Purchase Order Change Form This form is used to request an increase to the total dollar amount or change the expiration date of an existing Purchase Order that was issued by the Stanford Health Care – Purchasing department.* All applicable checkboxes and highlighted sections are required. Please submit the completed form and any applicable documents to Purchasing by clicking this link.

Purchase Order Number	[Enter the Existing Purchase Order Number.]	MediTract Contract Number:	[Enter the MediTract Contract Number.]
Existing Purchase Order Expiration Date:	[Select the Current Purchase Order’s Expiration Date.]	Existing Contract Expiration Date:	[Select the Current Contract’s Expiration Date.]

Check the following boxes as they relate to this request to increase the total dollar amount of the existing Purchase Order.
I have confirmed that there is a contract with this Vendor saved in the contract database (MediTract) that covers the goods and/or services provided.
I have attached a copy of the contract and Contract Approval Form.
I have confirmed that the contract with this Vendor is current and has not expired during the time goods and/or services were provided.
I have confirmed that the requested increase to the Purchase Order does not exceed a stated maximum dollar amount (e.g., the “not to exceed” amount, fixed price/lump sum, or grand total) in the contract with this Vendor.
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 Purchase Requisition 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 Tri-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.]
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 the Finance Activity Code.]	General Ledger Number:	[Enter One General Ledger Number.]
Name of Person Requesting Purchase Order Change:	[Enter First Name and Last Name.]	Phone Number of Person Requesting Purchase Order Change:	[Enter the Requestor’s Phone Number.]
Address Where Goods or Services are Delivered or Performed:	List 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.]
Amount of Increase:	[Enter the amount to be added to the Purchase Order.]	New Grand Total:	[Enter the new “New Grand Total” only if requesting a new Purchase Order or an increase to an existing Purchase Order.]
New Expiration Date of Purchase Order:	[Select the new expiration date of the Purchase order.]
Reason for Increase:	[Click here to enter a reason for requesting an increase to the total dollar amount of the existing Purchase Order. For example, travel/reimbursable expenses, shipping/freight, taxes.]
Special Notes for Purchasing:	[Click here to enter special notes for Purchasing. For example, provide the section or page on which the price or “not to exceed amount” appears in the contract. If no special notes are needed, enter “N/A”.]

I have the correct signature authority level over this Cost Center related to the “Amount of Increase” listed on this Purchase Order Change Form and approve this request:
Cost Center Signatory:
Printed Name:	[Enter Printed Name of Cost Center Signatory]
Title:	[Enter Title of Cost Center Signatory]
Date of Signature:

*This form may also be used to request a new Purchase Order related to an existing Master Agreement, when the Master Agreement does not require a new Statement of Work, Work Order, Sales Order, or similar ordering document.