Healthcare Provider Engagement Pack

HEALTHCARE PROVIDER ENGAGEMENT PACK

This Provider Engagement Agreement (the "Agreement") is made between Healthcare Organization Name: and Engaged Provider Name: . Effective Date: , .

Provider Information

Credentialing, Licenses & Background

State License Number: State of Issue: Expiration:

Scope of Engagement

Term of Engagement: beginning on , and continuing until terminated in accordance with this Agreement.

Compensation, Billing & Payment

Fee schedule / Rates: Provider will bill for services at the rates set forth in the attached fee addendum or as otherwise agreed in writing. Agreed base rate (per service/unit): $

Payment Terms: Organization will pay properly submitted undisputed invoices within days of receipt. Disputed amounts must be notified in writing within 30 days.

Insurance, Indemnity & Liability

Provider shall maintain professional liability insurance with limits no less than: $ per occurrence and $ aggregate. Insurance carrier:

Indemnification: Each party shall indemnify, defend and hold harmless the other party from claims arising from its negligence, willful misconduct, or breach of this Agreement, subject to applicable law and insurance coverage limits.

Confidentiality & HIPAA Compliance

Provider acknowledges obligations under federal and state privacy laws with respect to Protected Health Information (PHI). Provider shall: (a) use and disclose PHI only as permitted by this Agreement and applicable law; (b) implement administrative, physical and technical safeguards to protect PHI; and (c) notify Organization without unreasonable delay upon discovering any security incident or unauthorized disclosure, and cooperate in breach mitigation and notification.

Quality, Records & Audit

Records: Provider will maintain clinical and billing records in accordance with applicable law and Organization policy. Records shall be retained for at least the minimum period required by law and shall be made available to Organization or its authorized designees upon reasonable notice for audit and quality review.

Audits & Monitoring: Provider agrees to cooperate with credentialing, peer review, billing audits and quality improvement activities, including providing documentation and participating in corrective action plans where required.

Representations, Warranties & Status

Provider represents and warrants that Provider is duly licensed, credentialed and authorized to perform the services described, that all information provided to Organization is true and complete, and that Provider will comply with Organization policies and applicable law. Provider is an independent contractor and not an employee of Organization. Nothing in this Agreement shall be construed to create a partnership, joint venture, or employment relationship.

Termination

Either party may terminate this Agreement for convenience upon days written notice. Immediate termination may occur for cause, including loss of required license or failure to maintain required insurance.

Notices

Dispute Resolution & Governing Law

Governing Law: This Agreement shall be governed by the laws of the state identified in Organization Notice Address, without regard to choice of law principles. The parties agree to attempt informal resolution of disputes and, if unsuccessful, to submit disputes to binding arbitration or mediation as mutually agreed prior to initiating litigation.

Amendment; Entire Agreement

This Agreement constitutes the entire understanding between the parties regarding the engagement and may be amended only by a written instrument signed by both parties.

Certifications

By signing below, Provider certifies under penalty of perjury that the information provided in this Engagement Pack is true and correct to the best of Provider's knowledge, that Provider will notify Organization promptly of any material changes, and that Provider will comply with applicable laws, regulations and applicable Organization policies while performing services.

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