| County Name: _____________________ |
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| LEGAL-2 PROVIDER ARRANGEMENTS |
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| Category |
Type of Agreement |
Number of Agreements |
Various Dates Executed |
Automatic Renewal of Agreements |
Page Number for Contract Template in this Application |
| Staff |
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| Physicians |
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| Non-Physicians |
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| Non-staff Physicians |
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| Group |
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| Member Physicians |
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| Member Non-Physicians |
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| Non-Member Physicians |
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| Non-Member, Non-Physicians |
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| IPA |
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| Member Physicians |
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| Member Non-Physicians |
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| Non-member Physicians |
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| Non-member, Non-Physicians |
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| Direct Contract HMO Physicians |
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| Lab Services |
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| X-ray Services |
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| Hospitals |
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| Home Health |
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| Other (specify) |
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| Medicare/HMO Health Services |
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Prepare a separate table for each county requested |
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| PROVIDER ARRANGEMENTS |
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TABLE: Legal-2 |
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| Instructions: |
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| Provide a separate table for each county or partial county. |
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| Column Explanations: |
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| 1. Category - Staff/Group/IPA/PHO/Direct: |
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| Member Physicians - Licensed Medical Doctors (M.D.) and Doctors of Osteopathic Medicine (O.D.) |
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| who are members of the entity. |
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| Member Non-Physicians - Mid-wives, nurse practitioners, or chiropractors, etc. who are members of |
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| the entity. |
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| Non-Member Physicians - Licensed M.D. and D.O. who are subcontracted to provide services to the. |
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| entity. |
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| Non-Member, Non-Physicians - Mid-wives, nurse practitioners, or chiropractors, etc. who are |
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| subcontracted to provide services to the entity but are not members of the entity. |
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| Direct Contract HMO Physicians - Licensed M.D. and D.O. who have entered into a contract with the |
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| HMO. |
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| 2. Type of Agreement - Only contracts or Letters of Agreement (LOA) are acceptable. Letters of |
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| intent are not acceptable. |
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| 3. Number of Agreements - List the total number of signed agreements. |
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| 4. Automatic Renewal of Agreements - Provide "Yes" or "No" response. |
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| 5. Date Executed - Enter the date all agreements were finalized for the particular category. |
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| 6. Page Number in Contract - List the page number where the agreement is located in the application |
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| package. |
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