This agreement is not a contract for any specific period of time and
client as well as Physician Services may terminate their relationship
with a 30 day written notice.
This agreement is between __________________________________ (Provider)
and Physician Services (PS), made this ____________ day
of ______________ 20______.
All monies will go directly to said provider from any and all insurance
companies or payers and at no time will money go to (PS).
Provider will pay a set up Fee of $250 mailed with a signed copy of
agreement form before any billing begins. Doctor understands fees
from "Billing Service Fees and Program" and $600.00 monthly invoice
policy.
Provider agrees to speak to (PS) account representative on a monthly
basis to assure satisfactory service.
Provider will email in all billing and will fax or email EOB's. Any
software necessary to allow doctors computer to down load billing to
us will be paid by doctor.
This agreement can be amended by the Provider and (PS). This agreement
is to abide by the laws of Florida.
Any collection fee necessary to collect a debt will be paid by the
debtor.
____________________________________
Provider's signature
____________________________________
Greg Barnes/PHYSICIAN SERVICES
State License Number: _________________________
Invoice payment policy:
I do hereby understand that my personal insurance CA with Physician
Services gets paid upon my payment of invoice. All invoices will be
faxed on the 1st of each month and all invoice payments are due in
Physician Services office by the due date.
I do understand that if invoice is not received then all work on my
account will cease until invoice is paid. If payment of invoice is
late, a late fee of 10% of invoice amount will be assessed. If my
check bounces I agree to pay a $50 bounced check fee as well as I
understand that until I make my check good and pay the $50 bounced
check fee all work on my account will cease.
I do understand this invoice payment policy and will comply with
the terms.
________________________________________________ ______________
Doctors signature and date
Indemnification
(This page must be signed and attached to the agreement form with
payment before any billing is started.) Client shall indemnify and
defend Company, and its trustees, officers, contractors, employees
from and against any actions, suits, claims, judgments, liabilities,
costs and expenses (including reasonable attorneys' fees) arising
out of or relating to any acts of the Client, especially, but not
limited to, client's furnishing Company with any information
concerning billing matters. It is clearly understood that the
Company makes no investigation of the coding or bills furnished
to it by the Client. The Client's obligation to so indemnify and
defend the Company shall be for a period of six (6) years following
the termination of this Agreement. Nothing in this paragraph or
elsewhere in this Agreement shall create or give to third parties
any claim or right of action against the Company.
____________________________________
Client Signature
____________________________________
Date
____________________________________
Please Print Client Name
