| Concierge Mental Health Agreement for Agencies | |
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This Concierge Mental Health Services agreement dated ______/______/______between Avera Behavioral Management, Inc. (henceforth referred to as the "Provider") and ______________________________(henceforth referred to as the "Agency") is for the purpose of providing on-site, on-line, and on-call ___ Caregiver Education ___Behavioral Monitoring ___Staff Training ____Competency Evaluation ____Clinical Assessment ____ Case Management services for the aforementioned Agency. Any relevant and reasonable clinical, mental, or behavioral service or item deemed medically neccessary and provided directly (face-to-face) to the resident will be billed against the Resident's Medicare account. Any related co-pay or deductable will be billed to and paid for by the responsible party for the Resident. Any informational, administrative, clerical, legal, educational, technical, instructional, testimonial, referral, environmental, reporting, or training services executed by the provider and delivered at the request of the Agency on behalf of or for the benefit of a staff member, resident, or family member will be billed to the Agency at an hourly rate of $____________, daily rate of $________, or monthly rate of $_____________. Agency payables shall accrue and will be invoiced on the last day of every month and be paid by the Agency to the provider by the 15'th day of the following month as compensation for the aforesaid services for a period of _______ month(s) from the signed date of this agreement. This agreement can be terminated without cause or fault by either party. If in agreement please print, date, sign, and fax to 770-973-3587 or scan to and e-mail to: averamgmt@bellsouth.net. ____________________ _________________________ DATE Executive Director for Agency ____________________ _________________________ DATE Avera Behavioral Management, Inc. |
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