National Physician Care

NPC Group Purchasing Program Membership Agreement

AS A MEMBER OF NPC, I AGREE TO KEEP ALL PRICING AND CONTRACT INFORMATION CONFIDENTIAL EVEN AFTER THE TERMINATION OF ANY MEMBERSHIP.

I agree that all pricing and contract information shall be kept confidential both during the pendency of my membership, and after any termination by me or NPC of my membership.

I recognize that the purchasing programs offered by NPC may include an administrative fee paid by the contracted pharmaceutical companies/vendors to NPC. Such compensation may be a fixed amount or a percentage of the value of purchases made by your Medical Practice from a vendor, but in no case shall it exceed three percent (3%) without appropriate notification to your Medical Practice.

Furthermore, I understand that some contracted pharmaceutical companies/vendors may impose purchasing requirements as a condition of participation in our contracts for their respective discount program(s). Membership in NPC does not automatically provide access to NPC’s pharmaceutical company/vendor contracts. I understand that I am bound by NPC’s contracts with its pharmaceutical company/vendors and I agree to review each pharmaceutical companies/vendor’s Contract Enrollment Form that I intend to use and abide by any requirements and conditions contained therein.

NPC represents and warrants that it is a Group Purchasing Organization and its activities comply with applicable state and Federal laws, including the relevant provisions of the Federal "Safe Harbor" regulations found at 42 C.F.R § 1001.952(h) and (j). On the reporting timeline required, your medical practice, by executing this Agreement, agrees to disclose and appropriately reflect any discount or reduction in price received in any cost report submitted to any governmental programs including, but not limited to, the Medicare and Medicaid programs.

This Group Purchasing Program Membership Agreement shall remain in effect for one year from the date of signature unless terminated by either party upon thirty (30) days advance written notice. Unless otherwise notified, this agreement shall renew for additional one-year periods on the anniversary date each year hereafter.

Authorized agent for:*

Practice Entity:*

DEA # for your main office*

DEA Expiration Date*

HIN # for your main office*

Name

First*

Last*

Title*

Primary Email*

Primary Office Address

Street Address*

Suite Number

City*

State*

ZIP Code*

Phone*

Phone Extension

Fax*

Website - Must start with "http://www."
All websites must feature http://www.

Managing Physician

First*

Last*

Title*

Managing Physician Email*

Type of Practice

Pediatric

Family Practice

Internal Medicine

Travel Medicine

Practice Manager

First*

Last*

Title

Practice Manager Email*

Representative Responsible for Office Purchasing

First*

Last*

Office Purchasing Representative Email*

Number Of:

Office Locations*

Physicians*

Nurse Practitioners*

P.A.s*

Authorized Signature*

By signing this document, I hereby authorize and appoint NDC NPC, LLC as our group limited purchasing agent for the purpose of negotiating contracts pursuant to which we may purchase goods and services for our use as long as this Group Purchasing Program Membership Agreement and NPC’s manufacturer contracts remain in effect. I hereby acknowledge that I will be bound by the terms of both this Group Purchasing Program Membership Agreement and any NPC manufacturer contracts in which I elect to enroll.

Date*

Print Name

First*

Last*

Date*