(800) 326-8223 MBAK@epix.net | 1079 Main Street Swoyersville PA 18704


This Agreement entered into the _________ of _________ 20___, between MBA Medical Billing Associates of Wyoming, Pennsylvania ( herein called MBA) and ______________ of ______________, (herein called Doctor).

Whereas, MBA is Professional Services for the purpose of providing professional claim processing for Doctor and patient of medical forms of all kinds.

Whereas, Doctor is a duty licensed and qualified specialist who desires the services of the billing and collecting of professional services performed by doctor to be performed by MBA.

Now, therefore, MBA and Doctor, for and in consideration of the mutual convenants herein contained and for other good an valuable consideration, the adequacy and receipt of which are hereby acknowledged, agree as follows:

  1. Doctor is responsible for providing all patient demographic, insurance information, a procedure code and a diagnosis code to MBA. MBA is not responsible for errors on billing that arise from inaccurate information provided by Doctor.
  2. MBA will be the exclusive biller for professional services rendered by Doctor to inpatients and outpatients. Such billing will occur two (2) working days after billing has been received from office.
  3. MBA will prepare follow-up inquires to third party payers when such payers have not responded to claims within ninety (90)days.
  4. MBA will receive all telephone and written inquires regarding patient accounts.
  5. MBA will prepare up to three (3) patient follow-up notices at 0, 30, and 60 days, with dunning message specified by Doctor for balances over ten dollars ($10). Appropriate correspondence between MBA and patient will take place. MBA will turn accounts over to Doctor with the code RT after 90 days unless MBA is actively involved in collection.
  6. Each patient and/or his insurance carrier will be billed by MBA under the Doctor’s individual/group name and provider numbers of:
  7. All patient bills will be paid to Doctor and Doctor will forward explanation of benefit documents to MBA once (1) a week. Doctor will routinely forward a list of all payments accepted by him to insure than an accurate accounting of each month’s collections can be maintained.
  8. MBA will provide the following management reports to the Doctor on a monthly basis. Daily/Monthly Transaction Register, Daily /monthly Revenue of service Analysis, A/R Status Report, Other reports as requested.
  9. Fees: In consideration for the service outlined above, Doctor Agrees to pay MBA ________ percent (________%) of the collected. Doctor will be invoiced monthly for services rendered. If desired, the fee for MBA to appear at legal proceedings to collect a bill is 25% of collections, as well as, actual court costs. At final termination, MBA shall be entitled to one-half (½) of the above fee on outstanding receivable less 20% allowance for contractual and bad debt write-offs.
  10. Term: The term of this Agreement shall be for a period of ________ year(s) from the date hereof, and shall thereafter be extended automatically from year to year unless MBA or Doctor serves ninety (90) days written notice of termination of this Agreement with a written acknowledgement from the other at the end of the initial term or any such succeeding year term; provided, that all obligations of this Agreement shall be performed during the intervening time until final termination.
  11. Entire Agreement: MBA and Doctor agree that this Agreement contains the entire agreement between them and that there are no other agreements, warranties or representation, oral or written, between them. MBA and Doctor agree further that this Agreement may only be altered, amended or modified by another instrument in writing duly executed by both of them.

IN WITNESS WHEREOF, and intending to be legally bound hereby, MBA and Doctor have caused this Agreement to be executed by hereto setting their hand as of the day and the year first written.






DATE : _______/_______/_______

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