Piedmont Healthcare Meditract Contract Information Cover Sheet printable pdf download

PIEDMONT HEALTHCARE

MEDITRACT CONTRACT INFORMATION COVER SHEET

(Scanning Checklist and Up-load Criteria Form)

Please complete this form in its entirety for each new and/or replacement contract, amendment, and any other contract-related

document that affects, changes or modifies the terms of an existing agreement. Contracts will be uploaded into the MediTract

database only when this form is completed and submitted to Legal Services along with a fully signed copy of the contract

document(s), completed contract review form per Policy 0044 and the completed compliance form. Incomplete forms will be

returned to the originator. If you have any questions on completing this form, contact Legal Services at extension 4570 or 4560.

Contracts must meet the following criteria to be uploaded into the MediTract database:

q

Contract document is fully executed by all parties (including verification that the PHC signature is an

authorized signer per the Limits of Authority Policy (Policy 0044).

q

All schedules and exhibits have been completed and attached to the contract.

q

All blanks have been completed (including, without limitation, execution and effective dates, dollar

amounts, names and titles of signers and notice addresses).

q

If physician contract, appropriate approvals and process completed in accordance with applicable policies.

q

Contract review form per Policy 0044 (for contracts signed after February 2011).

Scanning and Up-load Profile Information:

Piedmont Healthcare Contracting Entity:

Note: If more than one Entity, list all Entities

Vendor (Other Party):

Note: If more than one party, list all parties

Contract type: _________________________________________________________________________________

(e.g., Master Services Agreement, Equipment Purchase, Software License, Maintenance)

Sites:

Note: List all sites (e.g., PHC entities, PPG/PHI practice locations, buildings)to which this contract applies

Department:

Responsible Parties:

Primary:

Secondary:

Third:

Effective Date:

Expiration Date:

Critical Dates to be captured upon load:

Date:

Description:

Piedmont Healthcare Meditract Contract Information Cover Sheet