f8k1010ex10ix_amsurg.htm


Exhibit 10.9






 


THREE RIVERS PROVIDER NETWORK


AGREEMENT WITH







______________________________












This Agreement is made this 23rd day of October 2008, by and between Three Rivers Provider Network, Inc., a Nevada Corporation (“TRPN”) and Fort Bend SA Services a Provider Group of health care services.  TRPN contracts with hospitals, physicians, ancillaries and entities hereinafter referred to as “Provider” rendering medical and health care services at pre-determined rates as follow.







1.  Clients.  Covered Services. Contract Rates: TRPN contracts with insurance companies, third party administrators, health plans, individuals and entities hereinafter referred to as “Clients” that directly or indirectly access TRPN contracted providers for covered services.  Covered Services shall include all services that are medically necessary including health, workers’ compensation, automobile and general liability.  The rate used in conjunction with this Agreement will be a * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles.  Clients are obligated to make payment directly to provider only at the contracted rate as payment in full.  Provider shall not balance bill the patient upon receipt of payment in full at the contracted rate.  TRPN has no responsibility to make payments on behalf of Clients.  Payments shall be made within thirty (30) calendar days of receipt of clean claim.  Where a state mandated fee schedule exists, provider agrees to accept a * discount below the state schedule.  Payments made and cashed by the provider shall be accepted as payment in full and fulfillment of all terms of the agreement, providing the total payment including the member’s portion is not less than the contracted rate.







2.  Licenses, Standards of Care:  Provider agrees to deliver health care services that meet all legal standards of care complying with applicable Federal, State and Local laws and maintains the standards of NCQA and/or JCAHO.  The provider is delegated by TRPN to carry out and/or assign credentialing responsibilities.  Evidence of such licenses, certificates and standards shall be made available to TRPN upon request.







3.  Term and Termination:  This Agreement shall continue in effect for a period of one (1) years with automatic successive one (1) year terms.  This Agreement may be terminated by either party without cause with a ninety (90) day prior written notice to the other party at the mailing addresses listed under the signatures.  This Agreement may be immediately terminated with cause by TRPN should Provider lose applicable licenses, malpractice coverage, fail to honor the applicable contracted rates pursuant to this Agreement, or if any information provided in Attachment A is illegible, incomplete, or invalid.







4.  Dispute Resolution:  This Agreement shall be construed and interpreted in accordance with the laws of the State of Nevada.  Provider agrees to meet and confer in good faith to resolve any disputes that may arise under this Agreement. If a dispute between TRPN and Provider arises out of this Agreement and is not resolved, either party may submit the dispute to arbitration which shall be commenced and conducted in accordance with the Rules of Practice and Procedures of the Judicial Arbitration and Mediation Services, Inc. (“JAMS”) as in effect at the time (“JAMS Rules”).







5.  Attachment A:  All information provided in Attachment A of this Agreement is complete and accurate to the best of Provider’s knowledge and Provider shall immediately notify TRPN of any changes thereto.  Provider agrees to mark “N/A” next to any blank that is not applicable to Provider’s business.







6.  Faxed Signatures:  The parties agree that facsimile signatures of authorized representatives of the parties shall legally bind the parties to the terms and conditions of this Agreement as if the signatures were original and shall be considered evidence of a fully executed Agreement.

























	
*

	
Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act.  Confidential portions of this document have been filed separately with the Securities and Exchange Commission.







 




  





Page 1











  




 




IN WITNESS WHEREOF, the authorized parties hereto have executed this Agreement and intend to be bound thereby.


 



	PROVIDER GROUP NAME (Please Print): 	 	ATTENTION:LANI HAZELTON
	 	 	TRPN CONTRACTING COORDINATOR
	 	 	 
	 	 	THREE RIVERS PROVIDER NETWORK
	 	 	 
	Signature:  /s/ Jaime Olmo	 	Signature:
	 	 	 
	Title:    COO	 	 
	 	 	 
	Date:     10/23/08	 	 
	 	 	NAME:  Todd Breeden, C.O.O.
	 	 	Mailing Address:  1620 Fifth Avenue Suite 900
	 	 	San Diego, CA 92101    Phone:  (619) 230-0530
	 	 	Date: 





 


ATTACHMENT A: PROVIDER INFORMATION


(Please attach a roster of all the provider’s full names, titles, NPI#s, and all locations under the group’s Tax Id#, use Addendum A)


 


 



	Tax ID:  35-2318359	Practice Name: Fort Bend SA Services
	 	 
	National Provider Identifier (NPI):	 
	 	 
	126569033	Group / IPA Affiliation:___________
	
(If there is more than one NPI Number, please attach a listing.)

	 
	 	 
	 	 
	Degree:  LSA, CSA,SA-C, CST/CFA, CRNFA, RN, CNOR	Office Hours:  8-4:30
	Specialty :  Surgical Assisting	 
	                    First Assist	Primary Address:  P.O. Box 481
	 	Alief TX 77411
	 	 
	 	County:  Harris
	 	Phone:  713-779-9800  Fax:  713-779-9862
	 	 
	 	Email:  Jaimeolmo@me.com
	 	 
	 	Other Practice and/or Billing Address:  Yes □  No □
	 	If “yes”, attach page with additional information
	 	 
	 	Hospital Affiliations (list name, date and type):
	 	 
	 	See Attachment.
	 	 
	 	 
	 	 
	 	 





 


Provider agrees to mark “N/A” next to any blank that is not applicable to Provider’s business.


 




  





Page 2











  






 


ADDENDUM A:







MEDICAL STAFF LISTING & FACILITY LOCATIONS







_______________________________




 



	i.    	The attached roster of providers and or locations will be participating under this Agreement between Fort Bend SA Services and Three Rivers Provider Network and shall include Tax Identification Numbers, NPI Numbers, Address(s), Phone and Fax Numbers.





 


  




  





Page 3











  






 



	
FORT BEND SA SERVICES


	
Bayshore Medical Center


4000 Spencer Highway


Pasadena TX 77504


	
Christus St. Catherine’s


701 South Fry Road


Katy TX 77450


	
Christus St. John Hospital


18300 St. John Dr.


Nassau Bay, TX 77058


	
Clear Lake Medical Center


500 Medial Center Blvd.


Webster TX 77598


	
Cypress Fairbanks Medical Center


10655 Steepletop Drive


Houston, TX 77065


	
Doctors Surgical Center


8111 Southwest Freeway


Houston TX 77074


	
East Houston Regional Medical Center


13111 East Freeway


Houston TX 77015


	
East Side Surgery Center


10918 East Freeway


Houston TX 77029


	
First Street Hospital


4801 Bissonnet


Bellaire TX 77401


	
First Surgical Memorial Village


12727 Kimberly Lane #100


Houston TX 77024


	
First Surgical Partners LLC


411 First Street


Bellaire TX 77401


	
Foundations Surgery Center


5410 West Loop South


Bellaire TX 77401


	
Houston NW Medical Center


710 FM 1960 West


Houston, TX 77090


	
Katy St. Catherine’s Surgery Center


707 South Fry Road #150


Katy TX 77450







 




  





 











  




 





	
FORT BEND SA SERVICES


	
Kingwood Medical Center


22999 US Highway 59


Kingwood TX 77339


	
Memorial Hermann


6411 Fannin


Houston, TX 77030


	
Memorial Hermann Memorial City


921 Gessner Road


Houston TX 77024


	
Memorial Hermann Northwest


1635 North Loop West


Houston TX 77008


	
Memorial Hermann Southeast


11800 Astoria Blvd


Houston TX 77089


	
Memorial Hermann Southwest


7600 Beechnut


Houston TX 77074


	
Memorial Hermann Surgery Center Northwest


1634 North Loop West #300


Houston TX 77008


	
Memorial Hermann Surgery Center Southwest


7789 Southwest Freeway #200


Houston TX 77074


	
Memorial Hermann The Woodlands


9250 Pinecroft


The Woodlands TX 77380


	
Methodist Sugar Land


16655 Southwest Freeway


Sugar Land TX 77479


	
Methodist Willowbrook


18220 Tomball Parkway


Houston TX 77070


	
North Cypress Medical Center


21214 Northwest Freeway


Cypress TX 77429


	
Northeast Medical Center


18951 Memorial North


Humble TX 77338


	
OakBend Medical Center


1705 Jackson Street


Richmond TX 77469


 





 




  





 











  






 


 


	
FORT BEND SA SERVICES


	
Palladium Surgery Center


4120 Southwest Freeway #230


Houston TX 77027


	
Park Plaza Hospital


1313 Hermann Drive


Houston TX 77004


	
Special Surgery Centre


9180 Katy Freeway Suite 202


Houston TX 77055


	
Spring Branch Medical Center


8850 Long Point


Houston TX 77055


	
St. Joseph Medical Center


1401 St. Joseph Parkway


Houston, TX 77002


	
St. Luke’s Episcopal Hospital Sugar Land


1317 Lake Point Parkway


Sugar Land TX 77478


	
St. Luke’s Episcopal Hospital


6720 Bertner Street


Houston TX 77030


	
Sugar Land Surgical Hospital


1211 Highway 6 Suite 70


Sugar Land TX 77478


	
The Woman’s Hospital


7600 Fannin


Houston TX 77054


	
West Houston Medical Center


12141 Richmond Avenue


Houston TX 77082


	
West Houston Surgicare


970 Campbell Road


Houston TX 77080







 




  





 











  






 


Provider List


10/23/2008


 



	Code 	Name  	National Provider Identifier	Credentials	License Number
	  Last Name   	 	 	 	 
	 	 	 	 	 
	
BA


   ABORDO


 

	
ABORDO, BELTRAN


 

	
 


1225155880

	
LSA

	
SA00024


 


	
SA


   ADIL


 

	
ADIL, SAYED

	
 


1649397217

	
LSA

	
SA00289


	
HA


   AGUILAR


 

	
AGUILAR, HUGO

	
 


1578680153

	
LSA

	
SA00283


	
OA


   AKUPUE


 

	
AKUPUE, OKECHUKWU

	
 


1346368917

	
LSA

	
SA00307


	
MA


   AL ALAM


 

	
AL ALAM, MOHD

	
 


1487772901

	
LSA

	
SA00309


	
RA


   ARAGON


 

	
ARAGON, RECTO

	
 


1427176981

	
SA-C

	
A01143


	
AA


ARREOZOLA


 

	
ARREOZOLA, ALEJANDRO

	
 


1649398108

	
LSA

	
SA00299


	
JA


   ASPORT

	
ASPORT, JORGE

	
 


1710005053


 

	
LSA

	
A03119


	
MA01


   ATHANS


 

	
ATHANS, MARK

	
 


1093833576

	
LSA

	
SA00029


	
IA


   AYUB


 

	
AYUB, ILIA

	
 


1568580058

	
CSA

	
CSA04209


 


	
QB


   BABURI


 

	
BABURI, QASIM

	
 


1043338445

	
LSA

	
SA00160


	
VB01


   BARCES


 

	
BARCES, VICENTE

	
 


1932227287

	
LSA

	
SA00161


	
VB


   BATTAD`


 

	
BATTAD, VENERANDO

	
 


1003934357

	
LSA

	
SA00290


	
CB


   BENITEZ


 

	
BENITEZ, CARLOS

	
 


1700904067

	
LSA

	
SA00163


	
WB


   BERRY


 

	
BERRY, WILLIAM

	
 


1851589386

	
CST/CFA

	
109540














  





1











  











Provider List


10/23/2008


 



	Code 	Name  	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
DGB


   BESSON


 

	
BESSON, DORKA G

	
 


1750501565

	
LSA

	
SA00291


	
AC


   CALLEGARI


 

	
CALLEGARI, ANDRES

	
 


1275651226

	
LSA

	
SA00108


	
JC01


   CANSECO


 

	
CANSECO, JOSE

	
 


1700904737

	
LSA

	
SA00110


	
JC002


CARRION


 

	
CARRION, JOSE

	
 


1629196704

	
SA-C

	
06114


	
LC


   CERDAN


 

	
CERDAN, LAURO

	
 


1922126002


 

	
CSA

	  
	
BC   CHAMBERLAIN


 

	
CHAMBERLAIN, BLAND

	
 


1891813804

	
LSA

	
SA00237


	
JC


   CHAPA


 

	
CHAPA, JOSE

	
 


1467570374

	
LSA

	
SA00255


	
MC


   CHAUDHRY

	
CHAUDHRY, MUBASHIR

	
 


1427176379

	
LSA

	
SA00277


	
MC01


   COLELLO


 

	
COLELLO, MARY

	
 


1386829521

	
SA-C

	
07272


	
VC


   CRUZ

	
CRUZ, VIRGINIA

	
 


1053439885

	
CSA

	
A05223


	
AD


   DARWISHS-SALAMA


 

	
DARWISHS-SALAMA,


ALFREDO

	
 


1699893354

	
LSA

	
SA0315


	
ND


   DAVIS


 

	
DAVIS, NORMAN

	
 


1164553772

	
CSA

	
ABSA 001163


	
BE


   EATON


 

	
EATON, BRENT

	
 


1699894378

	
CRNFA

	
061022


	
ZE


ELGAMAL


 

	
ELGAMAL, ZAK

	
 


1194786046

	
LSA

	
SA00011


	
MF


FARAG


 

	
FARAG, MAURICE

	
1548389216

	
LSA

	
SA00038







 




  





2











  






 


Provider List


10/23/2008


 



	Code	Name	National Provider Identifier	Credentials	License Number
	  Last Name  	 	 	 	 
	 	 	 	 	 
	
DF


   FLORES


 

	
FLORES, DAVID


 

	
 


1407975162

	
LSA

	
SA00069


	
LF


   FLORES


 

	
FLORES, LETICIA

	
 


1053502385

	
CNOR

	
CNOR030775


	
RF


   FOGLE

	
FOGLE, ROSA

	
 


1245359611

	
LSA

	
SA00170


	
AG


   GARCIA

	
GARCIA, ABEL

	
 


1013193721

	
LSA

	
SA00073


	
CG


   GARCIA-MAYORCA

	
GARCIA-MAYORCA, CARLOS

	
 


1265551949

	
LSA

	
SA0313


	
EG


   GLORIA


 

	
GLORIA, EDUARDO

	
 


1982723672

	
LSA

	
SA00270


	
FG


GONZALEZ

	
GONZALEZ, FLOR

	
 


1043339732

	
CSA

	
A06115


	
DG


   GRIFFITH

	
GRIFFITH, DAWN

	
 


1558548578

	
SA-C

	
07336


	
LH


   HERNANDEZ


 

	
HERNANDEZ, LUIS

	
 


1184800898

	
CSA

	
SA2582


	
AH


   HOWARD


 

	
HOWARD, ARTHUR

	
 


1013997261

	
CSA

	
CSA2667


	
SK


   KHAN

	
KHAN, SOSUN

	
 


1881713584

	
LSA

	
SA00272


	
ML


LEON

	
LEON, MARITZA

	
 


1831319524

	
SA-C

	
A03118


	
JL


   LORES


 

	
LORES, JULIO

	
 


1972622595

	
CSA

	
A05224


	
JM0-1


   MACHADO


 

	
MACHADO, JANETSY

	
 


1851579551

	
CSA

	
CSA3044


	
RM


   MACHADO

	
MACHADO, RAUL

	
 


1710006333

	
LSA

	
SA00129







 




  





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Provider List


10/23/2008


 



	Code	Name	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
SM


   MAMLOUK


 

	
MAMLOUK, SAMUEL

	
 


1194844712

	
LSA

	
SA00263


	
OM


   MARTINEZ


 

	
MARTINEZ, OMAR

	
 


1164616298

	
LSA

	
SA00286


	
MM


   MAYOR


 

	
MAYOR, MASOUDA

	
 


1225158918

	
LSA

	
SA00296


	
FM


   MEDINA


 

	
MEDINA, FELIPE

	
 


1306965025

	
SAC

	
03132


	
JM


   MORIN


 

	
MORIN, JOSE

	
 


1154440983

	
CSA

	
A06119


	
DM


   MURANOVIC


 

	
MURANOVIC, DUBRAVKA

	
 


1023137734

	
LSA

	
SA00084


	
NN


   NASSAR


 

	
NASSAR, NAYEF

	
 


1467570846

	
LSA

	
SA00135


	
JN


   NESIC


 

	
NESIC, J-PHILIP

	
 


1104046895

	
LSA

	
SA00312


	
CN


   NNA-WOSU


 

	
NNA-WOSU, CHI

	
 


1629283031

	
LSA

	
SA00085


	
JLO


   OLMO


 

	
OLMO, JAIME A

	
 


1619095627

	
LSA

	
SA00184


	
HP


   PANIAGUA


 

	
PANIAGUA, HENRY

	
 


1972621993

	
CSA

	
A05207


	
AP


   PARMAR


 

	
PARMAR, ABRAHAM

	
 


1487772307

	
LSA

	
SA00020


	
KP01


   PATEL


 

	
PATEL, KIRAN

	
 


1538287461

	
SA-C

	
A05217


	
LP01


   PATRONE


 

	
PATRONE, LOUIS

	
 


1417075201

	
LSA

	
SA00138


	
LP


   PERALTA

	
PERALTA, LEOPOLDO

	
 


1225156029


 

	
SA-C

	
A96160







 




  





4











  








 


Provider List


10/23/2008


 



	Code	Name 	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
FP


   PEREZ


 

	
PEREZ, FRANCIS

	
 


1245206481

	
CSA

	
CSA2617


	
KP


   PITA


 

	
PITA, KLEBER

	
 


1275651051

	
LSA

	
SA00274


	
CP


   PITTY


 

	
PITTY, CATALINO

	
 


1497885560

	
LSA

	
SA00279


	
FR


   RAMIREZ


 

	
RAMIREZ, FELIX

	
 


1801092010

	
LSA

	
SA00303


	
HR


   ROA


 

	
ROA, HERNAN

	
 


1184742066

	
LSA

	
SA00276


	
SR


   ROBIN


 

	
ROBIN, SCOTT

	
 


1437134962

	
LSA

	
SA00090


	
RR


   RODELA


 

	
RODELA, ROBERT

	
 


1508063728

	
CSA

	
A07252


	
ER


   RODRIGUEZ


 

	
RODRIGUEZ, EDUARDO

	
 


1831218593


 

	
LSA

	
SA00091


	
JR


   RUSSELL


 

	
RUSSELL, JAMES

	
 


1801871363

	
CST/CFA

	
CST85399


	
NS


   SANCHEZ


 

	
SANCHEZ, NORBERTO

	
 


1790970788

	
LSA

	
SA TEMPORARY


	
MS


   SHOKRALLA


 

	
SHOKRALLA, MAHER

	
 


1275652968

	
LSA

	
SA00269


	
JS


   SKORUPPA


 

	
SKORUPPA, JACOB

	
 


1215113022

	
CST/CFA

	
109194


	
PS


   SLAVCHEV


 


 

	
SLAVCHEV, PLAMEN

	
 


1194844803

	
LSA

	
SA00316


	
AS


   SOLOMAY


 

	
SOLOMAY, ALAN

	
 


1982723532

	
SA-C

	
A99216


	
PT01


   TAMARGO

	
TAMARGO, PEDRO

	
 


1114199809

	
SA-C

	
08120







 




  





5











  






 


Provider List


10/23/2008


 



	Code	Name	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
PT


   TROMBLEY

	
TROMBLEY, PATRICIA

	
 


1023136868


 

	
LSA

	
SA00156


	
IV


   VELEZ-VEGA


 

	
VELEZ-VEGA, IVELISSE

	
 


1700090701

	
LSA

	
SA00191


	
RV


   VILLARREAL


 

	
VILLARREAL, ROSENDO

	
 


1104930304


 

	
LSA

	
SA00249


	
HW


   WASSEF


 

	
WASSEF, HALA

	
 


1255508909

	
CSA

	
ABSA 08138


	
LW


   WU


 

	
WU, LARRY

	
 


1881807220

	
CSA

	
CSA2958


	
RZ


   ZAMARRON


 

	
ZAMARRON, ROGER


 

	
 


1275651010

	
LSA

	
SA00056


	
BZ


   ZHONG

	
ZHONG, BING TANG

	
 


1740308063

	
LSA

	
SA00158







 




  





6











  






 


AMENDMENT TO


AGREEMENT







BETWEEN


THREE RIVERS PROVIDER NETWORK


AND







FORT BEND SA SERVICES, INC.












This AMENDMENT to the Agreement between THREE RIVERS PROVIDER NETWORK (“TRPN”) AND (Tax  Id# 35-2318359), dated 10-23-2008 (“Agreement”), is entered into and made effective as of   05-07-2010.







FOR VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby acknowledged, and in consideration of the mutual promises and mutual covenants of the parties, the parties agree that the Agreement is hereby amended as follows:







1.           This Agreement is being amended due to renegotiations of the reimbursement rate in Section 1. and will now reflect the following change in rate:








a) The rate used in conjunction with this Agreement will be * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles.









2.           The remaining terms and conditions of the Agreement shall remain in full force and effect unless so amended pursuant to the terms of the Agreement.







IN WITNESS WHEREOF, the parties have executed this Amendment to the Provider Service Agreement to be effective as of the Effective Date.


 


 


 



	 	 	THREE RIVERS PROVIDER NETWORK
	 	 	 
	 	 	 
	By /s/  Jaime A. Olmo, Jr.	 	By /s/   Todd Breeden 
	Signature	 	Signature
	 	 	 
	Name: /s/ Jaime A. Olmo, Jr.    	 	Name Todd Breeden
	 	 	 
	Title:  COO                               	 	Title   Chief Operating Officer
	 	 	 
	Date   5/7/2010                       	 	Date    5/7/2010                               





 


















	
*

	
Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act.  Confidential portions of this document have been filed separately with the Securities and Exchange Commission.