2019 membership - United Rheumatology

Member Application 2019

1Questionnaire

2Providers

3Practice 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*
MM slash DD slash YYYY

Effective Date
Practice Name*
Legal Entity Name
(If different from Practice Name)
Primary DEA on Legal Entity*
Primary Practice Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County Name
Primary Practice Phone Number*
Tax ID #
Estimated yearly drug spend
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*
Primary Contact Name*
Primary Contact Phone #*
Phone Type:
- Office
- Cell
- Home
Primary 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*
Additional Location #1
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County*
Phone
HIN #
Additional Location #2
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County*
Phone
HIN #
Additional Location #3
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County*
Phone
HIN #
Additional Location #4
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County*
Phone
HIN #
Additional Location #5
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County*
Phone
HIN #
Additional Location #6
Address*
Street Address City State ZIP Code
County*
Phone
HIN #
Additional Location #7
Address*
Street Address City State ZIP Code
County*
Phone
HIN #
Additional Location #8
Address*
Street Address City State ZIP Code
County*
Phone
HIN #
Additional Location #9
Address*
Street Address City State ZIP Code
County*
Phone
HIN #
Additional Location #10
Address*
Street Address City State ZIP Code
County*
Phone
HIN #

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Number of Full-Time Providers*
Number of Part-Time Providers*
Full-Time Provider #1
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #2
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #3
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #4
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #5
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #6
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #7
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #8
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #9
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #10
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #11
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #12
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #13
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #14
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Full-Time Provider #15
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #1
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #2
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #3
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #4
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #5
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #6
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #7
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #8
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #9
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*
Part-Time Provider #10
Name*
First Middle Initial Last
Title*
DEA #*
NPI #*
Email*

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In-house Infusion?*
Participate in clinical trials?*
Current Supplier*
Current Supplier Contract/Term
Primary Order Method
Current GPO Name
EMR/EHR (system name/vendor)*
Is your EMR on a local server in your office or on the cloud?*
Please indicate whether you consider your practice to be rural, suburban, or urban.*
- Rural
- Suburban
- Urban
How did you hear about UR?
If conference, UR meeting or UR member, please specify by name.
Notes
Name
This field is for validation purposes and should be left unchanged.

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Member Application 2019

Non-Disclosure Agreement

Additional Location #1

Additional Location #2

Additional Location #3

Additional Location #4

Additional Location #5

Additional Location #6

Additional Location #7

Additional Location #8

Additional Location #9

Additional Location #10

Full-Time Provider #1

Full-Time Provider #2

Full-Time Provider #3

Full-Time Provider #4

Full-Time Provider #5

Full-Time Provider #6

Full-Time Provider #7

Full-Time Provider #8

Full-Time Provider #9

Full-Time Provider #10

Full-Time Provider #11

Full-Time Provider #12

Full-Time Provider #13

Full-Time Provider #14

Full-Time Provider #15

Part-Time Provider #1

Part-Time Provider #2

Part-Time Provider #3

Part-Time Provider #4

Part-Time Provider #5

Part-Time Provider #6

Part-Time Provider #7

Part-Time Provider #8

Part-Time Provider #9

Part-Time Provider #10