Medical Director Sponsor Registration Medical Director Sponsorship Registration If you are human, leave this field blank. View a list of included benefits with your registration! Company Details Company Name * Name of Contact * Phone * Email * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Does your company or organization require provisions or restrictions for sponsorship monies? * Yes No Please Describe: * Medical Director Meeting Details Date * September 10, 2020 December 4, 2020 Title of Presentation * Please submit an electronic sponsor logo and title of your presentation along with a 50 word or less description of your organization. Company Profile Description (50 words or less): * Company Logo * Drop a file here or click to upload Choose File Maximum upload size: 100MB Participants Participant 1 Name * Title * Phone * Email * Participant 2 Name Title Phone Email Payment and Terms Is your company an OAHP Affiliate or Supporting member? * Yes - $5,000 No - $7,500 Which Member? * Access 2 Care Allergan AMAG Pharmaceuticals Amplifon Hearing Healthcare AstraZeneca Bayer Healthcare Biodesix Biogen CAQH CareCentrix Conexia, Inc. Delta Dental Dialyze Direct Exact Sciences Genentech Gilead Sciences HMA Merck Neurocrine Biosciences Newgen Software Novo Nordisk Optum OSU Health Plan Partners for Kids PerformRx Provide A Ride Sarepta Therapeutics Squire Patton Boggs UCB Pharma Vatica Health Veyo LLC Total to be processed: Payment Method * Check: Mail to OAHP, 230 E. Town St., Suite 200, Columbus, Ohio 43215 PayPal / Credit Card Payment is requested within 45 days of registration date. All cancellations for general or non-Convention OAHP Sponsorship opportunities MUST be received in writing by OAHP 45 days prior to the scheduled event to receive a refund less an amount equal to 25% of the total sponsorship amount. After the 45 day advance event cancellation deadline, then the full sponsorship payment is still required even if sponsor is unable to participate or OAHP is able to resell the the sponsorship opportunity. NO cancellations will be accepted or refunds issued for no-shows. By submitting this electronic form you provide OAHP the authority to charge the credit card provided and agree to all terms. Submit
