EXHIBIT 10.3
MEDSERV IPA, INC.
PHYSICIANS CARE FOR CONNECTICUT, INC.
PRIMARY CARE PHYSICIAN ATTACHMENT
I, ____________________, with a principal business address at
_____________ __________________________, acknowledge that I am a
participating provider in MedServ IPA, Inc. ("MedServ IPA"), and I agree as
follows:
1. I agree to be a participating provider in all Physicians Care for
Connecticut, Inc. ("Physicians Care") products for which MedServ IPA and its
participating physicians and Physicians Care share financial risk under the
terms of the [NETWORK/INSURER AGREEMENT] dated as of [DATE]. I agree to be
bound by all terms and conditions of such Agreement.
2. Recognizing that I must elect to participate in any Physicians Care
product for which I will be paid on a fee-for-service basis without
financial risk (the "Non-Risk Products"), the following constitutes my
election:
_____ I will participate in Non-Risk Products.
_____ I will not participate in Non-Risk Products.
3. I agree:
(i) to assume responsibility for the total management of the health
care of any Enrollee who has designated me as their Primary Care
Physician under any Physicians Care product requiring selection
of a Care Manager
(ii) to provide Enrollees regular preventative health examinations and
services (E.G., immunizations, hypertension screening) as
recommended by MedServ IPA and Physicians Care; and
(iii) to offer Enrollees such health education as deemed appropriate
pursuant to MedServ IPA and Physicians Care guidelines.
4. I shall maintain an open panel of patients; provided, however, that
my practice may be closed provided that it is closed to enrollees of all
managed care payors with whom I contact and for all products offered by such
payors. In the event that I do close my panel, I may accept immediate family
members of existing patients or patients with whom I have had a pre-existing
relationship in the immediately preceding thirty-six (36) months.
IN WITNESS WHEREOF, the undersigned have set their hands and seals this
___day of _________, 1997.
PHYSICIANS CARE FOR
CONNECTICUT, INC.
--------------------------------------------- ---------------------------------------------
By: Physician
MEDSERV IPA, INC.
PHYSICIANS CARE FOR CONNECTICUT, INC.
SPECIALTY PHYSICIAN ATTACHMENT
I, ______________, with a principal business address at ____________________
__________________________, acknowledge that I am a participating provider
in MedServ IPA, Inc. ("MedServ IPA"), and I agree as follows:
1. I agree to be a participating provider in all Physicians Care for
Connecticut, Inc. ("Physicians Care") products for which MedServ IPA and
its participating physicians share financial risk pursuant to the terms of
the [NETWORK/INSURER AGREEMENT] dated as of [DATE]. I agree to be bound by
all terms and conditions of such Agreement.
2. Recognizing that I must elect to participate in any Physicians Care
product for which I will be paid on a fee-for-service basis without
financial risk (the "Non-Risk Products"), the following constitutes my
election:
_____ I will participate in Non-Risk Products.
_____ I will not participate in Non-Risk Products.
3. I shall maintain an open panel of patients; provided, however, that
my practice may be closed provided that it is closed to enrollees of all
managed care payors with whom I contact and for all products offered by such
payors. Notwithstanding the foregoing, in the event that I do close my
panel, I may accept immediate family members of existing patients or
patients with whom I have had a pre-existing relationship in the immediately
preceding thirty-six (36) months.
IN WITNESS WHEREOF, the undersigned have set their hands and seals this
___day of _________, 1997.
PHYSICIANS CARE FOR
CONNECTICUT, INC.
--------------------------------------------- ---------------------------------------------
By: Physician
