Form of Network Agreement Exhibit 6.2
THIS AGREEMENT is made and entered into by and between Alliance HealthCard Inc.,
a Georgia corporation, (hereinafter called "Alliance") and the contracting
Provider Network identified in the Network Application (hereinafter called
"Network").
WHEREAS, Alliance wishes to develop and market a network of contracted providers
that HealthCard Members can use to access health care services not covered by
health or other insurance;
WHEREAS, Network desires to participate in such network so that its services may
be marketed to HealthCard Members;
NOW THEREFORE, in consideration of the mutual promises and covenants set forth
herein, the parties agree as follows:
I. OBLIGATIONS OF ALLIANCE
1.1 Alliance shall assume overall responsibility for the administration of the
Alliance HealthCard program including network development, marketing, and other
related activities.
1.2 Alliance shall maintain a current listing of all providers participating in
the Alliance network.
1.3 Alliance shall market the services of providers to HealthCard Members
through the issuance of directories and other materials identifying them as
participants in the Alliance network. Such directories will be made available
to HealthCard Members at the time of enrollment.
II. OBLIGATIONS OF NETWORK
2.1 Network will make best efforts to insure that its Providers shall provide
services and products to HealthCard Members that are standard and customary to
the practice or business in which its Providers are engaged.
2.2 Network agrees to accept as reimbursement for contracted services to
Alliance Members the reimbursement as outlined in Attachment A. These rates
shall be extended to all HealthCard Members who provide full payment at time of
service by cash, check or credit card. In applying these rates, Provider agrees
not to markup his or her usual fees prior to applying the negotiated rate or to
extend the rates to any individual whose participation as an Alliance Member has
expired.
2.3 Network shall make billing and other records relating to this Agreement
available to Alliance for inspection during normal working hours for up to two
(2) years after termination of this Agreement.
2.4 Network shall allow Alliance to use Network Provider names, addresses,
specialties and other relevant information in directories and other marketing
materials.
2.5 Network shall promptly notify Alliance of any changes in its business
address or any other problem that will materially impair the ability of Network
Providers to carry out the duties and obligations of this agreement.
III. WARRANTIES
3.1 Network warrants that the information contained in the Network Application
is accurate and complete and that Network is duly licensed, certified, and
authorized to deliver products and services in the state(s) where it conducts
business.
3.2 Network warrants that it is aware that the Alliance HealthCard program is
not a form of insurance and that Alliance is under no obligation to make any
payment to Provider for any services or products utilized by HealthCard Members.
IV. TERM AND TERMINATION
4.1 This Agreement shall commence on the date executed by Alliance. It shall
remain in effect for a period of one (1) year and shall thereafter
automatically renew for successive one-year terms.
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4.2 Either party may terminate this Agreement without cause with a 90 day
written notice or 60 day notice for a material breach. This Agreement shall
immediately terminate in the event that any license, certification or
authorization that is required for Network to engage in his or her usual and
customary business, is revoked, suspended or otherwise terminated. Alliance
reserves the right to terminate any individual Network Provider at any time
without cause.
V. MISCELLANEOUS PROVISIONS
5.1 This Agreement and any addenda constitute the entire Agreement between
Alliance and Provider with respect to matters contained herein and supersede all
prior Agreements or representations, written or oral, relating to the subject
matter hereof.
5.2 Any amendments to this Agreement shall be agreed to in writing by both
parties.
5.3 None of the provisions of this Agreement are intended to create, or shall
be deemed or construed to create, any relationship between the parties
hereto other than that of independent contractors. Neither of other
parties hereto, nor any of their respective directors, members, officers or
employees, shall act as or be construed to be the agent, employee or
representative of the other.
5.4 Either party may assign the Agreement in whole, or in part, with written
notification to the other party. Alliance retains the expressed right to lease,
sell, or assign its provider network under the terms of this Agreement.
5.5 Each party hereto agrees to indemnify and hold each other (including its
directors, members, officers, and employees) harmless against any and all
claims, damages, demands, liabilities and costs incurred by the other
party, including attorney fees, resulting from any act or omission by or
under the direction of the indemnifying party or its agents or employees
relating to the subject matter of this Agreement.
5.6 Both parties shall use their best reasonable efforts to resolve any dispute
arising under this Agreement before resorting to legal action thereafter. Where
a dispute cannot be resolved informally, the parties agree to bring the dispute
to the American Arbitration Association in the Atlanta office for resolution in
accordance with applicable rules and procedures. Arbitration decisions will be
considered binding and final.
IN WITNESS WHEREOF, the undersigned have executed this Agreement as of the date
and year indicated below.
PROVIDER ALLIANCE
_____________________________________ _______________________________
Signature Signature
_____________________________________ _______________________________
Title (if applicable) Title
_____________________________________ _______________________________
Date Date
_____________________________________
Tax ID#
THIS AGREEMENT is made and entered into by and between Alliance HealthCard Inc.,
a Georgia corporation, (hereinafter called "Alliance") and the contracting
provider identified in the Provider Application (hereinafter called "Provider").
WHEREAS, Alliance wishes to develop and market a network of contracted providers
that HealthCard Members can use to access health care services not covered by
health or other insurance;
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WHEREAS, Provider desires to participate in such network so that his or her
services may be marketed to HealthCard Members;
NOW THEREFORE, in consideration of the mutual promises and covenants set forth
herein, the parties agree as follows:
OBLIGATIONS OF ALLIANCE
1.1 Alliance shall assume overall responsibility for the administration of
the Alliance HealthCard program including network development, marketing,
and other related activities.
1.2 Alliance shall maintain a current listing of all providers
participating in the Alliance network.
1.3 Alliance shall market the services of providers to HealthCard Members
through the issuance of directories and other materials identifying them as
participants in the Alliance network. Such directories will be made
available to HealthCard Members at the time of enrollment.
OBLIGATIONS OF PROVIDER
2.1 Provider shall provide services and products to HealthCard Members that
are standard and customary to the practice or business in which Provider is
engaged.
2.2 Provider agrees to discount his or her usual fees to HealthCard Members
by the percentage specified below. The discount shall be extended to all
HealthCard Members who provide full payment at time of service by cash,
check or credit card. In applying the discount, Provider agrees not to
markup his or her usual fees prior to applying the discount or extend the
discount to any individual whose participation as a HealthCard Member has
expired.
Discount:_____%
2.3 Provider shall make billing and other records relating to this
Agreement available to Alliance for inspection during normal working hours
for up to two (2) years after termination of this Agreement.
2.4 Provider shall allow Alliance to use his or her name, address,
specialty and other relevant information in directories and other marketing
materials.
III. WARRANTIES
3.1 Provider warrants that the information contained in the Provider
Application is accurate and complete and that he or she is duly licensed,
certified, and authorized to deliver products and services in the state(s)
where he or she practices or does business.
3.2 Provider warrants that he or she is aware that the Alliance HealthCard
program is not a form of insurance and that Alliance is under no obligation
to make any payment to Provider for any services or products utilized by
HealthCard Members.
IV. TERM AND TERMINATION
4.1 This Agreement shall commence on the date executed by Alliance. It
shall remain in effect for a period of one (1) year and shall thereafter
automatically renew for successive one-year terms.
4.2 Either party may terminate this Agreement without cause with a 90 day
written notice or 60 day notice for a material breach. This Agreement shall
immediately terminate in the event that any license, certification or
authorization that is required for Provider to engage in his or her usual
and customary business, is revoked, suspended or otherwise terminated.
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V. MISCELLANEOUS PROVISIONS
5.1 This Agreement and any addenda constitute the entire Agreement between
Alliance and Provider with respect to matters contained herein and supersede all
prior Agreements or representations, written or oral, relating to the subject
matter hereof.
5.3 Any amendments to this Agreement shall be agreed to in writing by both
parties.
5.3 None of the provisions of this Agreement are intended to create, or
shall be deemed or construed to create, any relationship between the
parties hereto other than that of independent contractors. Neither of
other parties hereto, nor any of their respective directors, members,
officers or employees, shall act as or be construed to be the agent,
employee or representative of the other.
5.4 Either party may assign the Agreement in whole, or in part, with written
notification to the other party. Alliance retains the expressed right to lease,
sell, or assign its provider network under the terms of this Agreement.
5.5 Each party hereto agrees to indemnify and hold each other (including its
directors, members, officers, and employees) harmless against any and
all claims, damages, demands, liabilities and costs incurred by the
other party, including attorney fees, resulting from any act or omission
by or under the direction of the indemnifying party or its agents or
employees relating to the subject matter of this Agreement.
5.6 Both parties shall use their best reasonable efforts to resolve any dispute
arising under this Agreement before resorting to legal action thereafter. Where
a dispute cannot be resolved informally, the parties agree to bring the dispute
to the American Arbitration Association in the Atlanta office for resolution in
accordance with applicable rules and procedures. Arbitration decisions will be
considered binding and final.
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IN WITNESS WHEREOF, the undersigned have executed this Agreement as of the date
and year indicated below.
PROVIDER ALLIANCE
_____________________________________ ________________________________
Signature Signature
_____________________________________ ________________________________
Title (if applicable) Title
_____________________________________ ________________________________
Date Date
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