Home About Us Events Info Joining Members Tell Us Your Story Third-Party Payers Contract Services
Summer 2008 Newsletter
News Release
Winter Meeting, Houston TX
Membership Application
New Member Application
Updated Information

HTC Name:
Contact Name:
Contact E-mail:
Address:
 
City:
State:
Zip:
Phone:
Fax:
Please tell us more about your program:
Is your HTC based in a hospital?
Yes   No
Is Your Out-Patient Factor Program:
340B only   340B and non-340B (Dual Inventory)
Do you have a contract pharmacy?
Yes   No
Do you use 340B drugs for Medicaid beneficiaries?
Yes (Please make sure you have submitted your Medicaid Provider Number to the Pharmacy Affairs Branch. If you have questions about this, please call the number at the end of this form.)
No

How did you hear about the Hemophilia Alliance?


Dues can be paid in two equal installments in January and July and will be assessed as follows:

Start-up: no clotting factor sold in previous 12 mths. but HTC is starting a program - $1,000/yr

Medium: HTC that sold <10 million units of clotting factor in previous 12 mths - $5,000/yr

Large: HTC that sold >10 million units of clotting factor in previous 12 mths - $9,000/yr

Dues are pro-rated based on when in the year you join the Hemophilia Alliance



If you have questions about this form, please call Joe Pugliese at (215-439-7173). Please e-mail the completed form to joe@hemoalliance.org or fax it to 215-279-8679. Thank you!
Copyright © 2008 Hemophilia Alliance