Agreement For Participation Template - Department Of Vermont Health Access Page 3
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411. The PCP will follow the provisions of the Generic Drug Act where it permits substitution, and will
prescribe the lowest cost equivalent available.
12. The PCP will maintain hospital-admitting privileges or secure a waiver from DVHA of this requirement.
13. The PCP will participate in quality improvement projects agreed to by the participants in the PCCM
network and DVHA.
14. The PCP agrees to provide 90 days written notice before terminating this agreement.
15. The PCP will provide at least 60 days written notice prior to lowering the maximum number of enrollees
that may be assigned to the PCP.
16. The PCP agrees to accept at least 20 PCCM enrollees and not more that 1,500 enrollees. The PCP may
have fewer than 20 enrollees, if fewer beneficiaries have either selected the PCP or fewer have been
assigned by DVHA.
17. The PCP agrees to notify DVHA of any change in their office physical plant that might change physical
accessibility, or when there is a change in or addition to the location of the PCP’s office.
18. The PCP will cooperate with DVHA’s accessibility surveyors. DVHA will provide each PCP practice site
with the results of any accessibility survey conducted.
19. If there is any change in the composition of individual providers in a group that originally agreed to
participate in the Primary Care Plus Plan, the moving PCP is required to complete a new Agreement for
Participation prior to the effective date of change.
**************************************************************************************
For Admitting Physician:
I/we ________________________________ NPI#_________________ agree to be responsible for inpatient
hospital admissions for the patients assigned in the PC Plus program to
______________________________________________________ (Name of Naturopathic Physician)
____________________________________ (Admitting Physician or Authorized Party Signature)
___________________ Date
8-1-2012
Page 3
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