Healthcare Affiliation Contract

HEALTHCARE AFFILIATION CONTRACT

This Affiliation Contract ("Agreement") is entered into as of Effective Date: by and between Facility Name: located at and Practitioner Name: , License Number: , Specialty: .

RECITALS

WHEREAS, Facility maintains facilities, medical staff bylaws, policies, and procedures for the provision of patient care and seeks to ensure the provision of high-quality clinical services; and

WHEREAS, Practitioner is duly licensed and qualified to perform the clinical services described herein and desires affiliation for the purpose of exercising specified clinical privileges at Facility;

NOW, THEREFORE, in consideration of the mutual covenants set forth in this Agreement, the parties agree as follows.

1. DEFINITIONS

For purposes of this Agreement, the following definitions apply: "Privileges" means the clinical privileges granted by Facility to Practitioner to provide specified patient care services within Facility; "Policies" means Facility's medical staff bylaws, rules, regulations, policies and procedures as amended from time to time.

2. APPOINTMENT AND SCOPE OF PRIVILEGES

Facility hereby grants Practitioner the non-exclusive Privileges set forth in Appendix A to this Agreement and subject to Facility's credentialing process, supervision requirements, and applicable Policies. Practitioner shall practice only within the scope of granted Privileges and shall comply with all applicable professional standards.

3. TERM AND TERMINATION

The initial term of this Agreement shall be for from the Effective Date and shall renew automatically for successive one-year terms unless either party provides written notice of non-renewal at least days prior to the then-current term expiration. This Agreement may be terminated by either party for cause upon written notice specifying the grounds for termination in accordance with Facility Policies.

4. CREDENTIALING, PRIVILEGES AND MEDICAL STAFF OBLIGATIONS

Practitioner shall submit all credentials and documentation required by Facility's credentialing office. Granting and continuation of Privileges are conditioned upon satisfactory credentialing, ongoing reappointment, participation in peer review, and compliance with medical staff bylaws and Policies.

5. STANDARDS OF CARE; PROFESSIONAL RESPONSIBILITIES

Practitioner shall at all times provide care consistent with accepted standards of care, maintain current licensure, training and certifications, and comply with Facility infection control and safety protocols. Practitioner shall cooperate with quality improvement and peer review activities. Failure to meet Standards may result in limitation, suspension, or revocation of Privileges.

6. STATUS OF PRACTITIONER

Practitioner is engaged to provide professional services as: Independent contractor Employee

7. INSURANCE; INDEMNIFICATION

Practitioner shall maintain the insurance coverage described above and provide certificates of insurance upon request. Practitioner shall indemnify and hold harmless Facility for claims arising from Practitioner’s negligent acts or omissions, except to the extent caused by Facility’s gross negligence or willful misconduct.

8. CONFIDENTIALITY AND PRIVACY

Practitioner shall comply with all applicable patient privacy laws and Facility privacy Policies, including the safeguarding of Protected Health Information. Practitioner acknowledges that unauthorized disclosure of confidential information may result in disciplinary action and liability.

9. QUALITY ASSURANCE; PEER REVIEW

Practitioner agrees to participate in Facility's quality assurance and peer review programs. Information obtained through peer review shall be treated in accordance with applicable law and Facility policy.

10. BILLING; COMPENSATION

If Practitioner bills for professional services rendered at Facility, Practitioner shall comply with Facility billing policies and applicable payer requirements. Practitioner is solely responsible for accurate coding and compliance with applicable laws and third-party payer contracts.

11. REPRESENTATIONS; WARRANTIES

Each party represents and warrants that it has full authority to enter into this Agreement, that execution does not violate any other agreement, and that all information provided to the other party is true and accurate. Practitioner further warrants that there are no pending investigations, license limitations, or disciplinary actions not disclosed to Facility.

12. NOTICES

13. AMENDMENT; SEVERABILITY; GOVERNING LAW

This Agreement may be amended only by a written instrument executed by both parties. If any provision is held invalid or unenforceable, the remainder shall remain in full force. This Agreement shall be governed by the laws of the State of without regard to conflict of laws principles.

14. ENTIRE AGREEMENT

This Agreement, together with appendices and referenced Policies, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements and understandings.

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