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.