Healthcare Location Agreement

HEALTHCARE LOCATION AGREEMENT

Parties and Recitals

This Healthcare Location Agreement (the "Agreement") is entered into by and between Location Name: (hereafter "Location"), and Provider Name: (hereafter "Provider"). Location and Provider are sometimes referred to individually as a "Party" and collectively as the "Parties."

Effective Date and Term

Effective Date: . The initial term of this Agreement shall commence on the Effective Date and continue for a period of months, unless earlier terminated in accordance with Section Termination below.

Location Details and Access

Premises/Areas to be used (describe rooms, suite numbers, exam rooms, procedure rooms):

Access Days and Hours: from to . After-hours access and emergency access procedures shall be as set forth in the Location’s policies and as approved by the Parties in writing.

Services and Permitted Activities

Provider shall use the Premises solely to deliver the following permitted healthcare services (check all that apply):

Compensation, Fees and Billing

Provider shall pay Location the following fees for use of the Premises and services: Fee Type: ; Amount: $ . Payment terms: .

Insurance and Indemnity

Provider shall maintain and provide proof of professional liability insurance, general liability insurance, and workers' compensation insurance as required by applicable law. Minimum limits: Professional liability $ per claim and aggregate; General liability $ . Provider shall name Location as an additional insured where required by Location.

Indemnification: Provider agrees to defend, indemnify and hold harmless Location and its officers, agents and employees from and against any claims, liabilities, losses, damages or expenses (including reasonable attorneys' fees) arising out of Provider's acts, omissions, professional services, or breach of this Agreement, except to the extent caused by the gross negligence or willful misconduct of Location.

Compliance, Licensure and Staff Credentials

Provider represents and warrants that it holds all necessary licenses, permits and certifications to provide the permitted services at the Premises. Provider shall ensure that all personnel providing services at the Premises are appropriately credentialed and maintain current licensure. Provider shall provide to Location upon request copies of licenses, DEA registration (if applicable), and proof of credentials and training.

Medical Records, Privacy and HIPAA Compliance

Provider shall retain clinical records in compliance with applicable law, professional standards and Location policies. Provider is responsible for maintaining patient records created by Provider and for responding to requests for release of patient information, except as otherwise agreed in writing. Provider shall implement administrative, physical and technical safeguards to protect protected health information and shall comply with applicable privacy and security laws and regulations.

Authorization to access Location electronic systems (if any):

Equipment, Supplies and Storage

Responsibility for supply and equipment costs shall be as follows: Provider: ; Location: .

Safety, Incident Reporting and Quality

Provider shall follow Location’s safety, infection control and reporting policies. Provider shall report adverse events, sentinel events and incidents to Location within hours of discovery. Provider shall cooperate in any investigation and corrective action.

Termination

Either Party may terminate this Agreement for material breach if the breaching Party fails to cure the breach within days after written notice. Either Party may terminate without cause upon days' prior written notice.

Notices

Confidentiality and Proprietary Information

Each Party shall maintain the confidentiality of nonpublic information of the other Party and shall not disclose such information except as required by law, or as necessary to perform obligations under this Agreement. This obligation survives termination of the Agreement for a period of years.

General Provisions

Governing Law: The validity, interpretation and enforcement of this Agreement shall be governed by the laws of the state of , without regard to conflict of law principles.

Entire Agreement: This Agreement, together with any attachments and executed addenda, constitutes the entire agreement between the Parties with respect to the subject matter and supersedes all prior discussions and agreements.

On-site Patient Contact (Administrative Use)

Name: Phone:

Emergency Contact: Phone:

Acknowledgments and Certifications

By executing this Agreement, each Party certifies that the signatory is authorized to bind the Party and that all information provided is true and correct. Provider acknowledges its obligations to comply with applicable healthcare statutes, rules, and professional standards in performing services at the Premises.

Execution

The Parties have executed this Agreement as of the dates indicated below.

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