Visitation Policies

On this page:

Appointments & Passes

Visitation Policies

Vendor Access Agreement

All vendors who require access to Catholic Health's premises must receive authorization from the Purchasing Department and will be required to sign a Vendor Access Agreement. 

All vendors who require access to Catholic Health must complete and receive a badge in advance of the day access is requested. All exceptions must be approved by the Senior Director of Supply Chain for Catholic Health.

Vendors must meet the requirements related to their level of access as outlined below. The levels of access are:

  • Level I: Access to patient care areas but having no patient contact
  • Level II: Access to patient care areas and having noninterventional patient contact
  • Level III: Access to patient care areas and having interventional patient contact

Once you have received authorization from the Purchasing Department, all vendors should make appointments with Operating Room Business Managers or Catholic Health management prior to their arrival at the Catholic Health affiliate location. Overhead pages in our acute care facilities will not be permitted.

  • Appointments made with attending medical staff must be scheduled through the physician’s private office.
  • Any requests to meet with Operating Room Managers must be processed through the Senior Buyer in Purchasing.

Vendors will not have access to medical records or any other records, regardless of media or format, containing protected health information.

In the event a vendor incidentally gains access to patient health information during the course of any site visit, such patient health information shall be kept confidential in the manner described in the Vendor Access Agreement.

When approved for access, vendor representatives are expected to present themselves in a professional and courteous manner.

Sign In Procedure

NOTE: Departments are not required to meet with vendor representatives

Vendor representatives must check in with Security, the Front/Reception Desk, or Plant Operations and have an appropriate Badge. If a vendor representative refuses to sign in, security should be contacted and the incident reported to Supply Chain Management.

You must wear an appropriate nametag, or company badge at all times within any Catholic Health facility. Any vendor representative found in any area without proper authorization and identification will be asked to leave at once. Failure to do so may result in an escort off the premises and permanent revocation of access privileges for the vendor representative.

Vendor representatives may not be present in patient care areas alone and must be escorted by Catholic Health management or designated staff.

Exceptions from the sign-in process may be granted for certain vendor representatives. These include, but are not limited to:

  • Catholic Health-retained attorneys
  • Administrative level consultants
  • Circumstances that require business representatives to visit Catholic Health outside of regular business hours. In these circumstances, the vendor representative must wear a Vendor Badge and his/her company’s official name badge and sign in at the department.


Please do not solicit physicians, management or other personnel while on Catholic Health property without prior authorization from the Purchasing Department.

Back to top.

Access to Patients

If you will have access to patient or clinical areas while in Catholic Health facilities, you will be required to show proof of immunization to Rubella, Rubeola (MMR) and you must have had a PPD (tuberculosis) test within the past 12 months. You must also be fully vaccinated against COVID-19 (which includes the booster) and be able to show acceptable proof of vaccination. 


If you have access to patients or patient’s health information, you may be considered a HIPAA Business Partner of Catholic Health and you may be required to execute a HIPAA Business Associate Agreement, which will be kept on file within the Contracts Management division of the Purchasing Department.

You are also required to adhere to Catholic Health policies regarding treatment of Catholic Health patients and employees. If you have any questions regarding your obligations under this section, call the Purchasing Department at (716) 923-2900. 

Back to top.

Telephone Usage

Public telephones for vendor use are located in various locations within the hospitals. Use of cell phones in Catholic Health facilities is restricted, and may only be used in specific non-clinical areas. These areas include:

  • Admissions
  • Lobby
  • Waiting areas
  • Locker rooms
  • Physician lounge / Coat rooms
  • Residence sleeping areas
  • Cafeteria
  • Offices in non-patient care areas

Back to top.

Surgery / Operating Room Regulations

It is the responsibility of the physician to obtain patient consent to the presence of medical observers or vendor representatives. This form is a permanent part of the medical record.

  • Visits are limited to procedures by physician request and approved by the site Department Manager/designee.
  • The vendor representative may act as a resource regarding the representative’s product only and may not scrub in or participate in patient care.
  • The vendor representative may not handle Catholic Health stock products.
  • The vendor representative must leave the facility upon completion of the scheduled procedure(s) or earlier as requested.
  • Documentation of a representative’s presence during the procedure, with the exact in and out time, must be included in the permanent medical record.

In addition, vendors must do the following:

  • Deliver vendor trays 24 hours prior to case. Vendor will provide enough trays for a surgical day, and will provide closed sterilization containers for sets.
  • Report to Central Service Supervisor with tray count.
  • Sign Loaner Sheet with Inventory List.
  • Change into scrubs upon arrival. No Vendor Rep will leave the operating room with scrubs on.
  • Refrain from using operating room telephones or cell phones in surgical area.
  • Provide sufficient backup equipment and implants. Implants need to have a biological run before release, unless emergency.
  • Notify supervisor and sign out consignment or loaner trays that are housed in the facility if removing.
  • Restock consignment and loaner trays 24 hours after case.
  • Remove all shipping containers for facility. No storage will be proved for these containers. If left, they will be discarded.
  • Invoice after case.

After 24 hours, no purchase order will be provided.

No access will be given to vendor representatives stopping by to see surgeon between cases.

Back to top.