NEW MEMBER APPLICATION

Part 1 of 4

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: 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.


Please enter in the Health Industry Number (HIN #) associated with HQ Location

Please list all DEA Numbers associated with this organization












Part 2 of 4

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





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Location 9





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Part 3 of 4

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



For more than one Contact Functional Role: Hold "Ctrl" and Click on more than one Contact Functional Role









Contact 2












Contact 3












Contact 4












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Contact 8












Contact 9











Part 4 of 4

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.


Contact Information