Purchase Requisition Form This form is used to request a Purchase Order from the Stanford Health Care – Purchasing department to pay a Vendor when a contract is not required. All applicable checkboxes and highlighted sections are required. Please submit the completed form and any applicable documents to Purchasing by clicking this link.

I confirm a contract is not required for this Purchase Order request for the following reasons*:
The Vendor did not present a legal or contractual document to sign.
The Vendor did not include terms and conditions on a quote, proposal, estimate, or invoice for the purchase of services.
The Vendor will not provide services on the Stanford entity’s premises.
The Vendor will not be paid more than One Hundred Fifty Thousand Dollars ($150,000.00).
The Vendor is not considered a referral source. (Hover here for an explanation)
The Vendor will not have access to Protected Health Information, internal data, or the Digital Solutions/Information Services networks.
The Vendor is not an Independent Contractor that is providing services to the Stanford entity.
All of the boxes above must be true and checked. If any of the boxes above are not true and not checked, contact Contract Administration at ContractAdministration@stanfordhealthcare.org to request a contract with the Vendor.

Is this for the purchase of capital assets? Yes No If “Yes” is selected, please enter the Capital Expense Number in the box to the right. Also, a Capital Justification Form must accompany this form.	Capital Expense Number:
[Enter the Capital Expense Number or enter, “N/A.”]
Applicable Entity(ies):	Stanford Health Care Lucile Salter Packard Children’s Hospital at Stanford (“Stanford Medicine Children’s Health”) Stanford Health Care Tr-Valley Stanford University Medical Network Risk Authority, LLC (“The Risk Authority”)	University HealthCare Alliance (“Stanford Medicine Partners”) Packard Children’s Health Alliance Stanford Blood Center, LLC CareCounsel, LLC
Department Name:	[Enter the Department Name.]	Today’s Date:	[Select today’s date.]
Purchase Order Effective Date:	[Select Purchase Order Effective Date.]	Purchase Order Expiration Date:	[Select Purchase Order Expiration Date.]
Cost Center Number(s):	[Enter the Cost Center Number(s). For multiple cost centers, list the amount allocated to each cost center.]	Finance Category Code:	☐ Capital Expense (CAPEX) ☐ Operating Expense (OPEX) ☐ Inventory Expense (INV)
Finance Activity Code:	[Enter a Finance Activity Code or “N/A” if not applicable.]	General Ledger Number:	[Enter One General Ledger Number.]
Name of Person Requesting Purchase Order:	[Enter First Name and Last Name.]	Phone Number of Person Requesting Purchase Order:	[Enter the Requestor’s Phone Number.]
Address Where Goods or Services are Delivered or Performed:	Select the Site where the Goods, Services, or Goods & Services are to be Delivered or Performed
Vendor’s Legal Name:	[Enter the Vendor’s Name.]
Vendor’s Mailing Address:	[Enter the Vendor’s Address.]
Vendor’s Email Address:	[Enter the Vendor’s Email Address.]	Vendor’s Phone Number:	[Enter the Vendor’s Phone Number.]
Special Notes for Purchasing:	[Click here to enter. If no special notes are needed, enter “N/A.”]

Catalog Number and/or Description	Quantity	Unit of Measure	Estimated Unit Price	Unit Price	Extended Price
I have the correct signature authority level over this Cost Center related to the “Grand Total” listed on this Purchase Requisition Form and approve this request:	Sub-Total:
Cost Center Signatory:	Sales Tax Total:
Printed Name:	[Enter Printed Name of Cost Center Signatory]
Title:	[Enter Title of Cost Center Signatory]	Grand Total:
Date:

*A contract is not required if a purchase involves only advertising insertion orders providing for the placement of advertisements in print, online, or broadcast media.