Tell us more about your innovative impact on patient care.
We appreciate the opportunity to review your submission. Questions? Please contact
innovation@healthtrustpg.com
Your Name (First and Last):
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Your Email Address:
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Company Name:
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What is your role at your company?
Company Website:
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Product Name and Catalog Number(s):
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Have you reached out or submitted this product/service to another HealthTrust team?
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No
Yes
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Who else at HealthTrust have you shared your product/service with?
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Is your device or technology a clinical product or service? (Does it have direct impact on patient care or clinician?):
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No
Yes
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Site of Care:
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Acute
Ambulatory Surgery Center (ASC)
Physician Office or Outpatient Setting
Behavioral Health Facility
Long-Term Care Facility
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Are you a Minority and Woman Owned Business Enterprise (MWBE), Veteran owned, or LGBTQ+ owned company?
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MWBE
Service Disabled Veteran Owned
LGBTQ+ Owned
No
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Please attach your Diversity Certification here:
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Has this product received regulatory approval for the United States such as 510k, FDA, HTCP, etc.?
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Yes
No
Applied, Approval Pending
Regulatory approval does not apply
If yes, which pathway did you obtain approval?
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Please attach a copy of your regulatory approval:
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Name of predicate devices if applicable:
Are you aware of any HealthTrust members using your product?:
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No
Yes
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Which HealthTrust members are using your products?:
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Who do you consider your competitor in the market?:
Please explain why your product/service is considered innovative:
Do you have any published evidence regarding your product/service?
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Yes
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Please attach any published evidence regarding your product/service:
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If you are selected to move forward in the HealthTrust contracting process, it is our expectation that you will add the product to an existing HealthTrust agreement if appropriate or promptly negotiate a new contract with HealthTrust. Do you agree to enter into good faith negotiations based on the outcome of the review?
Move Forward Agreement is required.
Thank you for your submitting your request. Our team will review and send a note upon approval. Have any questions? Please email us:
clinical.services@healthtrustpg.com
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