In accordance with Drug Supply Chain Security Act requirements, Intermountain Healthcare requires that the following be completed for every drug transfer in our system. Please complete all of the following fields and attach any transaction documents you have for the drugs you'll be sending to Intermountain Pharmacies.

* Designates required information

Transaction History

Please attach a statement in electronic form, that includes the transaction information for each prior transaction going back to the manufacturer of the product. A previous transaction history from the wholesaler of manufacturer from which you acquired the drug is acceptable.

Allowed file types (you will only be allowed to choose these file types to upload): PDF, DOC, DOCX, RTF, TXT, XLS, XLSX, CSV, JPG, JPEG, PNG, GIF

Transaction Information
Will this ship today? *
Transaction Statement

By digitally signing this form I attest to the best of my knowledge I have complied with the following statements:

  • is authorized as required under the DSCSA
  • received the product from a person that is authorized as required under the DSCSA
  • received transaction information and transaction statement from the prior owner of the product
  • did not knowingly ship a suspect or illegitimate product
  • had systems and processes in place to comply with verification
  • did not knowingly provide false transaction information
  • did not knowingly alter the transaction history