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If your organization is ready to maximize its operating budget, please provide the following information. A member of our Customer Care team will be in touch shortly.

NEW MEMBER APPLICATION

Part 1 of 3

Company Headquarters

Name of Entity

Physical Address

City

State

Postal Code/Zip Code

Phone

Location Type

HQMedical CenterExpress CenterWarehousePharmacyLaboratoryMobile UnitAdmin Office

Class

-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 Qualified?

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

340b ID #

DEA Number(s)

Please list all DEA Numbers associated with this organization

Profit Type

% of Medicaid

% of Managed Medicare

% of Cash Payers

% of Commercial Payers

% of Donations/Charitable Care

How many scripting providers are in your organization (MD, DO, NP, PA)?

How many total locations in your organization?

Which of the following Organizations are you members of (check all that apply)?

NACHC – National Association of Community Health Centers, Inc.NAPHP – National Association for Public Health PolicyNSHD – National Survey of Health and DevelopmentNACCHO – National Association of County and City Health OfficialsNAFCC – National Association for Family Child CareNFPRHA – National Family Planning and Reproductive Health AssociationNAF – National Abortion FederationOtherNone

How did you hear about us?

Select additional information

Please specify "Other"

ADDITIONAL LOCATIONS

Please indicate ALL additional locations associated with your organization.

NOTE: You do NOT need to list your organization's HQ Location's details here.

This application allows you to add UP TO 8 locations.

If you fill out all 8 locations, we will contact you to see if there are any additional that you would like to add.

Does your organization have a second location?

Location #2 Information

Location #2 Name

Physical Address

State

City

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Does your organization have a third location?

Location #3 Information

Location #3 Name

Physical Address

City

State

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Does your organization have a fourth location?

Location #4 Information

Location #4 Name

Physical Address

City

State

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Does your organization have a fifth location?

Location #5 Information

Location #5 Name

Physical Address

City

State

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Does your organization have a sixth location?

Location #6 Information

Location #6 Name

Physical Address

City

State

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Does your organization have a seventh location?

Location #7 Information

Location #7 Name

Physical Address

City

State

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Does your organization have a eighth location?

Location #8 Information

Location #8 Name

Physical Address

City

State

Zip

Phone

Location Type

Medical CenterExpress CenterWarehousePharmacyLaboratoryOtherMobile UnitAdmin Office

Is this location 340b qualified?

340b ID #

Part 2 of 3

Contact Information

Please indicate the main contact for Afaxys Group Services.

***NOTE: We require a minimum of two (2) contacts with unique email addresses.***

Contact #1 Information

First Name

Last Name

Title

Contact Functional Role

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

Phone

Check "Yes" if Contact 1 is the main contact

Yes

Contact #2 Information

First Name

Last Name

Title

Contact Functional Role

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

Phone

Check "Yes" if Contact 2 is the main contact

Yes

Would your organization wish to provide a third contact?

Contact #3 Information

First Name

Last Name

Title

Contact Functional Role

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

Phone

Check "Yes" if Contact 3 is the main contact

Yes

Would your organization wish to provide a fourth contact?

Contact #4 Information

First Name

Last Name

Title

Contact Functional Role

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

Phone

Check "Yes" if Contact 4 is the main contact

Yes

Would your organization wish to provide a fifth contact?

Contact #5 Information

First Name

Last Name

Title

Contact Functional Role

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

Phone

Check "Yes" if Contact 5 is the main contact

Yes

Part 3 of 3

General Overview

Types of Products and Services You Utilize

Contraceptives

Contraceptive RingImplantsInjectablesIUDsOral Contraceptives (OCs)Patch

Medical

EquipmentOther Medications / PharmaceuticalsRepackaged PharmaceuticalsSuppliesUltrasound MachinesVaccines

General Business

Automated MessagingDocument Storage and ShreddingOffice Supplies and PaperScanning and CopyingSignageTelephone Services

What types of products and services are you interested in purchasing through the Afaxys GPO?

Ex: IUDs, PPE , vaccines, office supplies, etc.

What products or services do you currently purchase most often?

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

What distributors/suppliers do you currently purchase from?

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

Estimated Annual Spend on Medical Supplies

Estimated Annual Spend on Business Supplies

Estimated Annual Spend on Other Services

Are you a member of another GPO?

This does not affect membership approval.

GPO Name

Please check this box if you have reviewed all information above and it is true, complete and accurate to the best of your knowledge.

Yes

Contact Information

Don’t Forget!

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

Membership Agreement

Is the Afaxys GPO right for us?

Industry-leading products and services at your fingertips.

View Our FAQs

Perfect for Clinics

"Afaxys has truly been a business partner to our Affiliate. They have provided exceptional customer service, advocated with vendors on our behalf and have been extremely responsive, resourceful and friendly."
- Sandy, Purchasing Director

Perfect for Cost Savings

"Our organization realized monthly savings of +$3,000 shortly after implementing Afaxys GPO contract pricing. There was no effort involved on our part. It takes a village, and Afaxys has been the Town Hall."
- Mary, Customer

Perfect for Supply Chain Management

"The Afaxys agreement with McKesson for medical supplies provides annualized savings of 18.7% ($42,040.19). Working with Afaxys to identify opportunities really pays off!"
- John, Purchasing / Supply Chain Manager

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