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Please choose from the dropdown the type of help you are requesting today.
Please choose which type of Account Management assistance you need
Please choose the type of account maintenance you need
Please choose the type of Registration help you need
Please choose whether you need assistance with a new or existing token
Please choose from the dropdown the type of Billing assistance you need
Name of Pharmacy
National Council for Prescription Drug Programs ID - unique pharmacy identifier
Pharmacy Phone Number
Pharmacy Fax Number
If known, please provide the Prescription/Transaction ID
If you received an Error Message please provide
Please choose the date that the issue started
Please enter 9 digits for your NPI number
If you are not an EPCS Affiliate please enter Practice Username. If you are an EPCS Affiliate, please enter Name of Affiliate (Name of EPCS Organization)
To order a brand new EPCS Hard Token, visit: https://hardtokenrequest.drfirst.com/products/onespan-hard-token-device
DrFirst provides a 90-day limited warranty on hard tokens (excludes damage or loss). Ordering a brand new token instead (not a replacement)? Click https://hardtokenrequest.drfirst.com/products/onespan-hard-token-device for new token purchases
Select the number of tokens needed
Provide the number of tokens needed
Please enter the Provider's Full name for the Replacement Token
Please provide the Provider's NPI requesting the Replacement Token
Provide the following information in this free text field: Quantity of Tokens, Token Shipping Address, Invoice Recipient (email,first and last name), Additional Recipients (email, first and last name), and Organization/Practice Name.
Invoice number for Credit Request
Amount for Credit Request
Reason for credit
Please enter reason for Other
Please provide Quote number for Provider Renewing Notification
Environment where error occurred - Production or Non Production
Please choose from the dropdown the type of issue you are having.
Date of Occurrence
Time that Occurrence Happened including Am/Pm. In the following format: 10:00 AM ; 1:30 pm.
What is the Logged in user's Full Name
What is the Logged in User Position Code / Role
What is the Facility's Location Name
What is the Facility NPI
What is the Patient's First Name
What is the Patient's Last Name
Please provide Patient's Date of Birth
What is the Patient's Zip Code
What is the Provider's Full Name
What is the Provider's NPI
Please provide the Medication Name
Please provide the Medication NDC (if known)
Please provide the Medication Sig Info (ex: 1 tablet daily)
Are there any Known recent change(s) updates to environment/EMR/application
Please provide a Transaction ID(s) if applicable, or "NA" if none.
Which product is being used?
Example: Office Visits
Example: 11-Office
Check this box confirming you've attached your Insurance Discovery Request file