Contract Review Request Form

Contact Information

1. Name 1. Name * First Last
2. Title *
3. Department *
4. Phone 4. Phone * - ### - ### ####
5. Email *
6. VP signing contract 6. VP signing contract * First Last
Vendor information
7. Vendor Business Name *
8. Is Vendor a Premier GPO Supplier? *

8. Is Vendor a Premier GPO Supplier? Yes No Unsure
9. Is this a new Mercyhealth vendor? *

9. Is this a new Mercyhealth vendor? Yes No Unsure
10. Vendor Contact Name 10. Vendor Contact Name * First Last
11. Vendor Contact Phone 11. Vendor Contact Phone * - ### - ### ####
12. Vendor Contact Email *
13. List other contracts with vendor, if any:
14. The requesting party and the executing VP are responsible for the review of all business terms. Have the business terms been reviewed and approved? *

14. The requesting party and the executing VP are responsible for the review of all business terms. Have the business terms been reviewed and approved? Yes No Unsure
15. Do you require any changes to business terms during negotiation? *

15. Do you require any changes to business terms during negotiation? Yes No Unsure
If yes, please explain:
16. Mercyhealth entity that is contracting *

16. Mercyhealth entity that is contracting Mercy Health Corporation Mercy Health System Corporation Mercy Harvard Hospital, Inc. Mercyhealth Development Foundation Mercy Health System Association of Volunteers, Inc. MercyCare Insurance Company Mercy Assisted Care, Inc. Mercyhealth Visiting Nurses Association, Inc. Rockford Health Physicians Javon Bea Hospital Mercyhealth Hospital and Physician Clinic–Crystal Lake Unsure
Services/Products Being Purchased
17. Will Protected Health Information (PHI) be provided to this vendor or put on its products? *

17. Will Protected Health Information (PHI) be provided to this vendor or put on its products? Yes No Unsure
If yes, please provide details:
18. Total Contract Amount *
19. Term of Contract (Length in months) *
20. What problem(s) will purchase of the products/services solve? Please provide details: *
21. Are the Services/Products available from an alternate source? *

21. Are the Services/Products available from an alternate source? Yes No Unsure
22. Desired Completion Date: 22. Desired Completion Date: * / MM / DD YYYY

Please note that Legal Services will try to accommodate date requests, but a standard review generally requires at least a 2- to 3-week lead time.
Drop-Dead Completion Date: Drop-Dead Completion Date: / MM / DD YYYY

Please provide this date as the last possible date on which a contract can be executed (signed) ONLY IF THE CONTRACT IS TIME SENSITIVE AND AN EXTENSION WITH VENDOR IS NOT POSSIBLE. Otherwise, please leave this date blank.
Provide any additional details you believe are important to this transaction:
Please attach the Contract and ALL ancillary documents referenced in the Contract in Microsoft Word modifiable format (you may need to request this version from the vendor).

Attach Files

Contract Review Request Form

Contract Review Request Form

Vendor information

Services/Products Being Purchased