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Premier Medical Supplies and Pharmaceutical Program Enrollment Form

Please complete this form and read and agree to the Terms and Conditions in order to access the Premier Pharmaceutical, Medical Equipment, Supplies and Distribution Program (“The Program”). In order to enroll as a member in the Program, you must be a OMNIA Partners, Public Sector Participant (subsidiary U.S. Communities).

If you are not registered with OMNIA Partners, please register.

(*) Required fields.

Confimation

Contact Info
First Name

Last Name

Title

Phone

Fax

Account Information
Agency Name (Roster Participant)

Federal Tax/Employee Identification No.(TIN/EIN)

Primary Street Address

City

State

Zip Code

Phone

Fax

Agency Type
Agency/Facility Type

Specify (if you selected "Other")

Medical Supplies Purchasing
Estimated Annual Medical Suppiy Purchases: $

Primary Medical Supply Distributor

Secondary Medical Supply Distributor (if applicable)

Scheduled Deliveries Per Week

Pharmaceuticals Purchasing
If you would like to participate in the Premier Pharmacy Program, please complete the following:

Estimated Annual Pharmaceutical Purchases: $

Primary Pharmaceuticals Distributor

Secondary Pharmaceuticals Distributor (if applicable)

Scheduled Deliveries Per Week

*A DEA # must be provided to get access to the Premier Pharmacy Program.
If you do not have a DEA #, please provide your HIN#

DEA #

HIN #

Agency Relationships
Does your agency have a relationship with any other public agency? If yes, please explain the relationship. (ex. Yes, we are owned by the state.)

Facility Authorization & Vendor Fee Agreement
You must download, complete, sign, and submit a Facility Authorization & Vendor Fee Agreement ("Exhibit A") to premierreach@premierinc.com in order to become a member. Execution of this document is required for compliance with the regulatory safe harbor for group purchasing organizations.

Ship to/Child Sites
If you will be accessing the Program on behalf of ship to/child sites, please download and complete this spreadsheet template ("Exhibit D") and email it to premierreach@premierinc.com in order to ensure that they are linked to the program.

Terms and Conditions

I agree to the Terms of participation on behalf of the Prospective Member and all facilities listed on ("Exhibit D").

The individual who submits this form on behalf of the Prospective Member represents and warrants that he/she is duly authorized to bind the Prospective Member to the Terms and Conditions of Participation as indicated above.