Request date	5/16/2012
Requestor's name *	(Phone ext.) *
Entities involved	UK Hospital CAS KY Clinics ASC/Pain Clinic UK College (Intended for) Inpatient Outpatient

Budgetary Impact
UK Entity	Department Name	Cost Center Number
		*

Potential other users/services
Describe the current product/service *
Describe the proposed action/opportunity/product or service including catalog numbers *	(Or check applicable boxes below)
Types of opportunities *	(Check all applicable) Alternate supplier - same product Change in utilization pattern Reduce unit cost of existing goods and/or rates of existing services Evaluate new technology Standardize to lower cost brand, type, sizes Make vs. buy (in/out-source) New UHC/Novation contract Locally-negotiated contract Convert to lower cost equivalent/non-equivalent Labor impact - Attach labor impact form!
Stock preference *	Order as needed Shelf stock Consignment
CPT/ICD-9 code(s) & description *
Annual volume estimates *
Product(s) it replaces for this procedure? (include SAP #) *
Recommended suppliers
Sales rep name	(Home phone) (Cell phone)
Does product/service require review by	PPD? Clinical Engineering?
Attach files to this request?	No Yes