On-Line Purchasing

Order from vendors without the time consuming phone calls or faxes. Order on-line from Invacare Supply Group, Medline, Gulf South, McKesson, First Choice, Independence Medical and other wholesalers and manufacturers.

Networking Web Portal

Now your business partners can securely access and enter data via the web. Physicians can complete CMNs on-line. Referral sources can enter new patients. Sales Reps and clients can enter orders, virtually eliminating the need to enter data in the office.

Internet StoreFront

The Fastrack StoreFront offers providers a full solution to create a professional Internet presence to start generating additional revenue, accept insurance, credit and debit cards, Paypal and more. Orders and client information flow directly into the Fastrack System.

Available Standalone or
Integrated with Fastrack!

Fastrack MSO Membership Application

Thank you for your interest in joining the Fastrack Member Services Organization.
Please complete all sections of this application.

If you would prefer, you can click here to download a PDF of the application to fill out and mail or fax to us!

Applicant's Name:

Title:

Company Name:

Street:

Suite #:

City:

State:

Zip:

Country:

Phone:

Fax:

Email:

Web Site:

Current Software Application:

Purchasing Agent:

Annual Revenue:

Estimated annual expenditures:

on equipment

on supplies

on pharmaceuticals

Year started business:

Number of employees:

Number of locations:

Number of retail locations:

Do you have an On-Line StoreFront? Yes No

If yes, site address:

Do you belong to a national or state association or Buying Group? Yes No

If yes, which ones?

Service/Product Lines

Home Medical Equipment

% of total revenue

Respiratory Services

% of total revenue

Rehab and Assistive Services

% of total revenue

Supplies

% of total revenue

Pharmaceutical Services/Infusion

% of total revenue

Home Care Agency

% of total revenue

Other

(please specify)

% of total revenue

Ownership:

Independently Owned	Hospital Affiliated
Public Company	Subsidiary of

If you have multiple locations purchasing product, please indicate the addresses for each below or on a separate page:

Purchasing Agent:

Title:

Street:

City:

State:

Zip:

Phone:

Email:

What products or services do you offer?

Wheelchairs	Oxygen Concentrators	Phototherapy Equipment
Custom Rehab	Liquid Oxygen	CPMs
Ramps and lifts	Transfill on-site (gas)	Orthotics/Prosthetics
Vehicle mods. and conver.	CPAP/BiPAP	Ostomy/Colostomy
Hospital beds	Apnea monitors	Lymphedema pumps
Low air loss therapy	Volume ventilators	Wound care
Patient lifts	Diabetics	Nursing Services
Bath safety	Crutches	Walkers
Canes	Patient supports	Specialty pharmacy
Retail pharmacy	IV therapy	Enteral nutrition
Aerosol therapy	Other

Please indicate your top suppliers.
Key Suppliers	Annual Volume
1.
2.
3.
4.
5.

Please indicate other suppliers you would like Fastrack to offer:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Provide the names of staff that should receive information related to the following topics:

	Name/Position	Telephone	Email
Pricing
Promotions
Industry/Educational News
New Products/Services

How did you learn of Fastrack MSO?

Tradeshow	Article
Internet	Other (please specify)

Additional Comments:

Terms and Conditions:

Fastrack MSO is not responsible for the quality, delivery, warranty or conditions of any product or service purchased by the provider. Fastrack MSO is not the agent of the vendors.
Fastrack MSO is not responsible for any of the provider’s obligations as it relates to product purchased from the vendor. The provider is an independent contractor and not an agent of Fastrack MSO. Fastrack MSO is not the agent of the provider.
Member acknowledges that vendors, prices, promotions and any special terms are subject to change without notice although Fastrack MSO will make every reasonable attempt to notify the member as soon as possible upon notification of any changes from the vendor.
Fastrack MSO, Fastrack Healthcare Systems, Inc. and its’ affiliates shall not be liable for any indirect, special, or consequential damages (including, but not limited to, damages for loss of business or loss of profits), whether based on breach of contract, breach of warranty, tort, or otherwise, even if advised of the possibility of such damages.
Member agrees to keep all member’s vendor pricing and terms strictly confidential.
Fastrack MSO reserves the right to deny a member access to the on-line purchasing web portal if member fails to make purchases of product during the year from our approved vendors.
Membership is open to only Home Medical Equipment providers, Home Infusion & Specialty Pharmacies, Retail Pharmacies, Home Healthcare Agencies, Hospice and related providers.

By checking this box - I hereby certify that all the information I have provided on this application is correct and we agree to the term and conditions of FASTRACK MSO.

Name:
Title:
Date: