Membership Application

New Member Application
Updated Information

HTC Name:
Contact Name:
Contact E-mail:
Address:
 
City:
State:
Zip:
Phone:
Fax:

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?

Dues can be paid in two equal installments in January and July and will be assessed as follows:
Start-up: no clotting factor sold in previous 12 mths. but HTC is starting a program – $1,000/yr
Medium: HTC that sold <10 million units of clotting factor in previous 12 mths – $5,000/yr
Large: HTC that sold >10 million units of clotting factor in previous 12 mths – $9,000/yr

Dues are pro-rated based on when in the year you join 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!

Latest News
Healthcare Reform 2010: New Details

Details of our September Meeting, “Healthcare Reform 2010″, with special guest Dr. Mary Wakefield, Administrator HRSA, have been posted! Click here to see them. (more)

340B Coalition Meeting, Summer 2010

The recent 340B Coalition Meeting yielded a number of informative presentations. Members can click here to access them… (more)

Upcoming Events
  • September 12, 2010: Fall 2010 Meeting of the Hemophilia Alliance: Healthcare Reform 2010: Special Guest Dr. Mary Wakefield, Administrator HRSA (more)
Members Map
Contact Information
info@hemoalliance.org
Tel: 215-279-9236
Fax: 215-279-8679
Hemophilia Alliance
1758 Allentown Road
#183
Lansdale, PA 19446