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Institution Name:
Address:
 
City:
State:
Zip:
Website:
Telephone:
Fax Number:
Federal ID#:
Name of Institution Owner:
Nonprofit Corporation  For Profit Corporation
Other
If institution is operated by other than ower, is operation:
NonProfit       For Profit
Class of Trade:
Hospital: Acute Care Veterinarian Practice
Hospital: LTC Retail Pharmacy
Surgery Center Nursing Home Provider
HMO DME Vendor
Long Term Care Facility Dental Practice
Ind/Asst. Living Facility AIC
Residential Facility Prison
Alcohol/Drug Rehab Day Care Facility
Home Health Agency School/University
Church City/Town/State
Social Service Agency Other
Physician Practice**
Specialty:		 Physician Practice***
Specialty:
** 3 or fewer practicing physicians; *** 4 or more practicing physicians
Pharmacy DEA Number:
Health Industry Number:
Total Licensed Beds:     Total Acute Beds:     Total LTC Beds:
 
Contact Information:
Administrator/CEO
Name:
Title:
Phone:
Fax:
Email:
Finance
Name:
Title:
Phone:
Fax:
Email:
Materials Management
Name:
Title:
Phone:
Fax:
Email:
Pharmacy
Name:
Title:
Phone:
Fax:
Email:
Information Services
Name:
Title:
Phone:
Fax:
Email:
Food Services
Name:
Title:
Phone:
Fax:
Email:
Radiology
Name:
Title:
Phone:
Fax:
Email:
Laboratory
Name:
Title:
Phone:
Fax:
Email:
Facility Management
Name:
Title:
Phone:
Fax:
Email:
Operating Room
Name:
Title:
Phone:
Fax:
Email:
Alt. Site Coordinator
Name:
Title:
Phone:
Fax:
Email:
The CHA Shared Services Program is authorized to list this institution as a CHA SSP Member.  Healthcare member participants agree that all purchases through CHA SSP contracts are for their "own use" as such phrase is defined in Abbott Laboratories v. Portland Retail Druggists Ass'n US (1976).  (Except CHA SSP developed for and available only to Retail Pharmacy members.  These contracts have products designed for resale.)  All members agree to accept the "Responsibilities of Program Participants" outlined in the CHA SSP Operating Guidelines.
 
Authorized By:
Title:
Date:


The Connecticut Hospital Association

Copyright ©1999-2002 The Connecticut Hospital Association
Shared Services Program
110 Barnes Road | PO Box 90 | Wallingford, CT 06492-0090
Phone (203) 294-7380 | Fax (203) 265-9130
Email-chassp@chime.org

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