ENROLLMENT SERVICES TERMS AND CONDITIONS

These Enrollment Services Terms and Conditions govern Customer’s access to, and use of, the Enrollment Services and are incorporated into and made a part of the Agreement. All terms and conditions of the Agreement apply except to the extent expressly modified herein.

1. 1. Appointment. Customer hereby appoints and authorizes Prompt as its limited agent to prepare, execute (where permitted), and submit all documentation necessary to establish, maintain, modify, and terminate Electronic Data Interchange (EDI), Electronic Funds Transfer (EFT), and Electronic Remittance Advice (ERA) enrollments (each an “Enrollment”) with applicable Payors, clearinghouses, and financial institutions.

2. 2. Scope. The authorization in Section 1 above expressly includes, but is not limited to, the right for Prompt to:

   1. 2.1. Complete and submit Enrollment applications and related documentation;

   2. 2.2. Communicate with Payors, clearinghouses, and financial institutions;

   3. 2.3. Provide required business, provider, and banking information as provided by Customer;

   4. 2.4. Execute Enrollment forms on Customer’s behalf where permitted by Payor or Applicable Law; and

   5. 2.5. Follow up on, modify, or revalidate Enrollments as necessary. 

3. 3. Duration. These Enrollment Services Terms and Conditions shall remain in effect for the duration of the Agreement unless revoked in writing by Customer.

4. 4. Prompt Obligations. Prompt will use commercially reasonable efforts to:

   1. 4.1. Complete all Enrollments in a timely manner;

   2. 4.2. Maintain documentation of submitted Enrollments and confirmations; and

   3. 4.3. Notify Customer of any material issues impacting Prompt’s ability to provide the Enrollment Services. 

5. 5. Customer Obligations. Customer represents, warrants, and agrees that:

   1. 5.1. All information provided to Prompt will be complete, accurate, and current;

   2. 5.2. Customer will promptly provide all requested documentation, signatures, credentials, and confirmations necessary for Prompt to provide the Enrollment Services;

   3. 5.3. Customer shall immediately notify Prompt of any changes to:

      1. 5.3.1. Tax identification numbers;

      2. 5.3.2. National Provider Identifier(s);

      3. 5.3.3. Banking information;

      4. 5.3.4. Ownership, control, or legal structure; or

      5. 5.3.5. Practice locations or contact information;

   4. 5.4. Customer authorizes Prompt to disclose information to Payors, clearinghouses, and financial institutions as necessary for Prompt to be able to provide the Enrollment Services; and

   5. 5.5. Customer acknowledges and agrees that it retains sole responsibility for the accuracy and legality of all information submitted, regardless of whether submitted by Prompt on Customer’s behalf.

6. 6. Disclaimers. Prompt will not be responsible or liable in any manner for:

   1. 6.1. Delays, rejections, or failures in any Enrollment caused by Payors, clearinghouses, or financial institutions;

   2. 6.2. Delays or errors resulting from incomplete, inaccurate, or untimely information provided by Customer; or

   3. 6.3. Actions or omissions of third parties involved in the Enrollment process or otherwise impacting the Enrollment Services. 

7. 7. Indemnification. Customer agrees to indemnify, defend, and hold harmless Prompt and its Affiliates from and against any and all claims, damages, losses, liabilities, and expenses (including reasonable attorneys’ fees) arising out of or related to:

   1. 7.1. Inaccurate or incomplete information provided by Customer; 

   2. 7.2. Customer’s failure to comply with Applicable Laws or Payor requirements; or

   3. 7.3. Any unauthorized or improper use of banking or other information supplied by Customer. 

8. 8. Documentation Requirements. Customer will provide, at a minimum, the following information and supporting documentation (collectively, “Required Information”), as needed in order for Prompt to provide the Enrollment Services. Customer acknowledges that the failure to provide any of the Required Information may lead to delays in, or an inability to provide, the Enrollment Services. 

   1. 8.1. Business Information

      1. 8.1.1. Legal business name and any DBA names

      2. 8.1.2. Tax Identification Number (EIN or SSN)

      3. 8.1.3. Physical address and billing address

      4. 8.1.4. Phone number and email address

   2. 8.2. Provider Information

      1. 8.2.1. Individual and/or Group National Provider Identifier(s) (NPI)

      2. 8.2.2. Provider legal names as registered with Payors

      3. 8.2.3. Taxonomy codes

      4. 8.2.4. Credentialing details (if applicable)

   3. 8.3. Ownership and Authorized Representative

      1. 8.3.1. Name and title of authorized signer

      2. 8.3.2. Contact information

   4. 8.4. Banking Information (for EFT)

      1. 8.4.1. Bank name

      2. 8.4.2. Routing number

      3. 8.4.3. Account number

      4. 8.4.4. Account type (checking or savings)

      5. 8.4.5. Voided check or official bank letter verifying account details

   5. 8.5. Payor and Billing Information

      1. 8.5.1. List of contracted or intended Payors

      2. 8.5.2. Payor identification numbers (if available)

      3. 8.5.3. Legacy identifiers (if applicable)

      4. 8.5.4. Current Enrollment status (if known)

   6. 8.6. Clearinghouse Information 

      1. 8.6.1. Current clearinghouse name

      2. 8.6.2. Submitter ID and receiver ID

      3. 8.6.3. Access credentials or authorization to establish access

   7. 8.7. Supporting Documentation

      1. 8.7.1. Completed and signed IRS Form W-9

      2. 8.7.2. IRS CP-575 or equivalent EIN verification (if available)

      3. 8.7.3. Government-issued identification for authorized signer (if required)

      4. 8.7.4. Organizational formation or other documents (to the extent required by any Payor)