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Join DTA
Contact Us
DTx Products
Industry News
About
Join DTA
Contact Us
DTA Membership Application
Emilie Lopes-Fernandes
2019-04-24T16:18:09+00:00
DTA Membership Application
Name of Organization
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Website
*
Phone
Type of Organization
*
Digital Therapeutics Company
Patient Group
Healthcare System
Academic Institution
Contract Research Organization
Healthcare Insurer or Payer
Professional Member Association
Standard-setting Body
Professional Trade Association
Pharmacy Benefit Manager
Employer Group
Investment Firm or Group
Pharmaceutical or Biotechnology Manufacturer
Medical Technology Company
Wholesaler
Other
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:
Prevent, manage, or treat a medical disorder or disease
Produce a medical intervention that is driven by software, and delivered via software or complementary hardware, medical device, service, or medication
Incorporate design, manufacture, and quality best practices
Engage end users in product development and usability processes
Incorporate patient privacy and security protections
Apply product deployment, management, and maintenance best practices
Publish trial results inclusive of clinically-meaningful outcomes in peer-reviewed journals
Be reviewed and cleared or approved by regulatory bodies as required to support product claims of risk, efficacy, and intended use
Make claims appropriate to clinical validation and regulatory status
Collect, analyze, and apply real world evidence and product performance data
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
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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
*
Date Format: MM slash DD slash YYYY
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.
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