Section 1

This page serves as a PCI Acknowledgement and Attestation. Please use the directions below as a starting point for the agreement.

• Enter your pharmacy name in the name field
• Enter an email address that you have easy access to
• Press the "Process To Document" section to sign and download

Section 2

The attestation describes that you will have a Security Policy and Incident Response Plan – both are included here.

• After signing an email will be sent to the address provided in "Section 1" to confirm your signature
• After confirming the signature, another email will direct you to the sign document for review and download
• Download the "Completed PDF"