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Contact Us                                                                                                        

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
 
 

Vaccine Forms

To participate in CCPAPP's Vaccine Contracting Program, please submit the items below. Please note that you must be a member of CCPAPP to participate in our vaccine or vendor program. To become a member, please visit our Join page.

CCPAPP Vaccine Contracting Compliance Form - to be completed if your practice would like to participate in CCPAPP's Merck, Sanofi Pasteur, Pfizer, and/or AstraZeneca contract(s).This form allows you to select one contract option. Please ensure the form is signed and dated.

Depending on which vaccine contract(s) your practice elects, please submit the following:

Pfizer:

  • Pfizer New Ordering Account Application - to be completed if your practice would like to set up a direct ordering account with Pfizer.  Direct ordering is necessary for participation in discount pricing for Trumenba (Meningicoccal Group B Vaccine).

Sanofi Pasteur:

  • Sanofi Pasteur New Customer Form - to be completed only if your practice does not have an existing Sanofi Pasteur Account. If you have an existing Sanofi Pasteur account, please indicate your Sanofi account/customer number on the CCPA Purchasing Partners Vaccine Contracting Compliance form and complete the Sanofi Pasteur General Information Form noted below.
  • Sanofi Pasteur Contract Change Form – Membership (CCF) - to be completed by practices electing the Sanofi Pasteur agreement that have an existing account/customer number. Please also indicate your account number on CCPAPP's Vaccine Contracting Compliance form where indicated.

Merck:

  • Merck Application for Direct-Purchase Account - to be completed only if your practice does not have an existing Merck Account. Please submit the following with your Application: Copy of State Medical License(s) and DEA Certificate(s). If you have an existing Merck account, you do not need to complete a new application. Simply indicate your Merck account number on the CCPA Purchasing Partners Vaccine Compliance Commitment form.
  • Merck Request to Modify an Existing Direct-Purchase Account - to be completed if your practice does have an existing Merck Account and would like to make the following account modifications: add/delete a permanent shipping location, update current shipping/billing address, update office delivery times, and other modifications.

AstraZeneca:

  • AstraZeneca's GPO Declaration Form (coming soon) - to be completed if your practice would like to order AstraZeneca's FluMist product at CCPAPP's contracted rate. Orders must be placed through McKesson or another authorized distributor for AstraZeneca. When placing orders with McKesson, you may use the McKesson FluMist Order Form. (Please note that the early pre-booking window for the 2021-2022 season has been extended to April 30, 2021.)
  • If your practice does not currently use McKesson but would like to set up an ordering account, please complete a McKesson Customer Application and CCPAPP-Premier ProviderSelect:MD Application

Please note that the timeframe for being linked to our vaccine contracts is 5 business days for existing accounts and 7-10 business days for new accounts.

 

 

 

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