Account Information

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Principals *

Business Information

ACH AutoPayment Enrollment

Billing Info
Twice Monthly Payment - All invoices from the 1st to the 15th of the Month will be withdrawn on the 30th of the same month (or the last business day proceeding the 30th). All invoices from the 16th to the end of the Month will be withdrawn on the 15th of the following month (or the last business day proceeding the 15th).

Terms and Conditions

The undersigned agrees that the following terms and conditions are applicable to all purchases made by Applicant and shall constitute a contract between the Applicant and HealthSource Distributors, LLC.

1. Applicant warrants that all information set forth in this Application is a true representation for the purpose of obtaining credit from HealthSource. Any willful misrepresentation shall constitute a default by Applicant in its agreement with HealthSource Distributors, LLC ("HealthSource"), and shall result in disqualification of Applicant as a customer.
2. Payments terms are set forth on invoices. Payments not received on or before the date(s) set forth on the invoices shall be deemed late. Should the due date fall on a holiday or weekend, then payment is due on the preceding business day.
3. The signatories hereto hereby authorize HealthSource to conduct such investigations as it may deem necessary to verify their creditworthiness and agree to release all persons, companies, or corporations using or supplying such information, including HealthSource, from any claims and/or losses that may result therefrom.
4. HealthSource may in its sole discretion, at any time, without prior notice, discontinue service, change Applicant's credit terms, cost of goods, discount, services or programs and require payment in cash before shipment of any and all merchandise. Applicant waives any and all claims against HealthSource for said conduct.
5. In case of default by Applicant, Applicant and Guarantor (see below) agree to reimburse all of HealthSource's reasonable costs of collection, including but not limited to, attorneys' fees.
6. Applicant agrees to immediately notify HealthSource, in writing, of any of the following events affecting Applicant or its owners/operators: bankruptcy (business or personal), investigation (Medicaid or otherwise), disciplinary hearing, suspension, licensing issue, PFP/provider audit, legal proceedings, judgments, liens or any change in financial condition.
7. A late fee assessment of 1.5% per month or the highest amount allowed by law, if lower, may be charged to the outstanding balance if payment in full is not received timely.
8. Applicant understands, accepts and agrees that in the event a payment fails to clear the collection process, Applicant shall be subject to a $100.00 service charge per rejection.
9. HealthSource's acceptance of any payment for less than the full amount of the indebtedness owed shall not constitute a waiver of HealthSource's right to collect the balance (notwithstanding any endorsement on any check or other instrument) and shall not be deemed an accord and satisfaction.
10. Applicant agrees to provide HealthSource with advance written notice of any change in ownership, management and/or control of Applicant. In any such event, all open invoices shall immediately become due and payable. Applicant agrees not to transfer/assign any open balance without HealthSource's written consent.
11. Applicant agrees to abide by HealthSource's Return Goods Policy (as may be amended - see website for details). Unauthorized returns will be destroyed and no credit will be issued.
12. Applicant agrees to indemnify and hold HealthSource and its officers, shareholders and employees harmless from and against any and all claims, liabilities, losses, costs and expenses (including attorneys' fees), arising directly or indirectly out of: (a) the fraud, intentional misconduct, omission or negligence of Applicant; and (b) the marketing, storage, distribution, sale or use of products sold to Applicant by HealthSource, including claims for personal injury, death, and/or property damage.
13. No failure or delay to exercise any power, right or privilege and no course of dealing shall operate as a waiver of any power, right or privilege hereunder.
14. PERSONAL GUARANTEE - The undersigned personally guarantees prompt and full performance of all obligations due and owing by Applicant to HealthSource under this and/or any other agreement with HealthSource. In the event of default, HealthSource and/or any holder hereof is authorized to proceed against the undersigned guarantor, without first having to proceed against Applicant, for the full amount due, including late payment charges, interest, costs, and attorney's fees. The undersigned waives presentment, demand, protest, notice of protest, notice of dishonor and any and all other notices or demands of whatever character to which the undersigned might otherwise be entitled. The undersigned further consents to any extension granted by HealthSource and waives notice thereof. If more than one guarantor, the obligation of each Guarantor shall be joint and several. Termination of this Guarantee must be in writing, signed by HealthSource and undersigned, and in such event, shall only apply as to future obligations.
15. SECURITY AGREEMENT - To secure Applicant's existing and future liabilities to HealthSource, Applicant grants HealthSource a security interest upon all personal property of Applicant, wherever located, now owned or hereafter acquired, including but not limited to, accounts, insurance proceeds, inventory, prescription records, equipment, fixtures, contract rights, customer lists, cash on hand/deposit, telephone numbers and all other tangibles and general intangibles, including replacements and proceeds of the foregoing, now owned or that may hereafter arise (collectively, the "Collateral"). Applicant authorizes HealthSource to file a UCC-1, along with amendments and extensions thereto. Applicant will cooperate with HealthSource in obtaining control of the Collateral. Upon default by Applicant, HealthSource shall have the right to enforce its rights against the Collateral. HealthSource may pursue any remedy available at law and/or equity, including those available under the Uniform Commercial Code.
16. The undersigned, having the authority to bind Applicant, acknowledges having read and reviewed this document, and further warrants, covenants and agrees to pay and perform all of the obligations secured by this Credit Application according to the stated terms.
17. The undersigned agrees that the following terms and conditions are applicable to all purchases made by Applicant and shall constitute a contract between the Applicant and HealthSource Distributors, LLC. This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information processed through the Vendor Express Program. Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion.
18. Privacy Act Statement: The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.

Signatures

The Guarantor must be an owner of the pharmacy.