Become a Member - United Rheumatology

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 #

Save and Continue Later

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*

Save and Continue Later

WHY JOIN

UNITED RHEUMATOLOGY?

INNOVATION

THROUGH

COLLABORATION

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