County Name: _____________________ |
|
|
|
|
|
LEGAL-2 PROVIDER ARRANGEMENTS |
|
|
|
|
|
Category |
Type of Agreement |
Number of Agreements |
Date Executed |
Automatic Renewal of Agreements |
Page Number for Contract in this Application |
Staff |
|
|
|
|
|
Physicians |
|
|
|
|
|
Non-Physicians |
|
|
|
|
|
Non-staff Physicians |
|
|
|
|
|
Group |
|
|
|
|
|
Member Physicians |
|
|
|
|
|
Member Non-Physicians |
|
|
|
|
|
Non-Member Physicians |
|
|
|
|
|
Non-Member, Non-Physicians |
|
|
|
|
|
IPA |
|
|
|
|
|
Member Physicians |
|
|
|
|
|
Member Non-Physicians |
|
|
|
|
|
Non-member Physicians |
|
|
|
|
|
Non-member, Non-Physicians |
|
|
|
|
|
Direct Contract HMO Physicians |
|
|
|
|
|
Lab Services |
|
|
|
|
|
X-ray Services |
|
|
|
|
|
Hospitals |
|
|
|
|
|
Home Health |
|
|
|
|
|
Other (specify) |
|
|
|
|
|
|
|
|
|
|
|
Medicare/HMO Health Services |
|
Prepare a separate table for each county requested |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PROVIDER ARRANGEMENTS |
|
|
|
TABLE: Legal-2 |
|
|
|
|
|
|
|
Instructions: |
|
|
|
|
|
|
|
|
|
|
|
Provide a separate table for each county or partial county. |
|
|
|
|
|
|
|
|
|
|
|
Column Explanations: |
|
|
|
|
|
|
|
|
|
|
|
1. Category - Staff/Group/IPA/PHO/Direct: |
|
|
|
|
|
|
|
|
|
|
|
Member Physicians - Licensed Medical Doctors (M.D.) and Doctors of Osteopathic Medicine (O.D.) |
|
|
|
|
|
who are members of the entity. |
|
|
|
|
|
Member Non-Physicians - Mid-wives, nurse practitioners, or chiropractors, etc. who are members of |
|
|
|
|
|
the entity. |
|
|
|
|
|
Non-Member Physicians - Licensed M.D. and D.O. who are subcontracted to provide services to the. |
|
|
|
|
|
entity. |
|
|
|
|
|
Non-Member, Non-Physicians - Mid-wives, nurse practitioners, or chiropractors, etc. who are |
|
|
|
|
|
subcontracted to provide services to the entity but are not members of the entity. |
|
|
|
|
|
Direct Contract HMO Physicians - Licensed M.D. and D.O. who have entered into a contract with the |
|
|
|
|
|
HMO. |
|
|
|
|
|
|
|
|
|
|
|
2. Type of Agreement - Only contracts or Letters of Agreement (LOA) are acceptable. Letters of |
|
|
|
|
|
intent are not acceptable. |
|
|
|
|
|
|
|
|
|
|
|
3. Number of Agreements - List the total number of signed agreements. |
|
|
|
|
|
|
|
|
|
|
|
4. Automatic Renewal of Agreements - Provide "Yes" or "No" response. |
|
|
|
|
|
|
|
|
|
|
|
5. Date Executed - Enter the date all agreements were finalized for the particular category. |
|
|
|
|
|
|
|
|
|
|
|
6. Page Number in Contract - List the page number where the agreement is located in the application |
|
|
|
|
|
package. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|