Ancillary Provider Agreement by wan12683

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									                                Urgent Care Provider Agreement

This agreement is hereby made this 1st day of April 2009 by and between Co mmunity Bridges Management
Inc. (“CBM”) a Physician Network and ________________________________________________
_______________________________________________________ an Urgent Care Center provider to
provide urgent care services to Oakland Health Plan patients assigned to CBM.
Whereas CBM is a for pro fit corporation organized for the purpose of arranging for a improved and more
cost efficient health care delivery system wh ich includes Urgent Care Urgent Care services. CBM has
entered into a contract with Oakland Health Plan to provide covered med ical services to assigned members
of the program.
    1) Services:
       All Urgent Care services in which above entity is licensed and authorized to do.

    2) Urgent Care services at all locations of provider.

    3) The provider will provide Urgent Care services to members assigned to CBM as referred
       to by approved and authorized referrals approved by calling case management on call
       at 734-637-3984, or 313-815-8767.

    4) Compensation: For all approved and authorized services the Urgent Care provider will
       be paid the Flat Global Rate for all services provided of $70 per visit.

    5) All approved clean claims will be billed to CBM at PO Box 489, Linden, MI 48451 and
       be paid no later then 45 days.

    6) The provider shall be an independent contractor, and CBM shall not exercise any control
       or direction in a particular case over the provider’s performance professional duties or
       exercises of professional judgment.

    7) The provider will look solely to CBM for payment and shall not balance bill any portion
       to the patient directly.

    8) Either party may cancel this agreement with notice by providing 30 days to the other
       party of intention to do so.

    9) This contract will immediately cancel if Oakland Health Plan cancels its contract with
       CBM.

By signing this document Provider agrees to terms as stated above.

Provi der

By_________________________________                Date_____________
Signature

Communi ty Bridges Management Inc.
CBM PO Bo x 489
Linden, Michigan 48451
734-347-1462 Fax 810-458-4187

By_____________________________________ Date_______________
  Ch ief Executive Officer
Clai ms to be sent to: CBM PO Bo x 489, Linden, MI 48451


Urgent Care Information Sheet



Name________________________________________________________

Address of all locations in Oakland County




NPI
#____________________________________________________________
_____________

Tax ID
#____________________________________________________________
__________

Telephone____________________________________________________
_________________

Fax__________________________________________________________
_________________


Hours of Operation:




Fax Signed Contract and Information s heet to: CBM 810-458-4187

								
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