Moffitt
 
 

Please fill out the following form to begin the registration process. Be sure to complete all of the required information correctly. If any information in each tab is invalid or left blank, your profile may not be processed. Underlined words, indicate additional information viewable by clicking on the word. Should you require assistance, please contact the Purchasing Department at 813-745-7840.

Fields marked with an * are required for submission.These fields are in most sections please ensure you go through each section thoroughly.

Vendor Management and Credentialing Disclaimer:
All vendor representatives who intend on visiting Moffitt Facilities are required to be compliant with our Vendor Management Program. Please be aware that there is an associated cost for the Vendor. More information regarding our credentialing process can be provided upon request.

 

Vendor Purchase Form Information
  1.                                                         (Foreign Vendors: Please select "FO" in this field)







Vendor Remit Information
  1.  
  2.                                                         (Foreign Vendors: Please select "FO" in this field)
Business Information
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  2. Equipped for EDI Transactions (electronic data interchange) transmissions through GHX (Global Healthcare Exchange)?
  3. Which Credit Cards are Accepted:


  4. Are you Submitting:


  5.   Do you have a Doing Business as (DBA) name?
  Conflict of Interest
Yes No
* Does any employee, owner, board member, or any other representative of Vendor have a personal relationship with the Moffitt Staff (Employee , Physician , Researcher or Board Member)?
Conflict of Interest is a relationship between the vendor employees or representatives and Moffitt staff wherein a personal benefit would result from the business relationship. A conflict of interest does not preclude a business relationship but must be disclosed.
Business Classification
Yes No Yes No
* Corporation   * Small Business  
* Large Business   * Government Owned  
* Privately Held   * Non-profit  
Supplier Diversity
Business Ownership Information

The business must be at least 51% or more managed and controlled by the diversity classification selected and the majority owner/partner is “Involved in the management and daily operations of the business”.

Yes No Yes No
*Minority-Owned Business Enterprise (MBE)   *Woman-Owned Business Enterprise (WBE)  
*Veteran-owned Business Enterprise (VBE)   *Non-profit  
*Service Disabled Veteran-owned Business Enterprise (SDVBE)   *SBA (8A) Certified Small Business  
*SBA HUBZone Certified Small Business   *Certified Small Disadvantaged Business  

Please select the diversity category of the majority owner of the business below:

  1. Diversity Category:  


Non-Profit

Yes No Yes No
Non-Profit Minority Board   Historically Black Colleges & Universities (HBCU)  
Non-Profit Minority Employees   Non-Profit Minority Community  
Certification
Yes No
Is your business certified as Minority, Woman-Owned, SBA (8A) or Small Disadvantaged Business by a certifying agency, or verified/certified as a Service Disabled Veteran-owned Business Enterprise by the U.S. Dept. of Veterans Affairs or the State of Florida Office of Supplier Diversity?
HIPAA  
Yes No
* In the performance of Service for the Center, would your organization have access to patient medical information?
Federal Government Exclusions

Moffitt Cancer Center will screen all vendors and its senior management through the OIG (Office of Inspector General) and GSA (General Services Administration) databases. Any potential matches must be cleared by obtaining additional information from the organization or individual.

Yes No
  * Has the organization or any of its owners, board of directors, or employees been excluded, sanctioned or otherwise debarred from billing or receiving Medicare or Federal Government Agency Funds.
  * Has the organization or any of its owners, board of directors, or employees been issued a warning letter by Medicare, the FDA (Federal Drug Administration), or any other Federal Government Agency ?
Organization Information
Organizational Structure
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Agreements

As a vendor for H. Lee Moffitt Cancer Center, your organization and its products and services purchased will be required to adhere to the following. Please indicate your acceptance to the following:

Yes No N/A
  *Standard Purchase Order Terms and Conditions - (Applicable except if transaction specific agreement in writing exists)
  *Moffitt Policy ADM-V001 Vendor/Contractor Guidelines
  *Corporate Compliance - Standards and regulations administered by local, state, and federal agencies.
  *Certificate of Insurance
Type of Insurance
    -Workers Compensation Minimum Statutory Limits
    -Comprehensive General Liability, Bodily Injury, 
     & Property Damage 
    -Automobile Liability Insurance Bodily Injury,
     & Property Damage 
  *Equipment Purchases
   -National Bureau of Fire Underwriters
   -National Electronic code NFPA 70
   -Life Safety Code NFPA 101
   -Need FDA Approval, if applicable to application
  *Construction Transactions Subject to the following:
    -Standard Building Code
    -Standard Mechanical Code
    -Standard Plumbing Code
    -D.C.C. Florida Board of Building Codes 
     & Standard Accessibility Requirements Manual
    -American National Standard Institute for Handicapped
    -Standard Gas Code
    -National Fire Protection Association
    -Fire Protection Rules & Regulations 
     of the State Fire Marshall
    -AHCA Agency for Health Care Administration

Guidelines for Vendors and Vendor Representatives


In order to ensure a mutually successful business relationship, a brochure that outlines general business guidelines has been developed. The brochure can be obtained at any of the Centers Check-in desks or by clicking here
Yes No
  *As a vendor for the Center, your organization and its representatives agree to abide by the guidelines for Vendors and Vendor Representatives?
  *Is Vendor registered with the state of Florida to collect sales use tax?
  *A specific assignment of copyright will be required for vendor to execute identifying copyright materials. Is vendor willing to assign right/title/interest, and all copyrights in any work preformed to Moffitt Cancer Center?
  *By entering your name, you assert that the responses to this questionnaire are true and accurate. Providing incorrect answers could disqualify the company as a vendor for Moffitt.

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