Check Request
  • SEND COMPLETED FORM TO: ACCOUNTS PAYABLE VIA INTEROFFICE MAIL, 555 SOUTH BROADWAY BLDG B 2ND FL, TARRYTOWN NY 10591
  • REFER TO POLICY CHECK REQUEST POLICY JP05.1
  • All check requests must be approved by authorized signatures (minimum two, except for expenditures of $100,000 or greater, which require three). A stamped imprint of an authorized signature is not acceptable.

    The following amounts require additional signatures as follows:
    • Over $10,000 - Vice President Signature.
    • Over $100,000 -Senior Vice President Signature.
    • Over $1,000,000 -Executive Vice President Signature.
Check Request should be used to process the following payments. All other payments must be processed as a purchase Requisition
  • Membership Dues
  • Magazine Subscriptions
  • Permits and Licenses
  • Utility Bills
  • Patient or Insurance Refunds
  • Honorariums/Outside Speakers
  • Legal Settlement Agreements
  • Patients Research Studies
DATE PREPARED*
COMPANY CODE*
PAYEE NAME
PAYEE ADDRESS
APT. #
CITY
STATE
ZIP CODE
DEPARTMENT
DEPARTMENT TELEPHONE #

DETAIL EXPLANATION OF MONTEFIORE BUSINESS PURPOSE MUST BE PROVIDED IN THIS SECTION:

COMPANY CODE ACCOUNT (G/L #) COST CTR./ORDER # AMOUNT
TOTAL OF CHECK

SPECIAL INSTRUCTIONS
SUPPORTING DOCUMENT(S) MUST BE MAILED WITH CHECK TO VENDOR
TO FACILIATE:
ALL SUPPORTING DOCUMENTATION REQUIRED TO BE MAILED WITH CHECK MUST HAVE ALL INFORMATION COMPLETED AND INSERTED INTO A SELF-ADDRESSED ENVELOPE. THE ENVELOPE MUST BE ATTACHED TO THIS CHECK REQUEST.
DEPARTMENT PERSON TO CONTACT FOR QUESTIONS.
NAME
TELEPHONE
DEPARTMENT
LOCATION
APPROVER'S NAME*
SECOND APPROVER'S NAME*
THIRD APPROVER'S NAME