You can open the Physician Independent Contractor Agreement Template in multiple formats, including PDF, Word, and Google Docs.
Physician Independent Contractor Agreement Template Printable | Editable FormSample
[Name of the Physician]
[Physician’s ID]
[Physician’s Address]
[Physician’s Phone]
[Physician’s Email]
[Name of the Health Care Facility]
[Facility’s ID]
[Facility’s Address]
This agreement serves to formalize the relationship between the Physician and the Facility for the provision of medical services beginning on [Contract Start Date].
The Physician agrees to provide the following services: [Specify medical services, e.g., diagnosis, treatment, and consultation services].
The Facility agrees to pay the Physician a fee of [Amount] for services rendered, payable on the following schedule: [Specify payment terms, e.g., monthly, bi-weekly].
This agreement will commence on [Contract Start Date] and will continue until [Contract End Date] unless terminated under the conditions described herein: [Specify termination conditions].
The Physician is acknowledged as an independent contractor and is not an employee of the Facility. The Physician holds sole responsibility for all medical decisions made.
Both parties agree to comply with HIPAA regulations and to maintain confidentiality regarding all patient information.
The Physician agrees to maintain professional liability insurance with coverage levels of [Specify amount] and provide proof of such insurance to the Facility.
This agreement will be governed by the laws of [Jurisdiction], and any disputes will be handled in accordance with such laws.
[Signature of the Physician]
[Name of the Physician]
[Signature of the Facility Representative]
[Name of the Facility Representative]
[Name of the Physician]
[Physician’s ID]
[Physician’s Address]
[Physician’s Phone]
[Physician’s Email]
[Name of the Healthcare Organization]
[Organization’s ID]
[Organization’s Address]
This agreement outlines the terms under which the Physician will provide independent medical services to the Organization, effective as of [Contract Start Date].
The Physician will provide medical services including but not limited to: [List specific services, e.g., patient examinations, treatment planning].
The Physician will receive a fee of [Amount] per service rendered, with reimbursement procedures outlined as follows: [Specify procedures].
This agreement shall remain in effect until [Contract End Date] unless terminated for reasons including: [Specify termination reasons].
The Physician agrees to adhere to all applicable laws and regulations governing medical practice and healthcare standards.
Any intellectual property developed during the engagement remains the property of [Specify Owner], unless otherwise stated.
The Physician agrees not to provide services to competing facilities within [Specify area] for a period of [Specify duration] after termination of this agreement.
Disputes arising under this agreement shall be settled through mediation within [Specify duration], followed by arbitration if necessary.
[Signature of the Physician]
[Name of the Physician]
[Signature of the Organization Representative]
[Name of the Organization Representative]
Form
Please complete the form below to create the Physician Independent Contractor Agreement Template. All fields must be filled out to ensure a clear and complete agreement. We provide examples to guide you through each step. Physician Independent Contractor Agreement Template 1. Contractor Information 2. Client/Healthcare Facility Information 3. Agreement Details 4. Scope of Services 5. Compensation and Payment Terms 6. Patient Care Responsibilities 7. Confidentiality and Privacy Terms 8. Termination Conditions 9. Indemnification Clauses 10. Acceptance and Agreement 11. Declaration and Signatures
PDF
WORD
Physician Independent Contractor Agreement Template Printable | Editable FormPrintable
