Billing Form

Medical or Dental Billing Services Agreement

Agreement made on the , between , a corporation organized and existing under the laws of the state of , with its principal office located at , referred to herein as Medical Billing, and , a professional association organized and existing under the laws of the state of , with its principal office located at , referred to herein as Client.

Whereas, Medical Billing is a healthcare claims processing and services company and is a healthcare provider; and

Whereas, Medical Billing provides computerized claims, billing and collection services to healthcare providers and files medical insurance claims on behalf of healthcare providers with government and commercial companies by electronic and paper means, and also provides for billing services directly to patients or for patient's portion of healthcare provider fees not covered by insurance; and

Whereas, Client desires to retain Medical Billing to provide it with such claims and billing services pursuant to this Agreement;

Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:

1. Commencing on , Medical Billing will process all the Client's medical insurance claims for payment by government and commercial companies by either electronic or paper means and make available all information necessary to properly process the Client's claims and to submit all such billing and insurance information to the appropriate party (e.g., daily, weekly, etc.) . Medical Billing will process and submit all Clients’ claims within hours by electronic means wherever possible, and by paper means when otherwise necessary.

2. Medical Billing will provide to Client a direct fax number, through which Client will provide to Medical Billing claims and billing information necessary for Medical Billing to properly process Client's claims.

3. All patient information and data provided by the Client to Medical Billing shall be kept confidential and shall not be disclosed to anyone outside of Medical Billing other than to the extent necessary for Medical Billing to process and submit claims for the Client.

4. Neither Medical Billing nor Client will disclose the contents, terms or conditions of this Service Agreement to any third party without the express written consent of the other.

5. Client will pay Medical Billing a one-time setup fee of $ to cover the cost of gathering information from the Client and setting up the Client's files for entry into computer system. The information and initial setup covered by this initial fee includes, but is not limited to:

• Doctor Profile;

• Listing of Current Insurance Companies Used;

• Referring Physicians;

• Facilities at Which Doctor is Accepted or Transfers Work;

• Diagnostic Codes;

• Procedure Codes and Fees;

• Signed Patient Registration Forms (to be kept in Client's office); and

• Registration with Clearinghouse which will distribute claims to the carriers.

6. Client will pay to Medical Billing % of the total (gross) amount collected from all insurance companies and all patients as a result of the billing services performed by Medical Billing for Client, with a $ monthly minimum billed amount. Client agrees to provide copies of all Explanation of Benefits (EOB) forms received from insurance payers to Medical Billing as well as records of payments received directly from patients (e.g., weekly) . Medical Billing shall post the payments received from the insurance payers to the patient's file, shall file any secondary or tertiary claims, and shall bill the patient directly when necessary in order to secure full payment for the Client.

7. Medical Billing shall provide to Client management reports regarding the practice on a timely basis. The types of Monthly Management Reports shall include the following:

• Insurance Aging Report – monthly;

• Patient Aging Report – quarterly;

• Practice Analysis – monthly;

• Other(s)

8. Medical Billing will close its books for billing purposes on the last day of each month and will bill Client for its services on the business day of each succeeding month for the previous month's processing. Client will pay Medical Billing for its services upon receipt of receiving Medical Billing's invoice. If Client fails to submit payment within the time set forth in this Paragraph, Client will be responsible for paying, in addition to the principal amount billed, a % per month late charge for each month or any portion thereof payment of the billing is late.

9. During the term of this Service Agreement, Client will not use the services of any other claims processing companies and will allow Medical Billing to process all of the Client's medical insurance claims with the government and commercial companies.

10. Either party may terminate this Service Agreement at any time by providing a thirty (30) day written notice with explanation or reason why termination is desired to the other party.

11. Medical Billing will be serving as a conduit of information and claims data between Client and many insurance payers, both government and commercial. Client will be providing all such claims information and data to Medical Billing, including but not limited to procedure codes, identifying the exact procedures Client has performed on patients. Client verifies that all such procedures were in fact performed on the patients as specified. Medical Billing has no authority to and will not change any of these procedure codes without the express permission and direction of Client.

12. Client understands that Medical Billing is relying entirely on the claims and billing information supplied to Medical Billing by Client in preparing and submitting insurance claims for payment on behalf of Client. Client warrants and represents that all such claims and billing information is entirely accurate and truthful. If any investigation is initiated or if any action is brought by any individual, company or entity whatsoever regarding any of the claims filed by Medical Billing on behalf of Client, then Client agrees to cooperate fully in any such investigation or action and shall provide all relevant supporting documentation to support the claim(s) filed.

13. Client understands that Medical Billing will not provide insurance pre-authorizations.

14. Client agrees to indemnify and hold Medical Billing harmless for any and all damages or penalties imposed and any attorney’s fees incurred by Medical Billing in defending any such action resulting from Client's failure to provide truthful and accurate billing and claims information to Medical Billing.

15. Severability

The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision.

16. No Waiver

The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred.

17. Governing Law

This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of .

18. Notices

Any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement.

19. Attorney’s Fees

In the event that any lawsuit is filed in relation to this Agreement, the unsuccessful party in the action shall pay to the successful party, in addition to all the sums that either party may be called on to pay, a reasonable sum for the successful party's attorney fees.

20. Mandatory Arbitration

Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect.

21. Entire Agreement

This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement.

22. Modification of Agreement

Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party.

23. Assignment of Rights

The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party.

24. In this Agreement, any reference to a party includes that party's heirs, executors, administrators, successors and assigns, singular includes plural and masculine includes feminine.

WITNESS our signatures as of the day and date first above stated.