<PAGE>

                                                                   Exhibit 6.3

                          Form of Provider Agreement


THIS AGREEMENT is made and entered into by and between Alliance HealthCard Inc.,
a Georgia corporation, (hereinafter called "Alliance") and the contracting
provider identified in the Provider Application (hereinafter called "Provider").

WHEREAS, Alliance wishes to develop and market a network of contracted providers
that HealthCard Members can use to access health care services not covered by
health or other insurance;

WHEREAS, Provider desires to participate in such network so that his or her
services may be marketed to HealthCard Members;

NOW THEREFORE, in consideration of the mutual promises and covenants set forth
herein, the parties agree as follows:

I    OBLIGATIONS OF ALLIANCE

     1.1  Alliance shall assume overall responsibility for the administration of
     the Alliance HealthCard program including network development, marketing,
     and other related activities.

     1.2  Alliance shall maintain a current listing of all providers
     participating in the Alliance network.

     1.3  Alliance shall market the services of providers to HealthCard Members
     through the issuance of directories and other materials identifying them as
     participants in the Alliance network. Such directories will be made
     available to HealthCard Members at the time of enrollment.

II   OBLIGATIONS OF PROVIDER

     2.1  Provider shall provide services and products to HealthCard Members
     that are standard and customary to the practice or business in which
     Provider is engaged.

     2.2  Provider agrees to discount his or her usual fees to HealthCard
     Members by the percentage specified below. The discount shall be extended
     to all HealthCard Members who provide full payment at time of service by
     cash, check or credit card. In applying the discount, Provider agrees not
     to markup his or her usual fees prior to applying the discount or extend
     the discount to any individual whose participation as a HealthCard Member
     has expired.

                              Discount: ________%

     2.3  Provider shall make billing and other records relating to this
     Agreement available to Alliance for inspection during normal working hours
     for up to two (2) years after termination of this Agreement.

     2.4  Provider shall allow Alliance to use his or her name, address,
     specialty and other relevant information in directories and other marketing
     materials.

III  WARRANTIES

     3.1  Provider warrants that the information contained in the Provider
     Application is accurate and  complete and that he or she is duly licensed,
     certified, and authorized to deliver products and services in the state(s)
     where he or she practices or does business.

     3.2  Provider warrants that he or she is aware that the Alliance HealthCard
     program is not a form of insurance and that Alliance is under no obligation
     to make any payment to Provider for any services or products utilized by
     HealthCard Members.

IV   TERM AND TERMINATION

     4.1  This Agreement shall commence on the date executed by Alliance. It
     shall remain in effect for a period of one (1) year and shall thereafter
     automatically renew for successive one-year terms.

                                      73
<PAGE>

     4.2  Either party may terminate this Agreement without cause with a 90 day
     written notice or 60 day notice for a material breach. This Agreement shall
     immediately terminate in the event that any license, certification or
     authorization that is required for Provider to engage in his or her usual
     and customary business, is revoked, suspended or otherwise terminated.

V    MISCELLANEOUS PROVISIONS

     5.1  This Agreement and any addenda constitute the entire Agreement between
     Alliance and Provider with respect to matters contained herein and
     supersede all prior Agreements or representations, written or oral,
     relating to the subject matter hereof.

     5.4  Any amendments to this Agreement shall be agreed to in writing by both
     parties.

     5.3       None of the provisions of this Agreement are intended to create,
               or shall be deemed or construed to create, any relationship
               between the parties hereto other than that of independent
               contractors. Neither of other parties hereto, nor any of their
               respective directors, members, officers or employees, shall act
               as or be construed to be the agent, employee or representative of
               the other.

     5.4  Either party may assign the Agreement in whole, or in part, with
     written notification to the other party. Alliance retains the expressed
     right to lease, sell, or assign its provider network under the terms of
     this Agreement.

     5.5       Each party hereto agrees to indemnify and hold each other
               (including its directors, members, officers, and employees)
               harmless against any and all claims, damages, demands,
               liabilities and costs incurred by the other party, including
               attorney fees, resulting from any act or omission by or under the
               direction of the indemnifying party or its agents or employees
               relating to the subject matter of this Agreement.

     5.6  Both parties shall use their best reasonable efforts to resolve any
     dispute arising under this Agreement before resorting to legal action
     thereafter. Where a dispute cannot be resolved informally, the parties
     agree to bring the dispute to the American Arbitration Association in the
     Atlanta office for resolution in accordance with applicable rules and
     procedures. Arbitration decisions will be considered binding and final.




IN WITNESS WHEREOF, the undersigned have executed this Agreement as of the date
and year indicated below.


PROVIDER                                ALLIANCE


_________________________________       ____________________________________
Signature                               Signature


_________________________________       ____________________________________
Title (if applicable)                   Title


_________________________________       ____________________________________
Date                                    Date

                                      74