To enroll your pharmacy in ProfitAmp, please complete the required fields, sign where indicated and submit. Once all parties have reviewed and signed the agreement, you'll receive a copy for your records and FDS/AAP will begin the ProfitAmp onboarding process.
Click here to review the ProfitAmp Service Agreement.
Should you have questions, please contact AAP Member Support at 877-797-9227 or email firstname.lastname@example.org.
Authorization to Release Pharmacy Data
The undersigned pharmacy has an agreement with the pharmacy management system vendor named above ("PMS Vendor"), wherein PMS Vendor has agreed to perform certain services for pharmacy. The undersigned pharmacy authorizes and directs PMS Vendor, to deliver, certain information, including protected health information, contained in pharmacy claims transactions to FDS, for purposes of FDS performing ancillary services for the Pharmacy.
By executing this agreement, the undersigned pharmacy confirms that, notwithstanding anything to the contrary, PMS Vendor can deliver this data to FDS on behalf of pharmacy. The undersigned pharmacy hereby represents and warrants that it has all the rights, authority and necessary consents, business associate agreements, and approval to grant this authorization.
This authorization shall remain in effect until pharmacy provides FDS with written notice of termination with a copy to PMS Vendor. This Agreement contains the full understanding of the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and communications, whether oral or written, between the parties with respect to such subject matter.
Data Collection and Transfer Agreement
This agreement is entered into between New Tech Computer Systems, Inc. (being referred to as "NT") and the pharmacy listed below (being referred to as the "Pharmacy"), on the date that is shown below.
1. The “Pharmacy” expressly authorizes NT to collect from the “Pharmacy” prescription transaction data (“Data”) and to format and transfer the collected “Data” to the FDS MyDataMart data program.
2. The collection, aggregating, formatting, and transfer of “Data” shall be performed by “NT”. The “Pharmacy” is required to take no active participation in this process. Such authorization for data collection and transfer shall continue until revoked with 90 days written notice to NT.
3. In consideration for the storing, formatting and transferring this data, "NT" will charge the "Business Associate" who will pay on behalf of the "Pharmacy". No remuneration shall be paid for the data itself.
4. “NT” shall not be liable for any direct or indirect, consequential, special, exemplary or incidental damages (including but not being limited to lost profits, loss of good will or labor costs) related to the transfer of the “Data”. “Pharmacy” agrees to indemnify and hold “NT” harmless from any liability, expenses (including reasonable attorney’s fees), costs, damages, settlements.
5. The undersigned warrants that he is fully authorized to execute this agreement.
QS/1 Data Collection Authorization Form
Service Description: myDataMart through FDS, Inc. is business intelligence tool that provides interactive dashboards, reporting, along with planning and analysis capabilities. For more information, or for pricing, please contact FDS, Inc. or visit www.fdsrx.com.
Enrollment Information: Your signature is required for QS/1 to enroll your pharmacy in the myDataMart service.
By signing below I understand and authorize QS/1 to enroll the above pharmacy in the myDataMart service, which requires QS/1 to collect data, including Protected Health Information if applicable, and securely transmit it to FDS, Inc.
Fee Quotation & ACH Authorization
Per the terms and conditions outlined in Section 3 of the ProfitAmp Service Agreement, I understand that AAP will collect the Monthly Fee for the Full Service use of the ProfitAmp System on the 1st day of each calendar month, as set forth below.
I hereby authorize American Associated Pharmacies (THE COMPANY) to initiate debit entries to my checking account at the financial institution (THE FINANCIAL INSTITUTION) listed below, and if necessary, initiate adjustments for any transactions credited in error. This authority will remain in effect until THE COMPANY is notified by me in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it. In the event of Insufficient Funds or a Returned Item/ACH, I hereby authorize THE COMPANY to immediately deduct all program subscription fees and insufficient funds/returned item fees from future rebate and/or dividend payments made by THE COMPANY or its subsidiaries.