Pharmacy Benefits Report and Medicare Part D & Patient-Centered Medical Home Report Order Form

To receive a copy of the report, please provide the required information in the form below.

By providing the information below you are giving Kikaku America International, who is the publisher of the reports, and the publications' sponsor, Boehringer Ingelheim Pharmaceuticals, Inc., permission to contact you about these publication or their products. To better understand how we intend to use the data you provide on this site, please read our Privacy Policy. We will not sell your information, and you will not receive anything from us that you have not agreed to receive. If you do not want to be contacted by either party, please answer "No" to question #5 (below).

Once the form is completed, please enter "Done" button at the end of the form.

Question Title

* 1. Which report(s) are you requesting?

Pharmacy Benefits Report

Medicare Part D and Patient-Centered Medical Home Report

Question Title

* 2. Please provide the following information about yourself:

Name: *

Company: *

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Email Address: *

Phone Number:

Question Title

* 3. What type of organization do you work for?

Health Plan

Managed Care Organization

PBM/Specialty Pharmacy/Mail Service Pharmacy

Nursing Home/Assisted Living Facility

Pharmaceutical Manufacturer

Other (please specify)

Question Title

* 4. You are:

CEO/President/Chair

VP/Sr. Exec/Director of Markets

Medical Director/Chief Medical Officer

Long Term Care Medical Director

Physician

Pharmacy Director

Clinical Pharmacist

Consultant Pharmacist

Pharmacist

Director of Nursing

Geriatric Nurse Practitioner

Nurse

Office Manager

Consultant/Analyst

Sales/Marketing

Info Spec/Lib/Res

Professor/Educator

Other (please specify)

Question Title

* 5. May we contact you regarding other valuable information?

Yes

If you have any questions please contact Peter Sonnenreich at (202) 246-2525.

Thank you for your order. We will send you the report(s) you requested as soon as possible.