HomeMy WebLinkAboutContract 47186-P30 CITY SECRETARY/
ROGKPORT ` CONTRACT NO. 5D
A We1lComp.-company.
ADDENDUM
To
B1ackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Alfredo Marti, MD ("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
, ("Provider Agreement"),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.
I 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
j section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of
B1ackStone) 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.
i
Rockport will continue to provide applicable network administrative services.
j
Alfredo Marti.MD
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.
"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 of the Texas Labor Code.
4. Nothing in this Addendum or the Provider Agreement shall be interpreted to inure 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 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.
IN WITNESS WEWMOF,the parties hereto have executed this Addendum effective on the day and year
first written above.
For and on behalf of:
C IPI q FiVIT �Yt
BlackStone
Signature.
Name: A.
Title: SS 1 STGGI ►�-1 st ��(JtG E( yam. O�
Date:��'—� `�� V'• V 2
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C * �t
I(onald P. Gonzales,.Aid., _City. ••
V � T7 AS
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Adiedo Marti,MD
ROCHrORT COI1URlM NETWORK
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5lgaatw•e• � • a ��-•. '
Ii�me:3 Pavia
Title:Sr.Vide President
Date:
1V.t MMER PROVIDER or
RepxesentativelDesignee
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Title, Uf Uct w
Date: cel
TIN:01-05570
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ROCKPORT "
A WellCOrnp Company
PHYSICIAN AGREEMENT
ROCKPORT COMMUNITY NETWORK
This Physician Agreement("Agreement"),is entered 1.1 "Physician"means a licensed Medical Doctor or
into by and between Rockport Community Network, Doctor of Osteopathic Medicine, or group of same
Inc.,herein known as "Rockport", a Nevada who desire to become a Member Provider with
Corporation, and Alfredo Marti. MD ("Member ROCKPORT.
Provider"), and will become effective as of the date
the provider is fully credentialed by ROCKPORT. Pursuant to Title 28, Texas Administrative Code
§10.42 regarding Network Contracts with Providers
WHEREAS, ROCKPORT is engaged in the seeking to participate in Texas Certified Workers'
business of developing and acting in an Compensation Networks,
administrative capacity in providing Occupational
Injury and health provider networks that offer I.2 "Oualified Participant" means an "employee" as
direction of care while providing savings to defined and used in the Texas Labor Code, the
ROCKPORT clients and/or Payors. These networks Network Act Section 1305 and the implementing
will offer greater coverage of services and savings; rules who sustained a work-related injury/illness that
and is determined compensable by a Client and that
participates in the Rockport Community Network
WHEREAS, ROCKPORT has networks of through Rockport's Client. Unless in an emergency
contracted physicians, physician groups, hospitals or after business hours, initial services provided for
and providers of ancillary healthcare services the work-related injury/illness require authorization
(collectively, the "Member Providers") to provide a by the network either in writing or by telephone.
full-range of healthcare services. These services are
available for use by "Qualified Participants" as I.3 "Client" means an insurance company, certified
defined in I.2 of this Agreement; and self-insured or governmental entity as those terms
are defined and used in the Texas Labor Code, the
WHEREAS, Member Provider desires to provide Network Act Section 1305 and the implementing
medical care services to "Qualified. Participants" rules. These Clients have entered into a Client
who are covered by Payor Agreements at the rates in Agreement with ROCKPORT for the provision of
Exhibit B and in locations listed in Exhibit C: and healthcare services to Qualified Participants.
inclusive of the networks included in Exhibit D;and
L4 "Payor" means an insurance carrier or network
WHEREAS, ROCKPORT has entered into certified by an insurance carrier for its own benefit,
Agreements and/or services with one or more Payors certified self-insured or governmental entity as those
who provide payment of claims for medical care terms are defined and used in the Texas Labor Code,
rendered to Qualified Participants. the Network Act Section 1305 and the implementing
rules who is responsible for payment of medical
NOW, THEREFORE, in consideration of the benefits for on the job injuries and or illnesses
premises,the mutual promises contained herein,and according to State and/or Federal Rules and
other good and valuable consideration, the receipt Regulations.
and sufficiency of which are hereby acknowledged,
it is mutually agreed as follows: I.5 "Client Agreement" means the agreement
between ROCKPORT and a CIient, which
I. DEFINITIONS agreement is made before, on or after the effective
date of this Agreement and which expresses the
When used in this Agreement and unless the content agreed upon contractual rights and obligations of the
otherwise clearly requires, the following words and parties. Such Client Agreements will require Payors
terms shall mean: to pay Member Provider for Covered Services
rendered toQualif ert park ciramc suant to this
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Alfredo Marti,MD 3-15-17 n„ C��Gr RCNPHY TX_062016
s�c9�gG�9T�
Agreement. Furthermore, such Client Agreements including severe pain,that the absence of immediate
shall authorize ROCKPORT to enter this Agreement medical attention could reasonably be expected to
and contractually bind Payors to the terms hereof result in:
unless there is a conflict with State and/or Federal (a)placing the patient's health or bodily functions in
rules and regulations. serious jeopardy,or
(b) serious dysfunction of any body organ or part as
1.6 "Member Provider" means 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; experiencing the mental health condition or another
physical, occupational and speech therapist; etc. personas defined in TIC 1305.004(15).
licensed or certified to practice a healthcare
profession or licensed as a facility to offer healthcare 1.10 "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 ROCKPORT. Participants for treatment of a compensable, work-
related injury/illness as defined by either nationally
1.7 "Primary Treating Physician/Clinic" According recognized treatment guidelines and/or individual
to Texas law for certified workers' compensation treatment protocols that do not conflict with any
networks, the Network decides who will be a state and/or federal rules and regulations.
Treating Doctor.Therefore, a Member Provider who
is a Medical Doctor (MD) or a Doctor of I.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 Occ- Committee or CMS 1500 billing 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 ROCKPORT as a U. MEMBER PROVIDER OBLIGATIONS
Primary Treating Physician/Clinic (PTP). PTP
agrees to render medical care to Qualified H.I Services. Member Provider agrees to provide or
Participants without a scheduled appointment and arrange for all medically necessary medical care for
must be available and accessible to employees Qualified Participants who present themselves to
twenty-four (24) hours-per-day, seven (7) days per- Member Provider. Member Provider agrees to
week as per 28 TAC 10.80(b)(1). Should a Qualified perfonn such services with the same standard of
Participant need medical attention outside of care, skill and diligence for all Qualified
Member Provider's normal business hours, Member Participants, Member Provider agrees that it is their
Provider will be available and/or make arrangements sole responsibility to verify that the individual
to have another Member Provider render care to presenting for care is a Qualified Participant.
Qualified Participant twenty-four (24) hours-per- Member Provider agrees to render healthcare
day,seven(7)days-per-week. services to Qualified Participants at any and all
facility or practice locations listed in Exhibit "C".
1.8"Specialist Fhysician" means a Member Provider Member Provider shall make best efforts to ensure
who has met the credentialing requirements of that services provided are consistent with nationally
ROCKPORT to be a Specialist Physician, and to recognized treatment guidelines (i.e. Official
whom Primary Treating Physicians/Clinics may Disability Guidelines (ODG), American
refer for necessary and authorized care other than Occupational and Environmental Medicine's
primary treating services. Specialists will need to (ACOEM) and /or state rules and regulations.
maintain their current board certifications for their Member Provider agrees to comply with and be
particular specialty to maintain their ROCKPORT bound by all State/Federal Rules and Regulations.
classification as such and be willing and able to treat
} Qualified Participants as needed or required.. H.2 Treatment Guidelines. Member Provider agrees
to follow the treatment guidelines, return-to-work
1.9 "EmerQencv Medical or Mental Condition' is guidelines and individual treatment protocols
defined as the sudden onset of a medical condition outlined in Exhibit A of this Agreement,provided in
manifested by acute symptoms of sufficient severity, ROCKPORT's Provider Handbook and/or CIients'
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Alfredo Marti,MD 3-15-17 RCNPHY TX_062016
Utilization Review Programs. ROCKPORT agrees representative, and requested information is not
to furnish Member Provider or cause Payor to prohibited by state and/or federal rules and
furnish to Member Provider, and Member Provider regulations.
agrees to abide by, the list of any treatments and
services that require preauthorization and by any II.7 Professional Requirements.
procedures to obtain preauthorization. Unless in an
emergency or after business hours, initial services IL7.1 Licensure&Accreditation. Member Provider
provided for the work-related injury/illness require shall comply with all applicable federal, state and
authorization by the carrier and/or Network either in local laws, rules and regulations governing like
i; writing or by telephone. The Client and/or Payor providers and their provision of services. Evidence
may not deny treatment solely on the basis that a of such current licensing, certification and/or
treatment for a compensable injury in question is not accreditation shall be submitted promptly to
specifically addressed by the treatment guidelines ROCKPORT upon request. Member Provider
used by the Client and/or Payor. However,Member represents and warrants that it and each of its
Provider must demonstrate medical necessity to employees and contracted service providers has
support services rendered to Qualified Participants obtained, and shall maintain throughout the term of
that are outside of treatment guidelines. this Agreement, all necessary registrations,
certifications, licenses,permits and approvals as are
II.3 Non-Discrimination.Member Provider shall not required for the lawful provision of Member
differentiate or discriminate in the treatment of its Provider services to Qualified Participants. Member
patients as to the quality of services delivered to Provider shall immediately notify ROCKPORT of
Qualified Participants because of race, sex, age, any revocation, suspension or restrictions, that
religion, national origin, place of residence, source would affect any certifications, licenses or
of payment or health status. Member Provider shall accreditations. Member Provider warrants that it is
observe,protect and promote the rights of Qualified currently accredited by the Agency that governs like
Participants. providers and is certified as a provider under Title
XVIII (Medicare) and when appropriate, Title XIX
I1.4 Medical Staff Participation. Certain medical (Medicaid) of the Social Security Act and that it
specialties may not require hospital privileges such shall maintain such accreditation and certification
as Occupational Medicine,Pathology, Dermatology, during the term of this Agreement. Member
Allergy, and those Primary Treating Provider shall immediately notify ROCKPORT of
Physicians/Clinics whose practice is dedicated to any action, investigation or proceeding to revoke,
treating work-related injuries and illnesses. Where suspend, restrict, or otherwise affect such
appropriate, Physicians must maintain active, accreditation or certifications.
unrestricted staff privileges with at least one
ROCKPORT Member Provider hospital or Surgery 11.7.2 Organization's Requirements. Member
Center. Physician hereby consents to disclosure by Provider shall use best efforts to comply with
such facility to ROCKPORT of all data collected ROCKPORT's criteria for provider participation,
with respect to Physician in connection with including credentialing policies and procedures.
Physician's medical staff membership, including Member Provider shall cooperate with
without limitation all applications for staff privileges ROCKPORT's periodic evaluation of qualifications.
and any renewals thereof. In addition, Member Provider shall use best efforts
to cooperate with ROCKPORT's and/or state rules
II.5 Referrals. Except in a medical emergency or and regulations for the expeditious resolution of any
when authorized by ROCKPORT, Client, or its grievance or complaint.
designated representative, Member Provider agrees
to refer Qualified Participants only to other Member II.8 Notification to ROCKPORT. Member Provider
Providers,as defined in I.6. represents and warrants that information provided
I.6 Reports. For each encounter where Member herein and in the ROCICPORT application is true
Provider provides services to a Qualified Participant, and accurate in all respects and acknowledges that
Member Provider shall report such encounter on an ROCICPORT is relying on the accuracy of such
appropriate form and shall include statistical, information in entering into and continuing the term
descriptive medical and patient data and identifying of this agreement. In addition Member Provider
information, if and to the extent that reports are shall use best efforts to provide written notice to
specified by ROCKPORT, Client or its designated ROCKPORT of any(i) suspension,reduction or loss
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I
of license to provide healthcare services; (ii) denial, under this Agreement. Member Provider further
suspension, restriction, reduction or termination of agrees to allow ROCKPORT, Payor or a designated
accreditation/certification; (iii) changes in Federal representative thereof, including the designated
Tax Identification Number(s), (iv) other information utilization review, quality management, case
provided in its application or Exhibit C for management or peer review staff,to have reasonable
+ participation, (v) Member Provider's professional access to medical records and information of
liability insurance if such insurance falls below the Qualified Participants for services provided under
requirements of state law and (vi) Member the terms of this Agreement as necessary to enable
Provider's billing or facility address. A failure to such party to perform Utilization Review and
give any notice required by this Section shall be a Quality Assurance activities in accordance with the
material breach of Member Providers obligations applicable Utilization Review and Quality
and responsibilities hereunder, regardless of the Assurance Program. In addition, Physician agrees
status,pendency or outcome of the event giving rise that in the event an examination concerning the
to the obligation to give that notice, and may be quality of healthcare services is conducted by
grounds for termination of this Agreement. appropriate officials, as required by federal, state,
and/or local law, ROCKPORT shall submit, in a
11.9 Medical Records. Member Provider shall timely fashion, any required books and records and
maintain complete and timely medical records for shall facilitate such examination. ROCKPORT and
Qualified Participants treated by Member Provider Member Provider agree to assist one another with
and its medical staff. Such records shall be prepared on-site inspection of facilities and records by
in accordance with accepted principles of practice, representatives of authorized federal, state and local
shall document all services performed for Qualified regulatory agencies
Participants and shall comply with all applicable
state and federal laws. Member Provider shall 11.11 Relationship of Parties. Member Provider and
maintain such records for the length of time required ROCKPORT understands and agrees that they are
by applicable state or federal law. Subject to all each an independent legal entity. Nothing in this
applicable privacy and confidentiality requirements, agreement shall be construed or deemed to create a
such medical records shall be made available to each relationship of employer and employee, principal
Member Provider and other health professionals and agent, partnership or joint venture or any
treating the Qualified Participant, and upon request, relationship other than that of independent parties
to the Payor, ROCKPORT or its designated contracting with each other solely to carry out the
representative for review at the rates approved by provisions of this Agreement for the purposes
State law and as set.forth in the current State recited in this Agreement. With regard to the
Workers' Compensation Reimbursement Manual for provision of healthcare services, Member Provider
Hospitals, if applicable. Member Provider shall acts as an independent entity and the Member
obtain a valid consent for the release of the Qualified Provider-patient relationship shall in no way be
Participant's medical records to other providers, affected.
ROCKPORT, Payor, or its designated
representative. ROCKPORT agrees that medical 11.12 Standards of Care. Member Provider agrees
records of Qualified Participants shall be treated as that all duties performed hereunder shall be
confidential so as to comply with all federal and consistent with the proper practice of their
state laws and regulations regarding the healthcare profession, and that such duties shall be
confidentiality of patient records. The Member performed in accordance with the customary rules of
Provider's obligations under this Section 11.9 shall ethics and conduct of the appropriate and applicable
survive the termination of this Agreement. professional organizations and/or associations,as the
case may be, and such other bodies, formal or
I1.10 Inspection of Records and Operations. informal, state, government or otherwise, or by
ROCKPORT, Payor or a designated representative which they are subject to licensing/certification and
shall have the right to inspect and audit, at all control. Additionally, Member Provider shall
reasonable times during norinal business hours,upon perform all medical and healthcare services in
prior five (5) business days, any of Member conformance with the standards for their facilities as
Provider's medical records and operations established by the local/regional professional
reasonably pertaining to ROCKPORT Qualified healthcare community and applicable
Participants, services provided to Qualified accrediting/licensing agencies. Member Provider
Participants, and to Member Provider's performance agrees that,to the extent feasible,it shall utilize such
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Alfredo Marti,MD 3-15-17 RCNPHY TX 062016
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additional allied health and other qualified personnel Provider Locator System (ii) Provider Directories
as are available and appropriate for effective and (iii) Site-Specific Provider Panels (iv) Customized
r efficient delivery of care. Member Provider shall Local Networks and (v) Client Service Provider
ensure that all such personnel are properly licensed Referral Service.
and/or possess the necessary credentials to render
the services that they perform. 111.2 Credentialinl;. ROCKPORT will perform
and/or delegate to qualified organizations
1113 Right to Use Member Provider's or Network's credentialing of each Member Provider.
Name. Member Provider agrees to allow Credentialing may include verification of all
ROCKPORT to list Member Provider's name, information and documents provided in the
specialty, address, telephone number, and hours of application for participation and investigation,
operation in a Member Provider directory, Provider including but not limited to verification with all state
Search, ROCKPORT Site-Specific Provider and national licensing and certifying bodies that
Panel(s), ROCKPORT website and/ or other apply to the services rendered by the Member
materials to help promote and assist Clients with Provider, such as JCAIIO, AAAHC,NCQA, CLIA,
Qualified Participants needing medical care for URAC, etc. Inquiries may also be made to current
injuries/illnesses sustained. ROCKPORT agrees to and previous professional liability carriers,Medicare
allow Member Provider to list ROCKPORT's name, and Medicaid. ROCKPORT's credentialing policies
address, and telephone number on Member and procedures follow the American Accreditation
Provider's website or in other publications listing the Healthcare Commission (URAC) and/or NCQA
health plans accepted by Member Provider. In standards for Workers' Compensation provider
addition, Member Provider agrees to post in waiting networks.
room and make available to Qualified Participant
notice of Member Provider's participation with III.3 Operational Functions. ROCKPORT shall
ROCKPORT with name, address and telephone utilize systems to respond to Member Providers
number and process for Qualified Participants to requests for information and will provide
resolve complaints. The Member Provider is clarification of policies concerning the operation of
required to post,in Member Provider's office,notice ROCKPORT's programs. Member Provider agrees
to employees on the process for resolving workers' to work in cooperation with ROCKPORT to market
compensation health care network complaints. The the services of the Member Provider to Clients and/
notice must include the Texas Department of or Payors.
Insurance's toll-free phone number for filing a
complaint and must list all workers' compensation ROCKPORT shall act as a liaison with the Member
health care networks with which the Member Providers and Clients and/or Payors to devote
Provider contracts. necessary time and effort to perform ROCKPORT's
responsibilities hereunder.
11.14 Noncompliance.Member Provider understands
that failure to comply with any of the requirements IIIA Retaliatory Action. ROCKPORT agrees not to
imposed pursuant to this Agreement may result in engage in any retaliatory action including
termination of this Agreement by ROCKPORT. termination of contract or refusal to renew a contract
against Member Provider, because Member
11.15 Antitrust Guidelines. Member Provider agrees Provider, on behalf of an Qualified Participant,
to comply with all antitrust guidelines and reasonably filed a complaint against, or appealed a
procedures promulgated by Federal and State decision of ROCKPORT or Payor, or requested
entities. reconsideration or independent review of an adverse
determination.
III. ROCKPORT's OBLIGATIONS
111.5 Antitrust Guidelines. ROCKPORT agrees to
III.l Marketing to Clients/Payors. ROCKPORT comply with all antitrust guidelines and procedure
shall enter into agreements with Clients and/or promulgated by Federal and State entities.
Payors as defined in I.3 and I.4 for their access to
ROCKPORT quality Member Providers through IH.6 Audit Policy and Procedure Compliance. All
specific referral processes. ROCKPORT will bill audit requests by Payor shall be done in
market Member Providers for referral; including but accordance with the State Law and/or Federal Rules
not limited to the following: (i) Provider Search and Regulations.
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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.
I.1 Reimbursement. ROCKPORT shall arrange All billing and reimbursement will be made in
and provide the Member Provider, locations and/or accordance with Labor Code 408.027 and all other
any additional Tax Identification Numbers as listed applicable state rules and regulations.
in Exhibit C for Payors to pay Member Provider the
reimbursement rates for Covered Services rendered I.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
ROCKPORT is acting solely in an administrative other appropriate claim form or their successors)and
capacity in providing a network of quality health must include Member Provider's usual and
services.ROCKPORT is not the claims paying agent customary billed charges (not discounted rates) and
and will not be liable for the payment of any amount appropriate codes, consistent with policies
owed by a Payor to Member Provider in the event established or approved by applicable state and/or
that Member Provider is unable to collect such federal regulations. Member Provider must submit
amount of money up to and including the insolvency claims to Payor not later than the 95'h day after the
of the Payor. Under no circumstance will a Member date on which services are provided to the Qualified
Provider attempt to collect payment from a Qualified Participant, or as specified by state law. In
Participant for medical services rendered for a accordance with Labor Code §408.027 and other
compensable,work-related injury/illness. applicable statutes and rules,billing and payment to
Member Provider will be made within forty-five
I.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 B. Member Provider hereby agrees that
rates in Exhibit B,which may be amended from time IVA Limited Recourse Against Oualified
to time upon mutual written agreement,represent the Partidpants. 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 compensable injuries from
claim. A complete and accurate claim shall be Qualified Participants. In addition, Member
defined as a clean claim by Medicare. ROCKPORT Provider agrees that neither ROCKPORT, the Payor
does not guarantee, represent, warrant or covenant nor the Qualified Participant shall be billed or
regarding the selection or use of Member Provider's ultimately held responsible for payment of services
services by any Qualified Participant or Payor,or the deemed not to be covered by the Payor or its
number of patients, if any, which may result from designee.When Qualified Participant is covered by a
participation in ROCKPORT's provider network. state or federally regulated Occupational Injury and
The obligation of a Payor to reimburse Member Illness program,Member Provider agrees to comply
Provider in accordance with Exhibit B for the with state and federal regulations regarding holding
provision of Covered Services to a Qualified Qualified Participants harmless for amounts not paid
Participant shall be conditioned upon a good faith by Payor for any reason,including Payor or network
determination by the Payor or its designated insolvency. This provision does not preclude billing
representative that (i) such services are medically a Non-Qualified Participant for a non-compensable
necessary, whether such determinations are made injury.
before, on or after the provision of services to such
Qualified Participant. I.4.1 Transfer of Risk. This Agreement and any
subcontract within shall not be interpreted to involve
All services billed under the Tax Identification a transfer of financial risk for the provision of health
Number(s) indicated in this Agreement, any care services from Payor to ROCKPORT as defined
Amendments, Exhibit A, Exhibit B, Exhibit C, under Insurance Code §1305.004(a)(26). Member
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Alfredo Marti,MD 3-15-17 RCNPHY TX 062616
Provider agrees and acknowledges that ROCKPORT or representatives,in the performance or omission of
is acting solely in an administrative capacity in any act or responsibility under this Agreement. In
providing a network of quality health providers. the event that a claim is made against ROCKPORT,
ROCKPORT is not the claims paying agent and will it is the intent of ROCKPORT to cooperate in the
not be liable for the payment of any amount owed by defense of said claim. However, ROCKPORT shall
a Payor to Member Provider in the event that have the right to take any and all actions they believe
Member Provider is unable to collect such amount of necessary to protect their interest.
money up to and including the insolvency of Payor
or the Network. V.3 Indemnification of Member Provider. Member
Provider will be responsible for its own acts or
N.5 Payment of Claim Forms. ROCKPORT 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
Agreement within the tune 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 made against
IV.6 Erroneous Payment. In the event that a Payor Member Provider, it is the intent of Member
and/or its designated representative pays the Provider to cooperate in the defense of said claim.
Member Provider (i) 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 return of such
amount from Member Provider The Member VI, TERM AND TERNUNATION
Provider will not unreasonably withhold
reimbursement. If overpayment has been made VI.I Term. The term of this Agreement shall be for
Member Provider shall reimburse such overpayment one (1) year from the date hereof and shall be
within forty-five{45) days and/or follow State and automatically renewed on an annual basis for
Local Rules and Regulations. The Member Provider successive twelve (12)month periods,unless sooner
may not contest payment of Claims after one terminated in accordance with Section VI.2.
hundred eighty(180)days from the date of payment.
All claims for overpayment or underpayment shall VI.2 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. LNSURANCE AND INDEMNIFICATION VI.2.1 Termination by Member Provider. Member
Provider may terminate this Agreement in the event
V.l Insurance Requirement. Member Provider shall of a material default or breach of ROCKPORT's
provide and maintain such policies of professional obligations hereunder, upon ninety (90) days prior
liability insurance or a self-funded program. The written notice and the failure of ROCKPORT to cure
amounts and extent of such insurance coverage or such breach-or default within sixty (60) days of the
self-funded program shall be in the amounts notice. In addition, in the event of an "emergency
determined by community standards for relevant situation", Member Provider may terminate the
hospital/facilities. Member Provider shall promptly Agreement immediately with the acknowledgment
demonstrate evidence of insurability or self-funded by ROCKPORT that such an emergency condition
program and that the required insurance is paid and does exist. "Emergency Situation" shall mean an
in force upon request of ROCKPORT and/or meet unforeseeable event, not resulting from Member
the credentialing guidelines of ROCKPORT. Provider's act or omission, which materially affects
Member Provider's ability to continue the practice of
V.2 Indemnification of ROCKPORT. ROCKPORT medicine or to perform his obligations hereunder,
will be responsible for its own acts or omissions and The network will provide notification to employees
any and all claims, liabilities, injuries, suits and of the terminating Member Provider immediately
demands and expenses of all kinds which may result upon receipt of the Member Provider's termination
or arise out of any alleged malfeasance or neglect request or as soon as reasonably possible before the
caused or alleged to have be caused by its employees
Page 7 of 15
Alfredo Marti,MD 3-15-17 RCNPEY_TX 062016
i
effective date of termination as required by 28 TAC VI.2.4 Termination by Either Party. In case of
10.42(b)(6)(G). material breach of the terms of this Agreement,
either party may terminate the Agreement with at
VI.2.2 Termination by ROCKPORT. A Member least ninety (90) days prior written notice to the
Provider shall automatically be terminated on the other party; however, the party in breach may cure
date when: (i)Member Provider's license in the State the breach within sixty (60) days of the notice, in
where services are rendered is suspended or revoked, which case, the Agreement and applicable rates and
(ii) Member Provider is excluded from participation terms shall continue in effect. Either party may
in the Medicaid or Medicare programs, (iii)Member terminate this Agreement without cause upon ninety
Provider loses their 3CAHO, NCQA, AAAEC, (90)days prior written notice.
URAC, CLIA or other applicable license,
certification and/or accreditation, (iv) Member V1.2.5 Unforeseen Events. In the event that either
Provider loses or experience a material reduction in party's ability to perform their obligations under this
liability insurance and such insurance falls below the Agreement is substantially interrupted by war, fire,
requirements of State Law (v) Member Provider insurrection, riots, the elements, earthquake, acts of
engages in any act, omission, demeanor or conduct God, or other similar circumstances beyond the
that is reasonably likely to be detrimental to patient reasonable control of such party, the party shall be
safety or to the delivery of quality patient care,or to relieved of those obligations for the duration of the
lead to the provision of healthcare services below interruption upon notice to the other party. In the
applicable standards, or (vi) ninety (90) days event that the interruption is reasonably determined
following written notice by ROCKPORT of a likely to persist for at least ninety (90) days, either
material default or breach by Member Provider party may terminate this Agreement upon thirty(30)
hereunder and the failure of Member Provider to days prior written notice.
cure such default or breach within sixty(60) days of
the notice (vii) Member Provider fails to meet VI.3 Effects of Termination. Upon termination of
ROCKPORT's or the State's credentialing this Agreement, neither party shall have any further
requirements. ROCKPORT, however, may not obligation hereunder except for (i) obligations
terminate this Agreement in direct response to accruing prior to the date of termination, including
Physician filing a reasonable complaint,on behalf of without limitation, any obligation by Member
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 ROCKPORT deems it necessary to
terminate Member Provider's agreement based on VIA Qualified Participant and Payor Notification.If
the above requirements ROCKPORT will notify applicable, upon the termination of this Agreement,
Member Provider at least ninety(90)days before the by either party, Member Provider shall cooperate
effective date of termination. with ROCKPORT to notify Qualified Participants
and Payors of such termination.
Upon written notification from ROCKPORT,
Member Provider may request a review by VII. CONTINUATION OF BENEFITS
ROCKPORT's advisory review panel, not later than
thirty (30) days after notification. ROCKPORT VI1.1 Continuation of Benefits. If Member Provider
must then complete the review before the effective voluntarily terminates its contract with
date of termination. ROCKPORT, upon Member Provider's request,
Payor must continue to reimburse Member Provider
VI.2.3 Termination for Insolvency. This Agreement for a period not to exceed 90 days at the Member
shall terminate immediately in the event that either Provider's contracted rate set forth in Exhibit B of
ROCKPORT or Member Provider voluntarily or this Agreement with ROCKPORT, for care of an
involuntarily, liquidates, dissolves or becomes Qualified Participant with a life-threatening
subject to any proceeding for the rehabilitation or condition or an acute condition for which
conservation of their financial affairs with written discontinuing or disruption of care would harm the
notification. Qualified Participant as per 28 TAC 10.42(b) (5)(A).
Any disputes concerning continuity of care shall be
Page 8 of 15
Alfredo Marti,MD 3-15-17 RCNPHY Tx 062016
resolved through the complaint process under IX. MISCELLANEOUS
Insurance Code §1305.401 - §1305.405 and
Subchapter G of Title 28, Part 1 (relating to 1X.1 Disputes. All disputes and difference between
Complaints). the Member Provider and ROCKPORT upon which
an amicable understanding cannot be reached are to
be decided by the following method:
V1I.2 Survival. The provisions of this Article VII
shall survive the termination of this Agreement IX.1.1 Mediation through ROCKPORT. The
regardless of the cause - giving rise to such Member Provider shall notify ROCKPORT in
termination, as will sections 11.9, V.2, V.3, VI.3, writing of the dispute or disagreement and shall
VIII, and IX. The provisions of this Article VII provide all necessary information to ROCKPORT.
supersede any oral or written agreement to the ROCKPORT shall use best efforts to mediate the
contrary now existing or hereafter entered into dispute within the rules and regulations put forth by
between Member Provider and any Qualified the State as reference in ROCKPORT's Provider
Participant or any person acting on a Qualified Handbook.
Participant's behalf.
IX.1.2 Arbitration. If the dispute cannot be solved
VIII. CONFIDENTIALITY by the mediation process described above, either the
Member Provider, ROCKPORT or Payor may elect
All business, ]medical and other records relating to to submit the dispute to binding arbitration under the
the operation of ROCKPORT or Member Provider, rules of the American Arbitration Association or any
including but not limited to, books of account, other method of arbitration mutually agreed upon by
general administrative records, policies and the parties. Arbitration will be conducted in
procedures, pricing information, terms of this Houston, Texas. Each party will be responsible for
Agreement and all information generated and/or their own legal fees. The cost of the arbitration
contained in management information systems services will be the sole responsibility of the party
owned by or pertaining to ROCKPORT or Member requesting the arbitration.
Provider, and all systems, manuals, computer
software and other materials, but excluding patient IX.1.3 Provider Appeals. Except for termination due
charts, shall be and remain the sole property of to contract expiration, Member Provider has the
ROCKPORT or Member Provider respectively right to appeal his/her termination from the Network,
(collectively, the "Confidential Information"). as follows:
ROCKPORT and Member Provider acknowledges
that the Confidential Information and all other 1X.1.3.1 ROCKPORT will provide notice to the
infonmation regarding ROCKPORT or Member Member Provider at least 90 days before the
Provider that is competitively sensitive is the effective date of a termination by ROCKPORT;
property of ROCKPORT or Member Provider and
ROCKPORT or Member Provider may be damaged IX.1.3.2 Upon receipt of the written notification of
if such information was revealed to a third party, termination, a Member Provider may request in
Accordingly, ROCKPORT and Member Provider writing a review by the Network's advisory review
agrees to keep strictly confidential and to hold in panel no later than 30 days after receipt of the
trust all Confidential Information. Upon termination notification;
of this Agreement by either party for any reason
whatsoever, ROCKPORT and Member Provider IX.1.3.3 The Network will provide an advisory
shall promptly return to the other all material review panel that consists of at least three Providers
constituting Confidential Information or containing of the same licensure and the same or similar
Confidential Information, and neither party will not specialty as the Member Provider;
thereafter use, appropriate, or reproduce such
information or disclose such information to any third IX.1.3.4 The Network must complete the advisory
Party- ROCKPORT and Member Provider panel review before the effective date of the
specifically agree that under no circumstances will termination;
either party discuss the terms and conditions of this
Agreement,and in particular the pricing information 'IX 1.3.5 The Client,Payor, or ROCKPORT may not
herein, notify patients of the termination until the earlier of
the effective date of the termination or the date the
Page 9of15
Alfredo Marti,MD 3-15-17 RCNPHY TX—062016
advisory review panel ]Hakes a formal IX.6 Governing Law. This Agreement shall be
recommendation; governed by and construed in accordance with
applicable state law.
]X.1.3.6 If Member Provider terminates the contract,
the Network or ROCKPORT's Client will provide IX.7 Amendments. This Agreement may be
notification of the termination to employees amended as agreed to by both parties in writing 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 term or condition hereof shall
in no way affect the validity or enforceability of any
IX.2 Non-Exclusivity. Nothing in this Agreement other term or provision.
shall be construed to restrict Member Provider or
ROCKPORT from entering into other contracts or IX.9 Assienment. Member Provider may not assign
agreements to provide heaithcare 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 ROCKPORT. A
change in ownership will not negate the prior
IX.3 Entire Agreement. This Agreement contains contractual agreement without written notification to
the entire understanding of the parties and ROCKPORT. ROCKPORT retains the right to
supersedes any prior understandings and agreements, assign this Agreement, in whole or in part, to any
written or oral, respecting the subjects discussed entity with which ROCKPORT or its parent
herein. company or any of its subsidiaries is affiliated, or
with which it merges or consolidates.
1X.4 No Waiver. The waiver by either party of a
breach or violation of any provision of this 1X.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 ROCKPORT agree contained in this Agreement are for reference
that each shall comply with all applicable purposes only and shall not affect in anyway the
requirements of municipal,county, state and federal meaning or interpretation of this Agreement.
authorities, all municipal and county ordinances and
regulations, and all applicable state and federal IX.12 Execution of Counterparts. This Agreement
statutes and regulations, now or hereafter in force may be executed in any number of counterparts,
and effect, governing ROCKPORT, Member including facsimiles, each of which shall be deemed
Provider,sub-contracting providers,the provision of to be an original as against any part whose signature
services by Member Provider or sub-contracting appears thereon, and all of which shall together
providers,and/or Payors,including but not limited to constitute one and the same instrument.
applicable requirements under any state or federal
fair employment practices, equal employment IX.13 Partial Invalidity. If any part, clause or
opportunity,or similar laws declaring discrimination provision of this Agreement is held to be void by a
in employment based upon race, color, creed, court of competent jurisdiction, the remaining
religion, sex,or national origin as illegal,and,Titles provisions of this Agreement shall not be affected
VI and VII of the Civil Rights Act of 1964, Section and shall be given construction, if possible, as to
202 of Executive Order 11246 as amended by permit it to comply with the minimum requirements
Executive Order 11375, Sections 503 and 504 or the of any applicable law, and the intent of parties
Rehabilitation Act of 1973 and Title IV of the hereto.
Vietnam Era Veterans Readjustment Assistance Act
of 1974, and Sections 1 and 3 of Executive Order IX.14 Financial Incentives. Neither a Client, Payor,
11625, or any applicable rule or regulation nor ROCKPORT may use financial incentive or
promulgated pursuant to any such laws or orders. make a payment to a health care provider that acts
directly or indirectly as an inducement to limit
Page 10 of 15
Alfredo Marti,MD 3-15-17 RCNPHY TX 062016
i
medically necessary services. The adoption of 1X.17 Official lyotices. Any notice or
treatment and return to-work guidelines and conmmnication required pannitted or desired to be
F
individual treatment protocols by ROCKPORT or given hereunder shall,be deomed eMctively given
j Network is not in violation of this section as when persartally delivered or mailed, mann receipt
pursuant to Insurance Code §1305. 30.4 and requested, or overnight express mail addressed as
I §10.83(a)of Chp 10 of-itle 28 Part 1. follows:
MIS Financial.Disclosure Requirements. Member
Provider is required to file financial disclosures in Member Provider orRepresentative!Designee:
i accordance with Labor Co& §§408.023 and (Please Print)
§§413;041.
1X.16 Egonuc Profiling. Network must provide Name.Alfredo Marti.MD
written notice to Member Provider before the Organization.
Network conducts economic profiling, indix!ing
utilization management studies or other profit ng of Afters: 100112*Aw
the provider or group of providers.
City/State;My.Fga jNg h.7X 76104
Telephone:§17-810-0540
Thi'yRMSS WHEREOF,the undersigned will be Fax:
deemed to have executed this Agreement as of the
date the provider Is lolly credentialed by Organization:
ROCKPORT. WellComp Managed.Care Services,Inc.
One Upper PondRd.,Bldg.F,0 Floor
Parsippany,New Jersey 07454
Attn:Miftel Kravitz,General Counsel,SVP
Formed on belmlfoi;
or to such other address,and to the atterrtion of such
Rockport Community Network,Inc. outer person(s) or officer(s) as either party may
7 I Old Hickory Blvd.Ste.300 designate by written notice.
entwooa,,,7fN37Z.7
1.., For and on behalf of:
Douglas � kham
President MemberProviderr FrRepresenta€ivalDesignee
Date: 5 t t 20 17 Signature•
Name: �v�SG2
t�tl
TJX.01-0557074
4 Date: r 'l?
i
Page 11 of IS
!I AlfrrcloMnrH MD!Mi-17 BC.NFHY TX pf,'1a16
�I
EXMBIT A
STANDARDS AND GUIDELINES
UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS
ROCI(PORT 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.
ROCKPORT's Clients provide utilization review and quality improvement programs for Qualified Participants.
ROCKPORT shall review each Clients Utilization Review and Quality Improvement Program in accordance with
j ROCI(PORT's Credentialing Standards and Guidelines as described in this Exhibit. Physician and/or Member
1 Provider agrees to comply and be bound by such programs and any state or federal rules and regulations.
i
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 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 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.
16) Closed Formulary Drugs,as defined by 28 TAC Chapter 134,Subchapter 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
Page 12 of 15
Alfredo Marti,MD 3-15-17 RCNPHY TX_062016
i
{
Reimbursemenf Srhednle
L Rockport Community Network and its aB'9liiates.-Occupational l 4ury and illness
Provider fees for the programs listed above shall be reimbursed at the following:
All fees will be reimbursed at 87% (Righty seven percent) of the stalwa cw=t Workers'
Compensation fees,rules and regulations or usual and customary allowables.
Coverage: Coverage for all procedures on the fee schedule is subject to the Terms and conditions of
thus Agreement,state rules and regulations and/or the applicable Occupational h#juiy or Illness Benefit
Plan. .
Me accept the fees as outlined In ibis Exhibit B.
For and o;a behalf of: For and on behalf of:
(Name,address,etc.)
ROCEPORT C01VMMTY NETWORK,INC. Alfredo Marti,AM,
tool 12i°&Ve.
7 1 OldRi€kery Elvd.Ste,300 Fort Worth,TX 76104
atult
Dangias�d� larlsham l'r�i�ntedl+tame � 4
President r Tide AAS I _M.-c-)1t
Date 51(1 t Z�� -7 7CWAI- 5570 Date
Page 13 ot13
AlfroAnMard MDI-15.17 RCNFHY TX (0016
FAIUM C
Pbysidans andlor locations where services are to be rendered by Member Frovider
TheMember Provlaer agrees thatthe foltowingpbysidans and/or practicelmations lisped on attachei[FAI t C,
shall beludusive ofthe signed agreement and the signed rates in Exhibit E. By signing belowMember Provider or Its
RepresentativdDesignee allows Rockport Healthcare Group(ROCKPORI)and its representatives to use any and all
of thebelowinformatlon as agreed to in this signed agreement
Practice Name(1) Practice Name(2)
Atfrck IirtLMD
Physician Name(ifapplicable) Physician Name(if applicable)
1001 12' Ave.
PhysicaLAddress Physical Address
Fart Worth,TX 7610
City,Stats Zip city,State Zip
Mailing Address Of different) Mailing Address(if different)
817-810.0500
Phone Number/Fax Number Phone Number/Fax Number
01-0557074
Tax ID Number 'Fax 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
Mailing Address(if different) Mailii;Address(if di feient)
Phone Number/Fax Number Phone Number/Fax Number
Tax ID Number Tag IID Number
For and on behalf oD For and an behalf of
RecUport Community Network,Ine- Member Provider or RepresentativeMesignee
761 Old Hickory Blvd Ste.300
entwood,TN 37027
\ ( ,.. Signature:
k1k 4LIx—J,
Do gl J.r k am (print)
Date'.. 1 12th j Date.: .
Page14of1S
AlfmAo?Asff MT?8-75-17 R(WRY TX 0=16
i
EXHiMIT D
Workers'Compensation Networks(WCN)
Rockport may make this provider.agreement available to other networks through delegation. As defined within the
Physician agreement,Member Providers agree to provide treatment for injured employees who obtain workers'
compensation health care service through these networks. The named networks are listed below:
• Rockport Community Network
i • Wellcomp Managed Care Services,Inc.,Plan Name:CompKey Plus
• Broadspire HCN
Page 15 of 15
Revised 062016 RCNPHY TX 062016