Disclosure Of Contract Reimbursement Rate {DWC-5307.12}

DWC 5307(12) - DISCLOSURE OF CONTRACT REIMBURSEMENT RATE (LABOR CODE SECTION 5307.12). This form shall be used to disclose to a Payor the amount of reimbursement paid to a health care provider, or health facility licensed under Health and Safety Code section 1250 (“Health Care Provider”), by an entity that provides physician network services, as defined in Labor Code section 4616.5(b), or an entity that provides ancillary network services, as defined in Labor Code section 4616.5(c) (“Entity”) if: (1) a contract for reimbursement of services exists between the Health Care Provider and the Entity; and (2) the contract reimburses the Health Care Provider for services at rates that are more than twenty percent (20%) below the applicable rates in the Official Medical Fee Schedule (OMFS), excluding goods and pharmaceuticals. The disclosure of the amount of reimbursement, which shall be made by the Entity to the Payor, is mandated by Labor Code section 5307.12. www.FormsWorkflow.com