Prior to completing this form, please review the compliance requirements outlined below as well as the information provided in CCPAPP's Vaccine Contracting Guide (https://www.ccpapp.org/members/vendor-vaccines-pricing/). Once your practice understands the requirements of each contract, please complete all four sections of this form. Completed forms may be emailed to CCPAPP at applications@ccpapp.org or faxed to 888.276.2344. You may also complete this form online by logging into your account on the CCPAPP website and clicking on Vaccine Contracting & Compliance (https://www.ccpapp.org/members/).
Merck and Sanofi Pasteur Contracts:
My practice fully supports CCPA Purchasing Partners' Merck and Sanofi Pasteur contracts by agreeing to purchase Merck's Hepatitis A (Vaqta), Hepatitis B (Recombivax HB), MMR (M-M-R II), Varicella (Varivax), HPV (Gardasil/Gardasil9), Rotavirus (RotaTeq), and Pneumococcal (Pneumovax23) vaccine products as needed. My practice also agrees to purchase Sanofi Pasteur's Polio, Pertussis, HIB products (Pentacel, IPOL, DAPTACEL, and Quadracel), Meningococcal (Menactra or MenQuadfi), and Tdap (Adacel) vaccine products as needed.
If available, please provide your Merck Account number and your Sanofi Pasteur Customer number where indicated below. Please also complete and return the Sanofi Pasteur General Information Form if you have not done so previously. If you do not have a Merck and/or a Sanofi Pasteur ordering account, please complete the required Merck New Account application and/or Sanofi Pasteur New Customer Form and submit the documents directly to the vaccine manufacturer. Please inform CCPAPP once you have received your new account number(s) so that we may proceed with linking your account(s) to our agreements.
Merck Contract Only:
My practice fully supports CCPA Purchasing Partners’ Merck contract by agreeing to purchase Merck’s Hepatitis A (Vaqta), Hepatitis B (Recombivax HB), MMR (M-M-R II), Varicella (Varivax), HPV (Gardasil/Gardasil9), Rotavirus (RotaTeq), HIB (PeVax HIB) and Pneumococcal (Pneumovax23) vaccine products as needed.
If available, please provide your Merck Account number where indicated below. If you do not have a Merck ordering account, please complete the required Merck New Account application and submit it directly to Merck. Please inform CCPAPP once you have received your new account number so that we may proceed with linking your account to our agreement.
Sanofi Pasteur Contract Only:
My practice fully supports CCPA Purchasing Partners' Sanofi Pasteur contract by agreeing to purchase Sanofi Pasteur’s Polio, Pertussis, HIB products (Pentacel, IPOL, DAPTACEL, and Quadracel), Meningococcal (Menactra or MenQuadfi), and Tdap (Adacel) vaccine products as needed.
If available, please provide your Sanofi Pasteur Customer number where indicated below. Please also complete and return the Sanofi Pasteur General Information Form if you have not done so previously. If you do not have a Sanofi Pasteur ordering account, please complete the required Sanofi Pasteur New Customer Form and submit it directly to Sanofi Pasteur. Please inform CCPAPP once you have received your new account number so that we may proceed with linking your account to our agreement.
Merck and Sanofi Pasteur Contracts Declination:
My practice will not be participating in any of the above Merck and/or Sanofi Pasteur contracting options at this time. It is understood that CCPAPP’s contracted savings with Merck and/or Sanofi Pasteur are offered only to member practices that have elected to participate in the respective contract(s) and have signed and submitted this form. Should my practice choose to participate at a later time, it is understood that a newVaccine Contracting & Compliance Form must be submitted.
Section IV: Acceptance to Compliance Terms and Own-Use Requirements
On behalf of my practice, I understand and agree to the compliance terms listed for the contract option(s) selected on this form. I understand that CCPAPP’s discounted pricing applies only to the contract(s) selected on this form and that pricing through another manufacturer or distributor is at the discretion of that vendor.
Additionally, I understand and agree that any vaccine product purchased under any of CCPAPP’s contract options selected on this form is sold to members of CCPAPP for their "own use" and no such product purchased hereunder by my practice may be commercially resold to any other person or entity.
To help ensure that your practice is accurately linked to our discounts, CCPAPP may provide your practice name, address, and/or other information listed on this form to any or all of our business partners. Please check this box to acknowledge that you are aware that your information may be shared. Please note: CCPAPP cannot process your application unless this box has been checked.
Section V: Vaccine Contracting & Compliance Form
Please download and review the compliance requirements outlined in (CCPAPP’s Vaccine Contracting & Compliance Form). Once your practice understands
the requirements of each contract, please complete all sections of this form. For questions,
please call 312.227.7508 or email info@ccpapp.org.
Please select the vaccine contract(s) your practice wishes to participate in and enter your account information. If your practice does not have an account number, please visit each manufacturer’s website to obtain an account number.
Merck Contract
Merck Account Numbers(s):
DEA Number (if available):
Sanofi Pasteur Contract
Sanofi Account Number(s):
Merck/Sanofi Pasteur Vaxelis Performance Contract
Sanofi Account Number(s):
Pfizer Contract
*A CCPAPP staff member will be in touch with your practice shortly with instructions for how to register for Prevnar 13 and/or Trumenba on Pfizer’s Prime Contracts Portal.
Pfizer Account Number(s)*:
AstraZeneca Contract
On behalf of my practice, I understand and agree to the compliance terms listed for the contract option(s) selected on this form. I understand that CCPAPP’s discounted pricing applies only to the contract(s) selected on this form and that pricing through another manufacturer or distributor is at the discretion of that vendor. Additionally, I understand and agree that any vaccine product purchased under any of CCPAPP’s contract options selected on this form is sold to members of CCPAPP for their “own use” and no such product purchased hereunder by my practice may be commercially resold to any other person or entity.
To help ensure that your practice is accurately linked to our discounts, CCPAPP may provide your practice name, address, and/or other information listed on this form to any or all of our business partners. Please check this box to acknowledge that you are aware that your information may be shared. Please note: CCPAPP cannot process your application unless this box has been checked .
Premier Contract
As a Certified Premier Sponsor, CCPAPP members will have access to Premier’s highly competitive portfolio of more than $56 billion in purchasing volume and 2,800 + contracts. We partner with Premier, one of the largest group purchasing organizations covering more than 1 in 2 healthcare providers.
The program is specifically designed for independent physician practices, medical groups and other affiliates who are seeking trusted and creative ways to maximize cost efficiencies while delivering quality patient care. Members typically realize an aggregated savings of 15%. Membership is risk-free, with no fees to join and no compliance or commitment levels to meet.
Portfolio of Offerings:
- Medical/Surgical Supplies (McKesson)
- Pharmaceuticals (Brand Name, Generic, and Vaccines)
- Laboratory Supplies
- Office Products and Equipment (Staples and Warehouse Direct)
- Cell Phone Discounts (AT&T, Sprint, and Verizon)
- Car Rental (Hertz)
- Professional Footwear (Pedors and S&H)
- Paint Products and Supplies (Benjamin Moore and PPG)
- Reusable Textiles and Textile Services (Scrubs4Me)
Apply for Premier Today:
Submit Application
IMPORTANT:
FINAL STEP:
IMPORTANT: To complete our membership application process, a current W-9 Form is required from your practice . If you are unable to submit your W-9 Form at this time, a member of our staff will be in touch shortly to collect your W-9.