Join Our GPO For Group Purchasing | Physicians' Alliance of America

Membership Agreement

Membership is free!

Practice Name (d/b/a)*

Legal Name (as registered with the state)*

Practice Specialty*

Tax ID Number (EIN)*

Is your practice incorporated?*

Yes
No

Year Practice Established

Number of Providers*

Physician/DEA #*

Please list all physicians and their corresponding DEA numbers

Physician First Name	Physician Last Name	DEA #

Number of Locations*

Main Location Address*

Street Address Address Line 2 City State Zip Code

Phone Number*

Fax Number*

Practice Website

Main Location Contact Information

Office Manager Name*

Office Manager Email*

Purchasing Contact Name

Purchasing Contact Email

Managing Physician Name

Managing Physician Email

Additional Locations

Please list all additional locations, addresses, phone numbers and office manager contact information, if different than main location

Street Address	Address Line 2	City	State	Zip Code	Phone Number	Fax Number	Office Manager Name	Office Manager Email

PAA Website Registration

You must provide a valid email address to receive your membership confirmation and Purchasing Guide.

Email Address*

Username*

Password*

Enter Password Confirm Password

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List additional email addresses of all physicians and staff you would like to receive communications:

First Name	Last Name	Email Address

How did you hear about us?*

You selected Other. Please specify.

Purchasing Guide

All members will receive a link to download our Purchasing Guide. Select Yes below if you would also like a PDF copy emailed to you.

Yes, please send me an electronic copy!

Products & Services

To better serve you, please indicate if your practice vaccinates and select any of the below agreements your practice is most interested in.

Our practice currently vaccinates*

Yes
No

Choose areas of interest

Vaccines
IUDs
Professional Liability Insurance
Clearinghouse Services
Patient Communication and Printing

Agreement and Signature

I have read and understand the PAA Membership Terms and Conditions below. By entering my name in the signature box below, I acknowledge receipt and accept the terms as a condition of participation.

Signature*

Agreement*

Yes, I agree

Phone

This field is for validation purposes and should be left unchanged.

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Membership Agreement

Main Location Contact Information

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Products & Services

Agreement and Signature

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