Healthcare Procurement Solutions for Medical Practices What some say about HPS
"I am receiving the identical products that I have always used and my prices are 20% - 30% less than I was paying before joining HPS."
- OB/GYN Physician
"I really appreciate the honesty and integrity of the folks at HPS and the way their programs do not allow suppliers to play games with prices and product substitution."
-OB/GYN Practice Administrator
Request Information About HPS
Please complete the following enrollment form and submit it for inclusion into our program. Your information will be reviewed and you will be contacted with the appropriate account information.

You may use the online form below to enroll or you may download the HPS Enrollment Form and fax the completed form to 770.771.5945.
HPS Enrollment Form (pdf)

I. LOCATION INFORMATION

A. Practice/Business Name:

B. Billing Address:

C. City, State, Zip Code:

D. Primary Telephone Number:

E. Primary Contact/Title:

F. Email Address:

G. Shipping Address(es)(if different from billing):

II. PROGRAM PARTICIPATION:


We would like to enroll to participate in the following HPS Programs:
Office Supplies (Office Depot)
Medical/Surgical Supplies (McKesson)
Reference Laboratory Services (LabCorp)
Printing, Charts, Forms and Promotional Products (InHealth)
All current HPS Programs

III.OFFICE SUPPLIES (OFFICE DEPOT):


We would like to enroll to participate in the following HPS Programs:

A. Who is your current supplier for office supplies?

B. Do you have an existing account with Office Depot?

Yes No

C. If so, what is your Office Depot account number?

D. How would you prefer to place your orders? (indicate all that apply)

Telephone Fax Internet

NOTE: In order to place orders via internet, your email address must be provided as requested in section "I" above.

E. Billing Set-up?

a) How would you prefer to be billed for your orders?
Invoice Credit

b) If you selected to be billed by invoice above, how would you prefer that you invoices be sent?
Invoice each order separately
Send me a weekly summary invoice.
I will pay based on my monthly account statement.

F. If you will need to make purchases at the Office Depot retail stores, your practice will need a Store Purchasing Card ("SPC") in order to access HPS contract pricing in the stores.

Store Purchasing Card ordered.

IV. MEDICAL/SURGICAL SUPPLIES (McKESSON):

A. Who is your current supplier for medical/surgical supplies?

B. Do you have an existing account with McKesson?

Yes No

C. If so, what is your McKesson account number?

D. How would you prefer to place your orders? (indicate all that apply)

Telephone Fax Internet
NOTE: In order to place orders via internet, your email address must be provided as requested in section "I" above.

E. Billing Set-up?

a) How would you prefer to be billed for your orders?
Invoice Credit
b) If you selected to be billed by invoice above, how would you prefer that you invoices be sent?
Invoice each order separately
I will pay based on my monthly account statement.

V. REFERENCE LABORATORY SERVICES(LABCORP):

A. Who is your current provider of reference laboratory services?

B. Do you have an existing account with LabCorp?

Yes No

C. If so, what is your LabCorp account number(s)?

D. Primary Laboratory Services Contact/Telephone Number:

VI. DISCLOSURE AGREEMENT:

I have read and understand the HPS Member Disclosure Agreement. By entering my name in the signature box below, I acknowledge receipt and accept the terms of this Agreement as a condition of participation.

Signature