Join IPS GPO

IPS New Member Enrollment Form

To Enroll: Complete and submit this Enrollment Form along with any attachments requested by faxing to Lynne Sherman at: 1-(404) 953-6013. You may also scan and e-mail the completed form to: info@ipsgpo.com. You will receive a confirmation once enrollment with IPS is established. Questions? Please contact Lynne Sherman via email or directly @ 877-910-3616.

Contact Information

Main Office Ship To Address

Additional Ship To Address (if applicable)

Billing Address (if different from main office address)

Please provide your vaccine account numbers for

Sanofi Pasteur
Merck
Pfizer

Please list all Physicians and Mid-Levels

Primary Specialty

Attachments Required

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Questions

In order to ensure that the IPS Vaccine Program will suit the needs of your practice, please take a moment to answer the following questions. The information gathered will be reviewed by the Vaccine Program Director to determine compliance with program requirements. Please answer the following questions:

Q1: Is your practice currently affiliated with another vaccine purchasing program?
Q2: Do you have multiple locations linked under the same account number?
Q3: Total number of physicians in practice?
Q4: Total number of mid-levels in practice?
Q5: Please set me up with an account with Staples Business Advantage so that I may order office supplies on line at IPS discounted pricing.

NOTE: If you already have a Staples account, you will still need to set up an account with Staples Business Advantage in order to receive IPS discount pricing. This discount is only available for Staples Business Advantage on line orders and is not available at Staples retail stores.

Please indicate when you plan to place your next order (if applicable) with:

Agreement

THIS AGREEMENT is between the Medical Practice named herein and MTBC Health, Inc. d/b/a Integrated Physician Solutions ("IPS”) Group Purchasing Organization. The Medical Practice and IPS agree to enter into an agreement in which IPS will act as a group-purchasing agent so that by becoming a Member of the IPS Group Purchasing Organization, the Medical Practice will gain access to nationally contracted IPS pricing. 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) and a 90% market share with Merck’s Hep A (Vaqta), Merck’s Hep B (Recombivax), Merck’s Rotavirus (Rotateq), and Merck’s HPV (Gardasil). 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 90 days and a 2% prompt pay discount. Members agree to keep all IPS pricing and contract information strictly confidential except as may be required by any governmental programs, including but not limited to, Medicare and Medicaid. The Member is solely responsible for any and all returns. This Agreement may be canceled by either party hereto, with or without cause, through the provision of 30 days’ advanced written notice to the other party.

I understand and agree that any and all vaccines purchased through the 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 should a dispute occur between the Member and the vaccine manufacturer or other supplier/vendor regarding billing, payments, return of product,or nature of product,or any other issue, the dispute will be resolved solely and directly between the Member and the vaccine manufacturer or supplier/vendor.

Printable Form

You can download this form by clicking on the PDF Icon. Scan or fax enrollment form to IPS. See contact information below.

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Address:

MTBC Health, Inc. | A Subsidiary of MTBC
368 W Pike St Suite 102
Lawrenceville, GA 30046