This form is used to enroll as a site to receive and administer monoclonal antibody and oral therapeutics.

Facilities will be prioritized based on need, ability to meet previous weekly utilization using allocation and quantity on hand. All product ships directly from the distributors.

Product is allocated in cycles. Once your enrollment information is received and verified, account(s) will be created for the site with the distributor and in the HHS utilization management platform (HPOP).

Product is allocated in two-week cycles and you will receive your first survey at the start of the next ordering cycle.


Site Information

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* 1. Site Information

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* 2. Primary Contact

Please choose the facility type closest matching your organization.

Facility Type Description
FQHC FQHCs and independent pharmacies located within FQHCs. 
Free-Standing Emergency Departments and Urgent Care Urgent care, Free Standing EDs
Health Systems (outpatient) Ambulatory Surgical Sites, cancer centers and other outpatient health system settings.
Home Health Agencies and mobile clinics Home health and home infusion services.
Hospitals Hospital (all types)
Independent Clinics All clinics and administration sites not falling in another category (outpatient providers, stand up clinics, etc.)
Independent Clinics - Specialized Specialized clinics and medical practices service immunocompromised patients.
Infusion and Dialysis Centers Outpatient infusion and dialysis centers.
Pharmacies - Long Term Care Pharmacies serving primarily or exclusively long term care facilities
Pharmacies - Retail Retail pharmacy not within a health system
Pharmacies - Retail Health System Retail pharmacy within a health system.
Public Health Local health departments
Rural Health Clinics Rural health clinics

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* 4. Setting(s) where this location will administer products (select all that apply)

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* 5. Population(s) served by this location (select all that apply)

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* 6. State Provider PIN (also known as your COVID-19 vaccine ordering PIN); if none, enter NONE

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* 7. Hospitals and Health Systems Served

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* 8. Long Term Care Facilities Served

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* 9. Which product(s) are you interested in enrolling?

Ohio Board of Pharmacy Information

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* 10. Ohio Board of Pharmacy License Number

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* 11. Ohio Board of Pharmacy Expiration Date

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* 12. Please attach Pharmacy/TDDD License (if available)

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