Hpc New Customer Form

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HPC NEW CUSTOMER FORM
CUSTOMER/BUYER INFORMATION
Buyer’s Name: __________________________________________ Phone: _________________________________
Buyer’s Email: _________________________________________________________________
Facility/Company Name: _________________________________________________________
Parent Company (Health System) Name: ____________________________________________
Facility (Shipping) Address: _______________________________________________________
City/State/Zip: _________________________________________________________________
ACCOUNTING/BILLING INFORMATION
A/P Contact Name: ____________________________________________________________
A/P Contact Email Address: ______________________________________________________
A/P Contact Phone: __________________________________ Fax: __________________________________
Email address for Invoices to be sent: __________________________________________________________
Corporate Credit Card: _________________________________________________ Exp. Date: ____________
Billing Address: ____________________________________________________________________________
City/State/Zip: _____________________________________________________________________________
Do you have a corporate FedEx/UPS shipping account we should charge freight to? [ ] Yes
[ ] No
If yes, please provide your shipping account # and details: __________________________________________
Is your organization a member of a GPO (group purchasing organization)? [ ] Yes
[ ] No
If yes, please enter your GPO Member ID: _________________________ and select your GPO below:
AdvantageTrust
Premier
CoreTrust
Premier Continuum of Care (Non-Acute)
HealthTrust (HPG/HCA)
Premier Continuum of Care (REACH)
MedAssets
PSMAConnect
Novation/UHC/VHA (“VIZIENT”)
Other: ___________________________________
* We also require the following be submitted:
ACH Payment Information:
 Copy of your company’s W-9
HPC Bank: JP Morgan Chase
 Sales Tax Exemption form, if applicable
R – 071000013
A – 620380386

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