Hidden fields 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 Yes List of individual locations * Excel, CSV, Word, or PDF, 5 MB max. Practice Name * Phone Address Physician DEA # OR HIN # Please note that the address for this DEA # must match the practice address. Cell Email * Contact Name/Title * EMR Vendor Medical Supplies Vendor/Distributor 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. Watch the enrollment overview on YouTube 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? YesNo 2 Sanofi Account # Enroll - Tier 1Enroll - Tier 2Do Not Enroll 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 Merck Account # For indirect purchasing, your DEA # or HIN # will be used. Enroll - Roster 1Enroll - Roster 2Do Not Enroll 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 Pfizer Account # An invitation will be sent from Pfizer for you to complete the enrollment. Enroll - Full PortfolioEnroll - SelectDo Not Enroll Prevnar 20, Trumenba/Penbraya, Abrysvo, Comirnaty Prevnar 20 or Trumenba/Penbraya or Abrysvo or Comirnaty 5 Moderna Declaration Form Download the form, complete it, and upload it here. PDF or image, 4 MB max. EnrollDo Not Enroll Spikevax, mNexspike, mResvia, mFLUSIVA 6Influenza vaccines Select one or both vendors. Enroll - SanofiEnroll - CSL SeqirusDo Not Enroll Fluzone, High Dose, Flublok Flucelvax, Fluad Sanofi Account # Seqirus Declaration Form Do you purchase FluMist or plan to in the future? YesNo AstraZeneca Declaration Form Your selections mix Alignment Options A and B. That can reduce savings or cause compliance issues. Email cpp@nationwidechildrens.org if you’re unsure which partnerships fit your group. I agree to the terms & conditions outlined on each of the pricing sheets of the vendor programs for which I am enrolling. Individual vendor declaration forms can be found in subsequent pages of the enrollment packet. Section 3: W9 Information Upload your signed W9 here * PDF or image, 5 MB max. Blank W9 Form: www.irs.gov/pub/irs-pdf/fw9.pdf Please note all rebate checks will be mailed to the Business Name & Address listed in the W9 section unless otherwise specified below. Mailing Name & Address (if different from above) 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. Full Name * Date