HomeMy WebLinkAboutContract 47186-P32 JAN/12/2017/THU 10: 42 AM Dynamic Production FAX No. 8172880081 P. 002
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O C K P O R T ..
a CITY SECRETARY 2
1IVe11GDmp company CONTRACT NO.
ADDENDUM
To
181adrStone 504 Program
Provider Agreement
This Addendum is entered into by and among William Sheppard. LPC ("Member Provider"), Rockport
Community Network ("Rockport"), and the City of Fort Worth ("City") on this day of
20
W)IEREAS, Rockport and Member Provider entered into a Provider Agreement, effective October 16,
2016, ("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.
WHERRAS, the City has determined that a workers' compensation health care network certified under
Testas Insurance Code Chapter 1305 is not available or practical for its self-insured workers'
compensation program needs and,as such,have elected to provide medical benefits to injured workers by
directly contracting with health care providers,
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terms and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,THPR2'OR1, 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 wall 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
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 Agteement 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.
s
William Sheppard, LPC Provider Agreement.
3. When used in this Addendum, unless the content otherwise clearly requires, the following words and
terms shall have the meaning set forth below. All other defined terms shall have the meaning ascribed to
them in the Provider Agreement
"Payors" will be the City as they are responsible for payment of medical benefits for
compensable injuries and or illnesses sustained by its injured workers according to the Texas
Workers Compensation Act.
"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 inµre to the benefit of
a third party not a party to this contract. This contract may not be interpreted to waive any statutory
or common law defense, immunity,including governmental and sovereign immunity,or any limitation
of liability, responsibility, or damage of any party to this contract;party's agent; or party's employee,
otherwise provided by law.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates anew cause
of action.
6. All other terms of the Provider Agreement shall remain in force and unchanged. Any conflicts between
this Addendum and the Provider Agreement shall be superseded by the terms provided herein.
IN WITNESS WHEREOF,the parties hereto have executed this Addendum effective on the day and year
first written above.
For and on behalf of.
City of Fort Worth
Blackstone Provider Panel
Signatur . Date: f�
Name: Su an A nis Assistant Ci
Manager
APPROVED AS TO FORM AND LEGALITY:
C.
Atcrney
Attest
1�4
ary . Kayser, City Secretary
..........
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JAN/12/2017/TRU 10:43 AM Dynamic Production FAX No. 8172$8D081 P. 004
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jTfniversity Coutseling CoirtnrRrovider Agreexnent
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ROCIt7E'ORT COMMUNITYNE,TWORK
..y
Signature,
Name:John psolaaoi
title:Sr-Vice oal—d-c-M
Dal. Cat .
MEMBER PROVIDER or
RepreBontAtiVB(A48igk120
Name:M71111am Sheppard.LpC
bate; . I z ~- 1-7
TIN:80-4133804
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!Zt}G-rc n !l�l� 2 3g7
,a WelIComp COMPany
PHYSICIAN AGREE1Vt;E;NT
ROMORT COMhWNITY NETWORK
This Physician Agement("Agree-ment"),is entered
into by and between Rockport Community Network, I.1 "Physician'means a licensed Medical Doctor or
We.,herelu Known as "Rockport", a Nevada Doctor of Osteopathic Medicine, or group of same
Corporation, and University Counseling Center who desire to become a Member Provider Nvith.
("Wombat P.rovid-,V')., and will become effective as ROCKPORT.
of the date the provider is fillly crederrrialed by
ROCKPORT. Ptusuant to Title 28, Texas Admiivstnative Code
§10.42) regarding Network Contracts with Providers
Wl-iSREAS, ROCKPORT is engaged in the seeking to pgrticipate in Testas Certified IVorkers'
business of developing and acting in an Compensation Networks,
administrative capacity in providing Occupational
Injury and health provider -networks that offer 12"Qual&�Farftatit" means aTJ "employae" as
direction of care while providing savings to defined and used in the Texas Labor Code, the
ItOWOXT clients and/or Payors_These networks Network Acr Section 1305 and the implementing
will offer greater coverage of servioes and savings; rules who sustained a work-related ini�Vfillness tbat
and is determined compensable by a Client and that
park rIpates 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 Wiry/illness require authorization
(collectively,the"Member Provider")to provide a by the network either in writing or by telephone.
.fall-range of healtheate services. These services are
available for use by "Qualified Padoipmts" as 1,3 ''Clizn" means an insurance company, certified
{ d4med it,1,2 ofthis Agreement,and self-insured or governmental entity as those terms
are defined and used in the Te.us Labor Code, the
Wf1EREAS, Mamber Provider desires ro provide Network Act Section 1305 and the implementing
medical care services to "Qualified Printicipants" rules. These Clients have entered into a Client
—Who arra co`Veri'8-by'P'ayor Agiz�tm zits at"tlie'yateTiff --- ;Aru�cnzrrf wit$ROM ORT,foi"trio pmvr I—ai-off'-
l xl',lbit B and in locations listed in Exhibit C: and healthcare services to Qualified Participants.
inolusive of the networks included in Exhibit D;and
1.4 "Payor'° means an insurance carrier or network
WK MAS, AOC"ORT hes entered into ceiii$ed 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 providtr payment of claims f'er 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 bn the job injuries and or illnesses
prwnises,the mutual promises contained herein,and according to State and/or Federal Rules and
other good and valuable consideratign, the receipt Regulations,
and sufficiency of which are hereby acl,•ztowIedged,
it is mutually agreed as follows: I5 "Client Agreement" means the agreement
between ROCKPORT acid a Client, Which
X. X37 FINITIONS agrzement is made before, on or after the effrective
date of this Agreement and which expresses the
When used in this Agreement and unless the content agreed upon cgatractual rights end cbligWoas of•tha
otherwise clearly requires,the following words and parties. Such Client Agreements will rewire Payors
terms shall mean: to pay ]Member provider for Covered Services
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rendered to Qualified Par(icipatits ptusu8nt to #his manifested by aou(e symptoms of sufficient severity,
Agreement. Furdirimore., 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 jeopgrdy;or
(b)serious dysfluiotion 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 (e)in the case of a.mental health condition,ono that
imaging center, laboratory; clinic; chiropractor; could reasonably present danger to the person
dentist; podiatrist; psyehologlst; social worker; experiencing the mental health condition or another
physical, occupational and speech therapist; etc, perscm as defined in TIC 1305.004(15).
licensed or certified to practice a healthcare
profession or licensed as a facility to oar haaltboare IAO "Covered Services" are those healthcare and
services,in the state where servicers are rendered axed health-related services provi
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ROCKPORT's Provider Handbook and/or Clients' specified by ROCKPORT, Chant or ins designated
Utilization itevlew Programs. ROCKPORT agl•ees representative, and requested information is not
to furnish Member Provider or ca-uuso Payer to prohibited by stats aad!or federal niles and
Aunish to Member Provider,and Member Provider regulations,
ao ees to abide by, the list of any treatments and
services that requira preauthorization and by any 11.7 Professional Requdrements.
procedures to obtain preauthorlmtiotr. Unless in an
emergency or attar business hours, initial sm-viccs 11.7.1 Licensure&Accre itati n. 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
writing or by telaphone. The Client and/or payor providers and their provision of services, Evidence
may not deny tt-eatment 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 subiniEted promptly to
spocifrcally 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 demonstt-ate medical necessity to employees and contracted service p;ovidexs I)as
support services rendered to Qualified Participants obtained, and shall maintain throughout the terra of
that are outside of treadnent guidelines. this Agreement, all necessary registrations,
certifications, licenses, permits and approvals as are
II3 Non—Discrimination.Ivlbrnber Provider shall not required for the lawful provision of Member
differentiate or discriminate in the treatment of its ,Provider services to QLialifred Participants.Member
patients as to the quality of services delivered to Provider shall immediately notify ROCKPORT of
Quali#ied Pardoiparts because of race, sex, ago, any revocation, suspansion or restrictions, that
religion, national origin, puce of residence, source would affect any C tific2txQns; licenses or
of payment or health status. Member Provider shall accreditation. Member Provider wananfs that it is
observe,protect end promote the rights of Qualified currently accredited by the Agency that governs l&Ie
Participants. providers and is certified as a provider under Title
:VIII (Medicare) and when appropriate, Title=
11.4 Medical Staff Partici at'o . 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 tern of this Agreement Member
Allergy, and those Primary Treating Provider shall immediately notify ROCKYORT of
Physiciam/Clinics whose practice is dedicated to any action, investigation or proceeding to revolve,
treating work-related injuries and W-nesses, Where suspend, restrict, or otherwise affect such
appropriate, Physicians must maintain active, accreditation or certifications.
urrrastcr`tc a'staff-'prrvtleges_.�Vitn—at-least one
ROCKPORT Member Provider hospital or Surgery 11.7.2 Organization's Requirements, Member
Center. Physicieru hereby consents to disclosure by Provider shall use best efforts to comply tivith
such facility to ROCKPORT of all data collected ROCKPORT's criteria for provider particfpm!ion,
With respect to Physician in connection with including credentialino 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 qualifreations,
and any renewals thereof_ In addition, Member Provider shall use best efforts
to cooperate with ROCKPORT's and/or state rules
II.5 Referralsexcept it a medical emergency or and regulations for the expeditious resolution of any
when authorized by ROCIKPORT, Client, or its gtievance or complaint.
designated representative, Member Provider agees
to refer Qualii-led Participants only to other Member 11.$ Noti5cation to ROCKPORT. Member Provider
Providers,as defined in I.6. represents and warrants that information provided
1.6 &parts. For each encounter where Member herein and in the ROCKPORT application is true
Provider provides services to a QUalif ed Participaut, and accurate in all respects and aclarowledges that
Member Provider shall report such encounter on an ROCKPORT is relying on the accuracy of such
appropriate form and shall inchu r, 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
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ROCKPORT of any(i)suspension,reduction or loss Participants, and to Member Provider's per-fotxnanoe
of licamn to provide healthcare services; (ii)denial, under this Agreement Member Provider fcn-rher
suspension, restriction, reduction or termination of agrees to allow ROCKPORT,Payor or a designated
accreditation/certificatfon; (iii) changes In Federal representative thereof, including the designated
Tax Identifiication Ntunber(s), (iv)other information utilization reviaw, quality maxtapineht, case
provided in its application or Exlu'bit 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 bolow the Qualified PartWIpalats for services provided under
requirements of state law and (vi) Member the terms of this Agreement as necessary to enable
Provides billing or facility adchms. A Whim to such patty to perform Utilization REvlew and
give any notice required by this Section shall be a Quality Assurance activities im woordmea tivith 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,pendmay 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 duality of healthcare services is conducted by
grounds for tarr inatlon e,this Agreement. appropriate officials, as required by federal, state,
and/or Iocal law, ROCKPORT shall submit, in a.
ITS idedieal Records. Member Provider sha11 timely fashion, any required books and records and
tnzii_;Wn completo and timely medical records for sl-Al 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 onsite inspection of facilites and records by
in accordance with accepted pli-aciples of ptacticc, representatives of authorized federal,state and local
s1ha11 document all services performed for Qualified regulatory agencies
Participannts end shall Comply with all applicable
state and federal laws. Member Provider shall 11.11 Relationshiv of Parti,:s. Momu Provider and
maintaitl 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 r000rds shall be made available to=b relationship of employer and employee, principal
Member Provider and other health profas3iop4s; and agent, partnership or joint venture or any
treating the Qualified Participant, and upon request, relationship other than that of independent parties
to Ilia Payor, ROCKPORT or its designated contracting, with each other solely to carry out tha
representative for review at the rates approved by provisions of thts Agreement for the purposes
State la4v and as sec forth in the current State recited in this Agreement. 'V M regard to the
Workers'Compensation Reimbursement Manual for provision of healthcare services, Member Provider
- -----
_._ -----•---- ospl�a s;i app ice e, emliei hovrdae shall_— as is as an icpeiiaetz entity and rthe-lvietn�ar ---
obtain a valid owsent for the release of tho Qualified PTovider�padent relationship shall in no way be
Participant's medical records to other providers, affected,
ROCKPORT, Payor, or its designated
representative- ROCKPORT agree3 that medical 1I.12 Standards of Care. Member Provider agrees
records of Qualified Participants shall be treated as that all duties performed heinuider shall be
confidential so as to comply with all federal and causistent 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 I1.9 shalt ethics and conduct of the appropriate and applicable
sw'vive the termination of this Agreement. professional organizations and/or associations,as the
case may ba, and such other bodies, formal or
11-10 Inspection of cords and OoeritGorzs. informal, state, government or other,-'Vise, or by
ROCKPORT, Payor or a designated representative which they are subject to licensing/certification and
shall have the right to lnspect and audit, at all control, Additioaally, Nlember Provider shall
reasonable times during normal business hours,upon perform all medical and healthcare services in
prior title (S) business days, any of Member conformance v4th the standards for their facilities as
Providers medical records and operations established by the local/regional professional
reasonably pertaining to ROCKPORT Qualified healthcare community and applicable
Participants, services provided to Qualified accreditinelicensing agencies. Moznbcr Provider
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agreas that,to the extent feasible,it shall utilize such n.ct lhnitad to the following, (i) Provider Search
additional allied health and other qualified personnel Provider Locator System (h) Provider Directories
as are available and appropriate for effective and, (iii) Provider Panels (iv) Cnwtoinized
efficient delivery of care. Member Provider shall Local Networks and (v) Client Service Provider
ensure that all stitch persozural are properly licensed Referral Service.
and/or possess the necessary credentials to render
the services that theyperfornl. III Credenti&U- ROCXPORT will perform
and/or delegate to qualified organlzations
11.13 Right to Use MemberProvider's or Network's credcntialing of each Member Provider,
Name. Member provider agrees to allow Credentiaiing inay incfude verification of all
ROCKPORT to list Member Provider's name, information and documents provided in the
specialty, address, telephone number, and hoLn 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 hlovider and national licensing and eortit hV bodies that
Panel(s), ROCKPORT website and/ cn other apply to the services rendered by the Meraber
materials to help promote and assist Clients with Provider,such as 7CARO,AAAHC,NCQA, CLIA,
Qualified Participants reeding medical care for URAL, etc, Inquiries may also be made to current
injuriesrllnesses sustained. ROCKPORT agrees to and previous professional liabflity carriers,Medicare
allow Member Provider to list ROCKPORT's naive, and Medicaid.R.00KPORT's credez Baling policies
address, and telephone mumber on Member and procedures follow the Ainerican Accreditation
Provider's website ox in other publications listing the Kealtheare Commission (URAC) and/or NCQA
health plans accopted by Member Provider. In standards for 'Workers' Compensation provider-
addition,Member Provider agrees to post tai Walting networks.
roo= and make available io Qualified participant
,notice of Member Provider's participation vilth III.3 Operational rMotian 1ROCKPORT shall
ROCKPORT udth name, address and telephone ntilLt systems to respond to Member Providers
member and procass for Qualified Participants to requests for infvrmatlon 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 ROCKPOR.T's programs. Member Provider agrees
to employees on the process for rbsolving woricers' to work in cooperation wRh ROCkPORT to market
compensation health care network complaints. The the services of the Member Provider to Clients and/
notice roust include the Texas Department of or Psiyors.
Iri=arxoe's toll-free phone number for tiling a
complaint and must list all workers' compensation, ROCKPORT ahall act as S liaison with the Member
health cax•e ne4vorks 'with which. the Member Providers and Clients and/or Payors to devote
------ -- -- -neoessyMme and et�ort�a'perfonti7.tOCKI'aR"I"s - — --- - —
responsibilities hereunder,
11.14 Ngneompliance.Member Provider understands
that failure to comply with any of the requirements ill.4 etaliatory Action.ROCfSPORT agrees not to
imposed purwaat to flus Agreement may result in engage in any retaliatory action inalir&g
termination of this Agreement by ROCKPORT. termination of contract or refusal to renew a contract
against Member Provider, because Member
11.15 Antitrust Guidelines, Mzrnber Provider agrees Provider, on behalf of an QuAlified Participant,
to comply with all antitrust guidelines and reasonably f led a complaint against, or appealed a
procedures promulgated by Federal and State decision of ROCKPORT or Payer, or requested
entities. reconsideration or independent review of ah adverse
determination.
111, ROCKPORT's OBLIGATIONS
111.5 Antitrust Guidelines. ROCKPORT agrees to
IIL1 Marketing to Clients/Pa ars. ROCKPORT comply with all antitrust guidelines and procedure
shall enter into agreements witli Clients and/or promulgated by Federal and State entities.
Payors as defined in 1.3 and I.4 for their access to
ROCKPORT quality Member Providers through IIIb Audit Policy and Proc dere Comp'ante. All
specific referral processes. ROCKPORT will bill audit requests by PAYOr shall be, done in
market Member Provlftm for referral; including but
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F
accordance with the State Law and/or Federal Rules All services bil)ed under the Tbt Identification
and Regulations. Number(s) indicated in this Agreement, airy
Aineadmeats, Z xhlbit A, Exhibit )3, Exhibit C,
Applications or any updates tegaxding locations
IV, REIlv1)DMISEMENT,CLAIMS and/or a Member Provider as defined in section I.6
SLrBMISSION AND PAYME,NT will bo subject to the rRimbursemene rates
established in the.Exhibit B of this Agieemunt.
IV.1 Reimbursement. ROCKPORT shall arrange
and provide the Member provider, locations and/or All billing and reimbursement VAII be made in
any additional Tax Identification Numbers as listed accordance witli Labor Code 408.027 and all other
In Exhibit C for Payors to pay Member Provider the applicable state rules and regulations.
reimbursement rates for Covered Serv.acs rendered
to Qualified Participants pursuant to Exliibit 13. IV.3 Bill and/or Claim Forms. Claim fortes are
Member Provider agrees and acknowledges that required for all services. All claims must be
�ROCKPORT is acting solely in an administrative submitted complete and acclrr4te oil CMS 1500 (or
capacity in providing a network of duality health other appropriate claim form or their successors)and
services.ROCKPORT is not the claims paying agovnt must include Member Provider's itnial and
and will not be liable for the payment of any amount customary billed charges (not discounted rates) and
owed by a Payor to Member Pravidar in the event appropriate codes, consistent with policies
that Member Provider is unable to collect such established or approved by applicable state and/or
amount of money up to and including the insolvency federal regulatiam. Member Provider must submit
of the Payor. Under no circumstance will a Member claims-to Payor not later than the 95a'day after the
Provider attempt to collect payment from a Qualified date on which service-are provldad to the Qualified
Participant for medical sezvicos rendered for a Participant, or as specified by state law. In
compensable,work-related injury/ilhiess. accordance with Labor Code §403.027 and ottier
applicable statutes and rules,billing and payment to
rV.2 Rei b )ideznbor provider is to Member Provider will be made within forty-five
be paid by the Payor in accordance with State Law (45) days of receipt of bills which are accurate and
and/or rules and ragulations at the rates established complete, and otherwise in accordance with state
in Exhibit 13. Member Provider hereby agrees that rules and reg dations.
rotes in Exhibit g,which may be amended from time
to time upon m>.ltual written agreement,represent the rVA Limited Recourse A6aizist Qualified,
total arnmint to be received and agrees to look solely Fpagid s. Except as otherwise provided in this
to the Payor for payment for such Covered Services. Agreement(Section 1.10), Member Provider agrees
Payment will be made for Covered Services actually _to seek ps ent froTn each Pay r for Covered
raudered.All claims willbn paid,viheri ap ropriaCe, Services provided touts QuaUflfled Pazflcipar_ts, and
only after aubmisslon of a complete wad accurate agrees that it will not seek additional paymeWLs or
claim. A complete and accurate claim shall be reimbursement for compensable injuries from
defined as a clmn claim by Medicare. ROCKPORT Qualified Paiticipants. In addition, Member
does not guarantee, represent, warrant or covenant Providap ag Ges that neither ROCKPORT,the Payor
regarding the selection or use of Member Provider's nor the Qualified .participant shall be billed or
services by any Qualified Participant or Payor,or the ultlmately held responsible for payment of senices
number of patients, if any, which may result from deemed not to be covered by the Payor or its
participation in ROCKPORT's provider network, designee.Wheia Qualified Participant is covered by a
The obligation of a Payox to reimburse Member state or federally regulated Occupational Injury and
Provider in accordance with Exhibit B for the Illness program,Member Providw ao des to comply
provision of Covered Servioes to a Qualified with state and federal xegillatlons xegarding holding
Pauticipant shall be conditioned upon a good faith Qualified Participants harmless for amounts not paid
determination by the Payor or its designated by Payor for any reason,including Payor or tietwork
representative that (i) such services are medically insolvency. This provision does not preclude billing
ireoemary, whether such determinations are made a Non-Qualified Participaza for a non compensable
before, on or after the provision of smm-ces to such injury.
Qualified Participarrt,
rVAJ Transfer of Risk, This Agreement and any
subcontract within shall not be interpreted to involve
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a transfer of financial risk for the provision of health demands and expenses of all kinds wbich may result
care services from Payor to ROCKPQRT as defined or ariso out of any alleged malfeasance or neglect
imdar Insurance Code §1^705,004(a)(26), Member caused or alleged to have be caused by its employees
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•A,givement. In
providing a nem,,vork of quality health providers. the event that a maim is made against ROCICPORT,
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,ROCKTORT shall
a Payor to Mcmber Provider in the event that have the right to take any and all actions they believe
Member Provider is uaiable to collect such amount of necessary to protect their interest
money up to and including the insolvency of Payor
or the Network V.3 Inddmnificatim of Member Provider. Member
Provider mill be responsible for its otivri acts or
IV.5 Pavment of Clain Forms. ROCKPORT shall omissions and any and all claims,liabilities,injuries,
administratively ar1-ange for the Payor or its suits and demands and expenses of all kinds which
designated representative to pay zmdisputed 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
Agreermorrt 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. Ia 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 tho Provider to cooperate in the defense of said claim-
Member Provider (1) more than once, or (ii) an However, Member Provider shall have the right to
incorrect amount, or(ill)an overpayment,the Payor take any and all actions they believe necessary to
or its designated representative may, at its sole protectthoh•intorc8t.
option and discretion, raquest the return of such
amount from Member Provider The Member Vi. TERM AND TERNIINAUON1
Provider will not unreasonably withhold
reimbursement. If overpayment has been grade VI,1 Term. The Cerin of this Agreement shaU be for
Member Provider shall reimburse such overpayment vita (1) year from tha date hereof and shall be
within forty-five (45) days andlor follow State and automatically renewed on an su=ial 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_
huuidmd eighty(130)days from the date of payment
All Claims for overpayment or undt rpayment_shallV1,2 Termination This Agreement may be
-- ----^-be resolved is accordance 'Mth State Law and 7& ——terminated sooner on the first to occur of rho
Federal Rules acid Regulations, following:
V, INSUPANCE AND LNDEriINIFICATION VI.2.1 Tetaimtlga by Member Provider., Member
Provider play terminate this Agreement in the event
V,1 Insruance RcclUireunerit. Member Provider shall of a material default or breach of ROCKPORTa
.provide and maintain such policies of professional obligations hereunder, upon ninety (90) days prior
liabiltty insurance or a self-funded program. The written notice and the failure of ROCKPORT to pure
amounts and extent of such insurance caverage 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
deter mined by community standards for relevant situation", Member Provider may terminate the
hospital/facilities. Member Provider shall promptly Agreement immediately with the ackaowledgment
demonstrate evidence of insurability or self-funded by IZOCKPORT fl=such an emergency condition
program and that the required insurance is paid and does exist. "Emergenpy Situation" shall mean an
in force upon request of ROCKPORT and/or meet w1foreseeable event, not resulting from Member
the credentialing guidelines of ROCKPOl'J. Provider's act or omission,which materially affects
Member Provider's ability to continue the practice of
V.2 Irrdeimnifimdon of ROCKPORT.ROCKPORT medicine or to perform his obligations hereunder.
will be responsible for its own acts or omissions and The netvrork will provide notlAcation to employees
any and all claims, liabilities, injuries, suit and of tho tolTninating Member Provider immediately
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upon receipt of the Member Provider's termination conservation of their financial affairs with written
request or as soon as reasonably possible before the notification.
effective date of teriination as required by 2$TAC
10.42(b)(6)(0). VI.2.4 Teitnin�tj n byEither Pzu , In case of
material breach of the terms of this Agreement,
V1.2.2 Termlaation.bv_.ROCKPORT. .A, Member either pall)( May temin,ate the Agreement with at
Provider shall automatically be tenninated on the least ninety (90) days prier written notice to the
date when:(1)Member Provider's license in the State other party;however, the party in breach may cure
where services are tendered is suspended orrevoked, the breach witliia sixty (60) days of the notice, in
(ii)Member Provider is excluded fioin participation which case,the Agreement and applicable rates and
in the Medicaid or Medicare prograins, (iii)Member terns shall continue in of-ect, Efther party may
Provider lases their JCA,RO, 140QA, ARAM, to inir ate fibs Agreement withotrt cause upon ninety
(IRAC, CLIA or other applicable license, (90)days prior written notice.
certification and/or accreditation, (iv) Membet
Provider loses or experience a material reduction iiR V12,S Unforeseen Events. In the event that either
liability insurance and such insurance falls below the party's ability to perforins their obligations under this
requirements of State Law (v) Member Provider Agreement is substantially interrupted by war, fire,
eagaps in any act, omission,demeanor or conduct insurrection,riots, the elements, earthquake, acts of
that is reasonably likely to be detrimental to patient Gad, or other similar circumstances beyond the
safety or to the delivery of quality patient care,or to reasonable control of such party,the parry shall be
lead to the provision of healthcare services below relieved of those obligatlora for the duration of the
applicable standards, or (vi) ninety (90) days internuption upon notice to the other party. In the
following written notice by ROCKPORT of a event that the interruption is reasonably determined
material default or breach by Member Provider likely to persist for at least ninety(90) days, either
hereunder and the failure of Member Provider to patty may terminate this Agreement upon thirty(30)
cure,such default or breach witUti sixty(60)days of days prior wTMen notice.
the notice (vii) Member Provider fails to meet
ROCKPORT's or the; State's oredentialing V13 Bffgg3 of"Termination. Upon termination of
requirements. ROCKPORT, however, may not this Agreement,neither party shall have auy fiuther
terminate this Agreement in direct response to obligation hereunder except for (i) obligations
Mysiclan filing a ressozrable complaint,om behalf of accreing prior to the date of tezuxinatjon, including
a Qualified Participant against, or appealed a without laisitatiori, any obligation by Member
decision of, 6t nenvork, or requested Provider to continue to provide healthcard services
reconsideration or independent review of an adverse to Qualified Participants, and (is) obligations,
_ _-• -,•------aecisian_-,------_-__-- •--•-__-- -••_-•- —••__-.� .pr=ises-Qr-S0-W=ts_-=AiWsi: --- --•-•-•---._.
expressly made to extend beyond the term of this
In the event ROCKPORT deems it necessary to Agreement.
terminate Member Provider's agreement based on
the above requirements ROCKPORT will Notify VIA Qualified Participant and PayorNotiftcation.If
Member Provider at least tinety(90)days before the applicable,upon the termination of this Agreement,
e4teclive date o;ftannination, by eitber party, Member Frmider shall cooperate
with ROCKPORT to notify Qualified Participants
Upon written notification from ROCKPORT, and Payors of such termination.
Member Provider may request a review by
ROCKPORT's advisory review panel,not later than VII.COi1ITINUATYON OF DFNR:PITS
thirty (30) days after notification. ROCKPORT
must then complete the review before the effective VILI Continuation of Benefits..If Mernber Provider
date of termination. voluntarily terminates its contract vAth
ROCI�.PORT, upon Member Provider's request,
VI.2.3 Termination for Insolvency, This Agreement Payor must continue to reunburse MemberProvider
shall termii-zta iixuriediatety in the event that either for a period xiot to exceed 90 days at the Member
ROCKPORT or Member provider voltintraily or Provider's contracted rate set forth rix )exhibit B of
invoimtarily, Liquidates, dissolves or becomes this Agreement with ROGI-PORT, for care of an
subject to any proceeding for the rehabilitation or Qualified Participant with a life-threatening
condition or an acute condition for which
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discondnuing or disratption of care would harm the Ageeiaent,and in particular the pricing information
Qualified Participant as per 28 TAC 10.42(b)(5)(A). herein.
Any disputes concerning contlnulty of cafe shall be
r05olved ttuough the complaint process tiu-ider rX M1SCVLLANE0VS
Instivance Code §1305.401 - §1305.405 and
Subchapter 0 of Tltlo 28, Part 1 (relating to 1X.1 Dl5puteg. 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:
V11.2 &jyjyd, The provisions of this Article'VTI
shall survive the termination of thus Agreement IX.1.1 Mediation through ROCKPORT. The
rdgA-dless of the cause - giving rise to such Member Provider shall notify ROCKPORT in
termination, m wiII sections 71,9, V,2, V.3, VI.3, waiting of the dispute or disagreement aad shall
VIII, and I,€. The provisions of this Article VTI provide all necessary information to ROCKPORT.
supersede any oral or written ngreement to the ROCKPORT shall use best efforts t4 mediate the
contrary now existing or hereafter entered into dispute within the rules and regulations put fbrth by
between Member Provider and any Quallfled the State as reference in ROCKPORT's Provider
Participant or any person actin on a Qualified Handbook
Participant's behalf.
7X.1.2 Arbitration, If the dispute cannot be solved
VIII. CONT'IDEXTIALITY by the mediation process described above,either the
Member Provider,ROCKPORT or Payor may elect
All business, inedical and other records relating to to submit the dispute to binding arbitration under the
6a oparadota of ROCXPQRT or Member Provider, rules of the American Arbitration Associzrtion or any
including but not limited to, books of account, other method of arbitratlon mtrtually agreed upon by
general admmisteadve records, policies and the parties. Arbitration will be conducted in
p ocedi res, 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 sola responsibility of the party
owned by or pertaining to ROCKPORT or Member requcstingthe arbitration.
Provider, and all systems, manuals, computer
software and other materials, but excludirig patient JX.1.3 Provider Apucals. 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 "Confident(al Information"). as fallows;
_._ .._.--•--•--ROC-T�PRI�T-and-Ivlember••pro•videracknowledges•----•-•-------._. -•-- --• -•- —•- -•- --•--..-"---•-------- •-•
that the Confidential Informatian and all other IX.1.3.1 ROCKPORT will provide n9lice to the
irforrnatioa regarding ROCKPORT or Member Member Provider at least 90 days before the
Provider that is competitively sensitive is the effective date of a terminattion by ROCICPORT,
property of ROCKPORT or Member Provider and
ROCKPORT or Member Provider may be damaged X1,3,2 Upon receipt of the written notification of
if woh itrformation was revealed to a third party. termination, a Member Provider may request In
Accordingly, ROCKPORT and Member Provider writing e.review by the Network's advisory review
agoras 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 AWeement by either parry for any reason
whatsoever, ROCIUORT and Member Provider IX.1.3.3 The Network will provide an advisory
shall promptly return to the other all material review panel that coasists of at least three Providers
constituting Confidential Information or containing of the same Iicensme and the same or sitnflar
Confrdegtial Infe mation,and neither party will not specialty as the Member ProvldeT;
thereafter use, appropriate, or mprodvoe such
information or disclose such information to any third 1X.13.4 The Network must complete the advisory
party. ROCKPORT and lvlembcr provider panel review before the effective date of the
specifically agree that under uo circumstances will tertrrinaiion;
either party discuss the terms and conditions of this
Page 4 d Is
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IXA.3.5 The Client,Payor,or R00IQORT may Aot 11625, or any applicable rule or regulation
notify patients of the termination until tete earlier of promulgated pi tsuant to any such laws or orders.
the effective date of the tonrliaaaation or the date the
advisory review panel lmalces a formal IX.6 Governing l;aw. This Agreement shall be
reeea=a1idation; governed by and const<uod in accordanoa with
applicable state law.
IX.1.3.6 If IvIertaber Provider terminates the contract,
the Network or ROMPORT's Client will provide IX7 Amendments, This Agreement may be
notification of the tetmaination to employees amended as agreed to by both parties in writing upon
receiving care from the terminating provider. The thirty (30) days wrkten notice of such proposad
Network ahall give such notice immediately upon amendment.
receipt of the Member Provider's termination
request or as soon as reasonably possible before the IX8 SeyerabilitX, The. invalidity or un-
efieetive date of termination. enforceability of any term 4r condition hereof shall
in no way affect the validity or enforceability of any
DC-7 Nola-E„clusiv:V. Nothing in this Agreement other tern or provision,
spall be construed to restrict Member provider or
ROCKPORT from entering into other contracts or IX.9 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 pRa
employer groups, without the prior written consent of ROC<PORT, A,
change in otivnersbip will not negate the prior
1X,3 Entire AUG-e _ort This Agreement contains contractual agreement without written notii1cation to
the entire understanding of the parties and ROCKPORT. ROCICPOPT 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 patent
herein. company or any of its subsidiaries is affiliated, or
with wlich it merges or consolidates.
IXA No Waiver. The waiver by either party of a
breach or violation of any provision of this 1X.10 Third Vajttaq ci ies, 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 Agreoment.
IX:5 l MIatory Compliance. Member Provider, IX11 Captions. The captions and headings
– `-- — sub-co_rltracting providers, andROCKPORTa rs�ee contained in this Agreement a�ra for rafworice _ _..-•---_–.__.
that each shall comply With all applicable purposes only and shall not affect in anyway the
reqLdrements of municipal, county,state and federal meaning or inSerprotadcm of this Agreement
atrthorities,all municipal and county ordinances and
regulations, and all applicable state glad federal M12 Execution of Counterparts. This Agreement
statutes and regulations, now or hereaRer in force may be executed in arty numbor 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 orioinel as against any part whose signature
services by Membor ?rovider or stlb-contracting appears thereon, and all of wMch shall together
providers,and/or Payors,inchading but not limited to consftrute one and the same instrument:
applicable requirements trader any state or federal
fair employment practices, equal employment IX 13 Partial Invalidity. If any part, clwse or
opportunity,or similar laves declarizlg discrimination provision of this Agreememt is held to be void by a
in employment based upon race, color, creed, court of competent jurisdiction, tha remflining
relict on,sex,or national or!&as illegal, and,Titles provisions of this Agreement shall not be affected
VI and VTI of the Civil Rights Act of 1964,Section and shall be given constrtlotion, if possible, as to
202 of Exeatttiva Order 112246 as atnended by permit it to comply with the minhnum reglurements
Exeautivc Order 11375,Sections 503 and 504 or the of any applicable law, and the intent of patties
Rehabilitation Act of 1973 and Title 1V of the hereto.
Vietnam Era Veterans Readjustment Assistancc Act
of 1974, and Sections 1 and 3 of Executive Order
Pap 10 cels
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0_I4 Financial Incentives.Neither a Client, payor, ;:70.17 Official Notices. Any notice or
nor ROCKPORT may use financial incentive or colmmmvcation required,permitted or desired to be
make a payment to a health care provider that acts given hereunder shall be deemed affectively given
directly or indirectly as an induoemsat to Emit when personally delivered or ma;led, return receipt
medically necessary services. The adoption of requested, or overnight express man addressed as
treatment and return-to-work guidelines and follows
individval trazarnent protocols by ROCIUORT or
Network is not in Ylolation of this section as
pursualat to Insurance Code §1305. 304 and Mm-nbor Pzoviaw or RapresentativeJDesigaee:
§10.33(x)of Clap 10 of Title 28 Part 1. (Please Print)
f�1
DC-15 1✓inanoial Disclosure Requirements. Member Warne': �� Y '4 ct!!
Provider is required to file financial disclosures in
accordance with Labor Code §§406.023 and Organizatiox University Counseling Centex
§§413.041,
Address: 1533 Merrimac Circle Suite 1 1
IK.16 Economic Proflling. N'etwarl: must provide
Written notice to Manber provider bafora the City/StxteJ—I'ip:Fort Worth.TX 76107
Netwrl conducts economic profiling, including
utilization management studies or other profiling of Telephone:617-510-0030
the provider or group of providers.
Fax: 817-877-3562
Organization.
IN WITNESS WHEREOF, tlae undersigned will be WellComp Maned Cate Serviw s,InQ.
deemed to have executed this Agreement as of the One Upper Portd Rd.,Bldg.F,e Floor
data the provider is fully credentialed by Parsippany,New Jersey 07054
ROCKPORT, Am,Michael Kravitz,General Counsel,SVP
or to such orther address,and to ilia attoration of such
other person(s) or officer(s) as either party may
deslglaate by writteniaoti,e,
For and onbehalf otb
- — — - -w Roaitport CommunityYetworlt,Xao, For and on behalf of:.—
7i bidctcary Alva she,foo
147[ +
Bre two d, Member or Repreaentafiveesa ee
'Douglas rkbow
Presides \• Name
f(�, (Print)
Date., (>J' l��t TPI l:80-11133804
Date-
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1
EDIT A
S7f A.NlDA,"$AND GUIDELINES
UTILIZATION REVIFVV AND QCIAUTY IMPROVEMENT FROCRAIVIS
ROCKPORT and its Clients require Member providers to follow nationally recognized troatn*eat guide tos(i.e,
Official Disability Chlidetinm(ODO) and/or Amerloan Owupational and Environmental Medicine's (ACOEIvi)
guidelines)in the treatment of work-related injuries/illnesses for Qualified Parlioipams.
IROCIt_ Qn7s Clients provide utilization review acrd quality improvement programs for Qualified Part cipants.
ROCKPORT shall review each Clients Utilization Review and Quality Improvement Prograrn in accordance with
ROCiWORT's Cr6deniialing Stan&rds and Guidelines as described in this E;du`bit. Physician and/or Member
Provider aswes to comply and be bound by such programs and any state or federal rules and regulations.
Such Standards aixd(uidollnes for Utilization Review Programs may be amended from time to nine uport written
notice to Physician and/or Member Provider,
The primary goals of the Utilization Review Programs shall be to:
I) ;✓neem and certify foe'the payment of benefits that hCalthoare 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 Icvel 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 Preauthorizanoa;unless otbenrvint spwiffed by the p,etp%ork;
1) In-patient hospital admissions including the prinoipalsehcdidedpmccdaies(s)atrdrlxalaxrgtliof§tay;
2) Outpatient surgical or ambulatory surgical services;
3) Spinal surgery,as provided by Texas Tabor Code§405.026;
4) All psychologlcal testing and psydhotbempy,repeat interviews,and biofeedback;except when any service is
part of a preauthorized or exempt rehabilitation program;
5) All external and implantablebono growth dtimuletors;
6) All chenonupleolysis;
7) All myelograms,disc peram%or surface eladromyograms;
S) Unless othorwise specirled,repeat individual diagnostic study,witli a fez established in the current Medioal L ee
Guideline of greater than$350 or documentation ofprocedurz(DOP);
9) 'W❑rk her dan(ng and work cocclitioning services provided in a facility that has not been approved for exemption
------ -....- -by-#}xe-D v4s1cn;.. -
10) Rebabilliation programs to tnolado (a) outpatient medical rehetQ(tation and (b) chronic pain management!
interdisciplinary pain rehabilitation;
11) All durable medloal equipment(DME)in access of$500 per item (either pischase or expected cumulative
rental)and all transcutaneous elwuioal nerve stimulator(TENS)units;
12) Nursing home,convalescent,residential,and 9!1 home health care advices and treatments;
13) Chemical dependency or weight loss programs;
14) Any investigational or experimental servioe or deuioe far 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) Physiecl and occupa6cael therapy services;(a)physical and occupational therapy services are those listed in the
ldeatthcote Common Procedure, Coding System (RCPCS) Level 1 code range for Physicel Medicine and
Rehabilitation, but limited to; (i) modalities, both supervised and constant attendance; (ii) therapeutic
procedures,ekpluding work hardening and work conditioning;and(iii)other procedures,lh-dted to the unllsicd
physical medicine and rebebilitation procodurt coda
16) Closed'iorrmdary Dugs,as defined by 26 TAC Chapter 134,Subchapter F.
NOTl; Przwtharizataon is not requhd for the first two visits of physical or occupational therapy fallowing the
evalutillon when such treatment i9 rendered within the first two weeks immediately following;(i)the date of injury.
or(it)a surgical intervari&n previously approved by the payor.
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E IT D
Reimbursement Schedule
L kockport lComme]nity Npwo&and its affiliates,-Occupational Injury and Illness
Provider fees for the programs listed above shall be reimbursed at the following;
All fees will be. reimbursed at 85% (1Jighty five percent) of the states current Workers'
Compensation fees,rales and regulations or usual and ctstomary allowEtblw.
Coverage: Coverage for all procedures on the fee schedule,is subject to the terms and conditions of
this Agreement,state rules and re;ulations and/or the applicable Oocupat4orm1 Inf ruy or Illness Benefit
pltm.
I
I
x1'4'Ve accept the fees as outlined in this F.Thibit X
—--- -- For and 4n behalfof-, — - For and on behalf of,
(Name,address,etc.)
ROCKPORT CON ti�171`23f` Y NYT'SVOTUS ,Il`xC. University Comseling Center
1533141errimac Circle Suite 101
l(SI IMM oRy Nva at X40 E21w2Lth.TX 76107
antrvvdc3 2N. ,'
• Signature 04;-44;p { +
Douglu�d. e }Ftahx Printed Name U:4(l(; ( - ,.� �p41
)PTesident \11 Title c, s oy
hate _r ( 'r1W$070133aO4 Date
pma 13 of IS
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EXHIBIT C
Physicians and/or locations whore services Are to be rendered by Member Provider
{
Tbo Kowbor Provider agrees thatthe follovVing physlclaus and/or practice locations listed on attached Exhibit C,
slid]be iaCIUMIle of the signed agreement and the stgitted rates In Exhibit B. By signing below Member Provldor or its
I2opresentat1V&Das1,i at allows Izacltpart R644ca.ro Group(IROOXPORP aAd its representgtivas to use aUy a4d all
of the below liti'ormation as agreed to in this signed agreement.
University Counseling Center
Practice Name(1) Practice Namo(2)
William R(,Itob)Sheppard.tPC
Physician Name(if applicable) Physician Name(if applicable)
1533 Merrimac Circle Suite I01
Physical Address Physical Address
Fort Worth,TX 75107
City,State Zip City,staid Zip
Mailing Addxess(if different) Mailing Address(if different)
6717-810-00301917-57356-9
Phone Number/Fax Number Phone Nurabw/Fax Number
$0-013s"t;04
Tax M Number Tax ID Number
Practice Name(3) practice Name(4)
Physician Name(if applicabla) physiiclan Name(if applicable)
Physieal•A•ddress Physical Address
City,Stete zip City,State Zip
_-•. -•- -- -•_ _-- ..._ .. Nlailin Address'(if dif�erentj' - -- -- ---- - - �VlailingAd'dress(i'fdifferent) ------ _ .. - -•- -- --•--- .._. --
Phone Number/Fax Ntnnber Phone Number/Fax Number
Tax ID Ntunber Tax ID Number
Tor.and oil beRiaif ofi
For and an behalf of:
.Rockpor(Cbinmun*NeEwoAj Ine- Member Provider or Representative/
—761 Old Hickory B lYd.,Ste.300
i � � Signature:
- r
Name: 01
Daugg ms .I1T� ({115177 (print)
Presiders
Date:— j`t k1 Date:
-r
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EXHIBIT D
Workets'Compensation Networks(WQJ)
Rockport may make this provider agreement avultnhle to other networks through delcg1timt. As defined wlthln the
PhYliaiAt agreement,Member Providers agree to provide treatment for lured employees who obtain workers'
compensation health coxt service through these networks. The named networks art 1lsted below:
Rockport Commuzdty Network
• Wtllcomp Managed Care Services,Inky Plan NAme:CompXey Plus
• >9roadsplre�iCN
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