Referral Partner Agreement

Referral Partner Agreement 2
This Referral Partner Agreement ("Agreement") is entered into as of , by and between Central Florida Counseling & Recovery Centers, Inc., including its affiliated trade name Om to Home, with its principal offices at: Central Florida Counseling & Recovery Centers, Inc. 6900 Turkey Lake Rd Suite #1-2, Orlando, FL 32819 1120 S Park Ave, Apopka, FL 32703 ("CFCRC/Om to Home") — and — , ("Referral Partner") Recitals WHEREAS, CFCRC/Om to Home provides primary care services, outpatient mental health counseling, and inpatient services including detoxification and residential treatment through its affiliated programs; WHEREAS, Referral Partner provides complementary or related services in the healthcare field and wishes to collaborate with CFCRC/Om to Home to facilitate patient referrals for continued care; WHEREAS, both parties desire to enter into this Agreement to establish the terms of their referral relationship, in compliance with applicable laws and ethical standards, including but not limited to the laws of the State of Florida. NOW, THEREFORE, in consideration of the mutual covenants and promises set forth herein, the parties agree as follows: 1. Purpose The purpose of this Agreement is to establish a collaborative relationship between the parties to promote and facilitate referrals for patient care, ensuring continuity of services for individuals in need of the programs and treatments offered by CFCRC/Om to Home. 2. Scope of Referral Services Referral Partner agrees to identify individuals who may benefit from services offered by CFCRC/Om to Home and refer them in good faith. CFCRC/Om to Home agrees to evaluate referrals and provide appropriate services within the scope of their practice, maintaining compliance with all applicable healthcare laws and standards of care. Each party retains full discretion over the acceptance of any referred patients. 3. Non-Exclusive Relationship This Agreement does not create an exclusive relationship between the parties. Either party may enter into similar agreements with other providers or referral sources. 4. Compliance with Laws Both parties agree to comply with all applicable federal, state, and local laws and regulations, including but not limited to the Florida Patient Brokering Act, the Anti-Kickback Statute, and HIPAA. No fees, commissions, or other forms of payment will be made for referrals under this Agreement. Any compensation related to services rendered shall be for bona fide services performed and shall be fair market value. 5. Confidentiality and HIPAA Compliance Each party agrees to maintain the confidentiality of all patient information in compliance with HIPAA and other applicable privacy laws. Referral Partner agrees not to disclose any protected health information ("PHI") without proper authorization or applicable legal exceptions. 6. Term and Termination This Agreement shall commence on the date first written above and continue unless terminated by either party upon thirty (30) days' written notice. Either party may terminate this Agreement immediately upon written notice if the other party is found to be in material breach of any term of this Agreement. 7. Independent Contractors The relationship between the parties is that of independent contractors. Nothing in this Agreement shall be construed to create a partnership, joint venture, agency, or employment relationship between the parties. 8. Indemnification Each party agrees to indemnify, defend, and hold harmless the other party and its affiliates from any claims, liabilities, damages, or expenses (including reasonable attorneys' fees) arising out of or relating to the indemnifying party’s breach of this Agreement or violation of law. 9. Governing Law and Venue This Agreement shall be governed by and construed in accordance with the laws of the State of Florida, without regard to its conflict of law principles. Venue for any dispute arising under this Agreement shall be exclusively in the state or federal courts located in Orange County, Florida. 10. Entire Agreement This Agreement constitutes the entire understanding between the parties with respect to its subject matter and supersedes all prior agreements or understandings, whether written or oral. 11. Amendments No amendment or modification of this Agreement shall be valid unless in writing and signed by both parties. 12. Electronic Signature Consent and Disclosure By providing your full legal name and submitting this form, you agree that your typed name constitutes your legal signature and consent to execute this Agreement electronically. You understand that under the Electronic Signatures in Global and National Commerce Act (ESIGN) and the Florida Uniform Electronic Transaction Act (UETA), this electronic signature is legally binding and enforceable. Party Information Referral Partner: Company: Authorized Representative: Email: Address: , Date: Central Florida Counseling & Recovery Centers, Inc. and Om to Home: Authorized Representative: Internal Use Date: Agreement Confirmation: By checking the required box below and submitting this form, you acknowledge you have read, understood, and agree to the terms of this Agreement, and that this submission constitutes your electronic signature under applicable law." data-name="smart_agreement_text" >