Please complete the following non-binding form granting TRIARQ Health permission to request your practice’s historical data from CMS.

TRIARQ Health will use this date to provide you an accurate idea of the benefits you may see from joining the BPCI-Advanced program as part of the TRIARQ Health Alliance. Your data will be treated confidentially, will not be disclosed to any other parties, and will be destroyed by TRIARQ if you choose not to participate in the BCPI-Advanced Program.

Non-Binding Statement-of-Interest

Until you sign a binding contract with TRIARQ, both parties have the right to terminate all negotiations regarding the BCPI-Advanced Program without any liability or obligation to move forward. This is not a binding agreement

This Statement of Interest is made as of the date signed below by the undersigned Physician Group Practice (“PGP”) to TRIARQ LLC. (“TRIARQ”).

The Alliance is a Clinically Integrated Network of orthopedic surgeons and post-acute care participating providers (the “Alliance”) formed to contract with third party payers and employers to provide value-based care including bundled pricing for orthopedic surgery and other services, incorporating principles of clinical and financial integration. The Alliance is also a Medicare Convener participating in the BPCI-Advanced program.

The PGP is interested in learning more about participation in the Alliance and in having the Alliance receive and review its data provided by CMS during the CMS evaluation period, understanding it is a non-binding obligation to evaluate the CMS Advanced Bundled Payment Initiative for joint replacements or back/spine procedures. ACCORDINGLY, PGP STATES AND AGREES AS FOLLOWS:

1. I understand that this is an indication of interest only at this point. It is a non-binding commitment on my part and does not create any obligation to TRIARQ but will be used by TRIARQ to enter into discussions with CMS and/or Commercial Payers to determine participation in the BPCI Advanced Bundle Payment Program or Commercial Bundled Payment Programs.
2. Any binding commitment by me will be made only after I receive a participation agreement or offering memorandum, and TRIARQ and I sign all necessary legal documents and other materials, which TRIARQ will present for my final approval.
3. I hereby grant Triarq permission to request and receive historical data from CMS regarding PGP performance.