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Location Information Form

Toll Free Hot Line: (866) 841-2992
E-mail us at: Corp.AdvantageTrustMembership@HCAHealthcare.com 

Please complete the information below:

Your E-mail Address:

1 What is the exact shipping address of your clinic or office?
Shipping Address (with Suite #):  
Shipping City:
Shipping State:  
Shipping Zip:
2 Attach a copy of the federal DEA certificate for one of your doctors that matches the address in 1 above.
(Administrative centers skip section 2.)
Primary Provider First Name
Primary Provider Last Name
Federal DEA Certificate Number
Federal DEA Certificate Expiration Date
3 Tell us about your clinic or office and who will place orders.
Practice Legal Name
Doing Business as Name
Federal Tax ID Number
Practice specialty per MGMA
Number of Providers @ Shipping Location
Purchasing Contact Name
Purchasing Contact Title
Purchasing Contact Phone
Purchasing Contact Fax
Purchasing Contact E-mail
4 Tell us about your organization
and who can sign agreements.
Name of Corporate Owner (or none)
COID Number
Overhead Department Number:
Executive Contact Name
Executive Contact Title
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
6 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 200 contracts.)






7 Please submit this Location Information Form (LIF) to us and we in turn will forward to you a purchasing agreement for your signature. This LIF does not commit you to the program in any way. Only after you sign and return the agreement can we begin the enrollment process.
 

Please be advised that the following items are also required in order to complete your enrollment with Cardinal for the purchase of pharmacy products:

  • A copy of the state medical license for the provider whose name appears on your DEA certificate
  • One or more signed declaration forms required by Cardinal in order to purchase pharmacy products

These documents will be collected by your local Cardinal rep.