THREE RIVERS PROVIDER NETWORK

EX-10.10 11 f8k1010ex10x_amsurg.htm THREE RIVERS PROVIDER NETWORK AGREEMENT - AMERICAN SURGICAL ASSISTANTS, INC. 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.& #160; 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:   ###-###-####
      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:   ###-###-####  Fax:   ###-###-####
 
Email:   ***@***
 
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.