New Member Application

Part 1 of 4

NEW MEMBER APPLICATION

Company Headquarters









~PPFA: Planned Parenthood Affiliates. ~C&U: Colleges, Universities, and Pharmedix. ~CCS: City, county, and state government facilities ~FQHC: Federally qualified health centers and their look-a-likes ~IFP: Independent family planning clinics, offering only family planning services ~SCHOOL SYSTEM: high school systems ~OUTPATIENT/URGENT CARE: outpatient and urgent care clinics not federally funded ~FREE & CHARITABLE: facilities that are registered with the National Association of Free and Charitable Clinics (NAFCC) ~MEDICAL PRIVATE PRACTICE: Private practice physicians that offer more than family planning services ~HOSPITAL OWNED MEDICAL GROUP: hospital affiliated medical practices that do not have hospital locations ~OTHER/CHC: community health centers and other clinics not included in the above definitions. ~HOSPITAL: Hospital or Medical center location ~FEDERAL: Federal government and Military facilities including military mail order. ~CLOSED HMO: highly controlled closed health maintenance organization systems (e.g. Kaiser) – group of physicians that are employees or contract with the HMO.

340b is a government pricing program. To learn more, go to www.HRSA.gov.










Part 2 of 4

NEW MEMBER APPLICATION

List All Locations Associated with your Headquarters
***NOTE: You do not need to re-enter HQ information in this section.*** 
Location 1











Location 2











Location 3











Location 4











Location 5











Location 6











Location 7











Location 8











Location 9










Part 3 of 4

NEW MEMBER APPLICATION

Fill Out Contact Information for Each Contact Listed
Please indicate the main contact for Afaxys Group Services.
***NOTE: We require a minimum of two (2) contacts with unique email addresses.***

Contact 1



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider









Contact 2



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider









Contact 3



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider










Contact 4



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider









Contact 5



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider









Contact 6



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider









Contact 7



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider










Contact 8



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider









Contact 9



Contacts capable of prescribing MUST select Prescriber/HCP. *HCP = Health Care Provider








Part 4 of 4

NEW MEMBER APPLICATION

General Overview of the Types of Products and Services You Utilize




Ex: ABC Alliance, IUDs, vaccines, office supplies, etc.

Ex: IUDs, oral contraceptives, printing paper, uniform services, etc.

Ex: Bayer, Anda, Smith Medical, Staples, Aramark, etc.




This does not affect membership approval.


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