Before submitting your agreement, be sure you and your pharmacy owner/supervisor have carefully reviewed and considered the pharmacy minimum standards as well as the roles and responsibilities as detailed in the I-CPEN Participation Agreement.

Filling out and submitting these online forms confirms your eligibility as well as participation in the Illinois Community Pharmacy Enhanced Network. You must submit all three of these forms to be considered a network pharmacy of the I-CPEN; make sure all information is correct before submitting each form.

If you have any questions or concerns before submitting this form, do not hesitate to email Harry Zollars at illinoiscpen@gmail.com.

Only one attestation is allowed per pharmacy location or pharmacy division. 

If you prefer to fill out this form on paper, please download the Participation Agreement and email a scanned copy of the Attestation to illinoiscpen@gmail.com

 

ILLINOIS COMMUNITY PHARMACY ENHANCED NETWORK

PARTICIPATION AGREEMENT / ATTESTATION 2017

Participant Information 

 

Pharmacy Credentials

 

I-CPEN Attestation

Our names below indicate that we have read and agreed to the minimum required I-CPEN services, roles, and responsibilities of the Illinois Community Pharmacy Enhanced Network. We commit to providing high quality, high integrity care. We also agree to:

  • Support the Goals of the I-CPEN
  • Offer our expertise to help ensure the health and success of the I-CPEN's initiatives
  • Work with the rest of the I-CPEN participating network pharmacies to communicate details of the network to our most important audiences
  • Complete all necessary training and education as required for participation
  • Provide support for all data collection procedures
  • Actively participate and engage in all requests for our assistance and response

Failure to perform the minimum requirements with the highest integrity may result in removal from the network. All questions regarding our role in the network will be directed to the Pharmacy Contact as defined below. Our names below will constitute admittance to the network from today on.