HomeMy WebLinkAboutContract 47186-P4 CRY SECRETARY
CONTRACT
NO
ADDENDUM
To
BlackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Sherry R.Kondziela,MD("Member Provider"I Rockport
H thcar Group ("Rockport"), and the City of Fort Worth ("City") on this
y of
201 ,
WHEREAS,Rockport and Member Provider entered into a Provider Agreement, effective February 20,
2011 ("Provider Agreement"), and desire that this Addendum apply to covered services that are
govemed by the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code,
W11ERGAS, 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
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workers ofthe City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
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j 1. All teams and conditions ofthe 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 insiead 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.
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3. When used in this Addendumi unless-the-content otherwise clearly requires,the-followingwords and
terms shall have the meaning set forth below. All other defined terms shall have the meaning
ascribed to them in the Provider Agreement.
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oFFICr�►� ����
CITY
Sherry R.Kondziela,MD 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.
"BlackStone" 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 ofthe Texas Labor Code.
4, Member Provider agrees to participate in the BlackStone provider panel for the benefit of the City
and Qualified Participants.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a
new 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.
1N WITNESS'4VMPX1,0.r%the parties hereto have executed this Addendum effective on the day and year
first written above.
For and on behalf of.-
City
f:City of Fort Worth
BlackStone
Signatur ;
Name: S sananis
Title: Assistant City Manager
Date: a=e( l�
MIKOVED kS TO FORM AND LEGALITY: n �
istant City Attas's's'
0000000
A#Pftdby . ;
OFFICIAL RECORD 2
CITY SECRETARY ayser, City Secretary
WORTH,TX
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Shen.7R.Xondzlela,MD Provider,Agreement
ROMOORT O F�f71^7ifT��?
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1YS YB s R 'OVIDER or
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ROCKPCPTTM
PHYS-ICI<AN AGREE,141ENT
ROCXFORT UNffED NETWORK
ROCKPORT SELECTIMAUTH NEITWOR]K
This Physician Agreemept("Agreement"),is entered I, DEVINITYONS
into by and hetween Rockport Community Network,
Me,, 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 network for terms shall mean:
Occupational Lijuries and Illnesses), dba kockport
Select[With Network (an exclusive provider I.1 "Physician"means it licensed Medical Doctor or
network) and Sherry Kondziela, MD ("Member Doctor of Osteopathic Medicine, or group of same
Provider"), and will become effective as of the date - who desire to become a Member Provider with
the provider is fully credentialed by RHG, RHG.
WHEREAS, R40 is engaged in the business of Pursuant to Title 28, Texas Administrative Code
developing and acting in an administrative capacity §10.42 regarding Network Contracts with Providers
in providing Occupational Injury and health provider seeking to participate in Texas Certified Workers'
networks that offer direction of care while providing Compensation Networks,
savings to RHG clients and/or Payors. These
networks will otter greater enverage of services and I.2 "Qualified Eartjaipant" means an "employee"as
savings; and defined and used in the Texas Labor Code, the
Network Act Section 1305 and the implementing
WBEREAS, RHG has networks of contracted rules who sustained awork-related injury/f111tess that
physicians, physician groups, hospitals and ' is determined compensable by a Client and that
providers of ancillary healthcare services participates in the Rockport United Network or
(collectively, the "Member Providers") to provide a Rockport SelectHealth Network through Rockport's I
Cull-range of healthcare services. These services aro Client. Unless.in an emergency or after business
available for use by "Quallfied Participants" as hours, initial services provided for the work-related
defined in 1.2 of this Agreement;and injury/illness require authorization by the network
either in writing or by telephone.
WBEREAS, Member Provider desires to provide
medical care services to "Qualified Participants" 1.3 "Client" means an insurance company, certified
who arc covered by Payor Agreements at the rates in self-insured or governmental entity as those terms
Exhibit B and in locations listed in Exhibit C: and are defined and used in the Texas Labor Code,the
hi.clusive of the networks included in Exhibit D;and Network Act Section 1305 and tho implementing
rules. These Clients have entered into a Client
WHEREAS, RHG has entered into Agreements Agreement with RUt i 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. TA "Payor" means an insurance carrier or network
certified by an insurance carrier for its own benefit,
NOW, TIER FORE, in consideration of the Certified self insured or governmental entity as those �
premises,the mutual promises contained heroin, and torras are defined and used in the Texas Labor Code,
other good and valuable consideration, the receipt the Nefwork Act Section 1305 and the implementing
and sufficicney 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
according to State and/or Federal Rules and
j Regulations. J
Fage t of 14
Sherry Kondziela�1vff11/15/15 RLNyPHV_T'X i
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1.5 "Client Agreement" means the agreement specialty to maintain their RIIG classification as
between RHG and a Client, which agreement is such and be willing and able to treat Qualified
made before; on or after the effective data of this Participants as needed or required..
Agreement and which expresses the agreed upon
contractual rights and obligations of the parties. 1.9 "EmergeneyMedical or Mental Condition" is
Such Client Agreements will require Payors to pay defused as the sudden onset of a medical condition
Member Provider for Covered Services rendored to manifested by acute symptoms of sufficient severity,
Qualified Participants pursuant to this Agreement. including severe pain,that the absence of immediate
Furthermore,such Client Agreements shall authorize medical attention could reasonably be expected to
RHG to enter this Agreement and contractually bind result in:
Payom to the terms hereof unless thorc is a conRict (a)placing the patient's health or bodily functions in
with State and/or Federal rules and regulations. serious jeopardy;or
(b)serious dysfunction of any body organ or part as
1.6 "Member Provider" weans any physician; defined in TIC 1305.004(13);and
physician group;hospital; surgery center;diagnostic (c)in the case of a mental health condition, one that
imaging center; laboratory; clinic; chiropractor; could reasonably present danger to the person
dentist; podiatrist; psychologist; social worker; expecfeucing the mental health condition or another
physical, occupational and speech therapist; etc. person as defined in TIC 1305.004(l5).
licensed or certified to practice a healthcare
profession or licensed as a facility to offer healthcare I.10 "Covered Services'{ are those healthcare and
services,in the state where services are rendered and health-related services provided to Qualified
who has executed a contract with RHG. Participants for treatment of a compensable, Nvork-
related injury/illness as defined by either nationally
I.7 "Primary Treating Ph sician/Clip' " According recognized'treatmerit guidelines and/or individual
to Texas law for certified workers' compensation treatment protocols that do not conflict with any
networks, the Network decides wbn will be a state and/or federal rules and regulations.
Treating Doctor.Thereforo,a Member Provider who
is a Medical Doctor (MD) or a Doctor of T.I I "Bill and/or Claim Form"CMS 1500 (or other
Osteopathic Medicine (DO) that specializes in appropriate claim form or their successors)
Family Practice, General Practice, Occupational completed in accordance with the guidelines
Medicine or Internal Medicine as well as a physician established by the National Uniform Billing
that provides initial and/or follow-up care 'in Oec- Committee or CMS 1500 bitting guidelines, and/or
Med or Urgent Care Clinics whose practice is state rules and regulations.
largely dedicated to caring for work related injuries
and illnesses is designated by RHG as a Primary T1, AfElVMEjRJIROVIDER01311GA,TIONS
"Treating Physician/Clinic. (PTF). PTP agrees to
render medical care to Qualified Participants without 11.1 Services, Member Provider agrees to provide or
a_scheduled appointment and must be available and arrange for all medically necessary medical care.for
accessible to employees twenty-four (24)hours per- Qualified Participants who present themselves to
day, seven (7) days-per-week as per 28 TAC Member Provider, Member Provider agrees to
10.80(b)(1). Should u Qualified Participant need perform such services with the same standard of
medical attention outside of Member Provider's cure, skill and diligence for all Qualified
normal business hours, Member Provider will be Participants. Member Provider agrees that it is their
available and/or make arrangements to have another sole responsibility to verify that the individual
Member Provider render care to Qualified presenting for care is a Qualified Participant.
participant twentvZour(24)hours-per-day,seven (7) Member Provider agrees to render healthcare
days-per-week, services to Qualified Participants at any and all
facility or practice locations listed in Exhibit "C".
I.8"Snecialist Physician" means a Member Provider Member Provider shall make best efforts to ensure
who has mat the credentialing requirements ofR14G that services provided are consistent with nationally
to be a Specialist Physician, and to whom Primary recognized treatment guidelines (Le. Official
Treating Physicians/Clinics may refer fnr necessary Disability Guidelines (ODG), American
and authorized care other than primary treating Occupational and Environmental Medicine's
services, Specialists will need to maintain their (ACOEM) and /or state rules and regulations.
current hoard certifications for their particular
iPage 2 of 14
Srierry Kundz1da,M D 1.15115 AUNPHY TX_
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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.
1.6 Reports. For each encounter where Member
11.2 Treatment Guidelines. Member Provider agrees Provider provides services to a.Qualified Participant,
to follow the treatment guidelines, return-to-work Member Provider shall report such encounter on an
guidelines and individual treatment protocols appropriate form and shall include statistical,
outlined in Exhibit A of this Agreement,provided in descriptive medical and patient data and identifying
RHO's Provider Handbook and/or Clients' information, if and to the extent that reports are
IMlization Review Programs.RUG agrees to furnish specified by RHG, Client or its designated
Member Provider or cause Payor to furnish to representative, and requested information is not
Member Provider, and Member Provider agrees to prohibited by state and/or federal rules and
abide by, the list of any treatments and services that regulations.
require preauthorizatiou and by any procedures to
obtain preauthorization. Unless in an emergency or 1f.7 Professional Requirements.
after business hours,initial services provided for the
work-related injurer/illness require authorization by 11.7.1 Licensure&Accreditation. Member Provider
the carrier and/or Network either in writing or by shall comply with all applicable federal, state and
telephone. The Client and/or Payor may not deny local laws, rules and regulations governing like
treatment solely on the basis that a treatment for a providers and their provision of services. Evidence
compensable injury in question is not specifically of such current licensing, certification and/or
addressed by the treatment guidelines used by the accreditation shall be submitted promptly to RTTG
Client and/or Payor. However, Member Provider upon request. Member Provider represents and
must demonstrate medical necessity to support warrants that it and each of its employees and
services rendered to Qualified Participants that are contracted service providers has obtained, and shall
outside of treatment guidelines, maintain throughout the term of this Agreement, all
necessary registrations, certifications, licenses,
TT.3 Non-Discrimination.Member Provider shalt not permits and approvals as are required for the lawful
differentiate or discriminate in the treatment of its provision of Member Provider services to Qualified
patients as to the quality of services delivered to Participants. Member Provider shall immediately
Qualified Participants because of race, sex, age, notify RI IG of any revocation, suspention or
religion, national origin, place of residence, source restrictions, that would affect any certifications,
of payment or health status, Member Provider shall licenses or accreditations. Member Provider
observe,protect and promote the rights of Qualified warrants that it is currently accredited by the Agency
Participants, that governs like providers and is certified as a
provider under Title XV111 (Medicare) and when
11.4 Ivledical Staff Participatican, Certain medical appropriate, Title XIX (Medicaid) of the Social
specialties may not require hospital privileges such Security Act and that it shall maintain such
as Occupational Medicine,Pathology,Dermatology, accreditation and certification during the term of this
Allergy, and those Primary Treating Agreement. Member Provider shall immediately
Physicians/Clinics wbose practice is dedicated to notify RHG -of any action, Investigation or
treating work-related injuries and illnesses. 'Where proceeding to revoke,suspend,restrict,or otherwise
appropriate, Physicians must maintain active, affect such accreditation or certifications.
unrestricted staff privileges with at least one Rl t(3
Member Provider hospital or Surgery Center. 11:.7.2 Organization's Reguirements. Member
Physician hereby consents to disclosure by such Provider shall use best efforts to comply with RIdG's
facility to RHO of all data collected with respect to criteria for provider participation, including
Physician in connection with Physician's medical credentialing policies and procedures. Member
staff membership, including without limitation all Provider shall cooperate with RI-IG's periodic
applications for staff privileges and any renewals evaluation of qualifications. In addition, Member
thereof. Provider shall use best efforts to cooperate with
R14G's and/or state rules and regulations for the
11.5 Referrals, Except in a medical emergency or expeditious resolution of any grievance or
when authorized by RUG, Client, or its designated complaint.
representative, Member Provider agrees to refer
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Pave 3 of 14
SherryKondzlel%MI)ill 511S RU1%411KY TX_
HIS Notification to RI 1G, Member Provider 11,10 Inspection of Records and Operations, RHQ.
represents and warrants that information provided Payor or a designated representative shall have the
herein and in the RUG application is trite and right to inspect and audit, at all reasonable times-
accurate
imesaccurate in all respects and acknowledges that RHO during normal business hours, upon prior five (5)
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 REG 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 Agreemant. Member
healthcare services, (ii) denial, suspension, Provider further agrees to allow MG, 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)odrer 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
Providers 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 tho Physician agrees [bat 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
Wounds for termination of this Agreement. federal,state,and/or local law,RTiG shall submit,in
a timely fashion,any required books and records and
H.9 Medical Records, Member Provider shall shall facilitate such examination. R[-IG 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, stats;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 It1IG understands and agrees that they are each an
maintain such records for the length oftunc 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 requirement's, of employer and employee, principal and agent,
I such medical records shall be made available to each partnership or joint venture or any relationship other
Member Provider and other health profe:ssianals 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, RHO or its designated representative Agreement for the purposes recitedin this
for review at the rates approved by State law and as Agreement. With regard to the provision of
set forth in rile 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, RHO, Payor, or its designated 11.12 tandards of Care, Member Provider agrees
representative. RHO agrees that medical records of that all duties performed hereunder shall be
Qualified Participants shalt be treated as confidential conslstczit with the proper practice of their
so as to comply with all federal and state laws and healthcare profession, and that Stich duties shall be
regulations regarding the confidentiality of patient performed in accordance with the customary rules of
records. The Member Provider's obligations under ethics and conduct of the appropriate and applicable
this SecLion 11.9 shall survive the termination of this professional organizations and/or associations, as the
Agreement, case may be, and such other bodies, formal or
informal, state, government or otherwise, or by
which they are subject to licensing/certification and
Page d of 14
Sherry Kondziela,MD 1115115 81 tNP1lY TX
control. Additionally, Member Provider shall defined in 1.3 and IA for their access to REG quality
perform all medical and healthcare services in Member Providers through specific referral
conformance with the standards for their facilities as processes. RHO will mdrku Member Providers for
established by the local/regional professional reftrral; including but not limited to the following:
healthcare community and applicable (i) Provider Search Provider Locator System (11),
accrediting/licensing agencies. Member Provider Provider Directories (iii) Site-Specific Provider
agrees that,to the extent feasible,it shall utilize such Panels (iv) Customized Local Networks and (v)
additional allied health and other qualified personnel Client Service Provider Referral Sbrvice.
as are available and appropriate for effective and
efficient delivery of care, Member Provider shall 111.2 Credentialina. RI-IG will perform and/or
ensure that all such personnel are properly licensed delegate to qualified organizations credentialing of
and/or possess the necessary credentials to render each Member Provider. Crodentialing may include
the services that they perform. verification of all information and documents
provided in the application for participation and
11.13 Right to Use Member Providers or Network's investigation, including but not limited to
Name. Member Provider agrees to allow Rl IG to verification with all state and national licensing and
list Membor Provider's name, specialty, address, certifying bodies that apply to the services rendered
telephone number, and hours of operation in a by the Member Provider, such as JCAF10, AAAIIC,
Member Provider directory, Provider Search, RHG NCQA, CLIA, URAC, etc. Inquiries may also be
Site-Specific Provider Panels), 8140 website and/ made to current and previous professional liability
or other materials to help promote and assist Clients carriers, Medicare and Medicaid. R11G's
with Qualified Participants needing medical care for credentialing policies and procedures follow the
injurics/illnesses sustained. RPIG agrees to allow American Accreditation Healthcare Commission
Member Provider to list RHG's name, address, and (URAC) and/or NCQA standards for Workers'
telephone number on Member Provider's website or Compensation provider networks.
in other publications listing the health plans accepted
by Member Provider. In addition,Member Provider F1,3 Operational Functions, RHG shall utilize
agrees to post in waiting room and make available to systems to respond to Member Providers requests
` Qualified Participant notice of Member Provider's for information and will provide clarification of
participation with RHG with name, address and policies-, concerning the operation of RHG's
telephone number and process for Qualified programs. Member Provider agrees to work in
Participants to resolve complaints. The Member cooperation with RHG to market tho servicea of the
Provider is required to post, in Member Provider's Member Provider to Clients and/or Payors.
office, notice to employees on the process for
resolving worlcers' compensation health care RHG shall act as a liaison with the Member
uetwork complaints, The notice must include the Providers and Clients and/or Payors to devote
Texas Department of Insurance's toll-free phone necessary time and effort to perform R.HG's
number for filing a complaint and must list all responsibilities Hereunder.
workers' compensation health care networks with
which the Member Provider contracts, 111.4 Retaliatory AcWt'on. RHG agrees not to engage
in any retaliatory action including termination of
H.14 Noncompliance,Member Provider understands contract or refusal to renew a contract against
that failure to comply with any of the requirements Member Provider, because Member Provider, on
imposed pursuant to this Agreement may result in behalf of an Qualified Participant,reasonably filed a
termination of this Agreement by RHG. complaint against,or appealed a decision of RHCT or
Payor, or requested reconsideration or independent
II.15 Antitrust Guidelines. Member Provider agrees review of an adverse determination,
to comply with all antitrust guidelines and
procedures promulgated by Federal and State 111,5 Antitrust Guidelines. RHG agrees to comply
entities, with all antitrust guidelines and procedure
promulgated by Federal and State entities.
M. RHG's-OBLIGATIONS
III,6 Audit Policy and Procedure Com lip ante. All
I1I.1 Marketing to Clients)PgXors. RHCI shall enter bill audit requests by Payor shall be done in
into agreements with Clients and/or Payors as
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iSherry Kandzieia,MD 11I5115 Pap 5 of 14 RUNFLiYT_
accordance with the State Law and/or Federal Rules All services billed under the "fax Identification
and IRegulations. Numbcr(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 1.6
IV. >g1M-flU tS1!NffNT,CLAIMS will be, subject to the reimbursement rates
SUBMISSION AND PAY-yIENT established in the Ex-bibit E of this Agreement.
IV.1 Reimbursement. R11G 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 inust include Member Provider's usual and
is not the cLaims paying agent and will not be liable custoinary 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
1xicluding the insolvency of the Payor. Under no claims to Payor not later than the 45`' 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. It,
mediad services rendered for a compensable, work- accordance with Labor Code §445.027 and other
rotated i.njurylillness, applicable statutes and rules, billing and payment to
Member Provider will be made within forty-five
IV,2 Reimbursement Rates. A4ember 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 otherwiso in accordance with state
and/or rules and regulations at the rates established rules and regulations.
in Exhibit B. Member Provider hereby agrees that
rates in Exhibit B,which may be amended from time IVA I jinited Recourse . rl*ainst Qualified
to time upon mutual written agreement,represent the Participants. Except as t3therwise 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 rnade for Covered Services actually Services provided to its Qualified Participants, and
rendered.All claims will be paid,when appropriate; agrees that it will not seelc additional paymunts or
only after submission of a complete and accurate reimbursement for compensable injuries from
claim. A complete and accurate claim shall be Qualified Participants. In addition, Member
defined as a clean claim by Medicare.REIG does not Provider agrees that neither MG, Lhe Payor nnr 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 designoc. Waren
of patients, if any, which may result from Qualified participant is covered by a state or
participation in 1111G'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
Covered Services to a Qualified Participant shall be Qualified Participants harmless for amounts not paid
conditioned upon a good faith determination by the by Payor for any reason, including payors
Payor or its designated representative that (i) such insolvency. Taus provision does notpreelude billing
services are medically necessary, whether such a Non-Qualified Participant for a non-compensable
determinations are .trade before, on or after the injury.
provision of services to such Qualified Participant.
IV.4.I Transfer of Risk. This Agreement and any
i subcontract within shall not be interpreted to involve
(' page G of 14
S Sherry Kondzieta,MD 1115115 RVNPHK_T
a transfer or financial risk for the provision of health out of any alleged malfeasance or neglect caused or
care services from Payor to RHO as defined under alleged to have be caused by its elnployccs or
Insurance Code§1305.004(a)(26).Member Provider representatives, in the performance or omission of
agrees and act nowledgcs that RHG is acting sale-ly any act or responsibility.under this Agreement. In
in an administrative capacity in providing a network the event that a claim is made against RIG, it is tile,
of quality health providers. Rl IG is not the claims intent of RHG to cooperate in the defense of said
paying agent and will not be liable for the payment claim. kiowever, RHG shall have the right to take
of any amount owed by a Payor to Member Provider anyand all actions they believe necessary to protect
in the event that Member Provider is unable to their interest,
collect such amount of money up to and including
the insolvency of Payor or the Netwnrk. V.3 Indemnitiaa#ion of Member Provider, Member
Provider will be responsible for its own acts or
N.5 1 avment of Claim Forms. RHG shall omissions and any and all claims,liabilities,injuries,
administratively arrange for the Payor or its suits and demands and expenses of all kinds which
designated representative to pay undisputed claims may result or arise out of any alleged malfeasance or
which are accurate, complete and comply with the neglect caused or alleged to have be caused by its
AgTotinent within the time period mandated by state employees or representatives, in the performance Or
or federal law. omission of any act or responsibility under this
Agreement. In the event that a claim is matte against
IV.6 Erroneous Pa men#. In the event that a Payor Member Provider, it is the it-tent of Member
and/or its designated representative pays the Provider to cooperate in the defense of said claim.
Member Provider (f) more than once, or (ii) an However, Member Provider shall have the right to
incorrect amount,or(iii)an overpayment, the Payor take any and all actions they believe necessary to
or its designated representative may, at its sole protect their interest.
option and discretion, request the xeturn of such
amount from Member Provider The Member Vit. TT+Itlld AND TERMINATION
Provider will not unreasonably withhold
reimbursement. If overpayment has been made V1:.1 Term. The Lernl of this Agreement shall be far
Member Provider shall reirnbiirse such overpayment one (1) year from the data hereof and shall be
within forty-five (45) days and/or follow Stats: and automatically renewed on an annual basis for
successive twelve (12)month periods,unless sooner
Local Rules and Regulations. The Member Provider
may not contest payment of Claims after one terminated in accordance with Section VI.2,
hundred eighty(180)days from the elate of payment.
All claims for overpayment or underpayment shall V12 Termination. This Agreement may be
be resolved in accordance with State Law and /or terminated sooner on the first to occur of the
Federal Rules and Regulations. following,
V. INIsili ANCE AND INDti A MFICATI.ON VI.2.1 Termination by Member Provider. Member
Provider may terminate this Agreement ill the event
V.1 Insurance Requirement. Member Provider shall of a material default or breach of RI-IG's obligations
provide and maintain such policies of professional hereunder, upon ninety(90)days prior written notice
liability insurance ora self funded program, The and the failure of RHG to cure such breach or
i amounts and extent of such insurance coverage or default within sixty (60) days of the notice. In
self-funded program shall be in the amounts addition, in the event of an "emergency situation", _
determined by community standards for relevant Member Provider may terminate the Agreement
hospital/facilities. Member Provider shall promptly immediately with the acknowledgment by Rife that
demonstrate evidence of insurability or self funded such an emergency condition does exist.
program and that the required insurance is paid and "Emergency Situation" shall mean an unforeseeable
in force upon request of RHG and/or meet the event, not resulting from Member Provider's act or
eredentialing guidelines of RHG. omission, which materially affects Member
Provider's ability to continue the practice of
V.2 Indemnification of RHG. RT✓fG will be medicine or to perform his obligations hereunder.
E responsible for its own acts or wnissions and any The network will provide notification to employees
and all claims,liabilities,injuries,suits and demands of the terminating Member Provider immediately
and expenses of all kinds which may result or arise upon receipt of the Member Provider's termination
Page 7 of 14
sherry Kond2icla,MU U15115 RUNPI lY TX_
request or as soon as reasonably possible before the V1.2.4 Termination by Either Part . 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). eithor party may terminate the Agreement with at
C least ninety (90) days prior written notice to the
i
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 wbieh case,the Agreement and applicable rates and
services are rendered is suspended or revoked, (ii) terms shall continue iru effect, Either pm'ty 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 loses their 3CAHU, NC'QA, AAA'HC,
URAC, CLIA or other applicable license, V1,2.5 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 rolieved of those obligations for the duration of the
safety or to the delivery of quality patient care,or to inLerrttption 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 X1.3 Effects of Termination, Upon termination of
(vii) Member Provider fails to meet III1G's or the this Agraement, neither party shall have any further
State's credentialing requirements, RRG, however, obligation hereunder except for (i) obligations
may not terminate this Agreement in direct response accruing prior to the date of termination, including
e 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 RTIG 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 RHC- to notify Qualified Participants and
Payors of Suck termination.
Upon written notification from RHG, Member
Provider may request a review by RHG's advisory VIL CONTINUATTON OF BENEFITS
review panel, not later than thirty (30) days atter
notification. RHG must then complete the review VI1.1 Continuation of 13enefits, If Member Provider
before the effective date of termination. voluntarily terminates its contract with RHG, upon
Member Provider's request, Payor must continue to
VL2,3 Termination for Insolvent , This Agreement reimburse Member Provider for a period not to
,shall toxminate immediately in the event that either exceed 90 days at the Member Novider's contracted
RHG or Member Provider voluntarily or rate set forth in 1~x.hibit R of this Agreement with
involuntarily, liquidates, dissolves or becomes RI 10,for care of an Qualified Participant with a life-
subject to any proceeding for the rehabilitatioa or threatening condition or an acute condition for
conservation of their financial affairs with written which discontinuing or disruption of care would
notification. harm the Qualified Participant as per 28 TAC
10,42(b) (5)(A).Any disputes concerning continuity
of care shall be resolved through the complaint
'
Sherry Kondziela,i1dD IAS/15Parc 8 of 14 RLJNPHY TX_
process under Insurance Code §1305.401 - IX.I Dis Utes. All disputes and difference between
§1305,405 and Subchapter O of Title 23, Part the Member Provider and RHO upon which an
(relating to Complaints), amicable understanding cannot be reached are to be
decided by tho following method:
V11,2 Survival. The provisions of this Article VII_ 1X,1.1 Mediation through RHG. The .Member
shall survive the .termination of this Agreement Provider shall notify R14G in writing of the dispute
regardless of the cause - giving rise to such or disagreement and shall provide all .necessary
termination, as will sections If.9, V.2, V.3, VL3, information to R.HG. RHO shall use best efforts to
VIII and IX. Thep rovisions 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 RHGSs
contrary now existing or hereafter entered into Provider Handbook,
between Mcmber Provider and any Qualified
Participant or any person acting on a Qualified IX.i.2 Arbitration. If the dispute cannot be solved
Participant's bdial£ by the mediation process described above,either the
Member Provider, RHG or Payor may elect to
Via. CONMENTIAL€TY 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 RHO 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 perta ming; to RHG 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 fi om the Network,
charts,shall be and remain the sole property of RHG as follows:
or Member Provider respectively (collectively, the
"Confidential Information"). RHO and Mcmber IX.1.3.1 R1IG 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 RHG;
RHG or Member Provider that is competitively
sensitive is the property of RHG or Member IX.1,12 Upon receipt of the written notification of
Provider and RHG or IvMuniber 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
party. 'Accordingly, RHO and Member Provider panel no later than 30 days after receipt of the
agrees to keep strictly confidential and to hold in notification;
trust all Confidential Information. Upon termination
of this Agreement by either party for any reason IX,1.3.3 The Network will provide an Providers
advisory
Whatsoever, RHO and Member Provider shall review panel that consists of at least three
promptly return to the other all material constituting; of the same licensure and the same or similar
Confiidential Information or containing Confidential specialty as the Member Provider;
Information, and neither party will not thereafter
use:, appropriate, or reproduce such information or IX.1.3.4 The Network,must complete the advisory
disclose such information to any third party, RLIG panel review before the effective date of, the
and Member Provider specifically agree that under termination;
no elrcumstanees will either party discuss the terms
and conditions of this Agreement, and in particular IX.1.3.5 The Client,Payor, or RHG rrtay not notify
patients of the termination until the earlier of the
the pricing inforrnatiozz herein,
effuctive date of the termination or the date the
IX MISULLAN OUS advisory review panel makes a formal
i recommendation;
i Pop 9 of.t4
Sherry Kon6d0a,Mn 1/151)S RtjMHY 'rk
I
IX.1 3.6 If Vi ember Provider terminates the contract,
the Network or R-UG's Client will provide DU Amendme t , This Agreement may be
notification of the termination to employees amended as agreed to by both parties in vn•iting upon
receiving care from the terminating provider. The thirty (30) days written notice of such proposed
Network shall give such notice immediately upon amendment.
receipt of the Member Provider's termination
request or as soon as reasonably possible before the IX.8 Severability. The invalidity or un-
effective date of termination. enforceability of any tcrtn or condition hereof shall
in no way affect the validity or enforceability of any
IX.2 Non-Exclttsivi Nothing in this Agreument other term or provision.
shall be construed to restrict Member Provider or
RHG 'from entering into other contracts or M9 Assignment. Member Provider may not assign
agreements to provide healthcare services to Payors or otherwise transfer any right or delegate any duty
or other healthcare delivery plans, patients, and of performance hereunder, in whole or in part
employer groups. without the prior written consent of RHG, A change
in ownership will not negate the prior contractual
DU Entire Agreement. 'Phis Agreement contains agreement without written notification to RHG.
the entire understandingof the parties and RHG retains the right to assign this Agreement, in
supersedes any prior understandings and agreements, whole or in pant;to any entity with which RHG or its
written or oral, respecting the subjects discussed parent company or any of its subsidiaries is
berein. afliated,or with which it merges or consolidates.
1X.4 No Waiver. The waiver by either party of a 1X.10 ThirdFarty Benediaiaries. Except for Payors
breach or violation of any provision of this and the agents thereof; there are no third party
Agreement shall not operatc as or be construed to be beneticinries if this Agreement.
a waiver of any subsequent breach hereof.
IX.II Captions. The captions and headings
IX.5 Re ulatot Com lianc@. I4iember Provider, contained in this Agreement are for reforence
sub-contracting providers, and RHO agree that each purposes only and shall not affect in anyway the
shall comply with all applicable requirements of meaning or interpretation of this Agreement.
municipal, county, state and federal authorities, all
municipal and county ordinances and regulations, IX.12 Execution of Cour c arts. This Agreement
and all applicable state and federal statutes and may be executed in any number of counterparts,
regulations, now ei bLreafter in force and effect, including facsimiles, each of which shall be deemed
governing RHG, Nfember Provider, sub-contracting to be an original as against any part whose signature
providers, the provision of services by Member appears thereon, and all of which shall together
Provider or sub-contracting providers, and/or constitute one and the same instrument.
Payers, including but not limited to applicable
requirements under any state or federal fair IX..13 Partial Invalidity. if any part, clause or
employment practices, equal employment provision of this Agreement is.held to be void by a
opportunity, or similar laws declaring discrimination court of competent jurisdiction, the remaining
in employment based upon race, color, creed, provisions of this Agreement shall not be affected
religion,sort,or national origin as illegal, and,Titles and shall be given construction, it possible, as to
VY and VII of the Civil Rights Act of 1964, Section permit it to comply with the minimum requirements
202 of Executive Order 11246 as amended by of any applicable law, and the intent of parties
Executive Order 11.375,Sections 503 and 504 or the hereto.
Rehabilitation Act of 1973 and Title IV of the
Vietnam lira Veterans Readjustment Assistance Act
of 1974, and Sections I and 3 of.Executive Order
11625, or any applicable rule or regulation
promulgated pursuant to any such laws or orders.
IX.6 Goyerning_Law. This Agreement shall be
governed by and construed in accordance with
i
applicable state law.
i
Sherry Kondzlela,2AD 1/15/15 Page 10 of 14 RUNPHY^1'X
1
I
f Jan 161604'67p p.4
1X.14 Finanoial Incentives,Nolfhor a Client,Payor, 3X.17 olal Notiae& Any notice or
1 1tar jMfQ may usa iinanolal inrentive or-make a aommunI"catioa x6quired,permitted or dash-ed to be
i payment to n it%lth care provider•t#tat aots directty given herwWer shall be deemed eMotively given
or indimcdy as au it,ducement to limit medically when personally delivered or malted, return mceipt
i .necessory sarvices. The adoption of treatment and requested, or ovornight expross mail addressed as
aetutn-to-r1�vork guldeanes and individual treatmwf •foliows:
protocols by RHG or Network1s,not In Wolation of-
i this smdan as pursuant to Tnsuiance Code §1305.
304wd�10,33(4)o£Cbp 10 of Title 28 Part 1. '
IX,TS plt&,nelal DIsei6sure Reyulrements. Member
Provider is required to ale finanoial djsclosures in
awl-demo with Ubuor Code 99408.02$ and ,leer!berProviderorReprosenlat€ve/Designee:
0§413.041. (please Print)
t
M-16 15oonamie Ratlling• Network.roust provide Tlame:9-fiexr.KondAbla:M
w4tten notlee to Member lIr ovlder be#'oro the
i Net�vorkt o�ttduats ecortamtc profilin, 1nclucTiag Organization.
-atilizatlog Maoageincnt studies or other proQling of
the provider or group ofproviders. Address- 1307$th Ave Snite 1 Qd
CitylStatel,Zip:FortW rth q 661 4
Telephone,817-921-44oa
' X406
Cox; 817-9.2t� ,
1 Ucganlratfon:
Rool,•poi•tCommunity NetwDrk,Mo.
dbaP.ockpoxtIfeAtlx:ara Grovp
Afftn Network Development
$0 Wfir Hollow Lene,Soho 51 SKr
Houaon,TX17017
Yelophonm(913)621-9424
iia WivTNM WHEREOF,tho undcrsigne4 will be Fax:(?13)627-951)
deemed to Dave oxeouted'thio Agreement ag of its or to ncli other addross,and to the attorttion of strep
data die provideris fully eredentiuted by RHU. other pereon(s) or off eer(s) ns either party may
designate by written nodes.
Vor and on behalf of:
?`±or aiact on bahalfok
Ttontcpart Community NaMorki;Inc,
�ba.INckportkllcalltheare Group' lYlomborWovider or Aepresutt141rt'valD019n0
ISR k3zlar Hv[ko�v XruYt suite b7151rS� r
7027 Sigxleittxa2��-1�:-- .-
1=V Name-S herryx0y1dZie it
(<i?otigl� ,I Xarlillszut) � {rdncj
Prasid6'-53954 0
j 1:'Mw
II Pusatlort4 n ,
r ! S1ic!=_viCendzkia,btt}IJt5.rt5 TRtpi�i'3m
j .
i
EXRTBIT A,
STANDARDS AND GVEDELINES
UTILIZATION REVIEW AND QUALITY TiVIPROVEMENT PROGRAMS
WIG 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 ot'work-related injuries/illnesses Icor Qualified Participants.
IZI1G's Clients provide utilization review and quality improvement programs for Qualified Participants. RHO shall
review each Clients Utilization Review and Quality Improvement program in accordance with WIG's Credentialing
Standards and.Guidelines as described in this Exhibit, Physician and/or Member Provider agrees to comply and be
bound by such programs and any state or federal ruIes and regulations.
Such Standards and Ouidelines 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 ro:
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 Require Preauthorization;unless otherwise specified by the network:
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 Gabor Code§408.026;
4) All psychological testin r and psychotherapy, repeat Interviews, and biofeedback; except when any service is
part of a preauthorizcd or exempt rehabilitation program.;
5) All external and implantable bone growth stimulators;
6) All chemonucleolysis;
7) All myclogq'ams,discograms,or surFace electromyograms;
S) Unless otherwise,specified,repeat individual diagnostic study,with a fee established in the current Medical Fee
Guideline of greater than 5350 or documentation ofprocedure(DOP);
9) Work hardening and work conditioning services provided in a facility that has not been approved for exemption
by the Division;
ib) Rehabilitation progranns 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 e.cpected 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 e.Verimental 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 eons(ant "attendance; Ci) therapeutic
procedures,excluding work hardening and work conditioning;and(iii)other procedures,limited to the.unlisted
physical medicine and rehabilitation procedure code.
16) Closed Formulary Drugs,as defined by 28 TAC Chapter 134,Subebapter F.
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.
i
Pe6p 12 of A
Sherry Konklcla,MDIII S/t5 t2tJtdPHY TX
Jan TS 16 04:67p PS
j Reimbursement Schaduto
1.Radcporf lrulted Networl(Moelcporl Sel tWealth Network. xrijuryax d MOO
Pmvldor fees for the proge ms Ifded above-sliall bD reimbursed at tbo following:
All fees will bo relrnburscd at:90% of the state's curren't Woxbols' Compensation
fees,Tyles and roplarions oz usual aud,oustomaty allowablm ,
Coverage= Coverage for alt procedures on the fee Schedule is subjaot io tha terns awl coudittons of
tug Agraehnsat,state rules and regulations antlfor t3io applicable Omipadosial thjury or-Anass Bened'It
Plarh.
: Z
M'YL-accept the ibes as outllued in Eli's Vorldbit 13.
Noir and on bobalfofh Por and on baTialf ofi
(Name,00dress,et-Q.)
ROC12ORT+COlYiT44UIs11' )MR.T"WOI: . INC. Sier Xondzfebr.,N.ftt
dba Roakport Henithcara GroupP Ave Sulte 100
50)Drlarwollo Lax1e,SuitoAM .VortNVar>l1sx�7hl0d
au3 D T` s�776 '7�
' Bigl3ature �`
ZDou�Ia .�4)�rkllam.) 1?'Pl:nfed TTaatze$71er nd " .
X'rasl$ont: �'itXc .
Daie t
Page 1W 14
shon}'F:ncUh3dgh1D111vis RUNPRY TJX„
t
Jeri 951804,67p p.6
1'Ifysxelsus and/orlooationsYfiherQ serviees are to be rpj1 lored by Member J"rowido)r
ThiLMomborP" idekAgrees(hittIItetolfbaingphystefgns!Witt/orpradiialooRtfohs11steelonattaeBed, x jbIt
8htt11bn3ncIusfvaAPthes#gctedp roemenEandf&ostgruedrateslpl xljrbit)a, gysig„(ngbBlopy3L ernbor or Rs,
Represetainiis elDcsfg,tee allows IinrkportHealthenre Graup(R96)Avid its topresentatives to use any and alt of tho
E helow 1ni'Pruca11tm os ngrao-d to in this signed agroot»ant;
��yT:nndxlelK Mb
1}xaotlua Ndrrta(I) I'rantice Name{n)
Pbysic3�att itavta{if appli0ablo) Mwelciats Name(Xeappllcabfe)
E 1367 s A��s�SgjtpJOq
PhyslDal Address 7'hysleal.Addrms"
FQT()VarElr,'iX 76194
Com,State Zip ratty,State Zip
N
MailingAddross(ifdiflo ett i
Si7--921 0Q 181 ltrlallfngt3ddress(ffdlffexetxt)
-�f �921.4Q05
Phu O Number/.Viax N'umltcr MOM NUMber I Pax Namber
Tax ID Number Tax ID Number '
f
►
Practice-Aurone,(3) i
�W100 Nanic(4)
i
Physituart IJame(]fapplirablal J'.l 3101an A'a (ifapplRbie) i
PhyslcQ Undress — -- l
- 1'Itysica��ddzass �
City,State 7fli city,sztite ,p •
il�Jttllfng Address(ifd) oxattt) dV,taflulg Adclrcas(ifcllfervni}
Pact ep Number!Cax tE �"y
ItT tuber PhuaebluMber/Fax Nvtuber ;
)V8rand on bebtl1'oi's p'of�and on boltatrof:
ROORpoxt Community Not#vork,ZuF MemberProridep or 7topresentntfvelBesiguQa ;
dba Rookporb Roalth-bare Group
i`l 1411v Rolloty L o,Suite 5X5'+,'
�oudtonfT y7102471I 4
, �
[Dougra ark 'atti) Name:Sfltar . YCandy tint)
Presided
Aatat - t h5 u<*
Date., c
sh�m•x�nd���,�►nstts rano t�.ar to -i
. 1