Vendor Ownership Certification Form - Cartersville Medical Center 2026

1. Click ‘Get Form’ to open the Vendor Ownership Certification Form in the editor.
2. Begin by filling in the Vendor's name and address at the top of the form. Ensure that all details are accurate for proper identification.
3. Select the appropriate organizational form from the provided options, such as Corporation, LLC, or Partnership. This helps categorize your business type.
4. In Section I, check only one box that accurately describes your ownership type. Be sure to review each option carefully before making a selection.
5. If applicable, answer the follow-up questions in Section I.A, I.B, and I.C regarding sales intentions and physician ownership status.
6. Proceed to Section II and indicate whether there are any compensation arrangements with physicians or their immediate family members by checking 'Yes' or 'No'.
7. Initial next to each statement in Section II that applies to your current or future compensation arrangements.
8. Complete Section III by initialing your understanding of notifying changes promptly. Fill out HCA contact information as required.
9. Finally, certify the document by signing and dating it at the bottom. Ensure all necessary attachments are included before submission.

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