IPS GROUP PURCHASING ORGANIZATION (IPS GPO)

Contact Information
Contact Name **
Practice Name **
Contact Title **
Main Telephone **
Fax
Direct Line **
E-mail **

Main Office Ship To Address
Street **
Suit#
City **
State*
Zip-code **

Vaccine Account Numbers
Sanofi
Merck
Pfizer

Please List All Physicians and Mid-Levels
List*
First Name * Middle Name Last Name *

Attachments Required
Please Attach one copy of the primary or senior physician's current State License
Accepted file types: pdf.
Please Attach one copy of the primary or senior physician's current DEA License (Please Write the state and DEA numbers on the copies if they are eligible)
OR
State License Number
DEA License Number

Select Your Primary Speciality
Primary Speciality **
- Pediatrics
- Family Practice
- Internal Medicine
- OB
- Other
Other **

Questions
Please take a moment to answer the following questions. The information gathered will be reviewed by the Program Director to determine compliance with program requirements.
Q1. Is your practice currently aﬃliated with another group purchasing program?*
- Yes
- No
Please Name the program*
Q2. Do you have multiple locations linked under the same account number?*
- Yes
- No
Please list all locations*
Account Numbers*
THIS AGREEMENT is between the Medical Practice named herein and Integrated Physician Solutions Group Purchasing Organization (“IPS GPO”). The Medical Practice and IPS agree to enter into an agreement in which IPS will act as a group-purchasing agent so that the Medical Practice will gain access to nationally contracted IPS pricing. For vaccine purchases, IPS will help Members retain eligibility for pricing under this agreement based upon a 90% market share with Sanoﬁ Pasteur’s IPOL, Hib, and DTaP (Daptacel) or Tdap (Adacel), and Meningococcal vaccine (Menactra or MenQuadfi) and a 90% market share with Merck’s Pneumovax 23/Vaxneuvance, and Rotavirus (Rotateq). IPS Group Purchasing Organization may receive an administrative fee ranging from 0%-5% from the participating manufacturers as payment for administering and managing the organization and ensuring organizational compliance. Members in good standing with manufacturers are eligible to receive payment terms of net 60-90 days and a 2% prompt pay discount. Members agree to keep all IPS pricing and contract information conﬁdential except as may be required by any governmental programs, including but not limited to, Medicare and Medicaid. Returns are the responsibility of the Member. This Agreement may be canceled through written notice, with or without cause, by either party with 30days written notice. I understand and agree that any and all vaccines purchased through IPS GPO are for my practice’s “own use” and that I will not engage in re-sale of any vaccine to any other entity or individual. I understand and agree that any dispute that may occur between the manufacturer or other supplier/vendor and the practice including billing, payments, return of product or eﬃcacy of product will be resolved solely between the vaccine manufacturer/ supplier/vendor and the member. I agree to voluntarily participate in the IPS GPO and am authorized to contract for the Medical Practice named herein and its aﬃliated physicians listed. I understand that as a new member, my ﬁrst vaccine order could take up to 1 week for IPS pricing to be eﬀective with Sanoﬁ Pasteur, and up to 3 weeks for IPS pricing to be eﬀective with Merck.
*
- The parties agree that this Agreement may be executed and delivered by electronic signature(s) and that the signature(s) appearing on this Agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Signature **
Name **
Title **
Date **
Date Format: MM slash DD slash YYYY

First Name *	Middle Name	Last Name *

Contact Information

Main Office Ship To Address

Vaccine Account Numbers

Please List All Physicians and Mid-Levels

Attachments Required

OR

Select Your Primary Speciality

Questions

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