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Location Information Form

Please complete the information below:
* Required Field

Please fill in all required fields.

Facility Type: If Other:

Will you be participating in contracts for pharmaceuticals?

YesNo

* Your E-mail Address:

What is the exact shipping address of your facility?

* Shipping Address (with Suite #):
* Shipping City:
* Shipping State:
* Shipping Zip:

If physician office/clinic:
Who is the physician that you would like rostered?
(Note: The DEA certificate for the rostered physician must exactly match the shipping address of the facility.)

Primary Provider First Name
Primary Provider Last Name
Federal DEA Certificate Number

Tell us about your clinic facility who will place orders.

* Organization Legal Name
* Doing Business as Name
* Facility Phone
* Purchasing Contact Name (First & Last)
* Purchasing Contact Title
* Purchasing Contact Phone
Purchasing Contact Fax
* Purchasing Contact E-mail

Comments

Upon submission of this request, your facility information will be verified and the necessary legal documents will be sent to the HMA corporate office for signature. Once the legal documents have been fully executed and the GPOID has been assigned, the person listed as the purchasing contact will receive an email with information on how to begin accessing the HealthTrust agreements.