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Non Standard Insurance Billing Addendum

Download PDF of Non Standard Insurance Billing Addendum

This Addendum (“Addendum”) is intended to amend and supplement the Customer Software Agreement (“Agreement”) made and entered into by and between CollaborateMD, Inc. (hereinafter referred to as “CollaborateMD”) with its principal place of business at 111 N. Magnolia Ave. Suite 1100, Orlando, FL 32801, and and the individual or legal business entity agreeing to the terms set forth herein (“Customer”). The parties agree to the following terms that shall be additive to the terms found in the Agreement and restate and recite all other terms as defined in the Agreement. Unless otherwise specifically defined in this Addendum, terms shall have the same meaning as in the Agreement in effect between both parties. 

Customer acknowledges its acceptance and execution of this Agreement by electronic means and agrees that the electronic signatures of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as manual signatures. 

Purpose

The purpose of this Addendum is to outline the following terms for Customers who are not credentialed with any Payer(s) currently.

1. Terms.

(a) Customer agrees that the monthly service Plan(s) fees still apply to the Account regardless of any claim or billing capabilities, and agrees to pay all fees by or prior to their due dates.

(b) Customer agrees to fully understand Payer(s) requirements for billing claims when not credentialed or billing “Out of Network” and will be prepared with all claim and billing requirements in order to receive training.

(c) Customer agrees to fully understand Payer(s) requirements for receiving payment(s) when not credentialed or billing “Out of Network” and will be prepared with all payment requirements in order to receive training.

2. General.

(a) Any modifications or extensions of the terms defined in this Addendum must be made in writing and agreed to by both parties.

Last Modified December 13, 2013