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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









-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 list all DEA Numbers associated with this organization












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.

Location #2 Information











Location #3 Information











Location #4 Information











Location #5 Information











Location #6 Information











Location #7 Information











Location #8 Information










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




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



Contact #2 Information




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




Contact #3 Information




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




Contact #4 Information




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




Contact #5 Information




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



Part 3 of 3 

General Overview
Types of Products and Services You Utilize




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

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

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




This does not affect membership approval.


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

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