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Kena Norris

Executive Director

312.227.7406
knorris@ccpapp.org

Paresh Patel

Director of Operations

312.227.7436
papatel@ccpapp.org

Sonia Perez Gandara

Member Relations Specialist

312.227.7508
sgandara@ccpapp.org

Jennifer Jackson

Sr. Administrative Assistant

312.227.7442

jdjackson@ccpapp.org

General Inquiries:

312.227.7444
info@ccpapp.org

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Home.Member Registration

Member Registration

Thank you for your interest in joining CCPA Purchasing Partners (CCPAPP) as a Member!

Before you begin, please carefully review our Membership Agreement.

If you are agreeable to the terms and conditions of this agreement, please proceed with the Membership online application below.

In witness whereof, the parties have caused this Agreement to be executed by their respective authorized representatives, effective as of the date in which the information below is submitted electronically to CCPA Purchasing Partners. The parties expressly agree to enter into this Membership Group Purchasing Participation Agreement in electronic format, to be bound by the terms thereof as expressed electronically, and to the use of an electronic signature process as the parties' intent to be bound by such terms.

Legal Name of Provider *

Practice Name *

Practice Tax Identification Number *

Practice Mailing Address *

Practice Suite

Practice City *

Practice State *

Practice Zip *

Practice Phone *

Practice Fax *

Practice Email *

Name of Authorizing Signatory *

Title of Authorizing Signatory*

Yes, I agree

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.

If you like to add additional practice site for membership,

Please fill out practice information below on behalf of your entire practice.

red color - denotes required fields

Practice Name:

Address:

Suite:

City:

State:

Zip:

Phone
(Format: 123-456-7890):

Fax
(Format: 123-456-7890):

Primary Contact/Office Manager First Name:

Primary Contact/Office Manager Last Name:

Primary Contact/Office Manager Title:

Primary Practice Email:

Practice Type:

Number of Physicians:
Number of Pediatricians:
Number of FP:
Number of OB/GYN:
Number of IM:
Number of Other Speciality(s):
Please Specify Other(if applicable):
Additional Email1:
Additional Email2:

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/).

For questions, please call 312.227.7508 or email info@ccpapp.org.

SECTION I: Participation in CCPAPP’s Contracts with Merck and Sanofi Pasteur

Members may select one (1) of the options in this section. If no option is selected, your practice will not be enrolled in either contract.

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 I: Members may select one (1) of the options in this section

Please indicate your Merck/Sanofi Pasteur contract selection(s) *

If available, please provide your Merck Account Number:

If available, please provide the DEA # associated with this Merck Account:

If available, please provide your Sanofi Account Number:

SECTION II: Participation in CCPAPP’s Contract with Pfizer

Pfizer Contract:
My practice fully supports CCPA Purchasing Partners’ Pfizer contract by agreeing to purchase Pfizer’s Serogroup B Meningococcal (Trumenba) and/or Pfizer’s Pneumococcal Pneumonia (Prevnar 13) vaccine products, as needed.

If available, please provide your Pfizer Account number where indicated below. If you do not have a Pfizer ordering account, please complete the required Pfizer New Ordering Account application and submit it directly to Pfizer. Please inform CCPAPP once you have received your new account number so that we may proceed with linking your account to our agreement.

Pfizer Contract Declination
My practice will not be participating in the Pfizer contracting option at this time. It is understood that CCPAPP’s contracted savings with Pfizer is offered only to members that have signed and submitted this form electing to participate in the Pfizer contract. Should my practice choose to participate at a later time, it is understood that a new Vaccine Contracting & Compliance Form must be submitted.

Section II: Members may select one (1) of the options in this section

Please indicate your Pfizer contract selection(s) *

If available, please provide your Pfizer Account Number:

SECTION III: Participation in CCPAPP’s Contract with AstraZeneca

Members may select one (1) of the options in this section. If no option is selected, your practice will not be enrolled in this contract.

AstraZeneca Contract
My practice would like to participate in CCPA Purchasing Partners’ AstraZeneca contract for FluMist. I understand that in order to Receive CCPAPP’s contracted discounts, I must purchase FluMist through McKesson, VaxServe, or another distributor authorized by AstraZeneca.
To participate in the AstraZeneca agreement, please complete the required AstraZeneca GPO Declaration Form (www.ccpapp.org/vendor- partners/vaccine-forms/) and submit it directly to AstraZeneca. Please provide CCPAPP with a copy of your Declaration Form so we may help to ensure that your practice is linked to the agreement.

AstraZeneca Contract Declination
My practice will not be participating in the AstraZeneca contracting option at this time. It is understood that CCPAPP’s contracted savings with AstraZeneca is offered only to member practices that have elected to participate in the AstraZeneca contract and have signed and returned AstraZeneca’s GPO Declaration Form. Should my practice choose to participate at a later time, it is understood that a new Vaccine Contracting & Compliance Form must be submitted.

Section III: Members may select one (1) of the options in this section

Please indicate your AstraZeneca contract selection*

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 form unless this box has been checked.

Practice Name *

Practice Phone *

Practice Address *

Practice Suite

Practice City *

Practice State *

Practice Zip *

Authorizing Physician First Name *

Authorizing Physician Last Name *

Yes, I agree

Thank you for taking the time to complete CCPA Purchasing Partner's Group Purchasing Participation Agreement and for submitting your Member Login Information, Practice and Physician Details, and the Vaccine Contracting & Compliance Form. Please carefully review the information you have provided for all sections of the Member Registration process. You may go back to a section and make edits by clicking on the section link.

Once you have reviewed your information and are ready to submit your application, please click the button below where you will then be prompted to submit your practice's W-9, if available. You will receive a confirmation message that your information has been submitted. If you do not receive a confirmation, please email info@ccpapp.org or call us at 312.227.7508.

Thank you!

First Name:
Last Name:
Physician Title: (e.g., MD, DO, etc.)
Email:
Gender:
Specialty(-ies)/ Subspecialty(-ies):