Client MCAP Consent Form

Client MCAP Consent Form

Parties

Client Name:

Provider Name:

Recitals

WHEREAS, Client named above elects to participate in the Managed Client Assistance Program (MCAP) for the purpose of receiving administrative, financial and coordination services related to the client’s account and related activities; and

WHEREAS, Provider is engaged in the business of administering MCAP services and requires Client's written consent to perform program activities, to obtain and share information necessary for program administration, and to accept payment authorizations from Client; and

WHEREAS, the parties desire to set forth the terms under which Provider will perform MCAP services and Client will provide consents and authorizations to enable Provider to act on Client's behalf.

Scope of Work

Payment Terms

Total Fee / Compensation: $ payable as provided below.

Late Payment Fee: on any unpaid balance after days.

Client authorizes Provider to charge a credit/debit card on file for amounts due.

Client authorizes electronic funds transfer (ACH) or bank debit for payments.

Client consents to reasonable deductions or offsets permitted by this Agreement to satisfy unpaid balances.

Term and Termination

Effective Date:    Termination Date:

Either party may terminate this Agreement without cause by providing written notice at least days prior to the intended termination date. Provider may immediately suspend services for nonpayment or material breach, and either party may terminate for material breach if the breach is not cured within thirty (30) days following written notice.

Client Consents and Authorizations

By signing below, Client grants Provider express and voluntary consent to: (a) collect, use, and disclose Client information to third parties as necessary to administer MCAP services; (b) obtain records and information from financial institutions, payors, third-party vendors, or other entities where reasonably necessary to perform services; and (c) communicate with Client’s designated representatives. Such disclosures will be limited to information reasonably necessary for administration, payment, and reporting.

Specific consents (initial where applicable):

Consent to information sharing for program administration.

Consent to payment authorization and billing actions described above.

Consent to release limited information to third-party service providers engaged by Provider.

Confidentiality

Each party shall maintain as confidential and shall not disclose to any third party any Confidential Information (as defined below) of the other party except as expressly permitted by this Agreement or required by law. "Confidential Information" means nonpublic business, financial, technical, personal, and medical information disclosed in connection with MCAP services. Confidential Information does not include information that: (i) is or becomes publicly known through no breach of this Agreement; (ii) is developed independently by the receiving party without use of the disclosing party's confidential information; or (iii) is received from a third party without restriction and without breach of any obligation of confidentiality.

The receiving party will use commercially reasonable measures to protect Confidential Information, and will limit access to employees or contractors with a need to know and who are bound by confidentiality obligations at least as protective as those in this Agreement. Upon termination or written request, Confidential Information (and copies) shall be returned or destroyed, except where retention is required by law or for legitimate business recordkeeping consistent with confidentiality obligations.

Limitation of Liability

Except for liabilities arising from gross negligence or willful misconduct, neither party shall be liable to the other for consequential, incidental, special, or punitive damages. Provider's aggregate liability for claims arising out of or related to this Agreement shall not exceed the total fees paid by Client to Provider under this Agreement during the six (6) months preceding the event giving rise to liability.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of without regard to conflict of laws principles. Venue for any dispute shall be in the courts of that jurisdiction.

Entire Agreement

This Agreement, including any exhibits or schedules attached hereto and any written statements of scope or payment schedules signed by the parties, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, proposals, and communications, whether oral or written. Any amendment to this Agreement must be in writing and signed by both parties.

Notices

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