Three Rivers Provider Network Agreement

Three Rivers Provider Network Agreement With

Exhibit 10.1
THREE RIVERS PROVIDER NETWORK
______________________________


This Agreement is made this 2 day of December 2010, by and between Three Rivers Provider Network, Inc., a Nevada Corporation (“TRPN”) and Pasadena SA Services a Provider Group of health care services.  TRPN contracts with hospitals, physicians, ancillaries and entities hereinafter referred to as “Provider” rendering medical and health care services at pre-determined rates as follows.

1.  Clients. Covered Services, Contract Rates: TRPN contracts with insurance companies, third party administrators, health plans, individuals and entities hereinafter referred to as “Clients” that directly or indirectly access TRPN contracted providers for covered services. Covered Services shall include all services that are medically necessary including health, workers’ compensation, automobile and general liability.  The rate used in conjunction with this Agreement will be a * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles.  Clients are obligated to make payment directly to provider only at the contracted rate as payment in full.   Provider shall not balance bill the patient upon receipt of payment in full at the contracted rate.  TRPN has no responsibility to make payments on behalf of Clients.  Payments shall be made within thirty (30) calendar days of receipt of clean claim.  Where a state mandated fee schedule exists, provider agrees to accept a * discount below the state schedule.  Payments made and cashed by the provider shall be accepted as payment in full and fulfillment of all terms of the agreement, providing the total payment including the member’s portion is not less than the contracted rate.

2.  Licenses, Standards of Care:  Provider agrees to deliver health care services that meet all legal standards of care complying with applicable Federal, State and Local laws and maintains the standards of NCQA and/or JCAHO.  The provider is delegated by TRPN to carry out and/or assign credentialing responsibilities.  Evidence of such licenses, certificates and standards shall be made available to TRPN upon request.

3.  Term and Termination:  This Agreement shall continue in effect for a period of two (2) years with automatic successive one (1) year terms.  This Agreement may be terminated by either party without cause with a ninety (90) day prior written notice to the other party at the mailing addresses listed under the signatures.  This Agreement may be immediately terminated with cause by TRPN should Provider lose applicable licenses, malpractice coverage, fail to honor the applicable contracted rates pursuant to this Agreement, or if any information provided in Attachment A is illegible, incomplete, or invalid.

4.  Dispute Resolution:  This Agreement shall be construed and interpreted in accordance with the laws of the State of Nevada.  Provider agrees to meet and confer in good faith to resolve any disputes that may arise under this Agreement. If a dispute between TRPN and Provider arises out of this Agreement and is not resolved, either party may submit the dispute to arbitration which shall be commenced and conducted in accordance with the Rules of Practice and Procedures of the Judicial Arbitration and Mediation Services, Inc. (“JAMS”) as in effect at the time (“JAMS Rules”).

5.  Attachment A:  All information provided in Attachment A of this Agreement is complete and accurate to the best of Provider’s knowledge and Provider shall immediately notify TRPN of any changes thereto.  Provider agrees to mark “N/A” next to any blank that is not applicable to Provider’s business.

6.  Faxed Signatures:  The parties agree that facsimile signatures of authorized representatives of the parties shall legally bind the parties to the terms and conditions of this Agreement as if the signatures were original and shall be considered evidence of a fully executed Agreement.
 
7.  Final Agreement:  All terms and conditions agreed upon by the parties are contained in this Agreement.  All prior negotiations, promises, agreements and representations, either spoke or written concerning the subject matter of this Agreement that are not set forth herein are null and void and have no bearing on this Agreement.
 

*
Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act.  Confidential portions of this document have been filed separately with the Securities and Exchange Commission.
 
 
 

 
 
IN WITNESS WHEREOF, the authorized parties hereto have executed this Agreement and intend to be bound thereby.
 
 
PROVIDER GROUP NAME (Please Print):       ATTENTION:LANI HAZELTON  
      TRPN CONTRACTING SPECIALIST  
         
PASADENA SA SERVICES      THREE RIVERS PROVIDER NETWORK  
 
           
Signature: 
 /s/ Jaime Olmo    
  Signature:
/s/ Todd Breeden   
 
Title: 
Chief Operating Officer     
  Name: 
Todd Breeden, C.O.O.
 
Date: 
12/2/2010   
  Mailing Address:
910 Hale Place, Suite 101
 
        Chula Vista, CA  91914     
       
Phone:  (619) 600-4832
Date:  12/8/2010
 
 
 
ATTACHMENT A: PROVIDER INFORMATION
(Please attach a roster of all Providers that will be participating under this Agreement, use Addendum A)
 
 
Last Name:     Group/Practice Name: Pasadena SA Services
         
First Name:      Primary Address: P.O. Box 720417,
        Houston, TX  77272
Tax ID: 35-2318354      
      County: Harris
National Provider Identifier (NPI):   Phone: (713) 779-9800  Fax:  (713) 779-9862
         
1669626677   Email:  jaimeolmo@me.com  
(If there is more than one NPI Number, please attach a listing.)      
      Other Practice and/or Billing Address:  Yes □  /  No □
Specialty:   LSA, CSA, SA-C, CST/CFA, CRNFA, RN    CNOR   If “yes”, attach page with additional information
         
Subspecialty: Surgical Assistant  
Hospital Affiliations (list name, date and type):
  First Assistant    
       
       
 
Provider agrees to mark “N/A” next to any blank that is not applicable to Provider’s business.
 
 
 

 
 
ADDENDUM A:

PROVIDER LISTING & FACILITY LOCATIONS

_______________________________

 
i.
The attached roster of providers and or locations will be participating under this Agreement between Pasadena SA Services and Three Rivers Provider Network and shall include Tax Identification Numbers, NPI Numbers, Address(s), Phone and Fax Numbers.
 
 
 

 
 
Provider List
12/2/2010
 
Name Credentials   License Number
     National Provider Identifier    
     
GARCIA, ABEL
LSA
SA00073
 
 
GARZA, AMANDO
CST/CFA
117328
 
 
SILVA, ARTURO J
CSA
118382
 
 
MEDINA, DONNA
SA-C
07-155
 
 
GUERRERO, FIDENCIO
SCT/CFA
119954
 
 
VILLARREAL, GEORGE
CSA
3323
 
 
FARRELL, JAMES
RN
696762
 
 
OLMO, JAIME
LSA
SA00184
 
 
RUSSELL, JAMES W
CST/CFA
111677
 
 
SKORUPPA, JACOB
LSA
SA00374
 
 
BENESH, LEORA
SA-C
09-268
 
 
TROMBLEY, PATRICIA
LSA
SA00156
 
 
TAMARGO, PEDRO
SA-C
08120
 
 
RODELA, ROBERT
SA-C
07252
 
 
WOLFORD, STEPHEN M
CST,CFA
118383
 
 
ROBIN, SCOTT
 
LSA
SA00090
 
 
 
 
1

 
 
Provider List
12/2/2010
 
Name   Credentials   License Number
    National Provider Identifier    
     
EVANS, THADEUS J.
 
RN
781303
 
 
VIDAL LOPEZ, VALENTIN
 
CST
112413
 
 
BERRY, WILLIAM
 
CST/CFA
109540
 
 


 
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