Hero Appreciation Payment Form

Please complete the following information to apply for the Hero Appreciation Program. U.S. Hospitals will also need to submit a W9 Tax Form. If enrolling multiple hospitals with the same information, please include all of the hospital names below.

 
General Information:
 
Hospital Name*
 
 
First and Last Name*
 
 
 
Email*
 
 
Hospital Phone Number*
 
 
 

(This email will be used to send information on the Hero Appreciation Program, including your quarterly earnings report)

 
I acknowledge that I have read and understand the terms & conditions.*
 
 
 

By submitting this form, you’re confirming you have authority to enroll your hospital in the Hero Appreciation Program. Terms & Conditions.

 
 
 
 

Hero Appreciation Payment Form

Please complete the following information to apply for the Hero Appreciation Program. U.S. Hospitals will also need to submit a W9 Tax Form. If enrolling multiple hospitals with the same information, please include all of the hospital names below.

 
Address:
 
Address Line 1*
 
 
Address Line 2
 
 
 
City*
 
 
Zip/Postal Code*
 
 
 
Country*
 
 
State*
 
 
Province*
 
 
 
 
 
 
 

Hero Appreciation Payment Form

Please complete the following information to apply for the Hero Appreciation Program. U.S. Hospitals will also need to submit a W9 Tax Form. If enrolling multiple hospitals with the same information, please include all of the hospital names below.

 
Tax Information:
 
Legal Entity Name*
 
 
Tax Identification Number
 
 
 
Tax Classification
 
 
 
 
 
 

Hero Appreciation Payment Form

Please complete the following information to apply for the Hero Appreciation Program. U.S. Hospitals will also need to submit a W9 Tax Form. If enrolling multiple hospitals with the same information, please include all of the hospital names below.

 
Bank Name
 
 
Account Number
 
 
 
Routing Number
 
 
Bank Code