Access site type - Choose one before moving on*

Access Site Profile

Shipping Address*
Billing address
Billing Address
Pharmacy Type - Check all that apply*
Tax Status*
Facility description - Check all that apply*
Open-door Pharmacy*
Mail order services*

Patient Information

What guidelines do you use to qualify patients for free/reduced cost prescriptions?*
What guidelines do you use to qualify patients for free/reduced cost care?
Are you accepting new patients?*
Do you require proof of income?*
What documentation do you accept?*

Pharmaceutical Access

Is your pharmacy currently subsidizing prescriptions for low income patients?*
Additional medication sources:*
Does your facility purchase medicine?
Is your facility able to store medication in a regulatory compliant manner?*
Does your clinic require a special permit to dispense donated medication?*
Do you have cold storage capability?

Contact Information

Senior Leader Name*
Include any credentials ex. PharmD, MD,
Senior Pharmacy Leader*
Pharmacist In Charge*
Date of Birth*
Primary Contact placing orders*
Secondary Contact Placing orders - if different from above
Dispensary of Hope Annual Fee Invoice Recipient*
Medical Director Name*
MD Date of Birth

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Signature

I hereby certify that the statement and information in this application form are true and correct to the best of my knowledge and belief.

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