Contract Request Form

Collects everything a legal team needs to draft or review a contract: the parties involved, timelines, compliance risk factors, and who will sign.

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Describe in 3 to 4 sentences the purpose of this agreement. State any particular concerns and the purpose of the request versus the purpose of the agreement. Why are you engaging legal counsel? For example: help with redline language from a vendor. Provide enough background for legal to fully understand the request.

New Contract

New contract

1. Legal Name of Affiliate/Entity, including DBA if any:

2. Legal Name of Other Party:

3. What type of license does the other party hold, if any, and with what agency?

4. Business owner (business/risk decision maker) who will approve if outside counsel is needed:

5. Name of contract manager or requesting party

6. W-9. If applicable, attach a completed copy of the IRS Form W-9 for the person or entity providing these services.

7a. Does the contract need to be submitted to a regulatory agency?

7b. Will another party, such as a health plan, provide a copy of this contract to a regulatory agency?

Term and Timeline

3. Proposed Term: From (Potential Effective Date):

To:

Auto Renewals:

4. Date by which you need the completed final agreement (allowing time to obtain signatures):

5. If an existing agreement, attach a complete copy and the contract manager reference number

a. Existing Effective Date:

b. Existing Termination Date:

1. Is the aggregate dollar value over the term of the agreement in excess of $25 million?

Yes

2. Indicate whether the other party (or any owner of the other party) is now, or has been in the past 5 years, a director, trustee, officer, or key employee at any affiliate.

Yes

2a. If yes, specify name(s), position(s) held, affiliate name(s), and term of each position:

1. Will the parties be exchanging PHI? If so, are the parties exchanging PHI the same parties to the agreement?

2. If yes, does the PHI include claims or encounter data?

Yes

3. If yes, is there a current (within the past 18 months) BAA on file or a written exception from Privacy allowing use of the current form?

Yes

4. Is there a Security Risk Assessment (SRA) on file?

Yes

5. Has the other party been credentialed or had another background check performed (e.g., checked the OIG excluded provider website)? If so, please describe:

Special Terms and Considerations

2. Describe any non-standard provisions (e.g., small group RAF reconciliation, payment changes based on Stars ratings, risk share/risk pool, referral obligations, exclusivity).

3. Please identify any other existing contractual arrangement with this party that may impact this agreement (e.g., Master Services Agreement).

4. If a new product, is there a provider manual?

Yes

5. If attaching a proposed draft or proposal from the other party, has the business owner reviewed the document(s) and provided comments?

Yes

1. Do you anticipate another contract with this party for a different product during the term of the agreement? If yes, what types of products?

2. Do we have other affiliates or plans that would also want to be able to access the terms of this agreement?

Yes

2a. If yes, have you had any discussions with the affiliate or the other party about allowing additional access?

Yes

Signatory Information

Requesting Party

a. Name & title of individual who will sign the agreement

b. Name & title of individual who will receive notices

c. Address to which notices should be sent

Street Address

City

State / Province

ZIP / Postal Code

2. Other Party: Party Name

a. Name & title of individual who will sign the agreement

b. Name & title of individual who will receive notices

c. Address to which notices should be sent

Street Address

City

State / Province

ZIP / Postal Code

1. Select one

Option A Option B

2. Proposed Rate Terms?

3. What key terms must be included?

4. Type of LOA

Standard Amendment

Certification

a. I have reviewed all of the information contained in this form and it is complete and accurate

I confirm

Print Name of Submitted by

Date

Signature of Business Owner

Sign here

Print Name of Business Owner

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