Fee Discount Agreement {3659}

Note: Print this Fee Discount Agreement on the medical service provider222s or clinic222s letterhead. Fee Discount Agreement Medical service provider or clinic Provider or clinic name: National Provider Identifier: Address: Office contact: City/State/ZIP: Phone: Fax: Insurer or self-insured employer Company name: Billing address: (if different than mailing addr ess) Representative: City/State/ZIP: Mailing address: Phone: City/State/ZIP: Fax: 1. Thi s agreement is effective from through . 2. This agreement only applies to patients being treated for Oregon workers222 compensation claims. 3. The provider or clinic agrees to accept a discount rate of % of the Oregon Medical Fee Schedule. (Note: the discount rate may not exceed 10% of the fee schedule as calculated under OAR 436 - 009 - 0040.) 4. The insurer or employer may not direct patients to the provider or clinic, nor may the insurer or employer direct or manage the care a worker receives. 5. This agreement may not be amended. A new fee discount agreement must be executed to change the terms between the parties. 6. Either party may terminate this agreement by providing the other party 30 d ays written notice. 7. Other terms and conditions as follows: Check here if you include additional pages. By signing this agreement, I certify that I understand the terms of this agreement and voluntarily agree to its terms. Provider/clinic representative signature Date Insurer or self - insured employer rep resentative signature Date 440 - 3659 (12/08/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com