MED Membership Application

Thank you for your interest in becoming a MED Group Member. Please fill out the following information to get started with the application process. All applications will be reviewed by our Membership team and applicants will be contacted to discuss their membership qualifications. You may also fax this printable version to 806-687-1307 or call 800-825-5633 for assistance.

First Name:		Phone:
Last Name:		Mobile:
Title:		Fax:
Email:

Company:
Website:
Address:
City:	State:	Zip:

Annual Revenue:		Employees:
Year Founded:
Branch Locations:
Organizations:
AAHomeCare: State Association: RESNA: NRRTS: AARC: NCART:
Buying Groups:
Accreditation:
JCAHO: CHAP: ACHC: ISO: HQAA: Compliance Team:
Ownership:
Independently Owned: Hospital Affiliated: Publicly Held: Subsidiary of Parent Corporation:

Accreditation:	Competitive Bidding:	Operations:	Repair:
Benchmarking:	Employee Management:	Orthotics:	Respiratory/Sleep:
Business Financing:	Managed Care:	Regulatory:	Retail:
Business Modeling:	Mobility:	Reimbursement:	Supply Costs:

Traditional HME:	%	Respiratory Services:	%
Rehab & Assistive Technology:	%	Supplies:	%
Pharmaceutical Services:	%	Other:	%

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MED Membership Application

Contact Information

Alternate Contact Information

Company Information

Organizations:

Buying Groups:

Accreditation:

Ownership:

Please indicate the most important areas of concern for your business:

Please indicate the percentage of your business in each of the following categories:

Please indicate your top 5 suppliers and the purchasing volume in dollars of each of these suppliers:

Supplier 1:		Volume:
Supplier 2:		Volume:
Supplier 3:		Volume:
Supplier 4:		Volume:
Supplier 5:		Volume:
I hereby attest that our company is inquiring about MED Membership. I also attest, as the submitter below, that I am authorized to make these decisions for my company.