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

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

Health Industry Number

Location 2

Health Industry Number

Location 3

Health Industry Number

Location 4

Health Industry Number

Location 5

Health Industry Number

Location 6

Health Industry Number

Location 7

Health Industry Number

Location 8

Health Industry Number

Location 9

Health Industry Number

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

Contact 5

Contact 6

Contact 7

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.