MA Healthcare Professional Opt Out Request Form

The Commonwealth of Massachusetts enacted a regulation, 105 CMR 970.000, which requires pharmaceutical manufacturers to provide Massachusetts prescribers an opportunity to request that their prescriber data:

  • Be withheld from company sales representatives, and
  • Not be used for marketing purposes.

Please complete the following information if: 1) you want your prescriber data to be withheld from Endo Pharmaceuticals for sales and marketing purposes, or 2) you have previously requested that your prescriber data be withheld from Endo Pharmaceuticals for sales and marketing purposes, and you no longer want this data to be withheld from Endo Pharmaceuticals.

First Name:
Last Name:
Zip Code:
e.g., 94105-0011
E-mail address:
You will only be contacted if you cannot be identified
State License No:
Date of Birth:
MM/DD/YYYY
National Provider ID (NPI):
Click here to lookup our NPI. If you do not have one enter a zero('0')

Per Massachusetts law 105 CMR 970.000 I am requesting to have my data withheld from company sales representatives and not used for marketing purposes:

Request
(Selecting No will remove any previous request to withhold data)
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I certify to the best of my knowledge that the information given is truthful, accurate, and was provided by me.