Membership Application "*" indicates required fields 1Contact2Company Info3Services4Notes GeriMed Rep*(If you have yet to speak with a GeriMed Rep, enter ‘None at the moment’.)Check One* LTC (Closed-Door) Pharmacies Combo Pharmacies Purchase Only Sublocade Pharmacies Network Only Pharmacy Name*Pharmacy Address* Street Address Address Line 2 City * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State * Zip Code * Contact Name* First Last Title*Email* Enter Email Confirm Email Phone*Fax*Wholesaler (Primary)*Retail Account # (Primary)*LTC Account # (Primary)Wholesaler Representative (Primary) Name*Wholesaler Representative (Primary) Phone*Wholesaler Representative (Primary) Email* Wholesaler (Secondary)Retail Account # (Secondary)LTC Account # (Secondary)Wholesaler Representative (Secondary) NameWholesaler Representative (Secondary) PhoneThis field is hidden when viewing the formWholesaler (Secondary) Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Owner/President* First Last Email* Pharmacist in Charge* First Last PIC License*Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.Email Director of Operations First Last Email Purchasing Agent*Contact that is in charge of ordering for Pharmacy First Last Email Retail Buying Group*N/A if not applicableDEA #*Global Location Number (GLN)Retail NCPDP #*Retail NPI #*LTC NCPDP #LTC NPI # Check box if you have not yet been assigned LTC NCPDP and NPI numbers for your combo pharmacy associated with DEA# above. Tax ID*State Pharmacy License*Is this pharmacy under the same ownership of any other pharmacies currently a member of GeriMed?* No Yes (if ‘Yes’, enter required info below) Existing GeriMed /ComboMed/ ‘Network Only’ Affiliation*Pharmacy Group/NameLTC NCPDP Add RemoveDispensing Software Company*(please list software COMPANY, not software name)Does your pharmacy use a reconciliation vendor?* No Yes Enter Name of Vendor*DEA Certificate Copy*Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.EIN/Tax ID Documentation*Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.This field is hidden when viewing the formPharmacy PermitAccepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.State Pharmacy License/Pharmacy Permit*Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.Liability Insurance*Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.List of Long Term Care Facilities Serviced(required for some manufacturer contract access)Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB. Are you currently dispensing any Long Acting Antipsychotic Injections (LAIs)?*YesNoIf so, how many patients do you service that are receiving LAIs on a monthly basis?*Please enter a number greater than or equal to 1.Are you dispensing or are you interested in dispensing sublocade?*Please SelectYesNoMust provide a number of 25 Patients for at least one LTC setting or 50 if only servicing LTC at Home Patients or the application will not be processed.Skilled Nursing / Nursing HomeNumber of Facilities*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Skilled Nursing or Nursing Home Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Assisted LivingNumber of Facilities*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Assisted Living Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Group Home / Board & CareNumber of Facilities*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Group Home/Board & Care Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Intermediate Care (ICF-IID) (formerly ICF-MR)Number of Facilities*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Intermediate Care (ICF-IID) (formerly ICF-MR) Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Mental Health / Psychiatric Facilities or Outpatient Mental Health CentersNumber of Facilities*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Mental Health / Psychiatric Facilities or Outpatient Mental Health Centers Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.LTC Pharmacy at HomeNumber of LTC Pharmacy at Home Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.CaremarkPlease enter a number greater than or equal to 0.Percentage of PatientsOptumPlease enter a number greater than or equal to 0.Percentage of PatientsExpress ScriptsPlease enter a number greater than or equal to 0.Percentage of PatientsHumanaPlease enter a number greater than or equal to 0.Percentage of PatientsOtherPlease enter a number greater than or equal to 0.Percentage of PatientsCorrectionalNumber of Jails or Prisons*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Correctional Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.HospiceNumber of Hospice Serviced*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Number of Hospice Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Home InfusionNumber of Home Infusion Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Continuing Care Retirement Community (CCRC)Number of Continuing Care Retirement Community (CCRC) Patients*Please enter a number greater than or equal to 0.Please enter a number greater than or equal to 0.Total # of PatientsHow did you hear about us?*Member ReferralTrade ShowWholesaler ReferralWebsite InquiryOther*For Other, please specify*Must provide a number of 25 Patients for at least one LTC setting or 50 if only servicing LTC at Home Patients or the application will not be processed. NotesCAPTCHACommentsThis field is for validation purposes and should be left unchanged. Prefer to download the application? GeriMed Membership Application for Long Term Care Pharmacies ComboMed Membership Application for Combo Pharmacies
