Vendor Add Request Form

Please provide the following information:

* Denotes Required Field

Acknowledgement
*By checking the box, I agree with this Vendor Policy.

Your Boston Childrens Hospital Contact Information
*BCH Employee's Name:
*BCH Employee's Department:
*BCH Employee's Phone:
*Select the one most appropriate category of goods/services that best reflect what will be offered:

Description of Product / Service
*Describe the product / service you will provide and the scope of work involved:

General Information
*1. Your Contact Information
*First Name:
*Last Name:
*Contact Title:
*Email:
Cell Phone#:
*Phone#: Ext:
Fax#:


*2. Your Company Information
*Company Name:
*Doing Business As (DBA):
*Address:
*City:
*State:
*Zip:
*Email:

Remit address
*Remit Address:
*Remit City:
*Remit State:
*Remit Zip:
*Taxpayer Identification Number (TIN):
*Company Website:
*W9 form / W8 form (international vendor):
Adobe PDF file only.
*Do you accept ACH/Credit card process? Yes    No
*Preferred PO Dispatch Method? Fax    Email    N/A


*3. Please select "Yes" to all that apply to your company (descriptions).
Are you a Trainee? Yes    No
Are you a current vendor with Boston Children's? Yes    No
Are you a Manufacturer? Yes    No
Are you a Distributor? Yes    No
Are you a Service Provider? Yes    No


*4. Are you a U.S. owned business?
Yes    No


*5. How does your company provide products (select all that apply)?
Directly to Customer? Yes    No
Third Party Distributors? Yes    No
Service Provider? Yes    No


*6. Has your company been the subject of any regulatory, administrative, or judicial action, sanction, prosecution, or proceeding that would affect your ability to supply products or services?
Yes    No


*7. Has your company been excluded from participation in Medicare, Medicaid, or any state reimbursement programs?
Yes    No


*8. Is your company a Diverse Supplier?
Yes    No


HIPAA/HITECH*
9. Business Associate Decision Tree Questions:
*1. Is Protected Health Information (PHI) being disclosed to a person or entity other than in the capacity as a member of the covered entity's workforce?
Yes    No

Detailed Product or Service Information*
*10. Please provide the necessary contact information of someone within your organization that will have signing authority for a potential contract with Boston Children's:
*Job Title:
*First Name:
*Last Name:
*Email:
*Phone #:
*Address:
*City:
*State:
*Zip:










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