Purchasing Agreement: HIPAA Review

PRACTICE INFORMATION:
Practice Name (required)

Name of Primary Dentist (required)

Name of Employee responsible for marketing (required)

Email of Employee responsible for marketing (required)

State (required)

Do you currently work with HIPAA Review? (required)
—Please choose an option—YESNO

Instructions for the Cooperative: (optional)

TERMS AND CONDITIONS OF PARTICIPATION
To qualify for the Dental Cooperative negotiated volume discount pricing with our vendor partner, participants must meet the following criteria:
• Participants must be a current member of the Dental Cooperative in good standing.
• All associated items subject to discount must be purchased through the identified sales channels as specific above.
• Discount pricing structure begins only after agreement has been received and processed by the Dental Cooperative and vendor partner.
• Upon termination from the Dental Cooperative, Member will no longer have access to discount pricing defined in the terms.
• Additional program details and terms are available on Member Services.
I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed MM/DD/YYYY (required)

Once submitted, the Agreement will be sent to our the associated vendor partner for a rep assignment and flagging in their system. Confirmation will be emailed to you when your vendor rep has been assigned.