Fill and Sign the Physicians Agreement with Non Profit Corporation to Treat People Who Cannot Afford Healthcare Form

Agreement between Professional Corporation and Non-Profit Corporation to Treat People who cannot Afford HealthcareMedical services agreement made ________________ (date), between ________________________________ (Name of Non-Profit Corporation), with its principal office located at _______________________________________________________________ _________ (street address, city, county, state, zip code), referred to herein as Corporation , and _________________________________ (Name of PC Professional Corporation), a profession corporation 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 PC.Whereas, Corporation was organized for the purpose of securing the benefits of medical and surgical care, nursing and hospitalization to many individuals whose financial condition has made it impossible for them to receive such services in the past, which individuals are referred to in this agreement as patients ); and Whereas, PC is willing to assist in the execution of such corporate purpose in consideration of receiving such fees as the patient is able to pay for the services rendered;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. PC agrees to offer services of its shareholder physicians to those who shall make to Corporation the periodic payments agreed upon by PC and Corporation on the terms and conditions set forth below. This agreement shall constitute an irrevocable offer by PC to such patients for the performance of the services described below.2.To the extent that PC's services shall have been promised by Corporation to the patient and subject to the terms and conditions set forth in this agreement, PC shall treat all persons who make, or on whose behalf shall have been made, the periodic payments required for such services pursuant to this agreement. PC shall perform such services whether requested to do so by the patient or by the Corporation.3. PC shall accept in full for PC's services performed under this agreement the fees fixed as set forth in Exhibit A of this agreement.4. In furtherance of the charitable purposes of Corporation's organization, it shall not receive from PC any sums that PC collects. 5. This agreement may be canceled by either party at any time without cause on _____ days' (written) notice to the other.6. The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. 7. The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred.8. This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of _____________.9. Any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. 10. Mandatory Arbitration Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 11. This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 12. Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party.WITNESS our signatures as of the day and date first above stated.__________________________ __________________________(Name of Corporation) (Name of PC) By:______________________________ By:_____________________________ ______________________________________________________(Printed name & Office in Corporation) (Printed name & Office in Corporation____________________________ _________________________ (Signature of Officer) (Signature of Officer)