Fill and Sign the Contract Medical Service Form

Contract with Medical Management Consulting Service Agreement made on the ___________________________________ (date) , between ____________________________________________ (Name of Professional Corporation) , a professional corporation organized and existing under the laws of the state of ______________________, with its principal office located at ________________________ ___________________________________________________________________________ (street address, city, county, state, zip code) , referred to herein as CLIENT , and ________________________________________ (Name of Consultant) , a corporation organized and existing under the laws of the state of __________________, with its principal office located at _____________________________________________________________ ______________________________________ (street address, city, county, state, zip code) , referred to herein as Consultant . 1. Consultation Services By this Agreement, the CLIENT employs the Consultant to perform the services described in Exhibit A attached hereto and made a part hereof. The Consultant will consult with the officers and employees of the CLIENT concerning matters relating to the management and organization of the CLIENT , their financial policies, the terms and conditions of employment, and generally any matter arising out of the business affairs of the CLIENT 2. Term This Agreement will begin ________________________ (date) and will end ___________________________ (date) , hereinafter sometimes called the termination date . Either party may cancel this Agreement on __________ (number) days notice to the other party in writing, by certified mail or personal delivery. 3. Time Devoted by Consultant It is anticipated the Consultant will spend approximately ______________________ (number) (e.g. weeks) in fulfilling its obligations under this Agreement. The particular amount of time may vary from day to day or week to week. However, the Consultant shall devote a minimum of _______ (number) hours per month to its duties in accordance with this Agreement. 4. Place Where Services will be Rendered The Consultant will perform most services in accordance with this Agreement at a location of Consultant 's discretion. In addition, the Consultant will perform services on the telephone and at such other places as necessary to perform these services in accordance with this Agreement. 5. Compensation The Consultant will be paid at the rate of $_________ per hour for work performed in accordance with this Agreement. However, the Consultant will be paid at least $__________ per _____________________ (e.g., $_____ per hour) regardless of the amount of time spent in accordance with this Agreement. The Consultant will submit an itemized statement setting forth the time spent and services rendered, and the CLIENT will pay the Consultant the amounts due as indicated by statements submitted by the Consultant within ________ (number) days of receipt. 6. Independent Contractor Both the CLIENT and the Consultant agree that the Consultant will act as an independent contractor in the performance of its duties under this Agreement. Accordingly, the Consultant shall be responsible for payment of all taxes including federal, state and local taxes arising out of the Consultant 's activities in accordance with this contract, including by way of illustration but not limitation, federal and state income tax, Social Security tax, unemployment insurance taxes, and any other taxes or business license fee as required. 7. Confidential Information The Consultant agrees that any information received by the Consultant during any furtherance of the Consultant 's obligations in accordance with this Agreement, which concerns the personal, financial or other affairs of the CLIENT will be treated by the Consultant in full confidence and will not be revealed to any other persons, firms or organizations. 8. Employment of Others The CLIENT may from time to time request that the Consultant arrange for the services of others. All costs to the Consultant for those services will be paid by the CLIENT but in no event shall the Consultant employ others without the prior authorization of the CLIENT 9. 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. 10. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of _________________. 11. 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. 12 . 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. 13. 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. 14. 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. 15. 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. 16. Counterparts This Agreement may be executed in any number of counterparts, each of which shall be deemed to be an original, but all of which together shall constitute but one and the same instrument. WITNESS our signatures as of the day and date first above stated. ______________________________ ________________________________ (Name of CLIENT) (Name of Consultant) By: ____________________________ By: ______________________________ _______________________________ _________________________________ (P rinted or typed name) (P rinted or typed name) _______________________________ __________________________________ _______________________________ __________________________________ (Name and Office in Corporation) (Name and Office in Corporation)