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EXHIBIT 10.4
PROVIDER AGREEMENT
PART I
THIS AGREEMENT is made the ________ day of _____________________________, 200__,
by and between ___________________________________________________________, with
its principle place of business at
________________________________________________________________, hereinafter
referred to as ""Provider, and Eye Care International, Inc. (ECI) with its
principle place of business at 0000 X. Xxxxxxxxx Xxxx., Xxxxx 000, Xxxxx,
Xxxxxxx 00000.
RECITALS
WHEREAS, ECI markets a national vision plan Network consisting of, among others,
ophthalmologists providing ECI patient members with the highest quality of
ophthalmic services at reasonable prices; and WHEREAS, ECI and Provider desire
to enter into an agreement whereby ECI will refer to Provider ECI members and
participants located in the Providers geographical area; NOW THEREFORE, in
consideration of the mutual covenants contained herein, the parties agree as
follows:
DUTIES OF PROVIDER
1. Provider agrees to provide medical and surgical services and products (if
applicable) to all ECI members and participants (collectively called members) at
prices set forth below. ECI shall not serve as insurer, guarantor or underwriter
with respect to members' responsibility for payment for services or goods.
2. Provider understands that ECI may enter into agreements with patient groups
providing for third party payment of Providers fees. Provider agrees to xxxx the
member via either ECI or a designated payer for services (and products, if
applicable - see Part II) rendered to the member.
3. Provider is responsible for billing and collections. Provider shall charge
ECI non-Medicare patients 80% of the Medicare approved fees applicable to
Providers location. For procedures not usually covered by Medicare, ECI members
are to be charged 20% below your usual and customary fees. Medicare patients
should be billed in accordance with your usual billing practices.
QUALITY ASSURANCE
Provider agrees that he or she shall complete and return to ECI quality
assurance questionnaires which may be forwarded to the Provider by ECI.
LICENSES
Provider agrees to maintain all appropriate licenses required to conduct
business, including malpractice insurance of not less than one-million dollars,
and to otherwise conduct himself/herself in a manner consistent with the ethics
of the medical profession. If requested, Provider agrees to provide ECI with
proof of insurance coverage.
IDENTIFICATION OF PROVIDER AS PARTICIPATING IN THE ECI NETWORK
Provider hereby grants ECI the right to use his or her name, specialist
certifications, business ads and telephone number for purposes of informing the
ECI members (including sales efforts) and prospective members of the identities
of the participating providers and for otherwise carrying out the terms and
intents of this Agreement.
CONSIDERATION
PROVIDER WILL HAVE NO FINANCIAL OBLIGATION TO ECI.
TERM OF AGREEMENT
This Agreement shall be effective for a three (3) year period, commencing on the
date that this Agreement is signed by ECI. Unless terminated, this Agreement
shall be automatically renewed for successive yearly periods. This Agreement may
be terminated by either party immediately by reason of a material breach by the
non-terminating party.
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ENTIRE AGREEMENT
The Agreement contains the entire understanding between the parties.
AGREEMENT NOT EXCLUSIVE
Either party may enter into other similar agreements for performance of similar
services; except that the Provider agrees that during for so long as this
Agreement is in effect, and for a six (6) month period thereafter, he or she
shall not join a providers national network servicing an entity the same as or
similar to ECI; i.e., a non-insurance based national network of ophthalmologists
offering medical services based on a RBRVS fee schedule (or a comparable
schedule). Specifically excluded from the foregoing restrictions is any national
insurance carrier, HMO, PPO or substantially similar type plan.
CONFIDENTIALITY
Provider agrees not to divulge the compensation, fees, rates and charges subject
to this Agreement. Each party agrees on behalf of itself, its affiliates,
officers, agents and employees that it will not, directly or indirectly,
communicate, divulge or use for its own benefit, or for the benefit of any other
person, or legal entity, any information or data concerning marketing, finances,
methods, patients, contacts, operations, membership or any other information
acquired or learned through the other. This provision shall survive the
termination or expiration of this Agreement.
NOTICE
Any notice pertaining to the Agreement must be in writing, addressed to the
party to be notified, postage prepaid and registered or certified with return
receipt requested sent to the address of the respective parties herein set
forth.
GOVERNING LAW
THIS AGREEMENT IS MADE IN THE COUNTY OF PINELLAS, STATE OF FLORIDA, AND SHALL BE
CONSTRUED AND INTERPRETED IN ACCORDANCE WITH THE LAWS OF THE STATE OF FLORIDA.
IF ANY OF TERMS OF THIS AGREEMENT DIFFER OR CONFLICT WITH ANY FEDERAL OR LOCAL
LAWS, THE FEDERAL OR LOCAL LAWS SHALL PREVAIL AND THE CONFLICT PROVIDER
AUTOMATICALLY HEREIN SHOULD BE DEEMED STRICKEN.
FREE EYE EXAM PROGRAM: ECI members receive a certificate for one FREE EYE EXAM
per family membership each year (excludes exams for contact lenses). A condition
of this feature is that the initial prescription, if needed, must be filled at
the provider location performing the exam (if you dispense). All other family
members will pay the exam fee as provided for in this agreement. Please check
one of the options below:
____ Please include us in the participating provider list that
refers members to us for one free eye exam per family
membership in the ECI vision plan.
____ Please do not include me in the free eye exam program.
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PROVIDERS AND LOCATIONS
Primary Office Location:
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Address:
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City: State: Zip:
------------------------------------------- ----------- ---------
Telephone Office Hours:
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List below all office locations, including zip codes that you would like listed
in our computer directory, and the names of all providers servicing your
practice for purposes of patient referrals.
PROVIDERS NAME OFFICE LOCATION
----------------------------- --------------------------------------------
----------------------------- --------------------------------------------
(IF ADDITIONAL SPACE IS NEEDED, PLEASE LIST ON A SEPARATE SHEET OF PAPER AND
ATTACH TO THIS AGREEMENT.)
Complete all categories that apply to your office(s):
I. NUMBER OF II. SURGICAL PROCEDURES III. EXAMINATIONS/DISPENSING
--------- ------------------- -----------------------
YES NO YES NO
____ M.D' s __ __ Cataract/Corneal/Glaucoma __ __ Eyeglass Exams
____ O.D' s __ __ Oculoplastics __ __ Contact Lens Exams
____ Opticians __ __ Pediatric Surgery __ __ Dispense Eyeglasses
__ __ Retinal/Vitreal __ __ Dispense Contact Lenses
__ __ RK/ALK Surgery
__ __ Excimer Laser
PLEASE LIST LANGUAGES, OTHER THAN ENGLISH, THAT YOU AND/OR YOUR PROFESSIONAL
STAFF SPEAK.
I SPEAK MY STAFF SPEAKS LEVEL OF FLUENCY
------- --------------- ----------------
------------------------ ------------------------- ------------------------
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NOTE: IF YOU DISPENSE, PLEASE COMPLETE PART II OF THIS AGREEMENT; IF NOT,
PLEASE CHECK HERE .
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PLEASE BE SURE TO SIGN THIS AGREEMENT ON PAGE 4.
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PART II
ROVIDERS WHO DISPENSE EYE WEAR
1. Pricing and dispensing fees shall be as listed on PRICE SCHEDULE 1, or
your current sale price, if lower.
2. Prices on contact lenses (disposables not included), non-prescription
sunglasses, and all other sundry items shall be offered at a 20% discount
off established retail.
3. PROVIDER agrees that, except in the case of the Free Eye Exam program, it
will release to Program Members their eyewear prescription resulting from
an examination.
4. PROVIDER will honor a 30-day unconditional guarantee to Program Members by
refunding their money if for any reason they return their glasses or
contacts within 30 days from the date of purchase. Exams are not included
in the guarantee.
5. PROVIDER shall warrant and guarantee the satisfaction of the products and
services sold to ECI Members consistent with industry standards and other
guarantees otherwise offered by PROVIDER.
SIGNATURE
I (the individual eye care/eye wear {if applicable} provider or authorized
company officer) hereby applies for membership.
Authorized by: Authorized by Eye Care International, Inc.
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Name and title (signature) Name and title (signature)
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Print name Acceptance Date
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EYE CARE INTERNATIONAL, INC.
PRICE SCHEDULE 1
DISPENSING FEE (PER PAIR):
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Single Vision.................................. $30.00 Cataract or other specialty lenses.................$50.00
Bifocal........................................ 35.00 Frame only........................................ 15.00
Trifocal....................................... 40.00 Lenses only.................1/2the regular dispensing fee
Progressive.................................... 50.00
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GLASS AND PLASTIC LENSES:
Edged and Assembled for ZYL frames
Sphere PL to +/-400
Cylinder .025 to -400 (For higher powers add $1.00 per lens, per diopter)
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Per Pair Per Pair
Single Vision...................................$19.95 Executive Bifocal....................................$39.95
Bifocal (25, 28, RD)............................ 34.95 Executive Trifocal....................................54.95
Trifocal (25, 28)............................... 46.95 Blended Bifocal.......................................52.95
Bifocal (35).................................... 39.95 Progressive.......................................... 73.95
Trifocal (8X35)................................. 54.95 Varilux...............................................85.95
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ADDITIONAL CHARGES PER PAIR:
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SINGLE VISION BIFOCAL TRIFOCAL PROGRESSIVE
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Oversize 56 Eye Size and Over $ 7.00 $ 10.00 $ 10.00 $ --
FDA Hardening and Testing 4.00 4.00 4.00 4.00
Prescribed Prism (.25 to 3.00) 4.00 4.00 4.00 4.00
TINT:
Glass: Rose 1 & 2 6.00 9.00 10.00 --
Green & Xxxx 2 & 3 6.00 9.00 10.00 --
Plastic: all solid 7.00 7.00 7.00 7.00
Plastic: single gradient 9.00 9.00 9.00 9.00
Plastic: double gradient 11.00 11.00 11.00 11.00
UV 400 9.00 9.00 9.00 9.00
Photochromic 11.00 19.00 24.00 24.00
Transitions 53.00 66.00 66.00 66.00
Factory Scratch Coat 12.00 14.00 14.00 --
Polycarbonate 14.00 18.00 33.00 40.00
Lite Style 25.00 29.00 44.00 51.00
Ultra Litestyle 33.00 37.00 52.00 59.00
High Index 40.00 48.00 48.00 48.00
Wire Mounting 4.00 4.00 4.00 4.00
Rimless Mounting 8.00 8.00 8.00 8.00
Edge & Mount Half Eye 7.00 -- -- --
Polish Edges 8.00 8.00 8.00 8.00
Over 3.00 Add -- 9.00 9.00 9.00
Multi-Layered AR Coating 29.95 29.95 29.95 29.95
Mirage 2000 32.95 32.95 32.95 32.95
FRAMES:
Charge current FRAMES or FRAME FAX price. If the frame is not listed in either
aforementioned periodicals, charge acquisition cost.
OTHER ITEMS:
CONTACT LENSES (disposables not included), NON-PRESCRIPTION Sunglasses: give a
20% discount off your established retail price. ALL OTHER ITEMS NOT LISTED (i.e.
sundry items), give 30% off your established retail price.
NOTE: IF PROVIDER'S ACQUISITION COST OF FRAMES AND/OR LENSES IS HIGHER THAN THE
SCHEDULE, CHARGE THE ACQUISITION COST.
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