Program Enrollment

Address: 3330 Cumberland Blvd, Suite 240, Atlanta, Ga 30339
Telephone: 770-953-3026
Fax: 770-771-5945

Program Enrollment

Enrollment with HPS is easy. If you have any questions or concerns, please contact our office at 770-953-3026 for assistance.

Complete and submit the online HPS enrollment form (see below), choose the programs you need, and sign the online member disclosure agreement.

A member of our HPS team will send you a follow-up email to verify the programs you have selected and provide you with the necessary forms to enroll.

Business Information

Practice/Business Name:
Street Address:
City:
State:
Zip Code:
Primary Phone Number:
Primary Fax Number:
Contact Name:
Contact Title:
Email Address:
Specialty:
Number of Providers:
Number of Employees on Staff:
Shipping Street Address (if different from billing address):
Shipping City:
Shipping State:
Shipping Zip Code:
How did you hear of HPS?

Program Participation

Medical/Surgical Supplies (McKesson)

Who is your current supplier for medical/surgical supplies?

Do you have an existing account with McKesson?

Yes
No

If so, what is your McKesson account number?

Please list the name and phone number of your McKesson representative.

How would you prefer to place your orders? (Indicate all that apply)

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

Billing Set-Up

How would you prefer to be billed for your orders?
Individual Credit Card for Each Purchase
Invoice Company Account

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

Wireless Telephone Services

Which wireless telephone plan do you wish to enroll?

AT&T Employee Discount
Please Provide Expected Number of Employee Users:
AT&T Corporate Discount (25 line minimum)
Please Provide AT&T Corporate Account Number:

Verizon Employee Discount
Please Provide Expected Number of Employee Users:
Verizon Corporate Discount (5 line minimum)
Please Provide Verizon Corporate Account Number:

Federal Tax ID:

Provide Federal Tax ID at a later date:

Company Domain:

Healthcare or Non Healthcare:

Healthcare
Non Healthcare

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:

Request Information

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