Thank you for your interest in partnering with Paperflower Foundation. This packet is completed by the authorized representative of the group practice — typically the owner, director, or managing clinician. It establishes the practice as a recognized partner entity with the Foundation and governs the terms under which all clinicians within the practice may bill for Foundation-supported services.

This packet is about your practice as an entity. It covers the legal, financial, and compliance agreements that bind the practice as a whole. It does not replace the individual credentialing packets that each billing clinician within your practice must complete separately. No clinician, including you, if you are also a billing clinician, may submit invoices to Paperflower Foundation until both this practice-level packet and their individual clinician credentialing packet are received and verified.

 

What Is Included in This Packet

Please complete and return all of the following. Every item is required before any clinician in your practice can be activated for billing.

1. Partner Provider Agreement

This is the master agreement between your practice and Paperflower Foundation. It governs all terms of the provider relationship including billing obligations, approved rates, fraud prevention, audit rights, and repayment conditions. This agreement is signed once by the authorized representative on behalf of the practice and covers all clinicians billing under your group entity. No payments will be processed without a fully executed agreement on file.

2. IRS Form W-9

Submit a completed W-9 using your practice's legal business name and Employer Identification Number (EIN) if billing under a group entity. If individual clinicians in your practice bill under their own individual Tax IDs rather than the group EIN, each of those clinicians must submit their own W-9 as part of their individual credentialing packet. Paperflower Foundation is required by law to issue a Form 1099-NEC to any vendor receiving $600 or more in a calendar year. Failure to submit a W-9 will result in suspension of payment processing and may require mandatory backup withholding.

3. Certificate of Insurance (COI)

Submit a current Certificate of Insurance confirming active professional liability coverage for the practice. The COI must show coverage dates, policy limits, the name of the insuring carrier, and must cover all clinicians billing under the practice entity. If individual clinicians carry their own separate malpractice policies rather than being covered under a group policy, each clinician must provide their own COI as part of their individual credentialing packet. Paperflower Foundation reserves the right to set minimum coverage requirements and to request updated certificates upon renewal. Services rendered during any lapse in coverage may not be eligible for reimbursement.

4. Bill.com Account Setup

Accept the vendor invitation sent by Paperflower Foundation via Bill.com and complete your group practice vendor profile, including entry of valid banking information for ACH payment. All payments from Paperflower Foundation are issued exclusively through Bill.com to the practice entity. The practice is solely responsible for the accuracy of banking details and for updating that information promptly if it changes. Paperflower Foundation is not liable for misdirected payments resulting from incorrect or outdated banking information entered by the practice.

5. Business Associate Agreement (BAA)

The authorized representative must sign a Business Associate Agreement on behalf of the practice prior to the exchange of any protected health information. This agreement is required under HIPAA and applies to the practice as a whole. Practices that fail to maintain HIPAA compliance may be immediately terminated from the Foundation's partner network and reported to the U.S. Department of Health and Human Services Office for Civil Rights.

6. Conflict of Interest Disclosure

The authorized representative must complete and sign the Conflict of Interest Disclosure on behalf of the practice. This discloses any financial, personal, or organizational relationship between the practice, its ownership, and Paperflower Foundation leadership. Disclosed conflicts are permitted and managed through the Foundation's standard conflict management policy. Undisclosed conflicts are not.

7. Rate & Insurance Disclosure Form

The authorized representative must complete the Rate Disclosure Form indicating their current self pay rate(s). These rates establish the basis for Foundation reimbursements for all clinicians billing under the practice. 

8. Scope of Services Addendum

Paperflower Foundation staff will complete a Scope of Services Addendum for your practice identifying the approved state client population, session formats, and funding limits that apply to your arrangement. You will receive this addendum for your review and signature. Services rendered outside the scope documented in this addendum are not eligible for reimbursement and may constitute grounds for repayment of funds already disbursed.

 

A Few Things to Know Before You Begin

Your practice agreement covers the entity — not the individuals. The Partner Provider Agreement, BAA, and Conflict of Interest Disclosure you sign bind the practice as a whole. Each billing clinician is additionally responsible for their own individual credentialing packet. Both layers must be complete before billing begins.

You are responsible for your roster. By submitting the Group Practice Roster you are representing that every clinician listed is authorized to practice, is in good standing, and is covered under the practice's malpractice insurance. Billing by an unlisted, unverified, or unlicensed clinician under your group NPI is a billing violation and may result in termination of the practice's partner agreement and a repayment demand.

Paperflower Foundation verifies everything independently. We verify group NPI registration through NPPES, check the OIG List of Excluded Individuals and Entities, and confirm licensing through state board databases. Discrepancies between what you submit and what we find will pause onboarding pending review.

Disclosure does not automatically disqualify your practice. If your practice or any clinician has a prior disciplinary matter, a resolved board complaint, or a past license restriction, disclose it. We review these situations individually. What will disqualify you is discovering an undisclosed history after the fact.

Your information must stay current. You are responsible for notifying Paperflower Foundation within five (5) business days of any change in practice ownership, group NPI status, insurance coverage, clinician roster, or any disciplinary or legal matter affecting the practice or any clinician billing under your entity.

 

Acknowledgment

By signing below I confirm that I am the authorized representative of the practice named above, that I have the authority to enter into agreements on behalf of this practice, that I have read and understand all requirements in this packet, and that I will ensure all items are completed and submitted before any clinician in my practice invoices Paperflower Foundation for services rendered.

1. Parties

This Community Care Partner Agreement (“Agreement”) is entered into by and between:

Paperflower Foundation, a nonprofit organization (“Foundation”),
and

 

1. Purpose

The purpose of this Agreement is to establish the terms under which Paperflower Foundation provides financial support to eligible individuals accessing mental health, therapeutic, or supportive services provided by Partner. The Foundation administers direct payment subsidies to reduce or eliminate financial barriers to care for the clients it supports.

The Foundation does not provide clinical services, supervise clinical care, or influence treatment decisions. Partner retains full clinical autonomy and responsibility for all services rendered.

This Agreement is one part of a broader onboarding framework. Partner's obligations regarding billing codes, telehealth practices, HIPAA compliance, fraud prevention, licensure, NPI verification, rate disclosure, and scope of services are governed by the accompanying documents executed as part of Partner's onboarding, all of which are incorporated by reference into this Agreement.

2. Eligibility & Referral

The Foundation determines client eligibility for financial support based on Foundation-defined criteria including financial hardship, access barriers, and special population needs. Eligibility determinations are made solely by the Foundation.

Partner agrees to accept Foundation-supported clients without discrimination and without altering the standard of clinical care provided to those clients. Partner further agrees that the existence of Foundation funding for a client does not affect clinical decision-making, treatment planning, or the therapeutic relationship.

3. Compensation Structure
3.1 Tiered Participation Model
Paperflower Foundation compensates enrolled Partner providers based on a tiered participation model. The tier at which Partner participates is determined by Partner's annual donation to the Foundation and governs the reimbursement rate the Foundation pays per session for Foundation-referred clients. Tier placement and reimbursement rates are established in the Provider Tiered Participation and Rate Disclosure Form executed as part of onboarding.

The current tier structure is as follows:

 

Tier 1 Community Partner: $250 donation

• 25% self-pay rate coverage
• $500 annual cap per practice (updated to $600 annual cap per practice)
• Does not include extended services, paperwork or no-show fees

Tier 2  Primary Partner: $750 donation

• 40% self-pay rate coverage
• $1,200 annual cap per practice
• Group sessions covered at 25% (partial coverage, counts toward annual cap)
• Limited letter writing: up to 2 letters per year included per practice (ESA, school, or work letters)
• Includes one (1) late-cancellation or reschedule annually per practice

Tier 3 Partner Plus: $1,500 Donation

• 75% self-pay rate coverage
• Unlimited — no annual cap
• Covers group therapy, family therapy, and couples therapy in addition to individual therapy
• Covers intensives at 60% of self pay rate
• Covers select documentation costs for clients, including ESA letters and FMLA paperwork
• Includes four (4) late-cancellations or reschedules annually per practice

Voucher (no enrollment): $0

• $400 annual cap per session
• $50 flat per session/med check, $75 per evaluation

Tiers reset annually. To maintain tier status in a new participation year, Partner must make a qualifying donation within 30 days of their one year anniversary. Tier placement for a new participation year will be confirmed by the Foundation upon receipt of the donation.

3.2 Rate Basis
The Foundation's percentage-based reimbursement is calculated against the Partner's standard self-pay rate — the rate Partner charges clients who pay out of pocket without insurance — as disclosed on the Provider Tiered Participation and Rate Disclosure Form. This rate governs all reimbursements for the duration of the participation year.

If Partner changes their self-pay rate during the participation year, Partner must notify the Foundation in writing within 30 days and submit a revised Rate Disclosure Form. Reimbursements will reflect the updated rate from the date the Foundation receives the revised form.

3.3 What the Foundation Pays
The Foundation pays its tier-based percentage directly to Partner per session for each approved Foundation-referred client. The Foundation's payment represents its charitable subsidy toward the cost of that session. The Foundation's payment obligation is per session with no annual cap on total reimbursements across Partner's Foundation-referred clients.

3.4 Client's Remaining Balance
Partner agrees not to bill, collect, or attempt to collect any amount from a Foundation-supported client beyond the maximum compensation allowed under this Agreement. Any remaining balance shall be treated as a contractual adjustment and written off. Partner may not seek payment from the client for any portion of a session covered or capped under this Agreement.

Partner may not collect more than the disclosed self-pay rate for any Foundation-supported session regardless of the number of payors contributing.

3.5 No CPT Code Required for Reimbursement
Unlike traditional insurance billing, Paperflower Foundation does not require Partner to submit CPT codes as part of a reimbursement request. The Foundation pays a fixed percentage of Partner's self-pay rate per session. Partner maintains clinical documentation in their own records in accordance with their standard professional practice. The Foundation may request documentation to verify that a session occurred but does not review or retain clinical notes.

3.6 Donations Are Non-Refundable and Independent
The annual donation that establishes tier placement is a charitable contribution to the Foundation and is non-refundable regardless of how many Foundation-referred clients Partner sees during the participation year. The donation and the reimbursements are two entirely separate transactions. The Foundation does not offset, credit, or reduce reimbursements against the donation amount.

3.7 Maximum Compensation Is the Total — Not the Foundation's Portion
The rate established by Partner's participation tier — whether a percentage of self-pay rate or the voucher flat rate — is the maximum total compensation Partner may receive for a Foundation-supported session from all sources combined. This includes any amount paid by the client, any amount paid by the client's insurance, and any amount paid by the Foundation.

Partner agrees that for any session covered under this Agreement, total compensation from all sources shall not exceed the tier maximum. The Foundation's payment covers up to the tier maximum, which may include the client's copayment, coinsurance, deductible obligation, or the full cost of the session, depending on the client's circumstances and available Foundation funds.

 

Example — Tier 3 Partner Plus (75% coverage), client with insurance:

Provider self-pay rate: $150
Tier maximum = 75% of $150 = $112.50
Client has insurance; deductible owed = $80
Foundation pays up to $80 toward deductible
Provider collects $80 from Foundation plus remaining balance from insurance, not to exceed $112.50 total from all sources combined

Example — Tier 3 Partner Plus (75% coverage), client without insurance:

Provider self-pay rate: $150
Tier maximum = 75% of $150 = $112.50
Foundation pays up to $112.50
Client owes nothing for this session
Provider writes off the remaining $37.50

Example — Tier 2 Primary Partner (40% coverage), client without insurance:

Provider self-pay rate: $150
Tier maximum = 40% of $150 = $60
Foundation pays up to $60
Provider writes off the remaining $90 (or bills client per their policy, subject to the $1,200 annual cap per practice)

Example — Tier 1 Community Partner (25% coverage), client without insurance:

Provider self-pay rate: $150
Tier maximum = 25% of $150 = $37.50
Foundation pays up to $37.50
Subject to the $600 annual cap per practice

Example — Voucher (no enrollment):

Voucher maximum = $50 per session/med check ($75 per evaluation)
Foundation pays up to $50
Client pays the remainder up to the total self-pay amount
Subject to the $400 annual cap per session

4. Invoicing & Payment

All invoicing and payment processing is governed by the Partner Provider Agreement and Bill.com Payment Authorization Form executed as part of onboarding. Payments are issued exclusively through Bill.com. Invoices must be submitted in accordance with the requirements set forth in those documents.

The Foundation shall remit payment within thirty (30) days of receiving a complete and approved invoice. Incomplete or non-compliant invoices will be returned and will not be processed until corrected and resubmitted.

5. Privacy & HIPAA

Partner's HIPAA obligations are governed by the Business Associate Agreement executed as part of onboarding, which is incorporated by reference into this Agreement.

For Foundation reporting and grant compliance purposes, the Foundation may use fully de-identified aggregate data in accordance with HIPAA de-identification standards. De-identified reporting may include general information such as diagnosis category, age group, and geographic region. No individually identifiable protected health information will be retained by the Foundation.

6. Compliance with Law

The parties intend that all payments under this Agreement comply with applicable federal and state laws including anti-kickback statutes, fee-splitting prohibitions, and IRS nonprofit regulations. Payments made by the Foundation under this Agreement are charitable subsidies and not referral fees. They are not contingent on service volume, referral patterns, or treatment outcomes.

7. Record Retention

Partner agrees to retain all service and billing records related to Foundation-supported services for a minimum of five (5) years from the date of service and to make such records available upon request for compliance review, nonprofit audit, or Foundation-initiated billing review.

8. Non-Discrimination

Partner agrees to provide services to Foundation-supported clients without discrimination based on disability, gender identity or expression, sexual orientation, immigration status, race, ethnicity, religion, national origin, or socioeconomic status.

9. Independent Contractor Status

Partner is an independent contractor and not an employee, agent, or representative of the Foundation. Partner retains full responsibility for all clinical decisions, documentation and recordkeeping, licensure compliance, malpractice insurance coverage, and tax obligations. Nothing in this Agreement creates an employment relationship, joint venture, or agency between the parties.

10. Term & Termination

This Agreement becomes effective on the date of last signature below and remains in effect for one (1) year unless renewed in writing by both parties. Either party may terminate this Agreement with thirty (30) days written notice. The Foundation may terminate immediately and without advance notice for legal, ethical, compliance, or fraud-related concerns as described in the Partner Provider Agreement.

Upon termination all pending invoices will be reviewed prior to final payment and Partner's access to Foundation funding and referrals will cease immediately.

11. Indemnification

Partner agrees to indemnify, defend, and hold harmless Paperflower Foundation and its officers, directors, employees, and agents from and against any claims, losses, damages, or expenses — including reasonable attorneys' fees — arising out of or related to clinical care provided by Partner, professional negligence, licensing or regulatory violations, or any breach of this Agreement or its incorporated documents.

12. Governing Law

This Agreement shall be governed by the laws of the State of Arizona, without regard to conflict of law principles, and applicable federal law.

13. Entire Agreement

This Agreement, together with all documents executed as part of Partner's onboarding with Paperflower Foundation — including the Partner Provider Agreement, Rate & Insurance Disclosure Form, NPI Attestation, Professional Licensure Disclosure, Business Associate Agreement, Conflict of Interest Disclosure, Bill.com Payment Authorization Form, Telehealth Attestation where applicable, Supervising Clinician Agreement where applicable, and Scope of Services Addendum — constitutes the entire understanding between the parties. In the event of a conflict between this Agreement and any incorporated document, the more specific document controls.

This Agreement may be modified only by a written instrument signed by authorized representatives of both parties.

The current tier structure is as follows:

Tier 1 Community Partner: $250 donation

• 25% self-pay rate coverage
• $500 annual cap per practice (updated to $600 annual cap per practice)
• Does not include extended services, paperwork or no-show fees

Tier 2  Primary Partner: $750 donation

• 40% self-pay rate coverage
• $1,200 annual cap per practice
• Group sessions covered at 25% (partial coverage, counts toward annual cap)
• Limited letter writing: up to 2 letters per year included per practice (ESA, school, or work letters)
• Includes one (1) late-cancellation or reschedule annually per practice

Tier 3 Partner Plus: $1,500 Donation

• 75% self-pay rate coverage
• Unlimited — no annual cap
• Covers group therapy, family therapy, and couples therapy in addition to individual therapy
• Covers intensives at 60% of self pay rate
• Covers select documentation costs for clients, including ESA letters and FMLA paperwork
• Includes four (4) late-cancellations or reschedules annually per practice

Voucher (no enrollment): $0

• $400 annual cap per session
• $50 flat per session/med check, $75 per evaluation
  
  

Tiers reset annually. To maintain tier status in a new participation year, Partner must make a qualifying donation within 30 days of their one year anniversary. Tier placement for a new participation year will be confirmed by the Foundation upon receipt of the donation.

Benefit

Tier 1 pays for itself after 5 sessions used - but caps at $600 annually.
Tier 2 pays for itself after 10 sessions used but caps at $1,200 annually.
Tier 3 pays for itself after 10 sessions used but has no ceiling, so the value scales.

 

Remember, this isn't *just* a donation. This is an investment. When you give, you're not just making a donation, you're investing in the people and places that make our community thrive. Communities grow stronger when people show up for one another. 

What we're creating here will outlast and outgrow us all.

And you're making the choice to be a part of it.

National Provider Identifier (NPI) Attestation Form
 

This form must be completed by all Partner Providers prior to the processing of any payment. The information provided will be verified against the National Plan and Provider Enumeration System (NPPES) database maintained by the Centers for Medicare & Medicaid Services (CMS). Submission of false or inaccurate NPI information is a material breach of the Partner Provider Agreement and may constitute fraud.

Provider agrees to notify Paperflower Foundation in writing within five (5) business days of any of the following changes or events:

• Any change to the NPI number(s) used for billing Foundation-supported services
• Any change to the name, address, taxonomy code, or other information registered with NPPES
• Deactivation, suspension, or revocation of any NPI listed on this form
• Exclusion, suspension, or debarment from any federal or state healthcare program
• Initiation of any investigation, audit, or disciplinary proceeding by a licensing board, insurer, or government agency related to billing practices or professional conduct
• Any change in licensure status, including suspension, restriction, or revocation

Failure to provide timely notification of any of the above constitutes a material breach of the Partner Provider Agreement and may result in immediate suspension of payments, termination of the provider relationship, and demand for repayment of any funds disbursed during the period of noncompliance.

 

By signing this form, Provider expressly consents to Paperflower Foundation conducting verification of all NPI information provided herein through the NPPES database, the OIG List of Excluded Individuals and Entities (LEIE), the System for Award Management (SAM.gov) exclusion database, and any applicable state licensing board database. Paperflower Foundation may conduct such verification at the time of onboarding and at any time thereafter during the provider relationship, with or without prior notice.

Provider acknowledges that any discrepancy identified between the information submitted on this form and information found in public databases will be grounds for immediate suspension of payment processing pending investigation, and may result in termination of the provider relationship and demand for repayment.

Consequences of false NPI submission include:

• Immediate termination from the Paperflower Foundation partner network
• Written demand for full repayment of all funds disbursed based on false or misrepresented NPI information
• Civil legal action to recover disbursed funds, including attorneys' fees and applicable interest
• Reporting to the Centers for Medicare & Medicaid Services and the NPPES program
• Reporting to the OIG, applicable state licensing boards, and law enforcement as warranted

Reporting to any insurance carriers with whom the provider is paneled

By signing below, I attest under penalty of law that all NPI information provided on this form is true, accurate, and complete. I confirm that the NPI number(s) listed above are assigned to me or to my organization as indicated, are currently active and in good standing, and accurately reflect the credential and provider type under which I will render services to Paperflower Foundation-supported clients. I understand that Paperflower Foundation will verify this information independently and that any discrepancy may result in suspension, termination, repayment demand, and legal or regulatory action.

This section applies to provisionally licensed, registered, or associate-level providers practicing under supervision. If you are fully independently licensed, check the box below and proceed to Section 4.

Provisionally licensed or associate-level providers must ensure their supervising clinician is aware of and approves of all services rendered to Paperflower Foundation-supported clients. Paperflower Foundation reserves the right to contact the supervising clinician directly to verify the supervisory relationship. Services rendered outside the scope of the supervision agreement are not eligible for reimbursement.

Has any licensing board, professional association, or credentialing body ever:

 

Provider agrees to notify Paperflower Foundation in writing within five (5) business days of any of the following occurring at any point during the provider relationship:

• Expiration, lapse, suspension, restriction, probation, or revocation of any professional license
• Filing of any new complaint, investigation, or disciplinary proceeding by any licensing board or professional body
• Any new criminal charge, arrest, conviction, guilty plea, or no contest plea
• Any new malpractice claim or civil lawsuit related to professional practice
• Any new exclusion, suspension, or sanction from a federal or state healthcare program
• Any change in supervision status, including termination of a supervising relationship
• Any condition imposed on licensure that affects the scope of services the provider may render
• Any voluntary surrender of a license or resignation from a position while under or in anticipation of investigation
• Failure to provide timely notification of any of the above is an independent basis for immediate termination of the provider relationship and demand for repayment of all funds disbursed during the period of noncompliance

 

By signing this form, Provider expressly consents to Paperflower Foundation verifying all licensure information provided herein through any applicable state licensing board database, the OIG List of Excluded Individuals and Entities (LEIE), the System for Award Management (SAM.gov) exclusion database, the National Practitioner Data Bank (NPDB), and any other publicly available credentialing or verification resource. Paperflower Foundation may conduct verification at onboarding and at any time during the provider relationship without prior notice.

Provider acknowledges that any discrepancy between information submitted on this form and information found through independent verification will result in immediate suspension of payment processing pending investigation and may result in termination of the provider relationship, demand for repayment, and referral to applicable authorities.

Consequences of false or incomplete licensure disclosure include:

• Immediate termination from the Paperflower Foundation partner network
• Written demand for full repayment of all funds disbursed, including any funds paid during a period of unlicensed or restricted practice
• Civil legal action to recover disbursed funds, including attorneys' fees, court costs, and applicable interest
• Reporting to all applicable state licensing boards
• Reporting to the National Practitioner Data Bank
• Reporting to the OIG and applicable state Medicaid Fraud Control Units
• Reporting to law enforcement where criminal conduct is suspected
• Reporting to any insurance carriers with whom the provider is paneled

By signing below, I attest under penalty of law that all information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that Paperflower Foundation will verify this information independently and that any false statement, omission, or misrepresentation — regardless of whether it was intentional — may result in termination, repayment demand, and legal or regulatory action. I agree to notify Paperflower Foundation within five (5) business days of any change in my licensure status or any new disciplinary, legal, or regulatory matter affecting my professional practice.

Paperflower Foundation will cover up to the tier maximum per session for Foundation-supported clients, regardless of the client's insurance status. For clients who carry insurance, the Foundation's payment may be applied toward the client's out-of-pocket obligation — including copayments, coinsurance, or deductible amounts — so that the provider receives their full contracted insurance rate from insurance and Foundation combined, not to exceed the tier maximum.

The tier maximum is set by your participation tier as disclosed in your Provider Tiered Participation and Rate Disclosure Form and is calculated as a percentage of your disclosed standard self-pay rate. The tier maximum — not your contracted insurance rate — is the ceiling on total compensation per session from all sources combined, including insurance payments, client payments, and Foundation payments.

By initialing below, I agree that for any session covered under this Agreement, my total compensation from all sources combined — including insurance reimbursement, client payment, and Foundation payment — shall not exceed the tier maximum established by my participation tier. I understand that I may not bill the client any amount above the tier maximum for a Foundation-supported session, and that doing so constitutes a material breach of this Agreement.

The tier maximum is the ceiling on total compensation per session from all sources combined. The client may not be charged any amount above the tier maximum for a Foundation-supported session. Any remaining balance above the tier maximum is written off as a contractual adjustment.

By initialing below, I agree that for any Foundation-supported session, my total compensation from all sources combined — including any client payment and any Foundation payment — shall not exceed the tier maximum established by my participation tier. I understand that I may not bill the client any amount above the tier maximum for a covered session, and that doing so constitutes a material breach of this Agreement.

 

All Providers:
I understand that Paperflower Foundation reimbursements are intended to supplement or cover the cost of care for Foundation-supported clients and are not in addition to amounts billed to or collected from those clients or their insurers for the same service. Double-billing — collecting payment from both the Foundation and an insurer or client for the same session — is strictly prohibited and will be treated as fraud.

PLEASE READ THIS SECTION CAREFULLY BEFORE SIGNING.

Paperflower Foundation is a nonprofit organization with a legal and ethical obligation to ensure that all funds are used for their intended purpose. The rates, credentials, and billing information submitted on this form are relied upon by the Foundation to make funding decisions. Submission of false, misleading, or inaccurate information — whether intentional or reckless — is a serious matter with significant legal consequences.

The following actions constitute fraud or material misrepresentation under this agreement:

• Submitting rates that do not reflect your actual billing practices
• Understating your self-pay rate in order to receive a higher Foundation reimbursement
• Claiming to be private pay only while actively billing insurance carriers
• Failing to disclose rate increases or changes in insurance participation
• Billing Foundation-supported clients amounts above your disclosed rates
• Collecting payment from an insurance carrier and from the Foundation for the same session
• Submitting invoices for sessions that did not occur
• Misrepresenting credentials, licensure, or scope of practice on this form or any related document
• Consequences of Fraud or Misrepresentation

If Paperflower Foundation determines, in its reasonable judgment, that a provider has submitted false information, engaged in fraudulent billing, or otherwise misrepresented their rates or practices, the Foundation will take the following actions:

 

• Immediate termination
  
  The provider's participation in the Paperflower Foundation partner network will be terminated immediately, with no advance notice required.
  
  
• Full repayment demanded
  
  Paperflower Foundation will issue a written demand for repayment of all funds disbursed based on false or fraudulent information. This includes any payments made during the period of misrepresentation, regardless of whether individual sessions were legitimately rendered. Repayment is due within thirty (30) days of the demand.
  
  
• Legal action
  
  Paperflower Foundation reserves the right to pursue civil legal action to recover disbursed funds, including filing suit in a court of competent jurisdiction. The Foundation will seek recovery of the full amount disbursed, plus applicable interest, court costs, and attorneys' fees to the fullest extent permitted by law.
  
  
• Regulatory reporting
  
  Paperflower Foundation will report confirmed or suspected fraud to any or all of the following: the applicable state professional licensing board, the U.S. Department of Health and Human Services Office of Inspector General, state Medicaid Fraud Control Units where applicable, the Internal Revenue Service, and any insurance carriers with whom the provider is paneled. These reports may result in independent investigations, license discipline, civil penalties, or criminal prosecution entirely separate from any action taken by the Foundation.
  
  
• No safe harbor for errors claimed after the fact
  
  Providers who are found to have submitted inaccurate rates and later claim the discrepancy was unintentional will not automatically be exempt from repayment or reporting. The Foundation will evaluate the totality of the circumstances, and repeated or patterned inaccuracies will be treated as intentional misrepresentation.

By signing this form, Provider acknowledges that they have read, understand, and agree to the fraud warning and all provisions contained in this form, including the reimbursement rate agreement in Section 4.

SECTION 6:  Certification & Signature
I certify under penalty of law that all information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that submitting false or misleading information to Paperflower Foundation constitutes fraud, may result in civil and regulatory consequences, and will require full repayment of any funds disbursed based on that information.

I agree to notify Paperflower Foundation in writing within 10 business days of any change to my rates, insurance participation, licensure status, or billing practices.

This Business Associate Agreement ("Agreement") is entered into as of the date of last signature below ("Effective Date") by and between:

Paperflower Foundation, a nonprofit organization with its principal place of business in Phoenix, AZ ("Covered Entity")

and

("Business Associate")

Together referred to herein as the "Parties."

RECITALS
Paperflower Foundation is a nonprofit organization that provides funding and support to individuals and families seeking mental health and related services. In connection with this mission, the Foundation works with licensed clinicians, therapists, psychiatrists, and other healthcare professionals (collectively "Partner Providers") who may create, receive, maintain, or transmit protected health information on behalf of or in connection with services supported by the Foundation.

Business Associate provides services to or on behalf of Paperflower Foundation that may involve access to, creation of, or use of protected health information as defined under HIPAA.

The Parties enter into this Agreement to satisfy the requirements of HIPAA, HITECH, and applicable regulations, and to protect the privacy and security of protected health information shared between them.

ARTICLE 1 — DEFINITIONS
The following terms used in this Agreement shall have the meanings set forth below. Any term used but not defined herein shall have the meaning given to it under HIPAA, HITECH, or their implementing regulations.

1.1 Breach means the acquisition, access, use, or disclosure of Protected Health Information in a manner not permitted under the HIPAA Privacy Rule that compromises the security or privacy of the Protected Health Information, as defined at 45 CFR § 164.402.

1.2 Business Associate has the meaning given at 45 CFR § 160.103 and refers to the Partner Provider identified above.

1.3 Covered Entity means Paperflower Foundation, to the extent it qualifies as a covered entity or hybrid entity under HIPAA in connection with its funding and administrative functions.

1.4 Designated Record Set has the meaning given at 45 CFR § 164.501.

1.5 Electronic Protected Health Information or ePHI means Protected Health Information that is created, received, maintained, or transmitted in electronic form.

1.6 HIPAA Rules means the Privacy, Security, Breach Notification, and Enforcement Rules promulgated under HIPAA and HITECH, as amended from time to time.

1.7 Individual means the person who is the subject of Protected Health Information, and includes the person's personal representative where applicable under 45 CFR § 164.502(g).

1.8 Protected Health Information or PHI means any individually identifiable health information created, received, maintained, or transmitted by the Business Associate on behalf of the Covered Entity, as defined at 45 CFR § 160.103, limited to information received from or created or received on behalf of Covered Entity.

1.9 Required by Law has the meaning given at 45 CFR § 164.103.

1.10 Secretary means the Secretary of the United States Department of Health and Human Services.

1.11 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, as defined at 45 CFR § 164.304.

1.12 Subcontractor means a person or entity who acts on behalf of a Business Associate, other than in the capacity of a member of the Business Associate's workforce, as defined at 45 CFR § 160.103.

1.13 Unsecured PHI means Protected Health Information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through a technology or methodology specified by the Secretary.

ARTICLE 2 — OBLIGATIONS OF BUSINESS ASSOCIATE
2.1 Permitted Uses and Disclosures. Business Associate may only use or disclose PHI as necessary to perform the services described in the Partner Provider Agreement between the Parties, or as otherwise Required by Law. Business Associate shall not use or disclose PHI in any manner that would violate the HIPAA Privacy Rule if done by Covered Entity.

2.2 Minimum Necessary Standard. Business Associate shall use, disclose, and request only the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure, or request, consistent with 45 CFR § 164.502(b).

2.3 Prohibition on Sale of PHI. Business Associate shall not directly or indirectly receive remuneration in exchange for PHI, except as permitted under 45 CFR § 164.502(a)(5)(ii) and only with prior written authorization from Covered Entity.

2.4 Prohibition on Unauthorized Use. Business Associate shall not use or disclose PHI for marketing purposes or in any way that constitutes a sale of PHI without prior written authorization from Covered Entity and, where required, valid authorization from the Individual.

2.5 Safeguards. Business Associate shall implement and maintain appropriate administrative, physical, and technical safeguards to prevent the use or disclosure of PHI other than as provided for in this Agreement, consistent with the requirements of the HIPAA Security Rule at 45 CFR Part 164, Subpart C.

2.6 Subcontractors. Business Associate shall ensure that any Subcontractor that creates, receives, maintains, or transmits PHI on behalf of Business Associate agrees to the same restrictions, conditions, and requirements that apply to Business Associate under this Agreement by entering into a written agreement with the Subcontractor that complies with 45 CFR § 164.308(b)(2) and 45 CFR § 164.502(e)(1)(ii).

2.7 Access to PHI. To the extent that Business Associate maintains PHI in a Designated Record Set, Business Associate shall make such PHI available to Covered Entity upon request, and to the Individual upon request consistent with 45 CFR § 164.524, within fifteen (15) days of a written request.

2.8 Amendment of PHI. To the extent that Business Associate maintains PHI in a Designated Record Set, Business Associate shall make such PHI available for amendment and shall incorporate any amendments directed by Covered Entity consistent with 45 CFR § 164.526.

2.9 Accounting of Disclosures. Business Associate shall document and make available to Covered Entity information required for an accounting of disclosures of PHI as required by 45 CFR § 164.528 within fifteen (15) days of a written request.

2.10 Compliance with Privacy Rule. To the extent Business Associate is carrying out an obligation of Covered Entity under the HIPAA Privacy Rule, Business Associate shall comply with the requirements of the Privacy Rule that apply to Covered Entity in the performance of such obligation.

2.11 Access by Secretary. Business Associate shall make its internal practices, books, and records relating to the use and disclosure of PHI received from or on behalf of Covered Entity available to the Secretary for purposes of determining compliance with the HIPAA Rules.

2.12 Notification of Privacy Practices. Business Associate shall abide by the limitations of Covered Entity's Notice of Privacy Practices to the extent that such limitations affect Business Associate's use or disclosure of PHI and Covered Entity has notified Business Associate of such limitations.

ARTICLE 3 — BREACH NOTIFICATION
3.1 Reporting of Breaches. Business Associate shall notify Covered Entity without unreasonable delay and in no case later than five (5) calendar days after discovery of a Breach of Unsecured PHI. Notification shall be provided in writing to info@paperflowerfoundation.org and shall include, to the extent possible:

• The identity of each Individual whose Unsecured PHI has been or is reasonably believed to have been involved in the Breach
• A brief description of what happened, including the date of the Breach and the date of discovery
• A description of the types of Unsecured PHI involved
• Any steps Individuals should take to protect themselves from potential harm
• A description of what Business Associate is doing to investigate the Breach, mitigate harm, and protect against future Breaches

Contact information for Business Associate
3.2 Reporting of Security Incidents. Business Associate shall report to Covered Entity any Security Incident of which it becomes aware, including attempted Security Incidents, without unreasonable delay and no later than ten (10) calendar days after discovery.

3.3 Reporting of Impermissible Uses or Disclosures. Business Associate shall report to Covered Entity any use or disclosure of PHI not provided for by this Agreement of which it becomes aware, without unreasonable delay and no later than ten (10) calendar days after discovery.

3.4 Mitigation. Business Associate shall take reasonable steps to mitigate, to the extent practicable, any harmful effect resulting from a use or disclosure of PHI in violation of this Agreement.

ARTICLE 4 — OBLIGATIONS OF COVERED ENTITY
4.1 Notice of Privacy Practices. Covered Entity shall provide Business Associate with its Notice of Privacy Practices and any changes thereto that may affect Business Associate's use or disclosure of PHI.

4.2 Permissions and Restrictions. Covered Entity shall notify Business Associate of any restriction on the use or disclosure of PHI that Covered Entity has agreed to or is required to abide by under the HIPAA Rules, to the extent such restriction may affect Business Associate's use or disclosure of PHI.

4.3 Permissions from Individuals. Covered Entity shall obtain all necessary authorizations, consents, and permissions from Individuals as required by applicable law prior to disclosing PHI to Business Associate.

4.4 Minimum Necessary. Covered Entity shall use reasonable efforts to provide Business Associate only with the minimum PHI necessary to enable Business Associate to perform its obligations under this Agreement and the Partner Provider Agreement.

ARTICLE 5 — TERM AND TERMINATION
5.1 Term. This Agreement shall be effective as of the Effective Date and shall remain in effect until the termination or expiration of the underlying Partner Provider Agreement, unless terminated earlier as provided herein.

5.2 Termination for Cause. Either Party may terminate this Agreement immediately upon written notice if the other Party has materially breached any provision of this Agreement and has failed to cure such breach within fifteen (15) calendar days of receiving written notice of the breach. Covered Entity may terminate this Agreement immediately and without opportunity to cure if it determines, in its reasonable judgment, that Business Associate has violated a material term of this Agreement and that cure is not possible.

5.3 Automatic Termination. This Agreement shall automatically terminate upon termination of Business Associate's participation in the Paperflower Foundation partner network for any reason, including termination for fraud, misconduct, or license revocation.

5.4 Obligations Upon Termination. Upon termination of this Agreement for any reason, Business Associate shall, at the direction of Covered Entity:

• Return to Covered Entity all PHI received from or created on behalf of Covered Entity that Business Associate still maintains in any form, or
• Destroy all such PHI and provide written certification of destruction to Covered Entity within thirty (30) days of termination

If return or destruction is not feasible, Business Associate shall extend the protections of this Agreement to the PHI retained and limit further use or disclosure to those purposes that make return or destruction infeasible for as long as Business Associate maintains such PHI.

5.5 Survival. The obligations of Business Associate under Section 5.4 and under Article 3 with respect to any Breach discovered prior to termination shall survive the termination or expiration of this Agreement.

ARTICLE 6 — GENERAL PROVISIONS
6.1 Entire Agreement. This Agreement, together with the Partner Provider Agreement, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior negotiations, representations, or agreements relating to this subject matter.

6.2 Amendment. This Agreement may be amended only by a written instrument signed by authorized representatives of both Parties. Covered Entity may amend this Agreement as necessary to comply with changes in applicable law by providing thirty (30) days written notice to Business Associate.

6.3 No Third-Party Beneficiaries. Nothing in this Agreement shall confer any rights or remedies upon any person other than the Parties and their respective successors and permitted assigns.

6.4 Interpretation. Any ambiguity in this Agreement shall be interpreted to permit compliance with the HIPAA Rules. In the event of a conflict between this Agreement and the Partner Provider Agreement with respect to PHI, this Agreement shall control.

6.5 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Arizona, without regard to its conflict of laws principles, and applicable federal law including HIPAA and HITECH.

6.6 Severability. If any provision of this Agreement is found to be unenforceable, the remainder of the Agreement shall continue in full force and effect.

6.7 Indemnification. Business Associate shall indemnify, defend, and hold harmless Paperflower Foundation and its officers, directors, employees, and agents from and against any claims, losses, damages, penalties, fines, or expenses, including reasonable attorneys' fees, arising out of or relating to any violation of this Agreement or the HIPAA Rules by Business Associate or its Subcontractors.

6.8 Regulatory Changes. The Parties agree to negotiate in good faith any amendment to this Agreement required by changes in applicable law, regulation, or guidance issued by the Secretary. If the Parties are unable to agree on an amendment within sixty (60) days of written notice of a required change, either Party may terminate this Agreement upon thirty (30) days written notice.

SIGNATURES
By signing below, each Party represents that it has the authority to enter into this Agreement and agrees to be bound by its terms.

COVERED ENTITY — PAPERFLOWER FOUNDATION

 

BUSINESS ASSOCIATE — PARTNER PROVIDER

 

Paperflower Foundation takes the integrity of its funding seriously. The following policy applies to all partner providers and is incorporated into the Partner Provider Agreement. Any provider found to have engaged in fraud, misrepresentation, or financial misconduct will be subject to the full remedies described below.

What Constitutes Fraud or Misconduct

The following actions constitute fraud or material breach of the provider relationship with Paperflower Foundation:

• Billing for services not rendered, including sessions that did not occur or were canceled without proper documentation
• Falsifying client records, session notes, diagnostic codes, or billing documentation
• Misrepresenting credentials, licensure status, or insurance panel participation at the time of enrollment or at any point during the provider relationship
• Submitting duplicate claims for the same service
• Billing Foundation funds for services already reimbursed by an insurance carrier or another funding source, without disclosure
• Receiving payment through Bill.com for services not covered under the provider's Scope of Services Addendum
• Providing false or misleading information on the Partner Provider Enrollment Form, W-9, NPI Attestation, or any other required document
• Failing to disclose a disciplinary action, license suspension, or exclusion from a state or federal healthcare program
• Any scheme, arrangement, or pattern of conduct intended to obtain Foundation funds through deception

Foundation's Right to Investigate

Paperflower Foundation reserves the right to audit any provider's billing records, session documentation, and submitted invoices at any time, with or without prior notice, when there is reasonable cause to suspect fraud or noncompliance. Providers are required to cooperate fully with any such audit and to produce requested records within ten (10) business days of a written request. Failure to cooperate with an audit is itself grounds for immediate termination, demand for repayment and legal action.

Foundation's Right to Demand Repayment

In the event that Paperflower Foundation determines, in its reasonable judgment, that a provider has received funds through fraud, misrepresentation, billing error, or services rendered outside the approved Scope of Services, the Foundation reserves the right to:

• Issue a written demand for full repayment of all funds improperly received, including any payments made during the period of noncompliance
• Demand repayment of funds received for services not documented in accordance with the provider's agreement
• Withhold future payments pending resolution of any disputed amounts
• Offset any repayment obligation against future invoices or payments otherwise owed to the provider
• Pursue repayment through civil legal action, including filing suit in a court of competent jurisdiction
• Seek recovery of attorneys' fees, court costs, and interest on the outstanding balance at the maximum rate permitted by applicable law
• Repayment demands are due and payable within thirty (30) days of the date of the Foundation's written demand unless a written repayment plan is agreed upon by both parties.

Foundation's Right to Report

Paperflower Foundation reserves the right to report suspected fraud or misconduct to any or all of the following:

• The applicable state professional licensing board
• The U.S. Department of Health and Human Services Office of Inspector General (OIG)
• The HHS Office for Civil Rights (in the event of HIPAA violations)
• The Internal Revenue Service (in the event of tax fraud or false W-9 submissions)
• State Medicaid Fraud Control Units, if applicable
• Local, state, or federal law enforcement agencies
• Any insurance carrier with whom the provider is paneled, where overbilling or double-billing is suspected
• The National Practitioner Data Bank (NPDB), where applicable

Paperflower Foundation is not required to notify the provider prior to making such reports if doing so would interfere with an ongoing investigation or compromise the safety of clients.

Immediate Termination

Paperflower Foundation reserves the right to immediately terminate a provider's participation in its partner network, with no advance notice, upon reasonable determination that any of the following has occurred:

• Fraud or intentional misrepresentation of any kind
• Suspension or revocation of the provider's professional license
• Exclusion from a state or federal healthcare program
• Endangerment of or harm to a client
• Material breach of this Agreement or the Partner Provider Agreement
• Failure to repay funds within the timeframe specified in a repayment demand

Upon termination, all pending invoices will be reviewed prior to any further payment, and the provider's access to Foundation referrals and funding will cease immediately.

Provider Acknowledgment

By signing the Partner Provider Agreement and submitting the completed onboarding documents, Provider acknowledges that they have read, understand, and agree to the fraud prevention, reporting, and repayment provisions set forth above. Provider understands that Paperflower Foundation takes seriously its obligation to its donors, clients, and the communities it serves, and that the Foundation will take all necessary steps to protect the integrity of its funds.

License Status: Independent / Provisional — Supervised / Provisional — Unsupervised (not eligible to bill)

Attach additional sheet for practices with more than 10 clinicians:

Attestation
By signing below I confirm that all clinicians listed on this roster are currently employed or contracted with the practice, hold the credentials listed, are authorized to render services under the group NPI, and are in good standing with their applicable licensing boards as of the date of this submission. I understand that Paperflower Foundation will not reimburse services billed by any clinician not listed and individually verified on this roster, and that billing under the group NPI by an unlisted or unverified clinician is a billing violation subject to denial, repayment demand, and potential termination of the practice's partner agreement.

Authorization
By signing this form I authorize Paperflower Foundation to process all payments to me through Bill.com and confirm that I understand the following:

Bill.com is the only payment method. Paper checks, wire transfers, Venmo, Zelle, PayPal, cash, and any other method are not available under any circumstance.

I am responsible for accepting my invitation. Paperflower Foundation will send a vendor invitation to the email above. I must accept it and complete my vendor profile before any payment can be processed. Delays caused by my failure to do so are not the Foundation's responsibility.

I am responsible for my banking information. Paperflower Foundation does not collect or store my banking details. I am solely responsible for entering accurate routing and account information directly into Bill.com. Payments sent to an incorrect account due to information I have entered are not the Foundation's responsibility.

I will keep my information current. I will update my banking details in Bill.com and notify community@paperflowerfoundation.org within five (5) business days of any change to my banking information, business name, Tax ID, or payment email.

Misdirected payments may not be recoverable. If a payment is misdirected due to incorrect information I have entered, the Foundation will make reasonable efforts to assist in recovery but cannot guarantee the return of those funds.

This authorization remains in effect until I submit written revocation to community@paperflowerfoundation.org and is automatically revoked upon termination of my provider agreement.

Paperflower Foundation requires that all telehealth sessions with Foundation-supported clients be conducted on a HIPAA-compliant platform with a Business Associate Agreement in place between you and the platform. Standard consumer versions of Zoom, FaceTime, Google Meet, Skype, or any other non-healthcare-specific platform are not permitted. If you are unsure whether your platform qualifies, contact your platform provider before completing this form.

You must hold a valid license in the state where your client is physically located at the time of each session — not simply the state where you practice. Paperflower Foundation will not reimburse telehealth sessions rendered in states where you are not licensed or compacted to practice. You are solely responsible for ensuring your licensure covers each client's location before rendering services.

All telehealth sessions billed to Paperflower Foundation are conducted via synchronous audio-video only. I do not conduct and will not bill asynchronous sessions, text-based therapy, pre-recorded video sessions, app-based messaging interactions, or phone-only sessions as telehealth services to Paperflower Foundation. I understand that only live, real-time audio-video sessions are reimbursable.

 

I conduct all telehealth sessions from a private, confidential location. I take reasonable steps to ensure that client sessions cannot be overheard or observed by unauthorized persons. I do not conduct sessions from public spaces, shared workspaces without sound privacy, or any location where client confidentiality cannot be reasonably maintained.

I verify client identity and physical location at the start of each telehealth session. I confirm the client's identity and their physical location at the start of each session and document this in my session notes. I maintain current knowledge of crisis and emergency resources appropriate to the client's physical location and am prepared to provide those resources if needed. 

I am licensed to provide telehealth services in every state where my Foundation-supported clients are physically located during sessions. I understand that my licensure in my home state does not automatically authorize me to provide telehealth services to clients located in other states. I will not render services to a Foundation-supported client located in a state where I am not licensed or compacted to practice.

 

I will not bill telehealth platform fees, technology fees, or connectivity fees to Paperflower Foundation. Any costs associated with my telehealth platform are my own professional expense. These costs will not appear as a line item on any invoice submitted to the Foundation under any circumstance.

I will append the appropriate telehealth modifier to all telehealth claims submitted to Paperflower Foundation. I understand that only synchronous audio-video sessions with modifier 95 or GT appended to an otherwise approved CPT code are reimbursable. I understand that the GQ modifier — used for asynchronous telehealth — is not approved by Paperflower Foundation and that claims submitted with GQ will be denied.

I will maintain documentation sufficient to support every telehealth claim I submit. My session notes for telehealth sessions will include the date and time of the session, the platform used, confirmation of client identity and physical location, session duration, and clinical content consistent with the CPT code billed. I understand that Paperflower Foundation may request session documentation for any telehealth invoice and that claims without supporting documentation may be denied.

I will notify Paperflower Foundation within five (5) business days if any information on this form changes. This includes changes to my telehealth platform, the states in which I am providing telehealth services, my licensure status in any state, or my interstate compact participation. I understand that rendering telehealth services to Foundation-supported clients in a state where I am no longer licensed may result in denial of claims, repayment demand, and termination of my provider agreement.

 

 

By signing below I confirm that all information provided on this form is true and accurate, that I have read and initialed every item in Part E, and that I understand and accept all telehealth billing standards and restrictions described above. I understand that submitting telehealth claims that do not comply with these standards will be treated as a billing violation subject to claim denial, repayment demand, and potential termination of my provider agreement.