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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





Health Industry Number







Location 2





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Location 3





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Location 4





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Location 5





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Location 6





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Location 7





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Location 8





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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












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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.


Don’t Forget!

In addition to completing the online membership application below,
be sure to review and sign the membership agreement.

Membership Agreement

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