Maryland MPX Therapeutics Program: Interest Form

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Please complete the following MPX Therapeutics Program Interest Form. A member of the MPX Therapeutics Team will follow-up with you for more information.

Email *

Jurisdiction (please select the county where the provider site is located): *

Primary Contact Name *

Primary Contact Phone *

Primary Contact Email *

Name of Dispensing Site *

Full Address of Shipping Site (for delivery purposes)
*

Phone Number of Shipping Site (for delivery purposes)
*

Receiving Hours of Shipping Site (for delivery purposes)
*

Special Instructions/Comments
*

I understand that completing this form does not guarantee enrollment or a supply of antivirals. I understand that if my site is selected to receive antiviral medication, I am responsible for weekly reporting in the Federal government's HPOP system and may not charge patients for therapeutic products. I understand failure to abide by program regulations may result in my removal from the program.
*

I understand and agree to these terms.

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