Membership Application

	New Member Application
	Updated Information

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? If you have questions about this form, please call Joe Pugliese at (215-279-9236). Please e-mail the completed form to joe@hemoalliance.org or fax it to 215-279-8679. Thank you!