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HomeMy WebLinkAboutContract 2011 2397 ", mEDTox Pricing Agreement City of Columbia Heights (acct 3306) (Client) acknowledges that MEDTOX Laboratories (MEDTOX) will bill Client for laboratory services, and payment for such services shall be in accordance with the following Fee Schedule: Medical Review Officer Dr. Jetzer (Medical Review Officer Service — Positive Only) $20.00 Prices are based on a positive rate of 8% or less. Payment terms are net 30 *Asterisked prices include any reflex testing required for expanded test panels. Client will not be charged the flat rate indicate for these panels Client acknowledges that if it requests MEDTOX to perform laboratory services not listed on the above Fee Schedule it agrees to pay MEDTOX at its then current List Price for those services. Client acknowledges that it will contact MEDTOX Sales or Account Management for any laboratory testing services not listed on the above fee schedule in order to request appropriate pricing. To take effect, additions and /or deletions to the above fee schedule require a signed amendment by both parties to this schedule, listing those changes and effective date of such change(s). When MEDTOX provides a billing service subject to reimbursement by: (1) government payers (including Medicare and Medicaid programs) or (2) third party payers (HMO's other insurance companies etc.), Client agrees to provide MEDTOX at the time such services are ordered, with complete (1) patient demographics, (2) insurance information, (3) diagnosis code and (4) other information as required by the insurance carrier to properly bill for such services. If information provided by Client is incomplete or inaccurate, Client agrees to pay MEDTOX for such services. City of Columbia Heights acct 3300 �? t Printed Name: (2 /:;‘, C/ rc s Signature; i° Se Title: (A/ l� �y 1 ,(.c, gf' Date: a — 2? - -1/ MEDTOX Laboratories, Inc. Printed Name: Joe Luke Signature: Joe Luke Title: Associate Sales Representative Date: 8 -1 -11 Fax to: 1.866.760.0171 or Email to: iluke@medtox.com ©Copyright 2011, MEDTOX Laboratories, Inc. 1 MAR-25-2011 14:3E FROM:COLUMBIA HEIGHTS 7637063601 TO :918667577070 P.2 Pricing Agreement City of Columbia Heights #3306 ( Client) acknowledges that MEDTOX Laboratories ( MEDTOX) will bill Client for laboratory services, and payment for Such services shall be to accordance with the following Fee Schedule: Test Code D Price 34 Legal Blood Alcohol $33,00 Prices aro based on a positive rate of 8% or less. Payment terms are net 30. *Asterisked prices include any reflex testing tequired for expanded test panels, Client will not be charged the flat rate indicate for those panels. } Client acknowledges that if it requests MEDTOX to perform laboratory services not listed on the above Fee Schedule it agrees to pay MEDTOX at its then current List Price for those services, Client acknowledges that it will contact MEDTOX Sales or Account Management for any laboratory testing services not listed on the above fee schedule in order to request appropriate pricing. To take effect, • additions and/or deletions to the above fee schedule require n signed amendment by both parties to this schedule, listingthose changes and efibetive date of such change(s). When MEDTOX provides a billing service subject to reimbursement by: (1) government payers (including Medicare and Medicaid programs) or (2) third party payers (HMO's other insurance companies eta,) Client agrees to provide MEDTOX at the time such services are ordered, with complete (1) patient demographics, (2) insurance information, (3) diagnosis code and (4) other information as required by the insurance carrier to properly bill for such services, If information provided by Client is incomplete or inaccurate, Client agrees to pay MBPTOX for such services. City of Columbia ights *3306 Prin red Name: i r1 • 44 ' Signs �i�s`ir Tile : .� CBSID /,_v_ r Date: —J MEDTOX Laboratories, Inc, Printed Name: Barbara Webe' Signature: Barbara Weber sir ISA /w' tfter4 Title: Sales Representative ' W Date: Fax to: 1 866 757 7078 0 Copyright not MEOTOx Laboratories, Inc.