QUALCARE AMENDMENT TO PROVIDER NETWORK PARTICIPATION AGREEMENT
|
|
- Jody Snow
- 8 years ago
- Views:
Transcription
1 QUALCARE AMENDMENT TO PROVIDER NETWORK PARTICIPATION AGREEMENT This AMENDMENT (the Amendment ) amends that certain Provider Network Participation Agreement (the Agreement ) by and between QualCare and Hospital. WHEREAS, QualCare and Hospital each agree to amend the Agreement in order to conform the Agreement to changes in applicable federal and state laws, rules and regulations, and to incorporate other administrative changes to the Agreement. NOW, THEREFORE, in consideration of the premises and the mutual promises, covenants and conditions herein contained and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as I. DEFINITIONS. All defined terms not specifically defined in this Amendment shall have the meanings set forth in the Agreement. II. AMENDMENTS. A. The second WHEREAS paragraph of the Agreement is hereby deleted in its entirety and amended as WHEREAS, Hospital is a health care professional or facility that is duly licensed, certified, or otherwise authorized to practice his/her profession in the applicable jurisdiction where Covered Services will be furnished hereunder; and B. Article 1 of the Agreement is hereby amended to include the following: "Adverse Benefit Determination" means a denial, reduction or termination of, or a failure to make payment (in whole or in part) for, a benefit, including a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because the Carrier determines the item or service to be experimental or investigational, cosmetic, dental rather than medical, excluded as a pre-existing condition or because the Carrier has rescinded the coverage. C. The following definitions in Article 1 of the Agreement are hereby deleted in their entirety and amended as Carrier means an insurance company authorized to transact the business of insurance in New Jersey and doing health insurance business in accordance with N.J.S.A. 17B:17-1 et seq., a hospital service corporation authorized to transact business in accordance with N.J.S.A. 17:48-1, et seq., a medical service corporation authorized to transact business in accordance with N.J.S.A. BE: /QUA
2 17:48A-1, et seq., a health service corporation authorized to transact business in accordance with N.J.S.A. 17:48E-1, et seq., or a health maintenance organization authorized to transact business pursuant to N.J.S.A. 26:2J-1, et seq. Clean Claim means the claim is for a service or supply covered by the Health Benefits Plan that has been delivered to the proper billing address and has no defect or impropriety, including any lack of required substantiating documentation, or particular circumstance requiring special treatment that otherwise prevents timely payment being made on the claim. Providers shall be entitled to reimbursement on Clean Claims if: (a) The health care provider is eligible at the date of service; (b) The Member who received the health care service was covered on the date of service; (c) The claim is for a service or supply covered under the Health Benefits Plan; (d) The claim is submitted with all the information requested by the Payor on the claim form or in other instructions that were distributed in advance to the health care provider or Member in accordance with the provisions of section 4 of P.L.2005, c.352 (C.17B:30-51); and (e) The Payor has no reason to believe that the claim has been submitted fraudulently. Covered Services means, with respect to Health Benefits Plans, Medically Necessary services or supplies provided to a Member under the applicable Health Benefits Plan for which the Payor is obligated to pay benefits or provide services. Health Benefits Plan or Plan means a policy or contract for the payment of benefits for hospital and medical expenses or the provision of hospital and medical services delivered or issued for delivery in New Jersey by an applicable Payor. Material Change means any change or amendment taken by QualCare or Payor, as applicable, that could reasonably be expected to have a material adverse impact on either the aggregate level of reimbursement to Participating Provider or the administrative expenses incurred by Participating Provider in complying with such change or amendment. Participating Hospital means a general acute care facility licensed by the Commissioner of Health pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), including rehabilitation, psychiatric and long-term acute facilities, that has entered into an agreement with QualCare to provide Covered Services to Members. Participating Physician means a physician licensed pursuant to Title 45 of the New Jersey Revised Statutes, who has entered into an agreement with QualCare to provide Covered Services to Members, and who has privileges to admit patients to the acute care facilities of at least one Participating Hospital, if necessary or required. Participating Provider means a Participating Hospital, Participating Physician and/or another health care provider that, under a contract with QualCare, has agreed to provide Covered Services or supplies to Members for a predetermined fee or set of fees. Payor means a Carrier, third party administrator, or self-funded plan that is contractually obligated under the applicable Health Benefits Plan to make payment on behalf of Members with respect to Covered Services. BE: /QUA
3 Provider means any physician, other health care professional, hospital, health care facility, or any other person or entity who is licensed, certified, or otherwise authorized to provide health care or other services within the scope of his/her/its license, certification, or authorization in the state or jurisdiction in which the services are furnished. Urgently Needed Services means services for a non-life-threatening condition that requires care by a provider within twenty-four (24) hours. D. Article of the Agreement is hereby deleted in its entirety and amended as is duly licensed, certified, or authorized to practice his/her profession without restriction or limitation within the applicable jurisdiction where Covered Services will be furnished hereunder; and E. Article 3.2 of the Agreement is hereby amended to include the following new Article : has identified on the signature page all tax identification number(s) under which Participating Provider will submit claims for Covered Services rendered on behalf of Members hereunder. F. Article 4.5 of the Agreement is hereby deleted in its entirety and amended as Member Identification Cards; Verification. QualCare shall assist Payor in providing each of its Members with an identification card that indicates his/her enrollment in Payor s Health Benefits Plan. This identification card shall include the QualCare logo, a description of the network to be accessed, the applicable telephone number(s) for eligibility, benefits and UM questions, the Payor identification number, and other information as may be required by the applicable Payor. G. Article 4.7 of the Agreement is hereby deleted in its entirety and amended as No Liability for Covered Services. QualCare shall not be obligated to perform or be liable for the performance of any Covered Services required to be performed by Participating Provider pursuant to any Payor Agreement. QualCare shall not be liable for any payment of any claims for furnishing Covered Services to Members, and QualCare shall not be an insurer, guarantor, or underwriter of the responsibility or liability of any Payor to provide benefits pursuant to any Health Benefits Plan. H. Article 5.11 of the Agreement is hereby deleted in its entirety and amended as Notice of Changes. Participating Provider shall provide QualCare with at least thirty (30) days advanced written notice, or otherwise use its/his/her best efforts to provide such written notice, in the event of any change in the Participating Provider s status, including without limitation changes to Participating Provider s tax identification number(s), and/or changes or limitations on new patients, office hours, office locations, and scope of services. BE: /QUA
4 I. Article 6.1 of the Agreement is hereby deleted in its entirety and amended as Establishment. QualCare or Payor, as applicable, or its representative shall establish UM and QM programs to review and monitor the quality, Medical Necessity, and appropriateness of Covered Services furnished by Participating Provider on an inpatient and outpatient basis. To the extent that QualCare is responsible for establishing UM or QM programs, QualCare shall establish appropriate medical committees to assure effective utilization and quality of care for Members and a multidisciplinary committee for continuous quality improvement (CQI) to monitor the quality of the UM program. Such committees will assist QualCare in the development, implementation, administration, and monitoring of QualCare s UM and QM programs, as applicable. J. Article a of the Agreement is hereby deleted in its entirety and amended as Adverse Benefit Determinations of the UM and QM committee may be used to deny or reduce payment for those Covered Services provided to Members. A Member may not be billed for the amount of any such payment that is so denied. Reimbursement will not be denied retroactively for a Covered Service provided to a Member where Participating Provider relied upon the written or oral Authorization of QualCare or Payor, as applicable, prior to providing services to the Member, except in cases of misrepresentation or fraud, or in cases of Member ineligibility under the applicable Plan. K. Article b of the Agreement is hereby deleted in its entirety and amended as Adverse Benefit Determinations made under the UM and QM programs are for purposes of determining whether services are Covered Services under the terms and conditions of the applicable Health Benefits Plan and the extent to which benefit payments will be made. Unless otherwise expressly set forth below, Adverse Benefit Determinations shall be made as required by the exigencies of the situation within seventy two (72) hours of receipt of a claim for Urgently Needed Services, within fifteen (15) days of receipt of a claim for all other non- Urgently Needed Services, such as pre-authorizations, and within thirty (30) days of receipt of a post-service claim. Adverse Benefit Determinations shall be provided within two (2) business days. Such Adverse Benefit Determinations shall in no way affect the responsibility of Participating Provider to provide appropriate services to Members. L. Articles 6.4.1, a, and b of the Agreement are hereby deleted in their entirety and amended as Participating Provider, acting on behalf of the Member with the Member s consent, may appeal any Adverse Benefit Determination resulting in a denial, termination, or limitation of services or the payment of benefits therefor under the applicable internal appeal processes of Carrier. a. For group and individual Plans, under a stage 1 internal appeal, Participating Provider, acting on behalf of the Member with the Member s consent, shall have the right to speak, regarding an Adverse Benefit Determination, with the Carrier s medical BE: /QUA
5 director, or the medical director s designee who rendered the Adverse Benefit Determination. Stage 1 appeals shall be concluded as required by the exigencies of the situation within seventy-two (72) hours of receipt of the stage 1 appeal for any Urgently Needed Services, Emergency services, admissions, availability of care, continued stay and health care services for which the Member received Emergency services but has not been discharged from a facility, or within ten (10) calendar days in the case of all other stage 1 appeals. As applicable, at the conclusion of a stage 1 internal appeal, Carrier shall include a written explanation of the right to a further internal or external appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed. b. For group Plans, under a stage 2 internal appeal, Participating Provider, acting on behalf of the Member with the Member s consent, shall have the right to pursue his/her/its appeal before a panel of physicians and/or other providers selected by Carrier who have not been involved in Adverse Benefit Determination at issue. Stage 2 appeals shall be concluded as required by the exigencies of the situation within seventy-two (72) hours of receipt of the stage 2 appeal for any Urgently Needed Services, Emergency services, admissions, availability of care, continued stay and health care services for which the Member received Emergency services but has not been discharged from a facility, or within twenty (20) business days in the case of all other stage 2 appeals. As applicable, at the conclusion of a stage 2 internal appeal, Carrier shall include a written explanation of the right to a further external appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed. M. Article of the Agreement is hereby deleted in its entirety and amended as External Appeals. Participating Provider acting on behalf of a Member with the Member s consent, may appeal a final internal Adverse Benefit Determination, except where the final internal Adverse Benefit Determination was based on eligibility, including rescission, or the application of a contract exclusion or limitation not related to Medical Necessity, through the Independent Health Care Appeals Program to an independent utilization review organization ( IURO ). Any stage 3 external appeal through the Independent Health Care Appeals Program must be filed within four (4) months of receipt of the final internal Adverse Benefit Determination. The external appeal request shall be filed on the forms provided in accordance with N.J.A.C. 11:24A-3.5(k)4 and mailed to the Department of Banking and Insurance, Consumer Protection Services, Office of Managed Care, P.O. Box 329, Trenton, New Jersey N. Article of the Agreement is hereby deleted in its entirety and amended as An overdue payment shall bear simple interest when required by law. The Carrier shall pay interest, to the extent required by applicable law, at the time the overdue payment is made. If Carrier fails to make payment to Participating Provider in the manner, amount, or time provided for pursuant to law, rule, or regulation, in accordance with the Agreement, or otherwise fails to discharge its obligations to Participating Provider, QualCare may, in its sole discretion, use whatever contractual remedies QualCare possesses against Carrier to remedy the defaults. BE: /QUA
6 QualCare shall exercise its remedies in the manner it determines is reasonable. QualCare has no other obligations to Participating Provider under this Agreement with respect to any claim, liability, damage or expense that Participating Provider may incur as a result of the failure of Carrier to discharge its obligations under this Agreement or any agreement between QualCare and Carrier or Payor, as applicable. In the event of such default, nothing in this Agreement shall be construed to limit Participating Providers ability to seek from such Carrier or Payor, as applicable, such legal remedies as may be available to Participating Provider and which Participating Provider may deem appropriate. O. The first paragraph of Article 10.4 of the Agreement is hereby deleted in its entirety and amended as Continuation of Services. Termination hereunder shall result in immediate cessation of the Agreement on the effective date of such termination; provided, however, that (except where this Agreement was terminated for a Serious Breach or pursuant to Article ), Participating Provider and QualCare shall continue to abide by the terms and conditions of the Agreement, as may be amended from time to time, and Provider shall: P. Article 10.4 of the Agreement is hereby amended to include the following after Article : Except as otherwise may be required under Articles through above, if the Participating Provider terminates this Agreement, the Participating Provider shall continue to furnish Covered Services as set forth hereunder for those Members who were treated by the Participating Provider prior to the effective date of such termination for the greater of either (a) a period of thirty (30) days, or (b) a period of four (4) months if it is Medically Necessary for the Member to continue his/her course of treatment with the Participating Provider. Q. Article 11.1 of the Agreement is hereby deleted in its entirety and the remaining articles of Article 11 are correspondingly renumbered. R. Article 11.1 (previously Article 11.2), entitled Amendment, of the Agreement is hereby deleted in its entirety and amended as Amendment. This Agreement may be amended at any time by mutual consent of the parties. QualCare may amend this Agreement, the Provider Manual or the Payor s or QualCare s policies and procedures, as applicable, upon ninety (90) days advance written notice if the amendment results in a Material Change, or upon thirty (30) days advance written notice for all other amendments. If an amendment results in a Material Change, Participating Provider may terminate this Agreement only by providing QualCare with notice of its/his/her intent to terminate this Agreement within thirty (30) days of delivery of the notice of amendment, in which event this Agreement shall terminate on the effective date provided in the notice of amendment. Notwithstanding the foregoing, such notice shall not be required in the event the amendment is required due to a change in the applicable federal or state laws, rules, or regulations. S. Article 11.2 (previously Article 11.3), entitled Notices, of the Agreement is hereby deleted in its entirety and amended as BE: /QUA
7 Notices. Except as otherwise expressly required under this Agreement or by applicable law, rule, or regulation, notices or other written communications required or permitted hereunder may be effectuated if sent by letter, facsimile, electronic mail, or other generally accepted media. Notices required under Article 10 shall be made by either overnight mail and shall be effective on the date of receipt or one (1) business day from such overnight mailing, whichever is earlier, or by certified mail, return receipt requested, and shall be effective on the date of receipt or three (3) business days from such mailing, whichever is earlier. T. Article (previously Article ) of the Agreement is hereby deleted in its entirety and amended as This Article shall survive the termination or expiration of this Agreement. III. GENERAL PROVISIONS. A. Effect of Amendment. In all other respects, all other terms, covenants, and conditions set forth in the Agreement are hereby unmodified and shall apply in full force and effect. B. Resolution of Inconsistencies. In the event of a conflict or inconsistency between the provisions set forth in this Amendment and the Agreement, the terms, covenants, and conditions set forth in this Amendment shall control and be binding on the parties. C. Governing Law. This Amendment shall be governed by and construed and enforced in accordance with the internal laws of New Jersey without giving effect to the principles of conflicts laws. BE: /QUA
The New Jersey Worker's Compensation Addendum
WORKERS COMPENSATION PRODUCT ADDENDUM WHEREAS, QualCare, Inc. (hereinafter QualCare ) and (hereinafter Party ) have entered into an agreement (the Agreement ) whereby Party has agreed to provide, or where
More informationEXHIBIT C BUSINESS ASSOCIATE AGREEMENT
EXHIBIT C BUSINESS ASSOCIATE AGREEMENT THIS AGREEMENT is made and entered into by and between ( Covered Entity ) and KHIN ( Business Associate ). This Agreement is effective as of, 20 ( Effective Date
More informationADDENDUM TO AGREEMENT BETWEEN CHIROPRACTIC CARE OF MINNESOTA, INC. AND PROVIDER
ADDENDUM TO AGREEMENT BETWEEN CHIROPRACTIC CARE OF MINNESOTA, INC. AND PROVIDER This HealthPartners Workers Compensation Addendum (the Addendum ), dated as of the date set forth on the signature page (the
More informationDEPARTMENT OF CORRECTIONS NETWORK PHYSICIAN CONTRACT
DEPARTMENT OF CORRECTIONS NETWORK PHYSICIAN CONTRACT Updated 03-08-12 TABLE OF CONTENTS I. RECITALS...3 II. DEFINITIONS...3 III. RELATIONSHIP BETWEEN THE DEPARTMENT AND THE PHYSICIAN...5 IV. PHYSICIAN
More informationNetwork Provider. Physician Assistant. Contract
Network Provider Physician Assistant Contract Updated 10/1/02 HCPACv1.0 TABLE OF CONTENTS I. RECITALS...1 II. DEFINITIONS...1 III. RELATIONSHIP BETWEEN THE INSURANCE BOARD AND THE PHYSICIAN ASSISTANT...3
More informationLTC ELITE, LLC MEMBERSHIP AGREEMENT
LTC ELITE, LLC MEMBERSHIP AGREEMENT This Membership Agreement (this Agreement ) is made and entered into effective, (the Effective Date ), by and between LTC Elite, LLC, a Texas limited liability company
More informationHealth Plan Select, Inc. Business Associate Privacy Addendum To The Service Agreement
This (hereinafter referred to as Addendum ) by and between Athens Area Health Plan Select, Inc. (hereinafter referred to as HPS ) a Covered Entity under HIPAA, and INSERT ORG NAME (hereinafter referred
More informationTIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS
ADMINISTRATIVE POLICY TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS Policy Number: ADMINISTRATIVE 088.15 T0 Effective Date: November 1, 2015 Table of Contents APPLICABLE LINES OF
More informationAmendment and Consent No. 2 (Morris County Renewable Energy Program, Series 2011)
Execution Version Amendment and Consent No. 2 (Morris County Renewable Energy Program, Series 2011) by and among MORRIS COUNTY IMPROVEMENT AUTHORITY, COUNTY OF MORRIS, NEW JERSEY, U.S. BANK NATIONAL ASSOCIATION
More informationAgent Agreement WITNESSETH
PATRIOT NATIONAL UNDERWRITERS, INC. Agent Agreement THIS AGENT AGREEMENT (the Agreement ) is made and entered into by and between Patriot National Underwriters, Inc., a Texas corporation ( Patriot ), and
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ) by and between OUR LADY OF LOURDES HEALTH CARE SERVICES, INC., hereinafter referred to as Covered Entity, and hereinafter referred
More informationEXHIBIT COORDINATING PROVISIONS-STATE/FEDERAL LAW, ACCREDITATION STANDARDS AND GEOGRAPHIC EXCEPTIONS NEW JERSEY
EXHIBIT COORDINATING PROVISIONS-STATE/FEDERAL LAW, ACCREDITATION STANDARDS AND GEOGRAPHIC EXCEPTIONS NEW JERSEY I. INTRODUCTION: 1. Scope: To the extent of any conflict between the Agreement and this State
More informationSURA/JEFFERSON SCIENCE ASSOCIATES, LLC COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN. Amended and Restated
SURA/JEFFERSON SCIENCE ASSOCIATES, LLC COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN Amended and Restated Effective June 1, 2006 SURA/JEFFERSON SCIENCE ASSOCIATES, LLC COMPREHENSIVE HEALTH AND WELFARE
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ) is entered into by and between (the Covered Entity ), and Iowa State Association of Counties (the Business Associate ). RECITALS
More informationBUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS
BUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS This Business Associate Agreement (this Agreement ), is made as of the day of, 20 (the Effective Date ), by and between ( Business Associate ) and ( Covered Entity
More informationServices Agreement Instruction Sheet
Delta-T Group POB 884 Bryn Mawr, PA 19010 Phone: 800-251-8501 FAX: 610-527-9547 www.delta-tgroup.com Services Agreement Instruction Sheet We thank you for your interest in Delta-T Group. Below please find
More informationSERVICE AGREEMENT FOR FULL REIMBURSEMENT MANAGEMENT
SERVICE AGREEMENT FOR FULL REIMBURSEMENT MANAGEMENT This Service Agreement is entered into by and between the New Hampshire Alcohol and Other Drug Service Providers Association, a New Hampshire non-profit
More informationCONSULTING SERVICES AGREEMENT
CONSULTING SERVICES AGREEMENT This CONSULTING SERVICES AGREEMENT (this Agreement ) is dated as of the latest date set forth on the signature page hereto (the Effective Date ) and is entered into by and
More informationBusiness Associate Agreement
Business Associate Agreement This Business Associate Contract (Agreement) is entered into by and between, as a Covered Entity as defined in relevant federal and state law, and HMS Agency, Inc., as their
More informationBUSINESS ASSOCIATE ADDENDUM
BUSINESS ASSOCIATE ADDENDUM This Business Associate Addendum ( Addendum ) is entered into this day of 2014. Perry Memorial Hospital ( Covered Entity ) and [ABC Company] ( Business Associate ) referred
More informationStandardized Forms for Performance Guarantees 5:36-4 STANDARDIZED FORMS FOR PERFORMANCE GUARANTEES
5:36-4 STANDARDIZED FORMS FOR PERFORMANCE GUARANTEES 5:36-4.1 Performance surety bonds The standardized form of performance surety bond required by an approving authority pursuant to section 41 of P.L.
More informationSECTION 00900 PERFORMANCE BOND., hereinafter called PRINCIPAL, and
SECTION 00900 PERFORMANCE BOND KNOW ALL PERSONS BY THESE PRESENTS: THAT (Name or Contractor) a (Address of Contractor) (Corporation, Partnership, or Individual), hereinafter called PRINCIPAL, and (Name
More informationExpedited Dispute Resolution Bond (P3 Form)
Expedited Dispute Resolution Bond (P3 Form) Bond No. KNOW ALL WHO SHALL SEE THESE PRESENTS: THAT WHEREAS, (the "Owner") has awarded to (the "Obligee"), a Public-Private Agreement (the PPA ) for a project
More informationAGREEMENT BETWEEN TWELVE OAKS INDEPENDENT PHYSICIANS ASSOCIATION, INC. AND PHYSICIAN
AGREEMENT BETWEEN TWELVE OAKS INDEPENDENT PHYSICIANS ASSOCIATION, INC. AND PHYSICIAN This Agreement is made and entered into and is to be effective the date indicated on the signature page of the agreement,
More informationAGREEMENT FOR ADMISSION TO SANCTUARY CENTERS OF SANTA BARBARA RESIDENTIAL TREATMENT PROGRAM
AGREEMENT FOR ADMISSION TO SANCTUARY CENTERS OF SANTA BARBARA RESIDENTIAL TREATMENT PROGRAM 1. ( resident ), an individual, is admitted to Sanctuary Centers of Santa Barbara, Inc., (a California non-profit
More informationTitle 19, Part 3, Chapter 14: Managed Care Plan Network Adequacy. Requirements for Health Carriers and Participating Providers
Title 19, Part 3, Chapter 14: Managed Care Plan Network Adequacy Table of Contents Rule 14.01. Rule 14.02. Rule 14.03. Rule 14.04. Rule 14.05. Rule 14.06. Rule 14.07. Rule 14.08. Rule 14.09. Rule 14.10.
More informationCertain exceptions apply to Hospital Inpatient Confinement for childbirth as described below.
Tennessee Applicable Policies PRECERTIFICATION Benefits payable for Hospital Inpatient Confinement Charges and confinement charges for services provided in an inpatient confinement facility will be reduced
More informationCOLUMBIA GAS OF OHIO, INC. ACCOUNTS RECEIVABLE PURCHASE AGREEMENT
COLUMBIA GAS OF OHIO, INC. ACCOUNTS RECEIVABLE PURCHASE AGREEMENT This Agreement made this day of, 2, ( Agreement ) by and between, located at ( Supplier ) and Columbia Gas of Ohio, Inc. ( Company ), 290
More informationDEPARTMENT OF TRANSPORTATION OFFICE OF SMALL AND DISADVANTAGE BUSINESS UTILIZATION SHORT TERM LENDING PROGRAM GUARANTEE AGREEMENT
DEPARTMENT OF TRANSPORTATION OFFICE OF SMALL AND DISADVANTAGE BUSINESS UTILIZATION SHORT TERM LENDING PROGRAM GUARANTEE AGREEMENT This GUARANTEE AGREEMENT dated as of [DATE] (this Agreement) is made by
More informationPURCHASE AND SALE AGREEMENT
PURCHASE AND SALE AGREEMENT THIS PURCHASE AND SALE AGREEMENT (this Agreement ) is made as of, 2014, by the United States Marshals Service (the USMS ), on behalf of the United States, and ( Purchaser )
More informationKentucky Department of Education Version of Document A312 2010
Kentucky Department of Education Version of Document A312 2010 Performance Bond CONTRACTOR: (Name, legal status and address) SURETY: (Name, legal status and principal place of business) OWNER: (Name, legal
More informationCOMMONWEALTH OF VIRGINIA STANDARD PERFORMANCE BOND
(Rev 03/02) Page 1 of 6 COMMONWEALTH OF VIRGINIA STANDARD PERFORMANCE BOND KNOW ALL MEN BY THESE PRESENTS: That, the Contractor ( Principal ) whose principal place of business is located at and ( Surety
More informationFirstCarolinaCare Insurance Company Business Associate Agreement
FirstCarolinaCare Insurance Company Business Associate Agreement THIS BUSINESS ASSOCIATE AGREEMENT ("Agreement"), is made and entered into as of, 20 (the "Effective Date") between FirstCarolinaCare Insurance
More informationTEXAS FAIR PLAN PRODUCER REQUIREMENTS AND PERFORMANCE STANDARDS
Producer Requirements Page 1 TEXAS FAIR PLAN PRODUCER REQUIREMENTS AND PERFORMANCE STANDARDS The following Texas FAIR Plan Association ( Association ) requirements and producer performance standards (
More informationBENCHMARK MEDICAL LLC, BUSINESS ASSOCIATE AGREEMENT
BENCHMARK MEDICAL LLC, BUSINESS ASSOCIATE AGREEMENT This BUSINESS ASSOCIATE AGREEMENT ( Agreement ) dated as of the signature below, (the Effective Date ), is entered into by and between the signing organization
More informationExpanded Market Programs
Expanded Market Programs Empowering you to say Yes more often! Ivantage and NEA are affiliates of Allstate, who offer Exclusive Agents access to additional products for risks outside of Allstate s market
More informationPROVO CITY UTILITIES NET METERING LICENSE AGREEMENT
PROVO CITY UTILITIES NET METERING LICENSE AGREEMENT Customer-Owned Electric Generating Systems of 25kW or Less This NET METERING LICENSE AGREEMENT ( Agreement ) is between ( Customer ) and Provo City -
More informationDEFERRED LOAN CLOSING COST ASSISTANCE GRANT AND MORTGAGE CREDIT CERTIFICATE PROGRAMS LENDER PARTICIPATION AGREEMENT
THIS AGREEMENT ( Agreement ) is made and entered into this day of, 20, by and between the San Diego Housing Commission, a public agency, ( SDHC ), and a ( Lender ). RECITALS A. SDHC has implemented a Closing
More informationBelow is an overview of the Molex lease process as it applies to Molex Application Tooling equipment.
Dear Valued Customer, Below is an overview of the Molex lease process as it applies to Molex Application Tooling equipment. Lease process: Molex does not offer leases for all of the equipment that we promote.
More informationBROKER AND CARRIER AGREEMENT
P.O. Box 889 394 NE Hemlock Redmond, OR 97756 BROKER AND CARRIER AGREEMENT All loads tendered by Central Oregon Truck Company ("Broker") and accepted for transportation by third party carriers ("Carrier")
More informationAGREEMENT FOR CONSULTING SERVICES EXECUTIVE IN RESIDENCE PROGRAM CCIT. JERSEY ECONOMIC DEVELOPMENT AUTHORITY (the "Authority or NJEDA"), having its
AGREEMENT FOR CONSULTING SERVICES EXECUTIVE IN RESIDENCE PROGRAM CCIT AGREEMENT made this day of, 2015, by and between the NEW JERSEY ECONOMIC DEVELOPMENT AUTHORITY (the "Authority or NJEDA"), having its
More informationReverse Mortgage Specialist
ADVISOR/LENDER APPLICANT ASSISTANCE AGREEMENT This ADVISOR/LENDER APPLICANT ASSISTANCE AGREEMENT (the Agreement ) is made this day of, 200_ by and between Oaktree Funding Corporation, a California Corporation
More informationCUSTOMER LIST PURCHASE AGREEMENT BY AND BETWEEN RICHARD PENNER SELLER. and S&W SEED COMPANY BUYER
EXHIBIT 10.1 CUSTOMER LIST PURCHASE AGREEMENT BY AND BETWEEN RICHARD PENNER as SELLER and S&W SEED COMPANY as BUYER CUSTOMER LIST PURCHASE AGREEMENT THIS CUSTOMER LIST PURCHASE AGREEMENT ( Agreement )
More informationPHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group. APPLICATION MD & DO Locum Tenens. 1. First Name: Middle Initial: Last Name:
PHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group APPLICATION MD & DO Locum Tenens Applicant Information: 1. First Name: Middle Initial: Last Name: CA Medical License #: Expiration Date: Date
More informationSAMPLE MANAGED CARE CONTRACT
SAMPLE MANAGED CARE CONTRACT PHYSICIAN AGREEMENT THIS AGREEMENT is entered into by and between, Inc., a corporation, ("Network") and, M.D. ("Physician"). WHEREAS, the Network is developing a provider network
More informationSOLICITOR APPLICATION
Date: / / SOLICITOR APPLICATION General Information Name: Birth Date: / / Office Address: City: State: Zip: E-mail address: Business phone: ( ) - Fax number: ( ) - Assistant s Name: Registered Investment
More informationTHE UNIVERSITY OF UTAH INDEPENDENT CONTRACTOR SERVICES AGREEMENT INSTRUCTIONS
THE UNIVERSITY OF UTAH INDEPENDENT CONTRACTOR SERVICES AGREEMENT INSTRUCTIONS Contracting for Independent Contractor services with the University of Utah may require completion of the following: Employee/Independent
More informationHIPAA BUSINESS ASSOCIATE AGREEMENT
HIPAA BUSINESS ASSOCIATE AGREEMENT This HIPAA Business Associate Agreement ("BA AGREEMENT") supplements and is made a part of any and all agreements entered into by and between The Regents of the University
More informationATHENS AREA HEALTH PLAN SELECT, INC. HMO / POINT OF SERVICE / PPO GROUP HEALTHCARE CONTRACT
ATHENS AREA HEALTH PLAN SELECT, INC. HMO / POINT OF SERVICE / PPO GROUP HEALTHCARE CONTRACT This Group Healthcare Contract ("Group Contract" or the "Contract"), effective as of the day of, 20 _ (the Effective
More informationInsurance Market Solutions Group, LLC Sub-Producer Agreement
Insurance Market Solutions Group, LLC Sub-Producer Agreement This Producer Agreement is made and entered into effective the day of, 20, by and between Insurance Market Solutions Group, LLC a Texas Company
More informationPRODUCER AGREEMENT. Hereinafter ("Producer"), in consideration of the mutual covenants and agreements herein contained, agree as follows:
PRODUCER AGREEMENT Hereinafter First Choice Insurance Intermediaries, Inc "FCII", a Florida company, having an office at 814 A1A North, Suite 206, Ponte Vedra Beach, FL 32082 and " Producer" having an
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (the Agreement ), is made effective as of the sign up date on the login information page of the CarePICS.com website, by and between CarePICS,
More informationGROUP HEALTH CARE CONTRACT
This Group Health Care Contract ("Group Contract") is made between Alliant Health Plans, Inc. a Georgia non- profit "Provider Sponsored Health Care Corporation" hereinafter referred to as "Alliant" and
More information388 Blohm Ave. PO Box 388 Aromas CA 95004-0388 (831)726-3155 FAX (831)726-3951 email aromaswd@aol.com ADDENDUM NO. 1
388 Blohm Ave. PO Box 388 Aromas CA 95004-0388 (831)726-3155 FAX (831)726-3951 email aromaswd@aol.com May 6, 2015 To: All Plan Holders From: Vicki Morris General Manager Subject: Water Serviceline Installation
More informationMEMBERSHIP AGREEMENT OF HEALTHCARE SERVICES PLATFORM CONSORTIUM RECITALS
MEMBERSHIP AGREEMENT OF HEALTHCARE SERVICES PLATFORM CONSORTIUM Hunton & Williams LLP draft dated 12/19/14 This Membership Agreement (this Agreement ) is entered into effective as of, 2014 by and between
More informationHaving health insurance is a
Fully-Insured and Issued in New Jersey Having health insurance is a good thing, and health insurers usually do what they re supposed to do. They authorize coverage for services that are medically necessary
More informationGOODS AND SERVICES AGREEMENT BETWEEN SOUTHERN CALIFORNIA PUBLIC POWER AUTHORITY AND COMPANY/CONTRACTOR NAME
GOODS AND SERVICES AGREEMENT BETWEEN SOUTHERN CALIFORNIA PUBLIC POWER AUTHORITY AND COMPANY/CONTRACTOR NAME This GOODS AND SERVICES AGREEMENT ("Agreement") is entered into and effective [DATE], by and
More informationTHESE FORMS ARE NOT A SUBSTITUTE FOR LEGAL ADVICE.
DISCLAIMER The forms provided on our site were drafted by lawyers with knowledge of equine and contractual matters. However, the forms are not State specific. THESE FORMS ARE NOT A SUBSTITUTE FOR LEGAL
More informationBROKER AGREEMENT. NOW THEREFORE, in consideration of promises, covenants and agreements hereinafter contain, the parties agree as follows:
THIS AGREEMENT is entered into in the State of California this day of 2006, between Crestline Funding Corporation, hereinafter referred to as Crestline Funding, and, hereinafter referred to as Broker.
More informationCOLLABORATION AGREEMENT
COLLABORATION AGREEMENT This Collaboration Agreement ( Agreement ) is made by and between Microryza Inc., a Delaware corporation (the Company ) and, a Delaware Corporation (the University ) (together with
More informationREFERRAL ENDORSER AGREEMENT - ADDITIONAL TERMS AND CONDITIONS
1. Definitions. REFERRAL ENDORSER AGREEMENT - ADDITIONAL TERMS AND CONDITIONS a. Sales Lead Form shall mean the form provided by PAETEC on which Referral Endorser shall document prospective customer information
More informationNOW, THEREFORE, in consideration of the mutual promises and covenants herein contained, the Parties hereby agree as follows:
Tulane Template PSA and Medical Director (for TUMG physicians providing services to physician group/community practice) PROFESSIONAL AND MEDICAL DIRECTOR SERVICES AGREEMENT For the services of [insert
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT (the AGREEMENT ) is entered into this (the "Effective Date"), between Delta Dental of Tennessee ( Covered Entity ) and ( Business Associate
More informationINDEPENDENT CONTRACTOR AGREEMENT (Between Broker and Licensee)
INDEPENDENT CONTRACTOR AGREEMENT (Between Broker and Licensee) This Independent Contractor Agreement ( Agreement ), is made between Realtyka LLC ( Broker ), operating under the assumed name Real and (
More informationBuyer s 7 net 3 Telecommunications Service Agreement
Buyer s 7 net 3 Telecommunications Service Agreement This Agreement is made and entered into this day of, 2012, between BARR TELL USA, INC.( BARR TELL ) a Corporation, existing under the Laws of New York,
More informationCLS Investments, LLC Instructions for the Solicitor Application and Agreement
CLS Investments, LLC Instructions for the Solicitor Application and Agreement Please complete all fields on page 1 of the Solicitor Application and Agreement. Some general guidelines are set forth below.
More informationAMWELL SERVICE PROVIDER SUBSCRIPTION AGREEMENT
Revised: July 27, 2015 AMWELL SERVICE PROVIDER SUBSCRIPTION AGREEMENT Welcome to the AmWell Exchange Service (the Service ), which is owned and operated by American Well Corporation, a Delaware corporation
More informationCOMPUTER SOFTWARE AS A SERVICE LICENSE AGREEMENT
COMPUTER SOFTWARE AS A SERVICE LICENSE AGREEMENT This Agreement is binding on the individual and the company, or other organization or entity, on whose behalf such individual accepts this Agreement, that
More informationINTERGOVERNMENTAL AGREEMENT FOR EMERGENCY MANAGEMENT
INTERGOVERNMENTAL AGREEMENT FOR EMERGENCY MANAGEMENT WITNESSETH THAT: WHEREAS, intergovernmental agreements to provide functions or services, including the sharing of costs of such services or functions,
More informationSALES PARTNER AGREEMENT
SALES PARTNER AGREEMENT This Agreement is made this day of, 200_ between ACOM SOLUTIONS, INC. ( ACOM ) having offices at 2850 East 29th Street, Long Beach, California 90806-2313 and (Partner) having offices
More informationThis form may not be modified without prior approval from the Department of Justice.
This form may not be modified without prior approval from the Department of Justice. Delete this header in execution (signature) version of agreement. HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate
More informationSCHEDULE 14. Part 1 Performance Bond PERFORMANCE BOND NO.
SCHEDULE 14 BONDS Part 1 Performance Bond PERFORMANCE BOND NO. $ KNOW ALL PERSONS BY THESE PRESENTS, that Contractor s Name as Principal ( the Principal ) and Surety / Insurance Company name and address,
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT Please complete the following and return signed via Fax: 919-785-1205 via Mail: Aesthetic & Reconstructive Plastic Surgery, PLLC 2304 Wesvill Court Suite 360 Raleigh, NC 27607
More informationVA Authorized Agent Agreement
VA Authorized Agent Agreement This VA Authorized Agent Agreement (the Agreement ), entered into this day of, 20 (the Effective Date ) by and between Data Mortgage Inc., d/b/a Essex Mortgage ( Lender )
More informationCONSULTING SERVICES AGREEMENT
CONSULTING SERVICES AGREEMENT THIS AGREEMENT ("Agreement") is entered into on / /, between SCWOA ("Consultant"), a CA corporation with its principal place of business located at PO Box 1195, Pacifica,
More informationAgreement for Net Metering and Interconnection Services (Level 1, 2 and 3 Interconnection)
Agreement for Net Metering and Interconnection Services (Level 1, 2 and 3 Interconnection) This Agreement for Net Metering and Interconnection Services ( Agreement ) is made and entered into this day of
More informationSenate Bill No. 1665 CHAPTER 864
Senate Bill No. 1665 CHAPTER 864 An act to amend Section 2060 of, and to add Section 2290.5 to, the Business and Professions Code, to amend Sections 1367 and 1375.1 of, and to add Sections 1374.13 and
More informationBROKERAGE Development General Agent AGREEMENT
BROKERAGE Development General Agent AGREEMENT BANNER LIFE INSURANCE COMPANY ROCKVILLE, MARYLAND Agreement of Brokerage Development General Agent 1. APPOINTMENT Subject to the terms and conditions of this
More informationPATIENT TRANSFER AGREEMENT
Appendix 2 SAMPLE PATIENT TRANSFER AGREEMENT THIS AGREEMENT is made effective as of by and between ( Children s Hospital) a nonprofit corporation, and ( Hospital ), a corporation. WHEREAS, operates a tertiary
More informationRetail Gas Supplier Tariff Service Agreement
Retail Gas Supplier Tariff Service Agreement This Agreement ( Agreement ), executed (date), is entered into by and between Ameren Illinois Company d/b/a Ameren Illinois ( Company ), an Illinois corporation,
More informationPRIME BROKERAGE CLEARANCE SERVICES AGREEMENT SIA FORM 151
Legent Clearing Account Number PRIME BROKERAGE CLEARANCE SERVICES AGREEMENT SIA FORM 151 1 LC12 07/05 Customer Agreement for Prime Brokerage Clearance Services: Customer Name: Account Number: This Agreement
More informationBusiness Associate and Data Use Agreement
Business Associate and Data Use Agreement This Business Associate and Data Use Agreement (the Agreement ) is entered into by and between ( Covered Entity ) and HealtHIE Nevada ( Business Associate ). W
More informationElectronic Data Interchange (EDI) Trading Partner Agreement
Electronic Data Interchange (EDI) Trading Partner Agreement THIS ELECTRONIC DATA INTERCHANGE TRADING PARTNER AGREEMENT (the Agreement ) is made as of (date) by and between Ameren Services Company, for
More informationELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT THIS ELECTRONIC DATA INTERCHANGE TRADING PARTNER AGREEMENT
ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT THIS ELECTRONIC DATA INTERCHANGE TRADING PARTNER AGREEMENT (the Agreement ) is made as of, by and between Potomac Electric Power Company (Pepco),
More information175 TownPark Drive, Suite 400, Kennesaw, GA 30144 APPROVED UNDERWRITER AGREEMENT
175 TownPark Drive, Suite 400, Kennesaw, GA 30144 APPROVED UNDERWRITER AGREEMENT THIS APPROVED UNDERWRITER AGREEMENT (the Agreement ) is made and entered into as of this day of, 20, by and between, (the
More informationSOFTWARE ESCROW AGREEMENT. ( Effective Date ), this Software Escrow Agreement ( Agreement ) is
SOFTWARE ESCROW AGREEMENT As of ( Effective Date ), this Software Escrow Agreement ( Agreement ) is entered into by and between a (insert state of incorporation) corporation, located at ( Licensor ); a
More informationINDEPENDENT BROKER AGREEMENT October 1, 2011 edition
INDEPENDENT BROKER AGREEMENT October 1, 2011 edition This INDEPENDENT BROKER AGREEMENT made this day of 20 by and between Morstan General Agency of New Jersey, Inc. its affiliates and/or subsidiaries,
More informationR: 2015-179 RESOLUTION APPOINTING RISK MANAGEMENT CONSULTANT
R: 2015-179 RESOLUTION APPOINTING RISK MANAGEMENT CONSULTANT WHEREAS, the Town of Phillipsburg (hereinafter Local Unit ) has joined the Statewide Insurance Fund (hereinafter Fund ), a joint insurance fund
More informationTHE CORPORATION OF THE CITY OF BURLINGTON D1 - AGREEMENT
Agreement 2006 Page 1 THE CORPORATION OF THE CITY OF BURLINGTON D1 - AGREEMENT THIS AGREEMENT made in triplicate this day of 20 THE CORPORATION OF THE CITY OF BURLINGTON (hereinafter called "the City")
More informationRULES AND REGULATIONS FOR THE UTILIZATION REVIEW OF HEALTH CARE SERVICES (R23-17.12-UR)
RULES AND REGULATIONS FOR THE UTILIZATION REVIEW OF HEALTH CARE SERVICES (R23-17.12-UR) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Department of Health August 1993 (E) As amended: August 1993 December
More informationSTANDARD AGREEMENT FOR CONSULTANT SERVICES. THIS AGREEMENT, made and entered into in the City of Modesto, State of
STANDARD AGREEMENT FOR CONSULTANT SERVICES THIS AGREEMENT, made and entered into in the City of Modesto, State of California, this day of, 20, ( Effective Date ) by and between the CITY OF MODESTO, a municipal
More informationHEALTH INSURANCE PLAN OF GREATER NEW YORK SELLING AGENT AGREEMENT
HEALTH INSURANCE PLAN OF GREATER NEW YORK SELLING AGENT AGREEMENT THIS AGREEMENT is made and entered into as of the 1 st day of, by and between HEALTH INSURANCE PLAN OF GREATER NEW YORK (hereinafter referred
More informationAetna Life Insurance Company
Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment (GR-GrpAppealsER 03) Policyholder: Group Policy No.: Effective Date: GP- This Amendment is effective on the later of: July 12, 2012; or
More informationNORTH CAROLINA STATE UNIVERSITY MASSAGE THERAPIST AGREEMENT
STATE OF NORTH CAROLINA WAKE COUNTY Rev. 3/14 NORTH CAROLINA STATE UNIVERSITY MASSAGE THERAPIST AGREEMENT THIS AGREEMENT ( Agreement ) is made by and between ( Contractor ), and North Carolina State University,
More informationAGENT / AGENCY AGREEMENT
AGENT / AGENCY AGREEMENT This Agreement entered into this day of, 20, by and between Guardian Legal Services, Inc. (GUARDIAN), and General Agent, hereinafter called GA. GUARDIAN has organized a Legal Insurance
More informationAGREEMENT. Solicitor Without Per Diem Compensation
Solicitor Without Per Diem Compensation AGREEMENT Products underwritten by: American General Life Insurance Company Houston, Texas The United States Life Insurance Company in the City of New York New York,
More informationProposed Amendments: N.J.A.C. 11:4-23A.2, 23A.6 and 23A.12. Authorized By: Holly C. Bakke, Commissioner, Department of Banking and Insurance
INSURANCE DEPARTMENT OF BANKING AND INSURANCE DIVISION OF INSURANCE Medicare Supplement--Under 50 Coverage Proposed Amendments: N.J.A.C. 11:4-23A.2, 23A.6 and 23A.12 Authorized By: Holly C. Bakke, Commissioner,
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT is made and entered into as of the day of, 2013 ( Effective Date ), by and between [Physician Practice] on behalf of itself and each of its
More informationNON EXCLUSIVE BROKER REFERRAL AGREEMENT
NON EXCLUSIVE BROKER REFERRAL AGREEMENT THIS NON-EXCLUSIVE BROKER REFERRAL AGREEMENT (this Broker Contract ) is made this day of, 2013 by and between [NAME] (herein after called the "IFPG FRANCHISE CONSULTANT/BROKER
More informationCLIENT REFERRAL AGREEMENT
CLIENT REFERRAL AGREEMENT This CLIENT REFERRAL AGREEMENT ("Agreement") is made by, and between, JBH Processing and Paul Jones("REFERRER"), effective as of, 2010. 1. Reporting In the event Referrer receives
More information