Enrollment Form for Future Members of Healthcare Procurement Solutions, LLC (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

View more testimonials »

Request Information About HPS

First Name

Last Name

Phone

Company

City/State

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.

Please send me an application for an Office Depot Store Purchasing Card.

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:

Wireless Telephone Services

Which wireless telephone plan do you wish to enroll?

Verizon AT&T

VI. Overnight Shipping & Freight Services (FedEx)

What is your Fed Ex Account number?

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.

ABOUT HPS	ENROLLMENT

HPS SUPPLIERS	MEMBER AREA

HPS FAQS	CONTACT US

TESTIMONIALS	PRIVACY

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):

H. How did you hear of HPS?

II. PROGRAM PARTICIPATION:

III.OFFICE SUPPLIES (OFFICE DEPOT):

A. Who is your current supplier for office supplies?

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

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

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

E. Billing Set-up?

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.

IV. MEDICAL/SURGICAL SUPPLIES (McKESSON):

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

B. Do you have an existing account with McKesson?

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

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

E. Billing Set-up?

V. REFERENCE LABORATORY SERVICES(LABCORP):

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

B. Do you have an existing account with LabCorp?

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

D. Primary Laboratory Services Contact/Telephone Number:

Wireless Telephone Services

Which wireless telephone plan do you wish to enroll?

VI. Overnight Shipping & Freight Services (FedEx)

What is your Fed Ex Account number?

VII. DISCLOSURE AGREEMENT:

Signature