Healthcare Split Fee Agreement

HEALTHCARE SPLIT FEE AGREEMENT

This Healthcare Split Fee Agreement (the Agreement) is entered into as of Effective Date: by and between the parties identified below. The parties agree to allocate professional fees for the healthcare services described herein in accordance with the terms and conditions set forth.

Parties

Patient Information

Date of Birth:    Gender:

Phone:    Emergency Contact:

Insurance Information

Policy Number:    Group Number:

Services and Fee Allocation

For services listed above, the parties agree the professional fee shall be split as follows:

Referring Provider (Provider A) shall receive: of the professional fee    Performing Provider (Provider B) shall receive: of the professional fee.

Alternatively, parties may allocate a fixed split amount per case: $ paid to Referring Provider; remaining balance to Performing Provider.

Which party will submit claims to payors: Provider A    Provider B

Payment from payor will be disbursed within days of receipt; adjustments for denials or recoupments shall be handled as follows:

Patient Notification and Acknowledgment

The parties represent that the patient has been notified about this fee-splitting arrangement and that such arrangement will not alter the nature of care or impair any patient rights. Patient consent is required under applicable law; patient consent has been: Obtained    Refused/Declined

If patient consent is required by payor or law and has been obtained, the parties certify that such consent was obtained without coercion and with full disclosure of the fee allocation.

Representations; Compliance with Law

Each party represents and warrants that: (a) the split fee arrangement is consistent with applicable federal and state law and payer rules; (b) the split is commercially reasonable and not tied to the volume or value of referrals; (c) neither party will offer or accept remuneration for the purpose of inducing referrals in violation of applicable anti-kickback or similar statutes.

Each party agrees to maintain complete records of services, billing, collections and distributions made pursuant to this Agreement and to make such records available to the other party and to authorized auditors as required by law or payer contract for a period of not less than years.

Indemnification and Liability

Each party shall indemnify, defend and hold harmless the other party from and against any losses, claims, damages, liabilities or expenses (including reasonable attorneys' fees) arising from the indemnifying party's breach of representations, misuse of funds, improper billing practices, or failure to comply with applicable laws.

Term, Termination and Amendment

This Agreement is effective as of the Effective Date and shall continue in effect until Expiration Date: unless earlier terminated in accordance with this section.

Either party may terminate this Agreement without cause upon days' written notice to the other party. Termination shall not affect obligations incurred prior to termination, including payment reconciliations and record retention.

Amendments to this Agreement must be in writing and signed by authorized representatives of both parties.

Confidentiality

The parties agree that the terms of this Agreement and patient-specific billing information are confidential and will not be disclosed except as required by law, by payor contract, or as reasonably necessary for administration of claims and payments. Each party will comply with applicable privacy and security laws in the handling of protected health information.

Dispute Resolution and Governing Law

Any dispute arising out of or relating to this Agreement shall be resolved first by good faith negotiation between the parties. If unresolved, the dispute shall be resolved by arbitration or litigation as mutually agreed. Governing law shall be the laws of the state of .

Notices

Notices under this Agreement shall be sent to the billing contacts provided above or to such other addresses as a party designates in writing. Notices are effective upon receipt.

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