Rev. 05.24.2019

Vendor Registration

Methodist Le Bonheur Healthcare 1350 Concourse Avenue · Purchasing Department · Suite 668 · Memphis, TN 38104

Send Completed Information via Email to: Contractrequest@mlh.org ~ For Questions or Assistance 901.516.0626 ~

In addition to the information contained hereon, each applicant will be required to also provide a Certificate of Insurance and complete a W-9. General information about our Vendor Registration can be found by going to www.methodisthealth.org and clicking on About Us then For Vendors.

Please submit the name of your MLH Contact/Sponsor ______________________________________________________________ Company Name ________________________________________________________________________________________

Company Address ________________________________________________________________________________________

City ___________________________________________ State __________ Zip Code ______________

Customer Service Phone ______________________ Fax ______________________ E-Mail _______________________________

Remit Address ________________________________________________________________________________________

City ___________________________________________ State __________ Zip Code ______________

Returns Address ________________________________________________________________________________________

City ___________________________________________ State __________ Zip Code ______________

Shipping Terms FOB Destination FOB Origin Other – Describe ____________________

Payment Terms 2/10 Net 30 Net 30 Other – Describe ____________________

Normal Delivery Time ________________________________________________________________________________________

Nature of Business (Check One)

Manufacturer Manufacturer's Rep Stocking Distributor

Contractor Consulting Other – Describe_____________________

Type of Business

(Check One) Sole Proprietorship Partnership LLP

Corporation LLC Other – Describe_____________________

Rev. 05.24.2019 Vendor Registration

~Cont~ Page 2 of 8

References ~

A Customer of Yours . . .

Company Name ________________________________________________________________________________________

Company Address ________________________________________________________________________________________

City ___________________________________________ State __________ Zip Code ______________

Contact Person ______________________ Phone ____________________ E-Mail ______________________________

A Vendor of Yours . . .

Company Name ________________________________________________________________________________________

Company Address ________________________________________________________________________________________

City ___________________________________________ State __________ Zip Code ______________

Contact Person ______________________ Phone ____________________ E-Mail ______________________________

Product and/or Services You Provide . . .

Medical/Surgical Laboratory Radiology Pharmacy

Accounting/Legal Consulting Advertising/Promotional Food Service/Dietary

Construction/Renovation Medical Support/Services Recruitment/Staffing

Other – Describe__________________________________________________________________________________________

Are You a Certified Minority Vendor? No Yes (select designation below)

Caucasian African African Hispanic Native Female American Female American Male American American

Asian Indian Asian Pacific Local Small Physically Other MinorityAmerican American Business Challenged _______________________

A MINORITY BUSINESS is defined as a business at least 51% of which is beneficially owned and controlled by minority group members. As further defined for these purposes, minority group members would be Women, African Americans, Hispanic Americans, Native Americans, Asian Pacific Americans and/or Asian Indian Americans.

A LOCAL SMALL BUSINESS is defined as a business located in Shelby County and owned at least 51% by Shelby County Resident(s) whose gross annual sales are less than Three Million Dollars ($3,000,000).

Print Name __________________________________________________________ Title ___________________________ Signature __________________________________________________________ Date __________________________

By signing above, it is affirmed that applicant company has received, understands and agrees to the Methodist Healthcare Purchasing Terms and Conditions. These can be referenced by going to www.methodisthealth.org clicking on About Us and clicking on For Vendors.

Vendor Registration ~Cont~ Page 3 of 8

MEDICARE WARRANTIES

Company Name: _________________________________________________________________________ ("VENDOR")

It is the policy of Methodist Healthcare ("MH") and its subsidiaries not to contract or have business relationships with individuals or entities

that have been excluded from federal healthcare programs by the U.S. Department of Health and Human Services Office of Inspector

General, and to routinely verify that an individual or entity with which it contracts or does business has not been excluded from federal

healthcare programs.

1) VENDOR hereby agrees that if it is excluded from participation in federal healthcare programs, it will immediately notify MH in

writing of such exclusion.

2) VENDOR agrees that it has an affirmative obligation to verify whether any of its employees or subcontractors has been excluded from

federal healthcare programs and warrants that it will routinely verify their status and will immediately notify MH in writing if it

determines that any of its employees or subcontractors have been excluded from federal healthcare programs.

3) VENDOR agrees that if MH learns that VENDOR or any employee or subcontractor of VENDOR has been excluded from

participation in federal healthcare programs, MH may immediately terminate, without penalty, any contracts or other business

arrangements it has with VENDOR upon written notice to VENDOR.

By VENDOR ~ Print Name __________________________________________________________ Title ___________________________ Signature __________________________________________________________ Date ___________________________

Rev. 05.24.2019

Vendor Registration ~Cont~ Page 4 of 8

Information Security Risk Pre-Assessment

1. Will the vendor or product process, store, transmit or access Protected Health Information (PHI), Personally Identifiable

Information(PII), Confidential Business Information (CBI), or credit card data (PCI)?

Choose an item.

2. If yes to question 1, please designate Data Type.

Choose an item.

3. Will data be stored On-Premise, Cloud-Based or Hybrid Solution:

Choose an item.

4. If Cloud-Based or Hybrid, is data stored or accessed outside of the Continental US?

Choose an item.

5. If remote access required, will there be Multi-Factor Authentication or Restrict by IP address supported for remote

access?

Choose an item.

6. Will the vendor install a server or other equipment on the MLH network?

Choose an item.

Vendor Registration ~Cont~ Page 5 of 8

INSURANCE AND INDEMNIFICATION

Company Name: ____________________________________________________________________________ ("VENDOR")

Methodist Healthcare and any or all of its subsidiaries and/or affiliates ("HOSPITAL")

A. Insurance and Indemnification:

VENDOR agrees to have and maintain at all times: (a) Commercial General Liability Insurance, and, if goods or merchandise are being sold by a manufacturer or a distributor, if said distributor modifies the goods or merchandise, to HOSPITAL hereunder, Product Liability insurance, in the minimum amounts of $1,000,000 per occurrence, with contractual liability endorsement, (b) statutory worker's compensation insurance, and (c) automobile liability coverage for all owned or leased vehicles with minimum coverage of $250,000 per person, $500,000 per occurrence (required only if vehicles are to be operated by VENDOR on HOSPITAL's premises during the contract term), all of the above with a carrier or carriers qualified to do business in the state of HOSPITAL's location. VENDOR shall provide certificates of such coverage to HOSPITAL within five (5) days of execution of this Agreement. VENDOR shall also provide, or require its insurer(s) to endeavor to provide, at least thirty (30) days prior written notice of any lapse, non-renewal, cancellation or material change of such coverage. HOSPITAL may terminate this Agreement immediately upon any such expiration or cancellation of coverage.

If VENDOR's insurance is of the "claims made" type, then the following additional requirement shall also apply:

The retroactive date shall be certified to be no later in time than the commencement date of the VENDOR's performance under this Agreement, and may not be adjusted or changed without written notice to and prior written approval of HOSPITAL.

If VENDOR's insurance is of the "occurrence" type, then the following additional requirements shall apply:

VENDOR shall maintain said insurance and provide certificates of such coverage, including after the full performance, termination or expiration of this Agreement, for a period representing the normal life expectancy of the goods or merchandise being provided.

All insurance certificates shall be mailed to (1) Director of Purchasing, 1350 Concourse Avenue, Suite 668, Memphis, TN 38104 and (2) Insurance Manager, 1211 Union Avenue, Suite 700, Memphis, TN 38104.

VENDOR further agrees to save, defend, hold harmless, and indemnify the HOSPITAL from and against any and all third party loss, claims, suits, or damages incurred, including reasonable attorneys' fees in defending any claim or cause of action, arising from personal or bodily injury or property damage caused by the acts or omissions of VENDOR or any of its agents, servants, employees, contractors, or subcontractors, including any product defect or product failure, as to any goods and/or services provided pursuant to the agreement or purchase order to which this Exhibit is intended to apply.

These requirements shall be deemed continuing and shall survive any termination or expiration of this Agreement.

By VENDOR ~ Print Name __________________________________________________________ Title ___________________________ Signature __________________________________________________________ Date ___________________________

Vendor Registration ~Cont~

Rev. 05.24.2019

Page 6 of 8

VENDOR/SALES REPRESENTATIVE REGISTRATION To be completed by each representative intending to interact with Methodist Le Bonheur Healthcare.

Company Name ________________________________________________________________________________

Rep Name ________________________________________________________________________________

Position/Title ________________________________________________________________________________

Company Address ________________________________________________________________________________

City ___________________________________________ State __________Zip Code ______________ Rep Contact Information ~

Business Phone _________________________________ Mobile Phone _________________________________ Pager _________________________________ Fax _________________________________________ E-Mail _______________________________________________________________________________ Company Website _______________________________________________________________________________

Rep Reports To/Managed By ~

Name __________________________________________ Title _______________________________

Company Address _______________________________________________________________________________

City ___________________________________________ State __________Zip Code ______________ Business Phone _________________________________ Mobile Phone _________________________________

E-Mail _______________________________________________________________________________

Signature __________________________________________________________ Date ________________________

Signature affirms the individual has read and understands the Methodist Healthcare Standards of Conduct, the Vendor/Sales Representative Relations Policy, the Methodist Healthcare Conflicts of Interest Policy, the Methodist Healthcare Code of Ethics Policy and the applicable HIPPA Privacy Rule and agrees to abide by their terms and conditions and the instructions for Emergency Codes and Vendor Rebate Payments, as applicable. See www.methodisthealth.org click on About Us, click on For Vendors for each of these documents.

Vendor Registration ~Cont~

Rev. 05.24.2019

Page 7 of 8

VENDOR/SALES REPRESENTATIVE CONFIDENTIALITY AGREEMENT To be completed by each representative intending to interact with Methodist Le Bonheur Healthcare.

Rep Name _______________________________________ Company _______________________________________ ("VENDOR")

In consideration of VENDOR'S continued business relationship or association with Methodist Le Bonheur Healthcare or any of its affiliates (hereinafter "METHODIST"), VENDOR agrees to the following terms:

VENDOR acknowledges that in the performance of its duties and obligations on behalf of METHODIST, that its employees, agents and/or contractors may be exposed to information relating to METHODIST's or its tenant's operations, methods of doing business, research and development, patients, patient's medical records, trade secrets, computer programs, finances, and other confidential and proprietary information belonging to METHODIST or any of its tenants in any format whatsoever, (all of which are hereinafter collectively called, "CONFIDENTIAL INFORMATION"). VENDOR agrees that it will not, nor any of its employees, agents and/or contractors, without written authorization of METHODIST, acquire, use or copy, in whole or in part, the CONFIDENTIAL INFORMATION. VENDOR further agrees that it shall not disclose, provide or otherwise make available, in whole or in part, the CONFIDENTIAL INFORMATION to any other person or entity.

VENDOR shall take all appropriate action, whether by instruction, agreement or otherwise, to ensure the protection, confidentiality and security of the CONFIDENTIAL INFORMATION and to satisfy the obligations under the Confidentiality Agreement. VENDOR agrees that its obligations with respect to the confidentiality and security of the Confidential Information exposed to VENDOR, its employees, agents and/ or contractors shall survive the termination of any agreement or relationship between METHODIST and VENDOR. VENDOR agrees that this Agreement shall be governed by the laws of the State of Tennessee.

Signature __________________________________________________________ Date ___________________________

Vendor Registration ~Cont~

8 of 8

Rev. 05.24.2019

In order to comply with federal law concerning financial arrangements between physicians and entities that provide certain health care services,

Methodist Le Bonheur Healthcare and its subsidiaries and affiliates (collectively, or individually “MLH”) requires all persons/entities (excluding

physicians and/or physician groups) to complete this form prior to entering into a business arrangement.

To better answer the questions, please read the definitions:

“Immediate family member” means the following individuals: husband or wife; birth or adoptive parent, child, or sibling; stepparent, stepchild,

stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or grandchild;

and spouse of a grandparent or grandchild.

“Physician” means a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor

of optometry or a chiropractor.

Questions Yes No 1. Is your company owned in whole or in part, directly or indirectly, by a physician who refers patients

to or treats patients at any MLH facility, or an immediate family member of a physician who refers patients to or treats patients at any MLH facility?

2. Is your company owned in whole or in part, directly or indirectly, by any person (other than a physician or an immediate family member of a physician) who refers patients to any MLH facility?

3. Does your company employ or contract with a physician (or an immediate family member of a physician) who refers patients to or treats patients at any MLH facility? If you answered “YES” to this question , please answer a. and b.

a. Does the employed or contracted physician, or immediate family member of the physician, receive compensation from your company that is based on the volume and/or value of referrals to a MLH facility?

b. Does the compensation paid to the physician or the immediate family member of the physician exceed fair market value (“FMV”) for the service provided by the physician or their immediate family members?

4. If you are entering into an arrangement with MLH or any MLH facility as an individual, are you a physician (or an immediate family member of a physician) who refers patients to or treats patients at any MLH facility?

5. If you answered “YES” to any of questions above, please complete the following:

a. Is the physician/person an owner of the company?

b. Is the physician/person an employee of the company?

c. Is the physician/person a contractor of the company?

d. Name of the Physician or other person who refers to an MLH facility:

e. The name(s) of any MLH facility to which the physician/person refers:

f. If applicable, the name of the physician’s immediate family member(s) who have ownership in the company:

ACKNOWLEDGMENT

I hereby represent that the answers provided herein are truthful and accurate as of the date of my signature below. I agree to immediately notify MLH of any changes in the above-disclosed information

Company Name:

Authorized Signature:

Date:

Print Name: Title