Customer Account Forms
Customer Request Form
This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of Arthrex, Inc.
Instructions
: All fields marked with
*
sign are required.
Is the Account New?
New
Existing
Bill-To Account #
(IF IT'S A CHANGE IN EXISTING ACCOUNT THEN A/C NUMBER IS REQUIRED)
Legal Name of Facility
Facility's Website
DBA, if applicable
Account Type
Please Select
Ambulatory Surgery Center
Finance Company
Government
Hospital
Long Term Care
Perfusion
Physician Office/Clinic
Surgical Hospital
ZVEN (for internal use only)
Do you have access to place online orders?
Yes
No
Would you like access to place orders online?
Yes
No
Primary Account User Email
(IF YES, PLEASE PROVIDE EMAIL ADDRESS TO BE ASSOCIATED WITH ONLINE)
For any additional changes, please
click here
to expand this form and fill
only
the fields that you want to update.
Are you a buying group Member?
None
Adventist Health System, Alamonte FL
Adventist Healthcare, Maryland
AHHC - Advocate Health and Hospitals Corporation
Allegheny Health Network
Allina Health
Amsurg
Ardent
Ascension Health
ASCOA - Ambulatory Surgical Centers Of America
Aurora Advanced Healthcare
Avera Health
Banner Healthcare
Baptist Healtcare System, Kentucky
Baylor Health Care System
Beaumont Health System
BJC Healthcare
Bon Secours Health System
Carolinas HealthCare System
Catholic Health East
Catholic Health Services (of Long Island)
Centura Health
CHI - Catholic Health Initiatives
CHRISTUS Health
Cirrus Health
Cleveland Clinic
Community Health Systems - CHS
Daughters of Charity Health System
Dignity Health
Erlanger Health System
Essentia Health
Fairview Health Services
Foundation Healthcare, Inc.
HCA - Hospital Corporation of America
Henry Ford Health System
Hospital Sisters Health System
Inova Health System
Intermountain Healthcare
Kaiser
Kettering Health Network
Lau Surgery Centers
LifePoint Hospitals
Mayo Clinic
McLaren Health Care Corporation
MedStar Health
Memorila Hermann Health System
Mercy Health System
Ministry Health Care
Mountain States Health Alliance
National Surgical Hospitals
New England Alliance for Health
Novant Health
Ochsner Health System
OSF Healthcare
Others
Partners HealthCare
Presence Health
Proliance Surgeons
Providence Health & Services
Quorum Health Resources
Regent Surgical Health
Sanford Health
SCA - Surgical Care Affiliates
Scott & White Healthcare
Sentara Healthcare
SMP - Surgical Management Professionals
SSM Health Care
St. Joseph Hospital of Orange
Steward Health Care System
Summa Health System
SurgCenter
Surgery Partners
Sutter Health
Symbion Healthcare
Tenet Healthcare Corporation
Texas Health Resources - THR
ThedaCare
TriHealth
Trinity Health
UMMS - University of Maryland Medical System
UnityPoint Health
Universal Health Services - UHS
USPI - United Surgical Partners International
Wisonsin Valley Health Network
Yankee Alliance
(IF YES, THEN PLEASE SELECT FROM DROP DOWN LIST)
GLN (Global Locator Number)
Do you have a primary GPO?
None
Amerinet
HPG - HealthTrust Purchasing Group
MedAssets
Novation (VHA, UHC, Provista)
Premier
ROi - Resource Optimization & Innovation
US Department of Defense (DOD)
US Department of Veteran Affairs
(IF YES, THEN PLEASE SELECT FROM DROP DOWN LIST)
Secondary GPO?
None
Amerinet
HPG - HealthTrust Purchasing Group
MedAssets
Novation (VHA, UHC, Provista)
Premier
ROi - Resource Optimization & Innovation
US Department of Defense (DOD)
US Department of Veteran Affairs
(IF YES, THEN PLEASE SELECT FROM DROP DOWN LIST)
Bill To Address
Address
City
County
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Country
United States
Canada
Ship To Address
Same As Bill To
Is this New Ship-To or update to Existing Ship-To address?
New
Existing
NoChange
Address
City
County
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Country
United States
Canada
Name of Facility
Ship-To Account#
How long has this facility been open?
Please Select
Not Yet Open
1-5 Years
5-10 Years
Over 10 Years
Expected Open Date
Ship To Address 2
Address
City
County
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Country
United States
Canada
Name Of Facility
How long has this facility been open?
Please Select
Not Yet Open
1-5 Years
5-10 Years
Over 10 Years
Expected Open Date
Credit and References
Credit amount requested $
Please Select
0 - $25,000
$25,001 and over
($25,001 AND OVER REQUIRES REVIEW BY CREDIT TEAM)
Trade References
Reference 1:
Reference 2:
Company Name
Company Name
Account #
Account #
Phone
Phone
Fax
Fax
Email
(Preferred)
Email
(Preferred)
Contact
Contact
Address
Address
City
City
County
County
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Zip
Country
United States
Canada
Country
United States
Canada
Have you had a prior bankruptcy in last 10 years?
Yes
No
Case number
(IF YES, PLEASE PROVIDE CASE NUMBER)
Purchasing Detail
Contact Name
Contact Email
Phone
FAX
Compliance Officer
Contact Name
Contact Email
Phone
FAX
Accounting Detail
Contact Name
Contact Email
Phone
FAX
Risk Management Contact Name
Phone
Invoice and Statement Delivery Preferences
How would you like Statements?
Emailed
Mailed
Both
NoChange
Statement Delivery Email
(IF EMAILED OR BOTH IS SELECTED, PLEASE PROVIDE STATEMENT DELIVERY EMAIL)
How would you like Invoices?
Emailed
Mailed
Both
NoChange
Invoice Delivery Email
(IF EMAILED OR BOTH IS SELECTED, PLEASE PROVIDE INVOICE DELIVERY EMAIL)
Would you like to view and/or pay invoices online?
Yes
No
NoChange
(For questions please email
billerdirect@arthrex.com
)
Biller Direct User Email
(IF YES, PLEASE PROVIDE BILLER DIRECT USER EMAIL)
Would you like a third party freight account number stored in your customer master record?
Yes
No
NoChange
Freight Company Name
Account Number
(IF YES, PLEASE PROVIDE COMPANY NAME & A/C NUMBER)
All Arthrex shipments will ship Federal Express Ground Shipping unless otherwise specified
Click here to agree
Click here to decline
NoChange
(Please note temperature sensitive products will ship Federal Express Overnight)
Shipping Options
Please Select
FedEx Priority Overnight
FedEx Standard Overnight
FedEx 2nd Day
FedEx Express Saver
FedEx Ground
UPS Ground
UPS Three Day Select
UPS 2nd Day Air
UPS Next Day Air Saver
UPS Next Day Air
(IF DECLINE, THEN PLEASE SELECT AN OPTION FROM DROP DOWN LIST)
Is the customer tax Exempt?
Yes
No
NoChange
Tax Exempt Certificate
(IF YES, A COPY OF THIS CERTIFICATE MUST BE UPLOADED WITH THIS FORM)
By selecting No you acknowledge you are aware you will be charged taxes
Yes
(YOU MUST CLICK YES TO ACKNOWLEDGE THE NOTE TO CONTINUE)
Does the customer obtain Direct Pay permit?
Yes
No
NoChange
Direct Pay Permit
(IF YES, A COPY OF THIS PERMIT MUST BE UPLOADED WITH THIS FORM)
Arthrex Sales Representative 1
Arthrex Agency
Arthrex Sales Representative 2
Is there an order Pending?
Yes
No
NoChange
Is there a pending bill only?
Yes
No
NoChange
Will Initial purchase be financed?
Yes
No
NoChange
Finance Company Detail
Name Of Person Completing Form
Phone
Do you have any additional information pertaining to your account?
Select File(s) to Add
✖
Email
Additional Comment
Type of Change Requested
Please acknowledge the
confidentiality
agreement before submission.
Confidentiality
. The
Applicant
acknowledges that all pricing provided by Arthrex is “Confidential Information” and shall not be disclosed to any third party except for a party’s employees, attorneys, or accountants (“Third Party”) on a need-to-know basis to perform services utilizing Arthrex Products; provided that such Third Party is under a written obligation of confidentiality.
Applicant
further acknowledges that pricing will not be sold, shared, or bartered in exchange for compensation or services rendered.
ⓘ