Live Urgent Care Medical Service Agreement

MEDICAL SERVICES AGREEMENT
SECTION 1—EMPLOYER ACCOUNT PROFILE

1.1 COMPANY IDENTIFICATION
This Medical Services Agreement ("Agreement") is made and entered into as of today's date, ("Effective Date"), by and between Live Urgent Care, LLC, located at 300 Carnegie Center Drive, Suite 150, Princeton, NJ 08540 ("Live Urgent Care"), and ("Company"), a company duly organized and existing under the laws of its state of formation.
Effective Date:

MonthDayYear
Date
Company Name:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Office Phone:
Format: (000) 000-0000.
1.2 DESIGNATED EMPLOYER REPRESENTATIVE (DER)
The DER is the primary point of contact authorized to request services and receive sensitive medical results/clearances.
Name:

First NameLast Name
Position:
Direct Phone:
Format: (000) 000-0000.
Email:
example@example.com
Secondary Authorizer/DER
Full Name:
Position:
Direct Phone:
Format: (000) 000-0000.
Email:
example@example.com
1.3 ACCOUNTS PAYABLE & BILLING
Billing Contact Name:

First NameLast Name
Billing Email:
example@example.com
Is the billing address different from the mailing address?
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION 2 — SCOPE OF SERVICES
Live Urgent Care, LLC shall provide occupational health services, including, but not limited to:
- Physical Exams: DOT/CDL, Pre-Employment, and Fit-for-Duty.
- Testing: DOT and Non-DOT Drug & Alcohol testing (Urine/Breath).
- Injury Care: Evaluation and treatment of Workers' Compensation injuries.
- Clinical Diagnostics: X-ray, Lab testing, Audiometry, PFT, and ECG.
- Screening: TB Testing (Skin/Quantiferon), Immunizations, and Respirator Fit Testing.
SECTION 3—CLINIC OPERATIONS & ARRIVAL POLICY
3.1 Hours of Operation:
- Monday - Friday: 8:00 AM - 8:00 PM
- Saturday - Sunday: 8:00 AM – 4:00 PM
3.2 Drug Screen Cut-Off Times:
To ensure adequate time for processing and collection, employees must arrive by the following times. Employees arriving after these times may be deferred to the next business day:
- Weekdays: Before 5:00 PM
- Weekends: Before 1:00 PM
SECTION 4—CONFIDENTIALITY & COMPLIANCE
4.1 Regulatory Standards: Live Urgent Care, LLC shall maintain all required state licenses and FMCSA Medical Examiner Certifications.

4.2 Medical Records: All services shall be performed in compliance with HIPAA and applicable state privacy laws. COMPANY acknowledges that clinical records are the property of Live Urgent Care, LLC, though fitness-for-duty results and drug test outcomes will be shared with the DER as permitted by law.
SECTION 5—WORKERS' COMPENSATION PROVISIONS
For work-related injuries, the COMPANY must provide a completed Authorization to Treat. If Workers' Compensation insurance information (Carrier, Policy #, and Claim #) is not provided at the time of service, the visit will be billed to the COMPANY at the Self-Pay Rate defined in the Fee Schedule. The COMPANY assumes ultimate financial responsibility for services rendered, regardless of carrier disputes.
SECTION 6— BILLING AND PAYMENT TERMS
6.1 Invoicing: Live Urgent Care, LLC will invoice the COMPANY electronically.
6.2 Terms: Standard payment terms are Net 30. The full invoice amount is due within thirty (30) days.
6.3 Delinquency: Accounts more than 30 days past due are subject to a late fee of 1.5% per month and a temporary suspension of services until the balance is cleared.
6.4 Payment Methods: Credit Card, ACH/eCheck, or Debit Card.
SECTION 7—TERM AND TERMINATION
This Agreement remains in effect until terminated. Either party may terminate this Agreement with 30 days written notice. Termination does not waive the COMPANY'S obligation to pay for services rendered prior to the termination date.
SIGNATURES
Full Name

First NameLast Name
Signature:
Should be Empty:

MEDICAL SERVICES AGREEMENT

SECTION 1—EMPLOYER ACCOUNT PROFILE

1.2 DESIGNATED EMPLOYER REPRESENTATIVE (DER)

Secondary Authorizer/DER

1.3 ACCOUNTS PAYABLE & BILLING

SECTION 2 — SCOPE OF SERVICES

SECTION 3—CLINIC OPERATIONS & ARRIVAL POLICY

3.1 Hours of Operation:

3.2 Drug Screen Cut-Off Times:

SECTION 4—CONFIDENTIALITY & COMPLIANCE

SECTION 5—WORKERS' COMPENSATION PROVISIONS

SECTION 6— BILLING AND PAYMENT TERMS

SECTION 7—TERM AND TERMINATION

SIGNATURES