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 EnlivenHealth/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 membersupport@rxaap.com.

Select ProfitAmp Participation Level:*

Full Access Service Monthly Assessment (No Access) Service

Pharmacy Name (DBA)*

City/State*

NCPDP*

Phone*

Email*

Corporate Structure*

(i.e. Wisconsin LLC, California Corporation)

Estimated Average Rebate % from All Suppliers*

Average Number of Prescriptions Dispensed Per Month*

Pharmacy Management System*

Only pharmacies using one of the systems listed above are eligible to participate.

Please note that your software vendor may charge your pharmacy a nominal monthly fee to send your dispensing data to ProfitAmp. Contact your software vendor for more information.

By initialing here, I confirm that I have read and agree to the ProfitAmp Service Agreement linked above, and by submitting the applicable information below, I represent and warrant that such information is true and correct and that I agree to be bound by, and have the legal authority to enter into, the ProfitAmp Service Agreement on behalf of the pharmacy and/or legal entity listed below.*

[clear]

Use your mouse or finger to draw your initials above

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.

Terms and Conditions

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.

RedSail Technologies Service Authorization Form

myDataMart by FDS

An authorized signature is required for RedSail Technologies, LLC ("RedSail") to enroll your pharmacy in the MYDATAMART service ("service") as described below.

Service Description: The Service is a business intelligence tool that provides interactive dashboards, reporting, along with planning and analysis capabilities.

Enrollment and Pricing Information: For more information, including any applicable pricing, visit fdsrx.com. To enroll please return completed form to FDS.

By signing below I authorize RedSail to enroll the above Pharmacy in the Service as described above. The Service requires RedSauk to collect data, including Protected Health Information, from the Pharmacy and securely transmit the data to Service provider. The Pharmacy understands that FDS is the Service provider and that the Pharmacy is responsible for obtaining any applicable patient authorizations required to utilize this Service. The Pharmacy agrees to notify RedSail in writing if it desires to terminate the Service.

I attest and affirm that I am authorized to sign this Authorization on behalf of the Pharmacy.

System ID*

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.

$179 ProfitAmp Full Access Monthly Fee for first pharmacy location for AAP Members
$169 ProfitAmp Full Service Monthly Fee for each subsequent pharmacy location for AAP Members
$199 ProfitAmp Full Access Monthly Fee for each pharmacy location for API Customers

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.

Business Name (as it appears on the account below)*

Bank Name*

Routing No*

Account No*

Bank Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Pharmacy Signature (Covered Entity)*

[clear]

Use your mouse or finger to draw your signature above

Date*

Name*

First Name

Last Name

Title*

Unique PMID*

AAP or API No*

Pharmacy Name (Legal/Corporate)*

Fax*

DEA/HIN No*

NPI*

Federal Tax ID*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

ProfitAmp Fee*

Full Access - AAP Member: $179/month for first pharmacy location Full Access - AAP Member: $169/month for each subsequent pharmacy location Full Access - API Customer: $199/month for each pharmacy location Monthly Assessment - AAP Member: $0 Ineligible to Participate