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Location Information Form

Enrollment Coordinator: Barbara Wilson
Phone: 615-465-7588
Fax: 615-465-2988
E-mail: Barbara_Wilson@chs.net
Please complete the information below:

Your E-mail Address:
Please select one of the following:


Member # (if known)

1 Who is responsible for completing this enrollment form and providing documentation?
Administrative Contact Name
Administrative Contact Title
Administrative Contact Phone
Administrative Contact Fax
Administrative E-mail
2 Who will be responsible for placing your orders?
Purchasing Contact Name
Purchasing Contact Title
Purchasing Contact Phone
Purchasing Contact Fax
Purchasing Contact E-mail
3 Tell us about your practice and the health care provider.
Practice Legal Name
Doing Business as Name
Primary Provider First Name
Primary Provider Last Name
Federal Tax ID Number
Primary Business Phone Number
Practice specialty per MGMA
Number of Providers @ Shipping Location
4 What is the exact shipping address of your clinic or office, including building, suite or floor numbers?
Shipping Address (with Suite #):  
Shipping City:
Shipping State:  
Shipping Zip:
5 Tell us where you want
vendors to send invoices for
purchased products.
Billing Name
Billing Address (with Suite #): 
Billing City:
Billing State:
Billing Zip
Department Number
6 Attach a copy of the current state license and an authorization letter for the provider in Section 3 above.
(Administrative centers skip section 6.)
State Medical License Number
State Medical Expiration Date
Federal DEA Certificate Number
Federal DEA Certificate Expiration Date
7 Tell us which contracts you want us to set up for your clinic. (These are only the primary physician clinic contracts. You will gain access to over 500 contracted vendors.)






8 Submit  this request to us and we will send an agreement package to you for review. This request does not commit you to the program in any way. Only after you sign and return the agreements can we begin the enrollment process.