NEW VENDOR REGISTRATION PACKET

HOPE is a not-for-profit Federally Qualified Health Center (FQHC) serving both insured and uninsured patients throughout Macon and Sumner counties of Tennessee, as well as the southern most parts of Kentucky, with comprehensive and affordable medical and behavioral health services. As one of the fastest growing organizations in this community, HOPE has adopted policies and procedures that guide in the selection process of new vendors and others who seek to do business with the organization.

The first step in this process is to complete this “New Vendor Registration Packet” that will help HOPE’s finance department determine vendor eligibility and will assist in establishing important objectives such as payment arrangements and terms of service.

Please complete this packet in full. After it is submitted, a member of our team will contact you shortly!

Thank you for your interest in doing business with HOPE!

CONTACT INFORMATION

Company Name (as it appears on invoices, tax returns & W-9) *

Legal Address 1 *

Legal Address 2

City *

State *

Postal Code *

Company Phone *

Fax

Company Website

Representative's Name *

Representative's Phone *

Representative's Email *

INVOICING & PAYMENT INFORMATION

Remit-to Address 1 *

Remit-to Address 1

City *

State *

Postal Code *

Federal Tax ID Number *

Dun & Bradstreet Number

Business Type *

Do any of the following apply?

Vendor Description (please describe the type of services/products you provide and what the nature of your business with HFH will include) *

Payment Terms (check all acceptable options) *

Immediate Payment

Net 30

Net 15

Other

Payment Forms (check all acceptable options) *

Check

Credit Card

Direct Deposit

Have you/your company or any individual employed by you/your company been listed by a Federal agency as debarred, excluded or otherwise ineligible for participation in Federally funded healthcare programs? All potential vendors are checked against the OIG exclusion list. *

Yes

No

Conflict of Interest Disclosures

HOPE is a not-for-profit Federally Qualified Health Center (FQHC). As such, certain activities, and operations of the health center are funded in-part or in-full using federal grant funding. A such, federal grantees shall avoid real or apparent organizational conflicts of interests and non-competitive practices among contractors with procurement supported by Federal funds. Procurement shall be conducted in a manner to provide, to the maximum extent practical, open and free competition. In accordance with the procurement policy of HOPE Family Health - a very specific process must be followed if/when a business transaction occurs with a real and/or apparent conflict of interest. To help identify if you as a potential vendor has an existing conflict of interest with HOPE Family Health, please complete the following section.

Are you related to (by blood or marriage) or have a business relationship (of any type) with any member of the HOPE Family Health Board of Directors? To review a current list of board members please visit www.HOPEfamilyhealth.org/ourboard *

Yes

No

Are you related to (by blood or marriage) or have a business relationship (of any type) with any employee of HOPE Family Health? To review a current list of employees, visit www.HOPEfamilyhealth.org/ourstaff *

Yes

No

If you selected "Yes" to either of the above questions, please list below the name of the individual with whom the conflict of interest exists, and provide a detailed description of the nature of your relationship(s).

Business References

Reference 1

Name

Title

Phone

Email Address

Reference 2

Name

Title

Phone

Email Address

Reference 3

Name

Title

Phone

Email Address

Form W-9

Please complete and attach Form W-9, Request for Taxpayer Identification Number (TIN) and Certification. A copy of this form can be found by clicking on the following link:

IRS Form W-9

After completing the W-9 please attach it here

Submission

By signing below and clicking submit - you agree that all information provided in this packet is true to the best of your knowledge and hereby authorize HOPE Family Health to begin the process of registering you/your company as an authorized vendor.

Today's Date *

Name of individual who completed and is submitting this form *

*

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