Complete Healthcare Compliance Manual

Name of the Agreement

_____________________________

Other Party(ies) to the Agreement

_____________________________ and

____________________________

Effective Date

_____________________________

Termination Date

_____________________________

Other Contracts with this Party(ies)

____________________________

Name of the Agreement(s):_____________________________

Party(ies) to the Agreement: _____________________________and

_____________________________

Effective Date:_____________________________

Termination Date:___________________________

Meets Stark Exception (circle)

Yes or No

Requirements of Personal Services Arrangement Exception

Satisfied

Not Satisfied

Explanation

Each agreement is in writing.

Each agreement is signed by all parties.

Agreement specifies the services covered by the arrangement.

Arrangement(s) cover all the services to be furnished by the physician (or immediate family member of the physician) to the entity. Condition is met if:

• All separate agreements between entity and physician and entity and family members incorporate each other by reference, or, if they cross-reference a master list of contracts, that is maintained and updated centrally and is available for review by the Secretary upon request.

• Master list should preserve historical record of contracts.

Aggregate services contracted do not exceed those that are reasonable and necessary for the legitimate business purpose of the arrangement(s) and would be commercially reasonable even if no referrals were made by the parties to the agreement.

The term of each arrangement is at least one year. If an arrangement is terminated during the term with or without cause, the parties may NOT enter into the same or substantially the same arrangement terms during the first year of the original term of the arrangement.

Compensation over the term is set in advance.

Compensation does not exceed fair market value (FMV).

Compensation is not determined in a manner that takes into account directly or indirectly the volume or value of any referrals or other business generated between the parties.

Arrangement does not otherwise violate the federal Anti-Kickback Statute.

Arrangement does not violate any federal or state law or regulation governing billing or claims submission (i.e., rules on reassignment of reimbursement).

Services to be furnished under each arrangement do not involve counseling or promotion of an activity or business arrangement that violates any state or federal law or regulation.