Premier Medical Supplies and Pharmaceutical Market Basket Analysis Request Form

Please complete this form and read and agree to the Market Basket Terms of Use in order to request a market basket analysis for the Premier Medical Supplies and /or Pharmacy Program. 

Once this form is submitted, Premier will follow-up within 24-48 hours to discuss the process for submitting your purchase data for analysis. Depending on the number of products submitted, market basket analyses can take up to 3-5 weeks to complete.

(*) Required fields.


Contact Info






E-mail

Phone  (000.000.000)

Fax  (000.000.000)


Account Information


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

Primary Street Address

City

State

Zip

Phone  (000.000.000)

Fax  (000.000.000) 


Agency Type 
Agency/Facility Type *


Specify (if you selected "Other") 



Medical Supplies Purchasing









Pharmaceuticals Purchasing

Estimated Annual Pharmaceutical Purchases: $








Terms and Conditions

*  I agree to the Market Basket Terms of Use ("Terms") required in order for a pricing analysis to be performed and represent and warrant that I am duly authorized to bind the Prospective Member to the Terms.