CHANGING GPO DESIGNATIONS. In the event Member has designated a GPO and its applicable agreements with Philips to govern Member purchases from Philips, Member acknowledges and understands that in the event Member subsequently elects to change this designation by electing to designate a different GPO and its applicable agreements for any future purchases, Philips may be bound by the terms of its agreement with the currently-designated GPO (“Current GPO”) to disclose the name and identification number of such Member to the Current GPO, upon Philips’ acceptance of the Member’s new Designation Form the changing its Current GPO. Accordingly, Member must indicate below whether it consents to the release of such information to the Current- GPO, by checking the appropriate box and signing below. If Member withholds consent, Philips will not disclose such information, pursuant to its obligation of confidentiality to Member. [ ] My organization consents to being included on the Membership Election Notice provided to the Current GPO. [_ _] My organization does not consent to being included on the Membership Election Notice provided to the Current GPO. In the event a Member wishes to withdraw its consent at a later time, please contact the following: Xxxxxxxx Xxxxxxxxx. Director Commercial Contracts Philips Healthcare, a division of Philips North America LLC 000 Xxxxxx Xxxxxx, 3rd Floor Cambridge, MA 02141 IMPORTANT!! Orders referencing a purchase agreement cannot be placed until Philips receives and accepts this signed Designation Form. All orders must reference the purchase agreement number to receive a discount. Upon Philips’ acceptance of this Designation Form, after it is signed by the Member and returned to Philips, Philips will countersign and return a copy to the MHS or GPO, referencing the applicable purchase agreement in the space below. MEMBER PHILIPS Hospital Name Xxxxxx Xxxxxxx Xxxxx Xxxx, Xxxxx, Zip Signature Name Date After completing this Designation Form, mail or fax to: Philips Healthcare Business Center- MS0400 0000 Xxxxxxxxx Xxxx Xxxxxxx, XX 00000 Phone: (000) 000-0000 Fax: (000) 000-0000 Xxxxxxxxxx.xxxxxx@xxxxxxx.xxx Title eMail Phone / Fax Signature Date Exhibit F PAYMENT INSTRUCTIONS - GPO ADMINISTRATIVE FEES
