Get Customer Enrollment Form - Henry Schein
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How to fill out the CUSTOMER ENROLLMENT FORM - Henry Schein online
This guide provides a detailed walkthrough on filling out the CUSTOMER ENROLLMENT FORM - Henry Schein online. By following these steps, you will ensure that all required information is accurately provided for smooth enrollment.
Follow the steps to complete the CUSTOMER ENROLLMENT FORM
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill out the customer information section. This includes entering the customer name, channel partner name, customer address (ensure no P.O. Box is used), city, state, zip code, and telephone number. Make sure to provide your AHA ID number, fax number, federal tax ID number, adjusted patient days, licensed bed count, and operating bed count if applicable.
- Determine customer eligibility by confirming the details for participation in PROVISTA contracts and programs. Understand that eligibility will commence within 45 days once the appropriate forms are received.
- Select the customer type by choosing one from the options provided: Stand Alone, System, or Satellite. Make sure to enter the System Name or MID number if applicable.
- Indicate the customer class of trade and provide a primary description. Choose from the listed options relevant to healthcare, education, or corporate/municipalities, and specify the type that best describes your organization.
- Provide primary customer contact information. This includes the contact name, title, email address, and phone number. Ensure that this contact is authorized to process the enrollment.
- Review all entered information for accuracy and completeness. Make necessary corrections before proceeding.
- Save changes to the form. You may then download, print, or share the completed form as required. Ensure that you retain a copy for your records.
Start filling out the CUSTOMER ENROLLMENT FORM - Henry Schein online now to efficiently enroll in the necessary programs.
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