Become a Supplier Partner Form - Capstone Health Alliance

Company Name

Company Address

Company Phone

Company Website

Primary Contact Name

Primary Contact Address

Primary Contact Phone

Primary Contact Email

Product/Service Description

Do you currently work with any Capstone members?

Yes No Please send me a complete Capstone Roster to confirm.

What is your current spend amount within the Capstone membership?

Company Overview / General Information

Company Ownership

Public Private

Is the company classified as a HUB (small, minority, woman owned, veteran owned)?

Are any of your product lines 100% made in the U.S.?

Yes No

Has the company been excluded from participation in Medicare, Medicaid, or any state reimbursement programs?

Yes No

Does your company have approval from all federal, state and local governments in the US?

Yes No

Does our company serve Non-Acute facilities as well as Acute Care Hospitals?

Yes No

Does your company serve the Business & Industry space?

Yes No

How many sales representatives does your company have?

Does your company serve our entire membership geography?

Yes No

How are your products available for purchase?

Direct Sale Wholesale Distribution All of the above

What is your current marketshare within the market?

Is your company utilizing Global Health Exchange (GHX)?

Yes No Unsure

Has your company ever been listed on any of the following databases?

Federal Government's Excluded Parties List (ELPS)- which contains the General Services Administration’s comprehensive list of excluded providers for all federal programs Office of Inspector General (OIG)- which contains a listing of excluded healthcare industry providers Treasury Department’s list of Specially Designated Nationals (OFAC)- which contains a list of individuals and companies owned or controlled by, or acting for or on behalf of, targeted countries. (which include terrorist organizations and organizations associated with countries with sanctions/embargoes) N/A

Is your company currently affiliated with HIRC?

Yes No

Do you currently hold a Transparency or Resiliency Badge from HIRC?

Yes No

If so, which Badge do you hold?

Please list all Group Purchasing Organizations (including Conductiv and other regional GPOs) and contract numbers your company currently has *

Other Comments

Become a Supplier Partner

Thank you for your interest in becoming a Supplier Partner with Capstone, one of the leading regional group purchasing organizations in the country.

Apply Today