THIS AGREEMENT is made and entered into this _______ day of __________ 20____, by and between

_________________________________________________, A (state) professional service corporation (the “Corporation”), and (the Contractor).

     WHEREAS, the Corporation is engaged in the practice of medicine specializing in ______________; and

     WHEREAS, the Corporation is desirous of obtaining the services of Contractor in order to
     provide ( what the service is), on an as needed basis; and

     WHEREAS, the Contractor provides certified Physician Assistants, licensed in the State of
____________, and who has agreed to provide (service) to the Corporation’s physician(s) on
     an as needed basis.

     NOW, THEREFORE, in consideration of the covenants and mutual promises contained herein, it is hereby agreed as follows:
1. Professional Services.  The Contractor will render services on behalf of the Corporation as  a Physician Assistant in the field of ____________________ on an as needed basis.  The Contractor must at all times be a staff member in good standing of any hospital where the procedures are performed.

2. Remuneration and Billing Procedures.
    a. __________________will bill and collect for all physician assistant services provided, and Corporation assumes no liability or responsibility for these services.  Corporation does agree to collect and reimburse (physician assistant) for all payments made directly to corporation for PA services; including, but not limited to Medicare.  All services provided by physician assistant under Medicare shall, by federal law, be billed under the physician’s/group’s Medicare provider number. Reimbursement shall be made to physician assistant within 15(fifteen days) after receipt of payment. There shall be a 2% monthly charge for all reimbursements due physician assistant that are held longer than 15 days after receipt.
    b. Physician Assistant agrees to maintain strict confidentiality of said Medicare provider numbers utilized in billing, and any deviation from this confidentiality can result in immediate termination of this agreement and appropriate legal recourse as directed by Corporation.
    c. At the conclusion of each calendar year, Corporation will furnish (physician assistant) an IRS Form 1099 documenting all monies received and distributed on (physician assistant’s) behalf in the previous year.  Physician Assistant is solely responsible for payment of all required local, state, and federal taxes, including federal income tax, Medicare and Social Security.

3. Terms of Agreement.  The effective date of this agreement is _________________  and will continue until termination as hereinafter provided.
4. Professional Expenses and Fringe Benefits.
    a. The Contractor will pay all of it’s own professional expenses including but not limited to medical society dues, occupational licenses, books and journals, travel and entertainment and the cost of continuing education.
    b. The Contractor agrees to acquire and maintain professional liability insurance, and to provide the Corporation with proof of such coverage upon request.
    c. The Contractor will receive no fringe benefits (health insurance, retirement plan funding, etc.) provided by the Corporation to or on behalf of its employees.

5.  Termination of Agreement.    This agreement may be terminated by the consent of the  parties, or by written notice delivered by one party to the other not less than thirty (30) days prior to the effective date of termination.

6.  Independent Contractor Status.  It is understood and agreed that the services will be rendered as an independent contractor and not as an employee.  In this regard, the Contractor will not be deemed to be employed by the Corporation for purposes of a tax or contribution levied by the Federal Social Security Act of Florida law with respect to employment of compensation for employment.  It is further agreed that there will be no requirement that the Contractor devote his exclusive time to the rendering of services for the Corporation, nor will any of the terms hereof be construed to prohibit the Contractor from engaging in any other business of practice.

7. Compliance with (state) Law.(insert appropriate statutes and verbiage)
            (a)Pursuant to the provisions of _________________ Statue #xxxxxxxx and the rules and regulations of  the Board of Medicine of the State of _____________ (as set forth in Chapter xxxxxxxx of the __________ Administrative Code), it is acknowledged that the Contractor has been certified by the Board of Medicine as a Physician Assistant.  The Contractor will perform no medical tasks, procedures or functions with respect to patients of the Corporation unless the same have been specifically approved by, and under the supervision of, a licensed physician employed or retained by the Corporation (the “Supervising Physician”), or, in his/her absence, an alternate physician to whom the Supervising Physician has delegated such supervisory authority.  Further, the Contractor will undertake any such medical task, procedures or functions only when they are within the scope of practice that has been determined by the hospital medical staff and/or governing body as appropriate to be performed by a Physician Assistant and which are provided for in the rules and regulations of that facility.

(a)  The Contractor will not independently and without responsible supervision treat patients, take histories, perform physical examinations, and determine appropriate laboratory tests or diagnostic procedures, or make any judgment or decision as to diagnosis or prescribe treatment.  The Contractor will carry out such functions only under responsible supervision or a clearly predetermined protocol and after consultation with the Supervising Physician or his/her designee.

(b)  The Contractor will in no way indicate or convey the impression to a patient or the public that he is a physician.  To that end, the Contractor will wear an identification tag setting forth his name, with the title “Physician Assistant” under the name.

(c)  Prior to performing any medical tasks, procedures or functions, the Contractor will assure himself that the Supervising Physician or his/her designee is reasonably available for consultation.

8.  Medical Records.  The Contractor will be required to keep accurate and detailed medical records on all patients treated under this Agreement, which records will be the property of the Corporation.

9.  Entire Agreement.  This Agreement contains all the terms relating to the subject of the Contractor’s relationship with the Corporation, and it replaces and supersedes any contractual arrangements previously in effect between the parties.

10.  Amendment.  No change or amendment to this Agreement will be valid in writing and signed by the parties.

11.  Applicable Law and Binding Effect.  This Agreement will be governed by and interpreted under the laws of the State of ________, and will inure to the benefit of and be binding upon the parties hereto and their heirs, personal representatives and successors.

12.  Attorney’s Fees.  In the event of a dispute arising under this Agreement, the prevailing party will recover from the non-prevailing party, in addition to remedies provided at law, all court costs and reasonable attorney’s fees (including charges attributable to law clerks and paralegals) incurred in the enforcement of its/his rights hereunder.

IN WITNESS WHEREOF, the parties have executed this Agreement on the date set forth above.

Signed, sealed and delivered
In the presence of:                                                                     “Corporation”

___________________________________                             By:________________________
As to the Corporation                                                                     (CORPORATE SEAL)
______________________________________                         By: ________________________
As to the Contractor

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