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Provider Participation Agreement Sample Contracts

Standard Contracts

IAC Ch 79, p.1
Provider Participation Agreement • June 30th, 2009
PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • February 14th, 2020

The purpose of this agreement is to allow participation in the Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program by the governmentally owned or operated provider, named above and hereinafter referred to as Provider, subject to the provider’s compliance with the requirements and responsibilities set forth in this agreement.

PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • October 5th, 2022 • Michigan

This Agreement is made by and between Blue Cross Blue and Shield of Michigan (BCBSM) and the undersigned Hearing Specialist (Provider) and is effective as of the date indicated in Section 4.1 of this Agreement.

PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • September 13th, 2019

The purpose of this Agreement is to allow participation in the Ground Emergency Medical Transportation Supplemental Reimbursement Program (GEMT program) by the governmentally owned or operated provider, named above and hereinafter referred to as Provider, subject to Provider’s compliance with the responsibilities set forth in this Agreement with the California Department of Health Care Services (DHCS), hereinafter referred to as the State or DHCS, as authorized in State law pursuant to section 14105.94 of the California Welfare and Institutions Code.

Section/Addendum Subject/Addendum Title
Provider Participation Agreement • September 20th, 2023
PROVIDER PARTICIPATION AGREEMENT Please review, sign page 5 and return to Laura Locicero at fax (516) 465-8002, or send a signed, scanned document to ciipa@nshs.edu.
Provider Participation Agreement • September 17th, 2020 • New York

THIS AGREEMENT, made by and between North Shore-LIJ Network, Inc. and its related IPA, North Shore-LIJ Clinical Integration Network IPA, LLC (the entities collectively shall be referred to as the “CIIPA”), and ___________________________________ (“Provider”) a Provider licensed to practice ________________________________ in the State of New York with an address at _________________________________, _______________________ is effective as of the date of its execution by CIIPA (“Effective Date”). This Agreement sets forth the terms under which Provider agrees to participate in CIIPA.

Home Energy Ratings Pilots Provider Participation Agreement
Provider Participation Agreement • April 3rd, 2020
Provider Participation Agreement
Provider Participation Agreement • October 8th, 2020 • New York

This FareHarbor Provider Participation Agreement (this “Agreement”) is a binding agreement between FareHarbor B.V., a Netherlands limited company (“FareHarbor”), and you, or if you are entering into this Agreement on behalf of an organization, the organization you represent (“Provider”). This Agreement governs your participation in the FareHarbor Distribution Network and is effective when you click “accept”. BY CLICKING “I ACCEPT”, YOU (A) AGREE TO PARTICIPATE IN THE FAREHARBOR DISTRIBUTION NETWORK AS A PROVIDER; (B) ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS AGREEMENT; (C) REPRESENT AND WARRANT THAT YOU HAVE THE RIGHT, POWER AND AUTHORITY TO ENTER INTO THIS AGREEMENT AND, IF YOU ARE ENTERING INTO THIS AGREEMENT FOR AN ORGANIZATION, THAT YOU HAVE THE AUTHORITY TO BIND THAT ORGANIZATION; AND (D) AGREE THAT YOU ARE BOUND BY THIS AGREEMENT’S TERMS. FAREHARBOR RESERVES THE RIGHT TO MODIFY OR AMEND THIS AGREEMENT FROM TIME TO TIME WITH 15 DAYS’ NOTICE (“Opt-out Period”). YOUR CONTIN

Michigan Homeowner Assistance Fund Michigan State Housing Development Authority Provider Participation Agreement
Provider Participation Agreement • January 21st, 2022

This Participation Agreement (Agreement) made this day of , 20 by and between the Michigan State Housing Development Authority (MSHDA) and

Provider Participation Agreement
Provider Participation Agreement • January 25th, 2022 • Colorado

This Provider Participation Agreement (“Agreement”) is entered into by and between the Colorado Department of Health Care Policy and Financing (“Department”), its Fiscal Agent for the Colorado Medical Assistance Program, and Provider (“Provider”),

Provider Participation Agreement
Provider Participation Agreement • August 30th, 2023

To receive federally funded Section 317 COVID-19 vaccines provided through the California Bridge Access Program at no cost, I agree to the following conditions, on behalf of myself and all the practitioners, nurses, and others associated with the health care location of which I am the medical director or equivalent.

PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • January 27th, 2015

The purpose of this Agreement is to allow participation in the Public Hospital Outpatient Services Supplemental Reimbursement Program by the governmentally owned provider, named above and hereinafter referred to as Provider, subject to Provider’s compliance with the responsibilities set forth in this Agreement with the California Department of Health Care Services (DHCS), hereinafter referred to as the State or DHCS, as authorized in State law pursuant to section 14105.96 of the California Welfare and Institutions Code.

Contract
Provider Participation Agreement • September 8th, 2023
Georgia Lions Lighthouse Foundation Hearing Aid Program Provider Participation Agreement
Provider Participation Agreement • October 8th, 2007
Provider Participation Agreements
Provider Participation Agreement • November 7th, 2024

California’s Medi-Cal program reimburses doula services for pregnant and postpartum individuals. Services may include prenatal and postpartum visits, as well services during labor and delivery, miscarriage, and abortion.

DH & THH TAX ID: 35-0593390
Provider Participation Agreement • February 9th, 2022

Allied National- (Joinder Agreements for only these groups, Meyer Trucking, Belt Tech, Bills Plumbing, Gudorf Supply, TSL Enterprises- Meyer Trucking, Home Mutual, Casey Electric, Roadhog, Don’s Automotive and Machine, Red Stitch, Bratco, Steinkamp Farms, Boonville Federal Saving Bank

EXHIBIT A
Provider Participation Agreement • February 14th, 2019
Contract
Provider Participation Agreement • September 22nd, 2021
THIS IS A SAMPLE. YOU WILL SIGN THIS WITH YOUR ONLINE REGISTRATION.
Provider Participation Agreement • August 17th, 2021
PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • April 21st, 2015 • New Mexico

THIS AGREEMENT IS FOR INDIVIDUAL APPLICANTS WHO PERFORM SERVICES WITHIN A GROUP OR OTHER ORGANIZATION. PAYMENTS WILL BE MADE ONLY TO THE GROUP OR ORGANIZATION. NO PAYMENTS WILL BE MADE DIRECTLY TO THE INDIVIDUAL IF THE APPLICANT WILL BE PROVIDING SERVICES FOR WHICH PAYMENTS ARE TO BE MADE DIRECTLY TO THE APPLICANT, THIS FORM SHOULD NOT BE USED. USE FORM MAD 335 INSTEAD. Return completed application to: New Mexico Medicaid Project XeroxP.O. Box 27460 Albuquerque, NM 87125-7460 (1) NM Medicaid Number (if previously assigned) (2) National Provider Identifier (NPI) (3) Primary Taxonomy (4) Applicant Name (for individuals – must match license name)First Name Middle Initial Last Name Professional Title (MD, DDS, etc) (5) Physical Street Address where services are rendered (PO BOX NOT ACCEPTED) City State Zip Code County (6) Billing Office Address(MAY BE PO BOX) City State Zip Code (7) Mailing Address for official correspondence (MAY BE PO BOX) City State Zip Code (8) Fax Number (9) Billing O

BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. NETWORKBLUE PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • July 27th, 2009 • Certified Diabetic Services Inc • Services-misc health & allied services, nec • Florida

THIS PARTICIPATION AGREEMENT (hereinafter referred to as “Agreement”) is made and entered into by and between the parties described in Section 1 of this Agreement.

Appendix I
Provider Participation Agreement • May 31st, 2022

Note: All those providers with a current Health First Colorado Provider ID number, or those providers submitting an application to become a Health First Colorado Provider MUST REVIEW AND ACCEPT the Provider Participation Agreement as part of the Online Enrollment process.

NOTICE OF AMENDMENT TO
Provider Participation Agreement • April 11th, 2018

WHEREAS, the parties have previously entered into a Provider Participation, Group Participation or Individual Participation Agreement and/or similar agreements to participate in the behavioral health network of Providers established by UBHIPA (collectively the “Agreements”);

Provider Participation Agreement
Provider Participation Agreement • November 5th, 2020

The purpose of this Provider Participation Agreement (PPA) is to permit qualified Local Educational Agencies (LEA) - Provider Type 55 to participate as providers (LEA Provider) of services under California’s Medicaid program (Medi-Cal). The mutual objective of the California Department of Health Care Services (DHCS) and the LEA is to improve access to needed services for children. This PPA sets out responsibilities relative to the LEA Provider’s participation in the LEA Medi-Cal Billing Option Program.

SPARKLE DENTAL PLAN PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • September 18th, 2020 • California

This Agreement includes and applies to all licensed dentists who are contracted with or employed by Dentist at each location Dentist submitted on application(s).

EDUCATION STUDENT ACCOUNTS FOR CHILDREN WITH DISABILITIES PROGRAM PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • January 20th, 2023

The Education Student Account for Children with Disabilities Program (“Program”) was established in 2021 by the North Carolina General Assembly to provide scholarships to certain students attending eligible nonpublic schools. The Program is administered by the State Education Assistance Authority (“Authority”) pursuant to Article 41 of Subchapter 10 of Chapter 115C of the North Carolina General Statutes, as may be amended from time to time. Providers, including providers of tutoring and teaching services that are approved by the Authority to provide services under the Program or practitioners or providers of educational therapies that are approved by the Authority to provide services under the Program (hereafter “Provider”) must comply with certain statutory and regulatory requirements. Proper execution of this Provider Participation Agreement (“Agreement”) is a prerequisite to a Provider’s participation in the Program. Funds for the scholarships are contingent each year upon appropria

NOTICE TO A PROVIDER THAT AGREEMENT WAS ACCEPTED
Provider Participation Agreement • October 26th, 2010

Your agreement for participation as a (identify type of provider) under the Medicare program has been accepted by the Centers for Medicare & Medicaid Services (CMS). Your effective date of Medicare participation is (date). Enclosed is one copy of the completed agreement for your records.

AMENDMENT TO OPTUMHEALTH CARE SOLUTIONS, LLC PROVIDER PARTICIPATION AGREEMENT FOR VA
Provider Participation Agreement • February 13th, 2019

OptumHealth Care Solutions, LLC (“OHCS”) and Provider are parties to a Provider Participation Agreement (the “Agreement”) under which Provider participates in OHCS’ network of participating providers.

Full-Time Private Tutoring Provider Participation Agreement 2023-2024
Provider Participation Agreement • August 2nd, 2023

This document must be signed by the individual providing the full-time private tutoring services. If another individual handles the administrative requirements for the full-time tutoring program for students and families participating in FES or FTC-PEP, they must also sign this document.

Section/Addendum Subject/Addendum Title
Provider Participation Agreement • October 20th, 2021
Provider Participation Agreement Form
Provider Participation Agreement • July 7th, 2022

IN WITNESS WHEREOF, the Parties hereto have executed this Participating Provider Agreement (Version 2022.1) on the date executed by the Authorized Signer below. The Effective Date is the first day of the month following execution.

PROVIDER PARTICIPATION AGREEMENT
Provider Participation Agreement • February 14th, 2020

The purpose of this Agreement is to allow participation in the Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program by the governmentally owned or operated provider, named above and hereinafter referred to as Provider, subject to the Provider’s compliance with the requirements and responsibilities set forth in this Agreement.

New Hampshire Medicaid Program
Provider Participation Agreement • April 9th, 2020
Contract
Provider Participation Agreement • September 23rd, 2022
Contract
Provider Participation Agreement • September 8th, 2023