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If you would like to open an account with Health Management Systems, Corp. please fill out the following form.  An HMSC sales rep will contact you with your account number and discuss your pricing. USE THE TAB OR MOUSE, NOT THE ENTER KEY, TO MOVE BETWEEN FIELDS.  The enter key will submit the form.  If you hit the enter key prior to completion of the form, use your back button and continue filling out the form.  Click submit or Enter when done. Billing Information: Company Name: A/P Contact Name: Address: City:  State:  Zip:  Phone: Fax: Email: Shipping Information:  If same as billing check here and move to next section. Company Name: Receiving Contact Name: Address: City:  State:  Zip:  Phone: Fax: Email: Trade References:  If opening a pay by credit card account check here and skip Trade Reference section. Supplier 1: Phone #: Contact: Address: Account #: Supplier 2: Phone #: Contact: Address: Account #: Supplier 3: Phone #: Contact: Address: Account #: Other Information: Company Website: Purchasing Contact: Name: Phone: Email: Purchase Order Required:  Yes No Special Invoice Requirements: Persons Authorized to charge on Account: Tax Exempt:  Yes   No   (if yes, please fax tax exempt certificate to (972) 578-9854) Legal Structure:  Corporation    LLC    LLP    Partnership    Sole Proprietor    Non-Profit Date of Incorporation: State: Federal Tax ID #: Duns#: In Business Since: Type of Business:

If you have any questions or problems with this site, please call Health Management Systems, Corp. customer service at 888-300-4672