Fill and Sign the Management Services Agreement Secgov Form

Medical or Dental Billing Services Agreement Agreement made on the _____________ (date), between ____________________ (Name of Medical Billing Company), a corporation organized and existing under the laws of the state of ______________, with its principal office located at _________________________ _____________________________________________________ (street address, city, state, zip code), referred to herein as Medical Billing, and _________________________ (Name of Medical Group), a professional association organized and existing under the laws of the state of ______________, with its principal office located at _________________________________ ____________________________________________ (street address, city, county, state, zip code), referred to herein as Client. Whereas, Medical Billing is a healthcare claims processing and services company and ________________________ (Name of Client) is a healthcare provider; and Whereas, Medical Billing provides computerized claims, billing and collection services to healthcare providers and files medical insurance claims on behalf of healthcare providers with government and commercial companies by electronic and paper means, and also provides for billing services directly to patients or for patient's portion of healthcare provider fees not coveredby insurance; and Whereas, Client desires to retain Medical Billing to provide it with such claims and billing services pursuant to this Agreement; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Commencing on _____________ (date), Medical Billing will process all the Client's medical insurance claims for payment by government and commercial companies by either electronic or paper means and make available all information necessary to properly process the Client's claims and to submit all such billing and insurance information to the appropriate party (e.g., daily, weekly, etc.) _______________. Medical Billing will process and submit all Clients’claims within ______ hours by electronic means wherever possible, and by paper means when otherwise necessary. 2. Medical Billing will provide to Client a direct fax number, thro
Which it can submit all such billing and claims information to medical billing, at (address of medical billing). 3. Medical billing will provide to client a direct mobile phone number which can be used in lieu of its own telephone number in accordance with this agreement if client so requests, at (number of telephone) , or which it elects the medical billing provider to use. (medical billing). 4. Medical billing will provide to client a mailing address of its principal office at (address of medical billing), for receipt and service of client's monthly billing and for electronic reporting to client of any changes in information or billing requirements that it elects to make in accordance with this agreement. 5. Medical billing will maintain records of all clients in its principal office, as well as on its e-mail server (or as otherwise required by client from time to time), for its own and its clients' use, and will provide the records subject to the client's right of inspection and copy, upon request. 6. Medical billing will make all client information available to client in a manner designed to permit client to obtain a complete understanding of any claim. 7. Medical billing, during the term of this agreement, will pay its client for medical services rendered for its clients, and will make available a copy of the client's account record to client on a monthly basis. Notwithstanding this, if medical billing determines that the medical services for which a client has claimed, have not been completed, then medical billing will not pay, and clients will be responsible for any additional fees charged by a third-party provider who has provided the services requested. 8. Medical billing will require client to sign, on an annual basis, and send to medical billing, a copy of, for all clients, (, the client's personal health statement, medical records, and medical insurance information), to ensure all client information remains current and accurate. 9. Medical billing will provide to clients only (, all billing services provided for their benefit by medical billing. For the avoidance of doubt, all information concerning medical billing rendered by medical billing may be transmitted only to the clients' healthcare providers. 10. When the services of medical billing to clients are no longer deemed necessary, medical billing will (, in its sole discretion, determine at any time, when this agreement expires, whether medical billing will continue to provide billing services for clients. To effect such decision, medical billing must provide to client, at least 30 days prior notice of any such decision, written notice of the basis.