Vendor Setup Packet

If the vendor legal name you listed is an individual, generally your taxpayer identification number (TIN) is your social security number (SSN). For other entities, it is your employer identification number (EIN) 

By proceeding, I hereby certify that, to the best of my knowledge, the provided information is true and accurate, and I am authorized to submit the form on behalf of the listed organization. 

We request that you include a blank, voided check or bank-generated account verification form for account and routing number verification.

This authorization is effective as of the signature date below and is to remain in full force and effect until Alliance Health has received written notification of its termination in such time and such manner as to afford Alliance Health and the financial institution a reasonable opportunity to act on it, or until Alliance Health deems it necessary to terminate this agreement. Under penalties of perjury, I hereby certify the checking OR savings account indicated on this form are under my direct control and access; therefore, I authorize Alliance Health to initiate, change, or cancel credit entries to the financial institution account as indicated above. If my financial institution information changes, I agree to submit to Alliance Health a revised Authorization Agreement for Electronic Funds Transfer form.

I understand that by signing this form, payments issued will be Federal and State funds, and that any falsification or concealment of a material fact may be prosecuted under Federal and State laws.

All vendors are required to provide a current IRS W-9. Please upload a completed and executed copy below. If you do not already have a current W-9 on file, you may download one from the IRS at https://www.irs.gov/pub/irs-pdf/fw9.pdf