Document:

f8k1010ex10ix_amsurg.htm

Exhibit 10.9

 

THREE RIVERS PROVIDER NETWORK

AGREEMENT WITH

______________________________

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

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

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

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

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

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

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

	
*

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

 

  

Page 1

  

 

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

 

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

 

ATTACHMENT A: PROVIDER INFORMATION

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

 

 

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

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

 

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

 

  

Page 2

  

 

ADDENDUM A:

MEDICAL STAFF LISTING & FACILITY LOCATIONS

_______________________________

 

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

 

  

  

Page 3

  

 

	
FORT BEND SA SERVICES

	
Bayshore Medical Center

4000 Spencer Highway

Pasadena TX 77504

	
Christus St. Catherine’s

701 South Fry Road

Katy TX 77450

	
Christus St. John Hospital

18300 St. John Dr.

Nassau Bay, TX 77058

	
Clear Lake Medical Center

500 Medial Center Blvd.

Webster TX 77598

	
Cypress Fairbanks Medical Center

10655 Steepletop Drive

Houston, TX 77065

	
Doctors Surgical Center

8111 Southwest Freeway

Houston TX 77074

	
East Houston Regional Medical Center

13111 East Freeway

Houston TX 77015

	
East Side Surgery Center

10918 East Freeway

Houston TX 77029

	
First Street Hospital

4801 Bissonnet

Bellaire TX 77401

	
First Surgical Memorial Village

12727 Kimberly Lane #100

Houston TX 77024

	
First Surgical Partners LLC

411 First Street

Bellaire TX 77401

	
Foundations Surgery Center

5410 West Loop South

Bellaire TX 77401

	
Houston NW Medical Center

710 FM 1960 West

Houston, TX 77090

	
Katy St. Catherine’s Surgery Center

707 South Fry Road #150

Katy TX 77450

 

  

 

  

 

	
FORT BEND SA SERVICES

	
Kingwood Medical Center

22999 US Highway 59

Kingwood TX 77339

	
Memorial Hermann

6411 Fannin

Houston, TX 77030

	
Memorial Hermann Memorial City

921 Gessner Road

Houston TX 77024

	
Memorial Hermann Northwest

1635 North Loop West

Houston TX 77008

	
Memorial Hermann Southeast

11800 Astoria Blvd

Houston TX 77089

	
Memorial Hermann Southwest

7600 Beechnut

Houston TX 77074

	
Memorial Hermann Surgery Center Northwest

1634 North Loop West #300

Houston TX 77008

	
Memorial Hermann Surgery Center Southwest

7789 Southwest Freeway #200

Houston TX 77074

	
Memorial Hermann The Woodlands

9250 Pinecroft

The Woodlands TX 77380

	
Methodist Sugar Land

16655 Southwest Freeway

Sugar Land TX 77479

	
Methodist Willowbrook

18220 Tomball Parkway

Houston TX 77070

	
North Cypress Medical Center

21214 Northwest Freeway

Cypress TX 77429

	
Northeast Medical Center

18951 Memorial North

Humble TX 77338

	
OakBend Medical Center

1705 Jackson Street

Richmond TX 77469

 

 

  

 

  

 

 

	
FORT BEND SA SERVICES

	
Palladium Surgery Center

4120 Southwest Freeway #230

Houston TX 77027

	
Park Plaza Hospital

1313 Hermann Drive

Houston TX 77004

	
Special Surgery Centre

9180 Katy Freeway Suite 202

Houston TX 77055

	
Spring Branch Medical Center

8850 Long Point

Houston TX 77055

	
St. Joseph Medical Center

1401 St. Joseph Parkway

Houston, TX 77002

	
St. Luke’s Episcopal Hospital Sugar Land

1317 Lake Point Parkway

Sugar Land TX 77478

	
St. Luke’s Episcopal Hospital

6720 Bertner Street

Houston TX 77030

	
Sugar Land Surgical Hospital

1211 Highway 6 Suite 70

Sugar Land TX 77478

	
The Woman’s Hospital

7600 Fannin

Houston TX 77054

	
West Houston Medical Center

12141 Richmond Avenue

Houston TX 77082

	
West Houston Surgicare

970 Campbell Road

Houston TX 77080

 

  

 

  

 

Provider List

10/23/2008

 

	Code 	Name  	National Provider Identifier	Credentials	License Number
	  Last Name   	 	 	 	 
	 	 	 	 	 
	
BA

   ABORDO

 

	
ABORDO, BELTRAN

 

	
 

1225155880

	
LSA

	
SA00024

 

	
SA

   ADIL

 

	
ADIL, SAYED

	
 

1649397217

	
LSA

	
SA00289

	
HA

   AGUILAR

 

	
AGUILAR, HUGO

	
 

1578680153

	
LSA

	
SA00283

	
OA

   AKUPUE

 

	
AKUPUE, OKECHUKWU

	
 

1346368917

	
LSA

	
SA00307

	
MA

   AL ALAM

 

	
AL ALAM, MOHD

	
 

1487772901

	
LSA

	
SA00309

	
RA

   ARAGON

 

	
ARAGON, RECTO

	
 

1427176981

	
SA-C

	
A01143

	
AA

ARREOZOLA

 

	
ARREOZOLA, ALEJANDRO

	
 

1649398108

	
LSA

	
SA00299

	
JA

   ASPORT

	
ASPORT, JORGE

	
 

1710005053

 

	
LSA

	
A03119

	
MA01

   ATHANS

 

	
ATHANS, MARK

	
 

1093833576

	
LSA

	
SA00029

	
IA

   AYUB

 

	
AYUB, ILIA

	
 

1568580058

	
CSA

	
CSA04209

 

	
QB

   BABURI

 

	
BABURI, QASIM

	
 

1043338445

	
LSA

	
SA00160

	
VB01

   BARCES

 

	
BARCES, VICENTE

	
 

1932227287

	
LSA

	
SA00161

	
VB

   BATTAD`

 

	
BATTAD, VENERANDO

	
 

1003934357

	
LSA

	
SA00290

	
CB

   BENITEZ

 

	
BENITEZ, CARLOS

	
 

1700904067

	
LSA

	
SA00163

	
WB

   BERRY

 

	
BERRY, WILLIAM

	
 

1851589386

	
CST/CFA

	
109540

  

1

  

Provider List

10/23/2008

 

	Code 	Name  	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
DGB

   BESSON

 

	
BESSON, DORKA G

	
 

1750501565

	
LSA

	
SA00291

	
AC

   CALLEGARI

 

	
CALLEGARI, ANDRES

	
 

1275651226

	
LSA

	
SA00108

	
JC01

   CANSECO

 

	
CANSECO, JOSE

	
 

1700904737

	
LSA

	
SA00110

	
JC002

CARRION

 

	
CARRION, JOSE

	
 

1629196704

	
SA-C

	
06114

	
LC

   CERDAN

 

	
CERDAN, LAURO

	
 

1922126002

 

	
CSA

	  
	
BC   CHAMBERLAIN

 

	
CHAMBERLAIN, BLAND

	
 

1891813804

	
LSA

	
SA00237

	
JC

   CHAPA

 

	
CHAPA, JOSE

	
 

1467570374

	
LSA

	
SA00255

	
MC

   CHAUDHRY

	
CHAUDHRY, MUBASHIR

	
 

1427176379

	
LSA

	
SA00277

	
MC01

   COLELLO

 

	
COLELLO, MARY

	
 

1386829521

	
SA-C

	
07272

	
VC

   CRUZ

	
CRUZ, VIRGINIA

	
 

1053439885

	
CSA

	
A05223

	
AD

   DARWISHS-SALAMA

 

	
DARWISHS-SALAMA,

ALFREDO

	
 

1699893354

	
LSA

	
SA0315

	
ND

   DAVIS

 

	
DAVIS, NORMAN

	
 

1164553772

	
CSA

	
ABSA 001163

	
BE

   EATON

 

	
EATON, BRENT

	
 

1699894378

	
CRNFA

	
061022

	
ZE

ELGAMAL

 

	
ELGAMAL, ZAK

	
 

1194786046

	
LSA

	
SA00011

	
MF

FARAG

 

	
FARAG, MAURICE

	
1548389216

	
LSA

	
SA00038

 

  

2

  

 

Provider List

10/23/2008

 

	Code	Name	National Provider Identifier	Credentials	License Number
	  Last Name  	 	 	 	 
	 	 	 	 	 
	
DF

   FLORES

 

	
FLORES, DAVID

 

	
 

1407975162

	
LSA

	
SA00069

	
LF

   FLORES

 

	
FLORES, LETICIA

	
 

1053502385

	
CNOR

	
CNOR030775

	
RF

   FOGLE

	
FOGLE, ROSA

	
 

1245359611

	
LSA

	
SA00170

	
AG

   GARCIA

	
GARCIA, ABEL

	
 

1013193721

	
LSA

	
SA00073

	
CG

   GARCIA-MAYORCA

	
GARCIA-MAYORCA, CARLOS

	
 

1265551949

	
LSA

	
SA0313

	
EG

   GLORIA

 

	
GLORIA, EDUARDO

	
 

1982723672

	
LSA

	
SA00270

	
FG

GONZALEZ

	
GONZALEZ, FLOR

	
 

1043339732

	
CSA

	
A06115

	
DG

   GRIFFITH

	
GRIFFITH, DAWN

	
 

1558548578

	
SA-C

	
07336

	
LH

   HERNANDEZ

 

	
HERNANDEZ, LUIS

	
 

1184800898

	
CSA

	
SA2582

	
AH

   HOWARD

 

	
HOWARD, ARTHUR

	
 

1013997261

	
CSA

	
CSA2667

	
SK

   KHAN

	
KHAN, SOSUN

	
 

1881713584

	
LSA

	
SA00272

	
ML

LEON

	
LEON, MARITZA

	
 

1831319524

	
SA-C

	
A03118

	
JL

   LORES

 

	
LORES, JULIO

	
 

1972622595

	
CSA

	
A05224

	
JM0-1

   MACHADO

 

	
MACHADO, JANETSY

	
 

1851579551

	
CSA

	
CSA3044

	
RM

   MACHADO

	
MACHADO, RAUL

	
 

1710006333

	
LSA

	
SA00129

 

  

3

  

 

Provider List

10/23/2008

 

	Code	Name	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
SM

   MAMLOUK

 

	
MAMLOUK, SAMUEL

	
 

1194844712

	
LSA

	
SA00263

	
OM

   MARTINEZ

 

	
MARTINEZ, OMAR

	
 

1164616298

	
LSA

	
SA00286

	
MM

   MAYOR

 

	
MAYOR, MASOUDA

	
 

1225158918

	
LSA

	
SA00296

	
FM

   MEDINA

 

	
MEDINA, FELIPE

	
 

1306965025

	
SAC

	
03132

	
JM

   MORIN

 

	
MORIN, JOSE

	
 

1154440983

	
CSA

	
A06119

	
DM

   MURANOVIC

 

	
MURANOVIC, DUBRAVKA

	
 

1023137734

	
LSA

	
SA00084

	
NN

   NASSAR

 

	
NASSAR, NAYEF

	
 

1467570846

	
LSA

	
SA00135

	
JN

   NESIC

 

	
NESIC, J-PHILIP

	
 

1104046895

	
LSA

	
SA00312

	
CN

   NNA-WOSU

 

	
NNA-WOSU, CHI

	
 

1629283031

	
LSA

	
SA00085

	
JLO

   OLMO

 

	
OLMO, JAIME A

	
 

1619095627

	
LSA

	
SA00184

	
HP

   PANIAGUA

 

	
PANIAGUA, HENRY

	
 

1972621993

	
CSA

	
A05207

	
AP

   PARMAR

 

	
PARMAR, ABRAHAM

	
 

1487772307

	
LSA

	
SA00020

	
KP01

   PATEL

 

	
PATEL, KIRAN

	
 

1538287461

	
SA-C

	
A05217

	
LP01

   PATRONE

 

	
PATRONE, LOUIS

	
 

1417075201

	
LSA

	
SA00138

	
LP

   PERALTA

	
PERALTA, LEOPOLDO

	
 

1225156029

 

	
SA-C

	
A96160

 

  

4

  

 

Provider List

10/23/2008

 

	Code	Name 	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
FP

   PEREZ

 

	
PEREZ, FRANCIS

	
 

1245206481

	
CSA

	
CSA2617

	
KP

   PITA

 

	
PITA, KLEBER

	
 

1275651051

	
LSA

	
SA00274

	
CP

   PITTY

 

	
PITTY, CATALINO

	
 

1497885560

	
LSA

	
SA00279

	
FR

   RAMIREZ

 

	
RAMIREZ, FELIX

	
 

1801092010

	
LSA

	
SA00303

	
HR

   ROA

 

	
ROA, HERNAN

	
 

1184742066

	
LSA

	
SA00276

	
SR

   ROBIN

 

	
ROBIN, SCOTT

	
 

1437134962

	
LSA

	
SA00090

	
RR

   RODELA

 

	
RODELA, ROBERT

	
 

1508063728

	
CSA

	
A07252

	
ER

   RODRIGUEZ

 

	
RODRIGUEZ, EDUARDO

	
 

1831218593

 

	
LSA

	
SA00091

	
JR

   RUSSELL

 

	
RUSSELL, JAMES

	
 

1801871363

	
CST/CFA

	
CST85399

	
NS

   SANCHEZ

 

	
SANCHEZ, NORBERTO

	
 

1790970788

	
LSA

	
SA TEMPORARY

	
MS

   SHOKRALLA

 

	
SHOKRALLA, MAHER

	
 

1275652968

	
LSA

	
SA00269

	
JS

   SKORUPPA

 

	
SKORUPPA, JACOB

	
 

1215113022

	
CST/CFA

	
109194

	
PS

   SLAVCHEV

 

 

	
SLAVCHEV, PLAMEN

	
 

1194844803

	
LSA

	
SA00316

	
AS

   SOLOMAY

 

	
SOLOMAY, ALAN

	
 

1982723532

	
SA-C

	
A99216

	
PT01

   TAMARGO

	
TAMARGO, PEDRO

	
 

1114199809

	
SA-C

	
08120

 

  

5

  

 

Provider List

10/23/2008

 

	Code	Name	National Provider Identifier	Credentials	License Number
	  Last Name	 	 	 	 
	 	 	 	 	 
	
PT

   TROMBLEY

	
TROMBLEY, PATRICIA

	
 

1023136868

 

	
LSA

	
SA00156

	
IV

   VELEZ-VEGA

 

	
VELEZ-VEGA, IVELISSE

	
 

1700090701

	
LSA

	
SA00191

	
RV

   VILLARREAL

 

	
VILLARREAL, ROSENDO

	
 

1104930304

 

	
LSA

	
SA00249

	
HW

   WASSEF

 

	
WASSEF, HALA

	
 

1255508909

	
CSA

	
ABSA 08138

	
LW

   WU

 

	
WU, LARRY

	
 

1881807220

	
CSA

	
CSA2958

	
RZ

   ZAMARRON

 

	
ZAMARRON, ROGER

 

	
 

1275651010

	
LSA

	
SA00056

	
BZ

   ZHONG

	
ZHONG, BING TANG

	
 

1740308063

	
LSA

	
SA00158

 

  

6

  

 

AMENDMENT TO

AGREEMENT

BETWEEN

THREE RIVERS PROVIDER NETWORK

AND

FORT BEND SA SERVICES, INC.

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

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

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

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

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

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

 

 

 

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

 

	
*

	
Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act.  Confidential portions of this document have been filed separately with the Securities and Exchange Commission.f8k1010ex10x_amsurg.htm

 

Exhibit 10.10

 

THREE RIVERS PROVIDER NETWORK

AGREEMENT WITH

______________________________

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

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

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

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

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

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

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

_______________

 

	
*

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

 

 

  

Page 1

  

 

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

 

	
PROVIDER GROUP NAME (Please Print): 

American Surgical Assistants 

	 	
ATTENTION: LANI HAZELTON 

TRPN CONTRACTING COORDINATOR

	 	 	 	 	 
	 	 	 	THREE RIVERS PROVIDER NETWORK
	 	 	 	 	 
	Signature:	
/s/ Jaime Olmo

	 	Signature:	
 

	Title:	
COO

	 	 	
 

	Date:	
11/5/08

	 	 	
 

	 	 	 	 	
NAME:  Todd Breeden, C.O.O.

Mailing Address:  1620 Fifth Avenue Suite 900

San Diego, CA 92101    Phone:  (619) 230-0530

	 	 	 	Date:	 

 

ATTACHMENT A: PROVIDER INFORMATION

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

 

  

	
 

Tax ID:  30-0213088

 

	
 

Practice Name:  American Surgical Assistants

	
 

National Provider Identifier (NPI):

1497789481

(If there is more than one NPI Number, please attach a listing.)

 

	
 

Group / IPA Affiliation:___________

 

	
 

Degree:  LSA, CSA ,SA-C, RUFA

Specialty :  Surgical Assistants

                     First Assist

 

	 

Office Hours:  8-4:30 PM

 

Primary Address:  10039 Bissonnet S-250

Houston, TX  77036

 

County:  Harris

Phone:  713-779-9800  Fax:  713-779-9862

 

Email:  Jaimeolmo@me.com

 

Other Practice and/or Billing Address:  Yes □  No □

If “yes”, attach page with additional information

 

Hospital Affiliations (list name, date and type):

	 	 
	 	     Attached
	 	 
	 	 
	 	 

 

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

 

 

  

Page 2

  

  

            

ADDENDUM A:

MEDICAL STAFF LISTING & FACILITY LOCAITONS

_______________________________

 

 

	
i. 

	
The attached roster of providers and or locations will be participating under thisAgreement between American Surgical Assistants and Three Rivers Provider Network and shall include Tax Identification Numbers, NPI Numbers, Address(s), Phone and Fax Numbers.

 

 

 

 

  

Page 3

  

 

Provider List

10/23/2008

 

	Code Last Name 	Name 	National Provider Identifier	Credentials 	License Number
	
BA

   ABORDO

 

	
ABORDO, BELTRAN

	
 

1225155880

	
LSA

	
SA00024

 

	
SA

   ADIL

 

	
ADIL, SAYED

	
 

1649397217

	
LSA

	
SA00289

	
HA

   AGUILAR

 

	
AGUILAR, HUGO

	
 

1578680153

	
LSA

	
SA00283

	
OA

   AKUPUE

 

	
AKUPUE, OKECHUKWU

	
 

1346368917

	
LSA

	
SA00307

	
MA

   ALALAM

 

	
ALALAM, MOHD

	
 

1487772901

	
LSA

	
SA00309

	
RA

   ARAGON

 

	
ARAGON, RECTO

	
 

1427176981

	
SA-C

	
A01143

	
AA

ARREOZOLA

 

	
ARREOZOLA, ALEJANDRO

	
 

1649398108

	
LSA

	
SA00299

	
JA

   ASPORT

	
ASPORT, JORGE

	
 

1710005053

 

	
LSA

	
A03119

	
MA01

   ATHANS

 

	
ATHANS, MARK

	
 

1093833576

	
LSA

	
SA00029

	
IA

   AYUB

 

	
AYUB, ILIA

	
 

1568580058

	
CSA

	
CSA04209

 

	
QB

   BABURI

 

	
BABURI, QASIM

	
 

1043338445

	
LSA

	
SA00160

	
VB01

   BARCES

 

	
BARCES, VICENTE

	
 

1932227287

	
LSA

	
SA00161

	
VB

   BATTAD`

 

	
BATTAD, VENERANDO

	
 

1003934357

	
LSA

	
SA00290

	
CB

   BENITEZ

 

	
BENITEZ, CARLOS

	
 

1700904067

	
LSA

	
SA00163

	
WB

   BERRY

 

	
BERRY, WILLIAM

	
 

1851589386

	
CST/CFA

	
109540

  

1

  

 

Provider List

10/23/2008

 

	Code Last Name 	Name 	National Provider Identifier	Credentials	License Number
	
DGB

   BESSON

 

	
BESSON, DORKA G

	
 

1750501565

	
LSA

	
SA00291

	
AC

   CALLEGARI

 

	
CALLEGARI, ANDRES

	
 

1275651226

	
LSA

	
SA00108

	
JC01

   CANSECO

 

	
CANSECO, JOSE

	
 

1700904737

	
LSA

	
SA00110

	
JC002

CARRION

 

	
CARRION, JOSE

	
 

1629196704

	
SA-C

	
06114

	
LC

   CERDAN

 

	
CERDAN, LAURO

	
 

1922126002

 

	
CSA

	  
	
BC   

  CHAMBERLAIN

 

	
CHAMBERLAIN, BLAND

	
 

1891813804

	
LSA

	
SA00237

	
JC

   CHAPA

 

	
CHAPA, JOSE

	
 

1467570374

	
LSA

	
SA00255

	
MC

   CHAUDHRY

	
CHAUDHRY,MUBASHIR

	
 

1427176379

	
LSA

	
SA00277

	
MC01

   COLELLO

 

	
COLELLO, MARY

	
 

1386829521

	
SA-C

	
07272

	
VC

   CRUZ

	
CRUZ, VIRGINIA

	
 

1053439885

	
CSA

	
A05223

	
AD

   DARWISHS-SALAMA

 

	
DARWISHS-SALAMA, ALFREDO

	
 

1699893354

	
LSA

	
SA0315

	
ND

   DAVIS

 

	
DAVIS, NORMAN

	
 

1164553772

	
CSA

	
ABSA 001163

	
BE

   EATON

 

	
EATON, BRENT

	
 

1699894378

	
CRNFA

	
061022

	
ZE

ELGAMAL

 

	
ELGAMAL, ZAK

	
 

1194786046

	
LSA

	
SA00011

	
MF

FARAG

 

	
FARAG, MAURICE

	
1548389216

	
LSA

	
SA00038

 

 

  

2

  

 

Provider List

10/23/2008

 

	Code Last Name 	Name  	National Provider Identifier	Credentials	License Number
	
DF

   FLORES

 

	
FLORES, DAVID

 

	
 

1407975162

	
LSA

	
SA00069

	
LF

   FLORES

 

	
FLORES, LETICIA

	
 

1053502385

	
CNOR

	
CNOR030775

	
RF

   FOGLE

	
FOGLE, ROSA

	
 

1245359611

	
LSA

	
SA00170

	
AG

   GARCIA

	
GARCIA, ABEL

	
 

1013193721

	
LSA

	
SA00073

	
CG

   GARCIA-MAYORCA

	
GARCIA-MAYORCA, CARLOS

	
 

1265551949

	
LSA

	
SA0313

	
EG

   GLORIA

 

	
GLORIA, EDUARDO

	
 

1982723672

	
LSA

	
SA00270

	
FG

GONZALEZ

	
GONZALEZ, FLOR

	
 

1043339732

	
CSA

	
A06115

	
DG

   GRIFFITH

	
GRIFFITH, DAWN

	
 

1558548578

	
SA-C

	
07336

	
LH

   HERNANDEZ

 

	
HERNANDEZ, LUIS

	
 

1184800898

	
CSA

	
SA25282

	
AH

   HOWARD

 

	
HOWARD, ARTHUR

	
 

1013997261

	
CSA

	
CSA2667

	
SK

   KHAN

	
KHAN, SOSUN

	
 

1881713584

	
LSA

	
SA00272

	
ML

LEON

	
LEON, MARITZA

	
 

1831319524

	
SA-C

	
A03118

	
JL

   LORES

 

	
LORES, JULIO

	
 

1972622595

	
CSA

	
A05224

	
JM0-1

   MACHADO

 

	
MACHADO, JANETSY

	
 

1851579551

	
CSA

	
CSA3044

	
RM

   MACHADO

	
MACHADO, RAUL

	
 

1710006333

	
LSA

	
SA00129

 

 

  

3

  

Provider List

10/23/2008

 

	Code Last Name	Name	National Provider Identifier	Credentials  	License Number
	
SM

   MAMLOUK

 

	
MAMLOUK, SAMUEL

	
 

1194844712

	
LSA

	
SA00263

	
OM

   MARTINEZ

 

	
MARTINEZ, OMAR

	
 

1164616298

	
LSA

	
SA00286

	
MM

   MAYOR

 

	
MAYOR, MASOUDA

	
 

1225158918

	
LSA

	
SA00296

	
FM

   MEDINA

 

	
MEDINA, FELIPE

	
 

1306965025

	
SAC

	
03132

	
JM

   MORIN

 

	
MORIN, JOSE

	
 

1154440673

	
CSA

	
A06119

	
DM

   MURANOVIC

 

	
MURANOVIC, DUBRAVKA

	
 

1023137734

	
LSA

	
SA00084

	
NN

   NASSAR

 

	
NASSAR, NAYEF

	
 

1467570846

	
LSA

	
SA00135

	
JN

   NESIC

 

	
NESIC, J-PHILIP

	
 

1104046895

	
LSA

	
SA00312

	
CN

   NNA-WOSU

 

	
NNA-WOSU, CHI

	
 

1629283031

	
LSA

	
SA00085

	
JLO

   OLMO

 

	
OLMO, JAIME A

	
 

1619095627

	
LSA

	
SA00184

	
HP

   PANIAGUA

 

	
PANIAGUA, HENRY

	
 

1972621993

	
CSA

	
A05207

	
AP

   PARMAR

 

	
PARMAR, ABRAHAM

	
 

1487772307

	
LSA

	
SA00020

	
KP01

   PATEL

 

	
PATEL, KIRAN

	
 

1538287461

	
SA-C

	
A05217

	
LP01

   PATRONE

 

	
PATRONE, LOUIS

	
 

1417075201

	
LSA

	
SA00138

	
LP

   PERALTA

	
PERALTA, LEOPOLDO

	
 

1225156029

 

	
SA-C

	
A96160

 

 

  

4

  

Provider List

10/23/2008

 

	Code Last Name 	Name 	National Provider Identifier	Credentials	License Number
	
FP

   PEREZ

 

	
PEREZ, FRANCIS

	
 

1245206481

	
CSA

	
CSA2617

	
KP

   PITA

 

	
PITA, KLEBER

	
 

1275651051

	
LSA

	
SA00274

	
CP

   PITTY

 

	
PITTY, CATALINO

	
 

1497885560

	
LSA

	
SA00279

	
FR

   RAMIREZ

 

	
RAMIREZ, FELIX

	
 

1801092010

	
LSA

	
SA00303

	
HR

   ROA

 

	
ROA, HERNAN

	
 

1184742066

	
LSA

	
SA00276

	
SR

   ROBIN

 

	
ROBIN, SCOTT

	
 

1437134962

	
LSA

	
SA00090

	
RR

   RODELA

 

	
RODELA, ROBERT

	
 

1508063728

	
CSA

	
A07252

	
ER

   RODRIGUEZ

 

	
RODRIGUEZ, EDUARDO

	
 

1831218593

 

	
LSA

	
SA00091

	
JR

   RUSSELL

 

	
RUSSELL, JAMES

	
 

1801871363

	
CST/CFA

	
CST85399

	
NS

   SANCHEZ

 

	
SANCHEZ, NORBERTO

	
 

1790970788

	
LSA

	
SA TEMPORARY

	
MS

   SHOKRALLA

 

	
SHOKRALLA, MAHER

	
 

1275652968

	
LSA

	
SA00269

	
JS

   SKORUPPA

 

	
SKORUPPA, JACOB

	
 

1215113022

	
CST/CFA

	
109194

	
PS

   SLAVCHEV

 

 

	
SLAVCHEV, PLAMEN

	
 

1194844803

	
LSA

	
SA00316

	
AS

   SOLOMAY

 

	
SOLOMAY, ALAN

	
 

1982723532

	
SA-C

	
A99216

	
PT01

   TAMARGO

	
TAMARGO, PEDRO

	
 

1114199809

	
SA-C

	
08120

 

 

  

5

  

 

Provider List

10/23/2008

 

	Code Last Name 	Name	National Provider Identifier	Credentials	License Number
	
PT

   TROMBLEY

	
TROMBLEY, PATRICIA

	
 

1023136868

 

	
LSA

	
SA00156

	
IV

   VELEZ-VEGA

 

	
VELEZ-VEGA, IVELISSE

	
 

1700090701

	
LSA

	
SA00191

	
RV

   VILLARREAL

 

	
VILLARREAL, ROSENDO

	
 

1104930304

 

	
LSA

	
SA00249

	
HW

   WASSEF

 

	
WASSEF, HALA

	
 

1255508909

	
CSA

	
ABSA 08138

	
LW

   WU

 

	
WU, LARRY

	
 

1881807220

	
CSA

	
CSA2958

	
RZ

   ZAMARRON

 

	
ZAMARRON, ROGER

 

	
 

1275651010

	
LSA

	
SA00056

	
BZ

   ZHONG

	
ZHONG, BING TANG

	
 

1740308063

	
LSA

	
SA00158

 

  

6

  

 

Provider List

10/23/2008

 

	Code Last Name 	Name	National Provider Identifier	Credentials	License Number
	
WB

   BERRY

 

	
BERRY, WILLIAM

	
 

1851589386

	
CST/CFA

	
109540

	
LF

   FLORES

 

	
FLORES, LETICIA

	
 

1053502385

	
CNOR

	
030775

	
AG

   GARCIA

 

 

	
GARCIA, ABEL

	
 

1013193721

	
LSA

	
SA00073

	
JR01

   RIOS

 

	
RIOS, JIMMI

	
 

1760500789

	
SA-C

	
A05263

	
SR

   ROBIN

 

	
ROBIN, SCOTT

	
 

1437134962

	
LSA

	
SA00090

	
JR

   RUSSELL

 

	
RUSSELL, JAMES

	
1801871363

	
CST/CFA

	
CST85399

	
JS

   SKORUPPA

 

	
SKORUPPA, JACOB

	
 

1215113022

	
CST/CFA

	
109194

	
PT01

   TAMARGO

 

	
TAMARGO, PEDRO

	
 

1114199809

	
SA-C

	
08120

	
PT

   TROMBLEY

	
TROMBLEY, PATRICIA

	
1023136868

 

	
LSA

	
SA00156

 

  

7

  

 

	  
	
Christus Spohn Health System

600 Elizabeth Street

Corpus Christi TX 78404

	
Corpus Christi Medical Center

1533 South Brownlee

Corpus Christi TX 78404

 

  

 

  

 

 

	  
	
Bayshore Medical Center

4000 Spencer Highway

Pasadena TX 77504

	
Christus St. Catherine’s

701 South Fry Road

Katy TX 77450

	
Christus St. John Hospital

18300 St. John Dr.

Nassau Bay, TX 77058

	
Clear Lake Medical Center

500 Medial Center Blvd.

Webster TX 77598

	
Cypress Fairbanks Medical Center

10655 Steepletop Drive

Houston, TX 77065

	
Doctors Surgical Center

8111 Southwest Freeway

Houston TX 77074

	
East Houston Regional Medical Center

13111 East Freeway

Houston TX 77015

	
East Side Surgery Center

10918 East Freeway

Houston TX 77029

	
First Street Hospital

4801 Bissonnet

Bellaire TX 77401

	
First Surgical Memorial Village

12727 Kimberly Lane #100

Houston TX 77024

	
First Surgical Partners LLC

411 First Street

Bellaire TX 77401

	
Foundations Surgery Center

5410 West Loop South

Bellaire TX 77401

	
Houston NW Medical Center

710 FM 1960 West

Houston, TX 77090

	
Katy St. Catherine’s Surgery Center

707 South Fry Road #150

Katy TX 77450

 

  

 

  

 

	
Palladium Surgery Center

4120 Southwest Freeway #230

Houston TX 77027

	
Park Plaza Hospital

1313 Hermann Drive

Houston TX 77004

	
Special Surgery Centre

9180 Katy Freeway Suite 202

Houston TX 77055

	
Spring Branch Medical Center

8850 Long Point

Houston TX 77055

	
St. Joseph Medical Center

1401 St. Joseph Parkway

Houston, TX 77002

	
St. Luke’s Episcopal Hospital Sugar Land

1317 Lake Point Parkway

Sugar Land TX 77478

	
St. Luke’s Episcopal Hospital

6720 Bertner Street

Houston TX 77030

	
Sugar Land Surgical Hospital

1211 Highway 6 Suite 70

Sugar Land TX 77478

	
The Woman’s Hospital

7600 Fannin

Houston TX 77054

	
West Houston Medical Center

12141 Richmond Avenue

Houston TX 77082

 

	
West Houston Surgicare

970 Campbell Road

Houston TX 77080

 

  

 

  

 

	
Kingwood Medical Center

22999 US Highway 59

Kingwood TX 77339

	
Memorial Hermann

6411 Fannin

Houston, TX 77030

	
Memorial Hermann Memorial City

921 Gessner Road

Houston TX 77024

	
Memorial Hermann Northwest

1635 North Loop West

Houston TX 77008

	
Memorial Hermann Southeast

11800 Astoria Blvd

Houston TX 77089

	
Memorial Hermann Southwest

7600 Beechnut

Houston TX 77074

	
Memorial Hermann Surgery Center Northwest

1634 North Loop West #300

Houston TX 77008

	
Memorial Hermann Surgery Center Southwest

7789 Southwest Freeway #200

Houston TX 77074

	
Memorial Hermann The Woodlands

9250 Pinecroft

The Woodlands TX 77380

	
Methodist Sugar Land

16655 Southwest Freeway

Sugar Land TX 77479

	
Methodist Willowbrook

18220 Tomball Parkway

Houston TX 77070

	
North Cypress Medical Center

21214 Northwest Freeway

Cypress TX 77429

	
Northeast Medical Center

18951 Memorial North

Humble TX 77338

	
OakBend Medical Center

1705 Jackson Street

Richmond TX 77469

 

  

 

  

 

AMENDMENT TO

AGREEMENT

BETWEEN

THREE RIVERS PROVIDER NETWORK

AND

AMERICAN SURGICAL ASSISTANTS, INC.

This AMENDMENT to the Agreement between THREE RIVERS PROVIDER NETWORK (“TRPN”) AND (Tax  Id# 30-0213088), dated 10-23-08 (“Agreement”), is entered into and made effective as of   05-07-2010.

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

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

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

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

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

 

 

 

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

 

 

	
*

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

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00179-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00179-of-00352.parquet"}]]