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    Section 1: Practice Demographics

    If you are submitting an application for multiple sites under one tax ID, use the toggle below to upload a list of individual locations. Please include all fields in Section 1 & Section 2 for each location.

    Click for Multiple Locations Upload
    Please note that the address for this DEA # must match the practice address.

    Section 2: CPP Enrollment Form

    Indicate which contract(s) you wish to access for each category below (1–6). By opting into a vendor contract, you are agreeing to the purchase guidelines and terms & conditions detailed on each vendor’s pricing sheet(s).

    Need help choosing, or want a cost analysis? Email cpp@nationwidechildrens.org.

    Savings can be maximized and compliance issues avoided by keeping your selections in one color group: Alignment Option A Alignment Option B
    1
    Do you purchase Vaxelis or plan to in the future?
    2
    Pentacel, Daptacel, Quadracel, ActHIB, IPOL, Tenivac, Adacel, MenQuadfi + Beyfortus and those who do not purchase any RSV antibody Pentacel, Daptacel, Quadracel, ActHIB, IPOL, Tenivac, Adacel, MenQuadfi
    3
    RotaTeq, Vaqta, Recombivax HB, MMRII, Varivax, ProQuad, Pneumovax 23, Gardasil 9 RotaTeq, Vaqta, Recombivax HB, MMRII, Varivax, ProQuad, Pneumovax 23, Gardasil 9 + Vaxneuvance, Capvaxive, Enflonsia and those who do not purchase any RSV antibody
    4
    Prevnar 20, Trumenba/Penbraya, Abrysvo, Comirnaty Prevnar 20 or Trumenba/Penbraya or Abrysvo or Comirnaty
    5
    Spikevax, mNexspike, mResvia, mFLUSIVA
    6Influenza vaccines
    Select one or both vendors.
    Fluzone, High Dose, Flublok Flucelvax, Fluad
    Do you purchase FluMist or plan to in the future?

    Individual vendor declaration forms can be found in subsequent pages of the enrollment packet.

    Section 3: W9 Information

    PDF or image, 5 MB max.

    Please note all rebate checks will be mailed to the Business Name & Address listed in the W9 section unless otherwise specified below.

    Participation Agreement for Group Purchases

    Children’s Practicing Pediatricians (“CPP”) has established a group purchase organization (“GPO”) and you have the opportunity to participate in this GPO. When you sign this Agreement below, you authorize CPP to act as your group purchasing agent under agreements which are entered into by CPP with vendors with respect to vaccines and other goods and services (these agreements are collectively referred to here as “Group Purchase Agreements”). You acknowledge that the Group Purchase Agreements specify the amounts CPP may receive in connection with such agreements and purchases by you and that any participating vendor from which you purchase goods or services under the Group Purchase Agreements can pay a fee to CPP. The net fee, after return of any rebates to participant, if applicable, may be up to 3% of the purchase price of the goods or services provided by such vendor, but in some cases will be less than 3% or may be no fee. You agree to abide by the terms and conditions of the Group Purchase Agreements which are made known to you and which are incorporated herein by this reference. The terms and conditions can impact your eligibility to receive discounts. You are responsible for complying with laws and regulations applicable to you and your activities in connection with the Group Purchase Agreements. You understand that CPP is not the seller of the goods or services, is not responsible for actions of the vendors or any defects, defaults or delays by the vendors and payment for the goods and services is to be made by you to the vendor.

    This Agreement may be amended by CPP’s giving written notice of such amendment to you and may be terminated at any time by either CPP or by you by written notice given to the other. Please sign this Agreement below to show your acceptance of these terms.

    Please type your full name below to show your acceptance of this Agreement. Today’s date is added automatically.