Medical services agreement template (US)

Occupational Health Services Agreement

This Occupational Health Services Agreement is made on Agreement Date between Clinic or Medical Group Name, a Clinic Entity Type and State, at Clinic Address ("Provider"), and Employer Name, at Employer Address ("Employer").

1. Services

Provider will offer the following services to Employer's employees and job applicants who have received a conditional offer, as Employer requests:

| Service | Price |

| --- | --- |

| First Service, such as post-offer physical exam | $First Service Price |

| Second Service, such as DOT physical | $Second Service Price |

| Third Service, such as drug and alcohol testing | $Third Service Price |

| Fourth Service, such as work injury treatment | Fourth Service Pricing |

Work injury care will be billed to Employer's workers' compensation insurer under the state fee schedule where one applies.

2. Licenses and Quality

Provider states that its clinicians are licensed in the state where they practice, that it holds all required facility licenses, and that drug testing will use laboratories certified as the law requires (such as HHS-certified labs and certified medical review officers for DOT testing). Provider will follow accepted standards of care and keep its own malpractice insurance of at least $Malpractice Insurance Amount.

3. Referrals and Authorization

Employer will send each person with a signed referral form stating the services authorized. Services outside the referral need Employer's approval, except emergency care, which Provider will give or arrange as needed.

4. Medical Judgment

All medical decisions belong to Provider's clinicians. Employer will not direct how they treat patients.

5. Confidentiality

Provider will protect health information as required by HIPAA, state privacy laws and the Americans with Disabilities Act. Provider will give Employer only the information it is allowed to receive, such as work status, restrictions and fitness for duty, and not diagnoses, unless the employee authorizes it or the law permits (for example, in a workers' compensation claim). Employer will keep any medical information it receives in a separate confidential file.

6. Reports and Turnaround

Provider will send work status reports within Report Turnaround and test results within Results Turnaround.

7. Billing

Provider will invoice Employer Billing Frequency for services not billed to an insurer. Employer will pay within Payment Days days. Employees will not be charged for exams or tests Employer requires.

8. Nondiscrimination

Exams after a conditional job offer will be given to all entering employees in the same job category, as the ADA requires.

9. Term and Termination

This Agreement runs from Start Date for Initial Term and renews for like periods unless either party gives Non-Renewal Notice Days days' notice. Either party may end it for an uncured material breach on Cure Days days' notice. Provider will keep medical records for the period the law requires.

General Terms

Governing law. This Agreement is governed by the laws of the State of Governing State, without regard to its conflict of laws rules. Any lawsuit will be brought in the state or federal courts located in Venue County and State.

Entire agreement. This Agreement is the parties' complete agreement on its subject and replaces all earlier discussions. It may be changed only in a writing signed by both parties.

Severability. If a court finds any part of this Agreement unenforceable, that part will be enforced to the extent the law allows, and the rest stays in effect.

Assignment. Neither party may assign this Agreement without the other's written consent, except to a successor to its whole business.

Notices. Notices must be in writing and sent to the addresses above by personal delivery, certified mail or a nationally recognized courier.

Counterparts and e-signatures. This Agreement may be signed in counterparts and by electronic signature, which has the same effect as an original.

| Provider | Employer |

| --- | --- |

| Signature: Provider Signature | Signature: Employer Signature |

| Name: Provider Printed Name | Name: Employer Printed Name |

| Date: Provider Signing Date | Date: Employer Signing Date |