Coherent Participation FormMain Practice LocationPractice NamePractice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Practice PhoneFax PhoneEmail* NPI #Tax ID #(must have to pay claims)Contact Person at this locationBest way to contactAdditional Practice LocationsPractice NamePractice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Practice PhoneFax PhoneEmail NPI #Tax ID #(must have to pay claims)Contact Person at this locationBest way to contactDues Authorization FormDoctor First Middle Last Suffix Doctor First Middle Last Suffix Doctor First Middle Last Suffix Please list any additional doctors to be paid by this draft.Check all that apply, please draft the following dues from my account:Basic Membership Dues (Optometrists) Quantity Price: $50.00 Quantity Basic Membership Dues (Ophthalmologists) Quantity Price: $100.00 Quantity Coherent Preferred Partner Program - Vendor Authorization FormIf you are interested in opening an account with any of the following vendors, please indicate so with a checkmark in the box. If you already have an account number, please provide us with that information. This is the best way to make sure that you are maximizing your office discounts and getting as much credit towards your dues as possible.Primary Strategic Vendor PartnersAbyde - HIPAA ComplianceChose "Other" if you have an account, please provide acct # Do not need an account Need Account ADO Practice Solutions - GPOChose "Other" if you have an account, please provide acct # Do not need an account Need Account Best Price Digital - Optical LabChose "Other" if you have an account, please provide acct # Do not need an account Need Account Biotissue - Amniotic MembraneChose "Other" if you have an account, please provide acct # Do not need an account Need Account BluePay - Card ProcessingChose "Other" if you have an account, please provide acct # Do not need an account Need Account Blythe Medical - Amniotic MembraneChose "Other" if you have an account, please provide acct # Do not need an account Need Account Compliancy Group - HIPAA ComplianceChose "Other" if you have an account, please provide acct # Do not need an account Need Account EyecarePro - Marketing/WebChose "Other" if you have an account, please provide acct # Do not need an account Need Account MODOChose "Other" if you have an account, please provide acct # Do not need an account Need Account Lunovus - SupplementsChose "Other" if you have an account, please provide acct # Do not need an account Need Account Modern Optical - FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account Paubox - Secure EmailChose "Other" if you have an account, please provide acct # Do not need an account Need Account Proof Eyewear - FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account REMI - Maintance ContractsChose "Other" if you have an account, please provide acct # Do not need an account Need Account RevolutionEHR - PM & EHR SoftwareChose "Other" if you have an account, please provide acct # Do not need an account Need Account Walman Optical - Optical Lab & FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account WestGroupE - FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account I hereby authorize Coherent Eye Care to obtain and record purchasing information on my strategic vendor account(s). I also agree to allow Coherent to receive a rebate on my purchases from the above listed strategic vendors as long as it does not negatively alter my own pricing. I agree to the terms of the GPO Participant Agreement with Coherent.SignatureName First Last Date MM slash DD slash YYYY Membership LoginUsername*Password* Enter Password Confirm Password Payment OptionsDiscount CodeTotal $0.00 Credit Card*Card Details Cardholder Name Please check box to indicate agreement* I hereby authorize Coherent Eye Care to collect my dues as outlined above. I understand that failed payments could jeopardize my membership.SignatureDate MM slash DD slash YYYY
