Instructions:

This Authorization is only valid if accompanied by a copy of the license specified in Part C. This Authorization will expire at the time of the expiration of the above-specified license (as applicable to the product ordered). Upon expiration, a new Authorization must be submitted for orders to be processed. If there is a change in Medical Director or Pharmacist-in-Charge, this Authorization will immediately become invalid and a new Authorization, including applicable license(s), must be submitted for orders to be processed.

Please complete this form and submit a copy of the license if appropriate to Customer Licensing by email to Customerservice@lexiconsupply.com or by mail to 4765 E Speedway Blvd. Tucson, AZ 85712. Please call for questions or assistance with this form: (520) 623-3830

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