Welcome to OPGA: The Orthotic & Prosthetic Group of America


	Membership
		Application
		Dues
		Standards of Conduct
		Participating Manufacturers

	Services
		Patient Care Clinic
		ABC Accreditation
		O&P 101

	Suggestion Box
	OPGA Department Directory
	Glossary of terms
	Estimating the Value of Your O&P Business
	Forms Library


	M.A.S. Qualified Prosthetists

Fill out the form below, or print it out,
and fax it to 888-449-0610
Or, if you prefer, mail to

OPGA
PO Box 1467
Waterloo, IA 50704
Attn: Jim Andreassen

General Information

Company
AKA
Mailing Address
City
State
Zip

Ship Merchandise
Address
City
State
Zip
Time Zone	East Central Mountain Pacific
Phone
Toll-Free

Is your fax machine on at night?	Yes No
Fax
Contact Name

Catalog Information

Purchasing Agent
Catalog Shipping Address
City
St
Zip

Internet Information

Do you utilize a computer as a business tool?	Yes No
Do you have an E-mail address?	Yes No
Email Address
Does your company have a website?	Yes No
URL of website
Does your company access the Internet from the office computer(s)? Yes No
If Yes: Bookmark our site: http://www.opga.com

Owner
Owner SS#
Do you belong to other buying groups? Yes No
Who?

Insurance Information

Do you carry comprehensive liability insurance?	Yes No
Would you like OPGA Insurance to provide you a quotation (or comparison quotation) within 15 minutes of your call?	Yes No
Contact Person For Insurance Concerns:

Financial Service Information

Do you use any type of equipment financing?
Bank Leasing Co. Manufacturers
Who are they?
Financial Services Contact

Accounts Payable Information

Number of Employees
Number of Years in Business
Business Hours
Accounts Payable Contact Person
Estimated Annual Sales

Telephone Information

Telephone Service Contact
Long distance phone service
Would you send us a copy of your most recent long distance bill for a comparable quote? Yes No

Branch Information

Do you have any branch facilities?	Yes No
Number of stores
Branch 1 address
Facility Manager
Phone
Fax

Branch 2 address
Facility Manager
Phone
Fax

Branch 3 address
Facility Manager
Phone
Fax

Branch 4 address
Facility Manager
Phone
Fax

HOMELINK Information

HOMELINK Contact Person
County
NPI #
Medicare #
Medicaid #
Are you accredited?	Yes No
By whom?	ABC BOC Other
Federal Tax ID #
Do you currently contract with HMOs and/or PPOs? Yes No

What products or services are you able to provide?

24 Hour Phone Yes No
High tech wheelchairs
Manual wheelchairs
Electric wheelchairs
Patient lifts
Mastectomy

Orthotics
Prosthetics
DME Products
Sports Medicine
Shoes

Comments

OPGA Associate
Date

By submitting this application, I authorize OPGA to enroll my company in its programs and I authorize Participating Manufacturers in OPGA to release credit information pertaining to the company listed above to OPGA. I also understand that OPGA is under no obligation to grant membership. Membership may be cancelled at any time by either party. Participating Manufacturers are under no obligation to grant dealership status to OPGA Members.

OPGA: The Orthotic and Prosthetic Group of America
PO Box 1467 | Waterloo, IA 50704
800-214-6742 | Fax: 319-274-4468