HomeMy WebLinkAboutContract 47186-P35 R C C K P Q R T 'm CITY SECRETARY`
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ADDENDUM
To
BlackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Fort Worth Brain and Spine Institute("Member Provider"),
Rockport Community Network("Rockport"),and the City of Fort Worth("City") on this day of
,20
WHEREAS, Rockport and Member Provider entered into a Provider Agreement, effective March 18,
2013, ("Provider A,greement'% and desire that this Addendum apply to covered services that are
governed by the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code.
WHEREAS, Rockport has contracted with Member Provider on behalf of the City in the process of
setting up a direct contracted 504 provider panel pursuant to Texas Labor Code Section 504.053.
WHEREAS, the City has determined that a workers' compensation health care network certified under
Texas Insurance Code Chapter 1305 is not available or practical for its self-insured workers'
compensation program needs and,as such,have elected to provide medical benefits to injured workers by
directly contracting with health care providers.
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terms and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
1. All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider
and the City, with full consent and agreement of Rockport, to apply as a direct contractual
agreement between Member Provider and the City.All references to certified networks as well as
the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the
Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under
section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of
Blackstone) shall instead apply to matters of notice, billing, dispute resolution, complaints,
preauthorization,and related matters.
2. The parties agree that the City will bear the financial responsibility for payment to Member Provider
under the terms of the Provider Agreement subject to the applicable Provider Manual and the
provisions of the Texas Labor Code and applicable rules under the Texas Administrative Code.
Rockport will continue to provide applicable network administrative services.
Fort Worth Brain& Spine Institute Provider Agreement.
3. When used in this Addendum, unless the content otherwise clearly requires, the following words and
terms shall have the meaning set forth below. All other defined terms shall have the meaning ascribed to
them in the Provider Agreement
"Payors" will be the City as they are responsible for payment of medical benefits for
compensable injuries and or illnesses sustained by its injured workers according to the Texas
Workers Compensation Act.
"B1ackStone" is the 504 Provider Panel established by the City of Fort Worth through this and
other direct contracts using Rockport as its contracting agent
'Provider Manual"means the BlackStone Provider Manual as amended from time to time and
available upon request to the Member Provider.
'Provider Panels"are those direct contracted panels formed by political subdivisions
or public pool entities authorized by Section 504.053 of the Texas Labor Code.
4. Nothing in this Addendum or the Provider Agreement shall be interpreted to ingre to the benefit of
a third party not a party to this contract. This contract may not be interpreted to waive any statutory
or common law defense, immunity,including governmental and sovereign immunity,or any limitation
of liability, responsibility, or damage of any party to this contract;party's agent; or party's employee,
otherwise provided by law.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates anew cause
of action.
6. All other terms of the Provider Agreement shall remain in force and unchanged. Any conflicts between
this Addendum and the Provider Agreement shall be superseded by the terms provided herein.
IN WITNESS WHEREOF,the parties hereto have executed this Addendum effective on the day and year
first written above.
For and on behalf of:
City of Fort Worth
Blackstone Provider Panel
Signature: Date: C)
Name: Su n A nis Assistant Ci1y Manage
APPROVED AS TO FORM AND LEGALITY:
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ROCKPORTT11
MEDICAL GROUP AGREEMENT
ROCKPORT UNITED NETWORK
ROCKPORT SELECTHEALTH NETWORK
This Medical Group Agreement ("Agreement"), is I. DEFINITIONS
entered into by and between Rockport Community
Network, Inc., a Nevada Corporation, dba Rockport When used in this Agreement and unless the content
Healthcare Group ("RHG"), dba Rockport United otherwise clearly requires, the following words and
Network (a preferred provider organization for terms shall mean:
Occupational Injuries and Illnesses), dba Rockport
SelectHealth Network (an exclusive provider 1.1 "Physician"means a licensed Medical Doctor or
network) and Fort Worth Brain and Spine Doctor of Osteopathic Medicine, or group of same
Institute ("Member Provider"), and will become who desire to become a Member Provider with
effective as of the date the provider is fully RHG.
credentialed by RHG.
Pursuant to §10.42 of Texas Insurance Code 1305
WHEREAS, RHG is engaged in the business of regarding Network Contracts with Providers seeking
developing and acting in an administrative capacity to participate in Texas Certified Vorkers'
in providing Occupational Injury and health provider Compensation Networks,
networks that offer direction of care while providing
savings to RHG clients and/or Payors. These I.2 "Qualified Paxticinant" means an "employee" as
networks will offer greater coverage of services and defined and used in the Texas Labor Code, the
savings;and Network Act Section 1305 and the implementing
rules who sustained a work-related injury/illness that
WHEREAS, RHG has networks of contracted is determined compensible by an employer and that
physicians, physician groups, hospitals and participates in the Rockport United Network or
providers of ancillary healthcare services Rockport SelectHealth Network through Rockport's
(collectively, the "Member Providers") to provide a Client. Unless in an emergency or after business
full-range of healthcare services. These services are hours, initial services provided for the work-related
available for use by "Qualified Participants" as injury/illness require authorization by the Employer
defined in I.2 of this Agreement; and and/or network either in writing or by telephone.
WHEREAS, Member Provider desires to provide I.3 "Client" means an insurance company, certified
medical care services to "Qualified Participants" self-insured or governmental entity as those terms
who are covered by Payor Agreements at the rates in are defined and used in the Texas Labor Code, the
Exhibit B and in locations listed in Exhibit C:and Network Act Section 1305 and the implementing
rules. These Clients have entered into a Client
WHEREAS, RHG has entered into Agreements Agreement with RHG for the provision of healthcare
and/or services with one or more Payors who services to Qualified Participants.
provide payment of claims for medical care rendered
to Qualified Participants. I.4 "Pavor" means an insurance carrier or network
certified by an insurance carrier for its own benefit,
NOW, THEREFORE, in consideration of the certified self-insured or governmental entity as those
premises,the mutual promises contained herein, and terms are defined and used in the Texas Labor Code,
other good and valuable consideration, the receipt the Network Act Section 1305 and the implementing
and sufficiency of which are hereby acknowledged, rules who is responsible for payment of medical
it is mutually agreed as follows: benefits for on the job injuries and or illnesses
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Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012
according to State and/or Federal Rules and and authorized care other than primary treating
Regulations. services. Specialists will need to maintain their
I.5 "Client Agreement" means the agreement current board certifications for their particular
between R4G and a Client, which agreement is specialty to maintain their RHG classification as
made before, on or after the effective date of this such and be willing and able to treat Qualified
Agreement and which expresses the agreed upon Participants as needed or required..
contractual rights and obligations of the parties,
Such Client Agreements will require Payors to pay I.9 "Emergency Medical or Mental Condition" is
Member Provider for Covered Services rendered to defined as the sudden onset of a medical condition
Qualified Participants pursuant to this Agreement. manifested by acute symptoms of sufficient severity,
Furthermore, such Client Agreements shall authorize including severe pain,that the absence of immediate
RHO to enter this Agreement and contractually bind medical attention could reasonably be expected to
Payors to the terms hereof unless there is a conflict result in:
with State and/or Federal rules and regulations. (a)placing the patient's health or bodily functions in
serious jeopardy;or
I.d "Member Provider" means any physician; (b) serious dysfunction of any body organ or part as
physician group; hospital; surgery center; diagnostic defined in TIC 1305.004(15); and
imaging center; laboratory; clinic; chiropractor; (c) in the case of a mental health condition, one that
dentist; podiatrist; psychologist; social worker; could reasonably present danger to the person
physical, occupational and speech therapist; etc. experiencing the mental health condition or another
licensed or certified to practice a healthcare person as defined in TIC 1305.004(13).
profession or licensed as a facility to offer healthcare
services, in the state where services are rendered and I.10 "Covered Services" are those healthcare and
who has executed a contract with RHO. health-related services provided to Qualified
Participants for treatment of a compensible, work-
I.7 "Primary Treating Physician/Clinic" According related injury/illness as defined by either nationally
to Texas law for certified workers' compensation recognized treatment guidelines and/or individual
networks, the Network decides who will be a treatment protocols that do not conflict with any
Treating Doctor. Therefore, a Member Provider who state and/or federal rules and regulations.
is a Medical Doctor (MD) or a Doctor of
Osteopathic Medicine (DO) that specializes in I.11 'Bill and/or Claim Form" CMS 1500 (or other
Family Practice, General Practice, Occupational appropriate claim form or their successors)
Medicine or Internal Medicine as well as a physician completed in accordance with the guidelines
that provides initial and/or follow-up care in Occ- established by the National Uniform Billing
Med or Urgent Care Clinics whose practice is Committee or CMS 1500 billing guidelines, and/or
largely dedicated to caring for work related injuries state rules and regulations.
and illnesses is designated by RHO as a Primary
Treating Physician/Clinic (PTP). PTP agrees to II. MEMBER PROVIDER OBLIGATIONS
render medical care to Qualified Participants without
a scheduled appointment and must be available and II.1 Services. Member Provider agrees to provide or
accesible to employees twenty-four (24) hours-per- arrange for all medically necessary medical care for
day, seven (7) days-per-week as per 28 TAC Qualified Participants who present themselves to
10.80(b)(1). Should a Qualified Participant need Member Provider. Member Provider agrees to
medical attention outside of Member Provider's perform such services with the same standard of
normal business hours, Member Provider will be care, skill and diligence for all Qualified
available and/or make arrangements to have another Participants. Member Provider agrees that it is their
Member Provider render care to Qualified sole responsibility to verify that the individual
Participant twenty-four(24)hours-per-day,seven(7) presenting for care is a Qualified Participant.
days-per-week. Member Provider agrees to render healthcare
services to Qualified Participants at any and all
I.8 "Specialist Physician" means a Member Provider facility or practice locations listed in Exhibit "C".
who has met the credentialing requirements of RHG Member Provider shall make best efforts to ensure
to be a Specialist Physician, and to whom Primary that services provided are consistent with nationally
Treating Physicians/Clinics may refer for necessary recognized treatment guidelines (i.e. Official
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Fort Worth Drain and Spine Institute 02212013 RUNPHY TX_01-2012
Disability Guidelines (ODG), American I1.5 Referrals. Except in a medical emergency or
Occupational and Environmental Medicine's when authorized by RHG, Client, or its designated
(ACOEM) and /or state rules and regulations. representative, Member Provider agrees to refer
Member Provider agrees to comply with and be Qualified Participants only to other Member
bound by all State/Federal Rules and Regulations. Providers,as defined in 1.6.
11.2 Treatment Guidelines. Member Provider agrees
to follow the treatment guidelines, return-to-work II.6 Reports. For each encounter where Member
guidelines and individual treatment protocols Provider provides services to a Qualified Participant,
outlined in Exhibit A of this Agreement, provided in Member Provider shall report such encounter on an
RHG's Provider Handbook and/or Clients' appropriate form and shall include statistical,
Utilization Review Programs.RHG agrees to furnish descriptive medical and patient data and identifying
Member Provider or cause Payor to furnish to information, if and to the extent that reports are
Member Provider, and Member Provider agrees to specified by RHG, Client or its designated
abide by,the list of any treatments and services that representative, and requested information is not
require preauthorization and by any procedures to prohibited by state and/or federal rules and
obtain preauthorization. Unless in an emergency or regulations.
after business hours, initial services provided for the
work-related injury/illness require authorization by 11.7 Professional Requirements.
the Employer and/or Network either in writing or by
telephone. The Client and/or Payor may not deny II.7.1 Licensure&Accreditation. Member Provider
treatment solely on the basis that a treatment for a shall comply with all applicable federal, state and
compensible injury in question is not specifically local laws, rules and regulations governing like
addressed by the treatment guidelines used by the providers and their provision of services. Evidence
Client and/or Payor. However, Member Provider of such current licensing, certification and/or
must demonstrate medical necessity to support accreditation shall be submitted promptly to RHG
services rendered to Qualified Participants that are upon request. Member Provider represents and
outside of treatment guidelines. warrants that it and each of its employees and
contracted service providers has obtained, and shall
11.3 Non-Discrimination.Member Provider shall not maintain throughout the term of this Agreement, all
differentiate or discriminate in the treatment of its necessary registrations, certifications, licenses,
patients as to the quality of services delivered to permits and approvals as are required for the lawful
Qualified Participants because of race, sex, age, provision of Member Provider services to Qualified
religion, national origin, place of residence, source Participants. Member Provider shall immediately
of payment or health status. Member Provider shall notify RHG of any revocation, suspension or
observe, protect and promote the rights of Qualified restrictions, that would affect any certifications,
Participants. licenses or accreditation's. Member Provider
warrants that it is currently accredited by the Agency
1I.4 Medical Staff Participation. Certain medical that governs like providers and is certified as a
specialties may not require hospital privileges such provider under Title XVIII (Medicare) and when
as Occupational Medicine, Pathology, Dermatology, appropriate, Title XIX (Medicaid) of the Social
Allergy, and those Primary Treating Security Act and that it shall -maintain such
Physicians/Clinics whose practice is dedicated to accreditation and certification during the term of this
treating work-related injuries and illnesses. Where Agreement. Member Provider shall immediately
appropriate, Physicians must maintain active, notify RHG of any action, investigation or
unrestricted staff privileges with at least one RHG proceeding to revoke, suspend, restrict, or otherwise
Member Provider hospital or Surgery Center. affect such accreditation or certifications,
Physician hereby consents to disclosure by such
facility to RHG of all data collected with respect to I1.7.2 Organization's Requirements. Member
Physician in connection with Physician's medical Provider shall use best efforts to comply with RHG's
staff membership, including without limitation all criteria for provider participation, including
applications for staff privileges and any renewals credentialing policies and procedures. Member
thereof. Provider shall cooperate with RHG's periodic
evaluation of qualifications. In addition, Member
Provider shall use best efforts to cooperate with
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Fort Worth Brain and Spine Institute 02212013 RUNPHY_Tx 01-2012
i
RHG's and/or state rules and regulations for the records. The Member Provider's obligations under
expeditious resolution of any grievance or this Section II.9 shall survive the termination of this
complaint. Agreement.
I1.8 Notification to RHG. Member Provider 11.10 Inspection of Records and Operations. RHG,
represents and warrants that information provided Payor or a designated representative shall have the
herein and in the RHG application is true and right to inspect and audit, at all reasonable times
accurate in all respects and acknowledges that RHG during normal business hours, upon prior five (S)
is relying on the accuracy of such information in business days, any of Member Provider's medical
entering into and continuing the term of this records and operations reasonably pertaining to
agreement, In addition Member Provider shall use RHG Qualified Participants, services provided to
best efforts to provide written notice to RHG of any Qualified Participants, and to Member Provider's
(i) suspension,reduction or loss of license to provide performance under this Agreement. Member
healthcare services; (ii) denial, suspension, Provider further agrees to allow RHG, Payor or a
restriction, reduction or termination of designated representative thereof, including the
accreditation/certification; (iii) changes in Federal designated utilization review, quality management,
Tax Identification Number(s), (iv) other information case management or peer review staff, to have
provided in its application or Exhibit C for reasonable access to medical records and
participation, (v) Member Provider's professional information of Qualified Participants for services
liability insurance if such insurance falls below the provided under the terms of this Agreement as
requirements of state law and (vi) Member necessary to enable such party to perform Utilization
Provider's billing or facility address. A failure to Review and Quality Assurance activities in
give any notice required by this Section shall be a accordance with the applicable Utilization Review
material breach of Member Providers obligations and Quality Assurance Program. In addition,
and responsibilities hereunder, regardless of the Physician agrees that in the event an examination
status, pendency or outcome of the event giving rise concerning the quality of healthcare services is
to the obligation to give that notice, and may be conducted by appropriate officials, as required by
grounds for termination of this Agreement, federal, state,and/or local law,RHG shall submit, in
a timely fashion,any required books and records and
II.9 Medical Records. Member Provider shall shall facilitate such examination. RHG and
maintain complete and timely medical records for Member Provider agree to assist one another with
Qualified Participants treated by Member Provider on-site inspection of facilities and records by
and its medical staff. Such records shall be prepared representatives of authorized federal, state and local
in accordance with accepted principles of practice, regulatory agencies
shall document all services performed for Qualified
Participants and shall comply with all applicable 11,11 Relationship of Parties. Member Provider and
state and federal laws. Member Provider shall RHG understands and agrees that they are each an
maintain such records for the length of time required independent legal entity. Nothing in this agreement
by applicable state or federal law. Subject to all shall be construed or deemed to create a relationship
applicable privacy and confidentiality requirements, of employer and employee, principal and agent,
such medical records shall be made available to each partnership or joint venture or any relationship other
Member Provider and other health professionals than that of independent parties contracting with
treating the Qualified Participant, and upon request, each other solely to carry out the provisions of this
to the Payor, RHG or its designated representative Agreement for the purposes recited in this
for review at the rates approved by State law and as Agreement. With regard to the provision of
set forth in the current State Workers' Compensation healthcare services, Member Provider acts as an
Reimbursement Manual for Hospitals, if applicable. independent entity and the Member Provider-patient
Member Provider shall obtain a valid consent for the relationship shall in no way be affected.
release of the Qualified Participant's medical records
to other providers, RHG, Payor, or its designated 11.12 .Standards of Care. Member Provider agrees
representative. RHG agrees that medical records of that all duties performed hereunder shall be
Qualified Participants shall be treated as confidential consistent with the proper practice of their
so as to comply with all federal and state laws and healthcare profession, and that such duties shall be
regulations regarding the confidentiality of patient performed in accordance with the customary rules of
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Fort Worth Brain and Spine Institute 02212013 RUNPHY_TX_O1-2012
I
ethics and conduct of the appropriate and applicable procedures promulgated by Federal and State
professional organizations and/or associations,as the entities.
case may be, and such other bodies, formal or
informal, state, government or otherwise, or by III. RHG's OBLIGATIONS
which they are subject to licensing/certification and
control. Additionally, Member Provider shall III.1 Marketing to Clients/Payors. RHG shall enter
perforin all medical and healthcare services in into agreements with Clients and/or Payors as
conformance with the standards for their facilities as defined in 1.3 and 1.4 for their access to RHG quality
established by the local/regional professional Member Providers through specific referral
healthcare community and applicable processes. RHG will market Member Providers for
accrediting/licensing agencies. Member Provider referral; including but not limited to the following:
agrees that,to the extent feasible,it shall utilize such (i) Provider Search Provider Locator System (ii)
additional allied health and other qualified personnel Provider Directories (iii) Site-Specific Provider
as are available and appropriate for effective and Panels (iv) Customized Local Networks and (v)
efficient delivery of care. Member Provider shall Client Service Provider Referral Service.
ensure that all such personnel are properly licensed
and/or possess the necessary credentials to render III.2 Credentialins. RHG will perform and/or
the services that they perform. delegate to qualified organizations credentialing of
each Member Provider. Credentialing may include
II.13 Right to Use Member Provider's or Network's verification of all information and documents
Name. Member Provider agrees to allow RHG to provided in the application for participation and
list Member Provider's naive, specialty, address, investigation, including but not limited to
telephone number, and hours of operation in a verification with all state and national licensing and
Member Provider directory, Provider Search, RHG certifying bodies that apply to the services rendered
Site-Specific Provider Panel(s), RHG website and/ by the Member Provider, such as JCAHO,AAAHC,
or other materials to help promote and assist Clients NCQA, CLIA, URAC, etc. Inquiries may also be
with Qualified Participants needing medical care for made to current and previous professional liability
injuries/illnesses sustained. RHG agrees to allow carriers, Medicare and Medicaid. RHG's
Member Provider to list RHG's name, address, and credentialing policies and procedures follow the
telephone number on Member Provider's website or American Accreditation Healthcare Commission
in other publications listing the health plans accepted (URAC) standards for Workers' Compensation
by Member Provider. In addition, Member Provider provider networks.
agrees to post in waiting room and make available to
Qualified Participant notice of Member Provider's III.3 Operational Functions. RHG shall utilize
participation with RHG with name, address and systems to respond to Member Providers requests
telephone number and process for Qualified for information and will provide clarification of
Participants to resolve complaints. The Member policies concerning the operation of RHG's
Provider is required to post, in Member Provider's programs. Member Provider agrees to work in
office, notice to employees on the process for cooperation with RHG to market the services of the
resolving workers' compensation health care Member Provider to Clients and/or Payors.
i network complaints. The notice must include the
Texas Department of Insurance's toll-free phone RHG shall act as a liaison with the Member
number for filing a complaint and must list all Providers and Clients and/or Payors to devote
workers' compensation health care networks with necessary time and effort to perform RHG's
which the Member Provider contracts. responsibilities hereunder.
II.14 Noncompliance. Member Provider understands IIIA Retaliatory Action. RHG agrees not to engage
that failure to comply with any of the requirements in any retaliatory action including termination of
imposed pursuant to this Agreement may result in contract or refusal to renew a contract against
termination of this Agreement by RHG. Member Provider, because Member Provider, on
behalf of an Qualified Participant,reasonably filed a
II.15 Antitrust Guidelines. Member Provider agrees complaint against, or appealed a decision of RHG or
to comply with all antitrust guidelines and Payor, or requested reconsideration or independent
review of an adverse determination.
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FortWorth Brain and Spine Institute 02212013 RUNPHY TX_01-2012
Covered Services to a Qualified Participant shall be
III.5 Antitrust Guidelines. RHG agrees to comply conditioned upon a good faith determination by the
with all antitrust guidelines and procedure Payor or its designated representative that (i) such
promulgated by Federal and State entities. services are medically necessary, whether such
determinations are made before, on or after the
III.6 Audit Policy and Procedure Compliance. All provision of services to such Qualified Participant,
bill audit requests by Payor shall be done in
accordance with the State Law and/or Federal Rules All services billed under the Tax Identification
and Regulations. Number(s) indicated in this Agreement, any
Amendments, Exhibit A, Exhibit B, Exhibit C,
Applications or any updates regarding locations
and/or a Member Provider as defined in section I.6
IV. REIMBURSEMENT,CLAIMS will be subject to the reimbursement rates
SUBMISSION AND PAYMENT established in the Exhibit B of this Agreement.
IV.1 Reimbursement. RHG shall arrange and All billing and reimbursement will be made in
provide the Member Provider, locations and/or any accordance with Labor Code 408.027 and all other
additional Tax Identification Numbers as listed in applicable state rules and regulations.
Exhibit C for Payors to pay Member Provider the
reimbursement rates for Covered Services rendered IV.3 Bill and/or Claim Forms. Claim forms are
to Qualified Participants pursuant to Exhibit B. required for all services. All claims must be
Member Provider agrees and acknowledges that submitted complete and accurate on CMS 1500 (or
RHG is acting solely in an administrative capacity in other appropriate claim form or their successors) and
providing a network of quality health services. RHG must include Member Provider's usual and
is not the claims paying agent and will not be liable customary billed charges (not discounted rates) and
for the payment of any amount owed by a Payor to appropriate codes, consistent with policies
Member Provider in the event that Member Provider established or approved by applicable state and/or
is unable to collect such amount of money up to and federal regulations. Member Provider must submit
including the insolvency of the Payor. Under no claims to Payor not later than the 95'h day after the
circumstance will a Member Provider attempt to date on which services are provided to the Qualified
collect payment from a Qualified Participant for Participant, or as specified by state law. In
medical services rendered for a compensible, work- accordance with Labor Code §408.027 and other
related injury/illness. applicable statutes and rules, billing and payment to
Member Provider will be made within forty-five
IV.2 Reimbursement Rates. Member Provider is to (45) days of receipt of bills which are accurate and
be paid by the Payor in accordance with State Law complete, and otherwise in accordance with state
and/or rules and regulations at the rates established rules and regulations.
in Exhibit S. Member Provider hereby agrees that
rates in Exhibit B,which may be amended from time IVA Limited Recourse Against Qualified
to time upon mutual written agreement,represent the Participants. Except as otherwise provided in this
total amount to be received and agrees to look solely Agreement (Section 1.10), Member Provider agrees
to the Payor for payment for such Covered Services, to seek payment from each Payor for Covered
Payment will be made for Covered Services actually Services provided to its Qualified Participants, and
rendered. All claims will be paid, when appropriate, agrees that it will not seek additional payments or
only after submission of a complete and accurate reimbursement for compensible injuries from
claim. A complete and accurate claim shall be Qualified Participants. In addition, Member
defined as a clean claim by Medicare. RHG does not Provider agrees that neither RHG, the Payor nor the
guarantee, represent, warrant or covenant regarding Qualified Participant shall be billed or ultimately
the selection or use of Member Provider's services held responsible for payment of services deemed not
by any Qualified Participant or Payor, or the number to be covered by the Payor or its designee. When
of patients, if any, which may result from Qualified Participant is covered by a state or
participation in RHG's provider network. The federally regulated Occupational Injury and Illness
obligation of a Payor to reimburse Member Provider program, Member Provider agrees to comply with
in accordance with Exhibit B for the provision of state and federal regulations regarding holding
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Fort Worth Brain and Spine Institute 022120I3 RIJNPHY_TX_01-2012
Qualified Participants harmless for amounts not paid "claims-made" policy, Member Provider agrees to
by Payor for any reason, including Payors provide and maintain such insurance coverage or a
insolvency. This provision does not preclude billing "tail" policy in the same amounts following the
a Non-Qualified Participant for a non-compensible termination of this Agreement. Member Provider
injury, shall promptly demonstrate evidence of insurability
or self-funded program and that the required
IV.4.1 Transfer of Risk. This Agreement and any insurance is paid and in force upon request of RHG
subcontract within shall not be interpreted to involve and/or meet the credentialing guidelines of RHG.
a transfer of financial risk for the provision of health
care services from Payor to REG as defined under V.2 Indemnification of RHG. RHG will be
Insurance Code §1305.004(a)(26). Member Provider responsible for its own acts or omissions and any
agrees and acknowledges that RHG is acting solely and all claims, liabilities, injuries, suits and demands
in an administrative capacity in providing a network and expenses of all kinds which may result or arise
of quality health providers. RHG is not the claims out of any alleged malfeasance or neglect caused or
paying agent and will not be liable for the payment alleged to have be caused by its employees or
of any amount owed by a Payor to Member Provider representatives, in the performance or omission of
in the event that Member Provider is unable to any act or responsibility under this Agreement. In
collect such amount of money up to and including the event that a claim is made against RHG, it is the
the insolvency of Payor. intent of RHG to cooperate in the defense of said
claim. However, RHG shall have the right to take
IV.5 Payment of Claim Forms. RHG shall any and all actions they believe necessary to protect
administratively arrange for the Payor or its their interest.
designated representative to pay undisputed claims
which are accurate, complete and comply with the V.3 Indemnification of Member Provider. Member
Agreement within the time period mandated by state Provider will be responsible for its own acts or
or federal law. omissions and any and all claims, liabilities,injuries,
suits and demands and expenses of all kinds which
IV.6 Erroneous Payment. In the event that a Payor may result or arise out of any alleged malfeasance or
jand/or its designated representative pays the neglect caused or alleged to have be caused by its
Member Provider (i) more than once, or (ii) an employees or representatives, in the performance or
incorrect amount, or (iii) an overpayment, the Payor omission of any act or responsibility under this
or its designated representative may, at its sole Agreement. In the event that a claim is made against
option and discretion, request the return of such Member Provider, it is the intent of Member
amount from Member Provider The Member Provider to cooperate in the defense of said claim.
Provider will not unreasonably withhold However, Member Provider shall have the right to
reimbursement. If overpayment has been made take any and all actions they believe necessary to
Member Provider shall reimburse such overpayment protect their interest.
within forty-five (45) days and/or follow State and
Local Rules and Regulations. The Member Provider VI. TERM AND TERMINATION
may not contest payment of Claims after one
hundred eighty(180)days from the date of payment. VI.1 Term. The term of this Agreement shall be for
All claims for overpayment or underpayment shall one (1) year from the date hereof and shall be
be resolved in accordance with State Law and /or automatically renewed on an annual basis for
Federal Rules and Regulations. successive twelve (12)month periods, unless sooner
terminated in accordance with Section VI.2.
V. INSURANCE AND INDEMNIFICATION
VI.2 Termination. This Agreement may be
V.1 Insurance Requirement. Member Provider shall terminated sooner on the first to occur of the
i provide and maintain such policies of professional following:
liability insurance or a self-funded program. The
j amounts and extent of such insurance coverage or V1.2.1 Termination by Member Provider. Member
iself-funded program shall be in the amounts Provider may terminate this Agreement in the event
determined by community standards for relevant of a material default or breach of RHG's obligations
hospital/facilities, If such coverage is under a hereunder,upon ninety(90)days prior written notice
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Fort Worth Brain and Spine Institute 02212013 RUNPHY TX_01-2012
and the failure of RHG to cure such breach or Upon written notification from RHG, Member
default within sixty (60) days of the notice. In Provider may request a review by RHG's advisory
addition, in the event of an "emergency situation", review panel, not later than thirty (30) days after
Member Provider may terminate the Agreement notification. RHG must then complete the review
immediately with the acknowledgment by RHG that before the effective date of termination.
such an emergency condition does exist.
"Emergency Situation" shall mean an unforeseeable VI.2.3 Termination for Insolvency. This Agreement
event, not resulting from Member Provider's act or shall terminate immediately in the event that either
omission, which materially affects Member RHG or Member Provider voluntarily or
Provider's ability to continue the practice of involuntarily, liquidates, dissolves or becomes
medicine or to perform his obligations hereunder. subject to any proceeding for the rehabilitation or
The network will provide notification to employees conservation of their financial affairs with written
of the terminating Member Provider immediately notification.
upon receipt of the Member Provider's termination
request or as soon as reasonably possible before the VI.2.4 Termination by Either Party. In case of
effective date of termination as required by 28 TAC material breach of the terms of this Agreement,
10.42(b)(6)(G). either party may terminate the Agreement with at
least ninety (90) days prior written notice to the
VI.2.2 Termination by RHG. A Member Provider other party; however, the party in breach may cure
shall automatically be terminated on the date when: the breach within sixty (60) days of the notice, in
(i) Member Provider's license in the State where which case, the Agreement and applicable rates and
services are rendered is suspended or revoked, (ii) terms shall continue in effect. Either party may
Member Provider is excluded from participation in terminate this Agreement without cause upon ninety
the Medicaid or Medicare programs, (iii) Member (90)days prior written notice.
Provider losses their JCAHO, NCQA, AAAHC,
URAC, CLIA or other applicable license, VI.2.5 Unforeseen Events. In the event that either
certification and/or accreditation, (iv) Member party's ability to perform their obligations under this
Provider loses or experience a material reduction in Agreement is substantially interrupted by war, fire,
liability insurance and such insurance falls below the insurrection, riots, the elements, earthquake, acts of
requirements of State Law (v) Member Provider God, or other similar circumstances beyond the
engages in any act, omission, demeanor or conduct reasonable control of such party, the party shall be
that is reasonably likely to be detrimental to patient relieved of those obligations for the duration of the
safety or to the delivery of quality patient care ,or to interruption upon notice to the other party. In the
lead to the provision of healthcare services below event that the interruption is reasonably determined
applicable standards, or (vi) ninety (90) days likely to persist for at least ninety (90) days, either
following written notice by RHG of a material party may terminate this Agreement upon thirty (30)
default or breach by Member Provider hereunder days prior written notice.
and the failure of Member Provider to cure such
default or breach within sixty(60) days of the notice VI.3 Effects of Termination. Upon termination of
(vii) Member Provider fails to meet RHG's or the this Agreement, neither party shall have any further
State's credentialing requirements. RHG, however, obligation hereunder except for (i) obligations
may not terminate this Agreement in direct response accruing prior to the date of termination, including
to Physician filing a reasonable complaint,on behalf without limitation, any obligation by Member
of a Qualified Participant against, or appealed a Provider to continue to provide healthcare services
decision of, the network, or requested to Qualified Participants, and (ii) obligations,
reconsideration or independent review of an adverse promises or covenants contained herein which are
decision. expressly made to extend beyond the term of this
Agreement.
In the event RHG deems it necessary to terminate
Member Provider's agreement based on the above VIA Qualified Participant and Payor Notification.If
requirements RHG will notify Member Provider at applicable, upon the termination of this Agreement,
least ninety (90) days before the effective date of by either party, Member Provider shall cooperate
termination. with RHG to notify Qualified Participants and
Payors of such termination.
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trust all Confidential Information. Upon termination
VII.CONTINUATION OF BENEFITS of this Agreement by either party for any reason
whatsoever, RHO and Member Provider shall
VII.1 Continuation of Benefits. If Member Provider promptly return to the other all material constituting
voluntarily terminates its contract with RHO, upon Confidential Information or containing Confidential
Member Provider's request, Payor must continue to Information, and neither party will not thereafter
reimburse Member Provider for a period not to use, appropriate, or reproduce such information or
exceed 90 days at the Member Provider's contracted disclose such information to any third party. RHO
rate set forth in Exhibit B of this Agreement with and Member Provider specifically agrees that under
RHO,for care of an Qualified Participant with a life- no circumstances will either party discuss the terms
threatening condition or an acute condition for and conditions of this Agreement, and in particular
which discontinuing or disruption of care would the pricing information herein.
harm the Qualified Participant as per 28 TAC
10.42(b) (A). Any disputes concerning continuity of IX. MISCELLANEOUS
care shall be resolved through the complaint process
under Insurance Code §1305.401 - §1305.405 and IX.I Disputes. All disputes and difference between
Subchapter G of Title 28, Part 1 (relating to the Member Provider and RHO upon which an
Complaints). amicable understanding cannot be reached are to be
decided by the following method:
VII.2 Survival. The provisions of this Article VII IX.1.1 Mediation throuirh RHO. The Member
shall survive the termination of this Agreement Provider shall notify RHG in writing of the dispute
regardless of the cause - giving rise to such or disagreement and shall provide all necessary
termination, as will sections II.9, V.2, V.3, VI.3, information to RHG. RHO shall use best efforts to
VIII, and IX. The provisions of this Article VII mediate the dispute within the rules and regulations
supersede any oral or written agreement to the put forth by the State as reference in RHG's
contrary now existing or hereafter entered into Provider Handbook.
between Member Provider and any Qualified
Participant or any person acting on a Qualified IX.1.2 Arbitration. If the dispute cannot be solved
i Participant's behalf by the mediation process described above, either the
Member Provider, RHO or Payor may elect to
VIII. CONFIDENTIALITY submit the dispute to binding arbitration under the
rules of the American Arbitration Association or any
All business, medical and other records relating to other method of arbitration mutually agreed upon by
the operation of RHG or Member Provider, the parties. Arbitration will be conducted in
including but not limited to, books of account, Houston, Texas. Each party will be responsible for
general administrative records, policies and their own legal fees. The cost of the arbitration
procedures, pricing information, terms of this services will be the sole responsibility of the party
Agreement and all information generated and/or requesting the arbitration.
contained in management information systems
owned by or pertaining to RHO or Member IX.1.3 Provider Appeals. Except for termination due
Provider, and all systems, manuals, computer to contract expiration, Member Provider has the
software and other materials, but excluding patient right to appeal his/her termination from the Network,
charts, shall be and remain the sole property of RHO as follows:
or Member Provider respectively (collectively, the
"Confidential Information"). RHO and Member IX.1.3.1 RHO will provide notice to the Member
Provider acknowledges that the Confidential Provider at least 90 days before the effective date of
Information and all other information regarding a termination by RHO;
RHO or Member Provider that is competitively
i sensitive is the property of RHO or Member IX.1.3.2 Upon receipt of the written notification of
Provider and RHO or Member Provider may be termination, a Member Provider may request in
damaged if such information was revealed to a third writing a review by the Network's advisory review
4
party. Accordingly, RHG and Member Provider panel no later than 30 days after receipt of the
agrees to keep strictly confidential and to hold in notification;
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j Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012
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requirements under any state or federal fair
IX.1.3.3 The Network will provide an advisory employment practices, equal employment
review panel that consists of at least three Providers opportunity, or similar laws declaring discrimination
of the same licensure and the same or similar in employment based upon race, color, creed,
specialty as the Member Provider, religion, sex, or national origin as illegal, and, Titles
VI and VII of the Civil Rights Act of 1964, Section
IX.1.3.4 The Network must complete the advisory 202 of Executive Order 11246 as amended by
panel review before the effective date of the Executive Order 11375, Sections 503 and 504 or the
termination; Rehabilitation Act of 1973 and Title IV of the
Vietnam Era Veterans Readjustment Assistance Act
IX.1.3.5 The Client, Payor, or RHO may not notify of 1974, and Sections 1 and 3 of Executive Order
patients of the termination until the earlier of the 11625, or any applicable rule or regulation
effective date of the termination or the date the promulgated pursuant to any such laws or orders.
advisory review panel makes a formal
recommendation; IX.6 Governing Law. This Agreement shall be
governed by and construed in accordance with
IX.1.3.6 If Member Provider terminates the contract, applicable state law.
the Network or RHG's Client will provide
notification of the termination to employees IX.7 Amendments. This Agreement may be
receiving care from the terminating provider. The amended as agreed to by both parties in writing upon
Network shall give such notice immediately upon thirty (30) days written notice of such proposed
receipt of the Member Provider's termination amendment.
request or as soon as reasonably possible before the
effective date of termination. IX.8 Severability. The invalidity or un-
enforceability of any term or condition hereof shall
IX.2 Non-Exclusivity. Nothing in this Agreement in no way affect the validity or enforceability of any
shall be construed to restrict Member Provider or other term or provision:
RHO from entering into other contracts or
agreements to provide healthcare services to Payors IX.9 Assignment. Member Provider may not assign
or other healthcare delivery plans, patients, and or otherwise transfer any right or delegate any duty
employer groups. of performance hereunder, in whole or in part
without the prior written consent of RHG. A change
IX.3 Entire ALxreement. This Agreement contains in ownership will not negate the prior contractual
the entire understanding of the parties and agreement without written notification to RHO.
supersedes any prior understandings and agreements, RHO retains the right to assign this Agreement, in
written or oral, respecting the subjects discussed whole or in part,to any entity with which RHO or its
herein. parent company or any of its subsidiaries is
affiliated,or with which it merges or consolidates.
IX.4 No Waiver. The waiver by either party of a
breach or violation of any provision of this IX.10 Third Party Beneficiaries. Except for Payors
Agreement shall not operate as or be construed to be and the agents thereof, there are no third party
a waiver of any subsequent breach hereof. beneficiaries of this Agreement.
IX.5 Regulatory Compliance. Member Provider, IX.11 Captions. The captions and headings
sub-contracting providers, and RHO agree that each contained in this Agreement are for reference
shall comply with all applicable requirements of purposes only and shall not affect in anyway the
municipal, county, state and federal authorities, all meaning or interpretation of this Agreement.
municipal and county ordinances and regulations,
and all applicable state and federal statutes and IX.12 Execution of Counterparts. This Agreement
regulations, now or hereafter in force and effect, may be executed in any number of counterparts,
governing RHG, Member Provider, sub-contracting including facsimiles, each of which shall be deemed
providers, the provision of services by Member to be an original as against any part whose signature
Provider or sub-contracting providers, and/or appears thereon, and all of which shall together
jPayors, including but not limited to applicable constitute one and the same instrument.
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Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012
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IX.13 Partial Invalidity. If any part, clause or IX.17 Official Notices. Any notice or
provision of this Agreement is held to be void by a communication required, permitted or desired to be
court of competent jurisdiction, the remaining given hereunder shall be deemed effectively given
provisions of this Agreement shall not be affected when personally delivered or mailed, return receipt
and shall be given construction, if possible, as to requested, or overnight express mail addressed as
permit it to comply with the minimum requirements follows:
of any applicable law, and the intent of parties
hereto.
IX.14 Financial Incentives. Neither a Client, Payor,
nor RHG may use financial incentive or make a
payment to a health care provider that acts directly Member Provider or Representative/Designee:
or indirectly as an inducement to limit medically (Please Print)
necessary services. The adoption of treatment and
return-to-work guidelines and individual treatment Name:
protocols by RHG or Network is not in violation of
this section as pursuant to Insurance Code §1305. Organization:Fort Worth Brain and Spine Institute
304 and §10.83(a)of Clip 10 of Title 28 Part 1,
IX.15 Financial Disclosure Requirements. Member Address: 1325 Pennsylvania,Ste 890
Provider is required to file financial disclosures in City/State/Zip:Fort Worth,TX 76014
accordance with Labor Code §§408.023 and
§§413.041. Telephone:(817) 878-5333
1X.16 Economic Profiling. Network must provide Fax:
written notice to Member Provider before the
Network conducts economic profiling, including Organization:
utilization management studies or other profiling of Rockport Community Network,Inc.
the provider or group of providers. dba Rockport Healthcare Group
Attn: Director of Network Development
50 Briar Hollow Lane,Suite 515W
Houston,TX 77027
Telephone:(713)621-9424
Fax: (713)621-9511
IN WITNESS WHEREOF, the undersigned will be or to such other address, and to the attention of such
deemed to have executed this Agreement as of the other person(s) or officer(s) as either party may
date the provider is fully credentialed by RHG, designate by written notice.
For and on behalf of:
For and on behalf of:
Rockport Community Network,Inc.
dba Rockport Healthcare Group Member Provider or Repr s t ve/Designee
50 Briar Hollow Lane,Suite 515W
Houston,f;�k
Signature•
Name: . eW!\ -
Mark C.Neer cL � {{ (Print)
Sr.Vice Preside t,Ne rk Dev lopment TIN: ! "j 4� `-1 I r al
Date: Date: Z I ko l
I
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Fort Worth Brain and Spine Institute 02212013 RUNPHY_TX_01-2012
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f
EY-=IT A
STANDARDS AND GUIDELINES
UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS
RHO and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e. Official
Disability Guidelines(ODG) and/or American Occupational and Environmental Medicine's (ACOEM) guidelines)
in the treatment of work-related injuries/illnesses for Qualified Participants.
RHO's Clients provide utilization review and quality improvement programs for Qualified Participants. RHO shall
review each Cliegts Utilization Review and Quality Improvement Program in accordance with RHG's Credentialing
Standards and Guidelines as described in this Exhibit. Physician and/or Member Provider agrees to comply and be
jbound by such programs and any state or federal rules and regulations.
Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written
notice to Physician and/or Member Provider.
The primary goals of the Utilization Review Programs shall be to:
1) Ensure and certify for the payment of benefits that healthcare services meet the definition of medical necessity
as defined by the network,Payor or the Payors designee;
2) Ensure that healthcare services are provided at the appropriate level of care;and
3) Ensure that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and
outcome-focused.
Treatments and Services that may Require Preauthorization:
1) In-patient hospital admissions including the principal scheduled procedures(s)and the length of stay;
2) Outpatient surgical or ambulatory surgical services;
3) Spinal surgery, as provided by Texas Labor Code§408.026;
4) All psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is
part of a preauthorized or exempt rehabilitation program;
5) All external and implantable bone growth stimulators;
6) All chemonucleolysis;
7) All myelograms,discograms,or surface electromyograms;
8) Unless otherwise specified,repeat individual diagnostic study,with a fee established in the current Medical Fee
Guideline of greater than$350 or documentation of procedure(DOP);
9) Work hardening and work conditioning services provided in a facility that has not been approved for exemption
by the Division;
10) Rehabilitation programs to include (a) outpatient medical rehabilitation and (b) chronic pain management /
interdisciplinary pain rehabilitation;
11) All durable medical equipment (DME) in excess of$500 per item (either purchase or expected cumulative
rental)and all transcutaneous electrical nerve stimulator(TENS)units;
12) Nursing home,convalescent,residential,and all home health care services and treatments;
13) Chemical dependency or weight loss programs;
14) Any investigational or experimental service or device for which there is early, developing scientific or clinical
evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly
accepted as the prevailing standard of care;and
15) Physical and occupational therapy services;(a)physical and occupational therapy services are those listed in the
Healthcare Common Procedure Coding System (HCPCS) Level I code range for Physical Medicine and
Rehabilitation, but limited to: (i) modalities, both supervised and constant attendance; (ii) therapeutic
procedures,excluding work hardening and work conditioning;and(iii)other procedures, limited to the unlisted
physical medicine and rehabilitation procedure code.
NOTE: Preauthorization is not required for the first two visits of physical or occupational therapy following the
evaluation when such treatment is rendered within the first two weeks immediately following: (i)the date of injury,
or(ii)a surgical intervention previously approved by the payor.
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Fort Worth Brain and Spine Institute 02212013 RUNPEY TX 01-2012
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EXHIBIT B
Reimbursement Schedule
I.Rockport United Network/Rockport SelectHealth Network-Occupational Injury and Illness
Provider fees for the programs listed above shall be reimbursed at the following:
All fees will be reimbursed at 100% (one hundred percent) of the state's current Workers'
Compensation fees, rules and regulations or usual and customary allowables with the following
hardcoded exceptions:
99201 $65. 99214 $156.
99202 $110. 99215 $210.
99203 $158. 72010 $120.
99204 $241. 72040 $54.
99205 $300. 72050 $73.
99211 $30. 72070 $50.
99212 $65. 97002 $62.
99213 $107. 97750 $50.
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of
this Agreement,state rules and regulations and/or the applicable Occupational Injury or Illness Benefit
Plan.
I/We accept the fees as outlined in this Exhibit B.
For and on behalf of: For and on behalf of:
(Name,address,etc.)
ROCKPORT COMMUNITY NETWORK,INC. Fort Worth Brain and Spine Institute
dba Rockport Healthcare Group 1325 Pennsylvania,Ste 890
50 Briar Hollow Lane,Suite 515W Fort Worth, TX 76014
Houston,Texas 77027
L� Signature `,, ,n (�,,
Mark C.Neer Printed a ��t \1 V lk- -Z
Sr.Vice President,Netw k Dev opment Title
!{ Date le h TIN Date
i
i
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Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012
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EXHIBIT C
Signature Page
Physicians and locations where services are to be rendered byMember Provider
Member Provider agrees that the following physicians and practice locations listed on this Exhibit C shall be
inclusive of the signed agreement and the signed rates in Exhibit B. By signing below,Member Provider or its
Representative/Designee allows Rockport Healthcare Group(RHG)and its representatives to use any and all of
the attached information as agreed to in the signed agreement.
Fort Worth Brain and Spine Institute Fort Worth Brain and Spine Institute
Practice Name Practice Name(2)
Brent Alford,MD Samir Lapsiwala,MD
Physician Name(if applicable) Physician Name(if applicable)
1325 Pennsylvania Ave,Ste 890 1325 Pennsylvania Ave. Ste 890
Physical Address Physical Address
Fort Worth,TX 76104 Fort Worth,TX 76104
City,State Zip City,State Zip
Mailing Address(if different) Mailing Address(if different)
(8 17)878-5333/«\—+) �'I %-S33y (817)878-5333 / '%--'d'S33Li
Phone Number/Fax Number Phone Number/Fax Number
57-1141121 57-1141121
Tax ID Number Tax ID Number
Practice Name(3) Practice Name(4)
Physician Name(if applicable) Physician Name(if applicable)
Physical Address Physical Address
City, State Zip City,State Zip
I
Mailing Address(if different) Mailing Address(if different)
Phone Number/Fax Number Phone Number/Fax Number
Tax ID Number Tax ID Number
For and on behalf of: For and on behalf of:
Rockport Community Network,Inc.
dba Rockport Healthcare Group Member Provider or Repres live esignee
50 Briar Hollow Lane,Suite 515W
Houston,TX 77027 Signature:
Name: {�
Marls C.Neer (print)
Sr.Vice Pres dent,Ne rk D velopment
Date
Date:
du
i
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Fort Worth Brain and Spine Institute 02212013 RUNPHY TX_01-2012
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