DEA number. Dispensing pharmacists leave blank. 4) Fill in board of registration number. 5) Contact information, business telephone number 6) Certification and signature. If you have not already read the MA Online PMP Terms and Conditions for Primary Account Holders they are available at You, the primary account holder, will receive the notices regarding the delegate s account and access to the MA Online PMP. The Virtual Gateway will send the delegate s login credentials. The MA PMP Access Administrator will send the delegate s enrollment status and end user instructions. The you provided on your MA Online PMP enrollment form (possibly a combined MCSR recall and automatic MA Online PMP enrollment form) will be used. ing the primary account holder is one way to prevent unauthorized use of your credentials or forging your signature to obtain unauthorized access to the MA Online PMP. Information for Delegate: 1) Print name. 2) If you are registered or certified by a Massachusetts Board of Registration, provide the name of the board and registration or certification number. Example: Nursing ) Enter the type (or role) of the delegate. For clarification purposes, the abbreviations displayed next to the check boxes for this question stand for the following: RN=Registered Nurse; LPN= Licensed Practical Nurse; PhIntern=Pharmacy Intern; CPhT=Certified Pharmacy Tech; DT=Dental Technician; DH=Dental Hygienist; LP=Licensed Psychologist. If the delegate is not one of those types, please check Other and print a description of the type. DPH will post a separate enrollment form for medical resident and intern delegates. Please do not use this application form when applying for that category of delegates. 4) The business address is required. This cannot be a home address or a P.O. Box number. If the business address is different than the business address on the primary account holder s MCSR certificate, please include a letter of explanation. Example: Bright Smile Dentists 1234 Main Street Hometown, MA ) Contact information, business telephone number of office or practice. The main phone number for a hospital or clinic is not acceptable. 6) and 7) These numbers (four digit birth month and day and four digit PIN) are used to establish your account and as a reference to reset forgotten passwords. Use standard ten digits (0,1,2,3,4,5,6,7,8,9) only. Do not use alpha characters or keyboard characters/symbols. 8) Certification and Notarized Signature. Do not sign the document immediately. a) If you have not already read the MA Online PMP Terms and Conditions for Delegates they are available at Please read the Terms and Conditions before signing the document, in the presence of a Notary Public*. b) You must sign in the presence of a Notary Public. This verifies your identify and protects you from having a person forge your signature. Make a copy of the signed and notarized document for your records. Send the signed and notarized original to: Department of Public Health Massachusetts Online Prescription Monitoring Program 99 Chauncy Street Boston, MA * is a website that can help you locate a notary public.

5 FACT SHEET FOR PRIMARY ACCOUNT HOLDERS AND DELEGATES In August 2013 statutory language was added to M.G.L Chapter 94C 24A to allow prescribers and dispensers, enrolled in the MA Online PMP, to have authorized support staff (delegates) obtain patient prescription information from the MA Online PMP on their behalf. An individual with a delegate account can assist health care providers in a busy practice or pharmacy by performing the queries for individual patients and loading files to run a batch look-up. There is no limit on the number of delegates a primary account holder can have and there is no limit on how many primary account holders a delegate can be authorized to work on behalf of. When establishing a delegate account for someone who is already a delegate under one or more other primary account holders, make sure to use the same first name, middle name, last name and four digit birth month and day for each application. If an individual is a delegate for more than one primary account holder, they must use a different username and password for each primary account holder. This one to one relationship is necessary for monitoring and auditing. Prescription records are protected health information and proper use of the MA Online PMP is the responsibility of the delegate and the primary account holder for whom they are querying the MA PMP. A primary account holder will have the right to request the audit records for their authorized delegates. The Terms and Conditions for Primary Account Holders and the Terms and Conditions for Delegates can be accessed at To complete the delegate enrollment form you will need the following information for the primary account holder and delegate. Incomplete enrollment forms will be returned to the delegate and the primary account holder will be notified by phone. Information Primary Account Holder Delegate Practitioner Type Name Prescriber DEA Board and Registration Number (if applicable) Title or Degree Business Address Business Telephone Four digit Birth Month and Day Four digit PIN Signature Notarized Signature The delegate applicant should make copies of the completed and notarized form for both the primary account holder and delegate. Mail the original document to: MA Department of Public Health MA Prescription Monitoring Program 99 Chauncy Street Boston, MA Attention: Delegate Enrollment Enrollment is processed by two entities, the MA PMP and the Virtual Gateway (VG), the MA portal platform for the MA Online PMP. The primary account holder will receive the notices regarding the delegate s account and access to the MA Online PMP. The Virtual Gateway will send the delegate s login credentials. The MA PMP Access Administrator will send the delegate s enrollment status and end user instructions. For questions about status of an enrollment, For technical questions, For assistance with password assistance, call the VG at [email protected] [email protected] Primary Account Holder and Delegate Fact Sheet v