Healthcare Makerspace Pay Application

HEALTHCARE MAKERSPACE PAY APPLICATION

Applicant Name:   Application Number:

Client / Requesting Facility:   Project / Order No.:

Billing Period & Contact

Period Covered: From to

Patient / Beneficiary Information (If applicable)

Date of Birth:   Gender:   MRN / ID:

Ordering Clinician:   Clinical Contact Phone:

Insurance / Billing Data (If billing insurer)

Scope of Work / Description of Services

Attachments & Compliance

Included Attachments (check all that apply): Drawings / CAD files Test reports / QA Supplier invoices Patient HIPAA authorization

Certifications & Affirmations

By submitting this Pay Application the applicant certifies under penalty of perjury that:

1. The labor, materials and services claimed herein were furnished in accordance with the scope of the applicable purchase order, contract, or written authorization and were performed to the standards required by the client and applicable healthcare regulations.

2. All charges are true, correct and reasonable; invoices from suppliers and subcontractors supporting claimed amounts are available upon request and have been paid or will be paid from the proceeds of this application unless otherwise noted.

3. The applicant has complied with applicable federal and state privacy laws regarding protected health information (PHI). Patient-identifiable information included in supporting documentation has been disclosed only with proper authorization; patient authorization expiration date (if applicable):

4. Any medical devices, prosthetics or patient-specific devices fabricated meet the client-approved specifications and applicable quality controls. The applicant accepts responsibility for corrective action resulting from fabrication defects attributable to the applicant's workmanship or materials.

5. The applicant acknowledges that payment of this application may be subject to verification, final inspection, and acceptance by the client. Payment shall not constitute waiver of the client's rights to assert claims for defects, nonconformance, or overcharges.

6. Upon receipt of payment in full for amounts claimed herein, the applicant shall, to the extent required by contract, execute lien waivers and releases for the work and materials paid for. Any partial payment shall be subject to partial waiver obligations as specified in the governing agreement.

Payment Terms

Payment Terms: Net days from receipt of undisputed invoice. Late payments may be subject to interest at the lesser of the contract rate or statutory maximum.

Method of Payment:

Representations Regarding Subcontractors & Suppliers

The applicant represents that all subcontractors and suppliers furnishing labor or materials for which payment is requested are properly licensed and have been paid or will be paid from the proceeds of this application unless specifically noted. Forwarding of supplier invoices is certification that charges are for work performed on the stated dates and locations.

Acknowledgments

I certify that the information provided in this application is accurate to the best of my knowledge and that I have authority to submit this request on behalf of the applicant. I understand that knowingly submitting false or fraudulent claims may result in civil or criminal penalties under applicable law.

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