CUSTOMER ENROLLMENT FORM CUSTOMER INFORMATION: A CUSTOMER NAME CHANNEL PARTNER NAME CUSTOMER ADDRESS (PO Box Address Not Valid) CITY STATE ZIP CODE CUSTOMER TELEPHONE NUMBER CUSTOMER FAX NUMBER FEDERAL TAX ID NUMBER AHA ID NUMBER *+ ADJUSTED PATIENT DAYS *+ LICENSED BED COUNT *+ OPERATING BED COUNT *+ * Per American Hospital Association (AHA) Guide + Please provide information if membership class of trade equals “Acute” CUSTOMER ELIGIBILITY: The Customer identified above will be eligible to participate in PROVISTA Contracts and Programs (where no commitment document is required) within 45 days after announcement to the appropriate Supply Partner(s). Some Supply Partners require completion of specific commitment or participation forms prior to contract access. Upon receipt of these completed commitment forms, the customer identified above will be eligible to participate in that specific agreement within 45 days after notification to the Supply Partner. All completed AD and commitment forms will be posted on PROVISTA Forms Manager within 24 business hours. CUSTOMER TYPE: (Please select one Customer Type) STAND ALONE: An independent facility with no affiliates or satellites SYSTEM: facility that owns, leases, and/or manages affiliates/satellites SATELLITE: A facility owned, leased, or managed by another PROVISTA Customer. Enter System Name or MID#: CUSTOMER CLASS OF TRADE and PRIMARY DESCRIPTION: HEALTHCARE Acute Medical School Cardiac Hospital General Medical & Surgical Long Term Care Acute Hospital Psychiatric Hospital Acute Care Rehabilitation Hospital Surgical Hospital Ambulatory Care Ambulatory Surgery Center Dialysis Imaging Center Urgent Care Center Ambulance Service/EMT Clinic/Medical Group Laboratory Student Health Clinic Clinic/Phys. Practice Other: HMO – Closed Group Model HMO Managed Care Plan Home Health Durable Medical Equipment Home Health Services Home Infusion Center Hospice Specialty Pharmacy Long Term Care Assisted Living Long Term Care Rehabilitation Retail Pharmacy Pharmacy EDUCATION University, College or College or University Community College K- 12 Early Learning School CORPORATE/MUNICIPALITIES Corporate and Corporations and Businesses Correctional Facilities Faith Based Organization State & Local Government Municipalities CUSTOMER PRIMARY CONTACT INFORMATION: (Required to process enrollment) CONTACT NAME (PRINT) CONTACT TITLE CONTACT E-MAIL ADDRESS PHONE# PROVISTA Sales Rep Initials: _________
CUSTOMER ENROLLMENT FORM CUSTOMER INFORMATION: CUSTOMER NAME CHANNEL PARTNER NAME CUSTOMER ADDRESS (PO Box Address Not Valid) CITY STATE ZIP CODE CUSTOMER TELEPHONE NUMBER CUSTOMER FAX NUMBER FEDERAL TAX ID NUMBER AHA ID NUMBER *+ ADJUSTED PATIENT DAYS *+ LICENSED BED COUNT *+ OPERATING BED COUNT *+ * Per American Hospital Association (AHA) Guide + Please provide information if membership class of trade equals “Acute” CUSTOMER ELIGIBILITY: The Customer identified above will be eligible to participate in PROVISTA Contracts and Programs (where no commitment document is required) within 45 days after announcement to the appropriate Supply Partner(s). Some Supply Partners require completion of specific commitment or participation forms prior to contract access. Upon receipt of these completed commitment forms, the customer identified above will be eligible to participate in that specific agreement within 45 days after notification to the Supply Partner. All completed AD and commitment forms will be posted on PROVISTA Forms Manager within 24 business hours. CUSTOMER TYPE: (Please select one Customer Type) STAND ALONE: An independent facility with no affiliates or satellites SYSTEM: A facility that owns, leases, and/or manages affiliates/satellites SATELLITE: A facility owned, leased, or managed by another PROVISTA Customer. Enter System Name or MID#: CUSTOMER CLASS OF TRADE and PRIMARY DESCRIPTION: HEALTHCARE Acute Care Acute Medical School Cardiac Hospital General Medical & Surgical Long Term Care Acute Hospital Psychiatric Hospital Rehabilitation Hospital Surgical Hospital Ambulatory Care Ambulatory Surgery Center Dialysis Imaging Center Urgent Care Center Clinic/Phys. Practice Ambulance Service/EMT Clinic/Medical Group Laboratory Student Health Clinic Other: HMO – Closed Group Model HMO Managed Care Plan Home Health Durable Medical Equipment Home Health Services Home Infusion Center Hospice Specialty Pharmacy Long Term Care Assisted Living Long Term Care Rehabilitation Retail Pharmacy Pharmacy EDUCATION University, College or School College or University Community College K- 12 Early Learning CORPORATE/MUNICIPALITIES Corporate and Municipalities Corporations and Businesses Correctional Facilities Faith Based Organization State & Local Government PRIMARY CUSTOMER CONTACT INFORMATION: (Required to process enrollment) CONTACT NAME (PRINT) CONTACT TITLE CONTACT E-MAIL ADDRESS PHONE# PROVISTA Sales Rep Initials: _________