Fillable Provider Enrollment Form (Page 3 of 3) in pdf

F. LETTER OF AGREEMENT

This Letter of Agreement, by and between CMN Global Inc. (hereinafter referred to as “CMN”) and the undersigned (hereinafter referred to as “PROVIDER”), commemorates the

following understanding:

WHEREAS, Europ Assistance Group has built a healthcare network and given delegation, on behalf of Europ Assistance Group to CMN, a fully owned subsidiary. CMN

contracts with foreign and domestic insurance carriers to provide global network management access services and CMN wishes to arrange health care services on behalf

of such insurance carriers and their insured clients at reasonable cost, and;

WHEREAS, PROVIDER wishes to provide services to CMN-referred patients (“Covered Persons”) as required by this Agreement and CMN wishes PROVIDER to provide those services to

referred Covered Persons;

NOW, THEREFORE, in consideration of the potential advantages that will accrue to the Covered Persons of CMN and each of the parties themselves, PROVIDER and CMN hereby covenant

and agree with each other as follows:

PROVIDER and CMN Agree:

Services. PROVIDER will perform services that PROVIDER is licensed, equipped and staffed to provide which are medically necessary and consistent with the standard of quality

of care generally accepted in its medical community.

Compensation. PROVIDER shall agree to bill the patient’s insurance carrier directly for covered services rendered with the understanding that CMN shall ensure that insurance

carriers and their clients forward payment to PROVIDER for covered services rendered based on the terms of reimbursement set forth in this agreement.

Notification. CMN will notify COVERED PERSONS that they must present at time of registration of service an ID card indicating participation through CMN or CMN must submit to

PROVIDER prior to or at time of service, other evidence that is satisfactory to PROVIDER. CMN will confirm that COVERED PERSONS have valid insurance coverage that is in effect

on the date that the proposed healthcare services are to be provided.

Timely Filing. PROVIDER shall ensure that claims are submitted within 180 days of the date of service.

Balance Billing. PROVIDER shall accept reimbursement as set forth in this Agreement as payment in full for covered services rendered. This provision shall not prohibit collection

of supplemental charges, co-payments, co-insurance, deductibles, or payment for non-covered services, in accordance with the terms of a COVERED PERSON’S health plan.

Term. This Letter of Agreement is effective on the

with consecutive yearly renewals and may be terminated by either

party with sixty (60) days written notice without cause. Either party may terminate immediately in the case of a material breach of this contract.

Confidentiality. CMN and PROVIDER shall ensure that they and their directors, officers, employees, contractors, and agents hold confidential information in the strictest confidence.

Hold Harmless. Each party agrees to indemnify and hold the other party and its officers, directors, employees, and agents harmless from liability, demands, damages, or claims,

including attorney’s fees arising from any failure to indemnify part or all of its officers, directors, employees, or agents, to perform obligations under this Letter of agreement.

Independent Contractor. The relationship of the parties hereunder shall be an independent contractor relationship, and not an agency, employment, joint venture, or partnership

relationship. Neither party shall have the power to bind the other party or contract in the name of the other party.

Venue. This Letter of Agreement shall be governed by and construed in accordance with the laws in force in the plaintiff’s country, and venue for proceedings to enforce the

terms hereof shall be agreed upon accordingly between PROVIDER and CMN.

Notices. All notices hereunder shall be in writing, delivered personally, by certified or registered mail.

This Letter of Agreement contains the entire agreement between the parties relating to the rights granted and the obligations assumed by this Letter of Agreement. Any prior

agreements, promises, negotiations, or representations relating to the subject matter of this Agreement not set forth herein are of no force or effect. This Letter may be amended

only by written instrument signed by both parties.

IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their officials thereunto duly authorized.

Joint Benefit Clause

The rights granted hereunder by PROVIDER shall also benefit to the parent company of CMN, Europ Assistance Holding SA and its subsidiaries. In case CMN is no longer a

member of the Europ Assistance Group, both CMN and Europ Assistance Holding SA (and its subsidiaries) shall still be entitled to such rights unless this Letter of Agreement

is terminated by PROVIDER pursuant to clause F above.

G. TERMS OF REIMBURSEMENT

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Fee Schedule - Please attach a copy of your current Fee Schedule

Copy Attached

Reimbursment

In what currency will claims be submitted?

What is your preferred method of reimbursement?

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Local Currency

USD

Cheque