Healthcare Provider Registration


The following registration form will allow you to create a user accout to access our comprehensive database of patient assistance programs. Registration information will be used to give us a better understanding of who is using our site so that we may better serve you. Your personal information will remain confidential and will not be shared with any outside party. You can read more about our privacy policy here.

*	First Name:
*	Last Name:
	Organization:
	Address:

*	City:
*	State:
*	Zip Code:
	Phone:


*	Email:
*	Confirm Email:
*	Password:	(Your Email Address will be your Login User Name)
*	Confirm Password:


	1. Which of the following best describes you?
*
	a. If you picked "Other" above:


	2. Which best describes your organization?
*
	a. If you picked "Physician's Office" above, please indicate specialty of physician?

	b. If you picked "Other" above:


	3. In one year, how many patients do you think you will help apply to patient assistance programs?
*	0-50 51-100 101-250 251-500 501-1000 1001+


	4. How long have you been using RxAssist.org?
*	New user Under 6 months 6-12 months 1-2 years 2+ years


	5. How did you hear about RxAssist.org?
*
	a. If you picked "Other" above:

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