Freedom Negotiators Client Agreement
HEALTHCARE EXPENSE NEGOTIATION SERVICES AGREEMENT
This HEALTHCARE EXPENSE NEGOTIATION SERVICES AGREEMENT (“Agreement”) is entered into as of the date of this agreement (hereafter the “Effective Date”) between Freedom Negotiators, Inc., a Texas Corporation, (“Freedom”) located at 5508 West Highway 290, Suite 300, Austin, Texas 78735, and , located at , , (referred to hereafter as the “Client”). Freedom and the Client shall each individually be referred to as a “Party” and together collectively as the “Parties.”
WHEREAS Freedom provides healthcare expense negotiation services ("the Services”) to its clients; and the purpose of this Agreement is to set forth the terms, conditions and scope under which Freedom will provide the Services to Client
NOW, THEREFORE, for valuable consideration, the Parties agree as follows:
Services: Client hereby engages Freedom to provide medical bill negotiation services for individual healthcare bills or invoices (“Healthcare Bill”) that are equal to or exceed $1,000, owed to healthcare professionals or entities (“Providers”). Freedom shall have the right to utilize third parties in connection with the provision of the Services.
Fees: As consideration for the performance of Services, the Client shall pay Freedom the following: (1) a Healthcare Bill processing fee of $150 for each Healthcare Bill that is less than $15,000, or (2) a Healthcare Bill processing fee of $300 for each Healthcare Bill that is greater than or equal to $15,000, and (3) a negotiation fee equal to 20% of the difference between the original billed amount from the Provider less the final negotiated amount (“Savings Percentage Fee”). The Savings Percentage Fee earned by Freedom will be capped at $5,000, inclusive of the Healthcare Bill processing fee. Services will not be provided under this Agreement until Freedom receives the Healthcare Bill processing fee from the Client and this signed agreement.
Payments of invoices for the Savings Percentage Fee will be due within ten (10) days after Client receives the invoice from Freedom. If Client fails to make the Savings Percentage Fee payment in a timely manner, a late charge equal to 11⁄2% per month, or the maximum rate permitted by applicable law if less, of the unpaid balance shall be payable for each month the delinquency remains outstanding. Costs incurred by Freedom in collecting amounts owed by Client, including reasonable attorneys’ fees, shall be paid by Client.
Client Responsible for Healthcare Expense Payment: The Client will remain solely responsible for payment of all Healthcare Bills submitted to Freedom for the Services. Freedom’s Services in no way serves to interfere with and/or alter the privity of contract between the Client and Provider, or agent thereof. Freedom does not represent that its negotiation of any Healthcare Bills, or Client’s payment of such Healthcare Bills, by itself fully satisfies, resolves, or settles fees due to the Provider(s).
No Guarantee of Healthcare Expense Reduction and Remedies: Freedom does not guarantee that it will be successful in negotiating a reduction with respect to any Healthcare Bill submitted by the Client. Should it become apparent that a reduction in the Healthcare Bill will not be successfully negotiated, Freedom will notify Client in writing. Freedom reserves the right to refuse any submitted Healthcare Expense for any or no reason. Unless Client is in breach of any of its’ obligations under this agreement including those referenced in Section 6, Freedom agrees to reimburse the Healthcare Bill processing fee if the Savings Percentage Fee is not equal to or exceed this amount.
HIPAA Compliance and Protection of Protected Health Information (PHI): Freedom agrees that that it is now, and will always be, in strict compliance with HIPAA laws and regulations, and shall hold all client PHI confidential consistent with the HIPAA PRIVACY AND SECURITY POLICY attached hereto as Exhibit A, as such policy may be amended.
Client Support and Cooperation. Client acknowledges that its cooperation, including but not limited to, the timely provision of documentation regarding the Healthcare Expense Bill, will be required for the performance of the Services by Freedom. Client agrees to execute the HIPAA release included as Exhibits B to provide Freedom and Client’s Healthcare Provider authorization to discuss and obtain records regarding the Healthcare Expense. In the event the Client fails to provide Freedom with required documentation to execute Services after 180 days from the Effective date, Client shall forfeit their Healthcare Bill processing fee.
Confidentiality. Information provided to Freedom by Client during the performance of this Agreement may be disclosed by Freedom as necessary to provide the Services pursuant to this Agreement. Client understands and agrees that Freedom’s Privacy Policy, published at https://www.Freedomadmin.com/privacy-policy/ will apply to the information provided herein.
Disclaimer of Warranties. THE SERVICES ARE PROVIDED ON AN “AS IS” AND “AS AVAILABLE” BASIS WITHOUT ANY REPRESENTATIONS OR WARRANTIES. NO ORAL OR WRITTEN INFORMATION OR ADVICE GIVEN BY FREEDOM OR ITS EMPLOYEES OR REPRESENTATIVES SHALL CREATE A WARRANTY OR IN ANY WAY INCREASE THE SCOPE OF FREEDOM’S OBLIGATIONS.
Remedies. In the event Freedom fails to perform the Services in accordance with this agreement, Client’s sole remedy shall be limited to the fees paid for the events giving rise to the claim. Client must provide written notice to Freedom specifying the deficiencies in the Services within ninety (90) days of such deficiencies.
Term and Termination. This Agreement shall become effective on the Effective Date and shall continue until terminated by either party with thirty days’ (30) notice. If Client fails to pay any fees owed to Freedom as set forth and such failure is not cured within fifteen (15) calendar days of Client’s receipt of written notice from Freedom, Freedom may terminate this Agreement immediately. Upon termination of this Agreement, Freedom will cease providing Services and all outstanding invoices will become immediately due and payable.
Miscellaneous:
Invalidity: If any part of this Agreement shall be declared invalid or unenforceable by a court of competent jurisdiction, it shall not affect the validity of the balance of this Agreement.
Legal Notices: Legal notices under this Agreement shall be delivered to the address set forth in the introduction above. Legal notices shall be sent via certified mail, return receipt requested, registered mail, by hand delivery, electronically or by overnight courier services (such as FedEx, UPS, etc.). Legal notices shall be valid upon the actual date of receipt by the addressee.
Venue; Forum; Choice of Law: The parties agree that the venue of any court proceeding shall be in Travis County, Texas unless such venue is waived in writing by both parties. This Agreement shall be governed by and interpreted in accordance with the laws of Texas, and without regard to the Texas conflict of law principles.
Dispute Resolution: The Parties agree to negotiate all disputes arising out of or relating to this Agreement, in good faith and if the Parties are unable to reach a resolution, the Parties agree that such dispute shall be determined by binding, non-appealable arbitration under the Commercial Arbitration Rules of the American Arbitration Association (“AAA”). The arbitration shall be conducted by a single arbitrator chosen by the Parties. The fees and expenses of the prevailing Party related to arbitration pursuant to this section shall be borne by the unsuccessful Party to the dispute as determined by the arbitrator.
EXHIBIT A
HPIAA PRIVACY AND SECURITY POLICY
Confidential information received by Freedom in the performance of the Healthcare Expense Negotiation Services Agreement includes “Protected Health Information” (‘PHI’) of the Client, as such term is defined in the Health Insurance Portability and Accountability Act of 1996, or any successor federal statute, and the rules and regulations thereunder, all as may be amended or supplemented from time to time (“HIPAA”).
Freedom shall, and shall cause any third parties utilized, to provide the Services to keep PHI confidential and use and disclose PHI only as necessary to carry out the Purpose of HIPAA and any other applicable law, rule or regulation of any jurisdiction relating to disclosure or use of personal information. Freedom shall cause any third parties utilized to provide the services, if any, implement and maintain an appropriate security program for PHI to (i) ensure the security and confidentiality of PHI, (ii) protect against any threats or hazards to the security or integrity of PHI, and (iii) prevent unauthorized access to or use of PHI. Client reserves the right to review Freedom and any third parties’ (as applicable) policies and procedures used to maintain the security and confidentiality of PHI.
Without limitation of Freedom’s obligation to comply with the requirements of all applicable Privacy Laws, Freedom shall immediately notify Client (i) of any disclosure or use of any PHI by Freedom or any third parties in breach of this Agreement and (ii) of any disclosure of any PHI to Freedom where the purpose of such disclosure is not known to Freedom. At Client’s direction and in Client’s sole discretion at any time, Freedom shall immediately return to Client or destroy and certify such destruction of any or all PHI (including such PHI as may have been rightfully distributed to Freedom or any other third parties).
Upon termination of this Agreement, Freedom shall immediately return to Client any and all PHI which it has received under this Agreement and shall destroy all records of such PHI (including such PHI as may have been rightfully distributed to Freedom and any other third parties).
If HIPAA or any other applicable state or federal law or regulation, now or hereafter in effect, imposes a higher standard of confidentiality or security with respect to PHI, such standard shall prevail over the provisions of this Exhibit and other applicable provisions of the Agreement.
EXHIBIT B
HPIAA Privacy Authorization Form for Healthcare Provider(s)
Authorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
for valuable consideration, the Parties agree as follows:
AuthorizationI (member/patient name) authorize the healthcare provider(s) listed below to use and disclose the protected health information described below to Freedom Negotiators.Authorized Healthcare ProvidersAuthorized Healthcare ProviderAuthorized Healthcare Provider
Effective PeriodThis authorization for release of information covers the period of healthcare services from:
Extent of Authorization :
I understand that this medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect until , at which time this authorization expires.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization, or if authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Patient Name:
Personal Representative:
Relationship To Patient:
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be duly executed as of the Effective Date first above written.
Demographic Information
Patient Name: Patient Birthdate:
Asset and Tax Information
Income Tax Filing Status:
Member Occupation:
Spouse Occupation:
Previous Year Gross Household Annual Income:
Previous Year Adjusted Household Annual Income:
How much can you commit to settling your balance?
Other Information
Motor Vehicle Accident:
Work Accident:
Other Forms of Coverage:
Brief Description
DISCLAIMER: Freedom Negotiators is a third-party entity that assists in reducing medical bills. Freedom Negotiators is not an insurance company, all medical bills will be paid directly to the provider by the patient.
Date Signed:
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