Requestor Terms of Service
ChartRequest has contracted with the Third-Party Retrieval company ChartX and the ChartX Requestor Terms of Service are below:
UPDATED: January 9, 2017 12:00PM ET
NOTICE: THIS IS A LEGALLY BINDING CONTRACT; PLEASE READ IT CAREFULLY. BY ACCEPTING THIS AGREEMENT, YOU ACKNOWLEDGE THAT YOU: 1) HAVE READ THIS AGREEMENT, 2) ACCEPT AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS OF THIS AGREEMENT, AND 3) HAVE THE LEGAL AUTHORITY TO ENTER INTO A CONTRACT AND BIND YOUR ORGANIZATION TO THIS AGREEMENT.
ChartX Requestor Terms of Service
This Service Agreement (“Agreement”) is entered into by and between WISEHOLDINGS TECHNOLOGY, LLC dba ChartX, a Georgia corporation (“CX”) and the individual enduser and his or her employer or other legal entity on behalf of which such individual is acting (collectively referred to as “CLIENT”).
FOR VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby mutually acknowledged, CX
and CLIENT agree as follows:
1. TERMS OF THE SERVICE.
The parties agree upon the terms and conditions in this Agreement for CX’s services for CLIENT, including without limitation, scanning, digitizing, and electronically transmitting medical and related records for CLIENT, and other related services (collectively, the “Service”) as may be ordered from time to time by CLIENT. Exhibit A: Description of Services sets forth CX’s Services as of the date of this Agreement.
2. TERM OF THE AGREEMENT.
This Agreement will be effective commencing on the date that CLIENT accepts and submits this agreement during the signup process with CX and shall continue indefinitely thereafter until terminated as provided herein.
a. Termination for Convenience. Either party may terminate this Agreement upon 30 calendar days advance written or electronic notice to the other party.
b. Effect of Termination. CLIENT shall pay CX for all Service performed up through the termination date. Any Service that is in process as of the termination date will be cancelled and invoiced per the contract terms unless CX is notified in writing to complete any in process Service beyond the termination date. Sections 2, 3, 6, 7, 8, 9, 10, 11 and 12 shall survive any termination of this Agreement.
3. PRICING; PAYMENT.
a. Pricing. The pricing for the Service shall be CX’s pricing in effect as of the date that CLIENT places an order for Service, as set forth in CX’s service description and fee schedule and which may be changed from time to time. Exhibit B: Pricing sets forth CX’s current pricing as of the date of this Agreement.
b. Payment Terms. CLIENT agrees that payment for CX service fees and charges for the Service ordered by CLIENT in U.S. dollars are due and owing upfront at the time an order is placed. CX may extend credit terms for payment net twenty (20) days from the date of CX ‘s invoice where satisfactory credit is established by CLIENT. If credit is extended to CLIENT, CLIENT will be invoiced on a monthly basis. CX reserves the right to alter credit limits and terms to suspend or delay Service or to require alternate terms and conditions based upon CLIENT’s payment history and financial Condition. Invoice notices will be sent electronically and can be viewed electronically under your user account at no fee. If CLIENT requires a paper or fax invoice, a fee will be assessed (refer to Exhibit B: Pricing). In the event of a payment dispute, CLIENT shall pay all undisputed amounts and all CX service fees and charges for undisputed orders to CX in accordance with the terms and conditions of this Agreement.
c. Credit Card; Bank Account. CX requires CLIENT to provide a credit card or bank draft information upfront to pay fees and charges as they are incurred, unless credit terms are extended to CLIENT. Unless otherwise agreed, by ordering Service through CX, CLIENT authorizes CX, at CX’s discretion, to keep records of CLIENT’s credit card and/or bank account and bank routing number and to charge or direct debit such credit card or account for Service fees, applicable facility charges and any other charges as incurred.
d. Late Payment. Any amount not paid when due will be charged finance charges equal to two and onehalf percent (2.5%) per month or the highest rate permitted by applicable law, whichever is less, determined and compounded daily from the date due until the date paid. In addition to the finance charge, there will be a monthly late payment fee of $50 for overdue balance of less than $2,000 and $100 for overdue balances of $2000 or more. This fee is intended to offset ChartX’s internal collection and accounting costs. CLIENT will also reimburse any costs or expenses (including, but not limited to, reasonable attorney and/or 3rd party collection fees including fees calculated as a contingent percentage of recovery obtained) incurred by CX to collect any amount that is not paid when due.CX may accept any check or payment in any amount without prejudice to CX’s right to recover the balance of the amount due or to pursue any other right or remedy. No endorsement or statement on any check or payment or in any letter accompanying a check or payment or elsewhere will be construed as an accord or satisfaction. If CLIENT fails to pay or if its financial condition becomes impaired or unsatisfactory to CX, CX may require CLIENT to provide satisfactory security and may suspend or terminate Service until such security is received. If services are suspended, CLIENT will be responsible for any additional charges that result in records closures or posting of records or payment of provider fees or courier charges.
e. Taxes. In addition to all fees and charges specified in this Agreement, CLIENT shall pay or reimburse CX for all federal, state, local or other taxes, including, without limitation, sales, use, excise and property taxes, or amounts levied in lieu thereof, based on Service provided under this Agreement; provided, however, CLIENT shall have no responsibility for taxes imposed on CX’s net income.
f. Provider Fees. The Provider Fees charged by medical or other providers generally for supplying copies of medical or other records may come in the form of a prepayment required before the provider begins the search for a record or may come as a result of an invoice sent from the medical provider to CX. It is difficult to predict what a provider may charge and some medical providers charge more than state statutes allow. CX passes on all such fees to CLIENT, including any such fees in excess of that allowed by state statutes. CLIENT acknowledges and agrees to pay all such Provider Fees. The Provider Fee also includes a handling fee added by CX to cover the cost of provider payments, copy services fees and other fees and expenses. The Provider Fee may also include a fee for verifying the patient and/or a separate copy service fee for copying the record and/or any bank or currency conversion fees incurred when retrieving records in a foreign country to pay the provider fee in the local currency.
g. CX’s Policy on State Statutes Governing Provider Fees. Many states have statutes prescribing the maximum fees medical providers may charge for providing copies of medical records. CX is not an enforcing agency. CX cannot force a medical provider to change their pricing practices even when they differ from state statutes. When CX becomes aware that a medical provider has or is attempting to charge more than applicable state statutes allow, CX may attempt to notify the medical provider concerning the improper fee and request that the medical provider change the fee to adhere to applicable state statutes. When the medical provider intends to invoice CX more than the state statute allows, the CLIENT will be responsible for paying CX the full invoiced amount whether the amount is over the amount permitted by the applicable state statute or not.
a. Orders. CLIENT may submit orders to CX through CX’s or its partners’ websites, through a CLIENT system integrated with CX’s systems or directly with CX. All orders shall be subject to acceptance by CX.
b. AutoCancellation Policy. CX automatically cancels requests for medical records once the record has aged beyond a certain date from the time the record was requested. When a request has been in CX’s system for sixty (60) calendar days and has not been retrieved, or when a request has been in a status awaiting information from the CLIENT for 14 calendar days, the record will be set for automatic cancellation and an email notification will be sent to the email address listed on the request by CLIENT. The CLIENT will also be invoiced the full retrieval fee and any provider and courier costs associated with this cancelled request. After a request has been cancelled through the automatic cancellation routing and CLIENT later decides that the record is needed, a new request for the record must be submitted or the closed request can be reopened and an additional fee will be charged in accordance with Exhibit B: Pricing.
c. Duplicate Orders. If duplicate requests are made for the same record, or two orders come back on one record, one of the requests may be canceled and the cancellation fee will be charged for the duplicate request. The original request will be charged full service fees.
d. Review of Records. CX shall transmit to CLIENT only those records that it actually retrieves from medical care providers and other record custodians under this Agreement, and makes no representations or warranties regarding the accuracy, completeness or legibility of such records.
e. Record Storage. All retrieved records will be stored online (available through CX’s website) for a limited period of time, not less than 60 days. Thereafter, all records retrieved may be permanently archived by CX and may be reposted online (available through CX’s website) upon written or electronic request by CLIENT for the Archive Record Reposting fee identified in Exhibit B for each set of records reposted.
f. Custom Programming Changes. In the event that custom programming changes are required, CLIENT may submit such request to CX, which may accept or reject such request in its sole discretion. Any such custom programming changes agreed to by CX shall be subject to a separate statement of work to be mutually agreed upon by the parties. In the absence of any such statement of work, CLIENT will be billed at the Custom Programming rate specified on Exhibit B. CX shall own all right, title and interest (including all intellectual property rights) to any such custom programming changes.
5. CLIENT RESPONSIBILITIES.
CLIENT acknowledges that CLIENT’s timely provision of assistance, cooperation, and complete and accurate information and data required for the Service is essential to the performance of the Service, and that CX shall not be liable for any deficiency in performing the Service if such deficiency results from CLIENT’s failure to provide
such assistance, cooperation, information and data. An order cannot be retrieved until CX receives a valid authorization signed by the patient or a subpoena authorized by a court of competent jurisdiction. The time calculation for order processing uses business days and begins once CX receives an order request with complete and accurate information including a valid authorization that is acceptable by the applicable medical provider. Such authorization should contain correct patient and provider information as described by the HIPAA Privacy Rule. CX has a HIPAA compliant authorization template that CLIENT may download and use at no additional charge. Some record custodians may require additional information including special authorizations, clarifications of information to be retrieved and clarification of patient information. While CX is waiting for CLIENT to gather this information, the time calculation for order processing shall be suspended until complete and accurate information is received. CLIENT warrants and represents that any authorization submitted to CX for the purposes of obtaining records has been signed by the patient or a person legally authorized to obtain the records. Special authorization forms will be provided by CX to CLIENT at the cost described in Exhibit B: Pricing. If a provider rejects an authorization due to an error by the CLIENT, CX may charge CLIENT a facility rejection fee in accordance with Exhibit B: Pricing.
6. AUTHORIZATION. CLIENT hereby authorizes CX to retrieve medical and other records on CLIENT’s behalf from medical service providers and other record custodians as CLIENT directs for CLIENT’s respective clients/customers. CLIENT unconditionally represents and warrants to CX that CLIENT: (i) has requisite authority to enter into this Agreement and obtain any and all medical and other records that CLIENT directs CX to obtain; and (ii) is not seeking any records for any illegal or unethical purpose including, without limitation, the purpose of prospecting for personal injury clients. CLIENT shall provide CX with a copy of the written authorization signed by CLIENT’s clients/customers, which written authorization shall include, without limitation, (1) the client’s/customer’s name, date of birth, social security number, and address, (2) the name, address and telephone number of the applicable medical care provider or other record custodian, with the name of the provider or record custodian specifically identified on the authorization (3) language that specifically and sufficiently authorizes CLIENT or CLIENT’s representatives to retrieve any and all medical and other records, (4) language that indicates that a copy of the authorization will have the same effect as the original, (5) the signature of the customer/principal dated within ninety (90) days prior to the date of CLIENT’s request for record retrieval with an expiration date specified, (6) description of the information to be disclosed, including specific types of treatment and dates of service, (7) HIV, alcohol, drug and mental health records are specifically authorized to be released, if such records are necessary, (8) purpose of the disclosure or reason for need of information, (9) specification of the date, event or condition upon which the consent expires, (10) statement that the authorization may be subject to redisclosure by the recipient and may no longer be protected by federal law, (11) if signed by a legal representative, a description of the representative’s authority or relationship to the individual and (12) language that indicates that Wiseholdings Technology, LLC dba ChartX is authorized as agent for CLIENT to retrieve any and all medical or other records on CLIENT’s behalf for the CLIENT or CLIENT’s customer.
7. NONSOLICITATION. For the term of this Agreement and for twelve (12) months thereafter, CLIENT agrees not to solicit or retain the services of any person who is an employee of CX and who performed Service for CLIENT pursuant to this Agreement.
8. DISCLAIMER OF WARRANTIES.
THE SERVICE IS PROVIDED “AS IS” AND, TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, CX MAKES NO WARRANTIES, EITHER EXPRESS OR IMPLIED, WITH RESPECT TO THE SERVICE, ANY RECORDS PROVIDED BY CX TO CLIENT OR ANY OTHER MATTER ARISING FROM OR RELATED TO THIS AGREEMENT, INCLUDING, WITHOUT LIMITATION, ANY IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, ACCURACY, NONINFRINGEMENT OF THIRD PARTY RIGHTS, AND ANY WARRANTIES THAT MAY ARISE FROM COURSE OF DEALING, COURSE OF PERFORMANCE OR USAGE OF TRADE.
9. INDEMNIFICATION. CLIENT hereby agrees to indemnify, defend and hold harmless CX, and CX’s employees, officers, directors, shareholders, agents and representatives, from and against any and all claims, demands, expenses, losses, liabilities, causes of action and the like which are or may be asserted by any of CLIENT’s customers or other third parties relating to, arising out of, or in anyway associated with CLIENT’s and CX’s performance of this Agreement including, without limitation, CX’s performance of the Service and the retrieval of medical and other records in connection therewith, except for any such liability solely and proximately caused by the gross negligence or willful misconduct of CX as determined in a final, nonappealable order of a court of competent jurisdiction.
“Confidential Information” as used herein shall include any and all written and verbal information provided by either party in connection herewith, which is not otherwise available from public sources. Each party acknowledges the representations of the other party that such party’s Confidential Information is proprietary and valuable to that party and that any disclosure or unauthorized use thereof may cause harm and loss. In consideration of the disclosure of Confidential Information, each party agrees to receive and to treat all Confidential Information on a strictly confidential and restricted basis and to use all Confidential Information for the sole purpose of performing this Agreement. CLIENT acknowledges that CX may disclose Confidential Information to its affiliates, contractors or other agents for the sole purpose of performing under this Agreement. Each party shall maintain the Confidential Information of the other party with at least the same degree of care it uses to protect its own confidential
information of a similar nature or sensitivity, but no less than reasonable care under the circumstances.
In addition, each party may use or disclose the Confidential Information of the other party to the extent (a) such party is legally compelled to disclose such Confidential Information, provided, however, that prior to any such compelled disclosure, such party shall give the other party reasonable advance notice of any such disclosure and shall cooperate with the other party in protecting against any such disclosure and/or obtaining a protective order narrowing the scope of such disclosure and/or use of the Confidential Information, or (b) approved by the other party.
Except as required by law or as reasonably required to assert its rights hereunder, CLIENT shall not disclose the terms, conditions or pricing of this Agreement without the prior written consent of CX.
CLIENT acknowledges and agrees that CLIENT bears sole responsibility for protecting all of CLIENT’s user names and passwords used to access information and records, including Confidential Information, on CX’s website, and CLIENT shall not provide any such user names or passwords to any third party. CLIENT shall remain fully responsible and liable for (and CX shall not be responsible or liable for) any unauthorized use of any of CLIENT’s user names and passwords.
11. LIMITATION OF LIABILITY.
a. Waiver of Consequential Damages. NOTWITHSTANDING ANY OTHER PROVISION OF THIS AGREEMENT AND TO THE EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT SHALL CX BE LIABLE TO CLIENT OR ANY THIRD PARTY UNDER ANY LEGAL THEORY FOR ANY INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, OR ANY DAMAGES FOR LOSS OF PROFITS, REVENUE, BUSINESS, SAVINGS, DATA OR USE INCURRED BY CLIENT OR ANY THIRD PARTY, EVEN IF CX HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
b. Limitation of Liability. NOTWITHSTANDING ANY OTHER PROVISION OF THIS AGREEMENT AND TO THE EXTENT PERMITTED BY APPLICABLE LAW, CX’S AGGREGATE LIABILITY ARISING FROM OR IN RELATION TO THIS AGREEMENT AND THE SERVICE, MEDICAL RECORDS AND OTHER INFORMATION AND MATERIALS PROVIDED BY CX HEREUNDER, WHETHER ARISING IN CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE, SHALL BE LIMITED TO THE AMOUNTS RECEIVED BY CX FROM CLIENT FOR THE SERVICE THAT IS THE BASIS FOR THE LIABILITY.
c. Essential Element. THE PARTIES ACKNOWLEDGE THAT THE LIMITATIONS OF LIABILITY IN THIS ARTICLE 11 AND IN THE OTHER PROVISIONS OF THIS AGREEMENT, AND THE ALLOCATION OF RISK HEREIN, ARE AN ESSENTIAL ELEMENT OF THE BARGAIN BETWEEN THE PARTIES, WITHOUT WHICH CX WOULD NOT HAVE ENTERED INTO THIS AGREEMENT. CX’S PRICING REFLECTS THIS ALLOCATION OF RISK AND THE LIMITATION OF LIABILITY SPECIFIED HEREIN.
d. Claims. Except for actions for nonpayment, no action, regardless of form, arising out of or related to this Agreement may be brought by either party more than two (2) years after the cause of action has accrued.
a. Governing Law; Jurisdiction. This Agreement shall be constructed and enforced in accordance with the laws of the State of Georgia, without regard to any conflicts of laws principles. Except for actions for injunctive or other equitable relief, which may be brought in any court of competent jurisdiction, any dispute arising under or regarding this Agreement shall be subject to the exclusive jurisdiction of the Georgia state courts in and for Fulton County, GA, U.S.A. (or, if there is federal jurisdiction, the United States District Court for the District of Georgia), and the parties agree to submit to the personal and exclusive jurisdiction and venue of these courts.
b. Electronic Contract. The parties to this Agreement expressly agree to conduct this transaction electronically pursuant to the Electronic Signatures in Global and National Commerce Act, 15 U.S.C. Section 7001 as amended or substituted.
c. Assignment. CLIENT shall not assign this Agreement, in whole or in part, whether voluntarily, by operation of law or otherwise, without the prior express written consent of CX. Any such assignment without such consent shall be null and void. CX may assign, delegate, or transfer this Agreement or any rights or obligations hereunder without the consent of CLIENT, including without limitation, in connection with a merger, consolidation, corporate reorganization, sale of all or substantially all of CX’s assets, sale of stock, change of name or like event. Subject to the foregoing, this Agreement shall be binding upon and shall inure to the benefit of the parties and their respective successors and permitted assigns.
d. Dispute Resolution. Except in the case of a claim of Infringement, any controversy, dispute or claim (“Dispute”) arising out of or relating to this Agreement, or the breach hereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with its applicable rules, and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Unless otherwise agreed to in writing between the CX and the CLIENT, the arbitration proceedings will be conducted in Atlanta, GA. This Section shall (a) be specifically enforceable; (b) not limit any obligations of a Party to defend, indemnify or hold harmless the other Party as set forth under the terms hereof; and (c) extend to the successors and assigns of the Parties. In no event shall arbitration be held after the date when institution of legal or equitable proceedings based on such Dispute, or other matters in question would be barred by the applicable statute of limitations. This Section shall survive termination of this Agreement.
e. Attorney’s Fees. In the event that one of the parties (the “NonBreaching Party”) to this Agreement shall be required to take any action to enforce its rights, whether hereunder, at law, or in equity, or to compel the other party (the “Breaching Party”) to comply with its responsibilities or obligations hereunder, the Breaching Party in any such action agrees to pay all damages, costs, and expenses including reasonable attorneys’ fees and legal expenses, incurred by the NonBreaching Party in enforcing or exercising any of its rights, whether hereunder, pursuant to
law, or at equity, regardless of whether formal legal proceedings are commenced.
f. Severability; Waiver. If any provision of this Agreement is held by a court of competent jurisdiction to be invalid, illegal, or unenforceable for any reason, such provision will be enforced to the maximum extent permitted by applicable law and the remaining provisions hereof shall be unaffected and remain in full force and effect. Any delay or omission on the part of either party to exercise or avail itself of any right, power or remedy that it has or may have hereunder shall not operate as a waiver of any such right, power or remedy, and the waiver of any right, power or remedy hereunder is not effective unless in writing and signed by the party against whom enforcement of such waiver is sought. A waiver of any term or condition of this Agreement by any party does not constitute a subsequent waiver of such term or condition or any other.
g. Force Majeure. CX will not be liable for any delay or failure to perform its obligations hereunder due to any cause or circumstance beyond its reasonable control, including, but not limited to, acts of God, natural disasters, earthquake, fire, flood, embargoes, labor disputes and strikes, third party nonperformance, utility or power or telecommunications outages, component or supplier shortages, riots, civil disturbances, war, terrorism, acts of civil or military authorities and any law, order, regulation, ordinance, or requirement of any government or legal body.
h. Ownership; No Implied License. CX owns and retains all right, title and interest (including all intellectual property rights) in and to the Service. Nothing in this Agreement shall be construed or interpreted as a grant by implication, inference, estoppel, or otherwise of any license or other right to any intellectual property rights of CX.
i. Relationship of Parties. This Agreement shall not be construed as creating an agency, partnership, joint venture or any other form of association, for tax purposes or otherwise, between the parties, and the parties shall at all times be and remain independent contractors. Except as expressly agreed by the parties in writing, neither party shall have any right or authority, express or implied, to assume or create any obligation of any kind, or to make any representation or warranty, on behalf of the other party or to bind the other party in any respect whatsoever.
j. Construction; Headings. This Agreement shall be deemed to have been drafted by both parties and, in the event of a dispute, neither CX nor CLIENT shall be entitled to claim that any provision should be construed against the other party by reason of the fact that it was drafted by the other party. The section headings used herein are inserted for convenience of reference only and shall not affect the meaning or interpretation of this Agreement or any section thereof.
k. Entire Agreement; Amendment. This Agreement represents the entire agreement and understanding between the parties relating to the subject matter hereof, and supersedes all prior or contemporaneous proposals, understandings, representations, warranties, promises and other communications, whether oral or written, relating to such subject matter. This Agreement may, from time to time, be amended by CX, who shall provide written notice of such amendment, either electronically via email, or by posting such amended Agreement on CX’s website at chartx.com or partner sites and CLIENT’s continued use of the Service following any such amendment shall be deemed acceptance of such amendment. It is CLIENT’s responsibility to check CX’s website to ensure familiarity with the most current version of this Agreement. CLIENT may not alter, modify or amend this Agreement except by mutual agreement of the parties in a written and signed amendment. Nothing contained in any CLIENT purchase order or similar document will in any way modify or add to this Agreement, and any terms or conditions contained in a CLIENT purchase order or similar document that are in any way additional to or different from this Agreement are hereby rejected. CLIENT has carefully read the entire Agreement, and has been given the opportunity to discuss it with CLIENT’s legal advisors, and CLIENT understands the meaning and effect of each and every provision of this Agreement. The individual enduser is duly authorized and empowered to accept this Agreement on behalf of CLIENT. CLIENT can reach CX at its website (www.chartx.com via email@example.com) or at 520 W PONCE DE LEON AVE SUITE 1418 DECATUR GA 30030-9998.
l. Notice for California Requestors. Parties agree to follow and abide by California Evidence Code Section(s) 1158 and 1563 as it relates to pricing of record requests in the State of California. Please contact firstname.lastname@example.org in the event that you believe this pricing is not being applied accurately and you’ll receive a response within 48 business hours.
Exhibit A: Description of Services
Services are provided on a onetime per record basis and are not ongoing. To obtain updated records, a new
Service order must be submitted or the system can be noted to reopen a request.
1. Standard Retrieval or ReRetrieval Services:
a. Medical Record Retrieval Online and offline medical record retrieval using CX’s team of retrieval specialists. Completed records are made available on the Internet for CLIENT’s review.
b. Billing Record Retrieval Online and offline billing record retrieval using CX’s team of retrieval specialists. Completed records are made available on the Internet for CLIENT’s review.
c. X-Ray Record Retrieval Offline retrieval of XRay records that are part of a medical record. Xray records are shipped at CLIENTS expense for CLIENT’s review.
d. Claims History Retrieval Online and offline claims history retrieval using CX’s team of retrieval specialists. Completed records are made available on the Internet for CLIENT’s review.
e. Retrieval of Other PaperBased Records Retrieval of paperbased records other than those listed above, which may include Autopsy, Education, EmploymentPersonnel, Fire, Health Department, Insurance, Medicaid, Motor Vehicle Report (DMV), Pathology, Pharmacy, Police, Psychiatry, Social Security, or Workers Compensation will obtain a copy of the requested records from the appropriate record custodian. Completed records are made available on the Internet for CLIENT’s review.
f. No Patient / No Record If the record provider informs CX that they never had the patient in the facility for the time period requested, or if they simply have no records for the patient, the applicable No Patient / No Record fee will be assessed to CLIENT.
g. Cancellation of Requests CX may be charged by the provider for cancellation of any request and any such costs will be charged to CLIENT. Such cancellations may be the result of CLIENT initiated cancels or CX auto cancel timeframes. CX will also charge a fee for any cancellation per the price outlined in Exhibit B: Pricing.
h. Facility Rejection Fee In the event that the facility rejects the request because the CLIENT failed to properly fill out the necessary paperwork/authorizations or provide the appropriate information, a Facility Rejection fee may be assessed. This fee is in addition to any other record request fee. If CLIENT subsequently fills out the necessary paperwork/authorizations properly and provides the appropriate information, CX will reprocess the request, but CLIENT will remain liable for the facility rejection fee (and all other standard fees and charges applicable to such request).
2. Optional Services:
a. Customizable Bates/Page Stamping Electronic page numbering included electronically on the retrieved medical record. Bates/page stamping can be customized in a variety of ways. CLIENT can request this service at the time
b. Chronological Sorting Chronological ordering of the retrieved record(s) for a patient.
c. Affidavit/Certification (with or without Notarization) CX can request legal certification by the medical provider as to the completeness of the medical records. CX does not itself review medical records for content quality, completeness, accuracy, etc.
d. Affidavit/Certification with Original Signature (with or without Notarization) CX can request legal certification by the medical provider as to the completeness of the medical records, with an original signature provided by the medical provider. CX does not itself review medical records for content quality, completeness, accuracy, etc.
e. Indexing Categorical ordering of the retrieved record(s) with hyperlinked table of contents. Examples of potential index categories include admission, diagnostic testing, fetal monitor strips, MRI reports, Pathology reports, Laboratory, etc.
f. Record Reviews/Summaries Physicians, nurses, or medical consultants review the medical record(s) and provide customized summaries/reports. Reports can be a one or two page summary of provider care and treatment, a detailed chronology of records, or compilation of billing records all customized to fit CLIENT needs.
g. Record Coding & Search A review of all digitized records to identify and Metatag key data fields (i.e. text strings, dates, and medical codes) enabling realtime search, discovery and reporting across all identified fields and tags.
h. Identification of Additional Providers A review of incoming medical records to identify “missing providers/doctors from which other medical records need to be retrieved. Often used in the legal arena to help build or defend cases, and can be used in the insurance market to ensure the complete health snapshot of an individual.
i. Record Aggregation The combination of multiple individual requests into a single composite record prior to bates stamping or indexing services being performed.
j. OCR Searchable Text Converts scanned images of the record into searchable text using Optical Character Recognition (OCR) technology, subject to the quality and legibility of the record. Allows CLIENT to use Adobe Acrobat Reader to rapidly search scanned records to quickly find key information.
k. Special Authorization Handling When a medical facility rejects the CLIENT authorization and requires a “special authorization, CX will obtain the correct authorization, fill it out and return it directly to the CLIENT for signature.
l. Delivery of Paper Copies When CLIENT requests that the retrieved record be delivered via paper format instead of standard electronic delivery via CX website. Printing and additional shipping charges apply. The option is not available on Xrays.
m. Delivery of Paper Invoice Electronically delivered or downloaded invoices are free of charge. However, if
CLIENT requests a paper copy, either in a summary or individual format, a fee will apply.
n. Archived Record Reposting Once a retrieved record is placed on the Internet for CLIENT, such record will remain available to CLIENT for at least sixty 60 days. Thereafter, CX may, at its option, archive the medical record. Once the record is archived a fee is charged if the CLIENT requires CX to make the record available again.
o. Rush Service CLIENT has the option of requesting CX to expedite the retrieval of records by facilitating the overnight delivery of the information to and from the medical provider. In addition, CX will increase the frequency of followup phone calls to the medical provider. CLIENT will be charged for the Rush Service as well as the cost of the overnight service.
p. Courier/Postage Fees Any courier or postage fees incurred are directly passed through to CLIENT. Please be aware that Rush requests may incur multiple carrier fees. There may be an additional fee markup to the actual costs charged by the courier.
q. Record Inspection Medical Record CX verification that the medical record received from the provider includes the information requested by the CLIENT at time of order such the dates of service specified, and the medical services specified
r. Record Inspection Billing Record CX verification that the billing record received from the provider includes the information requested by the CLIENT at time of order such the dates of service specified, and the medical services specified
s. Import Spreadsheet Tool CX offers a record import spreadsheet that may be utilized by client for mass imports of records requests. There is an additional charge for this service.
t. Data Entry to Support CLIENT This service is offered for certain clients where CX may agree to do the data entry for requests at an additional charge.
u. FTP Placement CX may push records to a designated FTP location with an agreed upon naming convention at regular intervals at an additional cost to CLIENT.
v. Extension of Auto Cancel Timeframes CX standard timeframe for auto cancellation based on age of a request is 60 days and based upon time in Need Information status is 14 days. CLIENT may seek extension of these timeframes on an account wide basis at an additional cost.
3. Additional Services Available Upon Request:
a. Custom Programming Services Custom programming changes requested by CLIENT and agreed to by CX.
b. Customer Account Reconciliation Research done at CLIENT’s request to summarize billing activity. Reports
can be run that detail amount invoiced by case number or by patient; such reports can facilitate passthrough billing for law firms
c. Rebilling When a CLIENT requests that CX bill an affiliated party in addition to themselves.
d. Technology Integration CX is able to technologically integrate its services with almost any case management or underwriting system. Technological integration can offer a number of advantages including simplification in ordering and automatic download of retrieved medical records into case and underwriting management systems. Integrations can be as simple as an automated, secure FTP transfer of completed medical records into CLIENT’s file management system, to full integration which can include automatic ordering and status information transfers. CX’s system has already been integrated into many commercially available case management and underwriting systems.
e. Image Archiving on CD or DVD CX will archive images of electronic records to CD or DVD for Client.
Exhibit B: Pricing
Pricing for each Service is on a per record basis, except where noted.
1) Standard Retrieval and ReRetrieval Services
a) Medical Record Retrieval (Up to 99 pages) = $50.00, plus Provider Fee*, plus $1.50 per page to 100 pages, $0.75 per page after 100
b) Billing Record Retrieval (Up to 99 pages) = $50.00, plus Provider Fee*, plus $1.50 per page to 100 pages, $0.75 per page after 100
c) XRay Record Retrieval (Up to 99 pages) = $89.00, plus Provider Fee*, plus $1.00 per page to 100 pages, $0.75 per page after 100 plus Courier / Postage Fees**
d) Claims History Retrieval (Up to 99 pages) = $99.95 plus Provider Fee*, plus $1.00 per page to 100 pages, $0.75 per page after 100
e) Retrieval of Other Paper-Based Records (Up to 100 pages) = $49.95, plus Provider Fee*, plus $1.00 per page to 100 pages, $0.75 per page after 100
f) No Patient / No Record = $49.95, plus Provider Fee*,
g) Cancelation of Request (Up to 99 pages) = $49.95, plus Provider Fee*, plus $1.00 per page to 100 pages, $0.75 per page after 100. Facility Rejection Fee (per rejection) = $4.95
*Provider Fee, any fees charged by the record provider and / or copy service (including patient verification fee), plus $3.00 handling fee, plus any bank or currency conversion fees (as applicable). Provider fees vary by provider.
**Courier / Postage Fees (per individual mailing), Courier / Postage fees are variable, Actual Cost plus $1.00 per individual mailing
2) Optional Services (selections made by requestor)
a) Customizable Page Stamping = $5.95
b) Chronological Sorting (up to 100 pages) = $4.95, plus $0.05 per page over 100 pages c. Affidavit / Certification = $8.95
c) Affidavit / Certification with original signature = $13.90, plus Courier / Postage Fees**
d) Notarized Affidavit / Certification = $17.95, plus notary fees, plus Courier / Postage Fees**
e) Notarized Affidavit / Certification, (with original signature) = 19.95, plus notary fees, plus Courier / Postage Fees**
f) Indexing (up to 100 pages) = $19.95, plus $0.20 per page over 100 pages
g) Record Reviews / Summaries = Variable, Contact CX For Quote
h) Record Coding and Search = Variable, Contact CX For Quote
i) Identification of Additional Providers = Variable, Contact CX For Quote k. Record Aggregation = $12.95, 10 records or less
j) OCR Searchable Text = $2.00
k) Special Authorization Handling (per special authorization) = $10.00
l) Special Authorization Retrieval (per special authorization) = $10.00
m) Delivery of Paper Record Copy (per page) = $0.11, plus Courier / Postage Fees**
n) Delivery of Paper Invoice Individual (per invoice) = $1.00 q. Delivery of Paper Invoice Summary (per invoice) = $5.00 r. Archived Record Reposting = $10.00
o) Rush Service = $10.00, plus Courier / Postage Fees**
p) Record Inspection Medical Record (up to 100 pages) = $14.95, plus $0.20 per page over 100 pages
q) Record Inspection Billing Record = $4.95
r) Extension of “Age” Auto Cancel Timeframe = $1.50, per 30 day extension per request
s) Extension of “Need Information” Auto Cancel Timeframe = $2.00, per 14 day extension per request
**Courier / Postage Fees (per individual mailing), Courier / Postage fees are variable, Actual Cost plus $1.00 per individual mailing
3) 3. Additional Services (selections made by requestor)
a) Custom Programming Charges (per hour) = $165
b) Customer Account Reconciliation (per hour) = $75.00 c. Rebilling Fee (per invoice) = $10.00
c) Image Placement on CD or DVD = $1.00, plus Courier / Postage Fees**, minimum charge of $50.00
d) Custom Reports (per hour) = $165.00
e) Technology Integration (per hour) = $165.00
**Courier / Postage Fees (per individual mailing), Courier / Postage fees are variable, Actual Cost plus $1.00 per individual mailing