Membership Application / Minnesota.gov

Facility Legal Name* (No abbreviations or acronyms)

Bill-to Address Line1

Bill-to Address Line2

Bill-to City

Bill-to State

Bill-to Zip Code

Ship-to Address Line 1*

Ship-to Address Line 2

Ship-to City*

Ship-to State*

Ship-to Zip Code*

Member Website Address*

Primary Contact First Name*

Primary Contact Last Name*

Primary Contact Title

Primary Contact Area Code*

Primary Contact Phone Number*

Primary Contact Email*

Second Contact First Name*

Second Contact Last Name*

Second Contact Title

Second Contact Area Code*

Second Contact Phone*

Second Contact Email*

What type of entity is the member?*

What is the primary purpose of the member?*

Health Industry Number (HIN) - If unknown, leave blank:

Member’s State Pharmacy License Number, if applicable:

DEA Number, if applicable (required for controlled substances):

Pharmaceutical Wholesaler Services (AmerisourceBergen, Cardinal Health, or Morris & Dixon)

Pharmaceutical Reverse Distribution

Pharmaceutical Repackaging

Pharmacy Products

Prescription Drugs (other than vaccines)

Vaccines (other than Influenza)

Over-the-Counter

Nutritionals

Diabetic Supplies (meters/strips/syringes)

Containers and Vials

Influenza Vaccine

Prescription Filling/Pharmacy Services

Animal Health

Emergency Preparedness/Stockpiling

Healthcare Products & Services

Medical Supplies & Distribution Services

Dental Supplies & Distribution Services

Drug Testing Kits & Services

Condoms

Within the past year, has this member been affiliated with a pharmaceutical group purchasing organization (GPO) other than MMCAP Infuse?

Please list the current pharmaceutical GPO Name:

Please list the current GPO products the member currently purchases:

Acute Care

Adult Daycare

Ambulatory Care Pharmacy

Assisted Living

Clinic (if checked, then check all that apply)

City

Dental

Dialysis

Oncology infusion clinic or practice

Outpatient

Radiology Services

State

Surgical

WIC (women, infant, children)

Central Purchasing/Business Office

Community/Public Health Nursing

Corrections

City Jail

County Jail

Juvenile Detention

State Prison

Dentist

Detoxification

Education

School District

Elementary

Secondary

Post-secondary

Emergency First Responders

Emergency Medicine & First Responders

Emergency Preparedness

Health Service Home Health

Home health provider, non-pharmacy

Home infusion

Home medical equipment

Hospice

Hospital (if checked, then check all that apply)

Acute care

City/county/state dialysis

Long-term care

Oncology infusion clinic or practice

Outpatient

Radiology services

Surgical

Juvenile Detention

Laboratory services

Long Term Care

Mail Order Pharmacy

Mental Health (if checked, then check all that apply)

ICF/IDD

inpatient outpatient

Developmental disabilities

No Care Provided

Nursing Facility

Concalescences

Nursing home

Inpatient

Outpatient

Nutrition Services

Patient Population Served

Pediatrics

Adult

Geriatrics

Public Health

Public Safety

Rehabilitation (if checked, then check all that apply)

Inpatient

Outpatient

Skilled Nursing Facilities

Research/Training

Senior Services

Skilled Nursing Facilities

Specialty Pharmacy/Special Care

Student Health

Surgery Center

University

Teaching Hospital

Training or research (clinic research centers)

College student health services

Pharmacy school

Urgent Care Center

Veterans Home - State

Veterinary

Veterinary Medicine

Veterinary medicine - university dept.

Veterinary zoological medicine

MMCAP Infuse Membership Application

Member Information

Member Identifiers

Indicate which MMCAP Infuse programs the member intends to use (Check all that apply)

Which best describes the member? (Check all that apply)