THREE RIVERS PROVIDER NETWORK AGREEMENT WITH
Exhibit 10.2
THREE RIVERS PROVIDER NETWORK
AGREEMENT WITH
______________________________
This Agreement is made this _____ day of ____________ 2010, by and between Three Rivers Provider Network, Inc., a Nevada Corporation (“TRPN”) and Sugar Land 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 follows.
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 two (2) 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.
7. Final Agreement: All terms and conditions agreed upon by the parties are contained in this Agreement. All prior negotiations, promises, agreements and representations, either spoke or written concerning the subject matter of this Agreement that are not set forth herein are null and void and have no bearing on this Agreement.
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*
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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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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 SPECIALIST | ||||
| SUGAR LAND SA SERVICES | THREE RIVERS PROVIDER NETWORK |
| Signature: |
/s/ Xxxxx Xxxx
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Signature: |
/s/ Xxxx Xxxxxxx
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||
| Title: |
Chief Operating Officer
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Name: |
Xxxx Xxxxxxx, C.O.O.
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| Date: |
12/2/2010
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Mailing Address: |
000 Xxxx Xxxxx, Xxxxx 000
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| Xxxxx Xxxxx, XX 00000 | |||||
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Phone: (000) 000-0000
Date: 12/8/2010
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ATTACHMENT A: PROVIDER INFORMATION
(Please attach a roster of all Providers that will be participating under this Agreement, use Addendum A)
| Last Name: | Group/Practice Name: | Sugar Land SA Services | ||
| First Name: | Primary Address: | X.X. Xxx 000, | ||
| Xxxxx, XX 00000 | ||||
| Tax ID: | 00-0000000 | |||
| County: | Xxxxxx | |||
| National Provider Identifier (NPI): | Phone: | (000) 000-0000 Fax: (000) 000-0000 | ||
| 0000000000 | Email: xxxxxxxxx@xx.xxx | |||
| (If there is more than one NPI Number, please attach a listing.) | ||||
| Other Practice and/or Billing Address: Yes □ / No □ | ||||
| Specialty: | LSA, CSA, SA-C, CST/CFA, CRNFA, RN, CNOR | If “yes”, attach page with additional information | ||
| Subspecialty: | Surgical Assistant |
Hospital Affiliations (list name, date and type):
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| First Assistant | ||||
Provider agrees to xxxx “N/A” next to any blank that is not applicable to Provider’s business.
ADDENDUM A:
PROVIDER LISTING & FACILITY LOCATIONS
_______________________________
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i.
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The attached roster of providers and or locations will be participating under this Agreement between Sugar Land SA Services and Three Rivers Provider Network and shall include Tax Identification Numbers, NPI Numbers, Address(s), Phone and Fax Numbers.
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Provider List
12/2/2010
| Name | Credentials | License Number |
| National Provider Identifier | ||
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XXXXX, XXXXX A
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CSA
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0000
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XXXXXXXXX, XXXXXX X
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XXX
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XX00000
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DARWISHS-XXXXXX, XXXXXXX
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LSA
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SA00315
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XXXXXX, XXXX
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LSA
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SA00073
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LARA, ATAHUALPA
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SA-C
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00-000
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XXXXXX, XXXXXXX
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XXX
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XX00000
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ABORDO, BELTRAN
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LSA
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SA00024
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XXXXXXXXXXX, XXXXX
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LSA
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SA00237
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XXXXX, XXXXX
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NP-C
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F0510035
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ZHONG, XXXX XXXX
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LSA
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SA00158
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XXXXXXX, XXXXXX
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XXX
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XX00000
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XXXXXX, XXXXXXXX
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SA-C
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09-165
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XXXXXXXX, XXXXXXXXX
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CSA
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X000
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XXXXXX-XXXXXXX, XXXXXX
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XXX
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XX00000
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NINA-WOSU, CHI
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LSA
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SA00085
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PITTY, XXXXXXXX
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LSA
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SA00279
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1
Provider List
12/2/2010
| Name | Credentials | License Number |
| National Provider Identifier | ||
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XXXXXXX, XXXXX R
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SA-C
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06-177
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XXXXX, XXXXX
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SA-C
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00-000
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XXXXXX, XXXXXX
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XXX
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XX00000
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XXXXXXXX, XXXX
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CSA
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00000
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XXXXXX, XXXXX X
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XXX
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XX00000
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XXXXXXXXX, XXXXXXXX
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XXX
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XX00000
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XXXXXX, XXXXXXX
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CST/CFA
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88303
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XXXXXX, XXXXXXX
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LSA
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SA00270
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XXXXXXXXX, XXXXXXX
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XXX
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XX00000
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XXXXX, XXXXXXXX
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CST/CFA
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119805
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XXXXXX, XXXXXX
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LSA
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SA00335
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XXXXXXX, XXXX
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LSA
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SA00289
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XXXXX, XXXXX K
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RN
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081124
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XXXXXX, XXXXXXX N
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CST,CFA
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114315
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XXXXXXX, XXXXX
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CSA
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00-000
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|
XXX, XXXXXX
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XXX
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XX00000
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2
Provider List
12/2/2010
| Name | Credentials | License Number |
| National Provider Identifier | ||
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XXXX, XXXX
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LSA
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SA00329
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XXXXX-XXXX, XXXXXXXX
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LSA
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SA00191
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XXXXXX, XXXXX
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LSA
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SA00304
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XXXXX, XXXX
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XXX
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XX00000
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CONSECO, XXXX
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LSA
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SA00110
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XXXXXX, XXXX XXXXXX
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SA-C
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09136
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XXXXX, XXXXX
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LSA
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SA00324
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XXXX, XXXXX A
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XXX
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XX00000
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XXXXXXX, XXXXXXX
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XXX
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XX00000
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XXXXXXX, XXXXX
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CST/CFA
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111677
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XXXXXXXX, XXXXX
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CST/CFA
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109194
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PITA, KLEBER
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LSA
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SA00274
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XXXXX, XXXXX
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CSA
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00-000
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XXXXXXX, XXXXXXXX
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XXX
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XX00000
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XXXXXXX, XXXXX
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LSA
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SA00138
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XX, XXXXX
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LSA
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SA00336
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3
Provider List
12/2/2010
| Name | Credentials | License Number |
| National Provider Identifier | ||
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ALALAM, MOHD
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LSA
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SA00309
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XXXXXX, XXXX
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LSA
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SA00029
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XXXXXXXX, XXXXXXXX
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XXX
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XX00000
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XXXXXXX, XXXX
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SA-C
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07272
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XXXX, XXXXX
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LSA
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SA00119
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XXXX, XXXXX E
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CSA
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00-000
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XXXXX, XXXXXXX
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XXX
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XX00000
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XXXX, XXXXXXX
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LSA
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SA00346
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MAYOR, XXXXXXX
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XXX
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XX00000
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XXXXXXXXX, XXXXXX
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CSA
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0000
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XXXXXXXXX, XXXXX
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XXX
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XX00000
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NASGAR, NAYEF
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LSA
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SA00135
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AKUPUE, OKECHUKWU
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LSA
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SA00307
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XXXXXXXX, XXXX
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XXX
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XX00000
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XXXXXX, XXXXXXXXX
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SAC
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00-000
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XXXXXXXX, XXXXXX
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XXX
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XX00000
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4
Provider List
12/2/2010
| Name | Credentials | License Number |
| National Provider Identifier | ||
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XXXXXXXX, XXXXXXXX
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LSA
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SA00156
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XXXXXXX, XXXXX
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CSA
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08120
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BABURI, OASIM
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LSA
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SA00160
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XXXXXX, RECTO
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LSA
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SA00954
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XXXXX, XXXX
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LSA
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SA00170
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XXXXXXX, XXXXXX
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CSA
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3457
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XXXXXXX, XXXX
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LSA
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SA00129
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XXXXXX, XXXXXX
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SA-C
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07252
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XXXXXXXXXX, XXXXXXX
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LSA
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SA00249
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XXXXXXXX, XXXXX
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LSA
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SA00056
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XXXX, XXXXX
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XXX
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XX00000
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DEVI, XXXXXXX
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XX-X
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00-000
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XXXX, XXXXX
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XXX
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XX00000
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XXXXXX, XXXXXXX
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SA-C
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00-000
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XXXXXXX, XXXXXX
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XXX
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XX00000
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XXXXX, XXXXX
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LSA
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SA00090
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5
Provider List
12/2/2010
| Name | Credentials | License Number |
| National Provider Identifier | ||
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XXXXXXXX, XXXXXXX
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SA-C
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00-000
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XXXXXX, XXXXXXXXX
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XXX
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XX00000
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XXXXXX, XXXXXXX
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LSA
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SA00161
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XXXX, VIRGINIA
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LSA
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SA00325
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XXXXXX, XXXXXX
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LSA
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SA00330
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XXXXX, XXXXXXX
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XXX/XXX
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000000
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XXXXXXX, XXX
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LSA
|
SA00011
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