Provider Network Agreement for Disability Medical Assessments

Provider Network Agreement for Disability Medical Assessments Provider network agreement for the provision of Disability Medical Assessments Medibank Health Solutions (MHS) manages a network of providers to deliver Disability Medical Assessments (DMAs) for Disability Support Pension (DSP) customers on behalf of the Department of Human Services (DHS). To apply to be a DMA provider please complete and submit this agreement via the details below. By signing below, you agree to be bound by the terms and conditions set out in this document and agree to abide by the Operational Procedures which are incorporated by reference. Please complete this form using capital letters and black pen only. The Personal Information collected on this form will be used in connection with the provision of medical assessment services for the DHS and will otherwise be handled in accordance with the Medibank Health Solutions Privacy Policy (which is available at medibankhealth.com.au). Specialty: Sub-specialty: (if relevant) I/we acknowledge that I/we have read and agree to abide by the Terms and Conditions, Operational Procedures and Schedule of Fees contained herein. To execute this Agreement as an individual please mark with a cross here: To execute this Agreement as a duly authorised signatory of a company, partnership or other legal entity, please mark with a cross here: Signature Date (DD/MM/YY) Practice name (if relevant): Title: PKI no: (if known) Practice address: (no PO boxes) Suburb: State: Post code: Phone: Fax: Email: Company or entity name ABN/ACN: GST registered? (mark with X) Yes No Bank name: Account name: BSB: Account no: PTO

If you are an individual detail other locations at which you provide services (if any): If you are a company, partnership or other legal entity please detail the providers working at your clinic that are a Party to this Agreement Submit your agreement via: Email: dmasenquiries@medibank.com.au Mail: Medibank s Disability Medical Assessment Services GPO Box 9999 Melbourne VIC 3001 Fax: 1300 787 026 Please retain a copy for your reference. For further information: Call: 1300 732 519 Fax: 1300 787 026 Email: dmasenquiries@medibank.com.au

Provider Network Agreement for Disability Medical Assessments Terms and Conditions 1. Consideration 1.1 The consideration for this agreement is your potential access to Disability Support Pension claimants (Customers) and associated revenue streams. These are made available by MHS in exchange for your provision of services as a Government Contracted Doctor (GCD) in connection with Medibank s contract for services with the Department of Human Services (Department). 2. Training 2.1 MHS will provide you with training in the legislative requirements for disability support pension eligibility, including comprehensive training in the application of the legislated Impairment Tables, in the form of an elearning training package and other training assistance. 2.2 You agree to complete the training as soon as reasonably possible and acknowledge that MHS cannot send you any referrals until the training has been completed to MHS reasonable satisfaction. 3. Services and standards 3.1 From time to time, MHS may request you to provide a Disability Medical Assessment (DMA) with respect to a Customer (Service Request). 3.2 In carrying out each Service Request, you must follow the operational procedures attached to this agreement, as reasonably updated from time to time by MHS and made available at www.medibankhealth.com.au (Operational Procedures). The Operational Procedures are incorporated into this agreement by reference. To the extent that there is any inconsistency between a provision in this agreement and a provision in the Operational Procedures, the provision in this agreement will prevail. 3.3 You must complete each DMA and submit it electronically using the online reporting system to be provided by the Department (or such other method as MHS may notify to you from time to time) within 7 business days of the date on which you examine the Customer, unless otherwise agreed in writing with MHS. 3.4 If requested by MHS, you will provide expert witness services in connection with a Customer s disability support pension application or a DMA, and will be entitled to payment for such services in accordance with paragraph 4. 3.5 You agree to provide services under this agreement with all due care, skill and diligence, to the best of your knowledge and expertise, and in accordance with all applicable laws and relevant industry standards, best practices and guidelines. 4. Charges 4.1 You may invoice MHS according to the attached Schedule of Fees for each DMA completed under this agreement (Service Charges). The Schedule of Fees is also available at www.medibankhealth.com.au. 4.2 You must not under any circumstances invoice or charge Customers for any fees associated with the provision of a DMA under this agreement. All invoices are to be sent to MHS. 4.3 Some Customers may require an interpreter. If this is the case, MHS will arrange an interpreter through the Department and the Department will pay the costs of the interpreter. You must not pay or incur any costs in relation to interpreter services for Customers. 4.4 Unless otherwise agreed in writing, you must not charge MHS for any fees, charges or expenses (such as travel and accommodation, document reproduction, transportation and courier charges, and telecommunications charges) in addition to the Service Charges. MHS is under no obligation to pay any amount in excess of the Service Charges. 5. Invoicing and GST 5.1 Invoices must comply with the requirements set out in the Operational Procedures (including all required data and particulars of the services provided) and must be sent by email, fax or post to MHS as soon as reasonably practicable and in any event within 4 weeks of the completion of the relevant services. MHS will use its best endeavours to pay within 14 days upon receipt of a valid, correctly rendered invoice. 5.2 MHS will not pay any invoices submitted more than three months after the date on which the services were provided. 5.3 MHS will pay an amount on account of GST where you are registered for GST and provide a correctly rendered tax invoice for the service provided. You must promptly inform MHS if your GST registration status changes. 5.4 Approval and payment of an amount of an invoice is not evidence of the value of the obligations performed by you, an admission of liability or evidence the obligations under this agreement have been completed satisfactorily, but is payment on account only. 5.5 If an invoice is found to have been rendered incorrectly after payment, MHS will be entitled to recover any underpayment or overpayment (as the case may be) from you and, without limiting MHS recourse to other available means, MHS may offset that amount against any amount subsequently due to you under this agreement.

6. Registration and insurance requirements 6.1 You warrant that you: a) are eligible and permitted to practice as a medical practitioner or clinical psychologist in Australia and are registered to practice with the Medical Board of Australia or the Psychology Board of Australia (as applicable), and your registration is not subject to any conditions, notations or undertakings; b) hold individual valid professional indemnity insurance that complies with the Medical Board of Australia s Professional Indemnity Insurance Registration Standard or the Psychology Board of Australia s Professional Indemnity Insurance Arrangements Registration Standard (as applicable) or are covered by your employer s professional indemnity and/or medical malpractice insurance policy that satisfies that same standard; c) hold valid public liability insurance with at least $10 million indemnity cover or are covered by your employer s public liability insurance policy that satisfies the same requirement; d) have not been subject to medical or professional disciplinary proceedings (of any form or name) at any time in Australia or an overseas jurisdiction; and e) are not subject to investigation by the Medical Board of Australia or the Psychology Board of Australia (or any other body). 6.2 MHS may request and you must provide evidence of the registrations and insurances which are required to be held by you under paragraph 6.1. 6.3 You must promptly notify MHS of any suspension or termination, or any other change imposed in response to unsatisfactory performance, complaints or concerns, to the registrations which are required to be held by you under paragraph 6.1, and cooperate with MHS in any related investigation. 6.4 You must co-operate fully and provide timely and appropriate assistance to any investigation of a complaint related to the provision of services under this agreement. 7. Confidentiality and Privacy 7.1 In the course of performing your obligations under this agreement, you may be provided with information that is by its nature confidential, designated as confidential by MHS or which you know or ought to know is confidential (Confidential Information). You must not, without the prior written consent of MHS, use or disclose Confidential Information other than for the purpose of performing your obligations under this agreement. You may disclose the Confidential Information if: a) it is to a person who needs to know the information for the purposes of you performing your obligations under this agreement (eg. a director (if you are incorporated), employee, professional advisor and/or independent contractor); or b) you are required to do so by law. Nothing in this clause 7.1 is intended to limit your disclosure of information which is or becomes public knowledge or has been independently developed or acquired by you otherwise than by a breach of this agreement or any other confidentiality obligation. 7.2 You acknowledge that by signing this agreement, you are a contracted service provider within the meaning of section 6 of the Privacy Act 1988 (Cth) (Privacy Act), and: a) will be provided with information that is subject to secrecy requirements under the Social Security (Administration) Act 1999 (Cth) and/ or is personal information under the Privacy Act (being information or an opinion about an identified individual, or an individual who is reasonably identifiable: (i) whether the information or opinion is true or not; and (ii) whether the information or opinion is recorded in a material form or not) (Personal Information); and b) may access information in relation to a Customer that is subject to the secrecy requirements of the Personally Controlled Electronic Health Records Act 2012 (Cth) and the Health Identifiers Act 2010 (Cth). 7.3 You must comply with all laws applicable to your provision of services under this agreement, including laws relating to privacy and health records (Privacy Laws). 7.4 You must not transfer any Personal Information held in relation to this agreement outside Australia, or allow any person outside Australia to have access to, use or disclose Personal Information that you hold without the prior written consent of MHS. 7.5 MHS will use your Personal Information in connection with the provision of services to the Department and in the administration and management of those services. MHS may also use your Personal Information to send you important information and newsletters in relation to this service or to contact you in relation to other programs and initiatives for which we believe your services may be appropriate. Otherwise, MHS handle your Personal Information in accordance with the Medibank Health Solutions Privacy Policy (available at www.medibankhealth.com.au). 7.6 As soon as you become aware or suspect that there has been a breach of Privacy Laws or of any other provision in this agreement, you must immediately: a) notify MHS; and b) disclose to MHS all information relevant to the actual or suspected breach, co-operate with MHS in investigating whether the breach has occurred and the circumstances surrounding the breach, and give MHS all information and access to your premises, staff, processes, systems reasonably required by MHS for the purpose of carrying out an investigation into the actual or suspected breach.

8. Right to conduct audits 8.1 The Department and/or MHS or a representative of either may conduct audits relevant to the performance of your obligations under this agreement and each Service Request. Audits may be conducted of: a) your operational practices and procedures as they relate to this agreement and any Service Request, including security procedures; b) the accuracy of the invoices and reports in relation to the provision of the services under this agreement and any Service Request; c) your compliance with confidentiality, privacy and security obligations under this agreement and each Service Request; d) material (including books and records) in your possession relevant to the Services, this agreement and any Service Request but excluding information protected by legal professional privilege; and e) any other matters reasonably determined by MHS to be relevant to this agreement or any Service Request. 8.2 You would not be required to provide to the auditor any: a) information protected by legal professional privilege; or b) confidential information of third parties provided that you can provide the Department and/or MHS with sufficient evidence such as a statutory declaration attesting that the information in question is genuinely the confidential information of a third party, subject to ongoing confidentiality obligations and not in the public domain. 9. No conflicts of interest 9.1 You warrant that, to the best of your knowledge after making diligent inquiry, at the date of signing this agreement you do not have any actual or potential conflicts of interest in relation to the performance of services under this agreement, and there no circumstances exist where a reasonable person might perceive you to have a conflict of interest in performing services under this agreement. 9.2 If any such conflict of interest arises, or appears likely to arise, while this agreement is in place, you must immediately notify MHS in writing, make full disclosure to MHS of all relevant information relating to the conflict of interest, and take such steps as MHS reasonably requires to resolve or otherwise deal with the conflict of interest. 10. Term and Termination 10.1 This agreement will commence on the date on which you sign it and will continue until it is terminated. Either party may terminate this agreement at any time, without giving reasons, by notifying the other party in writing. 127029788_0815