THREE RIVERS PROVIDER NETWORK AGREEMENT WITH ______________________________

EX-10.8 9 f8k1010ex10viii_amsurg.htm THREE RIVERS PROVIDER NETWORK AGREEMENT - BRAZOS SA SERVICES f8k1010ex10viii_amsurg.htm
Exhibit 10.8
 

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 Brazos 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 paymen t 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:     10/22/08
 
   NAME:  Todd Breeden, C.O.O.
   Mailing Address:  1620 Fifth Avenue Suite 900
   San Diego, CA 92101    Phone:   ###-###-####
   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:   ###-###-#### Practice Name:  Brazos SA Services
   
National Provider Identifier (NPI):  
   
1033382668 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 1172
  Alief TX 7741
   
  County:  Harris
  Phone:   ###-###-####  Fax:   ###-###-####
   
  Email:   ***@***
   
  Other Practice and/or Billing Address:  Yes □  No
  If “yes”, attach page with additional information
   
  Hospital Affiliations (list name, date and type):
   
   
   
   
   
   
 
Provider agrees to mark “N/A” next to any blank that is not applicable to Provider’s business.
 
 
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ADDENDUM A:

MEDICAL STAFF LISTING & FACILITY LOCATIONS

_______________________________


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

 
 
Provider List
10/23/2008
 
Code  Name  National Provider Identifier Credentials  License Number
Last Name         
         
OA
   AKUPUE
AKUPUE, OKECHUHUKWU
 
1346368917
LSA
SA00307
MC
   COLELLO
COLELLO, MARY
 
1386829521
SA-C
07272
BE
   EATON
EATON, BRENT
 
1699894378
CRNFA,SA-C
061022
DG
  GRIFFITH
GRIFFITH, DAWN
 
1558548578
SA-C
07336
WY
   YANG
YANG, WEN
 
1588849939
LSA
SA00306
 
 
1

 
 
BRAZOS SA SERVICES
 Southwestern Medical Center
 1602 Southwest 82nd Street
 Lawton OK 73505
 
 
 
 

 
 
 
AMENDMENT TO
AGREEMENT

BETWEEN
THREE RIVERS PROVIDER NETWORK
AND

BRAZOS SA SERVICES, INC.


This AMENDMENT to the Agreement between THREE RIVERS PROVIDER NETWORK (“TRPN”) AND (Tax  Id# 35 ###-###-####), 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.