Form of Agreement



 Exhibit 10.1 
 

 







 URGENT CARE CENTER PARTICIPATION AGREEMENT 
 ATTACHMENT E 
 PHYSICIAN REIMBURSEMENT 
  

	I.	COMMERCIAL AND MEDICARE HMO AND POS PLAN MEMBERS 

 GLOBAL
RATE: 
 CENTER REIMBURSEMENT 
 CENTER agrees to bill and accept as payment in full from HUMANA the rates as set out below for Urgent Care Service provided to all HUMANA Members. 
 The following global fee is all inclusive in the total reimbursement made to Center (no additional reimbursement will be made for Surgeries, Anesthesia, Pathology, Radiology, EKG Casting/Splinting, except Injectable Medication.) 

Global rate (all inclusive of facility/technical and professional components) 
 CPT Code 99245 - $125.00 
 Injectable Medications (Medication & Administration) 
 CPT Code 98782 - $20.00 
 Less any Copayments due from
Member. 
 All Fee for Service claims shall be billed by PHYSICIAN to HUMANA within Sixty (60) days from the date of service. HUMANA agrees to pay
PHYSICIAN within thirty (30) business days of receipt of properly completed and uncontented claims. 
  

	II.	HUMANA WORKER’S COMPENSATION PLAN MEMBERS 

 PHYSICIAN agrees to accept
as payment in full for Physician services rendered to members of any HUMANA (Worker’s Compensation) managed care arrangements N/A (%) of the Tricare Florida established Medicaid fee schedule, or HUMANA’s fee Schedule or
PHYSICIAN’s fee profile, whichever is less, less any applicable Copayments due from such Members. Further PHYSICIAN agrees to comply with all document and administrative requirements provided for under the Florida Worker’s compensation
laws, rules and regulations, and further to cooperate with HUMANA’s Workers Compensation Nurse Care Case Managers. 







 ANCILLARY PROVIDER PARTICIPATION AGREEMENT 
 ATTACHMENT B 
 PRODUCT PARTICIPATION LIST 
 PROVIDER agrees to participate in all of the following health benefits plans and agrees to accept the terms and conditions set forth in this Agreement as they apply to
such self-funded and fully insured health benefits plans offered or administered by HUMANA. 
  

					
		  	Health Benefits Plans	  	
			
		  	HMO Plans	  	
			
		  	PPO Plans	  	
			
		  	PCS Plans	  	
			
		  	EPO Plans	  	
			
		  	Freedom Plans	  	
			
		  	Freedom Plus Plans	  	
			
		  	ASO Plans (Both HMO & PPO)	  	
			
		  	Medicare HMO Plans	  	
			
		  	Medicare PPO	  	
			
		  	Medicare POS Plans	  	
			
		  	Medicare Supplement/Select Plans	  	
			
		  	Other Medicare Plans	  	
			
		  	Indemnity Plans	  	








 First Amendment To 
 Urgent Care Center Participation Agreement 
 This Amendment is entered into between Humana Plan, Inc. (a Florida
Insurance Company and Humana Insurance Company and Employers Health Insurance company (insurance competition) and their affiliate who underwritten or administer health plans (hereinafter collective) or the context may require referred to as
“HUMANA” and as Urgent Care Counter Center, and Urgent Care Center Provider under the laws of the State of Florida (the hereinafter referred to as “PROVIDER”) 
 Witnesseth 
 Wherein the Agreement between
HUMANA and PROVIDER was effective as of the 1st day of August 2001 and 
 Whereas, HUMANA and PROVIDER desire to aimed the Agreement as set forth herein. Except as specifically amended hereby, the terms and conditions of the Agreement remain the same. 
 NOW THEREFORE, The Agreement is amended as follows: 
 Adding the following
codes to the unique fee schedule 112/112 - commercial 
  

					
	 CPT Coder:
	  	 Description
	  	 Reimbursement Rate:

	99201	  	New Patient 10 min limit/minor	  	$125.00
	99202	  	New Patient 20 min low/moderate	  	$125.00
	99203	  	New Patient 30 min moderate	  	$125.00
	99204	  	New Patient complicated /exam complex	  	$125.00
	99205	  	New Patient 60 min moderate/high	  	$125.00
	99211	  	Established Patient 5 min no physical required	  	$125.00
	99212	  	Established Patient 10 min limit/minor	  	$125.00
	99213	  	Established Patient 15 min low/moderate	  	$125.00
	99214	  	Established patient 25 min moderate/high	  	$125.00
	99215	  	Established Patient 40 min moderate/high	  	$125.00








 

 
 Group Company                

 1382 NW 12” STREET SUNRISE, FL          
  

			
	 


	  	Patient Illegibility, Claims Status, Claim Submission, Reimbursement Policies, 

 more: 
 Visit: www.united.healthcareonline.com 
 July 28, 2006 
 ER URGENT CARE CENTERS 
 700 IVES DAlRY ROAD 
 NORTH MIAMI BEACH, PL 33179 
 Re: Participant Agreement–TIN# 661050592 
 Pear: ER Urgent Care Centers 
 We are pleased that you have signed a new
contract with United Healthcare of Florida, Inc. Enclosed please find an executed, original agreement for your records. This Agreement is effective for of services on or after 07/01/2006. Under this Agreement you are presently participating
in the lines of business as indicated below. 
  

							
		 	x	  	Choices/Choice Plus	  	
		 	x	  	National [ILLEGIBLE]	  	
		 	x	  	National HMO	  	
		 	x	  	Medicare Complete	  	
		 	x	  	Medicare HMO	  	

 Should you have any questions please contact Network Management at 854-858-4278 
 We look forward in a mutually successful relationship and your continued participation with our organization. 
 Sincerely, 
  

	
	 /s/ Christine M Jimdor

	Christine Jimdor
	Network Account Manager








 For reference purposes, the following fee schedules will be used to pay claims under this agreement: 
  

					
	 PRODUCTS:
	  	 FEE SCHEDULES:
	  	 PROVIDER DESCRIPTION

	Commercial	  	SFL 965	  	90% 2005 RBRVS
			
	Commercial—Other	  	SFL 9655	  	90% 200 RBRVS
			
	Medicare	  	SFL 6221	  	90% Current Year
			
		  		  	
			
		  		  	
			
		  		  	
			
		  		  	
			
		  		  	
			
		  		  	
			
		  		  	








 Appendix 4 
 Protocols for NHP Customers 
 For Customers enrolled in Benefit Plans issued or administered by Neighborhood Health
Partnership, Inc. (“NHP”) Medical Group will be subject to the Protocols described available to Medical Group through the NHP Provider Handbook (the “NHP Manual”). When this Agreement refers to the Administrative Manual of
Guidelines also referring to the NHP Manual. The NHP Manual is available in Medical Group on-line at www.mynhp.com or upon request in the event of any conflict between to NHP Manual and any of the following: this Agreement, any United Protocols,
Payment Policy, or the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide in connection with any matter pertaining to a NHP Customer, the NHP Manual shall govern, unlose applicable statutes or
regulations otherwise. United may make changes to the Administrative Manual or Guide or NHP Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group. 







 

 
 CAREPLUS HEALTH PLANS, INC. 
 ANCILLARY CARE AGREEMENT 
 This Ancillary Care Agreement (“Agreement”)
is made and entered into on this      day of             , 2007 by and between CarePlus Health Plans, Inc. (“Plan”), and ER URGENT CARE
MANAGEMENT CO., INC. (“Ancillary Provider”). 
 WHEREAS, Plan is a licensed in the State of Florida to operate an HMO Plan
under which members, under an agreement with Plan, may be provided with medical, services and hospital care; and 
 WHEREAS, Ancillary
Provider is duly licensed and authorized to provide ancillary health services in the State of Florida; and 
 WHEREAS, Plan wishes to
engage the Ancillary Provider to provide Ancillary Care Services to Plan Members (as outlined in Attachment A), and Ancillary Provider agrees to provide such Ancillary Care Services under the terms and conditions set forth in this Agreement; and

 WHEREAS, Ancillary Provider and Plan believe that this Agreement will be mutually beneficial, and, as such, both parties agree to
be bound by all terms and conditions contained herein. 
 In consideration of the above, it is mutually agreed as follows: 
  

	1.	Definitions 

 For the purposes of this Agreement, the
following words and phrases shall have the meaning specified: 
  

	 	1.1	“Admitting Physician” is a Primary Care Physician who admits Members to a Participating Hospital or to another hospital with the approval of Plan.


  

	 	1.2	“Agreement” means this Ancillary Care Agreement between plan and Ancillary Provider. 

  

	 	1.3	“Ancillary Services” means those Covered Services within the scope of the federal and state licensing and/or certification for providers of healthcare services of
the type specified in Attachment A hereto, that are; (i) Provided upon the referral of a Primary Cans Physician pursuant to the Plan’s rules and regulations, including the Plan Provider Manual, and (ii) Covered Services, but not
Primary Care Services. 

  


					
	Ancillary Agreement 2006	  	1	  	










 

 
  


	 	1.4	“Authorization” or “Authorized” means a Quality management and Utilization Management Program determination made by or on behalf of Plan, that
specific non-Emergency Services and supplies to be provided, or arranged, or Emergency Services which were provided, including without limitation, the extent and duration of such Covered Services, are or were Medically Necessary and meet standards
and criteria established by Plan for such Covered Services. 

  

	 	1.5	“Authorization Number” means the unique number issued by the Plan upon approval of a request for written Authorization of particular Covered Services to be provided
or arranged, or which have been provided in case of an Emergency, to a Member. 

  

	 	1.6	“Capitation Payment” means the predetermined monthly fee paid by Plan to Ancillary Provider to consideration of the agreement of Ancillary Provider to
provide Covered Services as are Medically Necessary pursuant to section 1.20 of this Agreement to Members who have been assigned to Ancillary Provider. To the extent a fee of this nature is paid to Ancillary Provider under this Agreement, such fee
is calculated on the basis of the formula(s) set forth in Attachment A, of which Attachment there may be multiple parts, depending on the types of Covered Services rendered by Ancillary Provider, and as set forth in said Attachment A.


  

	 	1.7	“Copayment” means the amount required to be paid by Member to Ancillary Provider as additional payments for Covered Services and shall include fixed payments to be
paid as well as percentage amounts based on the cost of a service (i.e. “co-insurance”). Copayments will vary in amount for Members, depending on benefit structure.” 

  

	 	1.8	“Covered Services” means those health care services to which Members are entitled under the terms of Plan’s Contract, Medicare Contract, other form of
agreement, applicable law (whether by applicable statute or regulation or determination of a Governmental Agency or court of law) and are Medically Necessary. 

  

	 	1.9	“Credential” or “Credentialing” means the process for verifying that Participating Providers providing services to Members are trained, licensed,
of good professional reputation, and capable or working with others in the provision of Covered Services to Members. 

  

	 	1.10	“Effective Date” shall mean the effective date of this Agreement which shall be the later of the date on the first page of this Agreement. 


 

	 	1.11	 “Emergency” means any situation in which Covered Services for the treatment of a suddenly occurring condition are 



  


					
	Ancillary Agreement 2006	  	2	  	










 

 
  


	 	 
Medically Necessary, to prevent deterioration of a Member’s health due to unforeseen injury or illness and cannot be delayed until the Member can
receive the necessary services from a Participating Ancillary Provider. 


  

	 	1.12	“Emergency Medical Condition” means (a) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a
prudent layperson, pursuant to Section 4704 of the 1997 Balanced Budget Act, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: 1. serious
jeopardy to the health of the individual including a pregnant woman or a fetus. 2. serious impairment of bodily functions. 3. serious dysfunction of any bodily organs or part. (b) with respect to a pregnant woman; 1. that there is inadequate
time to effect safe transfer to another hospital prior to delivery. 2. That a transfer may pose a threat to the health and safety of the patient or fetus. 3. that there is evidence of the onset and persistence of uterine contractions or rupture of
the membranes. 

  

	 	1.13	“Emergency Services” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable laws, by other appropriate,
personnel under the supervision of a physician, to determine whether an emergency medical condition exists, and if it does, the care, treatment, or surgery for a covered service by a physician which is necessary to relieve or eliminate the emergency
medical condition, within the service capability of a hospital. 

  

	 	1.14	“Fee for Service” means a payment structure in which reimbursement is paid to Ancillary Provider based on mutually agreed, upon rates for Covered Services rendered
to Members. 

  

	 	1.15	“Governmental Agencies” 

  

					
	 •        AHCA:
	  	State of Florida Agency for Health Care Administration
	 •        OIR:
	  	Office of Insurance Regulation
	 •        CMS:
	  	Center for Medicare and Medicaid Services
	 •        DHHS:
	  	U.S. Department of Health and Human Services
	 •        DCFS:
	  	Florida Department of Children and Family Services
	 •        GAO:
	  	U.S. Government Accounting Office
	 •        OIG:
	  	Office of the Inspector General

  

	 	1.16	“Individual Subscription Agreement” means an agreement between Plan and an Individual Subscriber by which such individual is entitled to become a Member of Plan in
accordance with the terms of such agreement, Individual Subscription Agreements shall include agreements between Plan and a Subscriber entitled to benefits under the Title XVIII of the Social Security Act, as amended. 

  


					
	Ancillary Agreement 2006	  	3	  	










 

 
  

  

	 	1.18	“Medical Director” means a physician designated by Plan to monitor and review Covered Services provided by a health care Ancillary Provider to Members or requested
by a health care provider for Members. 

  

	 	1.19	“Medical Staff” shall have the meaning ascribed such term in the medical staff bylaws of a Participating Hospital or a Participating Ancillary Provider which is an
ambulatory surgery center, or any other provider that has Medical Staff. 

  

	 	1.20	“Medically Necessary” means those services provided in accordance with 42 CFR § 440.230, as supplemented by that definition contained in
Section 59G-1.010(167), Florida Administrative Code. The term “Medically Necessary” requires that the medical or allied care, good or services furnished or ordered must meet the following conditions: (a) be necessary to protect
life, to prevent significant illness or significant disability, or to alleviate severe pain; (b) be individualized, specific and consistent with symptoms or confirmed, diagnosis of the illness or injury under treatment, and not in excess of the
patient’s needs; (c) be consistent with the generally accepted professional medical standards as determined by the Medicare program, and not experimental of investigational; (d) be reflective of the level of service that can be safely
furnished, and for which no equally effective and more conservative or less costly treatment is available, statewide; and (e) be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker,
or the provider. The terms “Medically Necessary or “Medical Necessity” as such are used to refer to impatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the
provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. The fact that a Participating Provider has prescribed, recommended, or approved medical or
allied, goods, or services does not in itself, make such care, goods or services Medically Necessary or a Medical Necessity or a Covered Service. 

  

	 	1.21	‘“Member” means an eligible Subscriber who has been enrolled in Plan, and may also include enrollees in other health care products administered by the Plan.


  

	 	1.22	“Participating Provider” means a hospital, physician, ambulatory surgical center, home health care agency, pharmacy, rnulti-specialty group practice, or any other
health care provider which or who has entered into agreement with, or is otherwise engaged by, Plan to provide Covered Services to Members. Any such Participating Provider may be designated as a Participating Hospital, Participating Physician,
Participating Pharmacy, etc. 

  

	 	1.23	“Plan Provider Manual” means the CarePlus Health Plans, Inc. Provider Manual; as amended, and revised from time to time by Plan in its discretion.


  


					
	Ancillary Agreement 2006	  	4	  	










 

 
  


	 	1.24	“Primary Care Physician” means a Participating Physician who practices as a general or family practitioner, internist, pediatrician, obstetrician, gynecologist or
other specialty approved by the Agency, who supervises, coordinates and provides Primary Care Services and patient management to Members, including the [ILLEGIBLE] of their referral for Specialist Services and other non-Primary Care Covered
Services, and who meets all the other requirements for Primary Care Physicians contained in the Plan Provider Manual and in this Agreement. 

  

	 	1.25	“Peer Review/Quality Improvement/Quality Management” means a program for reviewing and making determinations regarding the performance of Covered Services rendered
to Members, to include the review of the timeliness, quality and appropriateness of medical care by the Quality management and Utilization Management Committee (QM and/or UM Committee) and independent peer review and quality review and improvement
organizations. 

  

	 	1.26	“Quality management and Utilization Management Program (QA/UM)” means the program of utilization management and quality management established by Plan to assure the
proper level and quality of care is provided including, but not limited to, Plan’s policies and procedures The QA/UM Program outlined in the Plan’s policies and procedures may be changed by Plan upon written notice to Ancillary Provider.


  

	 	1.27	“Specialty Physician” means a Participating Physician who is appropriately qualified in a certain medical specialty consistent with the medical staff bylaws
[ILLEGIBLE] a Participating Hospital, who provides Covered Services to Members within the range of such specialty, who cloots to be designated as a Specialist Physician by Plan and who meets all other requirements for Specialist Physicians contained
in Plan’s rules and regulations, including the Plan Provider Manual, and in the Agreement between Plan and the Specialist Physician. 

  

	 	1.28	“Sick Care” means care provided for non-urgent problems which do not substantially restrict normal activity, but could develop complications if left untreated
(e.g., chronic disease), 

  

	 	1.29	“Subscriber” means a person who meets the eligibility requirements of the Plan, enrolls pursuant to the terms thereof, and for whom premiums are received by or on
behalf of the Plan. 

  

	 	1.30	“Urgent Care” means care provided for those problems which, though not life-threatening, could result in serious injury or disability unless medical attention is
received or do substantially restrict a Member’s activity. 

  


					
	Ancillary Agreement 2006	  	5	  	










 

 
  


	 	1.31	“Urgently Needed Services” means Covered Services provided when a Member is temporarily absent from the Plan’s service (or, if applicable, continuation) area
(or, under unusual and extraordinary circumstances, provided when the Member is in the service on continuation area but a Participating Provider is temporarily unavailable or inaccessible) when such Covered Services are Medically Necessary and
immediately required (a) as a result of an unforeseen illness, injury, or condition; and (b) it was not reasonable given the circumstances to obtain the Covered Services through a Participating Provider. 

  

	 	1.32	“Well Care” means a routine medical visit for one of the following: Child Health Checkup (EPSDT) visit, family planning, routine follow-up to a previously treated
condition or illness, adult physicals and any other routine visit for other than the treatment of an illness. 

  

	2.	Duties and Responsibilities of Plan 

  

	 	2.1	Compensation to Ancillary provider 

 Plan shall
compensate Ancillary Provider at the rate set forth in Attachments A-C. Plan agrees to reimburse Ancillary Provider within thirty (30) days of receipt of properly and correctly completed CMS 1500 Form for authorized non-capitated services or
within twenty (20) days if filed electronically. 
  

	 	2.2	Member Eligibility 

 Plan will provide each Member
with an identification card which shall be presented for purposes of assisting Ancillary Provider in verifying Member eligibility. Plan will not be responsible for services provided to non-eligible individuals. 
  

	 	2.3	Peer Review/Quality Improvement/Quality Management Programs 

 Plan shall maintain an active, integrated and organized process of peer review as part of its poor-based quality management and improvement programs. 
  

	 	2.4	Monitoring of Performance 

 Plan shall coordinate
and participate in the monitoring of performance and outcome measures of services rendered to Members by Ancillary Provider. 
  

	 	2.5	Marketing 

 Ancillary Provider understands that no
guarantees are afforded by Plan as to the number of Members who will select Ancillary Provider. Ancillary Provider also agrees to adhere to all marketing guidelines by CMS and other applicable regulatory agencies. 
  


					
	Ancillary Agreement 2006	  	6	  	










 

 
  


	 	2.6	Advertising Plan 

 Plan may include Provider’s
name, address, telephone number and type of practice in a roster of Participating Providers, it being understood by the parties that this roster may be inspected by and is intended for the use of current and prospective Members, Subscribers,
Participating Providers, and other health care providers. Ancillary Provider shall not engage in any marketing activities with respect to Plan and shall not use the trademarks and trade names employed by Plan without the prior written approval of
Plan. 
  

	 	2.7	Administrative Duties 

 Plan, through its Medical
Director and such other individuals as Plan designates, shall provide the Ancillary Provider a system for prior authorization of all referrals to Ancillary Provider and written notification of denied claim forms or covered services. 
 All procedures relating to the foregoing shall be contained in the Plan Provider Manual. 
  

	 	2.8	Administration of Plan 

 Plan shall provide the
appropriate personnel, facilities and equipment necessary for the administration of Plan. Plan has the sole responsibility and final decision making authority for: (i) payment of claims for health services rendered to Members;
(ii) eligibility for enrollment in Plan; (iii) termination of a Member’s coverage under the Plan; (iv) all benefit determinations; and (v) the Ancillary Provider and member grievance system established by Plan. Plan agrees
to recognize and abide by all state and federal laws, regulations and guidelines including those applicable to Plan’s Medicare Program. Plan supervises and is accountable to the Governmental Agencies for those functions that are outlined in
Plan’s contract with Medicare. Plan has not delegated any administrative duties to Ancillary Provider unless expressly set forth herein and only to the extent set forth herein. 
  

	3.	Duties and Responsibilities of Ancillary provider 

  

	 	3.1	Licensure 

 Ancillary Provider represents and
warrants that Ancillary Provider and all other health professionals employed, retained or in professional association with Ancillary Provider who will provide services under this Agreement are appropriately trained and qualified, licensed and
authorized by the State of Florida and all other applicable governmental entities to practice their profession and to perform procedures which are to be provided pursuant to this Agreement. Ancillary Provider covenants that Ancillary Provider and
the physicians and other health professionals employed by or associated with Ancillary Provider shall be duly credentialed by Plan and shall maintain their licenses and authorizations at all times during the term of this Agreement. 
  


					
	Ancillary Agreement 2006	  	7	  	










 

 
  


	 	3.2	Compliance with Plan Rules 

 Ancillary Provider
agrees to be bound by and comply with Plan’s policies, procedures and rules as promulgated from time to time, which, as now in effect and as hereafter adopted and amended, are incorporated in this Agreement, including without limitation those
policies and procedures set forth in the Plan Provider Manual. By executing this Agreement, Ancillary Provider acknowledges receipt of such policies, procedures and regulations, including the Plan Provider Manual. 
  

	 	3.3	Credentialing 

 a) Ancillary Provider and each and
every other health professionals employed, retained or in professional association with Ancillary Provider agree to complete a Credentialing application, when applicable and to provide appropriate credentialing information to commence the
credentialing process as set forth by Plan’s policies and procedures, including the Plan Provider Manual. Participation under this Agreement is subject to the satisfaction and maintenance in Plan’s sole judgment, of all credentialing
standards established by Plan and its Medical Director and as monitored by his/her designees. At the request of Plan, Ancillary Provider will authorize or will cause to authorize the release to Plan of any and all information compiled, maintained or
assembled by a Participating Provider for the Credentialing or Re-Credentialing of such Providers by Plan. Ancillary Provider will not be compensated for Covered Services in the absence of notification by Plan of the credentialing of Ancillary
Provider and all physicians and other health professionals associated with Ancillary Provider. Provider hereby authorizes Plan to obtain any credentialing information from any of Provider’s associates, as applicable. 
 b) Re-Credentialing and Re-Contracting 
 For purposes of Re-Credentialing and re-contracting, Plan shall consider quality performance, member satisfaction, compliance with Plan’s administrative procedures, utilization performance and practice patterns and attitudes as they
relate to managed care practices. 
  

	 	3.4	Verification of Eligibility 

 Ancillary Provider is
responsible for verifying eligibility of Plan’s Members before rendering services as appropriate. Provider agrees to verify eligibility of Members, in addition to the membership card, via Plan’s website and/or by calling Plan. 

 


					
	Ancillary Agreement 2006	  	8	  	










 

 
  


	 	3.5	Ancillary Provider Training 

 Ancillary Provider
agrees to receive and participate in the Ancillary Provider training as developed by Plan, the contents of which may be amended from time to time by Plan in its sole and absolute discretion. 
  

	 	3.6	Encounter and Other Related Information 

 Ancillary
Provider agrees and acknowledges that Plan is required to maintain a health information system that collects, analyzes and integrates all data necessary to compile, evaluate and report certain statistical data related to costs, utilization and
quality, and such other matters as the Governmental Agencies may require. Ancillary Provider agrees to submit such information as may be necessary for Plan to fulfill these obligations within all applicable time frames. The data shall be sufficient
to characterize the context and purpose of each encounter between Ancillary Provider and a Member. The information shall consist of statistical and descriptive medical and patient data as specified by Plan. Encounter information on capitated
Ancillary Providers shall be submitted to Plan within-thirty (30) days of the date of service to Members. Ancillary Provider represents, warrants and agrees that Ancillary Provider shall certify in writing at the time of submission of all
information to Plan, or such other party as is designated by Plan, that all information submitted, including all encounter data, shall be truthful, reliable, accurate and complete. In the event the encounter information is not submitted to Plan in a
timely manner (monthly), Plan will give Provider; a fifteen (15) day notice to provide the encounter information. In case of non-compliance by Provider, Plan may at its sole discretion withhold 10% of Provider’s future payments until such
time that the encounter information for the time period requested is submitted to Plan either electronically or as completed CMS 1500 forms. Ancillary Provider agrees to indemnify and hold Plan harmless against any loss or damage, including any or
penalties, Plan may incur as a result of Ancillary Provider’s inaccurate or incomplete information. 
  

	 	3.7	Office 

 Ancillary Provider shall maintain and
office located within a reasonable distance of a Participating Hospital that is capable of providing the full range Ancillary Services. 
  

	 	3.8	Ancillary Services 

 a) Ancillary provider agrees to
provide pre-authorized Ancillary Services in an ethical and legal manner, in accordance with professional standards of care in the medical community to all Members. Ancillary Services will only be provided by Ancillary Provider after receipt of
written authorization from the Plan. 
 b) Ancillary Provider agrees to provide pre-authorized Medically Necessary Ancillary Services to
Plan’s Members upon 

  


					
	Ancillary Agreement 2006	  	9	  	










 

 
  

 
referral to Ancillary Provider by Plan. Ancillary Provider shall cooperate with Plan’s procedures for timely access to care and Covered Services as
required by standards established by Governmental Authorities, including CMS. Ancillary Provider agrees to provide or arrange for the provision of advice and assistance to Members in Emergency situations, including any Emergency Medical Condition.
Provider agrees not to charge for any service provided to the Member at a rate in excess of the rates established by this Agreement in accordance with Section 1128B (d)(l), Social Security Act (enacted by Section 4704 of the 1997 Balance Budget
Act.) 
 c) Ancillary Provider further agrees to render Ancillary Services as specified in Attachment A, to Members in the same manner, in
accordance with the same standards of care and with the same time availability as offered his/her other patients and without regards to the degree of frequency of utilization of such Covered Services by a Member, race, religion, gender, color,
national origin, age, source of payment any factor related to physical or mental health status, or on any basis deemed unlawful under federal, state or local law. 
 d) Ancillary Provider agrees to make available Ancillary Services twenty four (24) hours per day seven (7) days per week including holidays, to comply with at least the following availability schedule (except as
otherwise set forth in Attachment A hereto): Urgent Care within one day; Sick Care within one week; and Well Care within one month. Ancillary Provider shall maintain adequate personnel and facilities to fulfill the contracted obligations hereunder
and shall communicate in the language of the Member, if requested. Ancillary Provider shall be responsible for the provision, authorization, coordination, supervision, monitoring and overall management of all Ancillary Services to each of
Provider’s Members in accordance with Plan’s policies and procedures. In any event, Ancillary Provider shall maintain twenty four (24)-hours-a-day, seven (7)-days-a-week telephone answering service to handle Member calls. 
 e) Ancillary Provider agrees that when the need arises, provisions will be made to appropriately communicate with patients in the language or fashion used
by Members. 
 f) Ancillary Provider shall maintain a level of experience through continuing education programs in Ancillary Provider’s
particular discipline and shall maintain the educational standards required by Ancillary Provider’s licensure when applicable. Ancillary Provider agrees to participate, in any continuing education programs established or recommended by Plan
appropriate to Ancillary Provider’s particular practice and/or services. 
 g) Ancillary Provider agrees to post a consumer assistance
notice prominently displayed in the reception area and clearly noticeable by all patients. The consumer assistance notice must state the addresses and toll-free numbers as follow: 
 Agency for Health Care Administration 
 2727
Mahan Drive, Building 1 
 Mail Stop #27 
 Tallahassee, Florida 32308 
 (800) 226-1062 
  



					
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 The Statewide Provider and Subscriber 
 Assistance Program 
 2727 Mahan Drive,
Building 1 
 Mail Stop #27 
 Tallahassee, Florida 32308 
 (850) 921-5458 
 The Department of Insurance 
 200 East Gaines Street Larson Bldg. 
 Tallahassee, Florida 32399(800) 342-2762 
 The
consumer assistance notice should also clearly state that provider will provide the address and toll-free telephone number of CarePlus Health Plans, Inc’s grievance department upon request by a member. 
  

	 	3.9	Members Medical Records 

 a) Ancillary Provider
agrees to recognize and abide by all applicable state and federal laws, regulations and guidelines, including those applicable to the Medicare program. 
 b) Ancillary Provider agrees to maintain appropriate, accurate and complete clinical record entries, as well as to participate in the record-keeping system established by Plan, as may be modified from time to time.

 c) Medical records of Members will include the recording of services provided by Ancillary Provider, Primary Care Physicians, Hospitals,
other reports from Participating Providers, discharge summaries, records of emergency care received by the Members. All such records shall be treated as confidential so as to comply with all federal and state laws and regulations regarding the
confidentiality of patient records. Ancillary Provider shall safeguard the privacy of any health information that identifies a particular Member in accordance with 42 CFR, Part 431, Subpart F and HIPAA privacy guidelines, and agrees that the
information from, or copies of, medical records may be released only to authorized individuals, and Ancillary Provider shall ensure that unauthorized individuals do not gain access to or alter patient records. Ancillary Provider shall release
original medical records only in accordance with federal or state laws, court orders or subpoenas. 
  


					
	Ancillary Agreement 2006	  	11	  	










 

 
  

 d) Plan shall have the right to inspect at reasonable times Ancillary Provider’s facilities and
Members’ medical records to comply with Plan’s Peer Review and Quality management and Utilization Management Programs. Plan shall have the right to inspect and to copy, at Plan’s expense, books, records (any and all) maintained by
Ancillary Provider pertaining to claims for Ancillary Services under this Agreement. Charges to Plan for copies of medical records for any audits may not exceed fifteen (15) cents per page. Review of Member Medical Records and other pertinent
information necessary to determine proper payment of claims and provision of care to Plan’s Members shall survive termination of this Agreement. 
 e) Ancillary Provider shall permit authorized representatives of Plan and any state or federal authority or agency, including DHHS, AHCA, CMS, OTR and the U.S. General Accounting Office or their respective designees,
to inspect Ancillary Provider’s facilities and to review any of the records of services provided to Members, including any books, contracts, medical records, patient care, documentation and other records that pertain to (i) the services
performed under this Agreement, (ii) reconciliation of benefits liabilities, (iii) determination of amount payable, (iv) other relevant matters as such persons conducting the audit, evaluation or inspection deem necessary, and (v) for QM use and
Peer Review. This includes access to medical records of Plan Members to Plan’s QM staff for HEDIS and HCC. Ancillary Provider shall retain such records and provide such access to any governmental agency, including those agencies listed above,
or to Plan for a period of not less than six (6) years after the expiration of this Agreement and retained further if the records are under review or audit until the review or audit is completed; provided that Ancillary Provider shall retain records
for a longer period of time than specified if (i) CMS determines that there is a need to maintain a record or group of records for a longer period, (ii) CMS determines that there has been a termination, dispute, fraud or similar fault, in which case
the retention may be extended to six (6) years from the date of any resulting final resolution of the matter, or (iii) CMS determines that there is a reasonable possibility of fraud, in which case the inspection of records may be conducted at any
time. Prior Plan approval for the disposition of records must be requested and approved by Plan if the subcontract is continuous. Without limiting the generality of the foregoing. Ancillary Provider agrees to cooperate, if requested, with any
inspection by any of the above listed agencies as a means of evaluation of the quality, appropriateness and timeliness of service performed to Members. These inspections may include inspections of any records pertaining to this Agreement, and the
premises; facilities and equipment of Ancillary Provider. 
  


					
	Ancillary Agreement 2006	  	12	  	










 

 
  


	 	3.10	Quality Management and Improvement Programs 

 a)
Ancillary Provider agrees to support and participate in Plan’s Quality management and Utilization Management Programs and all Peer Review/Quality Improvement/Quality Management programs, as well as in any reasonable internal and external
quality management, utilization review, peer review, grievances, continuing education and other similar programs of Plan that may be established from time to time by Plan to promote appropriate standards of medical care and to control the cost and
monitor the quality of material services rendered to Members, including without limitation programs relating to the pre-certification of elective admissions and procedures, referral process and reporting of clinical encounter data. Without limiting
the generality of the foregoing, with respect to all Medicare Members being provided Ancillary Services by Ancillary Provider, Ancillary Provider shall cooperate with and participate in all activities of any independent quality review and
improvement organization approved by CMS. 
 b) Ancillary Provider shall assist Plan in the development and application of the criteria used
to evaluate the care that the Ancillary Provider provides to Members. Ancillary Provider shall participate in and cooperate with Plan’s policies, procedures and processes for conducting an initial assessment of each Member’s health care
needs within 90 days of the effective date of such Member’s enrollment and for identifying Medicare Members with complex or serious medical conditions, assessment of those conditions and the establishment, of appropriate treatment plans for
those conditions. 
 c) In conjunction with any such review or program, Ancillary Provider will make available at no charge to Plan, whatever
information is required by Plan. Ancillary Provider further agrees to abide by all of Plan’s applicable rules and regulations, policies, procedures, missions and principles and acknowledges that failure to do so shall be sufficient basis for
immediate termination of this Agreement by Plan. 
  

	 	3.11	Compensation and Billing Procedures 

 a) Ancillary
Provider agrees to accept as payment in full, for services which he/she/it provides pursuant hereto, the rates as set forth in the fee schedule specified in Attachment A for Ancillary Services rendered to Members. There may be several versions of
Attachment A, each listed sequentially in numerical order addressing compensation to be made to Ancillary Provider in connection with the provision of Covered Services to various types of Members under the various health insurance products offered
by Plan. Each such version to Attachment A shall be binding on and enforceable against Ancillary Provider to the name extent as this Agreement upon Ancillary Provider’s execution of said version to Attachment A. Upon thirty (30) days prior
written notice, Plan may reduce the compensation payable under any one or more 

  


					
	Ancillary Agreement 2006	  	13	  	










 

 
  

 
Attachments, Exhibits or Schedules attached hereto in the event it determines, in its sole discretion, that such a reduction is necessary, appropriate or
advisable to protect the financial viability of Plan. With respect to said Attachments, Exhibits and Schedules under which Ancillary Provider’s compensation is determined in whole or in part through risk pools or similar arrangements,
Plan’s determination of the amount of compensation due Ancillary Provider under such Attachments or Schedules shall be conclusively binding upon Ancillary Provider in the absence of fraud. 
 b) When Ancillary Provider provides Covered Services to Members with Medicare Part B Coverage, Ancillary Provider shall accept the Medicare payment for
such Covered Services as payment in full. Ancillary Provider shall attempt to collect payment from third party payors whenever such alternative coverage is available. In the event that third party payments are received, these sums will offset the
amount due from the Plan. 
 c) When seeking to receive compensation above the Capitation Payment, if any, Ancillary Provider agrees to submit
to Plan a properly and correctly completed CMS 1500 form or electronically using the appropriate Plan assigned Ancillary Provider number for payment of Covered Services provided within 60 days from the date Covered Services are rendered to Members.
Plan will reimburse Ancillary Provider for services rendered pursuant to a written referral authorized by Plan within 30 days of receipt of a “clean claim” on a properly completed CMS 1500 form or electronically pursuant to Section
641.3155 Florida Statutes Failure of Ancillary Provider to submit an invoice/referral and written report within 120 days of the date of service will result in forfeiture by Ancillary Provider of funds due the Ancillary Provider under this Agreement.
Ancillary Provider agrees not to resubmit any claims already paid or previously denied by Plan. Claims will be denied payment unless accompanied by the Referral Authorization Form or Referral Authorization Number. All non-authorized claims will be
denied. Ancillary Provider will comply with all other applicable payment protocols, including all Medicare program protocols. 
 d) Ancillary
Provider hereby agrees, that in no event, including but not limited to, non-payment, Plan insolvency, or breach of this Agreement by either party shall Ancillary Provider bill, charge, collect a deposit from, seek compensation, remuneration or
reimbursement from, or have any recourse against a Member, [illegible] AHCA, OIR, CMS or person other the Plan acting on their behalf for services provided pursuant to this Agreement. Without limiting the generally of any of the foregoing, Ancillary
Provider shall not balance bill any Member. This provision shall not prohibit collection of Copayments on the Plan’s behalf made in accordance with the terms of the applicable agreement between the Plan and the Member. Ancillary Provider agrees
to use reasonable efforts to collect from Members applicable Copayments, and upon 

  


					
	Ancillary Agreement 2006	  	14	  	










 

 
  

 
request from Plan, Ancillary Provider will prepare reports on forms provided by Plan regarding Copayments billed and collected. In no event shall Ancillary
Provider hold a Member financially responsible for any fees that are the legal responsibility of Plan. Ancillary Provider further agrees that (a) this provision shall survive the termination of this Agreement regardless of the cause giving rise to
termination and shall be construed to be for the benefit of the Member, and that (b) this provision supersedes any oral or written contrary agreement now existing or thereafter entered into between Ancillary Provider and Member, or persons on their
behalf. The Ancillary Provider agrees to continue providing services to Members through any post insolvency period. Plan shall not alter the provisions contained in this paragraph without the prior written approval of the Secretary of a Director,
Superintendent or Commissioner of the U.S. Department of Health and Human Services. 
 e) Ancillary Provider shall immediately refund to Plan
any and all sums collected by Ancillary Provider from Members to which Ancillary Provider was not entitled under this Agreement, including the Attachments, Exhibits and Schedules hereto. Such refunds shall take the form of cash payments or setoffs
against amounts owed to Ancillary Provider by Plan. When appropriate, Plan shall return to the Member such sums improperly charged by Ancillary Provider. 
 f) If Plan becomes insolvent or otherwise ceases to operate, Ancillary Provider nevertheless agrees that Ancillary Provider’s obligations under this Agreement shall continue in full force with respect to Members
assigned to Ancillary Provider for a period equal to the longer of (i) sixty (60) days from the date of Plan’s insolvency, (ii) the period for which premiums have been paid or (iii) the period during which a Member is continuously confined in
an inpatient facility; Ancillary Provider shall not bill Members, ACHA, CMS and/or OIR for Covered Services provided during such period; Ancillary Provider further agrees that (a) this provision shall survive the termination of this Agreement and
shall be construed to be for the benefit of Members, and that (b) this provision supersedes any oral or written contrary agreement now existing or thereafter entered into between Ancillary Provider and Members, or persons on their behalf. Plan shall
not alter the provisions contained in this paragraph without the prior written approval of the Secretary or a Director, Superintendent or Commissioner of DHHS. 
 g) If and/or when a provider utilizes a “billing-agent/agency”, the provider remains fully liable for any and all billing procedures, resubmittals, appeals, overpayment liability, etc.. The use of a billing
service does not relieve a provider of any of its compliance responsibility. Provider agrees to bill in accordance with the Federal, State and Plan guidelines, Provider 

  


					
	Ancillary Agreement 2006	  	15	  	










 

 
  

 
shall comply with all billing and reporting procedures established by Plan as set forth in the Agreement or the Attachments, Exhibits and Schedules hereto
and in the Plan Provider Manual. 
  

	 	3.12	Malpractice Insurance 

 Ancillary Provider shall
maintain such policies of general liability, professional liability, and other insurance as shall be necessary to insure Ancillary Provider and Ancillary Provider’s employees or agents against any claim for damages arising by reason of personal
injury or death occasioned directly or indirectly in connection with the provision of Covered Services to Members by Provider’s employees or agents. Ancillary Provider shall keep Plan currently advised about such insurance, including the name
of insurer, policy number, nature and extent of coverage, and expiration date and/or about other arrangements pertaining to malpractice protection. Documentation to this effect is also required as part of this Agreement in the form of a copy of the
Certificate of Insurance Provider authorizes any past, present, or future, medical malpractice carrier to provide any and all information, including but not limited to, coverage dates, coverage amounts, renewal information, claims information,
policy provisions/exclusions, declarations page, and premium information, to Plan and its representatives to be used for the sole purpose of credentialing and verifying current medical malpractice coverage for the life of the Agreement. 

Ancillary Provider agrees to notify Plan of any claim or cause of action by or relating to a Member filed against Ancillary Provider within five
(5) working days of the Provider’s knowledge or receipt of notice that such a claim or cause of action has been filed. Ancillary Provider shall provide Plan with any information regarding such claim or cause of action reasonably requested
by Plan. 
  

	 	3.13	Grievances & Disputes 

 Ancillary Provider
agrees to participate in and cooperate with Plan’s Member Grievances procedures, as enacted by Plan from time to time, including all appeal and expedited appeal processes. Ancillary Provider shall comply with all final determinations rendered
in accordance with those procedures, Ancillary Provider agrees to cooperate with Plan in resolving any Member’s grievance(s) related to the provision of Covered Services, including by gathering and forwarding information to Plan on a basis that
will permit Plan to meet all applicable tune framen for disposition of grievances and appeals. Ancillary Provider shall notify Plan of any complaints from Members regarding Ancillary Provider. 
  

	 	3.14	Assignment of New Members by Plan 

 By written
notice to Ancillary Provider, Plan’s Medical Director may suspend referral of Members to Ancillary Provider if it is determined that Ancillary Provider is not complying with (i) the terms set forth in this Agreement, (ii) Plan’s
policies and procedures; or (iii) Plan’s requirements for Credentialing or re-Credentialing. 
  


					
	Ancillary Agreement 2006	  	16	  	










 

 
  


	 	3.15	Coordination of Benefits 

 Ancillary Provider shall
cooperate in the implementation of any provisions of Plan’s agreements relating to coordination of benefits and other third party claims. Ancillary Provider shall bill when requested by Plan any third party payor for services rendered to
Members. Ancillary Provider will, when permitted by law, reimburse the Plan in the event that payments are received from such payors for Covered Services provided to Members, or assign to the Plan all payments owed by such payors, and execute any
further documents that may be required of appropriate to permit the Plan to bill and process forms for any third party payor on Ancillary Provider’s behalf or to bill such payors directly, as determined by the Plan. Ancillary Provider shall
provide referral and assistance with scheduling of Members needing specialty healthcare services/transportation. 
  

	 	3.16	Worker’s Compensation 

 Ancillary Provider
agrees to secure and maintain, during the term of this Agreement, worker’s compensation insurance for all of its/his/her employees to cover them within the scope of their employment with Provider. Such insurance shall comply with Florida’s
Worker’s Compensation law. 
  

	 	3.17	Provision of Non-Covered Services 

 In the event
that the Ancillary Provider shall provide any Member non-Covered Services, Ancillary Provider shall, prior to the provision of such non-Covered Services, inform the Member in writing (1) of the service(s) to be provided, specifying the charges
to be billed to the Member, (2) that Plan will not pay for or be liable for said services, and (3) that the Member will be financially liable for such services as applicable by law. 
  

	 	3.18	Acceptance and Treatment of Members 

 Ancillary
Provider agrees to accept Members as patients. 
  

	 	3.19	Transfer of Members and Medical Records 

 a)
Ancillary Provider may request in writing to Plan that a Member be transferred to another Participating Provider. Ancillary Provider acknowledges that Members have a contractual right to request a transfer to another Participating Provider.

 b) In the event of (a) termination of this Agreement, (b) the selection by a Member of another participating Ancillary Provider
in accordance with Plan procedures, or (c) the approval by Plan of Ancillary Provider’s request to transfer a 

  


					
	Ancillary Agreement 2006	  	17	  	










 

 
  

 
member from their practice, to another Participating Provider, Ancillary Provider agrees to transfer copies of Member’s medical records, x-rays, and any
and all other pertinent data to Plan, and to the new Participating Provider as selected by Member, when requested to do so in writing by Plan or Member. This charge shall be billed at a reasonable charge, not to exceed Fifteen (15) cents per page
and shall not be billed to Medicare Members, AHCA or CMS. 
  

	 	3.20	Facilities & Environment 

 Ancillary Provider
agrees to provide a functionally safe and sanitary environment for all Members. Ancillary Provider further agrees that his/her/its medical service facilities will a) reasonably accommodate handicapped individuals, b) comply with applicable state and
local building code and regulations; c) comply with applicable state and local fire prevention regulations; d) comply with applicable federal laws and regulations; e) are inspected at least annually by the local or state fire control agency; f)
contain fire equipment and illuminated signs for cases of emergency ovacuation and also offer adequate lighting and ventilation and are clean and properly maintained; and (g) the facility is duly licensed by country or the state. Ancillary Provider
further agrees that he/she/it has in his/her/its facilities appropriate procedures to handle medical and other emergencies that may arise in connection with services provided. By written notice to Ancillary Provider, Plan’s Medical Director may
suspend referral of Members to Ancillary Provider if it is determined that the facts presented indicate that health or safety of Members could be endangered by Ancillary Provider’s continued participation in the Plan. 
  

	 	3.21	Formulary 

 Ancillary Provider agrees to comply with
Plan’s prescription formulary, to the extent applicable to the Ancillary Services, which may be amended from time to time by Plan. 
  

	 	3.22	Notice to Relocate 

 Ancillary Provider is currently
providing services to Members at the location(s) of service listed on the Credentialing application, page 2. If Ancillary Provider closer, changes, or adds new locations, Ancillary Provider shall notify Plan immediately. 
  

	 	3.23	Signs and Displays 

 Ancillary Provider hereby
consents to display in a visible and prominent place any reasonable card, plaque or similar identifying logo provided by Plan to identify Ancillary Provider to Members. 
  

	 	3.24	Additional Covered Services for Medicare Member. 

 With respect to all Medicare Members, Covered Services shall include, without limitation, renal dialysis services for Members by Participating Providers and by non-Participating Providers when Member is outside of the area covered by


  


					
	Ancillary Agreement 2006	  	18	  	










 

 
  

 
Participating Providers. To the extent Ancillary Provider is a provider of renal dialysis services, Ancillary Provider shall provide all Medicare Members
such Covered Services. 
  

	 	3.25	Binding Nature of Agreement; Subcontractors 

 If
Ancillary Provider is not an individual but is rather a medical group, facility or other entity whose staff of health care professionals consists wholly or partially of employees or independent contractors, Ancillary Provider represents, warrants
and covenants that it has the unqualified authority to bind all such employees or contractors to the terms of this Agreement. If Ancillary Provider has any arrangements with subcontractors in connection with the provision of Covered Services to
Members, Ancillary Provider shall ensure that all such subcontracts are duly amended to incorporate the terms contained in this Agreement. Provider shall ensure that the terms of this Agreement are included in all future and pending agreements with
subcontractors who agree to provide Covered Services to Members. Ancillary Provider further agrees to promptly amend the agreements with subcontrators, in the manner requested by Plan, to meet any additional legal requirements. Failure to comply
with the terms of this Section shall be cause for the termination of this Agreement by Plan or the exclusion of any non-complying subcontractor from Plan’s list of Participating Providers. 
  

	 	3.26	Notification of Ancillary Provider Status 

 Ancillary Provider shall immediately notify Plan in writing upon the occurrence of any of the following events: 
  

	 	(1)	Ancillary Provider’s license to practice medicine in the State of Florida is suspended, revoked, terminated, or subject to terms of probation or other restrictions;


  

	 	(2)	Ancillary Provider has become a party in any malpractice action, receives any pleadings, notices or demands of claim or potential claim, or service of process relating to alleged
malpractice involving a Member, or is required to pay damages in any such action by way of judgment or settlement; 

  

	 	(3)	Ancillary Provider becomes the subject of any disciplinary proceeding or action before a Governmental Agency, including any State of Florida department, board, or agency, or a
similar entity in any state; 

  

	 	(4)	Ancillary Provider is convicted of a felony relating directly or indirectly to the practice or conduct of Ancillary Provider’s profession; 

  

	 	(5)	Ancillary Provider no longer maintains medical staff membership and appropriate clinical privileges at a Participating Hospital; 

  


					
	Ancillary Agreement 2006	  	19	  	










 

 
  


	 	(6)	There is a change in Ancillary Provider’s business address; 

  

	 	(7)	Ancillary Provider becomes incapacitated; 

  

	 	(8)	An act of nature or any event beyond Ancillary Provider’s reasonable control likely to interrupt all or a portion of the Ancillary Provider’s practice for a period of
sixty (60) consecutive calendar days, or which may have a material adverse effect on the Ancillary Provider’s ability to perform his/her/its obligations for this period; 

  

	 	(9)	Any change in the nature or extent of services rendered by Ancillary Provider; 

  

	 	(10)	Any material change or addition to the information and disclosures submitted by Ancillary Provider as part of the application for a contract with Plan to provide Covered Services to
Members; 

  

	 	(11)	Any other act, event, occurrence or the like that might materially affect Ancillary Provider’s ability to carry out his duties and obligations to Members;


  

	 	(12)	Ancillary Provider, if a corporation, professional association or partnership, shall similarly notify Plan of the occurrence of any of the above events with respect to a physician
or other health professional who owns is employed by and/or is affiliated with Ancillary Provider. 

  


					
	Ancillary Agreement 2006	  	20	  	










 

 
  


	4.	Governmental Requirements 

  

	 	4.1	Maintenance of Records 

 Ancillary Provider agrees
to maintain complete and accurate fiscal records, as well as medical and social records applying solely to Members for whom the Ancillary Provider has claimed and received payment. Ancillary Provider shall maintain such records as are necessary for
evaluation of the quality, appropriateness and timeliness of service performed under this Agreement. Said records will be made available for fiscal audit, medical audit, medical review, utilization management, AHCA and other periodic monitoring upon
request of authorized representatives of Plan or a Governmental Agency. Ancillary Provider further agrees to comply with requirements issued as a result of any such inspection or audit. Ancillary Provider further agrees to pay Plan within thirty
(30) calendar days after Plan’s demand for such payment any and all amounts determined to be payable to Plan by Ancillary Provider as a result of such audit and any state and federal disallowance’s lawfully imposed on Plan as a result
of Ancillary Provider’s failure to abide by the terms of this Agreement. Said records shall be retained for a period of at least six years after starting date of the applicable retention period or until resolution of any ongoing audit occurs.

  

	 	4.2	Indemnification 

  

	 	a)	Plan Indemnification 

 Plan agrees to indemnify,
defend, and hold harmless Ancillary Provider, his/her/its employees, agents, independent contractors, officers and directors; AHCA and Plan Member against any and all claim which may arise and/or be incurred in connection with any actual or alleged
malpractice, gross negligence or willful wrongful conduct by Plan under this Agreement. This clause shall survive termination of this Agreement regardless of the reason for termination, including breach of this Agreement due to insolvency.

  


					
	Ancillary Agreement 2006	  	21	  	










 

 
  


	 	b)	Ancillary Provider Indemnification 

 Ancillary
Provider shall indemnify, defend and hold harmless Plan, its employees, agents, independent contractors, officers and Board of Directors, AHCA, OIR, CMS and Plan’s Members from and against all claims, damages, causes of action, cost or expense,
including court costs and reasonable attorney’s fees, which arise from any negligent act or other wrongful conduct by Ancillary Provider under this Agreement. This clause shall survive termination of this Agreement regardless of the reason for
termination, including breach of this Agreement due to insolvency. 
  

	 	4.3	Independent Ancillary Provider 

 It is expressly
agreed that the Plan and Ancillary Provider, in the performance of their obligations under this Agreement, are at all times performing as independent contractors. No act, work, commission, or omission by either party, its agents, servants,
contractors, or employees, pursuant to the terms and conditions of this Agreement shall be construed to make or render Plan or Ancillary Provider an agent, servant, employee of, or joint venturer with, the other. Ancillary Provider shall be solely
responsible and liable for all medical care, advice and treatments rendered or prescribed to Members. 
  

	5.	Non-Solicitation 

 During the effective term
of this Agreement and any of its amendments, and for a period of one (1) year following the termination or non-renewal of this Agreement or any of its amendments for any reason, Ancillary Provider shall not directly cause any Member to from the
Plan. By way of example but not limitation, Ancillary Provider shall not solicit Members through meetings, visits, telephone calls, or individual letters. If the Provider is found to have engaged in solicitation of Plan Members, Plan at its sole
discretion, may require Provider to pay or withheld any remaining payments to Providers until the situation is remedied by Provider. In case Provider is a capitated provider, this amount shall be equal to 12 monthly capitation payments. This Section
shall survive the termination of this Agreement. In the event of an actual or threatened breach by Ancillary Provider of this Agreement, Plan shall be entitled to an injunction restraining Ancillary Provider from the prohibited conduct. If the court
should hold that the duration and/or scope of the covenants contained in this Section are unreasonable, then, to the extent permitted by law, the court may prescribe duration and/or scope that is reasonable; and Plan and Ancillary Provider agree to
accept such determination, subject to their rights of appeal. Nothing herein shall be construed as prohibiting Plan from pursuing any other remedies available for such breach or threatened breach, including the recovery of damages from Ancillary
Provider. In the event of any action or proceeding to enforce the provisions of this Section, the prevailing party shall be reimbursed by other party for all costs and attorney’s fees incurred in such action or proceeding. 
 Nothing in this Agreement is intended to prohibit or restrict Ancillary Provider from advising a Member about (1) 

  


					
	Ancillary Agreement 2006	  	22	  	










 

 
  

 
the Member’s health status, medical care, or treatment options (such as alternative treatments that may be self-administered), including providing
sufficient information to the Member to provide an opportunity to decide among all relevant treatment options, (2) the risks, benefits and consequences of treatment or non-treatment, and (3) the opportunity for the Member to refuse
treatment and express preferences about future treatment decisions. Ancillary Provider must provide information regarding treatment options in a culturally competent manner, including the option of no treatment. Ancillary Provider must assure that
individuals with disabilities are furnished with effective communications in making decisions regarding treatment options. 
  

	6.	Participation as a Medicare Ancillary Provider 

 Ancillary Provider warrants that Ancillary Provider is a Medical certified provider in good standing under the Federal Medicare Program (Title XVIII of the Social Security Act, as amended) and the Medicare Program and that Ancillary
Provider will use Ancillary Provider’s best efforts to maintain this good standing. Ancillary Provider’s Medicare provider number is K5474. If for any reason, Ancillary Provider receives notice of any sanction from the Medicare
Program, Ancillary Provider agrees to notify Plan promptly of the sanction. Ancillary Provider shall not employ or contact with any individual who is excluded from participation in the Medicare program under sections 1128 or 1128A of the Social
Security Act (or with an entity that employs or contracts with such an individual) for the provision of any health or administrative services, including, without limitation, health care services, utilization review or medical social work. Ancillary
Provider agrees and acknowledges that Plan receives payment for Covered Services in whole or in part from federal funds and to the extent Ancillary Provider treats Members for whom Plan receives federal funds (e.g. Medicare Members), Ancillary
Provider is subject to certain laws that are applicable to individuals and entities, receiving federal funds. 
  

	7.	Confidentiality 

 Ancillary Provider agrees
that all information regarding Plan and Members is highly confidential (“Confidential Information”). Ancillary Provider further acknowledges that all such Confidential Information is confidential and proprietary to Plan and that such
confidential information shall not be disclosed or used for Ancillary Provider’s own or any other entity’s benefit or gain either during the term of this Agreement or after the date of expiration or termination of this Agreement for any
reason without Plan’s written consent unless required by law. Both Plan and Ancillary Provider agree and acknowledge that this section shall survive the termination of this Agreement. Both parties further agree that any violation of this
Section by Ancillary Provider shall result in irreparable injury to plan and, therefore, in addition to any remedies otherwise available to Plan. Plan shall be entitled to injunctive or equitable relief to enjoin or restrain Ancillary Provider or
any related individual from violating the Section, 
  


					
	Ancillary Agreement 2006	  	23	  	










 

 
  


	8.	Terms and Termination 

  

	 	8.1	Term 

 The term of this Agreement shall commence on
the date stated on the first page of this Agreement, and shall continue in effect for one (1) year from the date hereof. Thereafter, this Agreement shall automatically renew for additional one (1) year terms on each anniversary date of the
effective date of this Agreement unless and until (a) either party notifies the other party of its intention not to renew this Agreement at least ninety (90) days prior to the immediately following anniversary date of this Agreement or
(b) this Agreement is earlier terminated as provided herein. 
  

	 	8.2	Immediate Automatic Termination 

 This Agreement
shall terminate immediately in the event that the Ancillary Provider’s license to practice medicine, or the license of any of the principal physicians or other health professionals in association with Ancillary Provider, is revoked in any State
or if the Ancillary Provider or any of the physicians or health professionals associated or affiliated with Ancillary Provider is convicted of a felony or a crime involving moral turpitude. 
  

	 	8.3	Termination with Cause by Plan 

 This Agreement may
be terminated immediately by Plan with cause. “Cause” for immediate termination is the following: 
  

	 	a)	Ancillary Provider’s failure to obtain or maintain Medicare approved provider status; 

  

	 	b)	Material breach of terms and conditions of this Agreement; 

  

	 	c)	The willful breach, habitual neglect, or continued failure of Ancillary Provider to abide with Plan’s rules, procedures, policies or any other activity for which Ancillary
Provider has received notice; 

  

	 	d)	Commission of an act of fraud or theft by Ancillary Provider; 

  

	 	e)	Failure of Ancillary Provider to comply with the medical community standards of medical practice; 

  

	 	f)	Failure of Ancillary Provider to meet Credentialing standards and requirements of Plan; 

  

	 	g)	Good faith determination by Plan that continuation of Agreement may result in danger to the health, safety or welfare of any Member; and 

  

	 	h)	Ancillary Provider entering into a private contract with a Medicare Member. 

  


					
	Ancillary Agreement 2006	  	24	  	










 

 
  

 For purposes of this Section, if Ancillary Provider is a corporation, professional association or
partnership, the term Ancillary Provider shall include a physician or other health professional who owns, is employed by or is affiliated with Ancillary Provider. 
  

	 	8.4	Termination With Cause by Ancillary Provider 

 Ancillary Provider may terminate this Agreement for cause upon sixty (60) days written notice, which notice shall set forth the ground for termination, and Plan’s failure to cure such breach within such sixty (60) day period.
“Cause” is limited to the following purposes of this Section: 
  

	 	a)	a material breach of any provisions of this Agreement by Plan. Non-payment by Plan for goods or services rendered by Ancillary Provider shall not be a valid reason for avoiding the
sixty (60) days advance notice of cancellation; or 

  

	 	b)	a conviction for an act of fraud or theft by Plan against Ancillary Provider. 

  

	 	8.5	Termination Without Cause 

 Notwithstanding the
foregoing, either party may terminate this Agreement with or without cause, upon sixty (60) days written notice to the other party hereto. 
  

	 	8.6	Termination of Medicare Contract 

 Unless otherwise
agreed to between Plan and the State of Florida’s AHCA, this Agreement will automatically terminate upon the termination or non renewal of the Medicare contract between CMS and Plan (the “Medicare Contract”). Additionally, unless
otherwise agreed to between Plan and CMS, this Agreement will terminate (with respect to Medicare Members only) upon the termination or non renewal of the Medicare provider agreement between CMS/DHHS and the Plan (the “Medicare
Agreement”). Plan will give notice to Ancillary Provider of the non-renewal or termination of the Medicare Agreement and the date on which such will expire or terminate. The termination of the Medicare Agreement shall have no effect on this
Agreement as to Members other than the Medicare Members and with respect to such other Members this Agreement shall remain in full force and effect and enforceable by or against either party in accordance with its terms. 
  

	 	8.7	Notice of Termination 

 Ancillary Provider shall
provide AHCA and OIR with sixty (60) days’ notice of any intended termination of the Agreement. The Plan shall provide notice of any such termination by Ancillary Provider to AHCA and OIR within ten (10) days of receipt of such notice.

  


					
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	 	8.8	Obligation Upon Termination 

 a) In the event this
Agreement is terminated for any reason, Ancillary Provider shall complete the course of treatment of any Member then receiving treatment in accordance with the terms hereof until provision has been made by Plan for reassignment of such Member to
other Participating Ancillary Provider for further treatment, if being understood that the obligation of Ancillary Provider under this Agreement to the extent they pertain to Ancillary Services provided prior to termination, shall survive
termination. Ancillary Provider shall continue to provide services through any post insolvency period. Payment to Ancillary Provider for such services beyond termination date shall be made under the same terms and conditions as provided for under
this Agreement. 
 b) Notwithstanding the termination of this Agreement, Ancillary Provider shall not be released from any obligation which is
intended to continue past the termination of this Agreement, as set forth herein, including, without limitation, Ancillary Provider’s obligations to not seek compensation from Members for services provided prior to termination. In addition,
upon the termination of this Agreement, Ancillary Provider shall continue to provide treatment to Members who are under a course of treatment and have selected Ancillary Provider as their Provider for the longer of 180 days after termination of this
Agreement or through the period for which a premium has been paid to Plan; provided further that Ancillary Provider shall provide Covered Services to Members who are (i) in inpatient facilities, including hospitals and skilled nursing facilities,
until the longer of (a) their discharge from such facilities, (b) 180 days after termination of this Agreement or (c) through the period for which a premium has been paid to Plan; and (ii) in the third trimester of pregnancy through completion of
postpartum care. 
 c) Upon the termination of this Agreement, Ancillary Provider agrees to return any and all Plan provided materials,
provider manuals, or other documentation, related to its business, including all copies thereof, whether authorized or not to Plan. 
 d)
Following termination of this Agreement, Ancillary Provider will cooperate with Plan in the orderly transfer of (i) Member that may have been assigned to Ancillary Provider, and (ii) the Members Medical Records. 
  

	 	8.9	Order by Office of Insurance Regulation 

 This
Agreement may be terminated upon issuance of an order by the OIR requiring such termination pursuant to section 641 234(3), Florida Statute, or any successor statute. 
  


					
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	 	8.10	Explanation of Reason for Termination 

 In the event
of a termination or suspension by Plan of a Ancillary Provider who is a physician or other health care professional who provides Covered Services to Medicare Members, any written notice of suspension or termination shall include the following, to
the extent applicable: (a) the reason for termination; (b) the standards and profiling data used by Plan to evaluate Ancillary Provider; (c) the numbers and mix of physicians who are Participating Providers. In the event of any termination of a
Ancillary Provider who is a physician or other health care professional, Plan shall provide Ancillary Provider a statement regarding Ancillary Provider’s appeal rights under Plan’s policies and procedures, including the process and timing
for requesting a hearing. In the event of any termination of this Agreement by Ancillary Provider, Ancillary Provider shall provide Plan written notice of the reason for termination. 
  

	9.	General Terms 

  

	 	9.1	Modification and Assignment of this Agreement 

 The
terms and sections included hereunto and the Agreement executed by the parties together embody all of the terms and conditions relating to the Agreement between the parties, and all oral and parole representations or statements made by either party
prior to the execution of this Agreement are merged herein. Plan may amend this Agreement and any Addendum, Schedule or Attachment hereto upon thirty (30) days written notice to Ancillary Provider. Ancillary Provider shall be bound to any such
amendments unless Ancillary Provider provides notice of objection to such modification in writing and to submit such objection to Plan within thirty (30) days notice period. In addition, Plan may amend this Agreement to comply with the requirements
of state and federal Governmental Agencies, and shall give written notice to Ancillary Provider of such amendment and its effective date. Unless such Governmental Agencies direct otherwise, the signature of Ancillary Provider will not be required to
give effect to such amendment. Except as describe above, the provisions of this Agreement may not be amended, supplemented, waived or changed orally or by course of conduct of the parties but only by a written and signed document by the party by
whom enforcement is sought and which shall make specific reference to this Agreement. This Agreement, being intended to secure the services of and being personal to the Ancillary Provider, shall not be assigned, sublet, delegated or transformed by
Ancillary Provider without the prior written consent of Plan, which consent shall not be unreasonably withheld. If either party decides not to terminate the Agreement, even though it has the right to do so in a particular instance, such decision
shall not be considered a waiver of its right to terminate on a future occasion of the same or any other reason. 
  


					
	Ancillary Agreement 2006	  	27	  	










 

 
  


	 	9.2	Severability 

 The invalidity or unenforceability of
any terms or provisions hereof shall in no way affect the validity or enforceability of any other terms or provisions. 
  

	 	9.3	Headings 

 All section headings contained in this
Agreement are to be considered for reference purposes only, are not intended to define or limit the scope of any provisions of this Agreement. 
  

	 	9.4	Entire Agreement 

 This Agreement supersedes all
prior understandings and agreements, whether written or oral, between the parties, and together with all Attachments, Addenda, Schedules and other appendices to it, shall be considered as the Agreement by and between Plan and Ancillary Provider.

  

	 	9.5	Conformance with Law 

 Each party agrees to carry
out all activities undertaken by it pursuant to this Agreement in conformance with all applicable federal, state and local laws, rules and regulations and the Medicare contract with Plan. Without limiting the generality of the foregoing, Ancillary
Provider agrees to comply with all applicable Medicare laws, regulations and CMS instructions, as applicable, and all applicable federal, state and local laws, rules and regulations, including, but not limited to, Title VI of the Civil Rights Act of
1964, the Age Discrimination Act of 1975, the Rehabilitation Act of 1973, the Americans with Disabilities Act and other laws applicable to recipients of federal funds. Ancillary Provider shall require that all health care professionals employed by
or under contract with Ancillary Provider, including all Covering Physicians, render Covered Services in accordance with this provision. This Agreement shall be automatically amended to the extent necessary to comply with the requirements of the
state and/or federal law. In the event that any provision in this Agreement conflicts with the requirements of any applicable Medicare program provision, this Agreement shall be deemed modified to comply with such provisions of those programs.

  

	 	9.6	Governing Law 

 This Agreement has been executed and
delivered and shall be construed and enforced in accordance with the laws of the State of Florida. Any action by any party whether at law or in equity, shall be commenced and maintained and venue shall exclusively be in Miami-Dade County, Florida.

  

	 	9.7	Third Party Beneficiaries 

 This Agreement shall not
be construed to create any third party beneficiaries including without limitation, Members. 
  


					
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	 	9.8	Cumulative Remedies 

 Remedies provided for in this
Agreement shall be in addition to and not in lieu of any other remedies available to either party and shall not be deemed waivers or substitutions for any action or remedy the parties may have under law or equity. 
  

	 	9.9	Gender and Number 

 When the context of this
Agreement requires, the gender of all words shall include the masculine, feminine, neuter and the number of all words shall include the singular and plural. 
  

	 	9.10	Execution 

 This Agreement and any amendments may be
executed in multiple originals, each counterpart shall be deemed an original, but all counterparts together shall constitute one and the same instrument. 
  

	 	9.11	Force Majeure 

 Neither party shall be liable nor
deemed to be in default for any delay or failure in performance under this Agreement or other interruption of service or employment deemed resulting, directly or indirectly, from acts of God, civil or military authority, acts of public enemy, war,
accidents, fires, explosions, earthquakes, floods, failure of transportation, strikes or other work interruptions by either party’s employees, or any similar or dissimilar cause beyond the reasonable control of either party; provided, however,
in the event the provision of Covered Services is substantially interrupted, Plan shall have the right to terminate this Agreement upon ten (10) days prior written notice to Ancillary Provider. 
  

	 	9.12	Authority 

 Each signatory to this Agreement
represents and warrants that he/she/it possesses all necessary capacity and authority to act for, sign and bind the respective entity on whose behalf he is signing. 
  

	 	9.13	Costs and Fees 

 In the event of any litigation by
any party to enforce or defend its rights under the Agreement, the prevailing party, in addition to all other relief, shall be entitled to reasonable attorney’s fees. 
  

	 	9.14	Notices 

 Any notices and other communications to be
given hereunder shall be in writing and shall be deemed to have been duly given when delivered by hand or five (5) days after such notice is mailed, by registered or certified mail, postage prepaid, return receipt requested, addressed to such party
as follows: 
  


					
	Ancillary Agreement 2006	  	29	  	










 

 
  


			
	If to Ancillary Provider:	 	 
		
	 ER URGENT CARE Centers, Inc.
	 	
	NAME	 	
		
	 CHRISTIE Nichols
	 	
	ATTENTION	 	
		
	 5535 Memorial Highway
	 	
	ADDRESS	 	
		
	 Tampa, FL 33634
	 	
	CITY, STATE, ZIP	 	

 If to Plan: 
 CarePlus Health Plans, Inc. 
 1410 N. Westshore Blvd. Ste.200 
 Tampa, FL 33607 
 Attention: Provider
Operations 
 or such other addresses shall be furnished in writing by any party to the other party. 
  

	10.	Payments due to the Ancillary Provider should be sent to: 

  

			
	 	 	 ER URGENT CARE Center, Inc.

		 	NAME
		
		 	 CHRISTIE Nichols

		 	ATTENTION
		
		 	 5535 Memorial Highway

		 	ADDRESS
		
		 	 Tampa, FL 33634

		 	CITY, STATE, ZIP
		
		 	 65-1050592

		 	TAX ID#

  


					
	Ancillary Agreement 2006	  	30	  	










 

 
  

 IN WITNESS WHEREOF, the undersigned have executed this Agreement as of the date on the first page of this
Agreement. 
  

							
	CAREPLUS HEALTH PLANS, INC.	  	ER URGENT CARE MGMT CO., INC.
				
	SIGNATURE:	 	  
	  	SIGNATURE:	 	 /s/ Jerry Miller

	NAME:	 	  
	  	NAME:	 	Jerry Miller
	TITLE:	 	  
	  	TITLE:	 	  

	DATE:	 	  
	  	DATE:	 	2-7-07
	ADDRESS:	 	1410 N. Westshore Blvd.	  	ADDRESS:	 	  

		 	Suite 200	  	  

		 	Tampa FL 33607	  		 	
		 		  	FEDERAL ID#:	 	65-1050592

  


					
	Ancillary Agreement 2006	  	31	  	










 

 
  

 ATTACHMENT A 
 COVERED SERVICES AND MEDICARE/COMPENSATION FEE SCHEDULE 
  

	1.	BILLING TIMING. Health Plan agrees to pay Contracting Provider within thirty (30) days from Health Plan’s receipt of a properly completed clean CMS 1500 claim form or within
twenty (20) days if filed electronically. 

  

	2.	COPAYMENT. Contracting Provider may collect permitted Copayments from Members referred to Contracting Provider as indicated on the member’s I.D. Card. 


 

	3.	FEE SCHEDULE. Fees for Covered Services provided by Ancillary Provider to Members pursuant to this Agreement shall be as follows (the parties acknowledge and agree that the
description of Covered Services set forth below are also subject to their terms and conditions of the applicable Subscriber Contract). 

  

	4.	The effective date of this Attachment is this          day of
                , 200    . 

 SCOPE OF SERVICE: 
 URGENT CARE WALK-IN/CRITICAL CARE WALK-IN 
 COMPENSATION SCHEDULE: 
 The Provider will receive from the Plan the following amounts less applicable copayments:

 ALL INCLUSIVE FLAT RATE OF $140.00 TO BE BILLED USING CIT 99243 
 In Witness Whereof, this Agreement was entered into this          day of                 ,
200    . 
  

			
	CAREPLUS HEALTH PLANS, INC.	  	ER URGENT CARE MGMT CO. INC.
	  
	  	 /s/ Jerry Miller

	SIGNATURE	  	SIGNATURE
	  
	  	Jerry Miller
	NAME	  	NAME
	  
	  	  

	TITLE	  	TITLE
	  
	  	2-7-07
	DATE	  	DATE

  


					
	Ancillary Agreement 2006	  	32	  	










 

 
  

 ATTACHMENT B 
 MALPRACTICE INSURANCE WAIVER 
 I have decided not to obtain malpractice insurance. As a continuing condition for
staff privileges, I will comply with State Statute 458.320 by: 
 Please Check Appropriate Item: 
  

			
	                     	 	Maintaining an unexpired irrevocable letter of credit in an amount not less than $250,000 per claim with a minimum aggregate of not less than $750,000. (submit copy)
		
	                     	 	Maintaining an escrow account consisting of cash or assets in an amount not less than $250,000 per claim with a minimum aggregate of not less than $750,000. (submit copy)
		
	                     	 	“Going Bare” I Agree to be personally responsible for the payment of any settlement of final judgement up to $250,000 within (60) days after the date such becomes
final.

 “Going Bare” requires the following statement prominently displayed in the patient reception area
notifying patients that you have decided not to carry medical malpractice insurance (submit proof): 
 “Under Florida law, physicians are generally
required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida
law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgements arising from claims of medical malpractice. This notice is provided pursuant to Florida law.” 
  

					
	  
	 		 	2-7-07
	Physician Signature	 		 	Date
			
	  
	 		 	
	Print Name	 		 	

  


					
	Ancillary Agreement 2006	  	33	  	










 

 
  

 ATTACHMENT C 
 JOINDER TO ANCILLARY CARE AGREEMENT BETWEEN 
 CAREPLUS HEALTH PLANS, INC. (“Plan”) 

 AND 
 ER URGENT CARE
MGMT CO. INC. (“Provider”) 
 By signing below, the Participating Physicians agree in the terms and conditions set forth in this Agreement.

 Effective this          day of
                , 200    . 
  

							
	 NAME
	 	 SIGNATURE
	 	 MEDICARE NUMBER
	 	 DATE

				
	Ronald Luketsky, MD	 	 /s/ Ronald Luketsky
	 	E1237E	 	2/8/07

  


					
	Ancillary Agreement 2006	  	34