FORM OF BILLING AND CLAIMS PROCESSING SERVICES AGREEMENTBilling and Claims Processing Services Agreement • April 22nd, 2011 • Targeted Medical Pharma, Inc. • Blank checks • California
This Billing and Claims Processing Services Agreement (the “Agreement”) is made this _____ day of _____________, 20___ (the “Effective Date”) by and between ____________________________, M.D., an individual resident of the State of ___________________ (“Physician”), practicing at: ______________________________________________________ and Targeted Medical Pharma, Inc., a Delaware corporation (“TMP”), with offices at 2980 Beverly Glen Circle, Suite 301, Los Angeles, California 90077.
COMPLETE CLAIMS PROCESSING, INC. FORM OF BILLING AND CLAIMS PROCESSING SERVICES AGREEMENTBilling and Claims Processing Services Agreement • April 22nd, 2011 • Targeted Medical Pharma, Inc. • Blank checks • California
This Billing and Claims Processing Services Agreement (the “Agreement”) is made this _____ day of _____________, 20___ (the “Effective Date”) by and among ____________________________, M.D., an individual resident of the State of ___________________, doing business as ______________________________at __________________________________________________ (“Physician”), Complete Claims Processing, Inc., a Delaware corporation (“CCPI”), with offices at 2980 Beverly Glen Circle, Suite 301, Los Angeles, California 90077 and Targeted Medical Pharma, Inc., a Delaware corporation (“TMP”), with offices at 2980 Beverly Glen Circle, Suite 301, Los Angeles, California 90077.
