Can this agreement be signed electronically?

Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided intent, consent, attribution, and record retention are satisfied.

Do I need a HIPAA Business Associate Addendum?

Include a BAA when the counterparty will create, receive, maintain, or transmit protected health information; HIPAA requires appropriate safeguards and breach notification procedures.

Who is authorized to sign on behalf of the provider?

The authorized signer should be an officer or a person with documented authority; verify internal delegation and, when necessary, attach a corporate resolution or delegation letter.

Are notarization or witnesses required?

Most provider agreements do not require notarization, but state-specific practices vary; check state rules for documents that must be notarized or witnessed before acceptance.

How do I revoke or amend an executed agreement?

Follow amendment and termination provisions in the contract; mutual written consent is typical. For revocation of electronic consent, follow the disclosure and withdrawal processes required by ESIGN for consumer-facing records.

How long must I retain the executed agreement?

Retain contracts per regulatory standards: IRS generally 3 years (IRC §6501(a)), HIPAA records 6 years (45 CFR §164.530(j)), and longer where state law or industry rules require it.

Electronic Signature
Templates
Healthcare
Healthcare Core Provider Agreement

Healthcare Core Provider Agreement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE CORE PROVIDER AGREEMENT

PARTIES & IDENTIFICATION

Core Organization Name Organization Address for Notices Provider Legal Name Practice / Billing Address

Provider NPI

Taxpayer ID / EIN

Medical License Number

DEA Number (if applicable)

Specialty

Primary Contact

Provider Phone

Provider Email

RECITALS

This Healthcare Core Provider Agreement (the Agreement) is entered into by and between (referred to herein as "Organization") and (referred to herein as "Provider"). The parties agree that the Effective Date of this Agreement is .

DEFINITIONS

Terms defined in this Agreement shall include: "Covered Services" meaning medically necessary services provided within the Provider's scope of practice; "Claims" meaning submissions for payment in accordance with Organization's policies; "Confidential Information" meaning nonpublic business, clinical and patient-identifiable information protected under applicable law.

SCOPE OF SERVICES

Description of Services to be Provided

Provider shall provide Covered Services in a professional manner consistent with prevailing standards of care. Provider shall maintain licensure, credentialing, clinical privileges and staffing sufficient to perform the Covered Services.

CREDENTIALING AND ENROLLMENT

Provider represents and warrants that Provider is currently credentialed with applicable payers and will timely complete Organization's credentialing requirements. Provider shall promptly notify Organization of any change in license status, sanctions, Medicare/Medicaid exclusion actions, or any other material adverse action.

Participates in Medicare

Participates in Medicaid

PAYMENT, CLAIMS SUBMISSION & FEE SCHEDULE

Organization shall reimburse Provider for covered Claims in accordance with the Fee Schedule attached or listed below. Provider shall submit Claims in the format and within the timely filing period required by Organization. Provider agrees to accept payment as full satisfaction for Covered Services except as otherwise permitted under this Agreement.

Standard Timely Filing (days) Fee Schedule Summary

INSURANCE, INDEMNIFICATION AND LIABILITY

Provider shall maintain, at Provider's expense, professional liability insurance with limits not less than those set forth below and shall provide certificates evidencing such coverage upon request. Provider shall indemnify, defend and hold Organization harmless from any claims arising from Provider's negligent acts or omissions in the provision of care, except to the extent caused by Organization's gross negligence or willful misconduct.

Malpractice Carrier

Policy Number

Policy Limits

Policy Expiration Date

COMPLIANCE WITH LAWS, REGULATIONS AND PRIVACY

Provider and Organization each agree to comply with all applicable federal and state laws, rules and regulations, including but not limited to privacy and security laws governing protected health information. Provider shall implement and maintain administrative, technical and physical safeguards to protect Confidential Information.

By checking the box below, Provider acknowledges and warrants that Provider has implemented processes and policies to comply with privacy and security requirements applicable to protected health information and will enter into any required business associate agreement where appropriate.

Provider Compliance Acknowledgment Provider certifies compliance with applicable privacy and security laws and will cooperate in execution of requisite business associate agreements.

AUDIT, REPORTING & QUALITY ASSURANCE

Organization reserves the right to audit Claims, medical records, and quality indicators related to services performed under this Agreement. Provider shall retain medical records in accordance with applicable law and permit audits during normal business hours upon reasonable notice.

Provider Agrees to Audit Cooperation Provider agrees to cooperate with audits and supply records as reasonably requested.

TERM AND TERMINATION

The initial term of this Agreement shall commence on the Effective Date and continue for year(s), unless earlier terminated as provided herein. Either party may terminate without cause upon days' written notice. Termination for material breach may be immediate where permitted by law.

CONFIDENTIALITY

Each party shall safeguard Confidential Information and shall not disclose such information except as necessary to perform obligations under this Agreement or as required by law. Disclosure pursuant to legal process shall be made only after providing notice to the other party where permitted.

REPRESENTATIONS & WARRANTIES

Provider represents and warrants that Provider is authorized to provide the Covered Services, that all information supplied to Organization is true and complete, and that Provider is not excluded from participation in federal health care programs. Provider shall promptly notify Organization if any representation becomes untrue.

Provider Certification Provider certifies the representations and warranties above are true and acknowledges continuing obligation to notify Organization of material changes.

NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below by certified mail, return receipt requested, overnight courier or personal delivery.

Notice Address for Organization Notice Address for Provider

DISPUTE RESOLUTION & GOVERNING LAW

The parties shall attempt in good faith to resolve disputes arising under this Agreement through negotiation. If unsuccessful, disputes shall be resolved by binding arbitration or litigation as selected by Organization below. This Agreement shall be governed by the laws of the state identified in Organization's notice address.

Dispute Resolution Selection Arbitration Litigation in courts

MISCELLANEOUS

This Agreement constitutes the entire agreement between the parties relating to the subject matter herein and may be amended only by written instrument signed by both parties. Neither party may assign this Agreement without the other's prior written consent, except that Organization may assign to an affiliate or successor.

Additional Terms or Amendments

Provider Printed Name:

By:

Date:

Organization Printed Name:

By:

Date:

What the Healthcare Core Provider Agreement Is and When It Applies

The Healthcare Core Provider Agreement is a standardized contract used between healthcare providers and payers, networks, or health systems to define participation, billing, data sharing, compliance obligations, and service scope. Typical provisions cover credentialing, fee schedules, prior authorization processes, claims submission, audit rights, confidentiality, and dispute resolution. For electronic execution, the agreement can be signed under the federal ESIGN Act (15 U.S.C. ch. 96) and state UETA laws where applicable; however, certain exceptions and industry-specific addenda (for example HIPAA business associate provisions) must be included to preserve regulatory compliance and operational integrity.

Why a Clear Provider Agreement Matters for Healthcare Operations

A precise Healthcare Core Provider Agreement reduces payment disputes, clarifies responsibilities for patient care coordination and data protection, and documents compliance commitments such as HIPAA safeguards. Clear terms speed credentialing and help limit audit exposure while aligning expectations between providers and payers.

Who Typically Prepares and Signs This Agreement

These agreements are used by a range of healthcare parties involved in delivery, payment, and administration.

Hospitals and health systems — Legal, contracting, and revenue cycle teams finalize payer/provider terms and attachments.
Independent practices and clinics — Practice managers and medical directors sign to accept network rates and policies.
Managed care organizations and insurers — Network operations and provider relations teams execute participation agreements.

Signatory roles and internal review paths vary by organization size; document routing should include legal review and compliance signoff.

Essential Sections Every Healthcare Core Provider Agreement Should Include

A complete agreement structures operational, financial, and compliance obligations so both sides understand services, payment, and audit expectations.

Parties & Recitals

Identifies legal entities, addresses, and contract context. Use exact legal names to avoid later disputes and confirm federal tax ID and NPI where applicable.

Scope of Services

Defines covered services, referral processes, authorization responsibilities, and exclusions. Include CPT/HCPCS coding expectations and any bundled payment rules.

Compensation & Billing

Specifies fee schedules, claim submission formats, remittance processes, dispute resolution, and timetables for reimbursement and recoupment.

Compliance & Privacy

Requires HIPAA compliance and a Business Associate Addendum when PHI is exchanged; addresses sanctions, reporting, and security controls.

Termination & Remedies

Sets termination events, cure periods, survival of payment and confidentiality clauses, and indemnity provisions for fraud or material breach.

Audit & Recordkeeping

Grants audit rights, specifies retention periods, and outlines access procedures for claims and medical records during reviews.

Core Data Fields Required on the Agreement

Provider Legal Name: Exact entity or practitioner name

National Provider Identifier: NPI number for billing

Tax Identifier: TIN or EIN for payments

Billing Address: Street, city, state, ZIP

Credentialing Info: License numbers and board certifications

Authorized Signer: Name, title, and contact details

Step-by-Step: Completing the Agreement

Follow this sequence to prepare, validate, and execute a Healthcare Core Provider Agreement with minimal rework.

01

Prepare Draft: Populate parties, scope, and payment terms with accurate identifiers.
02

Internal Review: Legal and compliance confirm HIPAA and indemnity language.
03

Send for Signature: Route to authorized signer using eSignature or paper.
04

Confirm Execution: Verify signatures, dates, and distribute fully executed copies.

How to Configure an Online Signing Workflow

Set up an electronic workflow to reduce turnaround time and capture required audit information during execution.

Field	Configuration
Template Name	Use descriptive names for reuse (e.g., Provider Agreement — Standard)
Signer Roles	Assign roles for authorized signer, witness, and billing contact
Authentication	Choose email or SMS code; enable stronger auth for sensitive agreements
Conditional Fields	Show rate schedules or addenda only when applicable

Digital Signing and Delivery Requirements

Ensure the platform supports secure e-signature workflows, audit trails, document export, and necessary integrations.

File Formats: PDF and DOCX supported for upload and signed output
Integrations: Connectors for EHR, RCM, and CRM systems
Compliance: HIPAA BAA availability and audit logging

Confirm the solution meets encryption, access control, and retention requirements before executing agreements electronically.

Where to Send the Executed Agreement

After execution, route copies to parties responsible for contracting, credentialing, billing, and retention to complete downstream processes.

Payer Network: Upload to the payer portal or send to provider relations
Credentialing Office: Submit to credentialing vendor or internal team
Revenue Cycle: Provide billing and RCM teams executed fee schedules
Legal & Compliance: Retain final executed copy for audit and legal hold

Typical Timelines and Processing Expectations

Processing times vary by organization and payer; include realistic internal deadlines to prevent lapses in coverage or billing.

Effective Date Start:

Agreement effective on the date specified in the Effective Date field

Credentialing Turnaround:

Typically 30–90 days from complete submission

Contract Negotiation:

Allow 7–45 days depending on scope and redlines

Billing Activation:

Billing generally starts upon credentialing or the agreed start date

Record Retention:

Maintain executed agreements per retention schedule

Key Milestones from Draft to Active Network Participation

Track these milestones to coordinate contracting, credentialing, and billing activation across teams.

01

Draft Preparation

Assemble terms, attachments, and required identifiers before routing

02

Review & Negotiation

Legal and payer negotiate redlines and finalize rates

03

Execution

Obtain signatures and verify dates and signer authority

04

Credentialing Activation

Complete credentialing and enable claims submission

Common Mistakes to Avoid When Preparing the Agreement

Using inconsistent provider names across exhibits causes payment holds and slow processing.
Failing to attach the HIPAA Business Associate Addendum when PHI is exchanged increases breach risk.
Entering incorrect NPI or TIN values leads to claim denials and potential backup withholding.
Skipping internal compliance or legal review can result in unenforceable indemnity or audit clauses.

Penalties and Legal Risks from Errors or Noncompliance

HIPAA Fines: Civil monetary penalties for HIPAA violations (45 CFR §160/164)

Claim Denials: Incorrect billing details can lead to denied or recouped payments

Audit Exposure: Noncompliance increases risk of payer or government audits

Contractual Liability: Indemnity or breach obligations may create financial liability

Credentialing Suspension: Misrepresentations can result in suspension or termination

Tax Consequences: Missing TINs may trigger backup withholding and IRS notices

Representative eSignature Pricing and Feature Comparison

Compare common vendor pricing and core capabilities relevant to executing Healthcare Core Provider Agreements; signNow is listed first per platform comparison conventions.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Real-World Examples of Agreement Use and Outcomes

These brief examples illustrate how organizations used standardized provider agreements to solve operational problems.

John Butler, Founder — Fertility Centers of Illinois

They standardized provider agreements across clinics to reduce execution time and ensure compliance.

The team used consistent signature blocks and addenda for PHI handling.
As a result, contracting processed faster, legal reviews decreased, and copies were available immediately for billing and audits.

Tim Martin, Founder — Martin Properties

A chain of care facilities adopted a single agreement template for multiple sites to streamline onboarding.

The template included billing and credentialing exhibits.
Centralized management cut administrative delays, improved claims submission accuracy, and simplified renewals across locations.

Who Generally Signs and What Authority They Need

Primary Signer — Chief Medical Officer

The CMO or authorized executive typically has contractual authority to accept clinical and quality obligations; ensure board or corporate delegation is documented where required.

Billing Contact — Revenue Cycle Manager

The billing contact is responsible for submitting accurate billing identifiers and updates; signature authority may be limited to execution while operational changes require separate notices.

Supporting Documents and Export Options You Should Keep With the Agreement

Attach and store companion documents with the executed agreement to support credentialing, billing, and compliance reviews.

Export Formats

Save executed agreements as PDF/A for long-term retention and as DOCX for editable internal records to meet archival and retrieval needs.

Audit Trail

Keep a detailed audit trail including timestamps, IP addresses, and signer authentication artifacts for evidence and regulatory reviews.

Attachments

Include fee schedules, tax forms (W-9), licensure copies, and insurance certificates as signed exhibits to the agreement.

Supporting Forms

Retain credentialing packets, BAA, and any state-required provider registrations alongside the executed contract.

Practical Tips for Accurate and Efficient Completion

Apply these practices to reduce rework, maintain compliance, and shorten the contracting lifecycle.

Standardize Templates and Clauses

Maintain a central library of vetted templates and standard clauses to minimize legal reviews and keep language consistent across provider types and sites.

Validate Identifiers Before Routing

Confirm NPI, TIN, and license numbers prior to sending for signature to avoid billing rejections and credentialing delays.

Use Conditional Fields for Addenda

Expose HIPAA BAA, state-specific clauses, or rate exhibits only when applicable to reduce signer confusion and document clutter.

Capture Complete Audit Evidence

Ensure the eSignature platform records signer authentication, timestamps, and version history to support audits and legal enforceability.

Frequently Asked Questions About the Healthcare Core Provider Agreement

Answers to common execution, compliance, and retention questions for healthcare contracting teams.

Need help? Contact support

Can this agreement be signed electronically?
Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided intent, consent, attribution, and record retention are satisfied.
Do I need a HIPAA Business Associate Addendum?
Include a BAA when the counterparty will create, receive, maintain, or transmit protected health information; HIPAA requires appropriate safeguards and breach notification procedures.
Who is authorized to sign on behalf of the provider?
The authorized signer should be an officer or a person with documented authority; verify internal delegation and, when necessary, attach a corporate resolution or delegation letter.
Are notarization or witnesses required?
Most provider agreements do not require notarization, but state-specific practices vary; check state rules for documents that must be notarized or witnessed before acceptance.
How do I revoke or amend an executed agreement?
Follow amendment and termination provisions in the contract; mutual written consent is typical. For revocation of electronic consent, follow the disclosure and withdrawal processes required by ESIGN for consumer-facing records.
How long must I retain the executed agreement?
Retain contracts per regulatory standards: IRS generally 3 years (IRC §6501(a)), HIPAA records 6 years (45 CFR §164.530(j)), and longer where state law or industry rules require it.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now