Healthcare Call-Off Order

HEALTHCARE CALL-OFF ORDER

Call-Off Order No.:    Master Agreement Ref.:    Order Date:

Ordering Institution

Patient Information

Patient Name:    DOB:    Gender:

Phone:    MRN / Patient ID:    Emergency Contact:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Medical History (relevant to order)

Supplier / Provider to Perform Order

Call-Off Order: Items / Services

Enter each item or service requested. Attach additional sheets if needed.

Delivery, Performance & Acceptance

Service / Delivery Location:

Requested Start Date:    Requested End Date:    Lead Time / Notes:

Acceptance Criteria: The ordering institution will inspect and accept or reject deliverables within the timeframe set forth in the Master Agreement. Rejected items must be corrected or replaced at Supplier's expense. Final acceptance will be documented in writing by the requesting clinician or authorized representative.

Billing & Payment

Purchase Order / Billing Reference:    Billing Address:

Invoice Submission Instructions: Invoices shall reference the Call-Off Order No. and be submitted in accordance with billing instructions of the ordering institution. Payments will be made in accordance with the Master Agreement's terms unless otherwise stated herein.

Patient Data Use Authorization & HIPAA Compliance

By checking the box below, the ordering institution authorizes the minimum necessary patient information to be disclosed to the Supplier for the limited purpose of fulfilling this Call-Off Order. Supplier shall use and disclose patient data only as permitted by applicable health information privacy laws and the terms of the Master Agreement.

  I authorize disclosure of necessary patient information to Supplier for purposes of this order.

Authorization Expiration Date:

Compliance, Warranties & Indemnity

Supplier represents and warrants that: (a) all services and goods shall conform to the specifications and applicable professional standards; (b) Supplier and its personnel possess all required licenses, certifications, and clearances; and (c) Supplier will comply with all applicable federal and state healthcare laws, including privacy and data security requirements. Supplier further warrants that any clinical personnel supplied will have completed required background checks and compliance training.

Indemnification: Supplier shall indemnify, defend and hold harmless the ordering institution and its officers, employees and agents from and against any claims, liabilities, losses, damages and expenses (including reasonable attorneys' fees) arising out of Supplier's breach of this Call-Off Order, negligent acts, willful misconduct, or violation of applicable law.

Limitation of Liability: Except for liability resulting from gross negligence, willful misconduct, or infringement of third-party intellectual property, the parties' liability shall be limited as set forth in the Master Agreement.

Termination: This Call-Off Order may be terminated in accordance with the Master Agreement. For convenience or uncured material breach, the ordering institution may suspend or terminate this order with written notice to Supplier.

Records & Audit: Supplier shall maintain records related to this Call-Off Order for the period required by law and the Master Agreement and shall permit reasonable audits by the ordering institution or its designee.

Special Instructions / Additional Terms

Certification by Ordering Clinician

I hereby certify that the services or items requested in this Call-Off Order are medically necessary and appropriate for the patient named above and that funds are available for payment in accordance with the applicable agreement and institutional policies.

Clinician Print Name:    Title:

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