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 current U.S. Communities Participant.  If you are not a U.S. Communities Participant, please register with U.S. Communities. 

(*) Required fields.

Confirmation

Please confirm that you are a U.S. Communities Participant by checking the box to the left before continuing.


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








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.