Document:

Participation Agreement

 Exhibit 10.18 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 GROUP PARTICIPATION AGREEMENT 

COVER SHEET 
  

							
	General
Information
	 Group Name: Whiteglove House Call Health,
Inc.
  

	 Federal Tax ID
Number:
 208913558
  
	  	Name Associated with Federal Tax ID Number: Whiteglove House Call Health,
Inc.

					
	 Group UPIN:

 
	 	Group Primary Specialty:	 	Group Secondary Specialty:
	 Languages Spoken other than English:
  
	 	 	 	 

 

									
	Primary Service Address
	Primary Practice Name: Whiteglove House Call
Health, Inc.	 	Street Address: 515 Capital of Texas Hwy, Suite 225
	City: Austin	  	St. TX	 	Zip: 78746	 	County: Travis	 	Phone: 512-329-8081
	Contact Person: Robert Fabbio	 	 Email:
 bfabbio@housecallhealth.com
	 	Fax: 512-233-2808

 

									
	Secondary Service Address
	Primary Practice Name:	 	Street Address:
	City:	 	St.	 	Zip:	 	County:	 	Phone:
	 Contact Person:

 
	 	 Email:

 
	 	
Fax:
  

 

									
	Mailing Address	 	 
	Mailing Address Name: Whiteglove 
House Call Health Inc.	 	Street Address: 515 Capital of Texas 
Hwy, Suite 525
	City: Austin	 	 	 	State: TX	 	Zip: 78746

 

									
	Billing Address
	 Billing Address: Whiteglove House Call Health, Inc. 515 Capital of Texas Hwy, Suite 225

							
	City: Austin	  	State: TX	  	Zip: 78746	  	County: Travis
	Contact Person Name: Suzanne Lawlor	  	Email Address:
slawlor@housecallhealth.com

			
	Telephone Number: 512-329-8081	  	Fax: 512-233-2808

 

															
	** For ChoiceCare Use Only: **
	 							 
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	 		 	Default FS #/Area/PC:	 	  

	 
	Anesthesia $
                  Per 15 minute unit:
$                  Per 10 minute unit:
$                  New Contract:
Y                N            
	 
	Add to Existing Contract:
Y                  N                  Practice Name of
existing contract
                                         
               
	 
	Effective Date:
        /        /              Contact Name:
                                         
                       TSO#:
                    Date:
        /        /        
	 
	PK #
                            CIS#
                        Contract Changes:
Y              N               Humana Credentialed?
Y              N             

																			
	 									 
	Contracted Category	 		 	Area #	 		 		 		 	FS#	 		 		 	% of FS
	  
	 		 	  
	 		 		 		 	  
	 		 		 	  

	 
	Nomination:     ̈    Yes         ̈    No         
                               Directory Listing:
                                         
                           
	 
	 

 Group Participation Agreement 

This Group Participation Agreement (hereinafter referred to as “Agreement”) is made and entered into by and between the party
named on the signature page below (hereinafter referred to as “Group”) and Health Value Management, Inc-d/b/a ChoiceCare Network (hereinafter referred to as “ChoiceCare”). 

RELATIONSHIP OF THE PARTIES 

1.1 In performance of their respective duties and obligations hereunder, ChoiceCare and Group, and their respective employees and
agents, are at all times acting and performing as independent contractors and neither party, nor their respective employees and agents, shall be considered the partner, agent, servant, employee of, or joint venturer with the other party. Unless
otherwise agreed to herein, the parties acknowledge and agree that neither Group nor ChoiceCare will be liable for the activities of the other no/the agents and employees of the other, including but not limited to, any liabilities,
losses, damages, suits, actions, fines, penalties, claims or demands of any kind or nature by or on behalf of any person, party or governmental authority arising out of or in connection with: (i) any failure to perform any of the agreements,
terms, covenants or conditions of this Agreement; (ii) any negligent act or omission or other misconduct; (iii) the failure to comply with any applicable laws, rules or regulations; or (iv) any accident, injury or damage to persons or
property. Notwithstanding anything to the contrary contained herein. Group further agrees to and hereby does indemnify, defend and hold harmless ChoiceCare from any and all claims, judgments, costs, liabilities, damages and expenses
whatsoever, including reasonable attorneys’ fees, arising from any acts or omissions in the provision by Group of medical services to Members. This provision shall survive termination or expiration of this Agreement.  

GROUP SERVICES TO MEMBERS 
 2.1
Subject at all times to the terms of this Agreement. Group agrees to provide or arrange for medical and related health care services (hereinafter referred to as “Group Services”) to individuals (hereinafter referred to as
“Members”) covered under designated smlf4unded employer sponsored plans and trusts, insurance policies, or other third party payors’ health benefits contracts (hereinafter referred to as “Plan” or
‘Plans”). ChoiceCare administers the provider network for such other third party payor(s) (hereinafter referred to as “Payor” or “Payors”) issuing and/or administering the Plans. Members
shall have an identification card as a means of identifying the Payor Plan covering Member. Such identification cards shall display the ChoiceCare logo and/or name. Members in Payors Medicare Advantage Plans may not have the ChoiceCare
logo and/or name displayed on their ID cards. 
 THIRD PARTY BENEFICIARIES 

3.1 Except as is otherwise specifically provided in this Agreement with respect to Payors, the parties have not created and do not intend to create by
this Agreement any rights in other parties as third party beneficiaries of this Agreement, including, without limitation. Members. 

SCOPE OF AGREEMENT 
 4.1 This
Agreement sets forth the rights, responsibilities, terms and conditions governing: (i) the status of Group and Group’s employees and subcontractors as health care providers (hereinafter referred to as “Participating
Providers’) providing health care services and (ii) Groups provision of Group Services to Members. 

 4.2 Group acknowledges and agrees that all rights and responsibilities arising with respect to
benefits to Members shall be subject to the terms of the Payor Plan covering the Member. Further, with respect to such Plans, unless otherwise provided herein, Group acknowledges and agrees that ChoiceCare’s responsibilities are
limited to provider network administration for Payors. 
 4.3 Group represents and warrants that Participating Providers will abide by
the terms and conditions of this Agreement. The parties acknowledge and agree that nothing contained in this Agreement is intended to interfere with or hinder communications between Group and Members regarding the Members medical conditions
or treatment options, and Group acknowledges that all patient care and related decisions are the sole responsibility of Group and that ChoiceCare does not dictate or control Group’s clinical decisions with respect to
the medical care or treatment of Members. 
 TERM AND TERMINATION OF AGREEMENT 

5.1 The term of this Agreement shall commence on             ,
20     (hereinafter referred to as the “Effective Date”). (The Effective Date shall be inserted by ChoiceCare.) The initial term of this Agreement shall be one (1) year. This Agreement shall
automatically renew for subsequent one (1) year terms unless either party provides written notice of non-renewal to the other party at least ninety (90) days prior to the end of the initial term or any subsequent renewal terms. 

5.2 Notwithstanding anything to the contrary herein, either party may terminate this Agreement without cause at any time by providing to the other party
one hundred twenty (120) days prior written notice of termination. Group may terminate participation under this Agreement with respect to any Payor that fails to make payments to Group for covered services, but only after written
notice to ChoiceCare providing at least sixty (60) days in which the Payor may avoid termination by curing the default in payment. Covered services (hereinafter referred to as “Covered Services”) as used in this Agreement means
those services, as determined by a Payor, for which benefits are payable under a Member’s Plan. In the event of notice of such termination, Group agrees to provide Group Services for existing patients who are Members as may be
required by state or federal law. Payment to Group for services provided to such Members following the notice of termination shall be made in accordance with the terms of this Agreement. 

5.3 ChoiceCare may terminate this Agreement immediately upon written notice, stating the cause for such termination in the event
(i) ChoiceCare reasonably determines that Group’s or any other Participating Provider’s continued participation under this Agreement may adversely affect the health, safety or welfare of any Member or bring
ChoiceCare or its provider network into disrepute; (ii) Group fails to meet ChoiceCare’s or Payors’ credentialing or recredentialing criteria; (iii) Group or other Participating Provider is excluded
from participation in any federal health care program; (iv) Group voluntarily or involuntarily seeks protection from creditors through bankruptcy proceedings or engages in or acquiesces to receivership or assignment of accounts for the
benefit of creditors; or (v) ChoiceCare loses its authority to do business in total or as to any limited segment of business but then only as to that segment. 
 5.4 In the event of a breach of this Agreement by either party, the non-breaching party may terminate this Agreement upon at least sixty (60) days prior written notice to the breaching party, which
notice shall specify in detail the nature of the alleged breach; provided however, that if the alleged breach is susceptible to cure, the breaching party shall have thirty (30) days from the date of receipt of notice of termination to cure such
breach, and if such breach is cured, then the notice of termination shall be void and of no effect. If the breach is not cured within the thirty (30) day period, then the date of termination shall be that date set forth in the notice of
termination. Notwithstanding the foregoing, any breach related to credentialing or re-credentialing, quality assurance issues or alleged breach regarding termination by ChoiceCare in the event that ChoiceCare determines that continued
participation under this Agreement may affect adversely 

 
the health, safety or welfare of any Member or bring ChoiceCare or its health care networks into disrepute, shall not be subject to cure and shall be cause for immediate termination as set
forth in the immediately preceding paragraph. 
 5.5 Group agrees that notice of termination of this Agreement shall not relieve
Groups obligation to provide or arrange for Covered Services through the effective date of termination or expiration of this Agreement. 

POLICIES AND PROCEDURES 
 6 1
Group agrees to cooperate with ChoiceCare and Payors with respect to their quality assurance, quality improvement, accreditation, risk management, utilization review, utilization management and other administrative policies and
procedures, if applicable, established and revised from time to time by ChoiceCare and Payors. ChoiceCare administrative policies and procedures are posted by electronic means on ChoiceCare’s website, or are set out in
bulletins or other written material, current copies of which will be provided to Group upon request. Revisions to such policies and procedures shall become binding upon Group ninety (90) days after such notice to Group by
mail or electronic means, or such other period of time as necessary for ChoiceCare to comply with any statutory, regulatory and/or accreditation requirements. 
 CREDENTIALING AND PROFESSIONAL LIABILITY INSURANCE 
 7.1 Participation under this
Agreement by Group and Participating Providers is subject to the satisfaction of all applicable credentialing and recredentialing standards established by ChoiceCare. Group shall provide ChoiceCare or its designee the
information necessary to ensure compliance with such standards at no cost to ChoiceCare, or its designee. Group agrees to the use of electronic credentialing and recredentialing processes when administratively feasible. 

7.2 Group shall maintain, at no expense to ChoiceCare or Payors, such policies of comprehensive general liability, professional liability,
and workers’ compensation coverage as required by law, insuring Group, and Group’s employees and agents, against any claim or claims for damages arising as a result of injury to property or person, including death, occasioned
directly or indirectly in connection with the provision of medical services contemplated by this Agreement and/or the maintenance of Group’s facilities and equipment. Upon request, Group shall provide ChoiceCare with
evidence of said coverage, of which minimum professional liability coverage shall be one million dollars ($1,000,000) per occurrence and three million dollars (*3,000,000) in the aggregate, or such greater amounts as are required by state law.
Group shall provide ChoiceCare with written notice at least ten (10) days prior to any cancellations and/or modifications in the coverage. Group shall within ten (10) business days following service upon Group,
or such lesser period of time as may be required by any applicable state statute, rule or regulation, notify ChoiceCare in writing of any Member lawsuit alleging malpractice involving a Member. 

PROVISION OF MEDICAL SERVICES 

8.1 Group shall provide Members all available medical services within the normal scope of and in accordance with Group’s licenses,
certifications and privileges to provide certain services as delineated by ChoiceCare and/or Payors. Group agrees to comply with all requests for information related to ChoiceCare’s and/or Payors determination of
Group’s privileging status. Group shall not bill, charge, seek payment or have any recourse against ChoiceCare, Payors, or Members for any amounts related to the provision of Group Services for which privileges have
not been granted to Group by ChoiceCare. 

 8.2 Group shall maintain all office medical equipment including, but not limited to, imaging,
diagnostic and/or therapeutic equipment (hereinafter collectively referred to as “Equipment”) in acceptable working order and condition and in accordance with the Equipment manufacturer’s recommendations for scheduled service and
maintenance Such Equipment shall be located in Group’s office locations that promote patient and employee safety. Group shall provide ChoiceCare and/or Payors with access to such Equipment for inspection and an opportunity
to review all records reflecting Equipment maintenance and service history. Such Equipment shall only be operated by qualified technicians with appropriate training and required licenses and certifications. 

8.3 Equipment owned and/or operated by Group shall comply with all standards for use of such Equipment and technician qualifications established
by ChoiceCare and/or Payors. In the event: (i) Group’s Equipment fails to meet ChoiceCare’s and/or Payor(s) standards; or (ii) Group declines to comply with ChoiceCare’s and/or Payor(s)
standards for use of Equipment. Group agrees that it will not use such Equipment while providing services to Members and shall not bill, charge, seek payment or have any recourse against ChoiceCare, Payors, or Members for any amounts
for services with respect to such Equipment. 
 8.4 Group agrees if Group closes Group’s practice(s) to new
patients, such closure will apply to all prospective patients without discrimination or regard to payor or source of payment for services. Should Group subsequently re-open Group’s practice(s) to new patients, Group agrees
to accept Members as patients to the same extent and in the same manner as non-Member patients seeking Group’s services. 

STANDARDS OF PROFESSIONAL PRACTICE 

9.1 Group Services shall be made available to Members without discrimination on the basis of type of health benefits plan, source of payment, sex,
age, race, color, religion, national origin, health status or disability. Group shall provide Group Services to Members in the same manner as provided to their other patients and in accordance with prevailing practices and standards of
the profession. 
 MEDICAL RECORDS 
 10.1 Group shall prepare, maintain and retain as confidential the medical records of all Members receiving Group Services, and Members’ other personally identifiable health information
received from Payors, in a form, and for time periods required by applicable state and federal laws, licensing requirements and reimbursement rules and regulations to which Group is subject and otherwise in accordance with accepted medical
practice. Group shall obtain- authorization of Member permitting ChoiceCare, the Member’s Payor, and/or any state or federal agency as permitted by /aw, to obtain a copy and have access, upon reasonable request, to any medical
record of Member related to services provided by Group to any Member pursuant to applicable state and federal laws. Copies of records required for the processing of claims shall be made and provided by Group at no cost to
ChoiceCare, Payor, or the Member. 
 GRIEVANCE AND APPEALS PROCESS/BINDING ARBITRATION 

11.1 Grievance and Appeals; Internal Administrative Review. Group shall cooperate and participate with ChoiceCare and/or
Payor, as applicable, in grievance and appeals procedures to resolve disputes that may arise between ChoiceCare, Payor, Group and/or Members Group and ChoiceCare further agree that in the event they are unable to resolve
disputes that may arise with respect to this Agreement, Group will first exhaust any internal ChoiceCare administrative review or appeal procedures prior to submitting any matters to binding arbitration. 

11.2 Agreement to Arbitrate. The parties agree that any dispute arising out of their business relationship which cannot be settled by
mutual agreement shall be submitted to final and binding arbitration under the Commercial Arbitration Rules of the American Arbitration Association (“AAA”), including disputes concerning the scope, validity or applicability of this
agreement to 

 
arbitrate (“Arbitration Agreement”). The parties agree that this Arbitration Agreement is subject to, and shah| be interpreted in accordance with, the Federal Arbitration Act, 9 U.S.C.
§ 1-14. No claim or allegation shall be excepted from this Arbitration Agreement, including alleged breaches of the Agreement, alleged violations of state or federal statutes or regulations, tort or other common law claims, and claims of any
kind that a party to the Agreement has conspired or coordinated with, or aided and abetted, one or more third parties in violation of law. Without limiting the foregoing, this Arbitration Agreement requires arbitration of disputes involving
antitrust, racketeering and similar claims. This Arbitration Agreement supersedes any prior arbitration agreement between the parties, The parties agree to arbitrate disputes arising from the parties’ business relationship prior to the
effective date of the Agreement under the terms of this arbitration provision. This Arbitration A0roement, however, does not revive any claims that were barred by the terms of prior contracts, by applicable statutes of limitations or otherwise.

 11.3 Arbitration Process. The arbitration shall be conducted by one neutral arbitrator selected by the parties from a panel of
arbitrators proposed by the AAA. The arbitrator shall have prior professional, business or academic experience in healthcare, managed care or health insurance matters. In the event of an arbitration of antitrust claims, the arbitrator shall have
prior professional, business or academic experience in antitrust matters. The arbitration shall be conducted in a location selected by mutual agreement or, failing agreement, at a location selected by the AAA that is no more than fifty
(60) miles from Group’s place of business. The cost of any arbitration proceeding(s) hereunder shall be borne equally by the parties. With respect to any arbitration proceeding between ChoiceCare and Group whereby Group practices
individually or in a physician group of less than six (6) physicians, ChoiceCare agrees that it shall refund any applicable filing fees or arbitrators’ fees paid by such Group in the event that Group is the prevailing party with
respect to such arbitration proceeding; provided, however, that this paragraph shall not apply with respect to any arbitration proceeding in which Group purports to represent physicians outside his or her physician group. Each party shall be
responsible for its own attorneys’ fees and such other costs and expenses incurred related to the proceedings, except to the extent the applicable substantive law specifically provides otherwise. 

11.4 Joinder; Class Litigation. Any arbitration under this Arbitration Agreement shall be solely between ChoiceCare and Group, shall
not be joined with another lawsuit, claim, dispute or arbitration commenced by any other person, and may not be maintained on behalf of any purported class. 
 11.5 Expense of Compelling Arbitration. If either party commences a judicial proceeding asserting claims subject to this Arbitration Agreement or refuses to participate in an arbitration
commenced by the other party, and the other party obtains a judicial order compelling arbitration of such claims, the party that commenced the judicial proceeding or refused to participate in an arbitration in violation of this Arbitration Agreement
shall pay the other party’s costs incurred in obtaining an order compelling arbitration, including the other party’s reasonable attorneys’ fees. 
 11.6 Judgment on the Decision and Award. Judgment upon the decision and award rendered by an arbitrator under this Arbitration Agreement may be entered in any court having jurisdiction
thereof. 
 USE OF GROUP’S NAME 
 12.1 ChoiceCare and Payors may include the following information in any and all marketing and administrative materials published or distributed in any medium by Payors or ChoiceCare:
Group’s name, telephone number, address, office hours, type of practice or specialty, hospital affiliation, and the names of all other Participating Providers, including Group’s, providing care at Groups office, Group internet website
address, board certification, and other education and training history. ChoiceCare will provide Group with access to information or copies of such administrative or marketing materials upon request. 

 12.2 Group may advertise or utilize marketing materials, logos, trade names, service marks. or other
materials created or owned by ChoiceCare or Payors after obtaining ChoiceCare and/or Payors written consent. Group shall not acquire any right or title in or to such materials as a result of such permissive use. 

12.3 Group agrees to allow ChoiceCare to distribute a public announcement of Group’s affiliation with ChoiceCare. 

PAYMENT 
 13.1 Group shall accept
payment from Payors for services that are Covered Services provided to Member in accordance with the reimbursement terms in Attachment B. Group shall collect directly from Member any co-payment, coinsurance, or other member cost share amounts
(hereinafter referred to as “Copayments”) applicable to the Covered Services provided and shall not waive, discount or rebate any such Copayments. Payments made in accordance with Attachment B less the Copayments owed by Members pursuant
to their Plans shall be accepted by Group as payment in full from Payors for all Covered Services. This provision shall not prohibit collection by Group from Member for any services not covered under the terms of the applicable Member Plan.

 13.2 Group agrees that payment may not be made by Payor for services rendered to Members which are determined by Payors to be services not
covered under a Member’s Plan. In the event of such determination by a Payor, Group may pursue payment for such services from the applicable Member, unless such services are paid by the Payor. 

13.3 ChoiceCare’s agreements with Payors require Payors to pay Group for Covered Services in accordance with any applicable state prompt
payment laws or regulations and, except for Member Copayments, Group agrees to seek payment for such services solely from Payors. Group shall participate under the terms contained herein as a participating provider with respect to Payors that
contract with ChoiceCare for provider network administration and related services. ChoiceCare shall require Payors b: provide appropriate steerage mechanisms including benefits designs and/or directory and website publication to ensure
Members have appropriate financial incentives to utilize Group Services. ChoiceCare shall require Payor to include a reference in the explanation of benefits that the discounts outlined in Attachment B were utilized for all eligible payments
made by Payors for Covered Services provided to Members. 
 13.4 Group hereby agrees that its execution of this Agreement shall constitute
Group’s consent to the termination of other agreements for Group’s services with Employers Health Insurance Company Such terminations shall be effective upon the Effective Date of this Agreement. Nothing in this Agreement shall otherwise
limit or prohibit a Payor from contracting directly with or maintaining a direct agreement with Group and utilizing such direct agreements for payment for Covered Services to Members. In the event that Payor elects to apply discounts from its direct
agreement with Group, the Payor shall not apply the discount from this Agreement so long as its direct agreement with Group remains in effect. 

13.5 Group agrees that Payors may recover overpayment made to Group by Payors by offsetting such amounts from later payments to Group, including making
retroactive adjustments to payments to Group for errors and omissions relating to data entry errors and incorrectly submitted claims or incorrectly applied discounts. Payor shall provide Group thirty (30) days advance written notice of
Payor’s intent to offset such amounts prior to deduction of any monies due. If Group does not refund said monies or request review of the notice within thirty (30) days following receipt of notice from payor. Group agrees that Payors may
make adjustments to payments retroactive for a period not to exceed eighteen (18) months from original date of payment. 
 13.6 In the
event a member of a Humana HMO Plan receives authorization from Humana to receive medical services from an out of network provider and selects Group to provide such services, 

 
Group agrees to be reimbursed for such services at the rates and under the terms for payment set forth in this agreement. 
 13.7 In the event that Group provides medical services to a member of a Humana HMO Plan that are emergency medical services, Group agrees to be reimbursed for such services at the rates and under the
terms for payment set forth in this agreement. 
 13.8 Group agrees that in no event, including, but not limited to, nonpayment by Humana, or
Humana’s insolvency, shall Group bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against ChoiceCare or Humana’s HMO Plan members for services provided by Group to
members. This provision shall not prohibit collection by Group from Member for non-covered services and/or Copayments in accordance with the terms of the applicable Member Plan. 
 SUBMISSION OF CLAIMS 
 14.1 Group agrees to submit all claims to Payors or their
designees, as applicable, using a CMS 1500, its electronic equivalent, or its successor, within ninety (90) days from the date of service or within the time specified by applicable state law. Payors may, in their sole discretion, deny payment
for any claim(s) received by Payor after the later of ninety (90) days from the date of service or the time specified by applicable state law. Group acknowledges and agrees that at no time shall Members be responsible for any payments to Group
except for applicable Copayments and non-covered services provided to such Members. 
 14.2 Payor will process Group claims which are accurate
and complete in accordance with Payor’s normal claims processing procedures and applicable state and/or federal laws, rules and regulations with respect to the timeliness of claims processing. Such claims processing procedures may include,
without limitation, automated systems applications which identify, analyze and compare the amounts claimed for payment with the diagnosis codes and which analyze the relationships among the billing codes used to represent the services provided to
Members. These automated systems may result in an adjustment of the payment to the Group for the services or in a request, prior to payment, for the submission for review of medical records that relate to the claim. A reduction in payment as a
result of claims policies and/or processing procedures is not an indication that the service provided is a non-covered service. In no event may Group bill a member for any amount adjusted in payment. 

14.3 Group shall use best efforts to submit all claims to Payors or their designees by electronic means available and accepted as industry standards that
are mutually agreeable and which may include claims clearinghouses or electronic data interface companies used by Payor. Group acknowledges that Payors may market certain products that will require electronic submission of claims in order for Group
to participate. 
 COORDINATION OF BENEFITS 
 15.1 Payments for Covered Services provided to each Member are subject to coordination with other benefits payable or paid to or on behalf of the Member in accordance with applicable statutes, laws, rules
and regulations and in accordance with its Plans. In cases where a Member has coverage, which requires or permits coordination of benefits with another third party payor, Payors will coordinate their benefits with such other payor(s). In the event
Medicare is the primary payor, Payors shall pay Group the amount of deductible, coinsurance and/or other plan benefits which are not covered services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and
applicable rates of the applicable Plan. In no event will Payors pay an amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in this Agreement. 

 NO LIABILITY TO CHOICECARE FOR PAYMENT 

16.1 Group hereby agrees that in no event including, but not limited to, nonpayment by Payor, or Payor’s insolvency, shall Group b0, charge, collect
a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against ChoiceCare for services provided by Group to members. This provision shall not prohibit collection by Group from Member for non-covered
services and/or Copayments in accordance with the terms of the applicable Member Plan. 
 ACCESS TO INFORMATION 

17.1 Group agrees that ChoiceCare. Payors, or their designees, shall have reasonable access and an opportunity to examine Group’s financial
and administrative records as they relate to services provided to Members during normal business hours, on at least seventy-.two (72) hours advance notice, or such shorter notice as may be imposed on Payor by a federal or state regulatory
agency or accreditation organization. 
 NEW PRODUCT INTRODUCTION 
 18.1 From time to time during the term of this Agreement, ChoiceCare and/or Payors may develop or implement new products. Should ChoiceCare and/or Payor elect to offer any such new products
to Group, Group shall be provided with ninety (90) days written notice from ChoiceCare prior to the implementation of such new product. If Group does not object in writing to the implementation of such new product within such ninety
(90) day notice period, Group shall be deemed to have accepted participation in the new product. In the event Group objects to any such new product, the parties shall confer in good faith to reach agreement on terms of Group’s
participation. If agreement cannot be reached, such new product shall not apply to this Agreement. 
 18.2 ChoiceCare reserves the right,
in its discretion, to develop and market provider networks in which Group may not be selected to participate. The parties agree that this Agreement applies to those Members and Plans designated by ChoiceCare. 

ASSIGNMENT AND DELEGATION 
 19.1
The assignment by Group of this Agreement or any interest hereunder shall require notice to and the written consent of ChoiceCare. Any attempt by Group to assign this Agreement or its interest hereunder without complying with the terms of
this paragraph shall be void and of no effect, and ChoiceCare’s, at its option, may elect to terminate this Agreement upon thirty (30) days written notice to Group, without any further liability or obligation to Group.
ChoiceCare may assign this Agreement in whole or in part to any purchaser of or successor to the assets or operations of ChoiceCare, or to any affiliate of ChoiceCare, provided that the assignee agrees to assume
ChoiceCare’s obligations under this Agreement. Upon notice of an assignment by ChoiceCare. Group may terminate this Agreement upon thirty (30) days written notice to ChoiceCare. 

COMPLIANCE WITH REGULATORY REQUIREMENTS 
 20.1 Group acknowledges, understands and agrees that this Agreement may be subject to the review and approval of state regulatory agencies with regulatory authority over the subject matter to which this
Agreement may be subject Any modification of this Agreement requested by such agencies or required by applicable law or regulations shall be incorporated herein as provided in Article 2t10, of this Agreement. 

 20.2 Group and ChoiceCare agree to be bound by and comply with the provisions of all applicable state
and federal laws, rules and regulations. The alleged failure by either party to comply with applicable state and federal laws or regulations shall not be construed as allowing either party a private right of action against the other in any court or
administrative agency in matters in which such right is not recognized or authorized by such law or regulation. Group shall notify ChoiceCare immediately of any changes in licensure or certification status of Group and other Participating
Provider’s, as applicable. If Group violates any of the provisions of applicable state and/or federal laws, rules and regulations, or commits any act or engages in conduct for which Groups or other Participating Providers license or
certification is revoked or suspended, or otherwise is restricted by any state licensing or certification agency by which a Participating or the Group is licensed or certified, ChoiceCare may immediately terminate this Agreement or any
individual Participating Provider. 
 MISCELLANEOUS PROVISIONS 
 21.1 SEVERABILITY. If any part of this Agreement should be determined to be invalid, unenforceable, or contrary to law, that part shall be reformed, if possible, to conform to law, and if
reformation is not possible, that part shall be deleted, and the other parts of this Agreement shall remain fully effective. 
 21.2
GOVERNING LAW. This Agreement shall be governed by and construed in accordance with the laws of the state in which Group Services are provided. The parties agree that applicable federal and state laws and regulations may make it
necessary to include in this Agreement specific provisions relevant to the subject matter contained herein Such provisions, if any, are set forth in Attachment A hereto. The parties agree to comply with any and all such provisions and in the event
of a conflict between the provisions in Attachment A and any other provisions in this Agreement, the provisions in Attachment A shall control. In the event that state or federal laws or regulations enacted after the Effective Date expressly require
specific language in such provisions be included in this Agreement such provisions are hereby incorporated by reference without further notice by or action of the parties and such provisions shall be effective as of the effective date stated in such
laws, rules or regulations. 
 21.3 WAIVER. The waiver, whether expressed or implied, of any breach of any provision of this
Agreement shall not be deemed to be a waiver of any subsequent or continuing breach of the same provision. In addition, the waiver of one of the remedies available to either party in the event of a default or breach of this Agreement by the other
party shall not at any time be deemed a waiver of a party’s right to elect such remedy at any subsequent time if a condition of default continues or recurs. 
 21.4 NOTICES. Any notices, requests, demands or other communications, except notices of changes in policies and procedures pursuant to Article 6, required or permitted to be given under this
Agreement shall be in writing and shall be deemed to have been given: (i) on the date of personal delivery, or (ii) provided such notice, request, demand or other communication is received by the party to which it is addressed in the
ordinary course of delivery: (a) on the third day following deposit in the United States mail, postage prepaid, by certified ma||, return receipt requested; (b) on the date of facsimile transmission, or (c) on the date following
delivery to a nationally recognized overnight courier service, each addressed to the other party at the address set forth below their respective signatures to this Agreement. or to such other person or entity as either party shall designate by
written notice to the other in accordance herewith ChoiceCare may also provide such notices to Group by electronic means to the email address of Group set forth on the Cover Sheet to this Agreement or to other email addresses Group provides
to ChoiceCare by notice as set forth herein- Unless a notice specifically limits its scope, notice to any one party included in the term “Group” or “ChoiceCare” shall constitute notice to all parties included in the
respective terms. 
 21.5 CONFIDENTIALITY. Group agrees that the terms of this Agreement and information regarding any dispute
arising out of this Agreement are confidential, and agrees not to disclose the terms of this Agreement nor information regarding any dispute arising out of this Agreement to any third 

 
party without the express written consent of ChoiceCare, except pursuant to a valid court order, or when disclosure is required by a governmental agency. Notwithstanding anything to the
contrary heroin, the parties acknowledge and agree that Group may discuss the payment methodology included herein with Members requesting such information. 
 21.6 COUNTERPARTS AND HEADINGS. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original|, and all of which together constitute one and the same
instrument. The headings in this Agreement are for reference purposes only and shall not be considered a part of this Agreement in construing or interpreting any of its provisions. Unless the context otherwise requires, when used in this Agreement,
the singular shall include the plural, the plural shall include the singular, and all nouns, pronouns and any variations thereof shall be deemed to refer to the masculine, feminine or neuter, as the identity of the person or persons may require. It
is the parties desire that if any provision of this Agreement is determined to be ambiguous, then the rule of construction that such provision is to be construed against its drafter shall not apply to the interpretation of the provision. 

21.7 INCORPORATION OF ATTACHMENTS. Attachments A, Bond C are incorporated herein by reference and made a part of this Agreement.

 21.8 FORCE MAJEURE. Neither party to this Agreement shall be deemed to breach its obligations under this Agreement if that
party’s failure to perform under the terms of this Agreement is due to an act of God, riot, war or natural disaster. 
 21.9 ENTIRE
AGREEMENT. This Agreement, including the attachment, addenda and amendments hereto and the documents incorporated herein, constitutes the entire agreement between ChoiceCare and Group with respect to the subject matter hereof, and it
supersedes any prior or contemporaneous agreements, oral or written, between ChoiceCare and Group. 
 21.10 MODIFICATION OF THIS
AGREEMENT. This Agreement may be amended in writing as mutually agreed upon by the parties. In addition, ChoiceCare may amend this Agreement upon ninety (90) days’ written notice to Group. Failure of Group to object to such
amendment during the ninety (90) day notice period shall constitute acceptance of such amendment by Group. 
 21.11 MATERIAL ADVERSE
CHANGES. Notwithstanding anything to the contrary in this Agreement, in the event ChoiceCare makes a material adverse change in the terms of this Agreement it shall provide at least ninety (90) days written notice to Group of
such change; except where a shorter notice period is required to comply with applicable law or regulation. If Group objects to the change that is the subject of the notice, then Group must within thirty (30) days of the date of the notice give
written notice of termination of this Agreement which notice shall be effective at the end of the notice period of the material adverse change; provided, however, if ChoiceCare provides written notice within sixty-five (65) days of the
date of the original notice of the material adverse change that it will not implement such change as to Group, then Group’s notice of termination shall be of no force or effect. 

 IN WITNESS WHEREOF, the parties have the authority necessary to bind the entities identified herein and have
executed this Agreement to be effective as of the Effective Date. 

 

			
	GROUP/AUTHORIZED SIGNATORY

			
		
	 Signature:
	 	  

			
		
	 Printed Name:
	 	  

			
		
	 Title:
	 	  

			
		
	 Date:
	 	
 

			
	CHOICECARE NETWORK

			
		
	Signature:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

			
		
	Date:	 	  

 

  

					
			
	 Address for Notice:

Group:
	 		 	ChoiceCare Network:
			
	  
	 		 	ChoiceCare Network
			
	  
	 		 	P.O. Box 19013
			
	  
	 		 	Green Bay, Wisconsin 54307
			
	  
	 		 	Attn: President

 ATTACHMENT A 

STATE LAW COORDINATING PROVISIONS 
 TEXAS 
 ChoiceCare and Group agree that the following provisions are
incorporated into the Agreement as they relate to Payors, Plans and/or Members and solely to the extent specifically required to ensure compliance with Texas laws, rules and regulations. 

 ATTACHMENT B 

PHYSICIAN REIMBURSEMENT 
 A. CHOICECARE NETWORK REIMBURSEMENT 
 Group agrees to accept as payment in full from Payors
for Covered Services rendered to Members, the percentage defined below of ChoiceCare’s ( 079-787 ) fee schedule, or Group’s billed charges, whichever is less, less any Co-payments due from Members All payments due from
ChoiceCare will be reduced by any deductibles or co-payments due from Member. 
 Reimbursements broken down by code ranges and
percentage payable for the above listed plans indicating (070-787) fee schedule: 
  

	•	 	 Evaluation and Management Services (Codes 99201 to 99499): All covered services for evaluation and management services will be [****] with the
exception of 99214 and 99212. CPT Code 99214 will be reimbursed at [****]. CPT Code 99212 which will be [****]. 

  

	•	 	 Surgery Services (Codes 10021 to 11471 and 11720 to 11765): CPT Code 10060 will be reimbursed at [****]. All other covered services for surgery
services will be reimbursed at [****]. 

  

	•	 	 Surgery Services (Codes 11600 to 11719 and 11770 to 69990): CPT Code 11740 and 69210 will be reimbursed at [****]. All other covered services
for surgery services will be reimbursed at [****]. 

  

	•	 	 Radiology – Including Nuclear Medicine and Diagnostic Ultrasound Services (Code 70010 to 79999): All covered services for radiology
services will be reimbursed at [****]. 

  

	•	 	 Pathology and Laboratory Services (Codes 80048 to 89399): ChoiceCare’s STAT pathology and laboratory codes are fixed at [****]
schedule. ChoiceCare’s STAT laboratory codes are as follows: 81000, 91002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, 87880. CPT Code 36415 when
appropriate will be paid at [****]. All covered services for pathology and laboratory will be reimbursed at [****]. 

  

	•	 	 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to
99199 and 99500 to 99600): CPT Code 90772 and 92230 will be reimbursed at [****]. All other covered services for medicine services, excluding anesthesiology, [****]. 

 

	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508 and 97001 to
97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed [****]. 

  

	•	 	 HCPCS Codes: All covered services for HCPCS codes, with the exception of J Codes will be [****]. 

 

	•	 	 Drugs, Immunizations, Vaccinations and Injectables: [****] be utilized for reimbursement for drugs, immunizations or injectables. These drugs
and/or immunizations will be reimbursed [****]. 

 Group agrees that in the event that Group employs, subcontracts or
independently contracts with or uses the services of a physician extender (that is, a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist certified nurse midwife certified surgical assistant, certified
registered nurse first assistant or such other similarly situated individual) who will be providing services to Members under the supervision of Group, Group shall notify ChoiceCare in writing, upon execution of this Agreement and at any time
during the term of this Agreement when such physician 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 ATTACHMENT B 

PHYSICIAN REIMBURSEMENT 
  

 
extenders are employed, subcontracted or independently contracted with Group, and the specific services that such physician extenders will be performing, prior to the provision of services to any
Member. Group represents that physician extenders employed by or under contract with Group will comply with the terms and condition of this Agreement, maintain professional liability coverage and are appropriately licensed as required by applicable
state and federal laws, rules and regulations. Group acknowledges and agrees ChoiceCare retains the right to approve, suspend and/or terminate participation under this Agreement of any physician extender who will be providing services to
Members. Payor, in its sole discretion, may reimburse Group for services of such physician extenders rendered to Members covered under Plans offered by Payors with access to ChoiceCare Network and not otherwise specified in paragraphs B
and/or C below, [****],whichever is less, less any Co-payments due from Member. 
 B. HUMANA ADVANTAGE NETWORK 

Group agrees to participate in ChoiceCare’s Humana Advantage Network and agrees to accept as payment in full from Payors for Covered Services
rendered to Members covered under Plans offered by Payors with access to ChoiceCare’s Humana Advantage Network, [****] ChoiceCare’s (005-787) Fee Schedule or Group’s billed charges, whichever is less, less any Copayments
due from Member. 
 Physician agrees that in the event that Physician employs, subcontracts or independently contracts with or uses the services
of a physician extender (that is, a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, certified surgical assistant, certified registered nurse first assistant or such other
similarly situated individual) who will be providing services to Members under the supervision of Physician, Physician shall notify ChoiceCare in writing, upon execution of this Agreement and at any time during the term of this Agreement when
such physician extenders are employed, subcontracted or independently contracted with Physician, and the specific services that such physician extenders will be performing, prior to the provision of services to any Member. Physician represents that
physician extenders employed by or under contract with Physician will comply with the terms and condition of this Agreement, maintain professional liability coverage and are appropriately licensed as required by applicable state and federal laws,
rules and regulations. Physician acknowledges and agrees ChoiceCare retains the right to approve, suspend and/or terminate participation under this Agreement of any physician extender who will be providing services to Members. Payor, in its
sole discretion, may reimburse Physician for services of such physician extenders rendered to Members covered under Plans offered by Payors with access to ChoiceCare’s Humana Advantage Network and not otherwise specified in paragraphs A
above and/or C below, [****], whichever is less, less any Copayments due from Member. 
 This payment provision applies solely to
ChoiceCare’s Humana Advantage Network Alf other terms and conditions of this Agreement apply to Physician’s participation in ChoiceCare’s Humana Advantage Network. 

C. MEDICARE PPO NETWORK 
 Physician
agrees to participate in ChoiceCare’s Medicare PPO Network and agrees to accept as payment in full from Payors for Covered Services rendered to Members covered under Plans offered by Payors with access to ChoiceCare’s”
Medicare PPO Network [****], whichever is less, less any Copayments due from Member. 
 Physician agrees that in the event that Physician
employs, subcontracts or independently contracts with or uses the services of a physician extender (that is, a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, certified
surgical assistant, certified registered nurse first assistant or such other similarly situated individual) who will be providing services to Members under the supervision of Physician. Physician shall notify ChoiceCare in working, upon
execution of this Agreement and at any time during the term of this Agreement when such physician 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 ATTACHMENT B 

PHYSICIAN REIMBURSEMENT 
  

 
extenders are employed, subcontracted or independently contracted with Physician, and the specific services that such physician extenders will be performing, prior to the provision of services to
any Member. Physician represents that physician extenders employed by or under contract with Physician will comply with the terms and condition of this Agreement, maintain professional liability coverage and are appropriately licensed as required by
applicable state and federal laws, rules and regulations. Physician acknowledges and agrees ChoiceCare retains the right to approve, suspend and/or terminate participation under this Agreement of any physician extender who will be providing services
to Members. Paynr, in its sole discretion, may reimburse Physician for services of such physician extenders rendered to Members covered under Plans offered by Payors with access to ChoiceCare’s Medicare PPO Network and not otherwise specified
in paragraphs A and/or B above, [****], whichever is less, less any Copayments due from Member. 
 This payment provision applies solely to
ChoiceCare’s Medicare PPO Network. All other terms and conditions of this Agreement apply to Physician’s participation in ChoiceCare’s Medicare PPO Network, 
 D. FEE SCHEDULES 
 ChoiceCare’s (085-787) fee schedule is based on the current year Medicare
Resource Based Relative Value Scale (RBRVS) fee schedule and payment systems in effect as of the effective date of this Agreement and will change thereafter to reflect the annual updates to the schedule made by the Centers for Medicare/Medicaid
Services (CMS). .Additionaly, ChoiceCare will adjust the schedule to include and assign fees for services which are not covered by RBRVS. A list of those ChoiceCare adjusted codes and fees will be available to Physician upon request. 

Such annual updates by CMS and any corresponding adjustments by ChoiceCare shall be incorporated herein without notice to Physician, but will be
available to Physician upon request. ChoiceCare will provide to Physician a sixty (60) day written notice prior to implementation of other revisions to the fee schedule. 
 ChoiceCare has provided a representative sample of the fee schedule to Physician prior to Physician’s execution of this Agreement, and thereafter will supply a sample upon written request by
Physician. Physician hereby acknowledges receipt of fee schedule sample. 
 Physician understands that some Payors may market or administer
products that contain variable Copayment amounts due from the Member for Covered Services based on the medical specialty of certain physicians and the unit costs or reimbursement rates provided for in Physician participation agreements. Physician
agrees to participate in such Payor products and to bill and accept as payment in full for Covered Services rendered to Members of such Payors the reimbursement rates set above less any Copayment amounts due from the Member. Inquiries regarding
specific Payor products should be directed to the Payor. 
 ChoiceCare’s (079-787) fee schedule is based upon a modified fixed version of
the 2006 Medicare Resource Based Relative Value Scale (“RBRVS”) fee schedule and payment systems, including the site¬of-service payment differential 
 ChoiceCare may modify schedule (079’787) to include codes and/or fees for services that are not included in this fee schedule (hereinafter “Gap Codes”). In most cases, the Gap Codes
are adjusted by ChoiceCare using the relative value unit (“RVU”) multiplied by Medicare’s conversion factor and geographic factor to assign the fee at the same percentage applied by ChoiceCare for other codes within the code range

 Additionally, ChoiceCare may incorporate new CPT and HCPCS codes into schedule (079-787). The fee attributable to such code(s) will be
determined by applying the same percentage as ChoiceCare applied to other codes within such code range toe that codes RBRVS which is current as of the date of creation of the code. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 ATTACHMENT B 

PHYSICIAN REIMBURSEMENT 
  

 ChoiceCare will also modify the fee for a code if the RVU for the code changes as herein
described. RVU increases for a code will be measured by dividing the revised Total RVU by the prior Total RVU Total RVU” means the sum of all three, RVU components, physician work, overhead and mal-practice. If the resulting quotient if
125ofgreater, or .75 or lesser, the revised fee for such code will be determined by applying the same percentage as ChoiceCare applied to other codes within such code range to that code’s RBRVS which is current as of the date of
publication of the revised RVU. 
 Periodic updates for new CPT codes, HCPCS codes and/or Gap Codes, or for modification of fees resulting from
adjustments to a code’s RVU as specified above, shall be incorporated into schedule (079-787) without notice to Physician, but will be available to Physician upon request. ChoiceCare may make other adjustments and modifications to this
fee schedule. In such case, ChoiceCare will provide Physician a ninety (90) day written notice prior to implementation of any other modifications and adjustments to schedule (079-787) 

 

	•	 	 Evaluation and Management Services (Codes 99201 to 99499): All covered services for evaluation and management services are fixed at [****].

  

	•	 	 Surgery Services (Codes 10021 to 11471 and 11720 to 11765): All covered services for surgery services are fixed at [****].

  

	•	 	 Surgery Services (Codes 11600 to 11719 and 11770 to 69990): All covered services for surgery services are fixed at [****].

  

	•	 	 Radiology – Including Nuclear Medicine and Diagnostic Ultrasound Services (Codes 70010 to 79999): All covered services for radiology
services are fixed [****]. 

  

	•	 	 Pathology and Laboratory Services (Codes 80048 to 89399): All covered services for pathology and laboratory will be reimbursed at [****].
ChoiceCare’s STAT pathology and laboratory codes are fixed at [****]. ChoiceCare’s STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022,
85027, 85031, 87205, 87207, 87210, 87220, 87880. 

  

	•	 	 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to
99199 and 99500 to 99600): All covered services for medicine services, excluding anesthesiology, are fixed at [****]. 

  

	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508 and 97001 to
97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, are fixed at [****]. 

  

	•	 	 HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes, are fixed at [****]. 

 

	•	 	 Drugs, Immunizations, Vaccines and Injectables: ChoiceCare’s (201-544) fee schedule will be utilized for reimbursement for drugs,
immunizations or injectables. These drugs and/or immunizations will be reimbursed at [****]. 

 ChoiceCare’s
201-544: ChoiceCare’s injectable fee schedule (201-544) uses a percentage of the CMS Average Sales Price (ASP) or another industry standard as the basis of the (201-544) fee schedule. Notwithstanding anything to the contrary in the
Agreement, in the event the basis for the schedule is changed from a percentage of ASP to another basis, then ChoiceCare will provide ninety (90) days advance notice to Provider, of the new basis. The list of codes and associated fees
are reviewed and updated quarterly to reflect market pricing, These quarterly updates, if any, as well as any change in the basis may result in fees being adjusted either upwardly or downwardly. These updates shall be 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 ATTACHMENT B 

PHYSICIAN REIMBURSEMENT 
  

 
incorporated in the ChoiceCare injectable fee schedule (201-544) without notice to Provider, but will be made available to Provider upon request. 

E. ANCILLARY SERVICES 
 Physician and
other Participating Providers shall provide only those laboratory, injectable infusion therapy, durable medical equipment, radiology, nuclear medicine, physical therapy and other ancillary health care services which Participating Provider is
qualified to provide by license, certification, and state and/or federal law. 

 ATTACHMENT C 

MEDICARE ADVANTAGE PROVISIONS 
 Group agrees to participate in ChoiceCare’s Medicare Advantage Network. Group further agrees that the following additional provisions relate specifically to Medicare Advantage products and plans and
are hereby incorporated by reference into the Agreement. 
  

	a)	Group agrees to: (i) abide by all federal and state laws regarding confidentiality, privacy and disclosure of medical records or other health and enrollment
information, (ii) ensure that medical information is released only in accordance with applicable state or federal law, or pursuant to court orders or subpoenas, (iii) maintain all Member records and information in an accurate and timely
manner, and (iv) allow timely access by Members to the records and information that pertain to them. 

  

	b)	The parties agree that Payor will process all claims for Covered Services which are accurate and complete within thirty (30) days from the date of receipt.

  

	c)	Group agrees that in no event, including, but not limited to, nonpayment by Payor, Payor’s insolvency or breach of this Agreement, shall Group bill, charge,
collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members or persons other than Payor for Covered Services provided by Group for which payment is the legal obligation of Payor. This provision
shall not prohibit collection by Group from Member for any non-covered service and/or Copayments in accordance with the terms of the applicable Member health benefits contract. Group further agrees that: (i) this provision shall survive the
expiration or termination of this Agreement regardless of the cause giving rise to expiration or termination and shall be construed to be for the benefit of the Member; (ii) this provision supersedes any oral or written contrary agreement now
existing or hereafter entered into between Group and Member or persons acting on their behalf; and (iii) this provision shall apply to all employees, agents, trustees, assignees, subcontractors, and independent contractors of Group, and Group
shall obtain from such persons specific agreement to this provision. 

  

	d)	Group agrees to cooperate with Payor in its efforts to monitor compliance with its Medicare Advantage contract(s) and/or Medicare Advantage rules and regulations and to
assist Payor in complying with corrective action plans necessary for Payor to comply with such rules and regulations. 

  

	e)	Group agrees that nothing in the Agreement shall be construed as relieving Payor of its responsibility for performance of duties agreed to through its Medicare
Advantage contracts existing now or entered into in the future with CMS. 

  

	f)	Group agrees to comply with and be subject to all applicable Medicare program laws, rules and regulations, reporting requirements, and CMS instructions as implemented
and amended by CMS. This includes, without limitation, federal and state regulatory agencies’ including, but not limited to, HHS, the Comptroller General or their designees rights to evaluate, inspect and audit Group’s operations, books,
records, and other documentation and pertinent information related to Group’s obligations under the Agreement, as well as all other federal and state laws, rules and regulations applicable to individuals and entities receiving federal funds.
Group further agrees HHS’, the Comptroller General’s, or their designees right to inspect, evaluate and audit any pertinent information for any particular contract period will exist through ten (10) years from the final date of the
contract period between Payor and CMS or from the date of completion of any audit. whichever is later, and agrees to cooperate, assist and provide information as requested by such entities. 

 

	g)	Group agrees to retain all contracts, books, documents, papers and other records related to the provision of services to Medicare Advantage Members and/or as related to
Group’s obligations under the Agreement for a period of not less than ten (10) years from: (i) each successive December 31; or (ii) the end of the contract period between Payor and CMS; or (iii) from the date of
completion of any audit, whichever is later. 

 ATTACHMENT C 

MEDICARE ADVANTAGE PROVISIONS 
  

	h)	Group agrees in the event certain identified activity(ies) have been delegated to Group under the Agreement, any sub-delegation of the noted activity(ies) by Group
requires the prior written approval of ChoiceCare and/or Payor, as applicable. Notwithstanding anything to the contrary in the Agreement, ChoiceCare and/or Payor, as applicable, will monitor Group’s performance of any delegated activity(ies) on
an ongoing basis and hereby retains the right to modify, suspend or revoke such delegated activity(ies) in the event ChoiceCare, Payor and/or CMS determines, in their discretion, that Group is not meeting or has failed to meet its obligations under
the Agreement related to such delegated activity(ies). in the event that ChoiceCare and/or Payor, as applicable, has delegated all or any part of the claims payment process to Group under the Agreement, Group shall comply with all prompt payment
requirements to which Payor is subject. Humana agrees that it shall review the credentials of Group or, if ChoiceCare and/or Payor, as applicable, has delegated the credentialing process to Group, ChoiceCare and/or Payor, as applicable, shall review
and approve Group’s credentialing process and audit it on an ongoing basis. 

  

	i)	Group agrees to comply with ChoiceCare and Payor’s policies and procedures 

 

	j)	Group agrees to maintain full participation status in the federal Medicare program. This also includes all of Group’s employees, subcontractors, and/or independent
contractors who will provide services, including, without limitation, health care, utilization review, medical social work, and/or administrative services under the Agreement. 

 

	k)	Group agrees that payment from Payor for services rendered to Payor’s Medicare Advantage Members is derived, in whole or in part, from federal funds received by
Payor from CMS. 

  

	l)	Group agrees to disclose to Payor, upon request and within thirty (30) days or such lesser period of time required for Payor to comply with all applicable state or
federal laws, all of the terms and conditions of any payment arrangement that constitutes a “physician incentive plan” as defined by CMS and/or any federal Law or regulation. Such disclosure should identify, at a minimum, whether services
not furnished by the physician/provider are included, the type of incentive plan including the amount, identified as a percentage, of any withhold or bonus, the amount and type of any stop-loss coverage provided for or required of the
physician/provider, and the patient panel size broken down by total group or individual physician/provider panel size, and by the type of insurance coverage (i.e., Commercial HMO, Medicare Advantage HMO, Medicare PPO, and Medicaid HMO).

  

	m)	Group agrees that in the event of Payor’s insolvency or termination of Payor’s contract with CMS, benefits to Members will continue through the period for
which premium has been paid and benefits to Members confined in an inpatient facility will continue until their discharge. 

  

	n)	Group agrees to provide or arrange for continued treatment, including, but not limited to, medication therapy, to Medicare Advantage Members upon expiration or
termination of the Agreement. In accordance with all applicable state and federal laws, rules and/or regulations, treatment must continue until the Member: (i) has been evaluated by a new participating provider who has had a reasonable
opportunity to review or modify the Medicare Advantage Member’s course of treatment, or until Payor has made arrangements for substitute care for the Medicare Advantage Member; and (ii) until the date of discharge for Medicare Advantage
Members hospitalized on the effective date of termination or expiration of the Agreement. Group agrees to accept as payment in full from Payor for Covered Services rendered to Payor’s Medicare Advantage Members, the rates set forth in the
payment attachment which are applicable to such Member. 

  

	o)	Group agrees to cooperate with the activities and/or requests of any independent quality review and improvement organization utilized by and/or under contract with
Payor as related to the provision of services to Medicare Advantage Members. 

 ATTACHMENT C 

MEDICARE ADVANTAGE PROVISIONS 
  

	p)	Group agrees to cooperate with Payor’s health risk assessment program. 

 

	q)	Group agrees to provide to Payor accurate and complete information regarding the provision of Covered Services by Group to Members (“Data”) on a complete CMS
1500 or UB 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by law when submitting claims and encounters in an electronic format, or such other format as is mutually agreed upon by both
parties. The Data shall be provided to Payor on or before the last day of each month for encounters occurring in the immediately preceding month, or such lesser period of time as may be required in the Agreement, or as is otherwise agreed upon by
the parties in writing. The submission of the Data to Payor and/or CMS shall include a certification from Group that the Data is accurate, complete and truthful. In the event the Data is not submitted to Payor by the date and in the form specified
above, Payor may, in its sole option, withhold payment otherwise required to be made under the terms of the Agreement until the Data is submitted to Payor. 

 

	r)	Group agrees not to collect or attempt to collect copayments, coinsurance, deductibles or other cost-share amounts from any Payor Medicare Advantage Member who has been
designated as a Qualified Medicare Beneficiary (“QMB”) by CMS. 

  

	s)	Group agrees to maintain written agreements with employed and contracted health care providers and health care professionals providing services under the Agreement in a
form comparable to, and consistent with, the terms and conditions of the Agreement. Group’s downstream provider agreements shall include terms and conditions which comply with all applicable requirements for provider agreements under state and
federal laws, rules and regulations including, without limitation, the Medicare Advantage rules and regulations to which Payor is subject. In the event of a conflict between the language of the downstream provider agreements and the Agreement, the
language in the Agreement shall control. 

 APPENDIX A 

ADDITIONAL PROVISIONS APPLICABLE TO HUMANA HEALTH PLAN PAYORS 
 The following additional provisions apply to health plans underwritten or administered by Humana Insurance Company or its affiliates. 
 1. Notwithstanding anything to the contrary in the Agreement, Group agrees to submit all claims to Payors or their designees, as applicable, using a CMS 1500, its electronic equivalent, or its successor,
within one hundred eighty (180) days from the later of: (i) the date of service; or (ii) the date of Group’s receipt of the explanation of benefits from the primary payor when Payor is the secondary payor; provided, however, all
claims under self-insured plans must be submitted within one hundred eighty (180) days of the date of service. Payors may, in their sole discretion, deny payment for any claim(s) received by Payor after the later of the dates specified above.

 2. “Medically Necessary” (or “Medical Necessity”), unless otherwise defined by applicable law, shall mean health care
services that a Group, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally
accepted standards of medical practice, (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and (c) not primarily for the
convenience of the patient, Group, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of
that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally
recognized by the relevant medical community, Group specialty society recommendations and the views of Groups practicing in relevant clinical areas and any other relevant factors. Group agrees that in the event of a denial of payment for services
rendered to Members determined not to be Medically Necessary by Payor, that Group shall not bill, charge, seek payment or have any recourse against Member for such services. Notwithstanding the immediately preceding sentence, Group may bill the
Member for services determined not to be Medically Necessary if Group provides the Member with advance written notice that: (a) identifies the proposed services, (b) informs the Member that such services may be deemed by Payor to be not
Medically Necessary, and (c) provides an estimate of the cost to the Member for such services and the Member agrees in writing in advance of receiving such services to assume financial responsibility for such services. 

3. Group agrees to comply with the polices and procedures set forth in the Manual regarding inpatient and outpatient admissions including, but not
limited to, notifying ChoiceCare of the admission or obtaining preadmission authorization as the Manual so requires. Group recognizes that failure to comply with the Manual with respect to a Member admission could result in limitations on
ChoiceCare`s ability to administer Members’ benefits. In the event Group fails to comply with the Manual regarding a Member inpatient or outpatient admission, Group’s claim will be pended and may either not be paid (if it is not Medically
Necessary) or be subject to an administrative reduction in an amount equal to fifty percent (50%) of the allowed amount. Group agrees it shall not balance bill the Member for the amount of the reduction in payment. In the event the reduction
described herein is effected, the Member’s Copayments, if any, will be adjusted accordingly. 

 ATTACHMENT E 
 AMENDMENT TO AGREEMENT 
 The parties agree to amend the following language in bold and italics
print. Further, these changes replace, delete and/or add to the final language agreed to by the parties: 
 TERM AND TERMINATION OF AGREEMENT

 5.2 Notwithstanding anything to the contrary herein, either party may terminate the Agreement without cause at any time after one hundred
eighty (180) days from execution of this Agreement by providing to the other party a ninety (90) days prior written notice of termination...” 
 CREDENTIALING AND PROFESSIONAL LIABILITY INSURANCE 
 7.2 “...Upon request, Group shall
provide ChoiceCare with evidence of said coverage, of which minimum professional liability coverage shall be five hundred thousand dollars ($500,000) per occurrence and one million dollars ($1,000,000) in the aggregate or such greater amounts as are
required by state law... 
 PROVISION OF MEDICAL SERVICES 
 8.2 Deleted in its entirety 8.3 Deleted in its entirety 
 USE OF GROUPS NAME 

12.4 ChoiceCare may advertise or utilize marketing materials, logos, trade names, service marks of other materials created or owned by Group after
obtaining Group’s written consent. ChoiceCare shall not acquire any right to title in or to such materials as a result of such permissive use. 
 ACCESS TO INFORMATION 
 17.1 Group agrees that ChoiceCare, Payors or their designees shall have
reasonable access and an opportunity to examine Group’s financial records annually and administrative records as needed, as they relate to services provided to Members during normal business...” 

 ASSIGNMENT AND DELEGATION 
 19.2 The assignment by ChoiceCare of this Agreement or any interest hereunder shall require notice to and the written consent of Group. Any attempt by ChoiceCare to assign this Agreement or its interest
hereunder without complying with the terms of this paragraph shall be void and of no effect, and Group, at its option, may elect to terminate this Agreement upon thirty (30) days written notice to ChoiceCare, without any further liability or
obligation to ChoiceCare. Group may assign this Agreement in whole or in part to any purchaser of or successor to the assets or operations of Group, or to any affiliate of Group, provided that the assignee agrees to assume Group’s obligations
under this Agreement. Upon notice of an assignment by Group, ChoiceCare may terminate this Agreement upon thirty (30) days written notice to Group. 

 AMENDMENT TO 
 Whiteglove House Call Health PARTICIPATION AGREEMENT 
 WHEREAS Humana Insurance Company,
Employers Health Insurance Company and their affiliates (hereinafter referred to as “HUMANA”) and the Whiteglove House Call, Inc. (hereinafter referred to as “Provider”) entered into an Agreement signed effective as of
May 1, 2008 after referred to as “Agreement”) 
 WHEREAS, the Parties thereto have mutually agreed to amend said Agreement,
regarding compensation for Services to Humana Advantage Network and Medicare PPO Network members for outpatient services. Said Amendment shall be effective May 1, 2008. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and
agreed by and between the Parties hereto that the following is to amend Attachment C as it pertains to commercial PPO and indemnity: 

Attachment B: (B) Humana Advantage Network and (C) Medicare PPO Network will be amended to read the following: 

Group agrees to accept as payment in full from Payors for Covered Services rendered to Members, the percentage defined below of ChoiceCare’s (
079-787 ) fee schedule, or Group’s billed charges, whichever is less, less any Co-payments due from Members. All payments due from ChoiceCare will be reduced by any deductibles or co-payments due from Member. 

Reimbursements broken down by code ranges and percentage payable for the above listed plans indicating (079-787) fee schedule: 

 

	 	•	 	 Evaluation and Management Services (Codes 99201 to 99499): All covered services for evaluation and management services will be reimbursed [****]. CPT
Code 99214 will be reimbursed at [****]. CPT Code 99212 which will be [****]. 

  

	 	•	 	 Surgery Services (Codes 10021 to 11471 and 11720 to 11765): CPT Code 10060 will be [****]. All other covered services for surgery services will be
reimbursed at [****]. 

  

	 	•	 	 Surgery Services (Codes 11600 to 11719 and 11770 to 69990): CPT code 11740 and 69210 will be [****]. All other covered services for surgery services
will be reimbursed [****]. 

  

	 	•	 	 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services (Codes 70010 to 79999): All covered services for radiology services will be
reimbursed at [****]. 

  

	 	•	 	 Pathology and Laboratory Services (Codes 80048 to 89399): ChoiceCare’s STAT pathology and laboratory codes are fixed at [****]. ChoiceCare’s
STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, 87880. CPT Code 36415 when appropriate will be paid at [****].
All covered services for pathology and laboratory will be reimbursed at [****]. 

  

	 	•	 	 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to
99199 and 99500 to 99600): CPT . Code 90772 and 92230 will be reimbursed at [****]. All other covered services for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

	 	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508 and 97001 to
97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

  

	 	•	 	 HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes, will be reimbursed at [****]. 

 

	 	•	 	 Drugs, Immunizations, Vaccines and Injectables: ChoiceCare’s (201-544) fee schedule will be utilized for reimbursement for drugs, immunizations or
injectables. These drugs and/or immunizations will be reimbursed at [****]. 

 Group agrees that in the event that Group
employs, subcontracts or independently contracts with or uses the services of a physician extender (that is, a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, certified
surgical assistant, certified registered nurse first assistant or such other similarly situated individual) who will be providing services to Members under the supervision of Group, Group shall notify ChoiceCare in writing, upon execution of this
Agreement and at any time during the term of this Agreement when such physician extenders are employed, subcontracted or independently contracted with Group, and the specific services that such physician extenders will be performing, prior to the
provision of services to any Member. Group represents that physician extenders employed by or under contract with Group will comply with the terms and condition of this Agreement, maintain professional liability coverage and are appropriately
licensed as required by applicable state and federal laws, rules and regulations. Group acknowledges and agrees ChoiceCare retains the right to approve, suspend and/or terminate participation under this Agreement of any physician extender who will
be providing services to Members. Payor, in its sole discretion, may reimburse Group for services of such physician extenders rendered to Members covered under Plans offered by Payors with access to ChoiceCare Network and not otherwise specified in
paragraphs B and/or C below, [****], whichever is less, less any Co-payments due from Member. 
 Except as specifically amended hereby, the
terms and conditions of this agreement remain the same. 
 IN WITNESS WHEREOF, the undersigned have executed this Amendment effective
May 1, 2008. 

 

			
	 Provider

			
		
	 By:
	 	  

			
		
	 Printed Name:
	 	  

			
		
	 Title:
	 	  

			
		
	 Date:
	 	
 

			
	HUMANA

			
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
	
	Title: V.P. Network Management

			
		
	Date:	 	  

 

  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 CHOICECARE AMENDMENT TO 

Whiteglove House Call Health, Inc PARTICIPATION AGREEMENT 
 WHEREAS Humana Insurance Company, Employers Health Insurance Company and their affiliates (hereinafter referred to as “HUMANA”) and the Whiteglove House Call Health, Inc. (hereinafter referred
to as “Group”) entered into an Agreement signed effective as of May 1, 2008 after referred to as “Agreement”) 

WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, regarding compensation for Covered Services for the ChoiceCare Network Members
for covered services. Said Amendment shall be effective September 15, 2008. 
 NOW THEREFORE, in consideration of the promises and mutual
covenants herein contained and other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend Attachment B as it pertains to
commercial PPO and Indemnity: 
 Attachment B: (A) ChoiceCare Network will be amended to read the following: 

A. CHOICECARE NETWORK REIMBURSEMENT 
 Group
agrees to accept as payment in full from Payors for Covered Services rendered to Members, the percentage defined below of ChoiceCare’s ( 079-787) fee schedule, or Group’s billed charges, whichever is less, less any Co-payments due from
Members. All payments due from ChoiceCare will be reduced by any deductibles or co-payments due from Member. 
 Reimbursements broken down by
code ranges and percentage payable for the above listed plans indicating (079-787) fee schedule: 
  

	 	•	 	 Evaluation and Management Services (Codes 99201 to 99499): All covered services for evaluation and management services will be reimbursed zero with the
exception of 99214 and 99212. CPT Code 99214 will be reimbursed [****]. CPT Code 99212 which will be [****]. 

  

	 	•	 	 Surgery Services (Codes 10021 to 11471): CPT Code 10060, 10120, 11100, will be reimbursed at [****]. All other covered services for surgery services
will be reimbursed [****]. 

  

	 	•	 	 Surgery Services (Codes 11600 to 11719 and 11770 to 69990): CPT code 11730, 11740, 11750,12001, 12002, 12004, 12011, 12013, 12014, 12031, 12032, 12034,
12041, 12042, 12044, 12051, 12052, 12053, 16020, 16025,16030, 17100, 29505, 29515, 29125, 29105, 29130, 30901, 65205, 65220, and 69210 will be reimbursed at [****]. All other covered services for surgery services will be reimbursed at [****]

  

	 	•	 	 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services (Codes 70010 to 79999): All covered services for radiology services will be
reimbursed at[****]. 

  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

	 	•	 	 Pathology and Laboratory Services (Codes 80048 to 89399): ChoiceCare’s STAT pathology and laboratory codes are fixed at [****]. ChoiceCare’s
STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014. 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, and 87880. CPT Code 36415 when appropriate will be paid at
[****]. CPT Codes 82962, 86627, 87804, and 86308, will be paid at [****]. All other covered services for pathology and laboratory will be reimbursed at [****]. 

 

	 	•	 	 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to
99199 and 99500 to 99600): CPT Codes 90772, 92230, 93000, 94640, and 94664 will be reimbursed at [****] schedule. All other covered services for medicine services, excluding anesthesiology, will be reimbursed at [****] of 2006 Medicare RBRVS.

  

	 	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508 and 97001 to
97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

  

	 	•	 	 HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes, will be reimbursed at [****]. 

 

	 	•	 	 CPT CODE 99070 CPT CODE 99070 will be paid [****], which is [****]. Humana reserves the right to audit to insure accuracy.

  

	 	•	 	 Drugs, Immunizations, Vaccines and Injectables: ChoiceCare’s (201-544) fee schedule will be utilized for reimbursement for drugs, immunizations or
injectables. These drugs and/or immunizations will be reimbursed at [****] of ChoiceCare’s (201-544) fee schedule. 

Group agrees that in the event that Group employs, subcontracts or independently contracts with or uses the services of a physician extender (that is, a
physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, certified surgical assistant, certified registered nurse first assistant or such other similarly situated individual) who
will be providing services to Members under the supervision of Group, Group shall notify ChoiceCare in writing, upon execution of this Agreement and at any time during the term of this Agreement when such physician extenders are employed,
subcontracted or independently contracted with Group, and the specific services that such physician extenders will be performing, prior to the provision of services to any Member. Group represents that physician extenders employed by or under
contract with Group will comply with the terms and condition of this Agreement, maintain professional liability coverage and are appropriately licensed as required by applicable state and federal laws, rules and regulations. Group acknowledges and
agrees ChoiceCare retains the right to approve, suspend and/or terminate participation under this Agreement of any physician extender who will be providing services to Members. Payor, in its sole discretion, may reimburse Group for services of such
physician extenders rendered to Members covered under Plans offered by Payors with access to ChoiceCare Network and not otherwise specified in paragraphs B and/or C below, one hundred percent (100%) of ChoiceCare’s (079-787) Fee Schedule
or Group’s billed charges, whichever is less, less any Co-payments due from Member. 
 Except as specifically amended hereby, the terms and
conditions of this agreement remain the same. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 IN WITNESS WHEREOF, the undersigned have executed this Amendment effective September 15, 2008.

 

			
	Provider
		
	By:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

		
	Date:	 	
 

			
	HUMANA
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
		
	Title:	 	V.P. Network Management
		
	Date:	 	
 

 

 HUMANA AMENDMENT TO 

WHITEGLOVE HOUSE CALL HEALTH, Inc. PHYSICIAN AGREEMENT 
 WHEREAS Humana Health Care Plans of Austin, Inc., PCA Health Plans of Texas, Inc., and their affiliates (hereinafter referred to as “HUMANA”) and Whiteglove House Call Health, Inc. (hereinafter
referred to as “GROUP”) entered into an Agreement effective as of May 1, 2008 (hereinafter referred to as “Agreement”) 

WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards for the Humana Commercial HMO, ASO and POS members for covered
services. Said Amendment shall be effective September 15, 2008. 
 NOW THEREFORE, in consideration of the promises and mutual covenants
herein contained and other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend Reimbursement Attachment as it pertains to
Commercial HMO, ASO and POS: 
 REIMBURSEMENT Commercial HMO Plan(s) 
 Physician agrees to accept as payment in full from Humana for Covered Services rendered to Members of commercial HMO plan(s) covered by this Agreement, [****] below of Humana’s (079-787) fee
schedule, or Physician’s billed charges, whichever is less, less any Co-payments due from Members. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule,
Physician agrees to accept as payment in full from Humana, [****] Humana’s (201-544) fee schedule or Physician’s billed charges, whichever is less, less any Co-payments due from Members for vaccines, drugs and injectables. 

For services of a physician extender, Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for
Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] as defined below of Humana’s (079-787) fee schedule or Physician’s billed charges, whichever is less, less any Co-payments due from Member. For
any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule, Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for
such Covered Services, [****], less any Co-payments due from Member. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial EPO ASO and POS Plan(s) 
 Physician agrees to accept as payment in full from Humana for Covered Services rendered to Members of commercial EPO plan(s) covered by this Agreement. the percentage defined below of Humana’s
(079-787) fee schedule, or Physician’s billed charges, whichever is less, less any Co-payments due from Members. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s
(079/787) fee schedule, Physician agrees to accept as payment in full from Humana, [****] of Humana’s (201-544) fee schedule or Physician’s billed charges, whichever is less, less any Copayments due from Members. 

For services of a physician extender, Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for
Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] as defined below of Humana’s (079-787) fee schedule or Physician’s billed charges, whichever is less, less any Co-payments due from Member. For
any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule, Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for
such Covered Services, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from Member. 
 Traditional
Plan(s) 
 Physician agrees to accept as payment in full from Humana for Covered Services rendered to Members of traditional plan(s) covered by
this Agreement, [****], or Physician’s billed charges, whichever is less, less any Co- payments due from Members. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s
(079/787) fee schedule, Physician agrees to accept as payment in full from Humana, [****] schedule or Physician’s billed charges, whichever is less, less any Co-payments due from Members. 

For services of a physician extender, Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for
Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] reimbursement break down as defined below of Humana’s (079-787) fee schedule or Physician’s billed charges, whichever is less, less any
Co-payments due from Member. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule, Physician agrees and shall require the physician extender to agree to accept as
payment in full from Humana for such Covered Services, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from Member. 
 Reimbursement break down by code range and percentage payable: 
 Evaluation and Management
Services (Codes 99201 to 99499): All covered services for evaluation and management services will be reimbursed at [****] with the exception of 99214 and 99212. CPT Code 99214 will be reimbursed at [****]. CPT Code 99212 will be reimbursed [****].

  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Surgery Services (Codes 10021 to 11471 and 11720 to 11765): CPT Code 10060, 10120. 11100 will be reimbursed
at [****]. All other covered services for surgery services will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule. 
 Surgery
Services (Codes.11600 to 11719 and 11770 to 69990): CPT Code, 11730, 11740,11750, 12001, 12002, 12004, 12011, 12013, 12014, 12031, 12032, 12034, 12041, 12042, 12044, 12051, 12052, 12053, 16020, 16025,16030, 17100 29505, 29515, 29125, 29105, 29130,
30901, 65205, 65220, and 69210 will be reimbursed at [****] of the fixed 2006 RBRVS. All other covered services for surgery services will be reimbursed at [****] 
 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services (Codes 70010 to 79999): ): All covered services for radiology services will be reimbursed at [****]. 

Pathology and Laboratory Services (Codes 80048 to 89399): Humana STAT pathology and laboratory codes will be reimbursed at [****]. Humana STAT laboratory
codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, and 87880. CPT code 36415 when appropriate will be paid at [****]. CPT Codes
82962, 86627, 87804, 86308, will be paid at [****] allowable. All other codes will be reimbursed at [****]. 
 Medicine Services (except
Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to 99199 and 99500 to 99600): CPT code 90772, 92230, 93000, 94640, and 94664 will be reimbursed at [****]. All other covered
services for medicine services, excluding anesthesiology, will be reimbursed at [****] of 2006 Medicare RBRVS. Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508
and 97001 to 97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes will be reimbursed at [****]. 

Drugs, Immunizations, Vaccines and Injectables: 

[****] be utilized for reimbursement for drugs, immunizations or injectables. These drugs and/or immunizations will be reimbursed at [****]. 

CPT CODE 99070: CPT Code 99070 will be reimbursed at [****] billed charges, which is intended to [****]. Humana reserves the right to audit to insure
accuracy. 
 Except as specifically amended hereby, the terms and conditions of this agreement remain the same. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 IN WITNESS WHEREOF, the undersigned have executed this Amendment effective September 15, 2008.

 

			
	Provider	  	

			
		
	By:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

		
	Date:	 	
 

			
	HUMANA

			
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
		
	Title:	 	V.P. Network Management

			
		
	Date:	 	
 

 

 AMENDMENT TO 
 Whiteglove House Call Health, Inc. PARTICIPATION AGREEMENT 
 WHEREAS Humana Insurance
Company, Employers Health Insurance Company and their affiliates (hereinafter referred to as “HUMANA”) and the Whiteglove House Call Health, Inc. (hereinafter referred to as “GROUP”) entered into an Agreement signed effective as
of May 1, 2008 after referred to as “Agreement”) 
 WHEREAS, the Parties thereto have mutually agreed to amend said Agreement,
regarding compensation for Covered Services to Humana Advantage Network and Medicare PPO Network members for outpatient services. Said Amendment shall be effective September 15, 2008. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and
agreed by and between the Parties hereto that the following is to amend Attachment B, (B) Humana Advantage Network and (C)Medicare PPO Network as it pertains to: 
 Attachment B: (B) Humana Advantage Network and (C) Medicare PPO Network will be amended to read the following: 
 Group agrees to accept as payment in full from Payors for Covered Services rendered to Members, the percentage defined below of ChoiceCare’s ( 079-787 ) fee schedule, or Group’s billed charges,
whichever is less, less any Co-payments due from Members. All payments due from ChoiceCare will be reduced by any deductibles or co-payments due from Member. 
 Reimbursements broken down by code ranges and percentage payable for the above listed plans indicating (079-787) fee schedule: 

 

	 	•	 	 Evaluation and Management Services (Codes 99201 to 99499): All covered services for evaluation and management services will be reimbursed zero with the
exception of 99214 and 99212. CPT Code 99214 will be reimbursed at [****]. CPT Code 99212 which will be [****]. 

  

	 	•	 	 Surgery Services (Codes 10021 to 11471): CPT Code 10060, 10120, 11100, will be reimbursed at [****]. All other covered services for surgery services
will be reimbursed at [****]. 

  

	 	•	 	 Surgery Services (Codes 11600 to 11719 and 11770 to 69990): CPT code 11730, 11740, 11750,12001, 12002. 12004, 12011, 12013, 12014, 12031, 12032, 12034,
12041, 12042, 12044, 12051, 12052, 12053, 16020, 16025,16030, 17100, 29505, 29515, 29125, 29105, 29130, 30901, 65205, 65220, and 69210 will be reimbursed at [****]. All other covered services for surgery services will be reimbursed at [****].

  

	 	•	 	 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services (Codes 70010 to 79999): All covered services for radiology services will be
reimbursed at [****]. 

  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

	 	•	 	 Pathology and Laboratory Services (Codes 80048 to 89399): ChoiceCare’s STAT pathology and laboratory codes are fixed at [****] schedule.
ChoiceCare’s STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, and 87880. CPT Code 36415 when appropriate
will be paid at [****]. CPT Codes 82962, 86627, 87804, and 86308, will be paid at [****] allowable. All other covered services for pathology and laboratory will be reimbursed at [****]. 

 

	 	•	 	 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to
99199 and 99500 to 99600): CPT Codes 90772, 92230, 93000, 94640, and 94664 will be reimbursed at [****]. All other covered services for medicine services, excluding anesthesiology, will be reimbursed [****]. 

 

	 	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508 and 97001 to
97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed [****]. 

  

	 	•	 	 HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes, will be reimbursed at [****]. 

 

	 	•	 	 CPT CODE 99070 CPT CODE 99070 will [****], which is intended to [****]. Humana reserves the right to audit to insure accuracy.

  

	 	•	 	 Drugs, Immunizations, Vaccines and Injectables: ChoiceCare’s (201-544) fee schedule will be utilized for reimbursement for drugs, immunizations or
injectables. These drugs and/or immunizations will be reimbursed at [****]. 

 Group agrees that in the event that Group
employs, subcontracts or independently contracts with or uses the services of a physician extender (that is, a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, certified
surgical assistant, certified registered nurse first assistant or such other similarly situated individual) who will be providing services to Members under the supervision of Group, Group shall notify ChoiceCare in writing, upon execution of this
Agreement and at any time during the term of this Agreement when such physician extenders are employed, subcontracted or independently contracted with Group, and the specific services that such physician extenders will be performing, prior to the
provision of services to any Member. Group represents that physician extenders employed by or under contract with Group will comply with the terms and condition of this Agreement, maintain professional liability coverage and are appropriately
licensed as required by applicable state and federal laws, rules and regulations. Group acknowledges and agrees ChoiceCare retains the right to approve, suspend and/or terminate participation under this Agreement of any physician extender who will
be providing services to Members. Payor, in its sole discretion, may reimburse Group for services of such physician extenders rendered to Members covered under Plans offered by Payors with access to ChoiceCare Network and not otherwise specified in
paragraphs B and/or C below, [****] of ChoiceCare’s (079-787) Fee Schedule or Group’s billed charges, whichever is less, less any Co-payments due from Member. 
 Except as specifically amended hereby, the terms and conditions of this agreement remain the same. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 

			
	Provider	 	

			
		
	By:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

			
		
	Date:	 	
 

			
	HUMANA	 	

			
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
		
	Title:	 	V.P. Network Management

			
		
	Date:	 	
 

 

 CHOICECARE AMENDMENT TO 

Whiteglove House Call Health, Inc PARTICIPATION AGREEMENT 
 WHEREAS Humana Insurance Company, Employers Health Insurance Company and their affiliates (hereinafter referred to as “HUMANA”) and the Whiteglove House Call Health. Inc. (hereinafter referred
to as “Group”) entered into an Agreement signed effective as of May 1, 2008 after referred to as “Agreement”) 
 WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, regarding compensation for Covered Services for the ChoiceCare Network Members for covered services. Said Amendment shall be
effective March 1, 2009. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and other good valuable
consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend Attachment B as it pertains to commercial PPO and indemnity: Attachment B:
(A) ChoiceCare Network will be amended to read the following: 
 A. CHOICECARE NETWORK REIMBURSEMENT 

Group agrees to accept as payment in full from Payors for Covered Services rendered to Members, the percentage defined below of
ChoiceCare’s ( 079-787 ) fee schedule, or Group’s billed charges, whichever is less, less any Co-payments due from Members. All payments from ChoiceCare will be reduced by any deductibles or co-payments due from
Member. 
 Reimbursements broken down by code ranges and percentage payable for the above listed plans indicating (079-787) fee schedule:

  

	 	•	 	 Evaluation and Management Services (Codes 99201 to 99499): ALl covered services for evaluation and management services will be reimbursed zero
with the exception of 99214, 99215, and 99212. CPT Code 99214 will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule. CPT Code 99215 will be reimbursed at [****]. CPT Code 99212 which will be [****]. 

 

	 	•	 	 Surgery Services (Codes 10021 to 11471): CPT Code 10060, 10120, 11100, will be reimbursed at[****]. All other covered services for surgery
services will be reimbursed at [****]. 

  

	 	•	 	 Surgery Services (Codes 11600 to 11719 and 11770 to 69990): CPT code 11730, 11740, 11750, 12001, 12002, 12004, 12011, 12013, 12014, 12031,
12032, 12034, 12041, 12042, 12044, 12051, 12052, 12053, 16020, 16025, 16030, 17110, 29505, 20515, 29125, 29105, 29130, 30901, 65205, 65220, and 69210 will be reimbursed at [****]. All other covered services for radiology services will be reimbursed
at [****]. 

  

	 	•	 	 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services (Codes 70010 to 79999): All covered services for radiology services
will be reimbursed at [****]. 

  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

	 	•	 	 Pathology and Laboratory Services (Codes 80048 to 89399): ChoiceCare’s STAT pathology and laboratory codes are fixed at [***].
ChoiceCare’s STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, and 87880. CPT Code 36415 when appropriate
will be paid at [****]. CPT Codes 82962, 86677, 87804, and 86308, will be paid at [****]. All other covered services for pathology and laboratory will be reimbursed at [****]. 

 

	 	•	 	 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and 99000 to
99199 and 99500 to 99600): CPT Codes 90772, 92230, 93000, 94640, and 94664 will be reimbursed at [****]. All other covered services for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

 

	 	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) (Codes 92506 to 92508 and 97001 to
97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

  

	 	•	 	 HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes, will be reimbursed at [****]. 

 

	 	•	 	 CPT CODE 99070 CPT CODE 99070 will be [****]. Humana reserves the right to audit to insure accuracy. 

 

	 	•	 	 Drugs, Immunizations, Vaccines and Injectables: ChoiceCare’s (201-544) fee schedule will be utilized for reimbursement for drugs,
immunizations or injectables. These drugs and/or immunizations will be reimbursed at [****]. 

 Group agrees that in
the event that Group employs, subcontracts or independently contracts with or uses the services of a physician extender (that is, a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified
nurse midwife, certified surgical assistant, certified registered nurse first assistant or such other similarly situated individual) who will be providing services to Members under the supervision of Group, Group shall notify
ChoiceCare in writing, upon execution of this Agreement and at any time during the term of this Agreement when such physician extenders are employed, subcontracted or independently contracted with Group, and the specific services that
such physician extenders will be performing, prior to the provision of services to any Member. Group represents that physician extenders employed by or under contract with Group will comply with the terms and condition of this
Agreement, maintain professional liability coverage and are appropriately licensed as required by applicable state and federal laws, rules and regulations. Group acknowledges and agrees ChoiceCare retains the right to approve, suspend
and/or terminate participation under this Agreement of any physician extender who will be providing services to Members. Payor, in its sole discretion, may reimburse Group for services of such physician extenders rendered to Members covered
under Plans offered by Payors with access to ChoiceCare Network and not otherwise specified in paragraphs B and/or C below, [****] of ChoiceCare’s (079-787) Fee Schedule or Group’s billed charges, whichever is less, less any
Co-payments due from Member. 
 Except as specifically amended hereby, the terms and conditions of this agreement remain the same. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 

			
	Provider	 	

			
		
	By:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

			
		
	Date:	 	
 

			
	HUMANA

			
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
		
	Title:	 	V.P. Network Management

			
		
	Date:	 	
 

 

 AMENDMENT TO 
 WhiteGlove House Call Health, Inc. PARTICIPATION AGREEMENT 
 WHEREAS Humana Insurance
Company, Employers Health Insurance Company and their affiliates (hereinafter referred to as “HUMANA”) and the WhiteGlove House Call Health, Inc. (hereinafter referred to as “GROUP”) entered into an Agreement signed effective as
of May 1, 2008 and later amended effective March 1, 2009 (hereinafter referred to as “Agreement”) 

WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards to only the Humana Commercial fully insured
PPO members for covered services. Said Amendment shall be effective February 1st 2011. 
 NOW THEREFORE, in
consideration of the promises and mutual covenants herein contained and other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is
to amend the Reimbursement Attachment as it pertains to Commercial fully insured PPO members in the following counties: Travis, Hays, Williamson, Comal, Bexar, Dallas, Tarrant, Denton, Collin, Rockwall, Harris. 

REIMBURSEMENT 
 HUMANA agrees to
reimburse GROUP a capitation rate each month for HUMANA’s commercial fully insured PPO members for the counties listed above per the schedule below: 
 [****] for the quarter in which the number of visits provided by GROUP does not exceed [****] during that quarter; 
 [****] for the quarter in which the, number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 

[****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter;

 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during
that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed
[****] during that quarter; 
 [****] for the quarter in within which the number of visits provided by GROUP is equal to or greater than, [****]
but does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater
than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the, number of visits provided by GROUP is equal
to or greater than [****] but does not exceed [****] during that quarter. 
 In the event visits exceed [****] visits per quarter, the per
member per month capitation rate shall increase by [****] for each incremental increase of [****] visits per quarter in the same pattern as the rates outlined above. 
 DEFINITIONS 
 Quarterly shall be defined as January through March, April through
June, July through September and October through December. 
 Encounters shall be defined as a visit which will include an E&M coding
plus any other coded services provided during the member visit. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 CAPITATION RATE ADJUSTMENT 
 The GROUP will provide to HUMANA at the end of each quarter the total number of visits it has performed for HUMANA’s Commercial fully insured PPO members in that quarter. For each quarter, HUMANA
will supply the GROUP with the number of visits as previously submitted by the GROUP for reconciliation. HUMANA and GROUP shall review and mutually agree to the number of visits performed by GROUP within the quarter, fifteen (15) days after the
close of each quarter. In the event that the capitation rate for any quarter requires adjustment, the rates will be adjusted for the next quarter based on the total number of visits actually performed. 

REIMBURSEMENT CALCULATION AND BILLING 

HUMANA will provide to GROUP the actual number of Commercial fully insured PPO members for every month in the counties listed above no later than the 15th
of the month just past commencing February 15, 2011. GROUP will invoice HUMANA every month based on the then current quarterly pm/pm times actual membership count. The monthly capitation check shall be paid by HUMANA by the 15th of the
following month, from which the services are rendered. 
 RETROACTIVE ADJUSTMENTS FOR CAPITATION PAYMENTS: 

Payments to GROUP shall not be subject to retroactive adjustments resulting from additions and deletions of HUMANA’s Commercial fully insured PPO
Plan Members. 
 ENCOUNTER DATA 

GROUP agrees to provide to HUMANA accurate and complete information regarding the provision of Covered Services by GROUP to Members
(“Data”) on a complete CMS 1500 or UB 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by law when submitting encounters in an electronic format, or such
other format as is mutually agreed upon by both parties. The Data shall be provided to HUMANA on or before the last day of each month for encounters occurring in the immediately preceding month, or such lesser period of time as may be
required in the Agreement, or as is otherwise agreed upon by the parties in writing. In the event the Data is not submitted to HUMANA by the date and in the form specified above, HUMANA may, in its sole option, withhold any increase to
the payment otherwise required to be made under the terms of the Agreement until the Data is submitted to HUMANA. 
 TERMINATION

 Either party may terminate the Agreement with a six (6) months written notice and shall not affect either parties’ obligations
that contractually survive. 
 Except as specifically amended hereby, the terms and conditions of this agreement remain the same. 

 I 

 

			
	Provider	 	

			
		
	By:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

			
		
	Date:	 	
 

			
	HUMANA	 	

			
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
		
	Title:	 	V.P. Network Management

			
		
	Date:	 	
 

 

 HUMANA AMENDMENT TO 

WHITEGLOVE HOUSE CALL HEALTH, Inc. PHYSICIAN AGREEMENT 
 WHEREAS Humana Health Care Plans of Austin, Inc., PCA Health Plans of Texas, Inc., and their affiliates (hereinafter referred to as “HUMANA”) and WhiteGlove House Call Health, Inc.
(hereinafter referred to as “GROUP”) entered into an Agreement effective as of May 1, 2008 and later amended effective March 1, 2009 (hereinafter referred to as “Agreement”). 

WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards to only the Humana Commercial fully insured
HMO and POS members for covered services. Said Amendment shall be effective February 1st 2011. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and
other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend the Reimbursement Attachment as it pertains to Commercial fully
insured HMO and POS members in the following counties: Travis, Hays, Williamson, Comal, Bexar, Dallas, Tarrant, Denton, Collin, Rockwall, Harris. 
 REIMBURSEMENT 
 HUMANA agrees to reimburse GROUP a capitation rate each month for
HUMANA’s commercial fully insured HMO and POS members for the counties listed above per the schedule below: 
 [****] for the quarter in
which the number of visits provided by GROUP does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits
provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the
number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter
in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for
the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 

[****] for the quarter in within which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that
quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****]
during that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not
exceed [****] during that quarter. 
 In the event visits exceed [****] visits per quarter, the per member per month capitation rate shall
increase by [****] for each incremental increase of [****] visits per quarter in the same pattern as the rates outlined above. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 DEFINITIONS 
 Quarterly shall be defined as January through March, April through June, July through September and October through December. 
 Encounters shall be defined as a visit which will include an E&M coding plus any other coded services provided during the member visit. 
 CAPITATION RATE ADJUSTMENT 
 The GROUP will provide to HUMANA at the end of each quarter the
total number of visits it has performed for HUMANA’s Commercial fully insured HMO and POS members in that quarter. For each quarter, HUMANA will supply the GROUP with the number of visits as previously submitted by the GROUP for reconciliation.
HUMANA and GROUP shall review and mutually agree to the number of visits performed by GROUP within the quarter, fifteen (15) days after the close of each quarter. In the event that the capitation rate for any quarter requires adjustment, the
rates will be adjusted for the next quarter based on the total number of visits actually performed. 
 REIMBURSEMENT CALCULATION AND BILLING

 HUMANA will provide to GROUP the actual number of Commercial fully insured HMO AND POS members for every month in the counties listed
above no later than the 15th of the month just past commencing February 15, 2011. GROUP will invoice HUMANA every month based on the then current quarterly pm/pm times actual membership count. The monthly capitation check shall be paid by
HUMANA by the 15th of the following month, from which the services are rendered. 
 RETROACTIVE ADJUSTMENTS FOR CAPITATION PAYMENTS:

 Payments to GROUP shall not be subject to retroactive adjustments resulting from. additions and deletions of HUMANA’s Commercial
fully insured HMO and POS Plan Members. 
 ENCOUNTER DATA 
 GROUP agrees to provide to HUMANA accurate and complete information regarding the provision of Covered Services by GROUP to Members (“Data”) on a complete CMS 1500 or
UB 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by law when submitting encounters in an electronic format, or such other format as is mutually agreed upon by both parties. The Data
shall be provided to HUMANA on or before the last day of each month for encounters occurring in the immediately preceding month, or such lesser period of time as may be required in the Agreement, or as is otherwise agreed upon by the parties
in writing. In the event the Data is not submitted to HUMANA by the date and in the form specified above, HUMANA may, in its sole option, withhold any increase to the payment otherwise required to be made under the terms of the
Agreement until the Data is submitted to HUMANA. 
 TERMINATION 
 Either party may terminate the Agreement with a six (6) months written notice and shall not affect either parties’ obligations that contractually survive. 

 Except as specifically amended hereby, the terms and conditions of this agreement remain the same.

 

			
	Provider

			
		
	By:	 	  

			
		
	Printed Name:	 	  

			
		
	Title:	 	  

			
		
	Date:	 	
 

			
	HUMANA

			
		
	By:	 	  

			
		
	Printed Name:	 	Donnie Hromadka

			
		
	Title:	 	V.P. Network Management

			
		
	Date:	 	
 

 

 AMENDMENT TO 
 WhiteGlove House Call Health, Inc. PARTICIPATION AGREEMENT 
 WHEREAS Humana Insurance
Company, Employers Health Insurance Company and their affiliates (hereinafter referred to as “HUMANA”) and the WhiteGlove House Call Health, Inc. (hereinafter referred to as “GROUP”) entered into an Agreement signed
effective as of May 1, 2008 and later amended effective March 1, 2009, and later amended effective February 1, 2011 (hereinafter referred to as “Agreement”) 
 WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards to only the Humana Commercial fully insured PPO members for covered services. Said Amendment shall be effective
February 8, 2011. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and other good valuable
consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and, between the Parties hereto that the following is to amend the Reimbursement Attachment as it pertains to Commercial fully insured PPO members
in the following counties: Travis, Hays, Williamson, Comal, Bexar, Dallas, Tarrant, Denton, Collin, Rockwall, Harris. 
 REIMBURSEMENT

 HUMANA agrees to reimburse GROUP a capitation rate (“Caption Rate”) each month for HUMANA’s commercial fully insured PPO
members for the counties listed above per the schedule below: 
 [****] for the quarter in which the number of visits provided by GROUP
does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to
or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of
visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for
the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 

[****] for the quarter in within which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed
[****] during that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than
[****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits provided by
GROUP is equal to or greater than [****] but does not exceed [****] during that quarter. 
 In the event visits exceed
[****] visits per quarter, the per member per month capitation rate shall increase by [****] for each incremental increase of [****] visits per quarter in the same pattern as the rates outlined above. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 DEFINITIONS 
 Quarterly shall be defined as January through March, April through June, July through September and October through December. 
 Encounters shall be defined as a visit which will include an E&M coding plus any other coded services provided during the member visit. 
 CAPITATION RATE ADJUSTMENT 
 The GROUP will provide to HUMANA at the end of each quarter the
total number of visits it has performed for HUMANA’s Commercial fully insured PPO members in that quarter. For each quarter, HUMANA will supply the GROUP with the number of visits as previously submitted by the GROUP for reconciliation. HUMANA
and GROUP shall review and mutually agree to the number of visits performed by GROUP within the quarter, fifteen (15) days after the close of each quarter. In the event that the capitation rate for any quarter requires adjustment, the rates
will be adjusted for the next quarter based on the total number of visits actually performed. 
 REIMBURSEMENT CALCULATION AND BILLING

 HUMANA will provide to GROUP the actual number of Commercial fully insured PPO members for every month in the counties
listed above no later than the 15th of the month just past commencing February 15, 2011. GROUP will invoice HUMANA every month based on the then current quarterly pm/pm times actual membership count. The monthly capitation check shall be paid
by HUMANA by the 15th of the following month, from which
the services are rendered. 
 At the end of each quarter, new Capitalization Rates will be calculated based on the [****] (the combination of
the HMO and PPO membership will equal the total number of members used in the following formula. The total number of members will result in one single payment for both the HMO and PPO contract Amendments. There will not be separate calculations by
product type) at the end of the quarter using the following formula: [****]. 
 RETROACTIVE ADJUSTMENTS FOR CAPITATION PAYMENTS:

 Payments to. GROUP shall not be subject to retroactive adjustments resulting from additions and deletions of HUMANA’s Commercial
fully insured PPO Plan Members. 
 ENCOUNTER DATA 
 GROUP agrees to provide to HUMANA accurate and complete information regarding the provision of Covered Services by GROUP to Members (“Data”) on a complete CMS 1500 or
US 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by law when submitting encounters in an electronic format, or such other format as is mutually agreed upon by both
parties. The Data shall be provided to HUMANA on or before the last day of each month for encounters occurring in the immediately preceding month, or such lesser period of time as may be required in the Agreement, or as is otherwise agreed
upon by the parties in writing. In the event the Data is not submitted to HUMANA by the date and in the form specified above, HUMANA may, in its sole option, withhold any increase to the payment otherwise required to be made under the
terms of the Agreement until the Data is submitted to HUMANA. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions.Physician Participation Agreement

 Exhibit 10.19 

 

			
		  	[****]        Certain information on this page has been omitted and filed separately with the
Commission. Confidential treatment has been requested with respect to the omitted portions.

 PHYSICIAN
PARTICIPATION AGREEMENT 
 COVER SHEET 

 

	
	General
Information
	 Physician or Medical Group Name as applicable: Whiteglove House
Call Health, Inc.
  

	 Federal Tax ID Number: 208913558
  

	 Physician UPIN(s):
  

 

	
	Service
Address
	 Service Address: 515 Capital of Texas Hwy, Suite
225
  

	 City:
Austin
  

	 State: Texas

 

	 Zip: 78746

 

	 Contact Person Name: Robert Fabbio

 

	 Email Address:
bfabbio@housecallhealth.com
  

	 Telephone Number: 512-329-8081

 

	 Facsimile (FAX) Number: 512-233-2808
  

	 County: Travis
  

 

	
	Billing Address
	 Billing Address: 515
Capital of Texas Hwy, Suite 225
  

	 City: Austin

 

	 State:
Texas
  

	 Zip: 78746

 

	 Contact Person Name:
Robert Fabbio
  

	 Email Address: bfabbio@housecallhealth.com

 

	 Telephone Number: 512-329-8081
  

	 Facsimile (FAX) Number: 512-233-2808
  

 

	
	For Humana Use
Only
	  
 Nomination     ̈  Yes        
 ̈  No

 PHYSICIAN PARTICIPATION AGREEMENT 

This Physician Participation Agreement (“Agreement”) is made and entered into by and between the party named on the signature page below
(hereinafter referred to as “Physician”) and Humana Insurance Company, Humana Health Plan of Texas, Inc., and their affiliates that underwrite or administer health plans (hereinafter referred to as “Humana”).

  

	1.	RELATIONSHIP OF THE PARTIES 

  

	1.1	In performance of their respective duties and obligations hereunder, Humana and Physician, and Physician’s respective employees and agents,
are at all times acting and performing as independent contractors, and neither party, nor their respective employees and agents, shall be considered the partner, agent, servant, employee of, or joint venturer with, the other party. Unless otherwise
agreed to herein, the parties acknowledge and agree that neither Physician nor Humana will be liable for the activities of the other nor the agents and employees of the other, including but not limited to, any liabilities, losses,
damages, suits, actions, fines, penalties, claims or demands of any kind or nature by or on behalf of any person, party or governmental authority arising out of or in connection with: (i) any failure to perform any of the agreements, terms,
covenants or conditions of this Agreement; (ii) any negligent act or omission or other misconduct; (iii) the failure to comply with any applicable laws, rules or regulations; or (iv) any accident, injury or damage to persons or
property. Notwithstanding anything to the contrary contained herein, Physician further agrees to and hereby does indemnify, defend and hold harmless Humana from any and all claims, judgments, costs, liabilities, damages and expenses
whatsoever, including reasonable attorneys’ fees, arising from any acts or omissions in the provision by Physician of medical services to Members. This provision shall survive termination or expiration of this Agreement.

  

	1.2	The parties agree that Humana’s affiliates whose Members receive services hereunder do not assume joint responsibility or liability between or among such
affiliates for the acts or omissions of such other affiliates. 

  

	2.	SERVICES TO MEMBERS 

  

	2.1	Subject at all times to the terms of this Agreement, Physician agrees to provide or arrange for medical and related health care services to individuals
designated by Humana (herein referred to as “Members”) with an identification card or other means of identifying them as Members covered under a self-funded or fully insured health benefits plan to which Physician has
agreed to participate as set forth in the product participation list attachment. 

  

	2.2	Physician agrees to provide Physician’s services to individuals covered under other third party payors’ (hereinafter referred to as
“Payor” or “Payors”) health benefits contracts (hereinafter referred to as “Plan” or “Plans”) and agrees to comply with such Payors’ policies and procedures. For Covered
Services rendered to such individuals, Physician acknowledges and agrees that all rights and responsibilities arising with respect to benefits to such individuals shall be subject to the terms of the Payor Plan covering such individuals.
Individuals covered under such Plans will have an identification card as a means of identifying the Payor Plan which provides coverage. Such identification cards will display the Humana logo and/or name. 

  
 -2-

	2.3	For Covered Services provided to those individuals identified in Section 2.2 above, Payor will make payments for Covered Services directly to Physician in
accordance with the terms and conditions of this Agreement and the rates set forth in the payment attachment applicable to the Plan type of such individual. Physician agrees that in no event, including, but not limited to, nonpayment by
Payor, or Payor’s insolvency, shall Physician bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Humana for services provided by Physician to
Plans’ members. This provision shall not prohibit collection by Physician from Plans’ members for non-covered services and/or member cost share amounts in accordance with the terms of the applicable member Plan. Payors Plans will
provide appropriate steerage mechanisms including benefit designs and/or physician directory and web site listings to ensure their covered individuals will have incentives to utilize Physician’s services. All obligations of
Physician under this Agreement with respect to Humana’s Members shall equally apply to the individuals identified in Section 2.2 above. 

 

	3.	THIRD PARTY BENEFICIARIES 

  

	3.1	Except as is otherwise specifically provided in this Agreement, the parties have not created and do not intend to create by this Agreement any rights in other parties
as third party beneficiaries of this Agreement, including, without limitation, Members. 

  

	4.	SCOPE OF AGREEMENT 

  

	4.1	This Agreement sets forth the rights, responsibilities, terms and conditions governing: (i) the status of Physician and Physician’s employees,
subcontractors and/or independent contractors as health care providers (hereinafter referred to as “Participating Providers”) providing health care services; and (ii) Physician’s provision of professional medical
services (hereinafter referred to as “Physician Services”) to Members. All terms and conditions of this Agreement which are applicable to “Physician” are equally applicable to each Participating Provider, unless the
context requires otherwise. 

  

	4.2	Physician represents and warrants that it is authorized to negotiate terms and conditions of provider agreements, including this Agreement, and further to
execute such agreements for and on behalf of itself and its Participating Providers. Physician further represents and warrants that Participating Providers will abide by the terms and conditions of this Agreement, including each of
Physician’s employed, subcontracted or independently contracted physicians in the event Physician is organized and providing services hereunder as a group practice. The parties acknowledge and agree that nothing contained in this
Agreement is intended to interfere with or hinder communications between Physician and Members regarding the Members’ medical conditions or treatment options, and Physician acknowledges that all patient care and related decisions
are the sole responsibility of Physician and Humana does not dictate or control clinical decisions with respect to the medical care or treatment of Members. 

 

	4.3	Physician acknowledges and agrees that with respect to self-funded groups, unless otherwise provided herein, Humana’s responsibilities hereunder are
limited to provider network administration and/or claims processing. 

  
 -3-

	5.	SUBCONTRACTING PERFORMANCE 

  

	5.1	Physician shall provide directly, or through appropriate agreements with physicians and other licensed health care professionals and/or providers, Physician
Services for Members. It is understood and agreed that Physician shall maintain written agreements with Participating Providers, if any, in a form comparable to, and consistent with, the terms and conditions established in this Agreement.
Physician’s downstream provider agreements, if any, shall include terms and conditions which comply with all applicable requirements for provider agreements under state and federal laws, rules and regulations. In the event of a conflict
between the language of the downstream provider agreements and this Agreement, the language in this Agreement shall control. 

  

	5.2	Physician shall provide Humana an executed letter of agreement (in a form substantially similar to the form attached hereto as the letter of agreement
attachment) for each Participating Provider who is a physician and who is subcontracted or independently contracted with Physician prior to the provision of services by such Participating Provider to Members. Such Participating Providers, if
any, who do not execute a letter of agreement may not participate under this Agreement and may not be listed in Humana’s provider directories. 

 

	6.	TERM AND TERMINATION 

  

	6.1	The term of this Agreement shall commence on             , 20     (the
“Effective Date”). The initial term of this Agreement shall be for one (1) year. This Agreement shall automatically renew for subsequent one (1) year terms unless either party provides written notice of non-renewal to the
other party at least ninety (90) days prior to the end of the initial term or any subsequent renewal terms. 

  

	6.2	Notwithstanding anything to the contrary herein, either party may terminate this Agreement without cause at any time following the end of the initial term of this
Agreement by providing to the other party ninety (90) days prior written notice of termination. 

  

	6.3	Humana may terminate this Agreement, or any individual Participating Provider, immediately upon written notice to Physician, stating the cause for such
termination, in the event: (i) Physician’s, or any individual Participating Provider’s, continued participation under this Agreement may adversely affect the health, safety or welfare of any Member or brings Humana or
its health care networks into disrepute; (ii) Physician or any individual Participating Provider fails to meet Humana’s credentialing or re-credentialing criteria; (iii) Physician or any individual Participating Provider
is excluded from participation in any federal health care program; (iv) Physician or any individual Participating Provider voluntarily or involuntarily seeks protection from creditors through bankruptcy proceedings or engages in or
acquiesces to receivership or assignment of accounts for the benefit of creditors; or (v) Humana loses its authority to do business in total or as to any limited segment of business, but then only as to that segment.

  

	6.4	 In the event of a breach of this Agreement by either party, the non-breaching party may terminate this Agreement upon at least sixty (60) days
prior written notice to the breaching party, which notice shall specify in detail the nature of the alleged breach; provided, however, that if the alleged breach is susceptible to cure, the breaching party shall have thirty (30) days from the
date of receipt of notice of termination to cure such 

  
 -4-

	 	 
breach, and if such breach is cured, then the notice of termination shall be void of and of no effect. If the breach is not cured within the thirty (30) day period, then the date of
termination shall be that date set forth in the notice of termination. Notwithstanding the foregoing, any breach related to credentialing or re-credentialing, quality assurance issues or alleged breach regarding termination by Humana in the
event that Humana determines that continued participation under this Agreement may affect adversely the health, safety or welfare of any Member or bring Humana or its health care networks into disrepute, shall not be subject to cure
and shall be cause for immediate termination upon written notice to Physician. 

  

	6.5	Physician agrees that the notice, of termination or expiration of this Agreement shall not relieve Physician’s obligation to provide or arrange for
the provision of Physician Services through the effective date of termination or expiration of this Agreement. 

  

	7.	POLICIES AND PROCEDURES 

  

	7.1	Physician agrees to use best efforts with Humana’s quality assurance, quality improvement, accreditation, risk management, utilization review,
utilization management and other administrative policies and procedures established and revised by Humana from time to time and, in addition, those policies and procedures which are set forth in Humana’s Physician’s
Administration Manual, or its successor (hereinafter referred to as the “Manual”), and bulletins or other written materials that may be promulgated by Humana from time to time to supplement the Manual. The Manual and updated
policies and procedures may be issued and distributed by Humana in electronic format. Paper copies may be obtained by Physician upon written request. Revisions to such policies and procedures shall become binding upon Physician
thirty (30) days after such notice to Physician by mail or electronic means, or such other period of time as necessary for Humana to comply with any statutory, regulatory and/or accreditation requirements.

  

	8.	CREDENTIALING AND PROFESSIONAL LIABILITY INSURANCE 

  

	8.1	Participation under this Agreement by Physician and Participating Providers is subject to the satisfaction of all applicable credentialing and re-credentialing
standards established by Humana. Physician shall provide Humana, or its designee, information necessary to ensure compliance with such standards at no cost to Humana or its designee. Physician agrees to use
electronic credentialing and recredentialing processes when administratively feasible. Physician, as applicable, and all Participating Providers providing Physician Services to Humana Members shall be credentialed in accordance with
Humana’s credentialing process prior to receiving participating status with Humana. 

  

	8.2	 Physician shall maintain, at no expense to Humana, policies of comprehensive general liability, professional liability, and workers
compensation coverage as required by law, insuring Physician and Physician’s employees and agents against any claim or claims for damages arising as a result of injury to property or person, including death, occasioned directly or
indirectly in connection with the provision of Physician Services contemplated by this Agreement and/or the maintenance of Physician’s facilities and equipment. Upon request, Physician shall provide Humana with evidence of
said coverage, of which minimum professional liability coverage shall be two-hundred fifty thousand dollars ($500,000) per occurrence and seven-hundred fifty thousand dollars ($1,000,000) in the aggregate, or such greater amounts as are required by
state law. 

  
 -5-

	 	 
Physician shall provide Humana with written notice at least ten (10) days prior to any cancellations and/or modifications in the coverage. Physician shall within ten
(10) business days following service upon Physician, or such other period of time as may be required by any applicable law, rule or regulation, notify Humana in writing of any Member lawsuit alleging malpractice involving a
Member. 

  

	9.	PROVISION OF MEDICAL SERVICES 

  

	9.1	Physician shall provide Members all available medical services within the normal scope of and in accordance with Physician’s: (a) licenses and
certifications, and (b) privileges to provide certain services based upon Physician’s qualifications as determined by Humana. Physician agrees to comply with all requests for information related to
Physician’s qualifications in connection with Humana’s determination whether to extend privileges to provide certain services and/or procedures to Members. Physician shall not bill, charge, seek payment or have any
recourse against Humana or Members for any amounts related to the provision of Physician Services for which Humana has notified Physician that privileges to perform such services have not been extended. 

 

	9.2	Physician shall maintain all office medical equipment including, but not limited to, imaging, diagnostic and/or therapeutic equipment (hereinafter referred to as
“Equipment”) in acceptable working order and condition and in accordance with the Equipment manufacturer’s recommendations for scheduled service and maintenance. Such Equipment shall be located in Physician’s office
locations that promote patient and employee safety. Physician shall provide Humana or its agents with access to such Equipment for inspection and an opportunity to review all records reflecting Equipment maintenance and service
history. Such Equipment shall only be operated by qualified technicians with appropriate training and required licenses and certifications. 

  

	9.3	Equipment owned and/or operated by Physician shall comply with all standards for use of such Equipment and technician qualifications established by
Humana. Physician agrees to comply with all requests for information related to Equipment and Physician’s and/or Physician’s staff, qualifications for use of same. In the event: (i) Physician’s
Equipment fails to meet Humana’s standards; or (ii) Physician declines to comply with Humana’s standards for use of Equipment, Physician agrees that it will not use such Equipment while providing services
to Members and shall not bill, charge, seek payment or have any recourse against Humana or Members for any amounts for services with respect to such Equipment. 

 

	10.	STANDARDS OF PROFESSIONAL PRACTICE 

  

	10.1	Physician Services shall be made available to Members without discrimination on the basis of type of health benefits plan, source of payment, sex, age, race, color,
religion, national origin, health status or disability. Physician shall provide Physician Services to Members in the same manner as provided to their other patients and in accordance with prevailing practices and standards of the profession.

  

	11.	MEDICAL RECORDS 

  

	11.1	 Physician shall prepare, maintain and retain as confidential the medical records of all Members receiving Physician Services, and Members’
other personally identifiable health information received from Humana, in a form and for time periods required by 

  
 -6-

	 	 
applicable state and federal laws, licensing requirements, accreditation and reimbursement rules and regulations to which Physician is subject, and in accordance with accepted medical
practice. Physician shall obtain authorization of Members permitting Humana, and/or any state or federal agency as permitted by law, to obtain a copy and have access, upon reasonable request, to any medical record of Member related to
services provided by Physician pursuant to applicable state and federal laws. Copies of such records for the purpose of claims processing shall be made and provided by Physician at no cost to Humana or the Member.

  

	11.2	Physician and Humana agree to maintain the confidentiality of information maintained in the medical records of Members, and information obtained from
Humana through the verification of Member eligibility, as required by law. This Section 11 shall survive expiration or termination of this Agreement, regardless of the cause. 

 

	12.	GRIEVANCE AND APPEALS PROCESS/BINDING ARBITRATION 

  

	12.1	Physician shall cooperate and participate with Humana in grievance and appeals procedures to resolve disputes that may arise between Humana and its
Members for Physician Services that have been provided. 

  

	12.2	In the event of a dispute between Physician and Humana which is not resolved as set forth in Section 22 below, or which the parties cannot
settle by mutual agreement, the dispute shall be resolved by binding arbitration, conducted by a single arbitrator selected by the parties from a panel of arbitrators proposed by the American Arbitration Association (“AAA”). This
applies, without limitation, to any dispute arising out of the parties’ business relationship, including allegations or claims involving violations of state or federal laws or regulations. In the event the parties cannot agree on the
arbitrator, then the arbitrator shall be appointed by the AAA. The arbitration shall be conducted in Austin, Texas, in accordance with and subject to the Commercial Arbitration Rules of the AAA then in effect, or under such other
mutually agreed upon guidelines. Judgment upon the award rendered in any such arbitration may be entered in any court of competent jurisdiction, or application may be made to such court for judicial acceptance and enforcement of the award, as
applicable law may require or allow. The submission of any dispute to arbitration shall not adversely affect either party’s right to seek preliminary injunctive relief with respect to an actual or threatened termination, repudiation or
rescission of the Agreement. Except as expressly set forth in Section 22 below, the costs of any arbitration proceeding(s) hereunder shall be borne equally by the parties, and each party shall be responsible for its own attorneys’
fees and such other costs and expenses incurred related to the proceedings. Arbitrations hereunder shall be conducted solely between Physician and Humana; class-based arbitration shall not be permitted. The parties agree this Agreement
is a transaction involving interstate commerce and therefore that the Federal Arbitration Act, 9 U.S.C. §1 et seq. applies. 

  

	13.	USE OF PHYSICIAN’S NAME 

  

	13.1	 Humana may include the following information in any and all marketing and administrative materials published or distributed in any medium:
Physician’s name, telephone number, address, office hours, type of practice or specialty, hospital affiliation, Internet web-site address, and the names of Participating Providers, including physicians providing care at
Physician’s office, and hospital affiliation, board certification, and other education and training history, if applicable, of Participating Providers. Humana will

  
 -7-

	 	 
provide Physician with access to such information or copies of such administrative or marketing materials upon request. 

 

	13.2	Physician may advertise or utilize marketing materials, logos, trade names, service marks, or other materials created or owned by Humana after obtaining
Humana’s written consent. Physician shall not acquire any right or title in or to such materials as a result of such permissive use. Humana may advertise or utilize marketing materials, logos, trade names, service marks of other
materials created and owned by Physician after obtaining Physician’s written consent. Humana shall not acquire any right to title in or to such materials as a result of such permissive use. 

 

	13.3	Physician agrees to allow Humana to distribute a public announcement of Physician’s affiliation with Humana. 

 

	14.	PAYMENT 

  

	14.1	Physician shall accept payment from Humana for those services for which benefits are payable under a Member’s health benefits contract (hereinafter
referred to as “Covered Services”) provided to Member in accordance with the reimbursement terms in the payment attachment. Physician shall collect directly from Member any co-payment, coinsurance, or other member cost share
amounts (hereinafter referred to as “Co-payments”) applicable to the Covered Services provided and shall not waive, discount or rebate any such Co-payments. Payments made in accordance with the payment attachment less the Co-
payments owed by Members pursuant to their health benefits contracts shall be accepted by Physician as payment in full from Humana for all Covered Services. This provision shall not prohibit collection by Physician from Member
for any services not covered under the terms of the applicable Member health benefits contract. 

  

	14.2	Physician agrees that payment may not be made by Humana for services rendered to Members which are determined by Humana not to be Medically
Necessary. “Medically Necessary” (or “Medical Necessity”), unless otherwise defined in the applicable Member health benefits contract, means services or supplies provided by a licensed, certified or approved, as
applicable, hospital, physician or other health care provider to identify or treat a condition, disease, ailment, sickness or bodily injury and which, in the opinion of Humana, are: (i) consistent with the symptoms, diagnosis and
treatment of the condition, disease, ailment, sickness or bodily injury; (ii) appropriate with regard to standards of accepted medical practice; (iii) not primarily for the convenience of the patient or the hospital, physician, or other
health care provider; (iv) the most appropriate and cost-effective supply, setting, or level of service which safely can be provided to the patient; and (v) substantiated by records and documentation maintained by the provider of services.
When applied to an inpatient, it further means that the patient’s symptoms or condition requires that the services or the supplies cannot be provided safely to the patient as an outpatient. Physician agrees that in the event of a denial
of payment for Physician Services rendered to Members determined not to be Medically Necessary by Humana, that Physician shall not bill, charge, seek payment or have any recourse against Member for such services.

  

	14.3	 Physician agrees that Humana may recover overpayments made to Physician by Humana by offsetting such amounts from later
payments to Physician, including, without limitation, making retroactive adjustments to payments to Physician for errors 

  
 -8-

	 	 
and omissions relating to data entry errors and incorrectly submitted claims or incorrectly applied discounts. Humana shall provide Physician thirty (30) days advance written
notice of Humana’s intent to offset such amounts prior to deduction of any monies due. If Physician does not refund said monies or request review of the overpayments described in the notice within thirty (30) days following
receipt of notice from Humana, Humana may without further notice to Physician deduct such amounts from later payments to Physician. Humana may make retroactive adjustments to payments for a period not to exceed
eighteen (18) months from original date of payment or such other period as may be required or allowed by applicable law. 

  

	14.4	In the event Humana has access to Physician’s, or a Participating Provider’s, services through one or more other agreements or arrangements in
addition to this Agreement, Humana will determine under which agreement or arrangement payment for Covered Services will be made. 

  

	14.5	Nothing contained in this Agreement is intended by Humana to be a financial incentive or payment that directly or indirectly acts as an inducement for
Physician to limit Medically Necessary services. 

  

	15.	SUBMISSION OF CLAIMS 

  

	15.1	Physician shall submit all claims to Humana or its designee, as applicable, using the Health Insurance Portability and Accountability Act of 1996
(“HIPAA”) compliant 837 electronic format, or a CMS 1500 and/or UB-92, or their successors, within ninety (90) days from the date of service or within the time specified by applicable state law. Humana may, in its sole
discretion, deny payment for any claim(s) received by Humana after the later of ninety (90) days from the date of service, or the time specified by applicable state law. Physician acknowledges and agrees that at no time shall
Members be responsible for any payments to Physician except for applicable Copayments and non-covered services provided to such Members 

  

	15.2	Humana will process Physician claims which are accurate and complete in accordance with Humana’s normal claims processing procedures and
applicable state and/or federal laws, rules and regulations with respect to the timeliness of claims processing. Such claims processing procedures may include, without limitation, automated systems applications which identify, analyze and compare
the amounts claimed for payment with the diagnosis codes and which analyze the relationships among the billing codes used to represent the services provided to Members. These automated systems may result in an adjustment of the payment to the
Physician for the services or in a request, prior to payment, for the submission for review of medical records that relate to the claim. Physician may request reconsideration of any adjustments produced by these automated systems by
submitting a timely request for reconsideration to Humana. 

  

	15.3	Physician shall use best efforts to submit all claims to Humana by electronic means available and accepted as industry standards that are mutually
agreeable, and which may include claims clearinghouses or electronic data interface companies used by Humana. Physician acknowledges that Humana may market certain products that will require electronic submission of claims in
order for Physician to participate. 

  
 -9-

	16.	COORDINATION OF BENEFITS 

  

	16.1	When a Member has coverage, other than with Humana, which requires or permits coordination of benefits from a third party payor in addition to Humana,
Humana will coordinate its benefits with such other payor(s). In all cases, Humana will coordinate benefits payments in accordance with applicable laws and regulations and in accordance with the terms of its health benefits contracts.
When permitted to do so by such laws and regulations and by its health benefits contracts, Humana will pay the lesser of: (i) the amount due under this Agreement; (ii) the amount due under this Agreement less the amount payable or
to be paid by the other payor(s); or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In no event, however, will Humana, when its plan is a secondary payor, pay an amount, which, when
combined with payments from the other payor(s), exceeds the rates set out in this Agreement; provided, however, if Medicare is the primary payer, Humana will, to the extent required by applicable law, regulation or Centers for Medicare and
Medicaid Services (“CMS”) Office of Inspector General (“OIG”) guidance, pay Physician an amount up to the amount Humana would have paid, if it had been primary, toward any applicable unpaid Medicare
deductible or coinsurance. 

  

	17.	NO LIABILITY TO MEMBER FOR PAYMENT 

  

	17.1	Physician agrees that in no event, including, but not limited to, nonpayment by Humana, Humana’s insolvency or breach of this Agreement, shall
Physician or any Participating Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members or persons other than Humana (or the payor issuing the health
benefits contract administered by Humana) for Covered Services provided by Physician. This provision shall not prohibit collection by Physician from Member for any non-covered service and/or Copayments in accordance with the
terms of the applicable Member health benefits contract. 

  

	17.2	Physician further agrees that: (i) this provision shall survive the expiration or termination of this Agreement regardless of the cause giving rise to
expiration or termination and shall be construed to be for the benefit of the Member; (ii) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Physician and Member or persons
acting on their behalf; and (iii) this provision shall apply to all employees, agents, trustees, assignees, subcontractors, and independent contractors of Physician, and Physician shall obtain from such persons specific agreement
to this provision. 

  

	17.3	Any modification to this Section 17 shall not become effective unless approved by the Commissioner of Insurance, in the event such approval is required by
applicable state law or regulation, or such changes are deemed approved in accordance with state law or regulation. 

  

	18.	ACCESS TO INFORMATION 

  

	18.1	 Physician agrees that Humana, or any state or federal regulatory agency as required by law, shall have reasonable access and an
opportunity to examine Physician’s financial record annually and administrative records, as needed, as they relate to services provided to Members during normal business hours, on at least seventy-two

  
 -10-

	 	 
(72) hours advance notice, or such shorter notice as may be imposed on Humana by a federal or state regulatory agency or accreditation organization. 

 

	19.	NEW PRODUCT INTRODUCTION 

  

	19.1	From time to time during the term of this Agreement, Humana may develop or implement new products. Should Humana offer participation in any such new
product to Physician, Physician shall be provided with sixty (60) days written notice prior to the implementation of such new product. If Physician does not object in writing to its participation in such new product within
such sixty (60) day notice period, Physician shall be deemed to have accepted participation in the new product. In the event Physician objects to its participation in a new product, the parties shall confer in good faith to reach
agreement on the terms of Physician’s participation. If agreement on such new product cannot be reached, such new product shall not apply to this Agreement. Humana may in its discretion, establish, develop, manage and market
provider networks in which Physician may not be selected to participate. 

  

	20.	ASSIGNMENT AND DELEGATION 

  

	20.1	The assignment by Humana of this Agreement or any interest hereunder shall require notice to and the written consent of Physician. Any attempt by
Humana to assign this Agreement or its interest hereunder without complying with the terms of this paragraph shall be void and of no effect, and Physician, at its option, may elect to terminate the Agreement upon thirty (30) days
written notice to Humana, without any further liability or obligation to Humana. Physician may assign this Agreement in whole or in part to any purchaser of or successor to the assets or operation of Physician, or to any
affiliate of Physician, provided that the assignee agrees to assume Physician’s obligations under this Agreement. Upon notice assignment by Physician, Humana may terminate this Agreement upon thirty (30) days
written notice to Physician. 

  

	21.	COMPLIANCE WITH REGULATORY REQUIREMENTS 

  

	21.1	Physician acknowledges, understands and agrees that this Agreement may be subject to the review and approval of state regulatory agencies with regulatory
authority over the subject matter to which this Agreement may be subject. Any modification of this Agreement requested by such agencies or required by applicable law or regulations shall be incorporated herein as provided in
Section 23.10, of this Agreement. 

  

	21.2	 Physician and Humana agree to be bound by and comply with the provisions of all applicable state and/or federal laws, rules and
regulations. The alleged failure by either party to comply with applicable state and/or federal laws, rules or regulations shall not be construed as allowing either party a private right of action against the other in any court, administrative or
arbitration proceeding in matters in which such right is not recognized or authorized by such law or regulation. Physician and Participating Providers agree to procure and maintain for the term of this Agreement all license(s) and/or
certification(s) as is required by applicable law and Humana’s policies and procedures. Physician shall notify Humana immediately of any changes in licensure or certification status of Physician or Participating
Providers. If Physician or any individual Participating Provider violates any of the provisions of applicable state and/or federal laws, rules and regulations, or commits any act or engages in conduct for which Physician’s or
Participating Providers’ professional licenses are revoked or suspended, or otherwise is 

  
 -11-

	 	 
restricted by any state licensing or certification agency by which Physician or Participating Providers are licensed or certified, Humana may immediately terminate this Agreement or
any individual Participating Provider. 

  

	22.	DISPUTE RESOLUTION/LIMITATIONS ON PROCEEDINGS 

  

	22.1	Physician and Humana agree that in the event they are unable to resolve disputes that may arise with respect to this Agreement, Physician will
first exhaust any internal Humana administrative review or appeal mechanisms prior to submitting any matters to binding arbitration. 

  

	22.2	Physician may contest the amount of the payment, denial or nonpayment of a claim only within a period of eighteen (18) months following the date such claim
was paid, denied or not paid by the required date by Humana. In order to contest such payments, Physician shall provide to Humana, at a minimum, in a clear and acceptable written format, the following information: Member name
and identification number, date of service, relationship of the Member to the patient, claim number, name of the provider of the services, charge amount, payment amount, the allegedly correct payment amount, difference between the amount paid and
the allegedly correct payment amount, and a brief explanation of the basis for the contestation. Humana will review such contestation(s) and respond to Physician within sixty (60) days of the date of receipt by Humana of
such contestation. In the event a dispute about the contestations cannot be resolved by mutual agreement or as set forth above, either party may submit the matter for non-binding mediation to a board certified mediator selected by the parties or
from a panel of mediators proposed by the AAA. In the event the parties cannot agree on the mediator, then the mediator shall be appointed by the AAA. The mediation shall occur within sixty (60) days following the submission by Humana of
the matter to the mediator. If the mediation does not occur within such time period or neither party submits the dispute to mediation, either party may submit the dispute to binding arbitration in accordance with Section 12.2 above. The
dispute shall not be submitted to binding arbitration by either party prior to the expiration of the sixty (60) day period allowed for Humana’s response to the contestation. Except as set forth below, the cost of the mediation shall
be divided equally between the parties. The parties shall first exhaust the contestation procedures described above prior to submitting the contestations dispute to binding arbitration in accordance with Section 12.2 above. In the event
of a determination, following either the review of the claims contestations by Humana, or following mediation or the arbitration proceedings described in Section 12.2 above, that the claims in dispute, in the aggregate, were
processed and paid correctly, Physician shall, upon request of Humana, reimburse Humana for its costs in reviewing the claims contestations and reprocessing the claims and, in the event the matter was submitted by either party
for mediation or arbitration, the costs and expenses, and attorneys fees incurred by Humana that are attributable to the mediation or arbitration proceeding. In the event of a determination, following either the review of the claims
contestations by Humana or following mediation or the arbitration proceedings described in Section 12.2 above, that the claims in dispute, in the aggregate, were not processed and paid correctly by Humana, Humana
shall, upon request of Physician, reimburse Physician’s costs in preparing the claims contestation submission to Humana, and, in the event the matter was submitted by either party for mediation or arbitration, the costs and
expenses, and attorneys fees incurred by Physician that are attributable to the mediation or arbitration proceeding. 

  
 -12-

	23.	MISCELLANEOUS PROVISIONS 

  

	23.1	SEVERABILITY. If any part of this Agreement should be determined to be invalid, unenforceable, or contrary to law, that part shall be reformed, if
possible, to conform to law, and if reformation is not possible, that part shall be deleted, and the other parts of this Agreement shall remain fully effective. 

 

	23.2	GOVERNING LAW. This Agreement shall be governed by and construed in accordance with the applicable laws of the State of Texas. The parties agree that
applicable state and/or federal laws and/or regulations may make it necessary to include in this Agreement specific provisions relevant to the subject matter contained herein. Such state law provisions, if any, are set forth in the state law
coordinating provisions attachment hereto. Such federal law provisions, if any, are set forth in the Medicare Advantage provisions attachment hereto. The parties agree to comply with any and all such provisions and in the event of a conflict between
the provisions in the state law coordinating provisions attachment and/or the Medicare Advantage provisions attachment and any other provisions in this Agreement, the provisions in those attachments, as applicable, shall control. In the event that
state and/or federal laws and/or regulations enacted after the Effective Date expressly require specific language be included in this Agreement, such provisions are hereby incorporated by reference without further notice by or action of the parties
and such provisions shall be effective as of the effective date stated in such laws, rules or regulations. 

  

	23.3	WAIVER. The waiver, whether express or implied, of any breach of any provision of this Agreement shall not be deemed to be a waiver of any subsequent or
continuing breach of the same provision. In addition, the waiver of one of the remedies available to either party in the event of a default or breach of this Agreement by the other party shall not at any time be deemed a waiver of a party’s
right to elect such remedy at any subsequent time if a condition of default continues or recurs. 

  

	23.4	NOTICES. Any notices, requests, demands or other communications, except notices of changes in policies and procedures pursuant to Section 7,
required or permitted to be given under this Agreement shall be in writing and shall be deemed to have been given: (i) on the date of personal delivery; or (ii) provided such notice, request, demand or other communication is received by
the party to which it is addressed in the ordinary course of delivery: (a) on the third day following deposit in the United States mail, postage prepaid or by certified mail, return receipt requested; (b) on the date of transmission by
facsimile transmission; or (c) on the date following delivery to a nationally recognized overnight courier service, each addressed to the other party at the address set forth below their respective signatures to this Agreement, or to such other
person or entity as either party shall designate by written notice to the other in accordance herewith. Humana may also provide such notices to Physician by electronic means to the e¬mail address of Physician set forth on
the Cover Sheet to this Agreement or to other e-mail addresses Physician provides to Humana by notice as set forth herein. Unless a notice specifically limits its scope, notice to any one party included in the term
“Physician” or “Humana” shall constitute notice to all parties included in the respective terms. 

  

	23.5	 CONFIDENTIALITY. Physician agrees that the terms of this Agreement and information regarding any dispute arising out of this
Agreement are confidential, and agrees not to disclose the terms of this Agreement nor information regarding any dispute arising out of this Agreement to any third party without the express written consent of

  
 -13-

	 	 
Humana, except pursuant to a valid court order, or when disclosure is required by a governmental agency. Notwithstanding anything to the contrary herein, the parties acknowledge and agree
that Physician may discuss the payment methodology included herein with Members requesting such information. 

  

	23.6	COUNTERPARTS, HEADINGS AND CONSTRUCTION. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original, and all of
which together constitute one and the same instrument. The headings in this Agreement are for reference purposes only and shall not be considered a part of this Agreement in construing or interpreting any of its provisions. Unless the context
otherwise requires, when used in this Agreement, the singular shall include the plural, the plural shall include the singular, and all nouns, pronouns and any variations thereof shall be deemed to refer to the masculine, feminine or neuter, as the
identity of the person or persons may require. It is the parties desire that if any provision of this Agreement is determined to be ambiguous, then the rule of construction that such provision is to be construed against its drafter shall not apply
to the interpretation of the provision. 

  

	23.7	INCORPORATION OF ATTACHMENTS. All attachments attached hereto are incorporated herein by reference. 

 

	23.8	FORCE MAJEURE. Neither party to this Agreement shall be deemed to breach its obligations under this Agreement if that party’s failure to perform
under the terms of this Agreement is due to an act of God, riot, war or natural disaster. 

  

	23.9	ENTIRE AGREEMENT. This Agreement, including the attachments, addenda and amendments hereto and the documents incorporated herein, constitutes the entire
agreement between Humana and Physician with respect to the subject matter hereof, and it supersedes any prior or contemporaneous agreements, oral or written, between Humana and Physician. 

 

	23.10	MODIFICATION OF AGREEMENT. This Agreement may be amended in writing as mutually agreed upon by Physician and Humana. In addition,
Humana may amend this Agreement upon sixty (60) days’ written notice to Physician. Failure of Physician to object in writing to such amendment during the sixty (60) day notice period shall constitute acceptance of
such amendment by Physician. 

  
 -14-

 IN WITNESS WHEREOF, the parties have the authority necessary to bind the entities identified herein and have
executed this Agreement to be effective as of the Effective Date. 
  

					
	PHYSICIAN/AUTHORIZED SIGNATURE	  		  	HUMANA
			
	Signature:                            
                                         
                            	  		  	Signature:                           
                                         
                        
			
	Printed
Name:                                        
                                         
        	  		  	Printed
Name:                                        
                                         
   
			
	Title:                            
                                         
                                     	  		  	Title:                            
                                         
                                
			
	Date:                             
                                         
                                    	  		  	Date:                            
                                         
                                

 

			
	 Address for Notice:
  

PHYSICIAN:
	  	HUMANA:
	  
 Whiteglove House Call Health

515 Capital of Texas Hwy.
 Suite 225

Austin, T 78746
	  	
		
		  	 Copy to:
 Humana
Inc.
 P.O. Box 1438
 Louisville,
Kentucky 40201-1438
 Attn: Law Department

  
 -15-

 PRODUCT PARTICIPATION LIST 

ATTACHMENT 

Physician agrees to participate in the health benefits plan(s) selected below, whether self-funded or fully insured, that are offered or
administered by Humana. 
 Health Benefits Plan (Check only those which apply) 

 

			
	Commercial HMO Plans	  	x
		
	Commercial EPO Plans	  	x
		
	Traditional Plans (Indemnity)	  	x

  
 -16-

 PHYSICIAN INFORMATION 

ATTACHMENT 
 (To be provided by Physician prior to execution of this Agreement.) 
 The following
information is to be listed below for Physician and each Participating Provider: address, phone number, fax number, tax identification number, contact person, area of specialty, office hours, and area hospitals where Physician and
Participating Providers have admitting privileges and the corresponding hospital privilege category. 

  
 -17-

 LETTER OF AGREEMENT 

ATTACHMENT 

WHEREAS, Humana insurance Company, Humana Health Plan of Texas, Inc., and their affiliates who underwrite or administer health plans (hereinafter
referred to as “Humana”), and
                                         
                                       
.(hereinafter referred to as “Physician”) entered into a Physician Participation Agreement (hereinafter “Agreement”) on
                                        
 AND 
 WHEREAS, Physician and Humana agreed to be bound by the terms and conditions of the Agreement, AND

 WHEREAS, the undersigned physician (hereinafter referred to as “Participating Provider”) is a member of
Physician, and a Participating Provider pursuant to the Agreement between Physician and Humana, AND 

WHEREAS, Participating Provider acknowledges and agrees that the joinder of the Humana companies above shall not be construed as
imposing joint responsibility or cross guarantee between or among Humana companies. 
 NOW, THEREFORE, the parties hereby agree as
follows: 
 Participating Provider agrees to abide by all of the terms and conditions set forth in the Agreement, and to abide by all
Humana policies and procedures established and revised from time to time by Humana including, but not limited to, quality assurance, quality improvement, risk management, utilization management, credentialing and recredentialing, and
grievances/appeals. 
 Participating Provider unconditionally authorizes Humana and Physician to share information,
including but not limited to credentialing, recredentialing, quality management and utilization management information as related to treatment of individuals covered under those Humana health benefits plans covered under the Agreement
(hereinafter “Members”). However, it is understood expressly that the information shall not be shared with anyone not a party to the Agreement, unless required by law or pursuant to prior written consent of Participating
Provider. 
 Participating Provider acknowledges that Participating Provider has been provided an opportunity to read the
Agreement, all of the terms of which are hereby incorporated by reference. 
 Participating Provider further agrees that payment to
Physician or Participating Provider, as applicable, from Humana, less any Co-payments owed by the Member, is payment in full for health care services provided or arranged for Members in accordance with the applicable Member
health benefits contract and the terms and conditions of this Agreement. Participating Provider shall look solely to Physician for payment and agrees that payments made by Humana to Physician for Covered Services rendered
to Members by Participating Provider constitutes payment in full to Participating Provider. 
 Participating Provider
further agrees that in the event of termination or expiration of the Agreement, or in the event Physician is dissolved for whatever reason, Participating Provider shall continue to provide health care services under the terms and
conditions of the Agreement 

  
 -18-

 
and Humana agrees to continue to pay Participating Provider in accordance with the fee-for-service payment arrangements stated in the payment attachment of the Agreement, for a
period of one hundred and eighty (180) days after notice of dissolution of Physician or the effective date of termination or expiration of the Agreement, during which time a new physician agreement may be negotiated between Humana
and the individual Participating Provider. Humana may terminate such Participating Provider participation at any time after dissolution of Physician or termination or expiration of the Agreement upon written notice to
Participating Provider. 
  

					
	HUMANA	 		 	PARTICIPATING PROVIDER
			
	Signature:                           
                                      
                                  	 		 	Signature:                           
                                         
                             
	Print
Name:                                        
                                         
            	 		 	Print
Name:                                        
                                         
            
	Date:                             
                                         
                                    	 		 	Date:                            
                                         
                                     

  

  
 -19-

 LETTER OF AGREEMENT 

ATTACHMENT 

WHEREAS, Humana insurance Company, Humana Health Plan of Texas, Inc., and their affiliates who underwrite or administer health plans (hereinafter
referred to as “Humana”), and
                                         
                                       
.(hereinafter referred to as “Physician”) entered into a Physician Participation Agreement (hereinafter “Agreement”) on
                                        
 AND 
 WHEREAS, Physician and Humana agreed to be bound by the terms and conditions of the Agreement, AND

 WHEREAS, the undersigned physician (hereinafter referred to as “Participating Provider”) is a member of
Physician, and a Participating Provider pursuant to the Agreement between Physician and Humana, AND 

WHEREAS, Participating Provider acknowledges and agrees that the joinder of the Humana companies above shall not be construed as
imposing joint responsibility or cross guarantee between or among Humana companies. 
 NOW, THEREFORE, the parties hereby agree as
follows: 
 Participating Provider agrees to abide by all of the terms and conditions set forth in the Agreement, and to abide by all
Humana policies and procedures established and revised from time to time by Humana including, but not limited to, quality assurance, quality improvement, risk management, utilization management, credentialing and recredentialing, and
grievances/appeals. 
 Participating Provider unconditionally authorizes Humana and Physician to share information,
including but not limited to credentialing, recredentialing, quality management and utilization management information as related to treatment of individuals covered under those Humana health benefits plans covered under the Agreement
(hereinafter “Members”). However, it is understood expressly that the information shall not be shared with anyone not a party to the Agreement, unless required by law or pursuant to prior written consent of Participating
Provider. 
 Participating Provider acknowledges that Participating Provider has been provided an opportunity to read the
Agreement, all of the terms of which are hereby incorporated by reference. 
 Participating Provider further agrees that payment to
Physician or Participating Provider, as applicable, from Humana, less any Co-payments owed by the Member, is payment in full for health care services provided or arranged for Members in accordance with the applicable Member
health benefits contract and the terms and conditions of this Agreement. Participating Provider shall look solely to Physician for payment and agrees that payments made by Humana to Physician for Covered Services rendered
to Members by Participating Provider constitutes payment in full to Participating Provider. 
 Participating Provider
further agrees that in the event of termination or expiration of the Agreement, or in the event Physician is dissolved for whatever reason, Participating Provider shall continue to provide health care services under the terms and
conditions of the Agreement 

  
 -20-

 
and Humana agrees to continue to pay Participating Provider in accordance with the fee-for-service payment arrangements stated in the payment attachment of the Agreement, for a
period of one hundred and eighty (180) days after notice of dissolution of Physician or the effective date of termination or expiration of the Agreement, during which time a new physician agreement may be negotiated between Humana
and the individual Participating Provider. Humana may terminate such Participating Provider participation at any time after dissolution of Physician or termination or expiration of the Agreement upon written notice to
Participating Provider. 
  

					
	HUMANA	 		 	PARTICIPATING PROVIDER
			
	Signature:                            
                                         
                            	 		 	Signature:                           
                                         
                             
	Print
Name:                                        
                                         
            	 		 	Print
Name:                                        
                                         
            
	Date:                             
                                         
                                    	 		 	Date:                            
                                         
                                     

  

  
 -21-

 LETTER OF AGREEMENT 

ATTACHMENT 

WHEREAS, Humana insurance Company, Humana Health Plan of Texas, Inc., and their affiliates who underwrite or administer health plans (hereinafter
referred to as “Humana”), and
                                         
                                       
.(hereinafter referred to as “Physician”) entered into a Physician Participation Agreement (hereinafter “Agreement”) on
                                     AND 

WHEREAS, Physician and Humana agreed to be bound by the terms and conditions of the Agreement, AND 

WHEREAS, the undersigned physician (hereinafter referred to as “Participating Provider”) is a member of Physician, and a
Participating Provider pursuant to the Agreement between Physician and Humana, AND 
 WHEREAS, Participating
Provider acknowledges and agrees that the joinder of the Humana companies above shall not be construed as imposing joint responsibility or cross guarantee between or among Humana companies. 

NOW, THEREFORE, the parties hereby agree as follows: 
 Participating Provider agrees to abide by all of the terms and conditions set forth in the Agreement, and to abide by all Humana policies and procedures established and revised from time to
time by Humana including, but not limited to, quality assurance, quality improvement, risk management, utilization management, credentialing and recredentialing, and grievances/appeals. 

Participating Provider unconditionally authorizes Humana and Physician to share information, including but not limited to
credentialing, recredentialing, quality management and utilization management information as related to treatment of individuals covered under those Humana health benefits plans covered under the Agreement (hereinafter
“Members”). However, it is understood expressly that the information shall not be shared with anyone not a party to the Agreement, unless required by law or pursuant to prior written consent of Participating Provider.

 Participating Provider acknowledges that Participating Provider has been provided an opportunity to read the Agreement, all of
the terms of which are hereby incorporated by reference. 
 Participating Provider further agrees that payment to Physician or
Participating Provider, as applicable, from Humana, less any Co-payments owed by the Member, is payment in full for health care services provided or arranged for Members in accordance with the applicable Member health benefits contract
and the terms and conditions of this Agreement. Participating Provider shall look solely to Physician for payment and agrees that payments made by Humana to Physician for Covered Services rendered to Members by
Participating Provider constitutes payment in full to Participating Provider. 
 Participating Provider further agrees that
in the event of termination or expiration of the Agreement, or in the event Physician is dissolved for whatever reason, Participating Provider shall continue to provide health care services under the terms and conditions of the
Agreement 

  
 -22-

 
and Humana agrees to continue to pay Participating Provider in accordance with the fee-for-service payment arrangements stated in the payment attachment of the Agreement, for a
period of one hundred and eighty (180) days after notice of dissolution of Physician or the effective date of termination or expiration of the Agreement, during which time a new physician agreement may be negotiated between Humana
and the individual Participating Provider. Humana may terminate such Participating Provider participation at any time after dissolution of Physician or termination or expiration of the Agreement upon written notice to
Participating Provider. 
  

					
	HUMANA	 		  	PARTICIPATING PROVIDER
			
	Signature:                            
                                         
                	 		  	Signature:                           
                                         
            
	Print Name:                           
                                         
             	 		  	Print Name:                          
                                         
          
	Date:                             
                                         
                        	 		  	Date:                            
                                         
                    

  
 -23-

 PAYMENT ATTACHMENT 

 

	1.	REIMBURSEMENT 

 Commercial HMO
Plan(s) 
 Physician agrees to accept as payment in full from Humana for Covered Services rendered to Members of commercial
HMO plan(s) covered by this Agreement, [****] break down as defined below of [****], or Physician’s billed charges, whichever is less, less any Co-payments due from Members. For any claims for Covered Services rendered to such Members
that are billed under codes not listed on [****], Physician agrees to accept as payment in full from Humana, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from Members for vaccines, drugs
and injectables, 
 For services of a physician extender, Physician agrees and shall require the physician extender to agree to accept as
payment in full from Humana for Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from Member. For any claims
for Covered Services rendered to such Members that are [****], Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for such Covered Services, [****] or Physician’s
billed charges, whichever is less, less any Co-payments due from Member. 
 Commercial EPO Plan(s) 

Physician agrees to accept as payment in full from Humana for Covered Services rendered to Members of commercial EPO plan(s) covered by this
Agreement, [****], less any Co-payments due from Members. For any claims for Covered Services rendered to such Members that are billed under codes not listed on [****], Physician agrees to accept as payment in full from Humana, [****],
whichever is less, less any Copayments due from Members. 
 For services of a physician extender, Physician agrees and shall require the
physician extender to agree to accept as payment in full from Humana for Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] or Physician’s billed charges, whichever is less, less any
Co-payments due from Member, For any claims for Covered Services rendered to such Members that are billed under codes not listed on [****], Physician agrees and shall require the physician extender to agree to accept as payment in full from
Humana for such Covered Services, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from Member. 
 Traditional Plan(s) 
 Physician agrees to accept as payment in full from
Humana for Covered Services rendered to Members of traditional plan(s) covered by this Agreement, [****], or Physician’s billed charges, whichever is less, less any Co-payments due from Members. . For any claims for Covered
Services rendered to such Members that are billed under codes not listed on [****]. Physician agrees to accept as payment in full from Humana, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from
Members. 
 For services of a physician extender, Physician agrees and shall require the physician extender to agree to accept as payment
in full from Humana for Covered Services rendered to Members 
 [****] Certain information on this page has been omitted and filed
separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

  
 -24-

 
of commercial plan(s) covered by this Agreement, [****] or Physician’s billed charges, whichever is less, less any Co-payments due from Member. For any claims for Covered Services
rendered to such Members that are billed under [****], Physician agrees and shall require the physician extender to agree to accept as payment in full from Humana for such Covered Services, [****] or Physician’s billed charges,
whichever is less, less any Co-payments due from Member. 
 Reimbursement break down by code range and percentage payable: 

 

	 	•	 	 Evaluation and Management Services [****]: All covered services for evaluation and management services will be reimbursed at [****] will be
reimbursed at [****]. 

  

	 	•	 	 Surgery Services [****]: [****] will be reimbursed at [****]. All other covered services for surgery services will be reimbursed at [****].

  

	 	•	 	 Surgery Services [****]: [****] will be reimbursed at [****]. All other covered services for surgery services will be reimbursed at [****].

  

	 	•	 	 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services [****]: All covered services for radiology services will be reimbursed
at [****]. 

  

	 	•	 	 Pathology and Laboratory Services [****]: Humana STAT pathology and laboratory codes will be reimbursed at [****]. Humana STAT laboratory codes
are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, and 87880. CPT code 36415 when appropriate will be paid at [****]. All other codes
will be reimbursed at [****]. 

  

	 	•	 	 Medicine Services (except Anesthesiology and vaccines) [****]: CPT code [****] will be reimbursed at [****]. All other covered services for
medicine services, excluding anesthesiology, will be reimbursed at [****]. 

  

	 	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) [****]: All covered services
for medicine services, excluding anesthesiology, will be reimbursed at [****]. 

  

	 	•	 	 HCPCS Codes: All covered services for [****], with the [****], will be reimbursed at [****]. 

 

	 	•	 	 Drugs, Immunizations, Vaccines and Injectables: [****] will be utilized for reimbursement for drugs, immunizations or injectables. These drugs
and/or immunizations will be reimbursed at [****]. 

  

	2.	Fee Schedule Description (079-787) Fee Schedule: 

 Humana’s (079-787) fee schedule is based upon a modified fixed version of the 2006 Medicare Resource Based Relative Value Scale (“RBRVS”) fee schedule and payment systems,
including the site-of-service payment differential. 
 Humana may modify schedule (079-787) to include codes and/or fees for services
that are not included in this fee schedule (hereinafter “Gap Codes”). In most cases, the Gap Codes are adjusted by Humana using the relative value unit (“RVU”) multiplied by Medicare’s conversion factor
and geographic factor to assign the fee at the same percentage applied by Humana for other codes within the code range. 
 Additionally,
Humana may incorporate new CPT and HCPCS codes into schedule (079-787). The fee attributable to such code(s) will be determined by applying the same percentage as 
 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

  
 -25-

 
Humana applied to other codes within such code range toe that code’s RBRVS which is current as of the date of creation of the code. 

Periodic updates for new CPT codes, HCPCS codes and/or Gap Codes, or for modification of fees resulting from adjustments to a code’s RVU as
specified above, shall be incorporated into schedule (079-787) without notice to Physician, but will be available to Physician upon request. Humana may make other adjustments and modifications to this fee schedule. In such case,
Humana will provide Physician a ninety (90) day written notice prior to implementation of any other modifications and adjustments to schedule (079-787) 

 

	 	•	 	 Evaluation and Management Services [****]: All covered services for evaluation and management services are fixed at [****].

  

	 	•	 	 Surgery Services [****]: All covered services for surgery services are fixed at [****]. 

 

	 	•	 	 Surgery Services [****]: All covered services for surgery services are fixed at [****]. 

 

	 	•	 	 Radiology - Including Nuclear Medicine and Diagnostic Ultrasound Services [****]: All covered services for radiology services are fixed at
[****]. 

  

	 	•	 	 Pathology and Laboratory Services [****]: All covered services for pathology and laboratory will be reimbursed at [****]. Humana STAT pathology
and laboratory codes are fixed at [****]. Humana STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021, 85022, 85027, 85031, 87205, 87207, 87210, 87220, 87880.

  

	 	•	 	 Medicine Services (except Anesthesiology and vaccines) [****]: All covered services for medicine services, excluding anesthesiology, are fixed
at [****]. 

  

	 	•	 	 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except Anesthesiology) [****]: All covered services
for medicine services, excluding anesthesiology, are fixed at [****]. 

  

	 	•	 	 HCPCS Codes: All covered services for [****] are fixed at [****]. J codes (J0000 - J9999) will be reimbursed at [****].

  

	 	•	 	 Drugs, Immunizations, Vaccines and Injectables Not Included In Humana’s 2006 Medicare Fee Schedule: [****] will be utilized for
reimbursement for drugs, immunizations or injectables. These drugs and/or immunizations will be reimbursed at [****]. 

 Humana’s (201-544): [****] uses a percentage of the CMS Average Sales Price (ASP) or another industry standard as the basis of the 201-544 fee schedule. Notwithstanding anything to the
contrary in the Agreement, in the event the basis for the schedule is changed from a percentage of ASP to another basis, then Humana will provide ninety (90) days advance notice to Provider, of the new basis. The list of codes and associated
fees are reviewed and updated quarterly to reflect market pricing. These quarterly updates, if any, as well as any change in the basis may result in fees being adjusted either upwardly or downwardly. These updates shall be incorporated in the
Humana’s injectable fee schedule (201-544) without notice to Provider, but will be made available to Provider upon request. 
 Humana’s (005-787) fee schedule is based on the RBRVS fee schedule and payment systems, including the site-of-service payment differential, 

[****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect
to the omitted portions. 

  
 -26-

 
in effect as of the effective date of this Agreement and will change thereafter to reflect the annual updates to the schedule made by the Centers for Medicare and Medicaid Services
(“CMS”). Additionally, Humana will adjust the schedule to include and assign fees for services which are not covered by RBRVS. A list of those Humana adjusted codes and fees will be available to Physician upon request. 

Such annual updates by CMS and any corresponding adjustments by Humana shall be incorporated herein without notice to the Physician, but
will be available to the Physician upon request. Humana may make other adjustments and modifications to the fee schedule. In such cases, Humana will provide to Physician a sixty (60) day written notice prior to implementation of any other
modifications and adjustments to the fee schedule. 
  

	D.	Fee Schedule Samples 

Humana has provided a representative sample of these fee schedules to Physician prior to Physician’s execution of this
Agreement, and thereafter will supply a sample upon written request by Physician. Physician hereby acknowledges receipt of fee schedule sample. 
  

	3	PHYSICIAN EXTENDERS 

Physician agrees that in the event that Physician employs, subcontracts or dependently contracts with or uses the services of a physician
extender (that is a physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, certified surgical assistant, certified registered nurse first assistant or such other similarly
situated individual) who will be providing services to Humana Members under the supervision of Physician, Physician shall notify Humana in writing, upon execution of this Agreement and at any time during the term of this
Agreement when such physician extenders are employed, subcontracted, or independently contracted with Physician, and the specific services that such physician extenders will be performing, prior to the provision of services to any
Humana Member. Physician represents that physician extenders employed by or under contract with Physician will comply with the terms and conditions of this Agreement, maintain professional liability coverage and are
appropriately licensed as required by applicable state and federal laws, rules and regulations. Physician acknowledges and agrees Humana retains the right to approve, suspend and/or terminate participation under this Agreement of any
physician extender who will be providing services to Humana Members. 
  

	4.	SPECIFIC REFERRALS 

Physician and other Participating Providers acknowledge and agree that certain referrals are required to be made to specific providers designated
by Humana. 
 Physician and other Participating Providers further acknowledge and agree that such specific providers may be
changed or added to upon written notice by Humana to Physician. 
  

	5	MISCELLANEOUS 

 Physician
understands that Humana may market or administer products that contain variable Copayment amounts due from the Member for Covered Services based on the medical 

  
 -27-

 
specialty of certain physicians and the unit costs or reimbursement rates provided for in provider participation agreements. Physician agrees to participate in such products and to bill
and accept as payment in full for Covered Services rendered to Members in such products the reimbursement rates set forth above less any Copayment amounts due from the Member. 
 In circumstances where the Member’s Copayment for a Covered Service is equal to or greater than the rate set forth herein for that service, Physician agrees to accept as payment in full for
the service the Member’s Copayment, not to exceed the rates set forth herein. Furthermore, in such cases, Physician agrees to refund to Member the difference, if any, between the Copayment collected from the Member and such rate.

  
 -28-

 HMO PROVISIONS 

ATTACHMENT 

The following provisions apply solely to commercial HMO and/or Medicare Advantage HMO products and plans, as applicable. 

 

	I.	Services to Members. In the event Physician provides a Member a non-covered service or refers a Member to an out-of-network provider without
pre-authorization from Humana, Physician shall, prior to the provision of such non-covered service or out-of-network referral, inform the Member: (i) of the service(s) to be provided or referral(s) to be made; (ii) that
Humana will not pay or be liable financially for such non-covered service(s) or out-of-network referral(s); and (iii) that Member will be responsible financially for non-covered service(s) and/or out-of-network referral(s) that are
requested by the Member. 

  

	II.	Continuity of Care. Subject to and in accordance with all applicable state and/or federal laws, rules and/or regulations, treatment following termination
or expiration of this Agreement must continue until the Member: (i) has been evaluated by a new participating provider who has had a reasonable opportunity to review or modify the Member’s course of treatment, or until Humana has
made arrangements for substitute care for the Member, and (ii) until the date of discharge for Members hospitalized on the effective date of termination or expiration of this Agreement. Physician agrees to accept as payment in full from
Humana for Covered Services rendered to such Members, the rates set forth in the payment attachment, less any Co-payments due from such Members. 

  

	III.	Medical Records. Upon request from Humana or a Member, Physician shall transfer a complete copy of the medical records of any Member
transferred to another physician and/or facility for any reason, including termination or expiration of this Agreement. The copy and transfer of medical records shall be made at no cost to Humana or the Member and shall be made within a
reasonable time following the request, but in no event more than five (5) business days, except in cases of emergency where the transfer shall be immediate. Physician agrees that such timely transfer of medical records is necessary to
provide for the continuity of care for Members. Physician agrees to pay court costs and/or legal fees incurred by Humana or the Member to enforce the terms of this provision. 

 

	IV.	Acquisitions. In the event Physician acquires, through an asset acquisition, merger, consolidation, lease or other means, or enters into a
management agreement to manage the practice(s) of physician(s) or physician group(s) in Texas, and such practices or groups have in effect an agreement with Humana to provide services to Humana’s Members at rates which are more
favorable to Humana than those contained herein, the rates contained herein shall be adjusted downward to reflect such more favorable rate. 

  

	V.	 Equal Access. Physician agrees to accept Humana Members as patients within the normal scope of Physician’s
medical practice. If, due to overcapacity, Physician closes his/her practice to new patients, such closure will apply to all prospective patients without discrimination or regard to payor or source of payment for services, Should
Physician subsequently reopen his/her practice to new patients, Physician agrees to accept Humana Members seeking assignment and/or referral to Physician’s practice to

  
 -29-

	 	 
the same extent and in the same manner as all other non-Humana patients seeking Physician’s services. 

 

	VI	Physician Responsibilities. 

  

	 	A.	Services 

Physician agrees to be responsible twenty-four (24) hours a day, seven (7) days a week for providing Covered Services for
Members including, but not limited to, prescribing, directing and monitoring all urgent and emergency care for Members. 

Physician agrees to provide Humana upon request a written description of its arrangements for emergency and urgent care and
service coverage in the event of unavailability due to vacation, illness, and after regular office hours. Physician shall ensure that all physicians providing such coverage are contracted and credentialed physicians with Humana.
Physician will ensure that all physicians providing such coverage render services under the same terms and conditions and in compliance with all provisions of this Agreement. Compensation to physicians for “on call” coverage will be
the responsibility of Physician. 
 In the event that emergency or urgent care services are needed by a Member outside the
service area, Physician agrees to monitor and authorize the out-of-area care to provide direct care as soon as the Member is able to return to the service area for treatment without medically harmful or injurious consequences. 

 

	 	B.	Specific Referrals 

Except in the case of a medical emergency, Physician agrees to use its best efforts to admit, refer, and cooperate with the
transfer of Members for Covered Services only to providers designated, specifically approved by or under contract with Humana. 
 In addition, Physician acknowledges and agrees that certain Members may have health benefits contracts that limit coverage to certain types of participating providers. For such Members, referrals
are required to be made to specific providers designated by Humana. 
  

	 	C.	Disease/Case Management Programs 

 Physician agrees to participate in Humana’s disease/case management programs as they are developed and implemented. 

 

	 	D.	Humana First 

Physician agrees to participate in Humana’s twenty-four (24) hours nurse call program, HumanaFirst, or any such
successor program. 
  

	 	E.	Hospitalist/HIMS Programs 

 Physician agrees to cooperate with and participate in Humana’s hospitalist programs including, without limitation, Humana’s Hospital Inpatient Management Services
(“HIMS”) programs, where applicable, as they are developed and implemented. 

  
 -30-

	 	F.	Transplant Programs 

Upon request by Humana, Physician agrees to cooperate with and participate in Humana’s organ and tissue transplant
programs as they are developed and implemented. 
  

	 	G.	Health Improvement Studies 

 Physician agrees to participate in Humana’s health improvement studies as they are developed and implemented. 

 

	 	H.	Quality Improvement Activities 

 Physician agrees to cooperate with Humana’s quality improvement activities and, upon request by Humana, to participate in Humana’s quality improvement activities as
they are developed and implemented. 

  
 -31-

 HMO PROVISIONS 

ATTACHMENT 

The following provisions apply solely to commercial HMO and/or Medicare Advantage HMO products and plans, as applicable. 

 

	I.	Services to Members. In the event Physician provides a Member a non-covered service or refers a Member to an out-of-network provider without
pre-authorization from Humana, Physician shall, prior to the provision of such non-covered service or out-of-network referral, inform the Member: (i) of the service(s) to be provided or referral(s) to be made; (ii) that
Humana will not pay or be liable financially for such non-covered service(s) or out-of-network referral(s); and (iii) that Member will be responsible financially for non-covered service(s) and/or out-of-network referral(s) that are
requested by the Member. 

  

	II.	Continuity of Care. Subject to and in accordance with all applicable state and/or federal laws, rules and/or regulations, treatment following termination
or expiration of this Agreement must continue until the Member: (i) has been evaluated by a new participating provider who has had a reasonable opportunity to review or modify the Member’s course of treatment, or until Humana has
made arrangements for substitute care for the Member, and (ii) until the date of discharge for Members hospitalized on the effective date of termination or expiration of this Agreement. Physician agrees to accept as payment in full from
Humana for Covered Services rendered to such Members, the rates set forth in the payment attachment, less any Co-payments due from such Members. 

  

	III.	Medical Records. Upon request from Humana or a Member, Physician shall transfer a complete copy of the medical records of any Member
transferred to another physician and/or facility for any reason, including termination or expiration of this Agreement. The copy and transfer of medical records shall be made at no cost to Humana or the Member and shall be made within a
reasonable time following the request, but in no event more than five (5) business days, except in cases of emergency where the transfer shall be immediate. Physician agrees that such timely transfer of medical records is necessary to
provide for the continuity of care for Members. Physician agrees to pay court costs and/or legal fees incurred by Humana or the Member to enforce the terms of this provision. 

 

	IV.	Acquisitions. In the event Physician acquires, through an asset acquisition, merger, consolidation, lease or other means, or enters into a
management agreement to manage the practice(s) of physician(s) or physician group(s) in Texas, and such practices or groups have in effect an agreement with Humana to provide services to Humana’s Members at rates which are more
favorable to Humana than those contained herein, the rates contained herein shall be adjusted downward to reflect such more favorable rate. 

  

	V.	 Equal Access. Physician agrees to accept Humana Members as patients within the normal scope of Physician’s
medical practice. If, due to overcapacity, Physician closes his/her practice to new patients, such closure will apply to all prospective patients without discrimination or regard to payor or source of payment for services, Should
Physician subsequently reopen his/her practice to new patients, Physician agrees to accept Humana Members seeking assignment and/or referral to Physician’s practice to

  
 -32-

	 	 
the same extent and in the same manner as all other non-Humana patients seeking Physician’s services. 

 

	VI	Physician Responsibilities. 

  

	 	A.	Services 

Physician agrees to be responsible twenty-four (24) hours a day, seven (7) days a week for providing Covered Services for
Members including, but not limited to, prescribing, directing and monitoring all urgent and emergency care for Members. 

Physician agrees to provide Humana upon request a written description of its arrangements for emergency and urgent care and
service coverage in the event of unavailability due to vacation, illness, and after regular office hours. Physician shall ensure that all physicians providing such coverage are contracted and credentialed physicians with Humana.
Physician will ensure that all physicians providing such coverage render services under the same terms and conditions and in compliance with all provisions of this Agreement. Compensation to physicians for “on call” coverage will be
the responsibility of Physician. 
 In the event that emergency or urgent care services are needed by a Member outside the
service area, Physician agrees to monitor and authorize the out-of-area care to provide direct care as soon as the Member is able to return to the service area for treatment without medically harmful or injurious consequences. 

 

	 	B.	Specific Referrals 

Except in the case of a medical emergency, Physician agrees to use its best efforts to admit, refer, and cooperate with the
transfer of Members for Covered Services only to providers designated, specifically approved by or under contract with Humana. 
 In addition, Physician acknowledges and agrees that certain Members may have health benefits contracts that limit coverage to certain types of participating providers. For such Members, referrals
are required to be made to specific providers designated by Humana. 
  

	 	C.	Disease/Case Management Programs 

 Physician agrees to participate in Humana’s disease/case management programs as they are developed and implemented. 

 

	 	D.	Humana First 

Physician agrees to participate in Humana’s twenty-four (24) hours nurse call program, HumanaFirst, or any such
successor program. 
  

	 	E.	Hospitalist/HIMS Programs 

 Physician agrees to cooperate with and participate in Humana’s hospitalist programs including, without limitation, Humana’s Hospital Inpatient Management Services
(“HIMS”) programs, where applicable, as they are developed and implemented. 

  
 -33-

	 	F.	Transplant Programs 

Upon request by Humana, Physician agrees to cooperate with and participate in Humana’s organ and tissue transplant
programs as they are developed and implemented. 
  

	 	G.	Health Improvement Studies 

 Physician agrees to participate in Humana’s health improvement studies as they are developed and implemented. 

 

	 	H.	Quality Improvement Activities 

 Physician agrees to cooperate with Humana’s quality improvement activities and, upon request by Humana, to participate in Humana’s quality improvement activities as
they are developed and implemented. 

  
 -34-

 HUMANA AMENDMENT TO 

WHITEGLOVE HOUSE CALL HEALTH, Inc. PHYSICIAN AGREEMENT 
 WHEREAS Humana Health Care Plans of Austin, Inc., PCA Health Plans of Texas, Inc., and their affiliates (hereinafter referred to as “HUMANA”) and Whiteglove House Call Health,
Inc. (hereinafter referred to as “GROUP”) entered into an Agreement effective as of May 1, 2008 (hereinafter referred to as “Agreement”) 
 WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards for the Humana Commercial HMO, ASO and POS members for covered services. Said Amendment shall be effective
March 1, 2009. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and other
good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend Reimbursement Attachment as it pertains to Commercial HMO, ASO and
POS: 
 REIMBURSEMENT 

Commercial HMO Plan(s) 
 Group agrees to
accept as payment in full from Humana for Covered Services rendered to Members of commercial HMO plan(s) covered by this Agreement, [****] of the reimbursement break down as defined below of Humana’s (079-787) fee schedule, or
Group’s billed charges, whichever is less, less any Co-payments due from Members. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule,
Group agrees to accept as payment in full from Humana, [****] of Humana’s (201-544) fee schedule or Group’s billed charges, whichever is less, less any Co-payments due from Members for vaccines, drugs and
injectables. 
 For services of a Physician extender, Group agrees and shall require the physician extender to agree to accept as payment
in full from Humana for Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] of the reimbursement break down as defined below of Humana’s (079-787) fee schedule or Group’s billed
charges, whichever is less, less any Co-payments due from Member. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule. Group agrees and shall
require the physician extender to agree to accept as payment in full from Humana for such Covered Services, [****] of Humana’s (201-544) fee schedule or Group’s billed charges. whichever is less, less any Co- payments
due from Member. 
 Commercial EPO ASO and POS Plan(s) 
 Group agrees to accept as payment in full from Humana for Covered Services rendered to Members of commercial EPO plan(s) covered by this Agreement. the percentage defined below of
Humana’s (079-787) fee schedule, or Group’s billed charges, whichever is less, less any Co-payments due from Members, For any claims for Covered Services rendered to such Members that are billed under codes not listed on
Humana’s (079/787) fee schedule, Group agrees to accept as payment in full from Humana, [****] of Humana’s (201-544) fee schedule or Group’s billed charges, whichever is less, less any
Copayments due from Members. 
 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential
treatment has been requested with respect to the omitted portions. 

  
 -35-

 For services of a physician extender, Group agrees and shall require the physician extender to agree
to accept as payment in full from Humana for Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [****] of the reimbursement break down as defined below of Humana’s (079-787) fee schedule or
Group’s billed charges, whichever is less, less any Co-payments due from Member. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Group’s (079-787) fee schedule,
Group agrees and shall require the physician extender to agree to accept as payment in full from Humana for such Covered Services, [****] of Humana’s (201-544) fee schedule or Group’s billed charges, whichever
is less, less any Co-payments due from Member. 
 Traditional Plan(s) 
 Group agrees to accept as payment in full from Humana for Covered Services rendered to Members of traditional plan(s) covered by this Agreement, [****] of Humana’s (079-787) fee
schedule, or Group’s billed charges, whichever is less, less any Co-payments due from Members. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079/787) fee
schedule, Group agrees to accept as payment in full from Humana, [****] of Humana’s (201-544) fee schedule or Group’s billed charges, whichever is less, less any Co-payments due from Members. 

For services of a physician extender, Group agrees and shall require the physician extender to agree to accept as payment in full from
Humana for Covered Services rendered to Members of commercial plan(s) covered by this Agreement, [***] of the reimbursement break down as defined below of Humana’s (079-787) fee schedule or Group’s billed charges,
whichever is less, less any Co-payments due from Member. For any claims for Covered Services rendered to such Members that are billed under codes not listed on Humana’s (079-787) fee schedule, Group agrees and shall require the physician
extender to agree to accept as payment in full from Humana for such Covered Services, [****] of Humana’s (201-544) fee schedule or Group’s billed charges, whichever is less, less any Co-payments due from Member.

 Reimbursement break down by code range and percentage payable: 
 Evaluation and Management Services (Codes 99201 to 99499): All covered services for evaluation and management services will be reimbursed at [***] with the exception of 99214, 99215 and 99212. CPT
Code 99214 will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule. CPT Code 99215 will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule. CPT Code 99212 wilt be reimbursed at [****] of the fixed 2006 RBRVS schedule.

 Surgery Services (Codes 10021 to 11471 and 11720 to 11765): CPT Code 10060, 10120, 11100 will be reimbursed at [***] of the fixed 2006
RBRVS. All other covered services for surgery services will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule. Surgery Services (Codes 11600 to 11719 and 11770 to 69990): CPT Code. 11730, 11740, 11750, 12001, 12002, 12004, 12011, 12013.
12014. 12031, 12032, 12034. 12041. 12042, 12044, 12051, 12052, 12053, 16020, 16025.16030. 17110 29505, 29515, 29125, 29105, 29130. 30901, 65205, 65220 and 69210 will be reimbursed at [****] of the fixed 2006 RBRVS. All other covered services for
surgery services will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule 
 Radiology - Including Nuclear Medicine and Diagnostic
Ultrasound Services (Codes 70010 to 79999): All covered services for radiology services will be reimbursed at [****] percent of fixed 2006 Medicare RBRVS schedule. 
 Pathology and Laboratory Services (Codes 80048 to 89399): Humana STAT pathology and laboratory codes will be reimbursed at [****] of fixed 2006 Medicare RBRVS schedule. Humana 

[****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect
to the omitted portions. 

  
 -36-

 
STAT laboratory codes are as follows: 81000, 81002, 81005, 81015, 81025, 82270, 82947, 82948, 85007, 85008, 85009, 85013, 85014, 85021. 85022, 85027, 85031, 87205, 87207, 87210, 87220, and 87880.
CPT code 36415 when appropriate will be paid at [****] of the fixed 2006 RBRVS schedule. CPT Codes 82962, 86677, 87804, 86308, will be paid at [****] of the fixed 2006 Medicare RBRVS allowable. All other codes will be reimbursed at [****].

 Medicine Services (except Anesthesiology and vaccines) (Codes 90281 to 90474 and 90760 to 92504 and 92511 to 96999 and 97802 to 98929 and
99000 to 99199 and 99500 to 99600): CPT code 90772, 92230, 93000, 94640, and 94664 will be reimbursed at [****] of the fixed 2006 RBRVS schedule. All other covered services for medicine services, excluding anesthesiology, will be reimbursed at
[****] of 2006 Medicare RBRVS. 
 Medicine Services Chiropractic, Physical Therapy, Speech Therapy and Occupational Therapy (except
Anesthesiology) (Codes 92506 to 92508 and 97001 to 97606 and 98940 to 98943): All covered services for medicine services, excluding anesthesiology, will be reimbursed at [****] of 2006 Medicare RBRVS fee schedule. 

HCPCS Codes: All covered services for HCPCS codes, with the exception of J codes will be reimbursed at [****] of fixed 2006 Medicare RBRVS fee
schedule. 
 Drugs, Immunizations, Vaccines and Injectables: Humana’s (201-544) fee schedule will be utilized for reimbursement for
drugs, immunizations or injectables. These drugs and/or immunizations will be reimbursed at [****] of Human’s (201-544) fee schedule. 

CPT CODE 99070: CPT Code 99070 will be reimbursed at [****] of billed charges, which is intended to approximate cost plus [****]. Humana reserves
the right to audit to insure accuracy. 
 Except as specifically amended hereby, the terms and conditions of this agreement remain the same.

 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested
with respect to the omitted portions. 

  
 -37-

 IN WITNESS WHEREOF, the undersigned have executed this Amendment effective March 1, 2009. 

 

					
	Provider	 		 	HUMANA
			
	By:                             
                                         
                                        
	 		 	By:                            
                                         
                                         

			
	Printed
Name:                                        
                                         
        	 		 	Printed Name: Donnie Hromadka
			
	Title:                            
                                         
                                     	 		 	Title: V.P. Network Management
			
	Date:                             
                                         
                                    	 		 	Date:                            
                                         
                                     
			
	TIN: 208913858	 		 	

  
 -38-

 AMENDMENT TO 
 WHITEGLOVE HOUSE CALL HEALTH, Inc. PHYSICIAN AGREEMENT 
 WHEREAS Humana Health Care Plans
of Austin, Inc., PCA Health Plans of Texas, Inc., and their affiliates (hereinafter referred to as “HUMANA”) and WhiteGlove House Call Health, Inc. (hereinafter referred to as “GROUP”) entered into an Agreement effective as of
May 1, 2008 and later amended effective March 1, 2009 (hereinafter referred to as “Agreement”). 

WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards to only the Humana Commercial fully insured
HMO and POS members for covered services. Said Amendment shall be effective February 1st 2011. 
 NOW THEREFORE, in consideration of the promises and mutual covenants herein contained and
other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend the Reimbursement Attachment as it pertains to Commercial fully
insured HMO and POS members in the following counties: Travis, Hays, Williamson, Comal, Bexar, Dallas, Tarrant, Denton, Collin, Rockwall, Harris. 
 REIMBURSEMENT 
 HUMANA agrees to reimburse GROUP a capitation rate each month for HUMANA’s
commercial fully insured HMO and POS members for the counties listed above per the schedule below: 
 [****] for the quarter in which the number
of visits provided by GROUP does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits provided by
GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the number of visits
provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter in which the
number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter
in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for
the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 

[****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter;

 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during
that quarter; 
 In the event visits exceed [****] visits per quarter, the per member per month capitation rate shall increase by [****] for
each incremental increase of [****] visits per quarter in the same pattern as the rates outlined above. 
 DEFINITIONS 

[****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect
to the omitted portions. 

  
 -39-

 Quarterly shall be defined as January through March, April through June, July through September and October
through December. 
 Encounters shall be defined as a visit which will include an E&M coding plus any other coded services provided during
the member visit. 
 CAPITATION RATE ADJUSTMENT 
 The GROUP will provide to HUMANA at the end of each quarter the total number of visits it has performed for HUMANA’s Commercial fully insured HMO and POS members in that quarter. For each quarter,
HUMANA will supply the GROUP with the number of visits as previously submitted by the GROUP for reconciliation. HUMANA and GROUP shall review and mutually agree to the number of visits performed by GROUP within the quarter, fifteen (15) days
after the close of each quarter. In the event that the capitation rate for any quarter requires adjustment, the rates will be adjusted for the next quarter based on the total number of visits actually performed. 

REIMBURSEMENT CALCULATION AND BILLING 
 HUMANA will provide to GROUP the actual number of Commercial fully insured HMO and POS members for every month in the counties listed above no later than the 15th of the month just past commencing February 15, 2011. GROUP will
invoice HUMANA every month based on the then current quarterly pm/pm times actual membership count. The monthly capitation check shall be paid by HUMANA by the 15th of the following month, from which the services are rendered. 

RETROACTIVE ADJUSTMENTS OR CAPITATION PAYMENTS: 

Payments to GROUP shall not be subject to retroactive adjustments resulting from additions and deletions of HUMANA’s Commercial fully insured HMO and
POS Plan Members. 
 ENCOUNTER DATA 

GROUP agrees to provide to HUMANA accurate and complete information regarding the provision of Covered Services by GROUP to Members (“Data”) on
a complete CMS 1500 or UB 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by as law when submitting encounters in an electronic format, or such other format as is mutually agreed
upon by both parties. The Data shall be provided to HUMANAS on or before the last day of each month for encounters occurring in the immediately preceding month, or such lesser period of time as may be required in the Agreement, or as is otherwise
agreed upon by the parties in writing. In the event the Data is not submitted to HUMANA by the date and in the form specified above, HUMANA may, in its sole option, withhold any increase to the payment otherwise required to be made under the terms
of the Agreement until the Data is submitted to HUMANA. 
 TERMINATION 
 Either party may terminate the Agreement with a six (6) months written notice and shall not affect either parties’ obligations that contractually survive. 

Except as specifically amended hereby, the terms and conditions of this agreement remain the same. 

  
 -40-

 IN WITNESS WHEREOF, the undersigned have executed this Amendment effective February 1, 2011.

  

					
	GROUP	 		 	HUMANA
			
	By:                             
                                         
                               	 		 	By:                            
                                         
                                
			
	Printed Name: Robert Fabbio	 		 	Printed Name: Donnie Hromadka
			
	Title: Chief Executive Officer	 		 	Title: V. P. Network Management

									
					
	Date:	 	 12 /21/10
	 		 	Date:	 	 12/21/2010

  
 -41-

 HUMANA AMENDMENT TO 

WHITEGLOVE HOUSE CALL HEALTH, Inc. PHYSICIAN AGREEMENT 
 WHEREAS Humana Health Care Plans of Austin, Inc., PCA Health Plans of Texas, Inc., and their affiliates (hereinafter referred to as “HUMANA”) and WhiteGlove House Call Health, Inc. (hereinafter
referred to as “GROUP”) entered into an Agreement effective as of May 1, 2008 amended effective March 1, 2009, and later amended February 1, 2011 (hereinafter referred to as “Agreement”). 

WHEREAS, the Parties thereto have mutually agreed to amend said Agreement, with regards to only the Humana Commercial fully insured HMO and POS members
for covered services. Said Amendment shall be effective February 8, 2011. 
 NOW THEREFORE, in consideration of the promises and mutual
covenants herein contained and other good valuable consideration the sufficiency of which is hereby acknowledged, it is mutually covenanted and agreed by and between the Parties hereto that the following is to amend the Reimbursement Attachment as
it pertains to Commercial fully insured HMO and POS members in the following counties: Travis, Hays, Williamson, Comal, Bexar, Dallas, Tarrant, Denton, Collin, Rockwall, Harris. 
 REIMBURSEMENT 
 HUMANA agrees to reimburse GROUP a capitation rate (“Capitation Rate”)
each month for HUMANA’s commercial fully insured HMO and POS members for the counties listed above per the schedule below: 
 [****] for
the quarter in which the number of visits provided by GROUP does not exceed [****] during that quarter; 
 [****] for the quarter in which the
number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for the quarter
in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 
 [****] for
the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter; 

[****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during that quarter;

 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed [****] during
that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but does not exceed
[****] during that quarter; 
 [****] for the quarter in which the number of visits provided by GROUP is equal to or greater than [****] but
does not exceed [****] during that quarter; 
 In the event visits exceed [****] visits per quarter, the per member per month capitation rate
shall increase by [****] for each incremental increase of [****] visits per quarter in the same pattern as the rates outlined above. 

DEFINITIONS 
 Quarterly shall be defined as
January through March, April through June, July through September and October through December. 
 Encounters shall be defined as a visit which
will include an E&M coding plus any other coded services provided during the member visit. 
 [****] Certain information on this page has
been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

 CAPITATION RATE ADJUSTMENT 
 The GROUP will provide to HUMANA at the end of each quarter the total number of visits it has performed for HUMANA’s Commercial fully insured HMO and POS members in that quarter. For each quarter,
HUMANA will supply the GROUP with the number of visits as previously submitted by the GROUP for reconciliation. HUMANA and GROUP shall review and mutually agree to the number of visits performed by GROUP within the quarter, fifteen (15) days
after the close of each quarter. In the event that the capitation rate for any quarter requires adjustment, the rates will be adjusted for the next quarter based on the total number of visits actually performed. 

REIMBURSEMENT CALCULATION AND BILLING 
 HUMANA will provide to GROUP the actual number of Commercial fully insured HMO and POS members for every month in the counties listed above no later than the 15th of the month just past commencing February 15, 2011. GROUP will
invoice HUMANA every month based on the then current quarterly pm/pm times actual membership count. The monthly capitation check shall be paid by HUMANA by the 15th of the following month, from which the services are rendered. 

At the end of each quarter, new Capitation Rates will be calculated based on the actual number of Commercial fully insured HMO/POS members with the
addition of the number of Commercial fully insured PPO members combined (the combination of the HMO and PPO membership will equal the total number of members used in the following formula. The total number of members will result in one single
payment for both the HMO and PPO contract Amendments. There will not be separate calculation by product type) at the end of the quarter using the following formula: [****]. 
 RETROACTIVE ADJUSTMENTS OR CAPITATION PAYMENTS: 
 Payments to GROUP shall not be subject to
retroactive adjustments resulting from additions and deletions of HUMANA’s Commercial fully insured HMO and POS Plan Members. 
 ENCOUNTER
DATA 
 GROUP agrees to provide to HUMANA accurate and complete information regarding the provision of Covered Services by GROUP to Members
(“Data”) on a complete CMS 1500 or UB 92 form, or their respective successor forms as may be required by CMS, or such other form as may be required by as law when submitting encounters in an electronic format, or such other format
as is mutually agreed upon by both parties. The Data shall be provided to HUMANAS on or before the last day of each month for encounters occuring in the immediately preceding month, or such lesser period of time as may be required in the Agrement,
or as is otherwise agreed upon by the parties in writing. In the event the Data is not submitted to HUMANA by the date and in the form specified above, HUMANA may, in its sole option, withhold any increase to the payment otherwise required to be
made under the terms of the Agreement until the Data is submitted to HUMANA. 
 TERMINATION 

Either party may terminate the Agreement with a six (6) months written notice and shall not affect either parties’ obligations that
contractually survive. 
 Except as specifically amended hereby, the terms and conditions of this agreement remain the same. 

  
 -43-

 IN WITNESS WHEREOF, the undersigned have executed this Amendment effective February 1, 2011.

  

					
	GROUP	 		 	HUMANA
			
	By:                             
                                         
                	 		 	By:                            
                                         
                 
	Printed Name: Robert Fabbio	 		 	Printed Name: Donnie Hromadka
	Title: Chief Executive Officer	 		 	Title: V. P. Network Management

							
	Date:	 	 2 /8/11
	 		 	Date:
	         2/8/11
	 		 	

  
 -44-

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