BarrettHospital & HealthCare
Contract Review Form
Contracting Entity: ______
Originating Department: / Mgr Name: / Date:Manager Signature:
Contract Type: BHH services Equipment/supplies * Maintenance Software
BHH Provider Employment Professional services Rent/lease
Independent Provider/Locum Agreement other ______
If Provider Agreement, who bills for services: BHH Provider
*Equipment/Supplies-MedAssets (formally Broadlane) Quote Review Results:
Purpose of Contract:
New Renewal
If renewal, document summary evaluation of previous term performance (NA for services BHH provides to other entities):
Related Equipment:
Contact Name:
Contact E-mail:
Contact Phone Number:
Contact Fax Number:
Contact Address:
Invoice to be paid to: Same as contracting entity
ISSUE / YES / NO / NA
Identification of Parties (legal names)
Effective Date______
Length of Term ______
No automatic renewal
Termination without cause (30 days)( N/A for Provider Agreements)
Termination for failure to perform
Full description of each party’s obligations and responsibilities
Financial arrangements understandable and reasonable
All reference documents (amendments/exhibits) attached
Names, signatures, & titles of parties represented on signature page
Legal review completed and documentation provided (All Provider Agreements must be reviewed by legal)
Fair Market Value Analysis Complete and documentation provided. (Required for all Provider Agreements)
Comments:
Administrative Supervisor Signature Date:
Risk Mgr/ Compliance Officer
ISSUE
Insurance required/ proof upon request
Indemnification/ hold harmless clause
Business Associate Agreement
Corporate Compliance Agreement
Medical Staff Credentialing
Legal Review/Governing Law
Warranties
Amendments
Waivers
Subrogation
Assignment
Arbitration/mediation/dispute resolution
Federal Requirement for inspection of books and record (12 month value greater than $10,000)
OIG exclusion search
Chief Financial Officer
ISSUE
Financial arrangements understandable and reasonable
Human Resources
ISSUE
Staff licensure/ certification/ other requirements
Staff mandatory education (OSHA, etc)
Staff competency including HIPAA and other compliance-required knowledge
Employee Health Elements (TB testing, immunizations)
Required background checks, drug testing performed by contractor
No BHH liability for benefits or payroll taxes
Chief Clinical Officer
ISSUE
Staff Education Requirements
Director of Provider Services
ISSUE
Fair Market Value Assessment
Compensation
Productivity Measures
Provider Accountabilities
Legal Review
CEO
ISSUE
Requires Board Signature
BPM / Forms / Internal Forms / Administration / Contract Review Form 01/2013Page 1 of 2