| 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 payors 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 modem in all billing and will mail or fax 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.
All invoices for billing services will be faxed once every month to client and all invoices are due 10 days from faxing date. INVOICES MUST BE PAID ON TIME OR BILLING WILL BE DISCONTINUED.
____________________________________
PROVIDER
____________________________________
Greg Barnes/PHYSICIAN SERVICES
State License Number: _________________________
THIS FORM AND THE FOLLOWING PAGE MUST BE RECEIVED WITH CHECK BY PHYSICIAN SERVICES BEFORE BILLING CAN BEGIN. | |
