Cardinal MED56 New Account Packet Form v3_2024_Fillable.pdf

Ship to Name* (Names that exceed 35 characters will be abbreviated)

Ship to Name 2

Ship to address*

Ship to address 2

City*

State*

Zip*

Telephone*

Extension

Fax

Contact Name*

Contact Email*

Same as Ship to

Bill to Name (Names that exceed 35 characters will be abbreviated)

Bill to Name 2

Bill to Address

Bill to Address 2

Bill to City

Bill to State

Bill to Zip

Bill to Telephone

Extension

Bill to Fax

Bill to Contact Name

Bill to Contact Email

Name* Phone* Email*

MMCAP ID* 10 digits GLN (Global Location Number)* 13 digits More information about GLN at link --> HIN (Health Industry Number) *Leave blank if not known

Please provide Accounts Payable contact information* Use comment section below for additional AP info

Ship to Information

Bill to Information

Obtain from MMCAP Infuse Obtain from MMCAP Infuse

What legal entity is financially responsible for making payments on behalf of this account?*

MMCAP INFO (A MMCAP ID & GLN is required to begin account setup) Both are provided by MMCAP Infuse https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number https://www.gs1us.org/industries-and-insights/standards/global-location-number

Are you 340B eligible?

340B ID(s)

If adding a DEA you must proceed through the CSMP (Controlled Substance Monitoring Program) by completing the Registrant

Questionnaire. Link to the right. Once the site opens scroll to Registrant Questionnaire to open the questionnaire.

Business Hours (whole hours) Delivery Hours (whole hours)

Delivery Days (check each day you would like to receive delivery) *MMCAP allows up to 5 days of free delivery

M T W R F

Are you exempt from Sales Tax?

Email 1 Email 2 Email 3 Email 4

Do you require EDI interfaces? Yes or No

Please provide email(s) to receive invoice copies

If Physician License Physician Name (Enter Physician Name and

License information) Complete and return signed Letter of

Authorization with License Copy

Physician Name

License number Expiration

If State Pharmacy License Provide license number and expiration and

License number Expiration

Provide license number and expiration and provide a copy of license

License number Expiration

TAX INFORMATION

30 Day Pre-Pay 15 Day Net 15 Day Pre-Pay 30 Day Net 7 Day Pre-Pay 45 Day Net Next Day Pay 60 Day Net

7 Day Net 90 Day Net

STATE/MEDICAL LICENSE INFORMATION

In order to purchase Rx products you must provide either a State Pharmacy License ( The name and address on the State Pharmacy

License must match the Shipping Name and Address provided) or a Physician License with a completed and signed Letter of Authorization (see template page). COPIES OF LICENSES ARE REQUIRED

DEA LICENSE INFORMATION

Will you be purchasing controlled substances? If so, please provide current DEA copy

If yes, please provide a copy of your tax exempt certificate

EDI

WWW.CARDINALHEALTH.COM/CSMP

If Yes, Please provide more detail at the bottom of this documentin Additional Notes and Comments

340B INFORMATION

If you would like a 340B account setup please complete the below information. We must setup a separate account for each HRSA ID provided. If you do not need a 340B account you may leave this section blank.

DELIVERY INFORMATION

TO

TO

INVOICE TERMS

Please choose your invoice terms* 30 Day Net is the default unless you choose otherwise http://www.cardinalhealth.com/CSMP http://www.cardinalhealth.com/CSMP http://www.cardinalhealth.com/CSMP http://www.cardinalhealth.com/CSMP http://www.cardinalhealth.com/CSMP

NAME ADMIN

ADDITIONAL NOTES OR COMMENTS

ORDER EXPRESS (ONLINE ORDERING) ACCESS

Please choose at least one Administrator. Admins can add/delete users, mark closure days for facility, maintain licensing...

EMAIL

POST ACCOUNT SETUP PRISON RESTRICTED ITEMS

Manufacturershave put rules in place that do not permit certain items to be sold to correctionalfacilities and other customers that they deem ineligible.

To maintain its status as an authorized distributor, Cardinal Health abidesby thesedistribution restrictions.

https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html

PHONE

https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html https://www.cardinalhealth.com/en/cmp/un/phr/pd/restricted-ordering-questionnaire.html

PDQRA-RTN-P001/Form1 DCN: 4548 Effective Date: 15 Feb 2016 Page 1 of 1 >>THE USER OF THIS DOCUMENT IS RESPONSIBLE FOR CHECKING THE CURRENT EFFECTIVE DATE BEFORE USE<<

Cardinal Health

7000 Cardinal Place

Dublin, OH 43017

614.757.5000 main www.cardinalhealth.com

CARDINAL HEALTH RETURNED GOODS AUTHORIZATION

ONGOING ASSURANCE

The undersigned customer (“Customer”) of Cardinal Health, (the “Wholesaler”) hereby agrees that this document is being delivered to confirm Customer’s compliance with applicable federal, state, and local laws / guidelines concerning returned goods and shall apply to all returns by Customer to Wholesaler from time to time and shall supersede any inconsistent provisions which may be contained in any credit request, purchase order, or other documents pertaining to the supply relationship between Customer and Wholesaler.

Customer represents, warrants, and guarantees to Wholesaler that: (a) each such return shall be made only to the specific Wholesaler from which the item was originally purchased; (b) each such return shall be accompanied by Wholesaler’s credit request form (the “Return Form”), which shall specify both Customer’s and Wholesaler’s name and address, the date of the return, the quantity and description of the product returned, and such other information as may reasonably be requested on Wholesaler’s Return Form; (c) Customer shall retain a copy of each Return Form and related credit memo and make such documentation available to the manufacturer and to authorized federal, state, and local law enforcement officers upon request; (d) the credit claimed or accepted by Customer for any such return shall not exceed the original purchase price paid to Wholesaler; and (e) all merchandise returned to Wholesaler has been stored and handled by Customer in accordance with all applicable federal, state, and local laws, manufacturer guidelines when disclosed to customer by the manufacturer or wholesaler, and good trade practices, and such merchandise has not been adulterated or misbranded by customer within the meaning of the Federal Food, Drug, and Cosmetic Act and meets all FDA, state, and other applicable requirements and guidelines.

Print Customer Name (i.e., Store Name) (Include all that apply)

Print Store Address

By Authorized Person / Title (Print)

Date Signature of Authorized Person

INSTRUCTIONS FOR COMPLETING THE LETTER OF AUTHORIZATION ON NEXT PAGE

If you are u�lizing a physician, physician assistant or nurse prac��oner license you will need to complete the leter of authoriza�on on the next page.

*hover slowly over fields for guidance on what should be entered into each field

1. Leter of Authoriza�on (LOA) must be on official leterhead

2. LOA must be signed in wet ink or digitally by the license holder

3. Full name and address of facility should appear where requested in the body of the leter unless you have mul�ple facili�es. If mul�ple facili�es just put “see atached” in the facility name field and atach a spreadsheet or other document lis�ng the facility names and addresses

If you have any ques�ons about comple�ng the LOA please contact your Cardinal representa�ve.

Thank you, Cardinal Health

ATTN:

7200 Cardinal Place Dublin, OH 43017

I, , am the responsible person for all Prescription product(s) purchases made by the facilities listed below under my state license number(s) issued by the State of

For Hospital Supply customers ONLY, we will accept a pharmacy license and this letter MUST be signed by the hospital’s Director of Pharmacy.

I will notify Cardinal Health immediately if my responsibility status and/or relationship with this facility is changed or terminated.

**IF MULTIPLE: PLEASE LIST ALL NAMES AND ADDRESSES, PLEASE PROVIDE IN AN

ATTACHMENT AS AN APPENDIX

For electronically signed LOAs: I hereby attest that my electronic signature below, whether typed or generated by computer software, constitutes the legal equivalent of my manual signature. I understand that I may revoke this attestation of an electronic signature by notifying Cardinal Health in writing. I understand that this attestation is effective when signed and delivered to Cardinal Health.

This letter does not indicate I am the financially responsible party.

Attach a copy of the practitioner’s state license(s) to this Letter of Authorization (LOA).

Important: Cardinal Health is unable to load a practitioner’s Drug Enforcement Agency (“DEA”) registration for the above facility if the address listed on the practitioner’s DEA registration does not match the facility name and address.

Facility name and address MUST match the DEA registration loaded to your account. If you do NOT have a DEA registration, the facility name should be the name of the facility where the product is being shipped. The Legal Entity Name, if applicable, should be entered below the signature and not in the facility list section.

* References to license(s) pertain to state practitioner license and state-controlled substance license, if applicable.

** For multiple facility names and addresses; an appendix should be attached to this authorization letter.

Updated October 2023

Kevin.Wells Highlight

Page 8 PDMA Feb 2016.pdf

Physician LOA 10-30-23 FILLABLE.pdf