UHS - Purchase Request Form
Full Name
NetID
Email
I need help with:
Please select...
Making a Payment
Making a Purchase
What are you purchasing?
Tangible Goods
Software or online services
Cell Phone & Service Plan
Services
have you received your goods/services?
Yes
No
do you know your PO number?
Yes
No
please enter your PO number.
University PO Numbers start with A0
Please be aware that software and online services can be challenging to purchase.
Usually, these purchases require accepting a license agreement with terms and conditions unfavorable for the University. These packages also over interact with University data in some way, which requires additional review.
These types of purchases may take 6-8 months to reach the finish line.
General Description of Purchase
Purpose for incurring the expense
Is this purchase over $10,000?
Yes
No
Is this purchase over $50,000.00?
Yes
No
When your submission is received, UHS Finance will reach out to discuss any additional documentation that may be required.
is this a new or existing supplier?
New Supplier
Existing Supplier
Is this supplier a student at any UMass campus?
Yes
No
Please provide the student's campus name and Student ID Number.
Department
Please select...
Directors-A732001000
Human Resources-A732003000
Systems-A732005000
Facilities-A732006000
Ambulatory Care-A732008000
SRH: Specialty Health aka Women's Health-A732008000
North Clinic-Gen Med-A732008000
Central Clinic- Travel/Gen Med-A732008000
South Clinic-Room 101-A732008000
South Clinic-Room 104-A732008000
Financial Services-A732009000
Finance -A732009000
Billing Department-A732009000
Patient Services-A732010000
Acupuncture Clinic-A732011000
Health Records-A732012000
Laboratory-A732013000
Chemistry-A732013000
Haematology-A732013000
Micobiology-A732013000
Phlebotomy-A732013000
Radiology-A732014000
Pharmacy-A732015000
Physical Therapy-A732016000
Boyden Physical Therapy-A732016000
UTC - Urgent Care-A732018000
Housekeeping-A732019000
Parking & Courier-A732020000
Central Stores-A732021000
Equipment Mgmt-A732022000
Sterile Supply-A732023000
Medical Staff-A732026000
Eye Services-A732027000
Contact Lens- Eye Service-A732027000
Optical - Eye Service-A732027000
Amherst College-A732028000
Hampshire College-Medical-A732029000
Hampshire College-Counselling-A732029000
CCPH-A732030000
CHP-A732031000
Wellness Education & Serv-CHP-A732036000
Charles River (Mt Ida)-A732033000
Athletics Medicine-A732051000
Health Ride-A732050000
Credentialing (Enrollment) Insurance-A732034000
Credentialing-A732034000
Public Health - PHPC-A732035000
Language, Speech, Hearing CLSH-A732052000
UHS Admin Services-A732004000
Supplier/Business Name
dollar amount of purchase
Prior Inquiry Case Number (if applicable)
Business Contact Full Name
Business Contact Email
Do you expect to use this supplier more than once?
Yes
No
is the supplier asking you to sign a document?
Yes
No
Please Upload the quote that your supplier has provided. You can also fill the
PowerForm Signer Information | Docusign Form
.
Please Upload all documentation Your vendor has provided. You can also fill the
PowerForm Signer Information | Docusign Form
.
do not sign anything.
Please upload the quote that the supplier has provided. Also
attach the file that needs to be signed using the Add Another file button. You can also fill the
PowerForm Signer Information | Docusign
form.
do not sign anything.
PLEASE UPLOAD ALL DOCUMENTATION YOUR VENDOR HAS PROVIDED.
please attach the file they want signed, With your other documentation. You can also fill the
PowerForm Signer Information | Docusign
form.
Comments:
Please include any relevant information to help us assist you efficiently.
Your upload should clearly state that it is an invoice.
Please do not include any quotes or statements; attach invoices only.
Upload invoice
show
netid
email
UHS Finance cannot submit an invoice for payment until the goods or services are received.