Healthcare Contract Summary

HEALTHCARE CONTRACT SUMMARY

Parties and Contract Identification

Contracting Provider:

Contracting Party:

Contract Number:     Effective Date:

Term and Renewal

Initial Term Commencing:     Term Expiration:

  Automatic renewal of successive unless terminated in writing in accordance with Section on Termination.

Scope of Services

Patient Population and Data

Covered Patient Population:

Date of Birth:     Gender:

Insurance and Billing

Policy Number:     Group Number:     Subscriber Name:

Fee Schedule and Payment Terms

Billing Frequency:     Payment Terms: Net days from invoice date.

Late Payment Interest:

Performance, Reporting and Audit

Compliance, Privacy, and Data Security

Each party shall comply with all applicable federal and state healthcare laws and regulations, including requirements to safeguard protected health information. Provider represents that it will implement administrative, physical, and technical safeguards to protect electronic protected health information consistent with industry standards and applicable law.

  Parties acknowledge responsibility for compliance with HIPAA and related privacy obligations and agree to execute any required business associate agreements.

Indemnification and Insurance

Indemnification: Each party agrees to indemnify, defend, and hold harmless the other party from claims arising out of its negligent acts, omissions, or willful misconduct in connection with performance under this Agreement, subject to any limitations set forth in the underlying agreement.

Termination and Remedies

Amendment and Governing Law

This summary may be supplemented or amended only by a written instrument executed by authorized representatives of both parties. Governing law: . Venue:

Notices

Authorization Expiration

This summary and any authorizations described herein shall expire on:

Representations and Authority

Each party represents that it has full corporate or organizational authority to enter into this Agreement, that the individuals executing this document on its behalf are authorized to do so, and that performance hereunder will not violate any other agreement or legal obligation.

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