Global Preferred Provider Participation Form (Page 2 of 2) in pdf

Global Preferred Provider Participation Form - non-US (page 2)

E. SPECIALTY INFORMATION - Hospitals and Physicians

Please specify the specialty or specialties practiced by your hospitals/physicians

Allergy and Immunology

Emergency Medicine

Ophthalmology

Pulmonology

Andrology

Gastroenterology

Orthopedics

Psychiatry

Anesthesiology

Internal Medicine

Otolaryngology (ENT)

Radiology

Cardiology

General Practice

Pathology

Reconstructive/Cosmetic Surgery

Cardiothoracic Surgery

Long Term Care

Physiotherapy

Surgery (please specify type)

Counselling and Social Work

Neonatology

Pediatrics (please specify any sub-specialties)

_________________________________________

Dentistry

Neurology

_____________________________________________

Urology

Dermatology

Obstetrics and Gynecology

Podiatry

Other (please specify)

Durable Medical Equipment

Oncology and Hematology

Proctology

_________________________________________

F. ADDITIONAL HOSPITAL INFORMATION- Hospitals Only

Number of general acute care beds

Number of ICU beds

Number of pediatric ICU beds

Number of neonatal ICU beds

Number of inpatient admissions in the

last 12 months

Most common surgical procedure performed in the last 12 months

Mortality rate

Complication rate

Is the hospital currently a member of a broader hospital group?

If YES, which one?

Yes

G. ACCEPTANCE OF TERMS

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 bill the insurance carrier directly and not request any payment upfront from COVERED PERSONS and 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.

Terms of Reimbursement (please make your selection and initial).

10% Prompt Payment Discount

0% Discount on billed charges

on billed charges and payment within 30-days of receiving clean claim

and payment within 45-days of receiving a clean claim

(Initial)

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

a patient authorization form (PAF) prior to or at time of service, or 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 date of signature with consecutive yearly renewals and may be terminated by either party with sixty (60) days written notice without cause.

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.

10.

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.

11.

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.

12.

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.

Print Name

Title

Date (MM/DD/YYYY)

Signature _______________________________________________________________________________________________________

Global-Preferred-Provider-Participation-Form-Non-US-10.pg2 01/2011