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Electronic Ordering Registration From
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Request Form for Electronic Ordering
Requestor Information
Name
Phone
Email Address (*required)
Facility Name
Address
City
State
Zip
Country
Purchasing/Materials Management Contact Information
Name
Phone
Fax
Email
IS Contact Information
Name
Phone
Fax
Email
Software
X12 Version
TRANSACTIONS
EDI
Internet
810(Invoice) Internet Ordering
820 (Payment) Internet Confirmation
850 (PO)
855 (PO Acknowledgement)
832 (Sales Catalog)
Other
COMMUNICATION PARAMETERS (If unable to find, contact your I.S. department for assistance)
ISA (05) Qualifier
Password(s)
Approximate date you would like to begin ordering::
Baxter Account Number(s)
Frequency of ordering Daily Weekly Monthly Other
Communication method of transmitting data

Direct Async Bysinc Internet XML
VAN (i.e. GEIS, Sterling, Sears, IBM, etc.)
Do you order with any other vendors (i.e. Allegiance?)
What divisions do you currently order from?

Medication Delivery

Renal

Fenwal

BioScience
Will you be ordering through multiple methods? Yes No
Do you have a Duplicate Catch for invoices? Yes No
You were referred by:
Baxter Representative
Baxter Customer Service
Other
Additional Comments or Requests:

If you experience any problems with this form, please contact us in the following manners

eCommerce Toll Free phone number:
1-877-334-2298, option 1


Direct phone number:

847-948-4004

 

Mailing/Courier address:

Baxter Healthcare Corporation
eCommerce Support DF4-1E
One Baxter Parkway
Deerfield, IL 60015-4634

E-mail:

ecteam@baxter.com

 
 
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