CenseoHealth Provider Standards

Per CMS standards, each CenseoHealth provider must be licensed in the appropriate
state in which he/she works and must be qualified to submit risk adjustment data to
CMS. In order to meet CenseoHealth provider requirements, applicants must provide
the following:

 Completed CenseoHealth application and provider agreement

o An affirmative answer to any of the following application questions
automatically renders provider ineligible:
 Have you ever been denied provider participation in any state or federal
Medicare/Medicaid program?
 Have you ever been terminated, sanctioned, or penalized by any state or
federal Medicare/Medicaid program?
 Have you ever had to repay money to any state or federal Medicare/Medicaid
program?
 History of medical school, internships, residency, fellowship, training
programs, medical licensure
 Verification of active state license
o Name, license type, license number, status of license, expiration
date, issue date, address, and any public disciplinary actions by the
Department of Consumer Affairs and the appropriate licensing
board
o Evidence that CenseoHealth contacted the appropriate state
licensing board, or a copy of the licensing board’s verification
website
 Malpractice history of claims resulting in settlement or judgment on
behalf of practitioner
 Copy of Curriculum Vitae
 Verification of current NPI number
 Attestation addressing any current sanctions, limitations on licensure or
registration
 APPLICATION
Physician

ALL QUALIFIED APPLICANTS RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, AGE, NATIONAL
ORIGIN, DISABILITY, MARITAL STATUS, VETERAN STATUS OR ANY OTHER LEGALLY PROTECTED STATUS.

IDENTIFYING INFORMATION
LAST NAME - MD / DO FIRST NAME MIDDLE NAME ANY OTHER NAMES BY WHICH SOCIAL SECURITY NUMBER
YOU HAVE BEEN KNOWN
-- --

HOME ADDRESS CITY STATE ZIP CODE HOME TELEPHONE

EMERGENCY CONTACT RELATIONSHIP TELEPHONE

IN WHICH SPECIALTIES ARE YOU PURSUING LOCUM TENENS ASSIGNMENTS?

EDUCATION
UNDERGRADUATE TRAINING
COLLEGE / UNIVERSITY DEGREE MONTH YEAR
FROM

CITY STATE MONTH YEAR

TO
COLLEGE / UNIVERSITY DEGREE MONTH YEAR
FROM

CITY STATE MONTH YEAR

TO

MEDICAL TRAINING
MEDICAL SCHOOL DEGREE MONTH YEAR
FROM
CITY STATE MONTH YEAR
TO

INTERNSHIP (PGY-I)
FACILITY CITY STATE MONTH YEAR
FROM

TYPE OF INTERNSHIP MONTH YEAR

TO

RESIDENCIES (PGY-II & III)

FACILITY CITY STATE MONTH YEAR
FROM

TYPE OF RESIDENCY MONTH YEAR

TO

FACILITY CITY STATE MONTH YEAR

FROM

TYPE OF RESIDENCY MONTH YEAR

TO

FELLOWSHIPS
FACILITY CITY STATE MONTH YEAR
FROM

TYPE OF FELLOWSHIP MONTH YEAR

TO

FACILITY CITY STATE MONTH YEAR

FROM
TYPE OF FELLOWSHIP MONTH YEAR
TO

Page 1 Applicant’s Initials

 BOARD CERTIFICATIONS
ARE YOU CURRENTLY AMERICAN BOARD CERTIFIED?  Yes  No

NAME OF SPECIALTY BOARD DATE OF ORIGINAL CERTIFICATION

ONLY ANSWER THE FOLLOWING 2 QUESTIONS IF NOT CURRENTLY BOARD CERTIFIED

Have you ever taken a specialty board examination and failed to pass? Have you applied for the certification exam?
 Yes  No  Yes  No

If yes, how many times? If yes, when are you scheduled to take the exam?

EXAMINATIONS/REGISTRATIONS
 USMLE  FLEX In Which State? Number of Date Last Taken?
 National Board  State Exam Times Taken?
NPI # Federal DEA #

ONLY ANSWER THE FOLLOWING 3 QUESTIONS IF YOU GRADUATED FROM A MEDICAL SCHOOL OUTSIDE THE UNITED STATES, CANADA
OR PUERTO RICO
Do you have a permanent ECFMG certificate? Did you do a Fifth Pathway? ECFMG Number
 Yes  No  Yes  No

LIST ALL STATES IN WHICH YOU HAVE EVER BEEN OR ARE CURRENTLY LICENSED
STATE LICENSE NUMBER DATE ISSUED EXPIRATION CONTROLLED SUBSTANCES PERMIT NUMBER DATE ISSUED EXPIRATION

1.

2.

3.

4.

5.

PEER REFERENCES
PROFESSONAL REFERENCES, OR THOSE WITH WHOM YOU HAVE HAD CLINICAL
CONTACT DURING THE PAST 12 MONTHS
1. Name REFERENCES WILL NOT BE CONTACTED UNTIL
SpecialtyNEEDED FOR PRESENTATION OR TO BEGIN AN ASSIGNMENT
Phone

Address Email Fax Number

City State Zip Worked with in mm/yy format

From To

2. Name Specialty Phone

Address Email Fax Number

City State Zip Worked with in mm/yy format

From To

3. Name Specialty Phone

Address Email Fax Number

City State Zip Worked with in mm/yy format

From To

PROFESSIONAL LIABILITY INSURANCE

1. Present Carrier Policy number Phone number

Address City, State Effective Date Expiration Date

2. Previous Carrier Policy number Phone number

Address City, State Effective Date Expiration Date

Page 2 Applicant’s Initials

 PROFESSIONAL LIABILITY
IF YOU ANSWER YES TO THE FOLLOWING, PLEASE PROVIDE A FULL EXPLANATION OF EACH CASE ON THE PROVIDED
MALPRACTICE CLAIM DATA FORM
Have any malpractice claims, suits, settlements or arbitration proceedingsEVER been made against you or any professional entity in which
you are a member? If yes, please put the number on the appropriate line and total below.  Yes  No
Total Pending Cases . . . . . . . . . . . . . . . . . . . . . . .
Total Dismissed/Settled/Closed with No Payment . . ._
Total Dismissed/Settled/Closed with Payment . . . . .
Total Number . . . . .
*In addition to the Malpractice Claim Data Form for each case/claim/settlement/proceeding, please include ANY and ALL additional
documentation available from third parties for cases closed in or after 1990. Please see the “Information Regarding 3rd Party
Documentation for Malpractice Claims” insert for documentation CenseoHealth considers acceptable.
BACKGROUND QUESTIONS
IF YOU ANSWER YES TO QUESTIONS 2-16, PLEASE PROVIDE A FULL EXPLANATION ON A SEPARATE SHEET
1. Are you authorized to work as an independent contractor in the United States?  Yes  No
2. Are you currently abusing alcohol, using any illegal drugs, or failing to take legally prescribed drugs in the manner prescribed?  Yes  No
3. Have you abused alcohol, used illegal drugs, or failed to take legally prescribed drugs in the manner prescribed in the past? If yes,  Yes  No
what drugs, and how recently have you used these drugs?
4. Have you ever been convicted of a felony or a misdemeanor other than a minor traffic violation? (A “yes” answer will not
automatically disqualify you from consideration for placement on CenseoHealth‟s Roster of eligible providers. Factors such as when  Yes  No
the offense was committed and the seriousness and nature of the offense will be considered.)
5. Have you ever been convicted of any violation of a state or federal law relating to controlled substances? (A “yes” answer will not
automatically disqualify you from consideration for placement on CenseoHealth‟s Roster of eligible providers. Factors such as when the  Yes  No
offense was committed and the seriousness and nature of the offense will be considered.)
6. Have you ever been denied or surrendered a state or federal controlled substances certificate or state license?  Yes  No
7. Has your license to practice in your profession in any state been reprimanded, sanctioned, placed on probation, curtailed, suspended,
revoked, restricted, denied, formally investigated or voluntarily surrendered in order to avoid disciplinary action/investigation by a  Yes  No
state board?
8. Have you ever been denied a certificate by, or the privilege of taking an examination before, any state board?  Yes  No
9. Have your staff/clinic privileges at any hospital, health care facility, and/or clinic been denied, revoked, suspended, curtailed, limited,  Yes  No
placed under conditions restricting your practice, or voluntarily surrendered in lieu of investigation?
10. Have you ever resigned from a position in lieu of an investigation, or have you ever been terminated from employment?  Yes  No
11. Have you ever been disciplined by any state board for unethical conduct? No Yes
  No
12. Are you enrolled in the Medicare program and eligible to receive Medicare payment for covered services provided to Medicare No
 Yes  No
beneficiaries? *IF NOT, notify CenseoHealth and we will provide you with the Medicare application
13. Have you ever been denied provider participation in any state or federal Medicare/Medicaid program?  Yes  No
14. Have you ever been terminated, sanctioned, or penalized by any state or federal Medicare/Medicaid program? No
 Yes  No
15. Have you ever had to repay money to any state or federal Medicare/Medicaid program? o
 Yes  No
16. Have you ever been convicted of a violation of any federal or state narcotic law? (A “yes” answer will not automatically disqualify you
from consideration for placement on CenseoHealth‟s Roster of eligible providers. Factors such as when the offense was committed  Yes  No
and the seriousness and nature of the offense will be considered.)
17. Have you ever been disciplined by a hospital staff or an internship, residency, fellowship or other professional educational program?  Yes  No
18. Is there any other issue which should be disclosed that may have an adverse impact on your ability to deliver effective Locum Tenens
 Yes  No
provider services?

MILITARY SERVICE
Military Service: On a separate sheet of paper please explain the circumstances of any less than honorable discharge received. A less than
honorable discharge will not be an automatic bar to placement on CenseoHealth’s Roster of Eligible Providers.
Did you serve in the military?  Yes  No

Branch Date of Service

CONSENT
I hereby affirm and acknowledge that the information provided by me on this application and the attachments is true, complete and correct, and that
CenseoHealth will rely on the truthfulness of my statements in evaluating my potential to be placed with CenseoHealth‟s clients as a Locum Tenens provider.
I hereby release CenseoHealth, its staff, representatives and agents from liability for their acts performed in good faith and without malice in connection with
evaluating my application, credentials and qualifications. I further release from liability physicians, hospitals and other references for the good faith release of
information regarding my professional capabilities and performances. I acknowledge that the decision to place me on the roster of eligible providers for
placement as a Locum Tenens provider is solely at the discretion of CenseoHealth, I further acknowledge that I will not enter into an arrangement to
provide temporary or permanent provider services with any individual, group or institution to whom I am referred by CenseoHealth, except through
CenseoHealth, or with CenseoHealth‟s consent for a period of two years. By providing your name, signature, and phone numbers you are consenting to receive
phone calls from CenseoHealth and its‟ affiliates regarding our services
__________________________________
Page 3
RELEASE AND AUTHORIZATION

(Please read carefully)

By my signature below, I authorize CenseoHealth to confirm information contained on any

document that I provide to CenseoHealth, including my curriculum vitae, and to conduct
background and reference checks on me regarding any information related to possible
placement as a locum tenens provider. This includes information on my education,
licensing, work history, Medicare/Medicaid sanctions, malpractice claims and insurance
eligibility. CenseoHealth may gather the information from various sources including, but
not limited to, consumer reporting agencies, hospitals, medical institutions or organizations,
personal references, physicians, employers (past and present), business and professional
associates (past andpresent), governmental agencies and instrumentalities (local, state,
federal, or foreign), university transcript offices, medical schools, the Office of Inspector
General and the Federation of State Medical Boards.

I consent to CenseoHealth sharing this information with CenseoHealth clients and affiliates,
government or other licensing entities, or professional liability insurers. I understand
that, upon my request, CenseoHealth will disclose to me the nature and substance of the
information in accordance with federal law. A request for disclosure of information must be
made in writing and directed to my Recruiting Consultant.

I authorize the above-named entities and individuals to release to state licensing boards,
hospitals, and CenseoHealth any information (written or oral), including medical
information, files or records about me in their possession required for evaluation of my
qualifications for placement as a locum tenens provider. I hereby release the above-
named individuals and entities, including CenseoHealth and its agents, from liability or
damages that may result from the release of information described above.

I am signing this release for the purpose of allowing CenseoHealth to assist in my request
for a license to practice in my profession and to assist in my efforts to work as a locum
tenens provider for CenseoHealth‟s clients.

DATE

PLEASE PRINT NAME CLEARLY

SIGNATURE
Form W-9 Request for Taxpayer Give form to the
(Rev. October 2007)
Department of the Treasury
Identification Number and Certification requester. Do not
send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
See Specific Instructions on page 2.

Business name, if different from above

Print or type

Check appropriate box: Individual/Sole proprietor Corporation Partnership

Exempt
Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ©
payee
Other (see instructions) ©

Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the instructions on page 4.

Sign Signature of
Here U.S. person © Date ©

General Instructions Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted. ● An individual who is a U.S. citizen or U.S. resident alien,
● A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number (TIN) ● An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate ● A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701-7).
abandonment of secured property, cancellation of debt, or
Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA.
trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners’ share of income
resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct (or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
2. Certify that you are not subject to backup withholding, or provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on purposes of establishing its U.S. status and avoiding withholding
foreign partners’ share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester’s form if it is following cases:
substantially similar to this Form W-9.
● The U.S. owner of a disregarded entity and not the entity,

Cat. No. 10231X Form W-9 (Rev. 10-2007)

3RD PARTY DOCUMENTATION FOR
MALPRACTICE CLAIMS

For each malpractice claim that was settled/dismissed/closed in or after 1990:

• Complete the “Malpractice Claim Information” form below AND
• Provide at least one of the following forms of 3rd party documentation
• Correspondences must be on sender‟s letterhead and include:
The plaintiff‟s name (or identifying information)
Date of incident
Allegations

Pending Claims:

• Legal Counsel Correspondence

*In addition to above requirements, the letter must contain a statement that the “case is defensible”.

Finalized Claims: (In addition to the above requirements, all letters must contain the outcome of the claim
and total indemnity paid on your behalf)

• National Practitioner Data Bank Self-Query (Claims settled/closed since 1990)

*Customer Service 800-767-6732
*https://icd.npdb-hipdb.com:663/ - 'self-queries' link
*NPDB report cannot be older than ninety (90) days from the date you sign your application

• Final Court Order and/or Settlement Agreement

*The Records Department in the county where the claim was filed can assist you in obtaining the Final
Court Order and/or Settlement Agreement.

• Insurance Company/Legal Counsel Correspondence

*Claims History/Loss Run

• Facility/Hospital/Clinic Correspondence
*The Risk Management and/or Legal Department should be able to assist you in obtaining a letter from
the Facility/Hospital/Clinic.

• United States Government Correspondence

*If the claim occurred while working at a government facility and you were covered under the Federal
Tort Claims Act, the Risk Management and/or Legal Department should be able to assist you in
obtaining a letter from the Facility/Hospital/Clinic.

• Patient Compensation Fund Correspondence

*If the claim occurred in a state in which you were enrolled in the Comp Fund, contact the Comp Fund
to obtain a letter stating how much they paid on your behalf.
Patient Compensation Fund correspondence will not be accepted as sole 3rd party
documentation. One of the above must also be obtained.

At times, CenseoHealth‟s Quality Assurance team may require additional forms of 3rd party documentation
for a single claim in the event that the originally submitted information is insufficient.

You may contact your Recruiting Consultant with any questions.

Thank you for your cooperation.

MALPRACTICE CLAIM INFORMATION
(Please make copies if additional forms are needed)

Claimant Name:

Location of Occurrence (city/state):

Date of Occurrence:

Provider Case Narrative (use separate paper and write „see attached narrative‟ if necessary):

Claim Outcome: (check the appropriate outcome)

Pending
Withdrawn by Claimant
Dismissed/Settled/Closed with no Payment
Dismissed/Settled/Closed with Payment

Total Claim Payment (all defendants): $ Claim

payment on your behalf: $
By Insurance Carrier: $
By Patient Compensation Fund (if applicable): $

Provider Signature:

Print Name:
Date:

All of the above information is required.

Optional Information

Insurance Carrier Information (name, policy number, contact):

 AGREEMENT NOT TO PERFORM

We are pleased to have you joining our team at CenseoHealth. We strive to make this a great opportunity for you
and we dedicate ourselves to making your assignment with us one of ease and comfort. Whereas to be able to
provide you with industry leading malpractice and liability coverage, we will require that you sign this
“agreement not to perform”. This document is an agreement between you and CenseoHealth stipulating that you
will only be providing History and Physical evaluations for scheduled members and that you will not be
prescribing any drugs or performing any procedures on behalf of CenseoHealth. In the case of an emergency
during an evaluation please call the plan at the member services number provided to you or 911.

Provider – Please Print

Provider – Signature

Date
 CenseoHealth, LLC
Agreement for Providers

This agreement dated ____________________ shall be by and between CenseoHealth, LLC, a Texas based

company and ___________________________. CenseoHealth shall act as the agent for CenseoHealth clients (Clients) to

arrange for medical services to be provided on a Locum Tenens basis and Provider desires to provide medical services to

CenseoHealth’s contracted Clients on a Locum Tenens basis. Therefore, both parties agree to the terms below:

Payments and Expenses:

1.1 Rates: Rate will be $100 for each completed member assessment that passes CenseoHealth Quality Assurance.
1.2 Housing: CenseoHealth will provide reasonable housing accommodations on behalf of Client while on assignment and
for en route housing as needed. Provider will be responsible for all personal expenses such as meals and incidentals.
1.3 Release and Authorization: Provider authorizes CenseoHealth to release any information required for privileges
relating to an assignment, including drug screening results. In the course of presenting Provider to Clients for potential
services, CenseoHealth will reproduce Provider’s curriculum vitae and use good faith efforts to prevent any errors in
such reproduction. Provider agrees to release and hold CenseoHealth harmless from all liability for any such errors
made in reproduction.
1.4 Licensure: Provider agrees to provide accurate information in a timely manner to CenseoHealth and Client to meet
CenseoHealth Provider Standards and/or state licensure application requirements. CenseoHealth shall assist Provider
in obtaining necessary documentation. Provider may be required to submit to drug screening. Provider shall have a
current state license and shall be eligible to provide services to Medicare beneficiaries.
1.5 Malpractice History: Provider shall furnish a record of all ongoing malpractice claims and any settled claims.

Provider Duties:

2.1 Responsibilities: Provider shall complete health risk assessment and HIPAA training as detailed by CenseoHealth.
This training may change and may be repeated for different CenseoHealth clients. Provider will be expected to
demonstrate adequate understanding of the appropriate training.
2.2 Member relations: Provider is expected to perform health risk assessments only for Medicare members and is not
expected to provide care for that member’s medical problems or to enter into a physician patient relationship with that
member.
2.3 Records: Provider shall perform health risk assessments using an evaluation tool provided by CenseoHealth. The
evaluation is to be completed according to standards defined by CenseoHealth. Evaluations not completed according to
those standards will be deemed deficient and will be repeated by provider.
2.4 Limitations: Neither party shall be liable for damages or default in performing its respective obligations under this
agreement if such is out of either parties control, including government restrictions, flood, fire, strikes, or acts of thirds
parties. Each party shall keep the other informed at all times concerning matters causing delay or work stoppage.
2.5 Confidentiality: Provider agrees that the terms of this agreement are confidential and shall not be disclosed to third
parties. In addition, Provider agrees that any training or evaluation tools are the property of CenseoHealth and are
confidential.
2.6 Notification of Disciplinary Action: Provider agrees to notify CenseoHealth immediately of any disciplinary or quality
assurance proceedings involving Provider, including but not limited to: licensing boards, quality assurance committees,
hospitals or other medical entities, medical societies, or claims of suits. Provider also agrees to immediately notify
CenseoHealth in the event any such proceedings are pending or are instituted, regardless of relevancy to Client or
CenseoHealth.
2.7 Notification of Litigation: Provider shall immediately notify CenseoHealth in writing of any potential or actual
malpractice claims involving Provider, whether such claim took place before or during this agreement or related to
services in connection with this agreement. Provider also agrees to notify CenseoHealth immediately and in writing of
any situation relating to services provided under this agreement that Provider has any reason to believe may lead to a
malpractice claim. Provider understands and accepts that failure to comply with these terms could lead to Provider
being eliminated from CenseoHealth’s eligible roster.
2.8 Notifications: All notices by Provider shall be in writing to CenseoHealth via certified mail.

General Terms

3.1 Term: This agreement shall begin on the effective date and shall continue until terminated as set forth in this
agreement or until a new agreement is entered into between Provider and CenseoHealth.
3.2 Termination: Either party may terminate this agreement and Provider or Client may terminate any assignment with or
without cause by providing at least a 30 day written notice prior to the start date of assignment. Provider agrees to
provide Locum Tenens services at the location designation by Client during the entire notice period. CenseoHealth, nor
Client, shall be obligated to pay Provider for any scheduled period for services not actually performed by Provider
during such period.
 3.2.1 This agreement may be terminated by CenseoHealth, at its discretion, without prior notice to Provider upon the
occurrence any of the following events:
a) Provider becomes disqualified to practice medicine in any state or Provider’s license or hospital privileges are
revoked, suspended, or restricted, whether voluntarily or involuntarily.
b) CenseoHealth Client in which Provider provides services requests that provider be removed for reasons alleged
or actual, relating to competence or professional conduct.
c) Provider fails to qualify or becomes ineligible for coverage under the terms of CenseoHealth’s malpractice
insurance policy and is not covered by other malpractice insurance deemed acceptable by CenseoHealth.
d) Provider fails to perform the duties required by this agreement, violates its terms, or refuses to cooperate with
CenseoHealth.
e) CenseoHealth determines that Provider provided false or misleading information or omits relevant information
on Provider application materials.
3.2.2 If Client fails to meet financial obligations to CenseoHealth for services performed by Provider, Provider
understands that assignments may be canceled. Under no circumstances will CenseoHealth be obligated to
pay for services for which CenseoHealth has not received payment from Client. Provider will not be entitled to
payment for any scheduled services not actually performed on a canceled assignment; however, CenseoHealth
will use its best efforts to collect amounts due to provider for canceled term inside of 30 days.
3.3 Non-Solicitation: During the term of this agreement and for a period of 2 years after this agreement is terminated for
any reason, Provider shall not solicit or make any offer to become employed by, involved, affiliated with, directly or
indirectly, Client of CenseoHealth whose need for coverage was disclosed to Provider by CenseoHealth unless
otherwise agreed to in writing by CenseoHealth. In addition, for a period of 2 years after this agreement is terminated
for any reason, Provider will not perform health risk assessments for any Medicare Advantage plan or any members of
a provider group contracted to a Medicare Advantage plan.
3.4 Recruitment: For a period of 2 years after this agreement is terminated for any reason, Provider is recruited and
accepts a permanent position or locum tenens assignment with Client or Client affiliate, Client shall be responsible for
paying a recruitment fee. Provider agrees to immediately notify CenseoHealth in the event Provider accepts an offer
with Client or Client’s affiliate. If Client or third party refuses to pay such recruitment fee, Provider agrees to refuse offer
or agrees to pay the recruitment fee of $30,000 to CenseoHealth plus any attorneys fees incurred in the collection of
such amounts.
3.5 Independent Contractor Status: CenseoHealth acts as a placement agency for Client and Provider is an
independent contractor. CenseoHealth is not licensed to practice medicine and shall not influence or direct Provider’s
professional medical judgment. Provider agrees that CenseoHealth shall not provide health insurance, worker’s
compensation or unemployment benefits for Provider. Additionally, CenseoHealth shall not make or withhold state or
federal tax payments unless required to do so by law. CenseoHealth shall deliver Form 1099 to Provider annually
within the required time by law.
3.6 Indemnification: Provider hereby indemnifies CenseoHealth, and shall hold CenseoHealth harmless from any losses,
damages, liabilities, and claims not covered by CenseoHealth’s liability insurance that are incurred by CenseoHealth
arising out of or as a result of Provider rendering or failing to render medical services during the term of this agreement.
3.7 Governing Law: This agreement shall be governed by and interpreted in accordance with the laws of the State of
Texas. Exclusive jurisdiction and venue of any dispute or legal action relating to this agreement shall lie in the state or
federal courts of Dallas County, Texas.
3.8 Amendments: Any and all changes to agreement shall be agreed to and approved and signed by both parties
including both party’s signatures.
3.9 Severability: Each party acknowledges and agrees that each provision of this agreement shall be enforceable
independently of the other. In the event, any provision is determined to be unenforceable for any reason, the parties
agree to substitute a comparable provision dealing with the same subject matter that mimics the effect and intent of the
unenforceable provision to the maximum extent of permissible law.

In witness whereof, the parties have executed this agreement as of the effective date.

CenseoHealth Provider

By:_________________________ Provider:____________________________
CenseoHealth
4055 Valley View Lane City, St. Zip: _________________________
Suite 300
Dallas, TX 75244 SS#, Tax ID#:________________________