THREE RIVERS PROVIDER NETWORK AGREEMENT WITH
Exhibit 10.7
THREE RIVERS PROVIDER NETWORK
AGREEMENT WITH
______________________________
This Agreement is made this 23rd day of October 2008, by and between Three Rivers Provider Network, Inc., a Nevada Corporation (“TRPN”) and Woodbridge SA Services a Provider Group of health care services. TRPN contracts with hospitals, physicians, ancillaries and entities hereinafter referred to as “Provider” rendering medical and health care services at pre-determined rates as follow.
1. Clients. Covered Services. Contract Rates: TRPN contracts with insurance companies, third party administrators, health plans, individuals and entities hereinafter referred to as “Clients” that directly or indirectly access TRPN contracted providers for covered services. Covered Services shall include all services that are medically necessary including health, workers’ compensation, automobile and general liability. The rate used in conjunction with this Agreement will be a * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles. Clients are obligated to make payment directly to provider only at the contracted rate as payment in full. Provider shall not balance xxxx the patient upon receipt of payment in full at the contracted rate. TRPN has no responsibility to make payments on behalf of Clients. Payments shall be made within thirty (30) calendar days of receipt of clean claim. Where a state mandated fee schedule exists, provider agrees to accept a * discount below the state schedule. Payments made and cashed by the provider shall be accepted as payment in full and fulfillment of all terms of the agreement, providing the total payment including the member’s portion is not less than the contracted rate.
2. Licenses, Standards of Care: Provider agrees to deliver health care services that meet all legal standards of care complying with applicable Federal, State and Local laws and maintains the standards of NCQA and/or JCAHO. The provider is delegated by TRPN to carry out and/or assign credentialing responsibilities. Evidence of such licenses, certificates and standards shall be made available to TRPN upon request.
3. Term and Termination: This Agreement shall continue in effect for a period of one (1) years with automatic successive one (1) year terms. This Agreement may be terminated by either party without cause with a ninety (90) day prior written notice to the other party at the mailing addresses listed under the signatures. This Agreement may be immediately terminated with cause by TRPN should Provider lose applicable licenses, malpractice coverage, fail to honor the applicable contracted rates pursuant to this Agreement, or if any information provided in Attachment A is illegible, incomplete, or invalid.
4. Dispute Resolution: This Agreement shall be construed and interpreted in accordance with the laws of the State of Nevada. Provider agrees to meet and confer in good faith to resolve any disputes that may arise under this Agreement. If a dispute between TRPN and Provider arises out of this Agreement and is not resolved, either party may submit the dispute to arbitration which shall be commenced and conducted in accordance with the Rules of Practice and Procedures of the Judicial Arbitration and Mediation Services, Inc. (“JAMS”) as in effect at the time (“JAMS Rules”).
5. Attachment A: All information provided in Attachment A of this Agreement is complete and accurate to the best of Provider’s knowledge and Provider shall immediately notify TRPN of any changes thereto. Provider agrees to xxxx “N/A” next to any blank that is not applicable to Provider’s business.
6. Faxed Signatures: The parties agree that facsimile signatures of authorized representatives of the parties shall legally bind the parties to the terms and conditions of this Agreement as if the signatures were original and shall be considered evidence of a fully executed Agreement.
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Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act. Confidential portions of this document have been filed separately with the Securities and Exchange Commission.
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Page 1
IN WITNESS WHEREOF, the authorized parties hereto have executed this Agreement and intend to be bound thereby.
| PROVIDER GROUP NAME (Please Print): | ATTENTION:XXXX XXXXXXXX | |
| TRPN CONTRACTING COORDINATOR | ||
| THREE RIVERS PROVIDER NETWORK | ||
| Signature: /s/ Xxxxx Xxxx | Signature: | |
| Title: COO | ||
| Date: 10/23/08 | ||
| NAME: Xxxx Xxxxxxx, C.O.O. | ||
| Mailing Address: 0000 Xxxxx Xxxxxx Xxxxx 000 | ||
| Xxx Xxxxx, XX 00000 Phone: (000) 000-0000 | ||
| Date: |
ATTACHMENT A: PROVIDER INFORMATION
(Please attach a roster of all the provider’s full names, titles, NPI#s, and all locations under the group’s Tax Id#, use Addendum A)
| Tax ID: 00-0000000 | Practice Name: Woodbridge SA Services |
| National Provider Identifier (NPI): | Group / IPA Affiliation:___________ |
| 0000000000 | |
| (If there is more than one NPI Number, please attach a listing.) | |
| Degree: LSA, CSA,SA-C, CST/CFA, CRNFA, RN, CNOR | Office Hours: 8-4:30 |
| Specialty : Surgical Assisting | |
| First Assist | Primary Address: X.X. Xxx 000000 |
| Xxxxxx: _____________________ | |
| Phone: 000-000-0000 Fax: 000-000-0000 | |
| Email: Xxxxxxxxx@xx.xxx | |
| Other Practice and/or Billing Address: Yes □ No □ | |
| If “yes”, attach page with additional information | |
| Hospital Affiliations (list name, date and type): | |
Provider agrees to xxxx “N/A” next to any blank that is not applicable to Provider’s business.
Page 2
ADDENDUM A:
MEDICAL STAFF LISTING & FACILITY LOCAITONS
_______________________________
| i. | The attached roster of providers and or locations will be participating under this Agreement between Woodbridge SA Services and Three Rivers Provider Network and shall include Tax Indentification Numbers, NPI Numbers, Address(s), Phone and Fax Numbers. |
Page 3
Provider List
10/23/2008
| Code | Name | Credentials | License Number | |
| Last Name | National Provider Identifier | |||
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XX
XXXXX
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XXXXX, XXXXXXX
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0000000000
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CST/CFA
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109540
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XX
XXXXXX
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XXXXXX, XXXXXXX
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0000000000
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CNOR
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030775
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XX
XXXXXX
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XXXXXX, XXXX
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0000000000
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LSA
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SA00073
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JRO1
XXXX
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XXXX, XXXXX
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0000000000
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SA-C
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A05263
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SR
XXXXX
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XXXXX, XXXXX
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0000000000
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LSA
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SA00090
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|
JR
XXXXXXX
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XXXXXXX, XXXXX
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0000000000
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XXX/XXX
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XXX00000
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XX
XXXXXXXX
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XXXXXXXX, XXXXX
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0000000000
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XXX/XXXX
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000000
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XXX0
XXXXXXX
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XXXXXXX, XXXXX
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0000000000
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SA-C
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08120
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PT
XXXXXXXX
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XXXXXXXX, XXXXXXXX
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LSA
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SA00156
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1
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WOODBRIDGE SA SERVICES
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Christus Xxxxx Health System
000 Xxxxxxxxx Xxxxxx
Xxxxxx Xxxxxxx XX 00000
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Corpus Christi Medical Center
0000 Xxxxx Xxxxxxxx
Xxxxxx Xxxxxxx XX 00000
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AMENDMENT TO
AGREEMENT
BETWEEN
THREE RIVERS PROVIDER NETWORK
AND
WOODBRIDGE SA SERVICES, INC.
This AMENDMENT to the Agreement between THREE RIVERS PROVIDER NETWORK (“TRPN”) AND (Tax Id# 00-0000000), dated 10-23-2008 (“Agreement”), is entered into and made effective as of 05-07-2010.
FOR VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby acknowledged, and in consideration of the mutual promises and mutual covenants of the parties, the parties agree that the Agreement is hereby amended as follows:
1. This Agreement is being amended due to renegotiations of the reimbursement rate in Section 1. and will now reflect the following change in rate:
a) The rate used in conjunction with this Agreement will be * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles.
2. The remaining terms and conditions of the Agreement shall remain in full force and effect unless so amended pursuant to the terms of the Agreement.
IN WITNESS WHEREOF, the parties have executed this Amendment to the Provider Service Agreement to be effective as of the Effective Date.
| THREE RIVERS PROVIDER NETWORK | ||
| By /s/ Xxxxx X. Xxxx | By /s/ Xxxx Xxxxxxx | |
| Signature | Signature | |
| Name: /s/ Xxxxx X. Xxxx | Name Xxxx Xxxxxxx | |
| Title: COO | Title Chief Operating Officer | |
| Date 5/7/2010 | Date 5/7/2010 |
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Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act. Confidential portions of this document have been filed separately with the Securities and Exchange Commission.
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