INTERNATIONAL ASSOCIATION OF PHYSICIANS IN AIDS CARE
225 West Washington Street, Suite 2200, Chicago, Illinois 60606
Fax: 312 419-7160

IAPAC NORVIR ADVISORY
Document: Eligible Provider Enrollment Request
File: INA103A

Definition of Eligible Provider:

The IAPAC Norvir Advisory defines an "Eligble Provider" as a "physician prescribing ritonavir, or a pharmacist who dispenses ritonavir prescriptions, who does not have access to the Internet."

Please type or print.

Name ______________________________________________Degree_______________
Please print - (First) (Middle) (Last)

Telephone ______________________________________

I meet the definition of "Eligible Provider."

Please check one:

( ) I am a physician with approximately __________ patients on ritonavir.
( ) I am a pharmacist who dispenses ritonavir to approximately _____ patients.

Please send me a print copy of the IAPAC Norvir Advisory via (please check one)

( ) FAX (please indicate fax number )_______________________________

( ) Mail Address:__________________________________________________
(Organization, if applicable)

___________________________________________________
(Street Address)

_____________________________________________________
(City)

______________________________________________________
(State/Province)

_______________________________________________________
(Country) (Zip/Mail Code)

I understand that although updates may be made on the IAPAC Norvir Advisory daily, print copies can only be sent weekly.

Date:_________________________

Signature________________________________________