Appendix A
Virtual Group Agreement Template
PRA Disclosure Statement
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Sample Introductory Paragraph:
This Virtual Group Agreement (“Agreement”) is by and between Virtual Group Identifier provided by the Centers for Medicare & Medicaid Services, and XYZ Group Practice P.C. (“virtual group member”) and is effective [Month, Day, Year] (“Effective Date”).
<Body of Agreement>
Sample Signature Page:
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by the duly authorized representatives as of the dates below.
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CMS-10652 PRA Appendix A - Virtual Group Agreement Template |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |