a) I will record on a day sheet the fee codes or fees charged privately (my billings)
and diagnostic codes for all services I render on behalf of the Medical Practice. Fees
charged by myself will be in accordance with MSP regulations and your usual Medical
Practice policies. As a courtesy to your Medical Practice, I will avoid billing
restricted MSP services such as counselling and complete physical exams unless clearly
indicated or requested by the patient.
b) Your Medical Practice will submit all my billings to MSP, WCB, other third parties, and/or the
patients directly on my behalf. By signing the MSP transfer of payment release and
this Agreement, I cause all my billings to be paid directly to your Medical Practice.
c) Your Medical Practice will pay me ____% of all my billings for services performed
during the office hours listed above. Outside these hours, your Medical Practice will
pay me ____% of all my billings for services such as nursing home visits,
hospital visits, home visits, emergency room shifts and emergency on-call stipends.
d) If I am expected to do a walk-in clinic or treatment center shift as part of the
agreed-upon coverage for your Medical Practice, your Medical Practice is responsible
for any difference in payment if less than the terms in paragraph c) above.
e) Your Medical Practice will pay me whether or not full payment is received by your
Medical Practice for all my billings.
f) Your Medical Practice will pay me a minimum of $_____________ for the term.
g) Your Medical Practice will make payment in full to myself within two weeks of the end
of the Term.
h) Payments will be mailed to _____________________________________.