Provider Synergies, LLC

Pharmacy & Therapeutics Committee | Public Testimony Registration

1. Name:
2. Company or Organization:
3. Business Address:
4.  
5. Business City:
6. Business State: SELECT A STATE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
7. Zip Code -
8. Preferred E-mail Address: (ex: username@domain.com)
9. Telephone: / - (ex: 800/555-1234)
10. Fax: / -
11. Representation: Check here if you are representing or speaking on behalf of any company / organization.
12. If yes, name company:
13. Affiliation: Check here if you are a private practice physician not affiliated with any manufacturer / organization.
14. Please check the box of the statement that best applies.
15. Statement of No Conflicts: I do not have a current or recent (within the last 24 months) financial arrangement or affiliation with any organization that may have a direct interest in the business before the AHCCCS P&T Committee.
16. Disclosures: I have a financial interest, affiliation or am employed by an organization that may have a direct interest in the business before the AHCCCS P&T Committee.
17. If yes, name organizations and roles

    Organization	Role / Relationship

18. Summary of Testimony:
19. Drug/Product:
20. Therapeutic Drug Class:
21. Testimony Format: Oral
    Written
    

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