DTA Membership Application

Name of Organization*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website*

Phone

Type of Organization*

If other, please describe:

Number of employees (only for dues Category 3):

This is used to assess annual dues for Category 3 organizations: healthcare insurers, payers, PBMs, trade associations, CROs, analytics or data companies, and wholesalers.

Annual global revenue (only for dues Category 5):

This is used to assess annual dues for Category 5 organizations: pharmaceutical and biotechnology manufacturers, medical technology companies, device or diagnostics companies, and technology companies.

Industry Engagement

Describe your organization's interest in digital therapeutics and engagement within the industry:*

If applicable, outline your product portfolio as it relates to the development, support, and/or utilization of digital therapeutics:

Outline the regions and countries your organization is actively engaged in:

Describe your organization's engagement with regulatory agencies:

Percentage of your company’s product portfolio dedicated to the development and market engagement of digital therapeutics:

DTA Engagement

DTA’s mission is to broaden the understanding, adoption, and integration of clinically-validated digital therapeutics into mainstream healthcare through education, advocacy, and research.

Describe the value your organization will provide to furthering the mission and goals of the Alliance:

In line with DTA’s mission, companies engaged in the development, support, and utilization of digital therapeutics must be actively committed to the following core principles for all DTx products. Please indicate your organization’s support of:

Work Groups your organization would like to be considered for:

Industry Definitions and Taxonomy
Evidence & Clinical Guideline Integration
Healthcare Operations Integration
Quality & Regulatory Engagement
Value, Coverage & Reimbursement

Work Groups focus on Alliance priority issues and initiatives. Representatives from all member companies are eligible to apply for participation.

Designated Liaison

Primary individual responsible for communication with DTA.

Name*

First Last

Title*

Email*

Phone

Office Location*

Membership Invoice Contact

Primary individual responsible for receiving and processing membership invoices.

Name*

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone

Application Submission

In submitting this membership application, the applicant agrees to the following:*

Applicant acknowledges support of DTA’s mission and goals.
Applicant agrees to pay annual dues as determined by the DTA Board of Directors and comply with the provisions of the DTA Bylaws and Membership Agreement (available upon request).
Applicant certifies that the information in this application is true and correct.

Name*

First Last

Title*

Email*

Date*

Notices

DTA reserves the right to follow up with member applicants to clarify any of the information provided in this application. Once approved, members must sign a membership agreement, inclusive of the code of conduct, and make payment of applicable dues before membership becomes official. DTA reserves the right to deny or revoke membership if it learns that an applicant or member is engaged in any conduct deemed harmful to patients or the DTx industry. DTA reserves the right to not approve an organization’s application if any of the above criteria are found to be misrepresented or revoke membership for any company that later fails to meet the necessary criteria.