| NOW, THEREFORE, it is agreed as follows:
1. That the
DENTIST agrees to
require that all employees of DENTIST and all partners, associates,
supervisors,
and personnel under his control, render services to MEMBERS in
accordance
with this AGREEMENT.
2. That the
DENTIST agrees to
perform all necessary dental services which he customarily renders, to
each MEMBER during his regular office hours, subject to a prior
appointment;
provided, however, that DENTIST shall have the right within the
framework
of professional ethics to reject any patient seeking his
services.
If DENTIST should be absent from his practice for any reason for longer
than ninety (90) days, the PLAN may terminate this AGREEMENT upon ten
(10)
days notice by certified or registered mail.
3. That the
DENTIST agrees to
perform his obligations under this AGREEMENT in accordance with high
standards
of competence, care and concern for the welfare and needs of
MEMBERS,
who seek his professional services and in accordance with the
“principles
of ethics of the American Dental Association." DENTIST further
agrees
not to differentiate or discriminate in the treatment of MEMBER
patients
by reason of the fact that they are MEMBERS.
4. That the
DENTIST shall maintain
the Dentist-Patient relationship with MEMBERS who seek his professional
services, and shall be responsible to the patient for quality dental
advice
and treatment. The parties hereto agree that the DENTIST is an
independent
contractor and that the PLAN shall not have any control over DENTIST’S
practice, his personnel, or his facilities.
5. The PLAN
shall be responsible
for determining a person’s eligibility prior to their becoming a MEMBER.
6. That the
DENTIST shall perform
all services as required pursuant to the AGREEMENT and DENTIST agrees
that
all payments for all said services rendered by DENTIST to any MEMBER
are
required to be paid directly by the MEMBER. The DENTIST agrees to
look solely to the MEMBER for payment and to bill at rates not to
exceed
those set forth in the schedule attached hereto. If any service
provided
to MEMBER by the DENTIST is not listed in said schedule, DENTIST hereby
agrees to bill for said service at a rate not in excess of his
usual
and customary fee. No fee shall be due from DENTIST to PLAN with
respect to the services required pursuant to this AGREEMENT.
7. That the
DENTIST will charge
for his services at rates not to exceed those set forth in the attached
schedule.
8. That the
DENTIST hereby agrees
that in the event of any unresolved dispute for payment claimed by
DENTIST,
under no circumstances will DENTIST make or have any claim against the
PLAN.
9. That the
attached fee schedule
may be revised annually by the PLAN to reflect increased costs of
dental
care. Such revision will be in the PLAN'S sole discretion.
The PLAN agrees to notify the DENTIST in writing of the nature and
extent
of such revision.
10. That this
AGREEMENT is not exclusive
in any respect, and the PLAN and the MEMBERS are entitled to enter into
similar contracts with other dentists and DENTIST is free to enter into
similar contracts with other parties, or with other groups not
represented
by the PLAN, and to maintain his private practice.
11. That DENTIST
agrees to notify MAINLINE
DENTAL PLAN, INC. in the event that he/she receives notice of any type
of claim or litigation within thirty (30) days of receipt of such
action
brought by a PLAN MEMBER.
12. That DENTIST
agrees to carry Malpractice
Insurance coverage for his/her practice in an amount not less than
$1,000,000
per incident. DENTIST further agrees to provide the PLAN with a
"Certificate
of Insurance" which provides for ten (10) days notice of cancellation
to
the PLAN and agrees to indemnify and hold harmless PLAN or any of its
agents
from all liabilities, costs, and expenses that may be incurred by the
PLAN
or its agents in connection with any controversy proceeding or
litigation
arising from the execution of the AGREEMENT with DENTIST or arising
from
DENTIST'S performance of this AGREEMENT.
13. That the PLAN
shall appoint a Dental
Director who will be responsible for assuring the standards of dentists
who provide dental care to MEMBERS, and who will be a liaison between
the
PLAN and the DENTIST.
14. That this
AGREEMENT shall continue
in effect until terminated by wither party upon sixty (60) days notice
by registered or certified mail, except in cases of termination upon
ten
(10) days notice under Paragraph 2. Notices shall be mailed to
DENTIST
at the address set forth herein and to PLAN at such address as shall be
designated by PLAN from time to time.
15. That in the event
this AGREEMENT
is terminated by either party in accordance with the procedure set
forth
herein. DENTIST agrees that at the time the patient seeks an
appointment,
he will notify each patient who is a MEMBER prior to giving service
that
the DENTIST is no longer affiliated with the PLAN.
16. That this
AGREEMENT is intended
to secure the personal services of DENTIST and shall not be assigned or
transferred by DENTIST without the written consent of the PLAN.
17. That a waiver of
any breach of this
AGREEMENT or of any of the terms or conditions by either party shall
not
be deemed a waiver of any repetition of such breach or in any way
affect
any other terms or conditions. No waiver shall be valid or
binding
unless it shall be in writing and signed by the parties.
18. All written
notices shall be deemed
to have been made at the time of posting, and shall be sent to the
following
addresses as set forth below.
19. That this
AGREEMENT embodies the
entire understanding of the parties and may be amended only in writing.
20. That if any one or
more of the provisions
of this AGREEMENT should be found to be invalid, illegal, or
unenforceable
in any respect, the validity, legality and enforceability of the
remaining
provisions shall not in any way be affected or impaired. This
AGREEMENT
shall be governed by the laws of the State of New Jersey.
IN WITNESS WHERE OF, the parties hereto
have affixed their
signatures this ______ day of
___________________ 20____at
__________________________,
New Jersey.
MAINLINE DENTAL PLAN,
INC.
By: ______________________
Ryan C. Maher, President
DENTIST
By:
_________________________________________ Print Name:
___________________________
Signature
Address:
___________________________________________________
City/State/Zip Code:
__________________________________________
Telephone:
_________________________________________________
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