New Supplier Request Form

If you have questions or need assistance completing this form, please contact

Vendor/Supplier Information and Disclosures

I have reviewed the CMH "Outside Professional and Commercial Interests" policy regarding conflict of interest prior to submitting this request, and I have disclosed my relationship according to the policy."

Business Associate Agreement

A Business Associate Agreement (BAA) is a Legal agreement and will take some time to execute. Patient information will not be provided until the Business Associate Agreement is executed.

Vendor/Supplier Description

If yes, you MUST include a current copy of your certificate of diverse certification with this registration
Please Note: The Children's Mercy Hospital recognizes SAM supplier diversity certifications

Vendor/Supplier Contact Information