Get Form A Sponsor Enrollment Form

Filling out the FORM A SPONSOR ENROLLMENT FORM online is a crucial step for facilities looking to enroll as sponsors with The Safety Net Foundation. This guide will provide you with detailed, step-by-step instructions to ensure a seamless enrollment process.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Complete the sponsor (facility) mailing information section. Enter the name of your facility, the contact person's name, title, facility numbers, NPI, DEA, and HIN.
3. Provide your facility's mailing address, including city, state, phone number, zip code, and fax number. Also, include an email address for communication.
4. Select your preferred method of written communication. Indicate both the primary and secondary methods by checking the respective boxes for email, postal mail, or fax.
5. Indicate if your facility is part of a chain or group-purchasing organization by providing the name of the organization.
6. Specify the type of sponsor by selecting one from the list provided: physician office, hospital, pharmacy, dialysis center, etc.
7. If your facility utilizes a third-party administrator (TPA), fill out the additional information required for that section, including TPA company name and contact details.
8. If applicable, complete the pharmacy director information section by providing the director's name and contact details.
9. Confirm the shipping address for any products needed by your facility, especially if different from the mailing address.
10. Review the sponsor certification and consent section. Ensure all required agreements are acknowledged and signed by the authorized representative. Include the date and title.
11. Once all sections are completed, save the changes to your form. You can then download a copy, print it, or share the completed form as needed.

Begin filling out the FORM A SPONSOR ENROLLMENT FORM online to ensure your facility is successfully enrolled.