Exhibit 6.3 Form of Provider Agreement
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;
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:
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 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.
35
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.
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.
5.4 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
36
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
37
