The Phoenix at Dunwoody Credentialing Notification

Transcription

1 AGENCIES AND VENDOR COMPANIES Healthcare providers and/or vendors to The Phoenix at Dunwoody (Providing Private-sitters, Home Health, Home Care, Hospice, DME and other Non-healthcare related services) The Phoenix at Dunwoody Credentialing Notification Please make sure you are fully credentialed with Accushield in the next 30 days Your Community Name SUSAN SMITH JANUARY 1, 2015 MONDAY PROVIDER ACCUSHIELD CREDENTIALED After thirty days from your initial sign-in via the Accushield kiosk, only those outside healthcare providers and/or vendors that have faxed-in all required credentials will be able to print a daily badge via the kiosk. You may be denied access to this community if all required credentials are not faxed to the Accushield credential management department within the next 30 days. FOR MORE INFORMATION call info@accushield.com

2 Date: July 8, 2015 To: Healthcare providers and/or vendors (Private-sitters, Home Health, Home Care, Hospice, DME, and other Service Providers - including all Non-healthcare Related Vendors) From: The Phoenix at Dunwoody Re: Healthcare providers and/or vendors: New Vendor Screening Procedures / Resident safety procedures / HIPAA-related privacy requirements Valued Partner, Under state law, The Phoenix at Dunwoody is responsible for the safety and oversight of its residents and staff. The Phoenix at Dunwoody is committed to providing the safest and most confidential environment for its residents, staff, outside healthcare providers and/or vendors, and visitors. With this in mind, The Phoenix at Dunwoody is establishing specific healthcare provider and/or vendor credentialing requirements and sign-in/sign-out procedures for its outside healthcare providers and/or vendors. These safety and confidentiality procedures and requirements are similar to those that have been utilized by the hospital and childcare industry for many years. The following information communicates what we have established and what will be required of you to meet these new credentialing procedures. The attached packet of materials gives further detail on the documents that need to be submitted. As part of the new procedures, each outside healthcare provider and/or vendor that enters The Phoenix at Dunwoody will be required to fax in the following community-specific credentialing requirements (healthcare provider and/or vendor agencies or companies that provide healthcare providers and/or vendors will need to supply these credentials for each employee or contractor entering The Phoenix at Dunwoody): Registration Form Employment Verification (if you are self-employed refer to Required Credentials section) Signed Consent for Use of Information Proof of Criminal Background Check (per standards in Required Credentials section) Proof of negative TB Proof of General Liability Insurance (per standards in Required Credentials section) Proof of Workers Compensation Insurance (for Employees or Contractors of Agencies or Vendor Companies) Agency or Vendor Company Agreement and Employee or Contractors Authorization and Release Agreement (if you are an Agency or Vendor Company) Health Care Provider & Other Vendor Agreement (if you are Self-employed)

3 The Phoenix at Dunwoody has contracted with Accushield, LLC, an independent screening and credentialing management company, to assist in the collection and management of third-party credentials and the sign-in and sign-out process for healthcare providers and/or vendors entering The Phoenix at Dunwoody. The credentialing process began July 9, Healthcare providers and/or vendors that provide care and service to The Phoenix at Dunwoody are required to fax in all community specific credentials to Following the receipt and verification of all required credentials by Accushield, the healthcare provider and/or vendor will be able to print a badge via the Accushield kiosk. Accushield provides a digital check-in and check-out kiosk located at the entrance of The Phoenix at Dunwoody. It is a state requirement that each healthcare provider and/or vendor check-in and check-out when entering a community. This will be done via the digital kiosk, which will immediately verify that the individual healthcare provider and/or vendor (or their agency or company) has submitted to Accushield all required credentialing documents. Each credential submitted by a healthcare provider and/or vendor will be stored in a secure, private, cloud-based database. Accushield will notify each healthcare provider and/or vendor via or text upon satisfactory completion of registration and credentialing. Should you need assistance, please call Accushield s Help Line at or support@accushield.com. Following receipt of each healthcare provider and/or vendor s credentials, Accushield will begin charging a monthly fee for use of its credentials screening and management system. This recurring monthly fee covers the healthcare provider and/or vendor s use of the Accushield system for all Accushield partner communities. Self-employed and other Individual healthcare providers and/or vendors will pay a single monthly fee of $9.00. Agencies and Vendor Companies with multiple employees or contractors will be billed $9.00 at the end of each month for each employee or contractor that has worked in an Accushield partner community during the month. Please visit for payment instructions or if an Agency or Vendor Company please see the attached Accushield Agency and Vendor Company Payment Information Instructions. The Phoenix at Dunwoody is committed to adding an additional layer of protection for residents, staff, healthcare providers and/or vendors, and visitors. We appreciate your partnership with us to make a safer and more secure community. Regards, The Phoenix at Dunwoody

4 Directions: Agency or Vendor Company READ, SIGN AND FAX IN ALL REQUIRED DOCUMENTS TO IN ORDER TO ALLOW YOUR EMPLOYEES AND/OR CONTRACTORS ACCESS TO THE PHOENIX AT DUNWOODY. It is extremely important that you 1. Promptly submit required Agency or Vendor Company documentation to Accushield and 2. Cause all healthcare providers and/or vendors employed by or contracted by you to submit their individual credentials in order to access The Phoenix at Dunwoody. Failure to do so may result in denial of access to The Phoenix at Dunwoody for healthcare providers and/or vendors employed by or contracted by you. Your Agency or Vendor Company May Choose to Submit the Individual Documentation Necessary for Each of Your Employees and Contractors to Become Credentialed for The Phoenix at Dunwoody. In Order to Submit Credentials for Individual Employees or Contractors, Please Fax (packaged together by individual) All Documents Listed Under Required Credentials to the Fax Number Below. The Accushield team will process all documents within 3 business days of submission. If credentials are received after 5PM EST, they will be processed the following business day. Once credentials are processed, Accushield will send notification to the Individual Employee or Contractor via or text if there are any problems with the required credentials. The Employee or Contractor will also receive notification after credentials are reviewed and approved. Please do not include Social Security numbers and/or Driver s License numbers on any document. FOR MORE INFORMATION call info@accushield.com

5 FAX COVER PAGE: Agency or Vendor Company TO: Accushield, LLC. FROM: PAGES: PHONE: DATE: RE: Registration CC: PLEASE CHECK THE DOCUMENTS THAT ARE INCLUDED IN THIS FAX DOCUMENTS DUE FROM AGENCY OR VENDOR COMPANY 1. AGENCY OR VENDOR COMPANY REGISTRATION FORM 2. AGENCY OR VENDOR COMPANY AGREEMENT 3. PROOF OF GENERAL LIABILITY INSURANCE, INCLUDING WORKERS COMPENSATION INSURANCE COVERAGE 4. AGENCY OR VENDOR COMPANY CONSENT FOR USE OF INFORMATION 5. EMPLOYMENT VERIFICATION 6. CRIMINAL BACKGROUND CHECK 7. PROOF OF NEGATIVE TB EACH AGENCY OR VENDOR COMPANY NEEDS TO PROVIDE THE FOLLOWING INDIVIDUAL CREDENTIAL DOCUMENTS TO ACCUSHIELD FOR EACH OF ITS EMPLOYEES OR CONTRACTORS: SEE 5-7.

6 Required Credentials 1. Registration Form 2. Agency or Vendor Company Agreement To be signed by an authorized officer of the Agency or Vendor Company 3. Proof of General Liability Insurance, Including Workers Compensation Insurance Coverage A. GENERAL LIABILITY INSURANCE REQUIREMENTS (FOR ALL HEALTHCARE PROVIDERS AND OTHER VENDORS) A statement showing proof of general liability insurance coverage. This document needs to include name of insurance company, policy number and expiration date. Below is a list of the insurance requirements that must be met. All insurance is required to be written by insurance companies with an A.M. best rating of not less than A-. Healthcare provider and/or vendor shall provide renewal certificates of insurance at least thirty (30) days prior to the expiration of such policies required below. Such policies may not be adversely changed or canceled until after thirty (30) days prior written notice to The Phoenix at Dunwoody. Healthcare provider and/or vendor shall at all times comply with all requirements of the insurers issuing said policies. Healthcare provider or other vendor shall maintain the following insurance in amounts not less than those specified below: 1. Commercial General Liability Coverage and Auto Coverage LIMITS NOT LESS THAN: $1,000,000 Each Occurrence combined single limit for bodily injury, property damage, and disease per occurrence - and $3,000,000 general aggregate. ABOVE TO BE WRITTEN ON AN OCCURRENCE FORM AND TO INCLUDE:

7 Blanket contractual liability Products and completed operations Employees and Independent contractors of the Insured (if applicable) Broad form property damage Personal injury 2.Umbrella Liability Coverage (only if an Agency or Vendor Company) LIMITS NOT LESS THAN: $2,000,000 each occurrence and in the aggregate in excess of general liability PLEASE NOTE: The following statement shall appear naming additional insureds under Healthcare provider or other vendor s general liability policies: This insurance is primary to all other valid and collectible insurance relating to the following additional insured The Phoenix at Dunwoody. The individual, healthcare provider or other vendor company, or principal must provide a Certificate of Insurance (COI) or Declaration Page to prove general liability insurance coverage through a third party insurer. The document should include the name of the insurance company, policy number, and the expiration date. The insured company must match the listed company in your Accushield account. If you change companies you will be required to submit proof of your new company s general liability coverage. If you work for more than one company, you or your company will be required to submit proof of each company s general liability coverage. B. WORKERS COMPENSATION INSURANCE COVERAGE (for employees or contractors working for Agencies or Vendor Companies) A statement showing proof of Workers Compensation Insurance coverage. This document needs to include name of insurance company, policy number and expiration date. Workers Compensation insurance up to at least statutory levels and with an Employers Liability limit of not less than Five Hundred Thousand Dollars ($500,000). Where healthcare provider and/or vendor utilizes non-employees for the performance of any services completed at The Phoenix at Dunwoody, healthcare provider and/or vendor shall either declare the remuneration for all work performed by non-employees to its Workers Compensation carrier, and such shall be documented on healthcare provider and/or vendor s Workers Compensation coverage documentation, or healthcare provider and/or vendor shall

8 document that all non-employees engaged in such work are covered by Occupational Accident insurance that compensates them for injuries incurred, including medical expenses, loss of income, and death/ dismemberment/paralysis with benefits limits of not less than: 1. Five Hundred Thousand Dollars ($500,000) for medical expenses incurred over at least a 104 week period; 2. Twenty Five Thousand Dollars ($25,000) for death with a survivor benefit totaling at least One hundred Twenty Five Thousand Dollars ($125,000); and 3. 66% of earnings up to Five hundred Dollars ($500) per week for loss of income up to age 65 or older. 4. Consent for Use of Information An Agency or Vendor Company must complete and sign the enclosed Consent for Use of Information document, authorizing the submission and use of the credentialing information by Accushield. 5. Employment Verification A letter from your employer or agency on Company letterhead stating that you are currently an employee or contractor in good standing. All healthcare providers and/or vendors who are self-employed must submit a letter stating that they are self-employed. 6. Criminal Background Check If you are an employee or contractor of an agency or vendor company, a copy of the criminal background check performed by your agency or vendor company (this may be submitted on your behalf by your agency or vendor company). If your Agency or Vendor Company has not performed a criminal background check, you may call Accushield at and order an approved criminal background check through an independent provider recommended by Accushield. 7. Proof of Negative TB (Tuberculosis) A yearly Tuberculosis skin test (also known as PPD, Mantoux, TST). Each healthcare provider and/or vendor must provide a Valid Certificate of Tuberculosis Examination. The Certificate may be issued by an MD, DO, APRN, or PA. The Certificate must include the date of administration and reading of the PPD, the measurement in millimeters of the induration (raised skin reaction), and the signature or stamp of the MD, DO, APRN, PA, or clinic. If the transverse diameter of induration is 10 mm or greater, a chest x- ray (within 12 months) is also required to exclude communicable TB. A person with a past positive PPD may have a chest x-ray without a repeat skin test. We also accept negative results of Interferon Gamma Release Assay (IGRA) testing. Note: In the case of positive test results, you will need to submit one clear x-ray result and a statement (letter or form) from your physician that you are free of TB symptoms. This letter, not the x-ray, will need to be updated and submitted annually. Please do not fax actual X-ray.

9 Registration Form: Agency or Vendor Company Due to our commitment to provide a safe and HIPAA compliant environment for residents, staff, healthcare providers and other vendors, and visitors, The Phoenix at Dunwoody has partnered with Accushield, a third-party screening and credentialing company, to implement healthcare provider and other vendor risk management policies and computer based sign-in/sign-out requirements currently used in hospitals and other healthcare facilities. REQUIRED Name of Agency or Vendor Company Billing Address: Primary Telephone #: Primary Fax #: Primary Address: Primary Contact Person: Alternate Contact Person: CHECK ONE OF THE FOLLOWING: Our Agency or Vendor Company will provide payment for all of our Employees or Contractors who are Accushield credentialed (please see attached Accushield Agency or Vendor Company Payment Information Instructions) Our Employees or Contractors will each provide their own payment for Accushield s credentialing (please see Individual Payment Instructions)

10 Agency or Vendor Company Agreement This Agency Agreement ( Agreement ) is executed by ( Agency ), having principal offices in the State of. Accushield, LLC ( Accushield ) operates a vendor credentialing service on behalf of certain entities (each referred to herein as Company and, collectively, the Companies ). Each Company is the owner or operator of a senior living community (each referred to herein as a Facility, and, collectively, the Facilities ). Agency desires to arrange, and intends, for its employees, agents and/or independent contractors (each referred to herein as a Provider, and, collectively, the Providers ) to provide services ( Work ) to one or more residents at one or more of the Facilities, or directly for the Company itself. In order for the Work to be provided, Agency requests and requires access to one or more of the Facilities. NOW THEREFORE, in consideration of Agency and any of its employees, agents or independent contractors being allowed to enter and come upon the premises of any Facility and Accushield providing vendor credentialing services, which Agency acknowledges and agrees is valuable consideration, receipt of which is hereby acknowledged, sufficient to support the obligations and agreements undertaken by Accushield and the Agency herein, Agency hereby agrees to the above and as follows: 1. Disclaimer of Status. It is expressly understood that if Agency (or an employee, agent or independent contractor of Agency) has been engaged by one or more residents of one or more Companies, then Agency has not been engaged, directly or indirectly, by any such Company. Nothing in this Agreement or otherwise shall be construed to constitute Agency (or an employee, agent or independent contractor of Agency) in such situation as an employee, agent or independent contractor of any Company; nor shall anything in this Agreement or otherwise be construed to constitute any Company as an employee, agent or independent contractor of Agency (or of an employee, agent or independent contractor of Agency). Irrespective of whether Agency (or an employee, agent or independent contractor of Agency) is performing Work on behalf of a resident at a Facility or is performing Work on behalf of the Company, Agency acknowledges and agrees that no Company is directing or controlling the Work or has requested Agency (or an employee, agent or independent contractor of Agency) to provide any services on behalf of any resident of the Company. As such, Agency acknowledges and agrees that Agency (and any employee, agent or independent contractor of Agency) is not entitled to, and will not seek to, recover from any Company or its insurance companies or coverage, including without limitation any Company s worker s compensation insurance coverage, for Claims or Losses sustained while at any Facility of a Company or providing or performing Work. For purposes of this Agreement, Claims means any and all claims, actions and suits, and Losses means any and all injuries, costs, expenses (including without limitation attorneys and experts fees and expenses, and other legal expenses), debts, damages and losses, whether for personal injury or property damage, or known, unknown, foreseen, unforeseen, patent or latent. 2. Waiver. To the full extent allowed by applicable law, Agency hereby waives the right to assert, and

11 agrees not to assert, any Claim against any Company or Accushield, or their principals, officers, directors, partners, agents, assigns, attorneys, accountants, past and present employees, successors, predecessors, representatives, parents, subsidiaries, sister or affiliated entities, or insurers (collectively, the Released Parties ) arising out of or related to: (i) any and all Claims against or Losses sustained by Agency (or an employee, agent or independent contractor of Agency) while at any Facility or arising out of or related to the presence of Agency (or an employee, agent or independent contractor of Agency) at any Facility; (ii) the Work; (iii) any and all acts or omissions by any of the Released Parties in connection with the Information of Agency or of any employee, agent or independent contractor of Agency; or (iv) any third party access, damage or loss relating to the Information of Agency or of any employee, agent or independent contractor of Agency, in all cases including without limitation Claims and Losses resulting from the negligence of any of the Released Parties. 3. Confidentiality. (a) (b) Agency shall comply, and shall ensure that all of its employees, agents and independent contractors comply, with all applicable federal and state laws and regulations regarding the confidential and secure treatment of individually identifiable health information. Agency understands and acknowledges that, in connection with any of its employees, agents or independent contractors entering and coming on the property or premises of any Company, Agency (or an employee, agent or independent contractor of Agency) might acquire or be exposed to a Company s trade secret information, confidential information or other proprietary information, including but not limited to business plans, product plans, designs, inventions (whether or not patentable), costs, prices, finances, marketing and advertising plans, software, technology and other intellectual property, and information regarding customers, executives and employees. Agency hereby agrees that Agency shall hold, and shall ensure its employees, agents or independent contractors hold, such information in confidence and not disclose, distribute, transmit or transfer such information to any person or entity for any purpose, and shall not use such information for any purpose, except as required by applicable law. 4. Use of Information. (a) (b) Agency authorizes Accushield and each Company to view any and all documents, credentials, and related information provided by Agency, on behalf of itself or any employee, agent or independent contractor of Agency, to Accushield or obtained by Accushield with Agency s authorization in whatever form transmitted to Accushield (collectively, the Information ). Agency specifically authorizes Accushield to consult with or obtain its Information from a third-party that has access to, or the ability to provide, such Information. Agency agrees that this Information may be viewed by authorized users of Accushield system who are provided a secure username and password. Agency hereby certifies that all Information provided by Agency, on behalf of itself or any employee, agent and independent contractor of Agency, is true and accurate to the best of its knowledge. Agency agrees to inform Accushield of any new developments or changes with respect to the Information provided by Agency as soon as practicable after such change or development. Agency acknowledges and agrees that Accushield has no obligation to verify any Information related to Agency or any employee, agent or

12 independent contractor of Agency. (c) Agency acknowledges and agrees that, while Accushield has adopted reasonable measures to secure and protect the Information while in Accushield s possession, Agency accepts the inherent risk of storing Information online. (d) Agency acknowledges and agrees that each Company has established certain requirements to attain a credentialed status with Accushield for purposes of accessing Facilities operated by such Company. In the event that the Information does not satisfy a Company s requirements, Agency acknowledges and agrees that Agency, or any of its employees, agents or independent contractors on an individual basis, may not obtain a credentialed status with Accushield and that, as a result, a Company, at its sole discretion, may limit access to a Facility by Agency or any of its employees, agents or independent contractors. 5. Responsibility and Indemnity. Agency shall be responsible for any and all Claims and Losses arising out of or related to (a) the Work or any other acts or omissions by Agency (or an employee, agent or independent contractor of Agency), including without limitation any breach of this Agreement, or (b) the Information of Agency, or, to the extent provided by Agency to Accushield or any Company, the Information of any employee, agent or independent contractor of Agency. To the full extent allowed by applicable law, Agency shall indemnify, hold harmless and, at the option of any Company and Accushield, defend the Released Parties from or with respect to any and all Claims and Losses arising out of or related to (a) any and all acts or omissions by Agency (or an employee, agent or independent contractor of Agency) while at any Facility, (b) the Work or (c) any breach of this Agreement, including without limitation any of the certifications or covenants in Section 4 of this Agreement. 6. Insurance. Agency shall obtain and maintain, at Agency s expense, insurance coverage for itself and its employees and agents (including each Provider) of the types and at least in the amounts set forth on Exhibit A hereto, upon such terms and conditions as the applicable Company deems appropriate; provided that if any Company requires insurance coverage differing in type or amount from that set forth on Exhibit A, Agency shall obtain and maintain insurance in accordance with each Company s requirements for credentialing. At each Company s sole discretion, the amount of coverage required to maintain a credentialed status for such Company and its Facilities may be adjusted from time to time. Any insurance requirements shall be deemed continuing and shall survive any termination or expiration of this Agreement. Agency shall ensure that each Company at whose Facility such Agency s Providers are providing or performing work is added as an additional insured on Agency s general liability and umbrella excess liability insurance policies. Agency shall notify Accushield thirty (30) days prior to any non-renewal or cancellation of said insurance. 7. Miscellaneous. This Agreement shall bind and inure to the benefit of Agency and Agency s successors and assigns, and shall inure to the benefit of the Released Parties. This Agreement contains the entire agreement with respect to the subject matter hereof and supersedes all other written or oral statements

13 or agreements heretofore made with respect to the subject matter hereof. Any failure to enforce any provision of this Agreement shall not constitute a waiver thereof or of any other provision hereof. If any provision hereof is declared invalid by a court of competent jurisdiction, such provision shall be ineffective only to the extent of such invalidity, so that the remainder of that provision and all remaining provisions of this Agreement will continue in full force and effect. Headings of particular sections are inserted only for convenience and are not to be used to define, limit or construe the scope of any term or provision of this Agreement. In this Agreement, the disjunctive or shall include the conjunctive and, and vice versa. Should any provision of this Agreement require judicial interpretation, it is agreed that the court interpreting or construing same shall not apply a presumption or rule that the terms of this Agreement shall be more strictly construed against the drafter. Agency has read this Agreement in its entirety, understands the terms contained herein, has had the opportunity to consult counsel or has elected not to consult counsel, and intends to be bound hereby. The interpretation and enforcement of this Agreement will be governed by the laws of the State of Georgia, without regard to any conflicts of law, rules or provisions. Agency or Vendor Company By: Its: Date:

14 EXHIBIT A: INSURANCE REQUIREMENTS A. GENERAL LIABILITY INSURANCE REQUIREMENTS (FOR ALL HEALTHCARE PROVIDERS AND OTHER VENDORS) A statement showing proof of general liability insurance coverage. This document needs to include name of insurance company, policy number and expiration date. Below is a list of the insurance requirements that must be met. All insurance is required to be written by insurance companies with an A.M. best rating of not less than A-. Healthcare provider and/or vendor shall provide renewal certificates of insurance at least thirty (30) days prior to the expiration of such policies required below. Such policies may not be adversely changed or canceled until after thirty (30) days prior written notice to The Phoenix at Dunwoody. Healthcare provider and/or vendor shall at all times comply with all requirements of the insurers issuing said policies. Healthcare provider or other vendor shall maintain the following insurance in amounts not less than those specified below: 1. Commercial General Liability Coverage and Auto Coverage LIMITS NOT LESS THAN: $1,000,000 Each Occurrence combined single limit for bodily injury, property damage, and disease per occurrence - and $3,000,000 general aggregate. ABOVE TO BE WRITTEN ON AN OCCURRENCE FORM AND TO INCLUDE: Blanket contractual liability Products and completed operations Employees and Independent contractors of the Insured (if applicable) Broad form property damage Personal injury 2.Umbrella Liability Coverage (only if an Agency or Vendor Company) LIMITS NOT LESS THAN: $2,000,000 each occurrence and in the aggregate in excess of general liability PLEASE NOTE: The following statement shall appear naming additional insureds under Healthcare provider or other vendor s general liability policies: This insurance is primary to all other valid and collectible insurance relating to the following additional insured The Phoenix at Dunwoody. The individual, healthcare provider or other vendor company, or principal must provide a Certificate of Insurance (COI) or Declaration Page to prove general liability insurance coverage through a third party insurer.

15 The document should include the name of the insurance company, policy number, and the expiration date. The insured company must match the listed company in your Accushield account. If you change companies you will be required to submit proof of your new company s general liability coverage. If you work for more than one company, you or your company will be required to submit proof of each company s general liability coverage. B. WORKERS COMPENSATION INSURANCE COVERAGE (for employees and contractors working for an Agency or Vendor Company) A statement showing proof of Workers Compensation Insurance coverage. This document needs to include name of insurance company, policy number and expiration date. Workers Compensation insurance up to at least statutory levels and with an Employers Liability limit of not less than Five Hundred Thousand Dollars ($500,000). Where healthcare provider and/or vendor utilizes non-employees for the performance of any services completed at The Phoenix at Dunwoody, healthcare provider and/or vendor shall either declare the remuneration for all work performed by non-employees to its Workers Compensation carrier, and such shall be documented on healthcare provider and/or vendor s Workers Compensation coverage documentation, or healthcare provider and/or vendor shall document that all non-employees engaged in such work are covered by Occupational Accident insurance that compensates them for injuries incurred, including medical expenses, loss of income, and death/ dismemberment/paralysis with benefits limits of not less than: 1. Five Hundred Thousand Dollars ($500,000) for medical expenses incurred over at least a 104 week period; 2. Twenty Five Thousand Dollars ($25,000) for death with a survivor benefit totaling at least One hundred Twenty Five Thousand Dollars ($125,000); and 3. 66% of earnings up to Five hundred Dollars ($500) per week for loss of income up to age 65 or older.

16 Agency and Vendor Company Payment Instructions The Phoenix at Dunwoody requires that all Healthcare Providers and other Vendors (Providers) who access our community, whether on a regular or irregular basis, be credentialed. The Phoenix at Dunwoody and Accushield want to provide a fair and simple payment system for credentialing Providers who access The Phoenix at Dunwoody. We have established two primary options for Providers: 1) Agencies and other vendor companies ( Agencies/Vendor Companies ) can pay for their employees or contractors to be credentialed by Accushield or 2) the employees or contractors can personally provide payment for their individual credentialing. Please choose your Agency/Vendor Company payment preference below: Our Agency/Vendor Company will provide payment for the credentialing of our employees and contractors Our Agency/Vendor Company requires that our employees and contractors pay personally for their credentialing The Phoenix at Dunwoody and Accushield recommend that Agencies/Vendor Companies submit credentials to Accushield for all employees who access our community on a regular basis. For any employees and contractors who may access The Phoenix at Dunwoody on an infrequent basis, you have 30 days following the date of their first access to our community to submit their credentials. Agency/Vendor Company Credentialing Payment The Phoenix at Dunwoody and Accushield believe that it is important that you, as a valued supplier of services to The Phoenix at Dunwoody residents, only incur expense related to the credentialing process when your employee or contractor actually accesses The Phoenix at Dunwoody. Accordingly, we have established a payment program that will only bill you on a monthly basis in arrears for each individual employee or contractor that actually goes into The Phoenix at Dunwoody in a given month ( Monthly Plan ). Alternatively, you have the option of being billed per Provider in advance for one year of access ( Annual Plan ). Payment for both the Monthly Plan and the Annual Plan is due 10 days following the billing date. If the billing is not paid within this 10 day period, then your employees or contractors may be at risk of not being able to print a badge and access The Phoenix at Dunwoody Monthly Plan Accushield will bill your Agency/Company the monthly fee of $9 for each employee or contractor who accessed an Accushield-partner community (i.e. if 5 employees or contractors access The Phoenix at Dunwoody in a month, the monthly bill for your Agency/Company would be $45). The $9 fee covers unlimited visits to The Phoenix at Dunwoody and other Accushield-partner communities where the Provider meets all credential requirements. Annual Plan Accushield s Annual Plan also allows each Provider an unlimited number of visits during a consecutive 12-month period to any Accushield-partner community where they meet all credential requirements. If you choose the Annual Plan, Accushield will bill your Agency/Company $100 per employee in advance for each employee or contractor who is signed up for annual membership. Individual Credentialing Payment If your employees or contractors will be responsible for the payment of their monthly or annual fee, please refer them to to access Accushield s payment page.

17 Consent for Use of Information Please fill in all blanks This Accushield Consent for Use of Protected Information (this Accushield Consent ) is entered into and effective as of this date, 2015 (the Effective Date ) by and between Accushield, LLC ( Accushield ), and the individual or company identified below (the Accushield Client ). I,, give my full consent to Accushield, under this Accushield Consent, to use, store, and maintain in its private and cloud-based encrypted database (defined below) any and all documents and related information I provide to Accushield and/ or authorize Accushield to obtain (the Information ) regarding myself or contractors or employees working on my behalf, including, but not limited to, the following: Criminal Background Check General Liability Insurance Coverage Proof of Negative TB or chest X-ray Accushield Consent and Release/Authorization Forms Applicable Accushield Registration Forms Employment Verification Form (if applicable) Other Community Specific Requirements Further, I authorize Accushield to view my Information in whatever form transmitted to Accushield. I specifically authorize Accushield to consult with or obtain my Information from a third party that has access to or the ability to provide such Information. I understand that this Information may be viewed by authorized users of the Accushield system who are provided a secure username and password. I hereby certify that all Information provided by me is true and accurate to the best of my knowledge, and I agree to inform Accushield of any new developments or changes with respect to the Information provided as soon as practicable after such change or development. I acknowledge that this is an online private and encrypted database storage system of the above Information. I understand that Accushield has adopted reasonable measures to secure and protect this Information while in transit and stored, but I accept the inherent risk of malicious infiltration of the Accushield system and will not hold Accushield responsible for any harm if this Information is accessed by any third party, damaged or lost. I reserve the rights to access and change at any time this Information. I understand that I can delete any and all Information by ing info@accushield.com or by calling the Accushield helpline at (800) I acknowledge that I must include my Verification Information with my request. For purposes of this Consent, Verification Information means, collectively: 1) my Account Name; 2) the Mobile Number I use for sign in at Accushield s kiosk; and 3) my personal identification number ( PIN ). I hereby release from liability and agree to hold harmless Accushield and its affiliates, employees, agents and representatives for the acts or omissions performed in connection with my Information. I agree that by signing this Accushield Consent, I will not do the following:

18 Provide Accushield with any sensitive information that is beyond the scope of Accushield s request such as, but not limited to, any Social Security Numbers and Driver s License Numbers. Provide Accushield with any unrequested personal healthcare information. By signing this Accushield Consent, I understand and agree to the following: This Accushield Consent is valid as long as I am a member of Accushield. I may terminate my membership by calling (800) I understand and agree that in the event my membership with Accushield is terminated, the releases and waivers contained herein shall survive termination of my Accushield membership. This Accushield Consent may be executed in one or more counterparts, each of which shall be deemed an original but all of which together will constitute one and the same instrument. A photocopy or facsimile copy of the signed original of this Accushield Consent shall have the same force and effect as the original and shall be sufficient for the same purposes. By signing below, you agree to be bound by the terms of this Accushield Consent. Your signature creates a binding contract and constitutes your assent to the terms of this Accushield Consent. Your failure to sign below will result in you not being able to access or otherwise use the Accushield system, Website or related services. IF A COMPANY/AGENCY: IF AN INDIVIDUAL: By: By: Name: Title: Name: