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10/17/2018 AgreementMMC" MM CA D: 2-1 Minnesota Mulluatate Contras ' Mg AWjLn_cC for nharm Facility Membership Application Forward the completed application and executed Member Facility Agreement to your State Contact for final processing. (A list of State Contacts may be found at www.mmcap.org, dick on "What is MMCAP," then on "State Contacts.') The State Contact will then forward the authorized form to the MMCAP office for processing. Type or Print Clearly t. Indicate the suecific.le&F may purchase mods and services from MMCAP: (i.e., statutory autho`1`ity to be able to contract with the State offAinnesota or governing board resolution). blank if you need assistance with this question from the MMCAP State Contact or MMCAP. 2. Facility's Full regal Name (no abbreviations): V v 3. Complete "Bill To" Street Address: – f/1 Lown _ City: m Stater Zip: — 4. Complete "Ship To" Street Address, if different: City: State; Zip: * If this application includes multiple ship -to locations contact MMCAP Membership at 651.201.2420 5. Facility Website: �1/11�i / Y10111'�QCOLIYdif'"�I�QOI�� /�I� – I�GIfB __., . 6. What type of entity is the facility? (Check one) 0 State Government County /Parish Government © Municipal Government ❑ Non - government Private– for profit Cl Non - government Private – non -profit ❑ Federal Government 4) 7. What is the primary purpose of your facility? (Check one) 0 Central Purchasing/Business Office Public Safety /First Responders ❑ Correctional Facility ❑ School /College /University ❑ Convalescence /Nursing Facility ❑ Veterinary ❑ Mental Health ❑ Other ❑ Public Health 8. Health Industry Number (HIN), if known: - 0 AMCAP can assist in obtaining this number when the application is processed. indicate need for assists on tine above. 9. DEA Number, if applicable (required for controlled substances): BS14I69 S 10120117 ,oQ Rev. 1212016 Page 2 of 8 10. Facility's State Pharmacy License Number, if applicable: _ ilri i hit& tj 11. Indicate which MMCAP programs the facility intends to use? (Check all that apply) ❑ armacy Program of Pharmaceutical Wholesaler Services (AmerisourceBergen, Cardinal Health, or Morris & Dickson) © Products 13 Prescription Drugs (other than vaccines) 13 Vaccines (other than influenza) 0 Over - the - counter G Nutritionals a Diabetic Supplies (meters /strips /syringes) 13 Containers and Vials • Contract Price Auditing • Returned Goods processing R Pharmaceutical Repackaging Z Influenza Vaccine Program C3 Prescription Filling /Pharmacy Service Program o Student Health Oral Contraceptives Program W l Emergency Preparedness /Stockpiling Program Gf Healthcare Products and Services Program • Medical Supplies & Distribution Services • Dental Supplies & Distribution Services • Drug Testing Kits and Services • Laboratory Supplies • Condoms 12. Is the facility 340E (PHS)* Eligible? *The Federal 340B Drug Pricing Program provides significant pharmaceutical discounts to facilities receiving certain types of Federal government fending. V El Y31 s o 1 Q 1Zb f l 8✓ G'. © Unsure 13. Within the past year, has this facility been affiliated with a pharmaceutical group purchasing organization (GPO) other than MMCAP? (Please check one) dNo ❑ Yes, but the facility is switching to MMCAP. Attach a signed letter on the facility's letterhead stating that it wishes to discontinue your association with its current pharmaceutical GPO and use MMCAP instead. ❑ Yes and the facility will remain with its current GPO. Current pharmaceutical GPO Name: Products the facility currently purchases: Rev. 1212016 Page 3 of 8 14, Which best describes this Facility? (Check all that apply) M Care ❑ Adult Daycare ❑ Ambulatory Care Pharmacy 1] Assisted Living 0 Clinic (if checked, then check all that apply) C1 city Q dental ❑ d rab.[rs 13 oncology bif rrion c/nuc orprnrtice ❑ orrtpatrerrt ❑ radiology rervicer ll state Q tragical ❑ ill C (rvomu, mfw , ebild)rn) ❑ Central purchasing /Business Office CI Community /Public Health Nursing O Corrections ❑ city fail ❑ carrnt�� fail ❑ slate PHron Ct Dentist 0 Detoxification 0 Education ❑ .drool distrirl ❑ Ole rrrellmu R second -19 ❑ pasl- secandag Emergency First Responders 1➢( Emergency Medicine & Ambulance Emergency Preparedness Health Service ❑ Home Health ❑ home bealtb provider, non pbarirrag ❑ home infusion CI bome wediral egrripmenl ❑ Hospice ❑ Hospital (if checked, then check all that apply) 13 acute care ❑ tity/cannly /stale ❑ draj�arr ❑ long -terra care ❑ oncology iufrrrion rliuit ar prartire ❑ ontpadent ❑ r'adiology reivires ❑ srr►gical 13 Juvenile Detention ❑ Laboratory services ❑ Long Term Care ❑ Mail Order Pharmacy fa Mcntal ]Health (if checked, then check all that apply) Q I'CF'rbiR (inteswediate care fadkoforaieutally re coded) ❑ inpatient ❑ mrtp atient G denelopnrPnta! dirabilities CI No Care Provided ❑ Nursing facility ❑ cotmalernnces ❑ nursing bonne CI inpalierrl U vinpadvit ❑ Nutrition Services fl Other (State and Local Gov't) healthcare related: ❑ P Population Served Cf prdial&s k� adult geriatrics M( Public Health Public Safety ❑ Rehabilitation (if checked, then check all that apply) CI hpatient ❑ outpatient ❑ skilled nurSir�adlifies ❑ Research /Training ❑ Senior Services ❑ Skilled Nursing Facilities • Specialty pharmacy /Special Care • Student Health ❑ Surgery Center ❑ University (if checked, then check all that apply) ❑ leaching hospital © training or rraearrh (elnuc rgrearrh centerr) Cl callege stxdenl heahh remwr ❑ pharnrary school ❑ Urgent Care Center ❑ Veterans Home — State 0 Veterinary ❑ veterrnay. medicine 0 voerimg nredidne — u n i v e rrdy d ept a ve vina3 toological n Rev. 12; 2Q 16 Page 4 of 9 EacilitxContacts: Not all facilities will have three contacts. Listing at least one main contact person is required. 15. Designated Facility MMCAP contact person: U Title A LSISMNE Phone: &L" aff - 05' Fax Email Address- 1 6. Alternate facility MMCAP contact person: V9U wad C�}! �f pp Title: DEN f ___ Phone. SPEW -60 Fax: M3-W I = Email Address: hUdM-*J40 IRMWIN -ft 02V 17. Facility's Purchasing MMCAP contact person: Lf Title: Moye &W-se-WE __ __ Phone: 345 -g" --BOOS Fax: SO a- -G33 Email Address: APPROVALS Applicant Facility: The information above is true and correct. Signed: Facility Representative MMCAP State Contact Review: Date: Forward signed application and agreement on to the applicable MMCAP State Contact for final processing. A list of MMCAP State Contacts may be found at ; ti.. 3na':1 } - ate , click on "Wh is MMCAP," then on "State Contacts." Facilities located in Connecticut, Illinois, Massachusetts, Ohio, and Pennsylvania mail directly to mncrnJj ,cl;at fti st:ttr,.n}t3_�rs. 1 have reviewed aykd approve the facility's eligibility for membership in MMCAP. Signed: Contact Date: !-6 1 412 Rev. 12/201 G Page 5 of 8 V UN Minnesota Multistate Contracting Affiance for Pharmacy 511 Sherburne Avenue, Suite 112, St. Paul, MN 55155 651.201 -2424 wmy,.n3mcap.org Member Facility Agreement This Agreement is by and between the State of Minnesota, acting through its Commissioner of Administration on behalf of Minnesota Muldstate Contracting Alliance for Pharmacy ("MMCAP') and 01#006 &Udff Facility's complete legal name (do not use acronyms) �/ XSili�lll„ 1?a� lfll�►J�{/fi`f.�r`��rllh +►l�l�sT - . MMCAP is a free, voluntary, public sector group purchasing organization for government- authorized facilities and is operated by the Materials Management Division of the State of Minnesota's Department of Administration. It combines the purchasing power of its members to receive the best prices available for the products and services for which it contracts. Membership in MMCAP is limited to facilities with which the State of Minnesota may contract, as defined by Minnesota Statutes Section 471.59, subdivision 10. The.Member Facility desires to access MMCAP's programs to purchase products and services for the Member Facility. 1. Term of Agreement and Cancellation This Agreement, which is required by 42 C.F.R. § 1001.9520) and Minnesota law, will be effective upon the date it is fully executed by all parties; and will remain in effect until cancelled by MMCAP or the Member Facility. This Agreement may be cancelled by either party upon 30 days' written notice to the other party, or immediately upon material breach by one of the parties. 2. Member Pacllity The Member Facility. A. Certifies it has authority to enter into this Agreement with the State of Minnesota and, where applicable, authorizes MMCAP to negotiate contracts on its behalf. For non- government entities, also certifies it has statutory authority under which it may purchase goods and services from its state's contracts. B. Must comply with all applicable laws, rules, and regulations governing government purchasing of pharmaceuticals, and related products and sen'ices when utilizing MMCAP contracts and programs. C. Should endeavor, where practical, to purchase its goods and services from MMCAP contracts. D. Acknowledges it will be bound by applicable antitrust laws (Robinson - Parman (15 U.S.C. 13 (a)) and purchase products for its "own use" as defined by Abbott Lab; a Pon'lasd Rftail Daiggists (425 U.S. 1(1976)) and feffrrrar Comft Pbarmacen calAsivriation, Inn. P. AbbottLabs (460 U.S. 150 (1983)). R Will not resell (as may be prohibited by law) or divert products obtained under the MMCAP contracts, if there are any questions about the propriety of the use of products purchased from the MMCAP contracts, the Member Facility will obtain an opinion from its legal counsel and notify MMCAP of the decision. F. When applicable, acknowledges that the prices made available under M1vMCAP's contracts may represent a discount to price that must be properly and accurately accounted for and reported in accordance with all federal and state laws, including the anti - kickback law (42 C.F.R. § 1320a 7b(b)(3)(A)) and regulations thereunder (42 G.F.R. §1001.952(h)). Rev. 12;2016 Page 6 of 8 G. Must comply with the terms and conditions of the applicable MMCAP vendor contract data sheets; found on the MMCAP website at wN%tis, . H. Understands that MMCAP is not liable for any denied pricing, chargeback, refusal of vendors to honor contract pricing, or failure of vendors to deliver the products or services. THE MEMBER FAC ACKNOWLEDGES THAT MMCAP IS NOT THE MANUFACTURER OR DISTRIBUTOR OF ANY PRODUCT AND SERVICE AND MAI(ES NO REPRESENTATION AS TO WARRANTY OF QUALITY, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, CONDITION, OR OTHER ATTRIBUTE OF THE PRODUCTS SUPPLIED BY VENDORS UNDER. MMCAP CONTRACTS. I. Must update MMCAP regarding changes to the Member Facility information and contact person information. J. Must promptly pay MMCAP contracted vendors for all products or services purchased. MMCAP does not assume any responsibility for the accountability of funds expended by the member Facility. K. May be inactivated from MMCAP membership if there is no participation for 18 consecutive months. 3. MMCAP MMCAP will: A. Select products or services for cooperative contracting under the programs offered. B. Comply with Minnesota laws, including procurement and data practices, that require fair and open competition. C. Make available copies of contract documents. D_ Maintain vendor performance records. E. Assist in resolving administrative, contract, or supplier problems that cannot be resolved by the Member Facility. F. Provide information to the Member Facility regarding products and services available through the MMCAP program. G. Distribute to Member Facilities any unused administrative fees collected from contracted vendors (Article 4 below); and annually disclose in writing to Member Facilities, and to the Secretary of the United States Department of Health and Human Services upon request, the amounts received by MMCAP from vendors that were directly attributable to the Member Facility's purchases. 4. Admirdstrative Fee Collected from MMCAP's Vendors The MMCAP Managing Director may, pursuant to contract terms and conditions, require the contracted vendors (not Member Facilities) to pay an administrative fee to MMCAP. The fee of not more than three percent will be based on a percentage of sales made through the individual contracted vendor. Fees will be collected by the MMCAP office and used to pay for the administrative costs incurred in the operation of MMCAP as approved by the MMCAP Managing Director. Any remaining balance of funds will be returned to active members by means of either a credit to their wholesaler or distributor account, or other mechanism agreed to by the parties, in an amount proportional to the Member Facility's on- contract purchases. S. Assignment, Amendments, Waiver, and Contract Complete 5.1 Assignment. Neither patty may assign or transfer any rights or obligations under this Agreement without the prior consent of the other party and a fully executed assignment agreement. 5.2 Amendments. Any amendment to this Agreement must be in writing and will not be effective until it has been executed and approved by the same parties who executed and approved the original agreement. 53 Waiver. If either party fails to enforce any provision of this Agreement, that failure does not waive the provision or its right to enforce it. Rev. 129 =6 Page 7 of 6. ]Liability Each party will be responsible for their own acts and behavior and the results thereof Nothing in this membership agreement will be construed as expanding the limits of liability of the Member Facility beyond the limits of the law of its state. MMCAP's liability is governed by the Minnesota Tort Claims Act, Minnesota Statutes Section 3.736, and other applicable laws. 7. State Audits As mandated by Minnesota Statutes Section 160.05, subdivision 5, "the hooks, records, documents and accounting procedures and practices of the [Member Facility] relevant to this Agreement shall be made available and subject to examination by the State of Minnesota, including the contracting agency /division, Legislative Auditor, and State Auditor" for a minimum period of six years after the termination of this Agreement. IN WITNESS WHEREOF, the undersigned parties represent they have the authority to bind their respective patty and have signed intending to be bound thereby. Member Facility: State of Minnesota, through its Commissioner of (Person with legal authority t o biisd the facility) Administration on Behalf of M �n Bv- 7; JUI—L By; +'' Tid F d Title, Date: Date: _..1 L-/ Commissioner of Administration, os delegated ro rbe Materials lanagemeni Division: By: /,fps Date: Rev. 1212016 Page 3 of a