Healthcare Supplier Application

Healthcare Supplier Application

Application Date:

Supplier Identification

Primary Contact

Remittance / Payment Information

ACH Payable: Provide bank details below if ACH is requested

Products, Services and Qualifications

Select all categories that describe the goods or services your organization provides:

Durable Medical Equipment

Pharmaceuticals/Pharmacy Services

Laboratory Services

IT Services / Software

Facilities / Maintenance

Consulting / Professional Services

Licensure and Insurance

Certificate of Insurance attached:

References and Prior Performance

Please provide three business references for which you have provided similar goods or services within the last five years.

Attachment Checklist

Completed tax form (W-9 or equivalent)

Certificate of Insurance

Copies of professional/agency licenses

Product catalog / service description

Current pricing and discount schedule

Compliance, Certifications and Legal Terms

By submitting this application the Supplier certifies that all information provided in this application, and in any attachments, is true, complete and accurate to the best of Supplier's knowledge. Supplier authorizes the Organization to verify any information provided, including but not limited to credit history, insurance coverage, licensure, references, and performance history. Supplier agrees to notify the Organization in writing within ten (10) business days of any change in ownership, licensure, insurance status, or material changes to product lines or services.

Supplier represents and warrants that it will comply with all applicable federal and state laws and regulations governing the provision of goods and services in healthcare settings, including laws related to privacy and security of protected health information. Supplier further represents that it has not been excluded, sanctioned, debarred or otherwise prohibited from participation in any federal or state healthcare program and will immediately disclose any such action if it occurs after application. The Organization may terminate or suspend supplier onboarding or existing relationships for non-compliance or misrepresentation.

Indemnification: Supplier shall indemnify, defend and hold harmless the Organization, its officers, employees and agents from and against any and all claims, losses, liabilities, damages, costs and expenses, including reasonable attorneys' fees, arising out of Supplier's breach of this application, Supplier's negligence or willful misconduct, or Supplier's failure to comply with applicable laws.

Recalls and Safety: Supplier shall promptly notify the Organization of any product recalls, safety notices or similar actions affecting products supplied to the Organization. Supplier shall cooperate with the Organization in executing recall notifications and corrective actions.

Confidentiality: Supplier acknowledges that certain information disclosed by the Organization may be confidential or proprietary. Supplier agrees not to use or disclose such confidential information except as required to perform contracted services or as required by law.

Background Checks: Supplier agrees that the Organization may require criminal background checks, credential verification, and site inspections for Supplier personnel who will provide on-site services. Supplier consents to such checks and inspections where permitted by law.

Business Associate Status: If Supplier will create, receive, maintain or transmit protected health information on behalf of the Organization, Supplier acknowledges that a Business Associate Agreement will be required and must be executed prior to any exchange of protected health information. Indicate below whether Supplier expects to handle protected health information.

Handles PHI: Yes No

Additional Information

Certification

Certification: I certify that I am authorized to submit this application on behalf of the Supplier named herein. I attest under penalty of perjury that the information provided on this application and attachments is true, correct and complete. I understand that falsification of information may result in immediate disqualification from consideration and may subject the Supplier to civil or criminal penalties under applicable law.

Consent to Verification: By signing below, Supplier authorizes the Organization and its agents to obtain any information necessary to evaluate this application, including verification of financial, insurance and licensing information, and to conduct background screening of key personnel where permitted by law.

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