Attached files
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. 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.
_______________
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*
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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.
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Page 1
IN WITNESS WHEREOF, the authorized parties hereto have executed this Agreement and intend to be bound thereby.
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PROVIDER GROUP NAME (Please Print):
American Surgical Assistants
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ATTENTION: LANI HAZELTON
TRPN CONTRACTING COORDINATOR
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|||
| THREE RIVERS PROVIDER NETWORK | ||||
| Signature: |
/s/ Jaime Olmo
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Signature: |
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| Title: |
COO
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| Date: |
11/5/08
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NAME: Todd Breeden, C.O.O.
Mailing Address: 1620 Fifth Avenue Suite 900
San Diego, CA 92101 Phone: (619) 230-0530
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||||
| 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)
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Tax ID: 30-0213088
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Practice Name: American Surgical Assistants
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National Provider Identifier (NPI):
1497789481
(If there is more than one NPI Number, please attach a listing.)
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Group / IPA Affiliation:___________
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Degree: LSA, CSA ,SA-C, RUFA
Specialty : Surgical Assistants
First Assist
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Office Hours: 8-4:30 PM
Primary Address: 10039 Bissonnet S-250
Houston, TX 77036
County: Harris
Phone: 713-779-9800 Fax: 713-779-9862
Email: Jaimeolmo@me.com
Other Practice and/or Billing Address: Yes □ No □
If “yes”, attach page with additional information
Hospital Affiliations (list name, date and type):
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| 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
_______________________________
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i.
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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.
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Page 3
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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BA
ABORDO
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ABORDO, BELTRAN
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1225155880
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LSA
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SA00024
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|
SA
ADIL
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ADIL, SAYED
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1649397217
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LSA
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SA00289
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HA
AGUILAR
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AGUILAR, HUGO
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1578680153
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LSA
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SA00283
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OA
AKUPUE
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AKUPUE, OKECHUKWU
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1346368917
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LSA
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SA00307
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MA
ALALAM
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ALALAM, MOHD
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1487772901
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LSA
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SA00309
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RA
ARAGON
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ARAGON, RECTO
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1427176981
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SA-C
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A01143
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AA
ARREOZOLA
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ARREOZOLA, ALEJANDRO
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1649398108
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LSA
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SA00299
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JA
ASPORT
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ASPORT, JORGE
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1710005053
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LSA
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A03119
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MA01
ATHANS
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ATHANS, MARK
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1093833576
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LSA
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SA00029
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IA
AYUB
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AYUB, ILIA
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1568580058
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CSA
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CSA04209
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QB
BABURI
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BABURI, QASIM
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1043338445
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LSA
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SA00160
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VB01
BARCES
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BARCES, VICENTE
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1932227287
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LSA
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SA00161
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VB
BATTAD`
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BATTAD, VENERANDO
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1003934357
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LSA
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SA00290
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CB
BENITEZ
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BENITEZ, CARLOS
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1700904067
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LSA
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SA00163
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WB
BERRY
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BERRY, WILLIAM
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1851589386
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CST/CFA
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109540
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1
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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DGB
BESSON
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BESSON, DORKA G
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1750501565
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LSA
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SA00291
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AC
CALLEGARI
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CALLEGARI, ANDRES
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1275651226
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LSA
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SA00108
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JC01
CANSECO
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CANSECO, JOSE
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1700904737
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LSA
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SA00110
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JC002
CARRION
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CARRION, JOSE
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1629196704
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SA-C
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06114
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LC
CERDAN
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CERDAN, LAURO
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1922126002
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CSA
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|
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BC
CHAMBERLAIN
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CHAMBERLAIN, BLAND
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1891813804
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LSA
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SA00237
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JC
CHAPA
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CHAPA, JOSE
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1467570374
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LSA
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SA00255
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MC
CHAUDHRY
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CHAUDHRY,MUBASHIR
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1427176379
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LSA
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SA00277
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MC01
COLELLO
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COLELLO, MARY
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1386829521
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SA-C
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07272
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VC
CRUZ
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CRUZ, VIRGINIA
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1053439885
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CSA
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A05223
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AD
DARWISHS-SALAMA
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DARWISHS-SALAMA, ALFREDO
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1699893354
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LSA
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SA0315
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ND
DAVIS
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DAVIS, NORMAN
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1164553772
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CSA
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ABSA 001163
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BE
EATON
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EATON, BRENT
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1699894378
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CRNFA
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061022
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ZE
ELGAMAL
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ELGAMAL, ZAK
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1194786046
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LSA
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SA00011
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MF
FARAG
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FARAG, MAURICE
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1548389216
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LSA
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SA00038
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2
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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DF
FLORES
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FLORES, DAVID
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1407975162
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LSA
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SA00069
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LF
FLORES
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FLORES, LETICIA
|
1053502385
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CNOR
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CNOR030775
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RF
FOGLE
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FOGLE, ROSA
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1245359611
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LSA
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SA00170
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AG
GARCIA
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GARCIA, ABEL
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1013193721
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LSA
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SA00073
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CG
GARCIA-MAYORCA
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GARCIA-MAYORCA, CARLOS
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1265551949
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LSA
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SA0313
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EG
GLORIA
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GLORIA, EDUARDO
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1982723672
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LSA
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SA00270
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FG
GONZALEZ
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GONZALEZ, FLOR
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1043339732
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CSA
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A06115
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DG
GRIFFITH
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GRIFFITH, DAWN
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1558548578
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SA-C
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07336
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LH
HERNANDEZ
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HERNANDEZ, LUIS
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1184800898
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CSA
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SA25282
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AH
HOWARD
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HOWARD, ARTHUR
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1013997261
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CSA
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CSA2667
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SK
KHAN
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KHAN, SOSUN
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1881713584
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LSA
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SA00272
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ML
LEON
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LEON, MARITZA
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1831319524
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SA-C
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A03118
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JL
LORES
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LORES, JULIO
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1972622595
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CSA
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A05224
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JM0-1
MACHADO
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MACHADO, JANETSY
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1851579551
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CSA
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CSA3044
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RM
MACHADO
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MACHADO, RAUL
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1710006333
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LSA
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SA00129
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3
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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SM
MAMLOUK
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MAMLOUK, SAMUEL
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1194844712
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LSA
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SA00263
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OM
MARTINEZ
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MARTINEZ, OMAR
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1164616298
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LSA
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SA00286
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MM
MAYOR
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MAYOR, MASOUDA
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1225158918
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LSA
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SA00296
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FM
MEDINA
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MEDINA, FELIPE
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1306965025
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SAC
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03132
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JM
MORIN
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MORIN, JOSE
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1154440673
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CSA
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A06119
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DM
MURANOVIC
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MURANOVIC, DUBRAVKA
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1023137734
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LSA
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SA00084
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NN
NASSAR
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NASSAR, NAYEF
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1467570846
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LSA
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SA00135
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JN
NESIC
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NESIC, J-PHILIP
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1104046895
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LSA
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SA00312
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CN
NNA-WOSU
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NNA-WOSU, CHI
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1629283031
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LSA
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SA00085
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JLO
OLMO
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OLMO, JAIME A
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1619095627
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LSA
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SA00184
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HP
PANIAGUA
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PANIAGUA, HENRY
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1972621993
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CSA
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A05207
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AP
PARMAR
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PARMAR, ABRAHAM
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1487772307
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LSA
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SA00020
|
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KP01
PATEL
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PATEL, KIRAN
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1538287461
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SA-C
|
A05217
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LP01
PATRONE
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PATRONE, LOUIS
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1417075201
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LSA
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SA00138
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LP
PERALTA
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PERALTA, LEOPOLDO
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1225156029
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SA-C
|
A96160
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4
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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FP
PEREZ
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PEREZ, FRANCIS
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1245206481
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CSA
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CSA2617
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KP
PITA
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PITA, KLEBER
|
1275651051
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LSA
|
SA00274
|
|
CP
PITTY
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PITTY, CATALINO
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1497885560
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LSA
|
SA00279
|
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FR
RAMIREZ
|
RAMIREZ, FELIX
|
1801092010
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LSA
|
SA00303
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|
HR
ROA
|
ROA, HERNAN
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1184742066
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LSA
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SA00276
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|
SR
ROBIN
|
ROBIN, SCOTT
|
1437134962
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LSA
|
SA00090
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|
RR
RODELA
|
RODELA, ROBERT
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1508063728
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CSA
|
A07252
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|
ER
RODRIGUEZ
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RODRIGUEZ, EDUARDO
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1831218593
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LSA
|
SA00091
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JR
RUSSELL
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RUSSELL, JAMES
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1801871363
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CST/CFA
|
CST85399
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|
NS
SANCHEZ
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SANCHEZ, NORBERTO
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1790970788
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LSA
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SA TEMPORARY
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MS
SHOKRALLA
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SHOKRALLA, MAHER
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1275652968
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LSA
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SA00269
|
|
JS
SKORUPPA
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SKORUPPA, JACOB
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1215113022
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CST/CFA
|
109194
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|
PS
SLAVCHEV
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SLAVCHEV, PLAMEN
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1194844803
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LSA
|
SA00316
|
|
AS
SOLOMAY
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SOLOMAY, ALAN
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1982723532
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SA-C
|
A99216
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|
PT01
TAMARGO
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TAMARGO, PEDRO
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1114199809
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SA-C
|
08120
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5
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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PT
TROMBLEY
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TROMBLEY, PATRICIA
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1023136868
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LSA
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SA00156
|
|
IV
VELEZ-VEGA
|
VELEZ-VEGA, IVELISSE
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1700090701
|
LSA
|
SA00191
|
|
RV
VILLARREAL
|
VILLARREAL, ROSENDO
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1104930304
|
LSA
|
SA00249
|
|
HW
WASSEF
|
WASSEF, HALA
|
1255508909
|
CSA
|
ABSA 08138
|
|
LW
WU
|
WU, LARRY
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1881807220
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CSA
|
CSA2958
|
|
RZ
ZAMARRON
|
ZAMARRON, ROGER
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1275651010
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LSA
|
SA00056
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BZ
ZHONG
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ZHONG, BING TANG
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1740308063
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LSA
|
SA00158
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6
Provider List
10/23/2008
| Code Last Name | Name | National Provider Identifier | Credentials | License Number |
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WB
BERRY
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BERRY, WILLIAM
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1851589386
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CST/CFA
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109540
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LF
FLORES
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FLORES, LETICIA
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1053502385
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CNOR
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030775
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AG
GARCIA
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GARCIA, ABEL
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1013193721
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LSA
|
SA00073
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JR01
RIOS
|
RIOS, JIMMI
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1760500789
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SA-C
|
A05263
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SR
ROBIN
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ROBIN, SCOTT
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1437134962
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LSA
|
SA00090
|
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JR
RUSSELL
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RUSSELL, JAMES
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1801871363
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CST/CFA
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CST85399
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JS
SKORUPPA
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SKORUPPA, JACOB
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1215113022
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CST/CFA
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109194
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PT01
TAMARGO
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TAMARGO, PEDRO
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1114199809
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SA-C
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08120
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PT
TROMBLEY
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TROMBLEY, PATRICIA
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1023136868
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LSA
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SA00156
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7
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Christus Spohn Health System
600 Elizabeth Street
Corpus Christi TX 78404
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Corpus Christi Medical Center
1533 South Brownlee
Corpus Christi TX 78404
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Bayshore Medical Center
4000 Spencer Highway
Pasadena TX 77504
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Christus St. Catherine’s
701 South Fry Road
Katy TX 77450
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Christus St. John Hospital
18300 St. John Dr.
Nassau Bay, TX 77058
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Clear Lake Medical Center
500 Medial Center Blvd.
Webster TX 77598
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Cypress Fairbanks Medical Center
10655 Steepletop Drive
Houston, TX 77065
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Doctors Surgical Center
8111 Southwest Freeway
Houston TX 77074
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East Houston Regional Medical Center
13111 East Freeway
Houston TX 77015
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East Side Surgery Center
10918 East Freeway
Houston TX 77029
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First Street Hospital
4801 Bissonnet
Bellaire TX 77401
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First Surgical Memorial Village
12727 Kimberly Lane #100
Houston TX 77024
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First Surgical Partners LLC
411 First Street
Bellaire TX 77401
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Foundations Surgery Center
5410 West Loop South
Bellaire TX 77401
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Houston NW Medical Center
710 FM 1960 West
Houston, TX 77090
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Katy St. Catherine’s Surgery Center
707 South Fry Road #150
Katy TX 77450
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Palladium Surgery Center
4120 Southwest Freeway #230
Houston TX 77027
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Park Plaza Hospital
1313 Hermann Drive
Houston TX 77004
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Special Surgery Centre
9180 Katy Freeway Suite 202
Houston TX 77055
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Spring Branch Medical Center
8850 Long Point
Houston TX 77055
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St. Joseph Medical Center
1401 St. Joseph Parkway
Houston, TX 77002
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St. Luke’s Episcopal Hospital Sugar Land
1317 Lake Point Parkway
Sugar Land TX 77478
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St. Luke’s Episcopal Hospital
6720 Bertner Street
Houston TX 77030
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Sugar Land Surgical Hospital
1211 Highway 6 Suite 70
Sugar Land TX 77478
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The Woman’s Hospital
7600 Fannin
Houston TX 77054
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West Houston Medical Center
12141 Richmond Avenue
Houston TX 77082
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West Houston Surgicare
970 Campbell Road
Houston TX 77080
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Kingwood Medical Center
22999 US Highway 59
Kingwood TX 77339
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Memorial Hermann
6411 Fannin
Houston, TX 77030
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Memorial Hermann Memorial City
921 Gessner Road
Houston TX 77024
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Memorial Hermann Northwest
1635 North Loop West
Houston TX 77008
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Memorial Hermann Southeast
11800 Astoria Blvd
Houston TX 77089
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Memorial Hermann Southwest
7600 Beechnut
Houston TX 77074
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Memorial Hermann Surgery Center Northwest
1634 North Loop West #300
Houston TX 77008
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Memorial Hermann Surgery Center Southwest
7789 Southwest Freeway #200
Houston TX 77074
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Memorial Hermann The Woodlands
9250 Pinecroft
The Woodlands TX 77380
|
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Methodist Sugar Land
16655 Southwest Freeway
Sugar Land TX 77479
|
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Methodist Willowbrook
18220 Tomball Parkway
Houston TX 77070
|
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North Cypress Medical Center
21214 Northwest Freeway
Cypress TX 77429
|
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Northeast Medical Center
18951 Memorial North
Humble TX 77338
|
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OakBend Medical Center
1705 Jackson Street
Richmond TX 77469
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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.
|