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  • Provider Data Form

    Part I: Contact & Demographic Information
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  • CAQH & Credentialing

  • If you ARE credentialed and current with CAQH and provided your information above, please proceed to the next page and disregard the upload links.

    If you ARE NOT credentialed and/or current with CAQH, please upload your latest license & liability below.

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  • If you are not registered with CAQH, please ensure that you have accurately provided your email address, social security number, license information, and tax ID number, which is necessary to register you with the CAQH Universal Credentialing DataSource.

    Note: If you have already completed your application with CAQH, please ensure that you have authorized all applicable organizations to access your data. Using the CAQH Universal Credentialing DataSource does not grant participation or constitute applying for participation with any of the above organizations. If applicable, please contact the health plan directly to request contracting information.

  • Provider Data Form

    Part II: Specializations
  • If the following demographics were selected, please specify the age ranges for each:
    Adolescent:
    Child:    
    Teens: 

  • Provider Data Form

    Part III: Professional Background
  • Current Certifications (including CEAP) and/or Licenses. Please list States in which you hold the certification and/or license:
       

    Please list training, expertise, and/or experience in Critical Incident Stress Debriefings:
       

    Please list prior experience working with EAP's:
       

    Current membership in Professional Associations:
       

    Insurance Panels for which you are an in-network provider:
       

    What resources or methods do you utilize to research community referrals and/or resources for your clients? On average, how often would you say you make such referrals?
       

    Please list languages you speak fluently:
       

    Do you have experience presenting workshops/seminars in a worksite environment?
        

    If yes, would you be interested in providing this type of service to our client companies?
          

    If yes, please select the topics in which you can present (check all that apply):

                                                            

  • I certify that the information and attachments I have provided to LifeWork Strategies is true and accurate to the best of my knowledge.

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  • Business Associate Agreement

  • B E F O R E P R O C E E D I N G:

    The underlined parentheticals in the opening paragraph of this contract, and under "Notices" (Item 20.B.), are to serve as indications that these fields will be filled out based on prior questions, filled out earlier in your submission. They will carry over to this portion of the contract for your convenience. As such, please review & sign at the bottom.
  • This BUSINESS ASSOCIATE AGREEMENT (the "BAA") is made and entered into as of (date of submission) by and between Adventist HealthCare, Inc, a non-profit organized under the laws of Maryland, the ("Covered Entity") and (your practice name), a (practice type) organized under the law of (primary practicing State), the ("Business Associate" in accordance with the meaning given to those terms at 45 CFR 164.501). In this BAA, Covered Entity and Business Associate are each a "Party" and, collectively, are the "Parties".

    BACKGROUND


    I.              Covered Entity is either a “covered entity” or “business associate” of a covered entity as each are defined under the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended by the HITECH Act (as defined below) and the related regulations promulgated by HHS (as defined below) (collectively, “HIPAA”) and, as such, is required to comply with HIPAA’s provisions regarding the confidentiality and privacy of Protected Health Information (as defined below);

    II.            The Parties have entered into or will enter into one or more agreements under which Business Associate provides or will provide certain specified services to Covered Entity (collectively, the “Agreement”);

    III.          In providing services pursuant to the Agreement, Business Associate will have access to Protected Health Information;

    IV.          By providing the services pursuant to the Agreement, Business Associate will become a “business associate” of the Covered Entity as such term is defined under HIPAA;

    V.            Both Parties are committed to complying with all federal and state laws governing the confidentiality and privacy of health information, including, but not limited to, the Standards for Privacy of Individually Identifiable Health Information found at 45 CFR Part 160 and Part 164, Subparts A and E (collectively, the “Privacy Rule”); and

    VI.          Both Parties intend to protect the privacy and provide for the security of Protected Health Information disclosed to Business Associate pursuant to the terms of this Agreement, HIPAA and other applicable laws.

     

     

    AGREEMENT


    NOW, THEREFORE, in consideration of the mutual covenants and conditions

    contained herein and the continued provision of PHI by Covered Entity to Business

    Associate under the Agreement in reliance on this BAA, the Parties agree as follows:

     

    1. Definitions. For purposes of this BAA, the Parties give the following meaning

    to each of the terms in this Section 1 below. Any capitalized term used in this BAA, but

    not otherwise defined, has the meaning given to that term in the Privacy Rule or

    pertinent law.

     

    A. “Affiliate” means a subsidiary or affiliate of Covered Entity that is, or has been, considered a covered entity, as defined by HIPAA.

     

    B. “Breach” means the acquisition, access, use, or disclosure of PHI in a manner not permitted under the Privacy Rule which compromises the security or privacy of the PHI, as defined in 45 CFR §164.402.

     

    C. “Breach Notification Rule” means the portion of HIPAA set forth in Subpart D of 45 CFR Part 164.

     

    D. “Data Aggregation” means, with respect to PHI created or received by Business Associate in its capacity as the “business associate” under HIPAA of Covered Entity, the combining of such PHI by Business Associate with the PHI received by Business Associate in its capacity as a business associate of one or more other “covered entity” under HIPAA, to permit data analyses that relate to the Health Care Operations (defined below) of the respective covered entities. The meaning of “data aggregation” in this BAA shall be consistent with the meaning given to that term in the Privacy Rule.

     

    E. “Designated Record Set” has the meaning given to such term under the Privacy Rule, including 45 CFR §164.501.B.

     

    F. “De-Identify” means to alter the PHI such that the resulting information meets the requirements described in 45 CFR §§164.514(a) and (b).

     

    G. “Electronic PHI” means any PHI maintained in or transmitted by electronic media as defined in 45 CFR §160.103.

     

    H. “Health Care Operations” has the meaning given to that term in 45 CFR §164.501.

     

    I. “HHS” means the U.S. Department of Health and Human Services.

     

    J. “HITECH Act” means the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, Public Law 111-005.

     

    K. “Individual” has the same meaning given to that term i in 45 CFR §§164.501 and 160.130 and includes a person who qualifies as a personal representative in accordance with 45 CFR §164.502(g).

     

    L. “Privacy Rule” means that portion of HIPAA set forth in 45 CFR Part 160 and Part 164, Subparts A and E.

     

    M. “Protected Healh Information” or “PHI” has the meaning given to the term “protected health information” in 45 CFR §§164.501 and 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity.

     

    N. “Security Incident” means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.

     

    O. “Security Rule” means the Security Standards for the Protection of Electronic Health Information provided in 45 CFR Part 160 & Part 164, Subparts A and C.

     

    P. “Unsecured Protected Health Information” or “Unsecured PHI” means any “protected health information” as defined in 45 CFR §§164.501 and 160.103 that is not rendered unusable, unreadable or indecipherable to unauthorized individuals through the use of a technology or methodology specified by the HHS Secretary in the guidance issued pursuant to the HITECH Act and codified at 42 USC §17932(h).

     

    2. Use and Disclosure of PHI.

     

    A. Except as otherwise provided in this BAA, Business Associate may use or disclose PHI as reasonably necessary to provide the services described in the Agreement to Covered Entity, and to undertake other activities of Business Associate permitted or required of Business Associate by this BAA or as required by law.

     

    B. Except as otherwise limited by this BAA or federal or state law, Covered Entity authorizes Business Associate to use the PHI in its possession for the proper management and administration of Business Associate’s business and to carry out its legal responsibilities. Business Associate may disclose PHI for its proper management and administration, provided that (i) the disclosures are required by law; or (ii) Business Associate obtains, in writing, prior to making any disclosure to a third party (a) reasonable assurances from this third party that the PHI will be held confidential as provided under this BAA and used or further disclosed only as required by law or for the purpose for which it was disclosed to this third party and (b) an agreement from this third party to notify Business Associate immediately of any breaches of the confidentiality of the PHI, to the extent it has knowledge of the breach.

     

    C. Business Associate will not use or disclose PHI in a manner other than as provided in this BAA, as permitted under the Privacy Rule, or as required by law. Business Associate will use or disclose PHI, to the extent practicable, as a limited data set or limited to the minimum necessary amount of PHI to carry out the intended purpose of the use or disclosure, in accordance with Section 13405(b) of the HITECH Act (codified at 42 USC §17935(b)) and any of the act’s implementing regulations adopted by HHS, for each use or disclosure of PHI.

     

    D. Upon request, Business Associate will make available to Covered Entity any of Covered Entity’s PHI that Business Associate or any of its agents or subcontractors have in their possession.

    E. Business Associate may use PHI to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR §164.502(j)(1).

     

    3.    Safeguards Against Misuse of PHI. Business Associate will use appropriate safeguards to prevent the use or disclosure of PHI other than as provided by the Agreement or this BAA and Business Associate agrees to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the Electronic PHI that it creates, receives, maintains or transmits on behalf of Covered Entity. Business Associate agrees to take reasonable steps, including providing adequate training to its employees to ensure compliance with this BAA and to ensure that the actions or omissions of its employees or agents do not cause Business Associate to breach the terms of this BAA.

     

    4.    Reporting Disclosures of PHI and Security Incidents. Business Associate will report to Covered Entity in writing any use or disclosure of PHI not provided for by this BAA of which it becomes aware, and Business Associate agrees to report to Covered Entity any Security Incident affecting Electronic PHI of Covered Entity of which it becomes aware. Business Associate agrees to report any such event within five business days of becoming aware of the event.


    5.    Reporting Breaches of Unsecured PHI. Business Associate will notify Covered Entity in writing promptly upon the discovery of any Breach of Unsecured PHI in accordance with the requirements set forth in 45 CFR §164.410, within 3 (three) days after discovery of a Breach. Business Associate will reimburse Covered Entity for any costs incurred by it in complying with the requirements of Subpart D of 45 CFR §164 that are imposed on Covered Entity as a result of a Breach committed by Business Associate.


    6.    Mitigation of Disclosures of PHI. Business Associate will take reasonable measures to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of any use or disclosure of PHI by Business Associate or its agents or subcontractors in violation of the requirements of this BAA.


    7.    Agreements with Agents or Subcontractors. Business Associate will ensure that any of its agents or subcontractors that have access to, or to which Business Associate provides, PHI agree in writing to the restrictions and conditions concerning uses and disclosures of PHI contained in this BAA and agree to implement reasonable and appropriate safeguards to protect any Electronic PHI that it creates, receives, maintains or transmits on behalf of Business Associate or, through the Business Associate, Covered Entity. Business Associate shall notify Covered Entity, or upstream Business Associate, of all subcontracts and agreements relating to the Agreement, where the subcontractor or agent receives PHI as described in section 1.M. of this BAA. Such notification shall occur within 30 (thirty) calendar days of the execution of the subcontract by notifying Covered Entity. Business Associate shall ensure that all subcontracts and agreements provide the same level of privacy and security as this BAA.


    8.    Use of Artificial Intelligence (AI) Services. If Business Associate (Vendor) uses artificial intelligence (AI) or machine learning technologies as part of the services provided under this Agreement, the Business Associate must inform Adventist HealthCare in writing prior to implementation. The notification must include a description of how AI is used, the types of data processed by AI systems, and any associated risks.


    9.    Notification of Foreign Access to AI Data. In the event that any AI data, including but not limited to Protected Health Information (PHI), is accessible by or transmitted to any individual or organization outside of the United States, Business Associate shall provide Adventist Healthcare with prompt written notice prior to such access or transmission. This notification must include the name of the country where the data will be accessed, the identity of the entity or individuals, and the reasons for such access. Business Associate shall take all necessary steps to ensure that such access complies with all applicable U.S. privacy and security laws, including the Health Insurance Portability and Accountability Act (HIPAA) and any relevant regulations.


    10.  Audit Report. Upon request, Business Associate will provide Covered Entity, or upstream Business Associate, with a copy of its most recent independent HIPAA compliance report (ATC 315), HITRUST certification or other mutually agreed upon independent standards based third party audit report. Covered entity agrees not to re-disclose Business Associate’s audit report.


    11.  Access to PHI by Individuals.

     

    A. Upon request, Business Associate agrees to furnish Covered Entity with copies of the PHI maintained by Business Associate in a Designated Record Set in the time and manner designated by Covered Entity to enable Covered Entity to respond to an Individual’s request for access to PHI under 45 CFR §164.524.

     

    B. In the event any Individual or personal representative requests access to the Individual’s PHI directly from Business Associate, Business Associate within ten business days, will forward that request to Covered Entity. Any disclosure of, or decision not to disclose, the PHI requested by an Individual or a personal representative and compliance with the requirements applicable to an Individual’s right to obtain access to PHI shall be the sole responsibility of Covered Entity.

     

    12. Amendment of PHI.

     

    A. Upon request and instruction from Covered Entity, Business Associate will amend PHI or a record about an Individual in a Designated Record Set that is maintained by, or otherwise within the possession of, Business Associate as directed by Covered Entity in accordance with procedures established by 45 CFR §164.526. Any request by Covered Entity to amend such information will be completed by Business Associate within fifteen (15) business days of Covered Entity’s request.

     

    B. In the event that any Individual requests that Business Associate amend such Individual’s PHI or record in a Designated Record Set, Business Associate within ten business days will forward this request to Covered Entity. Any amendment of, or decision not to amend, the PHI or record as requested by an Individual and compliance with the requirements applicable to an Individual’s right to request an amendment of PHI will be the sole responsibility of Covered Entity.

     

    13. Accounting of Disclosures.

     

     

    A. Business Associate will document any disclosures of PHI made by it to account for such disclosures as required by 45 CFR §164.528(a). Business Associate also will make available information related to such disclosures as would be required for Covered Entity to respond to a request for an accounting of disclosures in accordance with 45 CFR §164.528. At a minimum, Business Associate will furnish Covered Entity the following with respect to any covered disclosures by Business Associate: (i) the date of disclosure of PHI; (ii) the name of the entity or person who received PHI, and, if known, the address of such entity or person; (iii) a brief description of the PHI disclosed; and (iv) a brief statement of the purpose of the disclosure which includes the basis for such disclosure.

     

    B. Business Associate will furnish to Covered Entity information collected in accordance with this Section 10, within ten business days after written request by Covered Entity, to permit Covered Entity to make an accounting of disclosures as required by 45 CFR §164.528, or in the event that Covered Entity elects to provide an Individual with a list of its business associates, Business Associate will provide an accounting of its disclosures of PHI upon request of the Individual, if and to the extent that such accounting is required under the HITECH Act or under HHS regulations adopted in connection with the HITECH Act.

     

    C. In the event an Individual delivers the initial request for an accounting directly to Business Associate, Business Associate will within ten business days forward such request to Covered Entity.

     

    14. Availability of Books and Records. Business Associate will make available its internal practices, books, agreements, records, and policies and procedures relating to the use and disclosure of PHI, upon request, to the Secretary of HHS for purposes of determining Covered Entity’s and Business Associate’s compliance with HIPAA, and this BAA.

     

    15. Responsibilities of Covered Entity. With regard to the use and/or disclosure of Protected Health Information by Business Associate, Covered Entity agrees to:

     

    A. Notify Business Associate of any limitation(s) in its notice of privacy practices in accordance with 45 CFR §164.520, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI.

     

    B. Notify Business Associate of any changes in, or revocation of, permission by an Individual to use or disclose Protected Health Information, to the extent that such changes may affect Business Associate’s use or disclosure of PHI.

     

    C. Notify Business Associate of any restriction to the use or disclosure of PHI that Covered Entity has agreed to in accordance with 45 CFR §164.522, to the extent that such restriction may affect Business Associate’s use or disclosure of PHI.

     

    D. Except for data aggregation or management and administrative activities of Business Associate, Covered Entity shall not request Business Associate to use or disclose PHI in any manner that would not be permissible under HIPAA if done by Covered Entity.

     

    16. Data Ownership. Business Associate’s data stewardship does not confer data ownership rights on Business Associate with respect to any data shared with it under the Agreement, including any and all forms thereof.

     

    17. Term and Termination.

     

    A. This BAA will become effective on the date first written above and will continue in effect until all obligations of the Parties have been met under the Agreement and under this BAA.

     

    B. Covered Entity may terminate without cause. Covered Entity may terminate immediately this BAA, the Agreement, and any other related agreements if Covered Entity makes a determination that Business Associate has breached a material term of this BAA and Business Associate has failed to cure that material breach, to Covered Entity’s reasonable satisfaction, within 30 days after written notice from Covered Entity. Covered Entity may report the problem to the Secretary of HHS if termination is not feasible.

     

    C. If Business Associate determines that Covered Entity has breached a material term of this BAA, then Business Associate will provide Covered Entity with written notice of the existence of the breach and shall provide Covered Entity with 30 days to cure the breach. Covered Entity’s failure to cure the breach within the 30-day period will be grounds for immediate termination of the Agreement and this BAA by Business Associate. Business Associate may report the breach to HHS.

     

    D. Upon termination of the Agreement or this BAA for any reason, all PHI maintained by Business Associate will be returned to Covered Entity or destroyed by Business Associate. Business Associate will not retain any copies of such information. This provision will apply to PHI in the possession of Business Associate’s agents and subcontractors. If return or destruction of the PHI is not feasible, in Business Associate’s reasonable judgment, Business Associate will furnish Covered Entity with notification, in writing, of the conditions that make return or destruction infeasible. Upon mutual agreement of the Parties that return, or destruction of the PHI is infeasible, Business Associate will extend the protections of this BAA to such information for as long as Business Associate retains such information and will limit further uses and disclosures to those purposes that make the return or destruction of the information not feasible. The Parties understand that this Section 17.D. will survive any termination of this BAA.

     

    18. Effect of BAA.

     

    A. This BAA is a part of and subject to the terms of the Agreement, except that to the extent any terms of this BAA conflict with any term of the Agreement, the terms of this BAA will govern.

     

    B. Except as expressly stated in this BAA or as provided by law, this BAA will not create any rights in favor of any third party.

     

    19. Regulatory References. A reference in this BAA to a section in HIPAA means the section as in effect or as amended at the time.

     

    20. Notices. All notices, requests and demands or other communications to be given under this BAA to a Party will be made via either first class mail, registered or certified or express courier, or electronic mail to the Party’s address given below:

     

     

    A.   If to Covered Entity, to:

        Adventist HealthCare, Inc., d/b/a LifeWork Strategies

    820 West Diamond Ave., 5th floor

    Gaithersburg, Maryland 20878

    Attention: EAP Provider Relations

     

    B. If to Business Associate, to:

     (your address will carry over)

     

     

    21. Amendments and Waiver. This BAA may not be modified, nor will any provision be waived or amended, except in writing duly signed by authorized representatives of the Parties. A waiver with respect to one event shall not be construed as continuing, or as a bar to or waiver of any right or remedy as to subsequent events.

     

    22. HITECH Act Compliance. The Parties acknowledge that the HITECH Act includes significant changes to the Privacy Rule and the Security Rule. The privacy subtitle of the HITECH Act sets forth provisions that significantly change the requirements for business associates and the agreements between business associates and covered entities under HIPAA and these changes may be further clarified in forthcoming regulations and guidance. Each Party agrees to comply with the applicable provisions of the HITECH Act and any HHS regulations issued with respect to the HITECH Act. The Parties also agree to negotiate in good faith to modify this BAA as reasonably necessary to comply with the HITECH Act and its regulations as they become effective but, in the event that the Parties are unable to reach agreement on such a modification, either Party will have the right to terminate this BAA upon 30days’ prior written notice to the other Party. 

  • In light of the mutual agreement and understanding described above, the Parties execute this BAA as of the date first written above.

  • Adventist Healthcare d/b/a LifeWork Strategies Provider Agreement for EAP Counselors

  • B E F O R E P R O C E E D I N G:

    The underlined parentheticals in the opening paragraph of this contract, and under "Notices" (Item 20.B.), are to serve as indications that these fields will be filled out based on prior questions, filled out earlier in your submission. They will carry over to this portion of the contract for your convenience. As such, please review & sign at the bottom.
  • THIS AGREEMENT, made this day of (date of submission) between and among Adventist Healthcare d/b/a LifeWork Strategies, 820 W. Diamond Ave, 5th Floor, Gaithersburg Maryland 20878 (referred herein as "Contractor"), and (your practice) ("Provider"). Contractors and Provider may hereafter be referred to individually as a "Party" and collectively as the ''Parties."

    WHEREAS, Contractors are engaged in arranging for the provision of employee assistance programs ("Programs") to employers, unions, employee benefit funds, insurance companies, governmental organizations, and various other purchasers of health services, for the benefit of their respective employees or covered persons ("Covered Persons"); and

    WHEREAS, Contractors wish to retain the services of Provider to provide clinical evaluation, treatment and other related health care service to such Covered Persons, and Provider wishes to provide such services;

    NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, and intending to be legally bound hereby, it is understood and agreed by the Parties as follows:

     

    I. DEFINITIONS


    "Covered Person" shall mean any insured employee of the Contractor and if so designated by Contractor, his/her dependents.

    B.      "Provider" shall mean a provider designated by Contractors to provide covered services.

    c. "Covered Services" shall mean all related services rendered to a Covered Person by a Provider to the extent that such services are for the treatment of personal and psychological problems.

    D.            "Dependents" shall mean any individual residing within the household of the Covered Person, including, but not limited to, significant others and life partners. Also included shall be dependent children living outside the household as prescribed by Contractors Health Plan for full-time students.

    E.            "Occurrence" shall mean the presentation of a specific set of problem issues.

     

    II. PROVIDER RESPONSIBILITIES


    The Provider shall:

    A.            Warrant and represent that he/she is the holder of a duly-authorized and valid professional license for independent practice of his/her profession.

    B.            Provide evidence of such license and certificate of insurance to Contractors with this signed contract and regularly thereafter upon renewal of such license and insurance.

    c. Provide services consistent with Provider's training, experience, specialization, if any, and the ethics of Provider's profession.

    D.            Accept Covered Members referred on an "as needed" basis by the Programs to provide clinical evaluation/assessment, counseling, treatment, referral, and other related services, as approved or directed by the Programs.

    E.            In the course of typical business:

    1.     Respond to telephone calls, either from contractor or covered person, within 24 hours.

    2.     For non-urgent referrals, offer appointments within fourteen days of covered person's call to provider.

    3.     For urgent referrals, offer appointments that are within forty-eight hours of covered person or contractors call to provider.

    Provide Covered Persons the number of hourly sessions which will be determined by the Contractor's Health Plan, subject to limitations communicated by the contractor and review agent(s).

    G.            Not be reimbursed for no-shows or cancellations. Provider may enforce his/her own policy so long as the policy is communicated to the covered person in advance.

    H.            Review with and ask the Covered Person to sign the Statement of Understanding, and Release of Information Form (if applicable), at the beginning of the initial session and complete the Case Closing Form after the last contact with the Covered Person, if required by Contractor.

    1.       Maintain a written record of initial assessment and all clinical contacts with Covered

    Persons for a minimum of seven years from date of last contact with Covered Person. Such information shall include, but not be limited to: client presenting concerns, pertinent family, social, occupational, health and substance use/abuse history, mental status, clinical diagnosis and recommendations for appropriate intervention.

    Cooperate with and provide Contractors and any external quality review organization approved by the Contractors with access to or mailed photocopies of Covered Persons' records upon request for the purposes of quality assessment, contract compliance, and

    quality improvement or investigation of member complaints or grievances. Provider further agrees to provide such information, including but not limited to encounter, utilization, referral and other data Contractors may require to be submitted to them for compliance with their own data reporting requirements.

    K.            Utilize the appropriate insurance network for referrals for ongoing treatment and clearly document the referral source name, address, and telephone number.

    L.             Return to the Programs all original paperwork, including the Case Closing Form,

    Statement of Understanding, and any necessary Release of Information Forms within (14) days of the last session with the Covered Person in order to receive reimbursement, if required by Contractor. This responsibility also extends to required paperwork associated with CISD's and trainings.

    M.           Understand and agree that all Covered Persons referred to the Provider by the Programs, directly or indirectly, shall remain at all times the sole and exclusive clients of the Programs.

    N.            Provider agrees to comply with and be bound by all rules, regulations, policies, and programs of the Programs that may have been or may hereinafter be adopted.

    III. CONTRACTOR'S RESPONSIBILITIES


    A.            If applicable, reimburse Provider within forty-five (45) days of receipt of the Case

    Closing Form, Statement of Understanding, and if indicated, Release of Information Forms, in the form required by the Programs if these reports are required. Contractor will compensate Provider for CISD's and trainings upon receipt of payment from Employer within forty-five (45) days of receipt of funds.

    B.            Notify the Provider of any significant changes in the Employee Assistance Program Agreement with the Employers and Contractors that would impact this Agreement.

    C.            Maintain adequate insurance for professional liability and comprehensive general liability to insure the Programs and their employees against liability for all claims, demands, costs, or damages that may arise in connection with the performance of any service or activity performed by the Programs in connection with this Agreement.

     

    IV. COMPENSATION AND PAYMENT


    A.            Provider shall be paid on a fee-for-service basis, or other basis as mutually agreed, at the rate indicated on Exhibit A, as full compensation for Provider's services to Covered Persons.

    B.            Provider shall submit required documentation and related materials to the Contractor for payment, in the form required by the Contractor, within fourteen (14) days of the last day

    of the month in which Provider's services were completed. Any required documentation and related materials submitted after sixty (60) days of the last day of the month in which Provider completed services will not be reimbursed to Provider.

    Provider agrees that in no event, including but not limited to, nonpayment by the Contractors, the insolvency of Contractors, or breach of this agreement, shall Provider bill, charge, or collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Covered Person or Persons other than the Contractors acting on their behalf for services listed in this agreement.

     

    V. TERM AND TERMINATION


    A.            This Agreement shall be in effect for a term of one (1) year from to and shall be renewed automatically at the end of this period for successive one (1) year terms from the Anniversary Date, unless otherwise terminated by either Party with sixty (60) days prior written notice to the end of each contract period.

    B.            This Agreement may be terminated at any time, without cause, upon ninety (90) days prior written notice to the other Party.

    c. This Agreement may be terminated upon breach by one Party provided that (i) the nonbreaching Party has provided written notice of such breach and the (ii) breaching Party has not cured the breach to the non-breaching Party's satisfaction within thirty (30) days.

    D.            Contractors shall have the right to terminate this Agreement immediately and without notice on such date as Provider's license and/or insurance, as specified in Section VI. Below, is terminated, suspended or not renewed.

    E.            Following the effective date of termination, each Party shall remain liable for any obligations or liabilities arising from activities carried on prior to the effective date of termination.

     

    VI. INSURANCE


    A.            Provider will possess and maintain, at Provider's own expense, professional liability insurance covering the Provider against claims arising out of the performance of Provider's services hereunder, in an amount not less than One Million Dollars

    ($1,000,000.00) per occurrence, and Three Million Dollars ($3,000,000.00) in the annual aggregate. If the insurance is maintained on a "claims-made" basis, Provider shall obtain and maintain "tail" coverage or "prior acts" coverage to cover claims made after the termination of such insurance or of this Agreement for any occurrence prior to such termination. Provider shall, upon execution of this Agreement and at other times as Contractors may request, provide Contractors with a certificate of insurance evidencing the required coverage. Provider shall notify, or cause its insurance to notify, Contractors at least ten (10) days prior to any reduction, modification or cancellation of the required coverage.

    B.            Provider warrants that if, at any future time, Provider's professional liability insurance is terminated, suspended or not renewed, Provider will notify Contractors in writing within seventy-two (72) hours of receiving such notification.

     

    VII. INDEMNIFICATION


    A.            Provider shall defend, indemnify and hold harmless Contractors, their governing board members, officers, employees, agents and affiliates against and from any and all liability, claims, demands, suits, administrative claims, actions, settlements, judgments, damages, costs or fee (including reasonable attorneys' fees), which Contractors, their governing board members, officers, employees, agents or affiliates may suffer or be required to pay, in law or in equity, whether or not formal legal action is commenced, resulting directly or indirectly from the actions or omissions of Provider or its officers, directors, agents or employees in the provision of services or performance under this Agreement.

    B.            Contractors shall defend, indemnify and hold harmless Provider, its governing board members, officers, employees, agents and affiliates against and from any and all liability, claims, demands, suits, administrative claims, actions, settlements, judgments, damages, costs or fees (including reasonable attorneys' fees), which Provider, its governing board members, officers, employees, agents or affiliates may suffer or be required to pay, in law or in equity, whether or not formal legal action is commenced, resulting directly or indirectly from the actions or omissions of Contractors or their officers, directors, agents or employees in the provision of services or performance under this Agreement.

     

    VIII. CONFIDENTIAL/PROPRIETARY INFORMATION


    A.            All patient records and information concerning the services provided to Covered Persons shall be kept confidential from all parties other than the Programs, as required by law. All such patient records shall constitute the property of the Programs.

    B.            All information and materials provided by the Programs to Provider constitute confidential information and shall remain proprietary to the Programs, including but not limited to contracts, fee schedules, procedures and operations manuals. Provider shall not use or disclose any such information or materials during or subsequent to Provider' s affiliation with the Programs, except as required to carry out Provider's obligations hereunder.

    c. Provider agrees that confidential information that may be disclosed by the Programs identifying eligible Covered Persons by name, social security number or other personal information, including applicable benefits coverage, may only be used by the Provider for the purpose of providing the services outlined in this Agreement.

    D.        Provider agrees not to solicit Contractor's employer or other contracts/relationships during the term of this contract and for one year after the termination of this contract.

    Provider recognizes Contractor has expended considerable energy and monies to enroll Provider within Contractor network. This provision may be nullified upon written consent by both parties.

     

    IX. MISCELLANEOUS


    A.            Independent Contractor. It is expressly acknowledged hereto that Provider is an independent contractor and nothing in this Agreement is intended nor shall be construed to create any relationship between Provider and Contractors other than that of independent entities contracting with each other solely for the purpose of effecting the provisions of this Agreement or to allow Contractors to exercise control or direction over the method or the manner of Provider's performance of this Agreement.

    B.            Use of name. During the term of this Agreement and any renewal thereof, Contractors may include Provider's name, address, telephone number and nature and scope of services to be included in any membership roster that may be prepared for distribution by the Programs.

    C.            Amendment. This Agreement may not be amended or revised except with the prior written consent of all Panies.

    D.            Assignment. No assignment, subcontracting or delegation of the rights, duties or obligations of this Agreement shall be made by Provider without the express written approval of the duly authorized representatives of the Programs.

    E.            Severability. Should any part of this Agreement be declared invalid, for any reason, the remainder shall continue in force and be interpreted as if the invalid portion were omitted.

    Force majeure. No Party shall be deemed to have breached this Agreement for delay caused by occurrences beyond the reasonable control of that party, including, but not limited to, acts of God, acts of any government, wars, rebellion and sabotage, strikes, or severe weather, and any time for performance shall be extended by the actual time of delay caused by such occurrence.

    G.            Governing law. This Agreement shall be construed in accordance with the laws of the State of Maryland.

    H.            Entire Agreement. This Agreement is the entire agreement between Contractors and Provider concerning the subject matters herein and supersedes any previous such agreements Provider may have entered with Contractors and/or the Programs. No other agreements or modifications to this Agreement, whether oral or written, shall be effective unless they are incorporated into this Agreement or a supplement hereto signed by all the Parties.

    I.               Waivers. No waiver of any term, provision or condition of this Agreement, whether by conduct or otherwise, in any one or more instances, shall be deemed or construed as a further or continuing waiver of any such term, provision or condition of this Agreement.

    J.              Gender. All terms as used in this Agreement, regardless of the number and gender in which they are used, shall be deemed to include singular and plural, masculine, feminine, or neuter, as the context or sense of this Agreement may require.

    K.            Nondiscrimination. The Parties agree that they shall perform their respective obligations hereunder without discrimination toward any Covered Person, employee or other persons regardless of their race, age, creed, color, gender, disability or ethnic background.

    M. Notices. Notices required hereunder shall be provided by first class mail, as follows:

     

    If to Provider:

    (your address will carry over)

     

    If to Programs:

    Adventist Healthcare d/b/a LifeWork Strategies

    820 W. Diamond Ave, 5th floor

    Attn: Provider Relations

    Gaithersburg, MD 20878

     

    X. EXCLUSION FROM FEDERAL HEALTHCARE PROGRAMS

     

    1.1 Provider represents that it has not been excluded from participation, is not about to be excluded, nor has it received any notice that it is the subject of any investigation, from participation in, but not limited to, any Federal or State program or by the U.S. Government from receiving federal contracts or subcontracts (collectively, "Federal/State Health Care Programs"). Provider agrees to notify AHC, within one (1) business day of Provider's receipt of any notice of intent to investigate and exclude or actual notice of exclusion from any Federal/State Health Care Program. The listing ofProvider or any Provider-owned subsidiary on the Office of Inspector General's ("OIG") exclusion list or OIG's website for excluded individuals/entities or U.S. General Service Administration's ("GSA") List of Parties Excluded from Federal Procurement and Non-procurement Programs shall constitute "exclusion" from a Federal/State Health Care Programs, for purposes of this Section of the contract. In the event that Provider is excluded from any Federal/State Health Care Program, this Agreement shall immediately terminate. If Provider is excluded from any Federal/State Health Care Program, and fails to notify AHC within (l) business day of receipt of notice of exclusion by Provider, Provider agrees to indemnify AHC for any sanctions, penalties, or fines incurred under the federal Civil Monetary Penalty Law (Section 1128A of the Social Security Act), the Health Insurance Portability and Accountability Act of 1996 or the

    Balanced Budget Act of 1997, as a result of AHC entering this Agreement with Provider.

     

    Xl. ACKNOWLEDGMENT OF ORGANIZATIONAL INTEGRITY PROGRAM

     

    1.1 Provider acknowledges that it has been notified of the fact and substance of the Organizational Integrity Program of AHC, and of the importance of the parties hereto in abiding by the terms of said Organizational Integrity Program, as well as by all federal program requirements. In compliance with the federal Deficit Reduction Act, AHC has adopted policies & procedures that are designed to detect and prevent fraud, waste and abuse. AHC's Organizational Integrity Handbook summarizes these policies and contains a description of the federal False Claims Act and Whistleblower protections. Provider may request a copy of this Handbook from AHC's Materiél Management department, Organizational Integrity Department, or General Counsel's Office.

    IN WITNESS WHEREOF, the parties have executed this Agreement on the date and year first above written.

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    Title:   *   
    Today's Date:   *   *   *   

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  • Payment Methodology

    Employee Assistance Program (EAP)
  • I. EAP Counseling sessions

    A. Contracted Rates*

    $65 per initial session

    $65 per 50-minute session thereafter

    II. Onsite Critical Incident Stress Management Services (CISM)*

    A. $75 per CISM hour if scheduled one week in advance (plus mileage)

    B. $100 per CISM hour if less than one week notice is required (plus mileage)

    C. $125 per CISM session hour if 24hrs or less notice is required (plus mileage)

    III. Parent Coaching (rates only apply if also onboarding as such)

    A. $50 per parent coaching session

    B. $75 per presentation

    C. $75 per presentation preparation (up to 1 hour)

     

    Claims should be sent to:

    Adventist Healthcare d/b/a Lifework Strategies lws@adventisthealthcare.com

    or

    Fax (301) 309-6042

  • * Paid within forty-five (45) days of receipt of case closing form.

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  • W-9

    Please fill out the following questions to submit an updated W-9 (Request for Taxpayer Identification Number and Certification):
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  • Direct Deposit

  • If you wish to enroll in payment via direct deposit, please follow the link below:

    Please note that a voiced check is required when establishing or updating ACH payment instructions.

    This voided check is uploaded, and the form cannot be completed without it. To prevent having to restart the form, please have this prepared prior to beginning.

     

    https://form.jotform.com/241643630759057

     

    Should you wish to receive payment via standard mailed checks, please disregard and continue.

  • Additional Providers

    Thank you so much for onboarding into the LifeWork Strategies EAP Provider Network! Should you wish to include any fellow clinicians (fully licensed, not under clinical supervision) with this application, please utilize the table below to provide each one's Full Name, Credential/Licensure, & CAQH Number:
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  • If onboarding more than 10, please provide requested information to lws@adventisthealthcare.com.

    If no other providers are being onboarded at this time, please disregard and submit by the green button below. 

    Thank you again for onboarding! We greatly anticipate working with you.

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