Pharmacy and Therapeutics Committee Application
This application is not open to persons representing the pharmaceutical industry, healthcare/pharmaceutical
consultants/lobbyists and employees of the pharmaceutical industry - see ACOM 111 AHCCCS Pharmacy
and Therapeutics Committee for more information.
Instructions: Please complete this application for consideration for membership on the AHCCCS P&T Committee.
If questions are not applicable, enter “NA”. Note: in addition to this application, applicants should include a
resume and/or curricula vitae.
Type of Application (select one):
Initial Appointment Reappointment
Position applying for (select category then choose from dropdown):
Health care provider
O
ther:___________________________________________________
M
embers of the public
AHCCCS Managed Care Organizations (MCOs) and Regional Behavioral Health Authority (RBHA)
representatives:
CONTACT INFORMATION
_____________________________ _____________________________ ____________________________
LAST FIRST MIDDLE
____
_______________________________________ _____________________________________________
ADDRESS CITY
_______ _______________________ _______________________________________________________
STATE ZIP COUNTY
____
_______________________ ___________________________ _____________________________
HOME PHONE OFFICE PHONE MOBILE
__________________________________________________ ____________________________________
EMAIL FAX
CURRENT EMPLOYMENT
(if applicable)
___________________________________________ _____________________________________________
BUSINESS/ORGANIZATION NAME CURRENT POSITION/TITLE
____
_______________________________________ _____________________________________________
ADDRESS CITY
____
___ _______________________ _______________________________________________________
STATE ZIP PHONE
Select One
Select One
Select One
AHCCCS P&T Committee Application - 2/2020
Professional Licenses, Registrations, Certifications and/or Experience:
Experience with AHCCCS Programs:
Are you currently an AHCCCS registered provider? Yes No
AHCCCS P&T Committee Application - 2/2020
Conflict of Interest Disclosure
As detailed in the Committee Operational Policy ACOM 111, Committee members and public individuals
external to the Committee who provide verbal or written public comment to the Committee shall not:
a. Be employed by, subcontract with, or directly or indirectly represent a pharmaceutical
manufacturer,
b. Be employed by, subcontract with, or directly or indirectly represent a pharmacy benefits
management (PBM) company,
c. Receive payments or compensation from the pharmaceutical industry in excess of the physician
mean general payment amount for the most recent year as specified on the CMSO Open Payments
website at openpaymentsdata.cms.gov.
Thus, any individual who meets a., b. or c is not eligible for serving on the Committee or providing
external public comment to the Committee.
Please initial the following:
I am not employed by, subcontract with, or directly or indirectly represent a pharmaceutical
manufacturer;
I am not employed by, subcontract with, or directly or indirectly represent a pharmacy benefits
management (PBM) company; and
I do not receive payments or compensation from the pharmaceutical industry in excess of the
physician mean general payment amount for the most recent year specified on the CMSO Open
Payments website at openpaymentsdata.cms.gov
The purpose of this Conflict of Interest Disclosure form is to require the individual completing the form to
affirmatively identify any potential conflicts of interest of that individual with respect to matters coming
before Committee to ensure that information considered by the Committee is evaluated in an impartial
manner.
The following individuals shall disclose any financial relationship, affiliation, or other relationship with any
organization that may have a direct or indirect interest in business that may be considered by the
Committee:
1. Committee members prior to serving on the Committee and at other timeframes described in the
Committee Operational Policy; and
2. Individuals external to the Committee interested in providing verbal or written public comment to
the Committee prior to providing comment to the Committee.
A financial relationship may include, but is not limited to: being employed by, being on retainer, having
research or honoraria paid by, or receiving other forms of remuneration from any organization that may
have a direct or indirect interest in business that may be considered by the Committee.
An affiliation other than one that is financial in nature may include holding a position on an advisory
committee or some other role or benefit to a supporting organization.
AHCCCS P&T Committee Application - 2/2020
The existence of such financial relationships or affiliation does not necessarily constitute conflict of
interest and will not preclude an individual from participating as a Committee member, or, for an
individual external to the Committee, from providing verbal or written public comment to the Committee.
Disclosures (select one)
I do not have a current or recent (within the last 24 months) financial relationship or
affiliation with any organization that may have a direct or indirect interest in the business
before the Committee.
I have a financial relationship or affiliation with an organization(s) in the past 24 months
that may have a direct or indirect interest in the business before the Committee. Please
complete table below.
Organization*
Role / Relationship*
*List additional organizations and role/relationships on additional page(s) if necessary
Your Attestation
I affirm under penalty of law that the information I have provided on this form is true, accurate,
and complete to the best of my knowledge.
Name: ______________________________________________
Signature: ______________________________________________ Date: __________________
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