FLORIDA MEDTRANS NETWORK, INC. PARTICIPATION ACKNOWLEDGMENT
I, ____________understand that Florida MedTrans Network, LLC have established a network of Providers who have agreed to provide transportation services to covered persons under benefit plans offered by health insurers, health maintenance organizations, prepaid health services plans, self- insured employers and other payors in exchange for reimbursement at negotiated rates.
Current Payor Benefit Plans. I hereby acknowledge that I have authorized FMN, through the participation agreements I have executed with Florida MedTrans Network, LLC, to bind me to participate in the Payor Benefit Plans checked below under the terms of such Payors’ participation agreements with FMN. I hereby certify that I have been given the opportunity to review the full terms of the FMN Payor Agreements, including the attached sample fee schedules. I further acknowledge that my participation under the FMN Participation Agreement supersedes any other contractual arrangement I may have with respect to the provision of Covered Services to Covered Persons.
Future Payor Benefit Plans. In addition, I affirm my intent to participate with all additional Payor Benefit Plans that may be offered in the future, except for those I opt out of pursuant to the terms of the relevant FMN Participation Agreement.
Agreed and accepted on this _day of , .
Provider Signature Witness
Provider Printed Name