ODH Therapeutics Enrollment

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

Question Title

* 1. Site Information

Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Site Phone Number

Question Title

* 2. Primary Contact

Name

Email Address

Phone Number

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

Question Title

* 3. Facility Type

Question Title

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

Child care or day care facility

College, technical school, or university

Community center

Correctional/detention facility

Health care provider office, health center, medical practice, or outpatient clinic

Hospital (i.e., inpatient facility)

In home

Long-term care facility (e.g., nursing home, assisted living, independent living, skilled nursing)

Pharmacy

Public health clinic (e.g., local health department)

School (K - grade 12)

Shelter

Temporary or off-site vaccination clinic - point of dispensing (POD)

Temporary location - mobile clinic

Urgent care facility

Workplace

Other

Question Title

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

Question Title

* 6. Hospitals and Health Systems Served

Question Title

* 7. Long Term Care Facilities Served

Question Title

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

Monoclonal Therapeutics (IV-administration)

Oral Therapeutics

Evusheld

National Provider Identifier

Question Title

* 9. National Provider Identifier (NPI) Number

Ohio Board of Pharmacy Information

Question Title

* 10. Ohio Board of Pharmacy License Number

Question Title

* 11. Ohio Board of Pharmacy Expiration Date

Question Title

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

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File