2024年4月30日发(作者：xp系统开机密码清除)

MEDICAL SERVICES AGREEMENT

THIS Medical Services Agreement is made this day of 2007, and

made effective on the 1st day of , 2007 ("Effective Date") by and between

("Medical Services Entity"), and Polk County Board of County

Commissioners, a political subdivision of the State of Florida ("County") (Medical Services

Entity and County jointly the "Parties").

WITNESSETH:

WHEREAS, the County has an indigent health care plan, hereinafter known as the Polk

HealthCare Plan ("Plan"), and wishes to arrange for the provision of medical services to eligible

county residents ("Enrollees");

WHEREAS, the Medical Services Entity is comprised of, or contracts with, one or more

qualified physicians capable of meeting the credentialing criteria of the County;

WHEREAS, the County desires to engage the Medical Services Entity to deliver, or

arrange for the delivery of medical services to the Enrollees of its Plan; and

WHEREAS, the Medical Services Entity is willing to deliver or arrange for the delivery

of such services on the terms specified herein.

NOW, THEREFORE, in consideration of the mutual promises set forth herein, and other

good and valuable consideration, the parties hereby agree as follows:

ARTICLE I

DEFINITIONS

1.1 Claim. A statement of services submitted to the County by the Medical Services

Entity following the provision of Covered Services to an Enrollee that shall include diagnosis or

diagnoses date of service, CPT 4/HCPCS code and treating provider for services rendered to the

Enrollee.

1.2 County. The designated division of the county government of Polk County, Florida,

Community Health and Social Services Division, Department of Human Services.

1.3 County Notice. A communication by the County to the Medical Services Entity

informing the Medical Services Entity of the terms of the Plan, modifications to the Plan, and

any other information relevant to the provision of Covered Services pursuant to this Agreement.

1.4 County Compensation. The Total Compensation, as defined herein (EXHIBIT B),

plus that portion designated by the Plan as a Co-payment.

1.5 Co-payment. A charge which may be collected directly by a Medical Services Entity

or Medical Services Entity's designee from an Enrollee in accordance with the Plan.

1.6 Covered Services. Health care services to be delivered by or through Medical Services

Entity to Enrollees pursuant to this Agreement, as further defined in ARTICLE II.

1.7 Emergency Condition. A medical condition manifesting itself by acute symptoms of

sufficient severity (including severe pain) such that the absence of immediate medical attention

could be expected to result in serious impairment to bodily function or serious dysfunction of any

bodily organ or part.

1.8 Enrollees. Any individual(s) who has/have been determined eligible by the County and

is/are enrolled in the Plan.

1.9 Medically Necessary. Health care services that a reasonably prudent physician would

deem necessary for the diagnosis or treatment of illness or injury or to improve the functioning of

an Enrollee.

1.10 Medical Services Entity. An individual or group of qualified physicians.

1.11 Non-Covered Services. Health care services that are not Covered Services, as defined

by the Plan.

1.12 Payer. The entity or organization directly responsible for the payment of Covered

Services to the Medical Services Entity under the Plan.

1.13 Payer of Last Resort. Should an Enrollee be determined to have other coverage for

services provided by a Qualified Physician under any other contractual or legal benefit, including,

but not limited to, Medicaid, Medicare, or a private group or indemnification program, the Medical

Services Entity is expected to bill the said entity and, when payment is received, must reimburse

Polk County for benefits paid on behalf of the Enrollee for services rendered by the Qualified

Physician.

1.14 Plan. A "managed care" product funded by the County and administered by the

County for the benefit of Enrollees, as it may be modified from time to time, and all the terms,

conditions, limitations, exclusions, benefits, rights and obligations thereof to which County and

Enrollees are subject.

1.15 Protected Health Information (PHI). Information that is (a) created or received by a

Medical Services Entity; (b) relates to: (1) the past, present, or future physical or mental health or

condition of an individual; (2) the provision of health care to an individual; or (3) the past, present,

or future payment for the provision of health care to an individual; and (c) identifies the individual

or there is a reasonable basis to believe the information can be used to identify the individual. PHI

does not include information excluded from HIPAA's definition of "protected health information" in

45 C.F.R. 160.103.