Document

Legal 2 and Instructions

ICR 200608-0938-002 · OMB 0938-0935 · Object 217101.

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County Name: _____________________
LEGAL-2 PROVIDER ARRANGEMENTS
Category	Type of Agreement	Number of Agreements	Date Executed	Automatic Renewal of Agreements	Page Number for Contract in this Application
Staff
Physicians
Non-Physicians
Non-staff Physicians
Group
Member Physicians
Member Non-Physicians
Non-Member Physicians
Non-Member, Non-Physicians
IPA
Member Physicians
Member Non-Physicians
Non-member Physicians
Non-member, Non-Physicians
Direct Contract HMO Physicians
Lab Services
X-ray Services
Hospitals
Home Health
Other (specify)

Medicare/HMO Health Services		*Prepare a separate table for each county requested*













PROVIDER ARRANGEMENTS				TABLE: Legal-2

Instructions:

Provide a separate table for each county or partial county.

Column Explanations:

1. Category - Staff/Group/IPA/PHO/Direct:

Member Physicians - Licensed Medical Doctors (M.D.) and Doctors of Osteopathic Medicine (O.D.)
who are members of the entity.
Member Non-Physicians - Mid-wives, nurse practitioners, or chiropractors, etc. who are members of
the entity.
Non-Member Physicians - Licensed M.D. and D.O. who are subcontracted to provide services to the.
entity.
Non-Member, Non-Physicians - Mid-wives, nurse practitioners, or chiropractors, etc. who are
subcontracted to provide services to the entity but are not members of the entity.
Direct Contract HMO Physicians - Licensed M.D. and D.O. who have entered into a contract with the
HMO.

2. Type of Agreement - Only contracts or Letters of Agreement (LOA) are acceptable. Letters of
intent are not acceptable.

3. Number of Agreements - List the total number of signed agreements.

4. Automatic Renewal of Agreements - Provide "Yes" or "No" response.

5. Date Executed - Enter the date all agreements were finalized for the particular category.

6. Page Number in Contract - List the page number where the agreement is located in the application
package.

File Type	application/vnd.ms-excel
File Title	legal-2 table
Last Modified By	CMS
File Modified	2006-03-24
File Created	2002-05-21