2019 membership Member Application 2019 1 Questionnaire2 Providers3 Practice Details Non-Disclosure Agreement Please review the United Rheumatology Mutual Non-Disclosure Agreement.By checking the box below, I certify that I have read and agree to the terms of the United Rheumatology Mutual Non-Disclosure Agreement* I agree Todays Date* Effective DatePractice Name*Legal Entity Name(If different from Practice Name)Primary DEA on Legal Entity*Primary Practice Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County NamePrimary Practice Phone Number*Tax ID #Primary Practice HIN #The Health Industry Number (HIN) for Providers. The HIN is a unique and standardized identifier that enumerates hospitals, providers, suppliers, and all other partners doing business in the supply chain. HIN is required for linkage to delivery of GPO products.Primary Contact Title*--Select--ProviderOffice AdministratorOffice ManagerBillerMedical AssistantPrimary Contact Name*Primary Contact Phone #*Phone Type:OfficeCellHomePrimary Contact Email* Certification* I certify that I am able to make application to United Rheumatology on behalf of the Practice named above. Number of Additional Locations*--Select--012345678910Additional Location #1Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #2Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #3Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #4Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #5Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #6Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #7Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #8Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #9Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN #Additional Location #10Address* Street Address City --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*PhoneHIN # Number of Full-Time Providers*--Select--0123456789101112131415Number of Part-Time Providers*--Select--012345678910Full-Time Provider #1Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #2Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #3Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #4Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #5Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #6Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #7Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #8Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #9Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #10Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #11Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #12Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #13Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #14Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Full-Time Provider #15Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #1Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #2Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #3Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #4Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #5Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #6Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #7Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #8Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #9Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* Part-Time Provider #10Name* First Middle Initial Last Title*- Select One -M.D.D.O.N.P.P.A.OtherDEA #*NPI #*Email* In-house Infusion?*- Select One -YesNoParticipate in clinical trials?*YesNoCurrent Supplier*CuraScript SD Account # (if applicable)Current Supplier Contract/TermPrimary Order Method- Select One -OnlinePhoneFaxEmailOtherCurrent GPO NameEMR/EHR (system name/vendor)*Is your EMR on a local server in your office or on the cloud?*In my officeOn the cloudI have no ideaPlease indicate whether you consider your practice to be rural, suburban, or urban.*RuralSuburbanUrbanHow did you hear about UR?If conference, UR meeting or UR member, please specify by name. NotesEmailThis field is for validation purposes and should be left unchanged.
