08/18/2004 Agreement Clerk of The
Circuit Court Danny L.Holhage
Office(306)2923560 Fax(306)295.3663
To: Louis LaTorre,Director
Social Services
Attn: April Cine
From: Isabel C.DeSantis,
Deputy Clerk ifra
Date: Friday, September 17, 2009
At the BOCC meeting of August 18, 2004, the Board approved the following:
Provider Subscriber Agreement between Monroe County and Envoy Corporation
d/b/a WebMD Envoy to allow Monroe County Transportation personnel to check on
-- ---Medicaid status as well as Medicaid numbers.
Enclosed please find one duplicate original and two copies for your handling.
Should you have any questions, please do not hesitate to contact this office.
cc: Finance
County Attorney
File ✓
Froro:WEBMD:MEMPHIS
8436688
07/20/2004 15:41 #578 P.003/012
WebMD Office Provider Subscriber Agreement Customer lJ:
Fde t#:
~~~~-~~ ~~~
This is a binding agreement ("Agreement") between ENVOY COrpoliltJon d/b/a WebMD ENVOY ('We", .Us. or "Our") and the organization named on this form
("You" or "YOur"). This Agreement governs YOlJlf use of the WebUD OffIce Web Site, including, without limitation. an content such as text, infonnation. images,
and audio (collectively, 1IIe "Conlenr) and all services ("Services.) made avaftable lD Vou lhrough the WebMO Office Web Site by Us and/or 1IIird parties
(lnellding, without limitation, WebMD Office ServiceS). ThIs Agreement Includes the General Tenns and Che Special Terms for WebMD OffICe Services set forth
on the reverse side of Chis document. .Site. as used in this Agreemant means the WebMD Office Web Site, the Content, and the Services.
Select One of the Following: Complete Sections:
~w Pl'OYider Customer organization and New USers , II. 1/1, IV, II. VI & '111, Users Enrollmenl Form & Payer Forms
o Changing Pricing Plan for Existing WebMD Office Provider CuslDmer Organizations and or VIII, V & VI
Users
o Adding New Users to existing WebMD Oftlce Provider Customer Organizations Vone; WebMD OffICe Users EnroUment Fcxm
o Adding Real.Tme Payers to Existing WebMD Office Provider Customer Organizations and 'lone; Additional Real- Time Payer Enrollment Forms
Users '
o Adding WebMD Office to Existing WebMD Practice Provider Customer Organizations and , II. 111, IV. V. Vf & VIf, Users Enrollment form & Payer FOf!Ds
Users
ill
eleptlane
ax
Section 11- Line of Business
~Ine of BusIness: 0 MedicaiD Hospital
Sect/on IV- Real-n",e Carners
Please see Schedule IV attached for Real-Time Carriers that may require additional paperwork.
Sect/on 111- Practice Management or Hospital Information System
/System Name:
Section V-Pricing - Please select a Packaae below
Non-Participating Participating
Prlc:lng Paek.ge Payer Payer Fees Owed
Monthly Transactions Transactions One Time
Subscription WebMD
Selection Fee Each AtId1Iion.1 Oftice 1" Month Monlhly (After
Name Included Included
Ttall$lJctIon Setup Fee (Monrhly Fee .. 1" Month))
(Per~/ioI1) Se~J<II
0 Real-Time Basic $9.95 None $0.45 Unlimited $24.95 $34.90 $9.95
~ Real-Time 1DD $24.95 100 $0.25 Unlimited $24.95 549.90 $24.95
TOTAL SETUP FEES $ "t q .G l)
NVOY CORPORA liON d/bJ~ WebMD ENVOY
, ~~~:.t~~.;,~
C lne -O-pn \ @.,moY! roe. GOLt t'1 't), -.c I';~l?~
WebMD Office Subsct'ib~r Agteetnent (Provider Direct RT Only) 01104
From:WEBMD:MEMPHIS
8436600
07/20/2004 15:40 #578 P .002/012
WebMD
JOSS Lebanon Road Bldg.3 Suite 2000
Nashville, 'fN 37214
If you nave questions on how to complete this form
or on the status of your enrollment. olea5e call
the enroUment help desk at 1-800-845-6592.
Florida Medicaid Enrollment for Real.. Time Transactions
For WebMD OffIce
I Please complete all information. Mail this form to the address listed above.
Provider/Group Name~
-
IrC\ns
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3 3040
OVl
Provider Address: II
ProvlderClty,Slate,Zlp: ~_~~ B
Contact Name: .:Ie~ f__ 1
Provider Phone Number: ~~ .. a'1 0> - L~\ d. :;z.
F.ax Number-for aptroval notice: 30:; - a ~a - L..\ Ll , I
CAI\."'i'".c::.&tiG OF G\ten-> 'ItltJ . . ~
Tax 10: 54D ();)D\5D5 FE.D'1J) ,..r. -~COCr7Y~
Provider Number (must be nine digits): 0 ~ cg 15 11 - DO
· Practice address must reflect the phy.;icallocation where eligibility will be verified.
· If Practice has multiple locations where eligibility will be verified, each location and corresponding
provider number must be submitted for enroJJnlent.PJease copy fonn as needed.
· Provider number must be associated with the Practice/Physician name and location.
· Billing Agencies must have a specific provider nu.nber assigned by the AReA (beginning with 99)
along with subm.ission of "intent and disclosure" and ~-ubsequent approval from AHeA for requesting
eligibility data.
For Internal Use On1X:
Please indk.ate all applicable HIP user names (please write clearly):
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From: WE8MD:MEMPHI S
8436688
07/20/2004 15:43 #578 P .007/012
SCHEI)ULE rv
REAL-TIllE CARRIERS
Please ..Iect the Real-TIme Camers 10 which you would IUc. to submit tnlnsactlons:
r'ddltlona' Enrollm...t Farm Reaulnld
o BLUE CROSS BLUE SHIELD OF GEORGIA
CJ NEW YOIltJ< MEDICAID
CJ UNITED HEAL THCARE REFERRALS I CLAIM STATUS
o BLUE CROSS OF CALIFORNIA
o BLUE CROSS BLUE SHIELD OF IWNOIS
n ' BLUE CROSS BLUE SHIELD OF MINNESOTA
B FLORIDA ~D1CA1D
AdditIona' EruIOJIment FOQII ReauIred with ORIGINAL Slanatln
D BWE CROSS BLUE SHIELD OF FLORIDA
o BLUE CROSS BLUE SHIELD OF TEXAS (Must be accompanied by form "Sample Lelt.... on Physician Letlerheacl)
00 BLUE CROSS BLlE SHIELD OF NEW MEXICO (Must be 8ClCXll1l...'-d by form "Sample LeIter" on PhyIIcIan L.eU8mead)
BLUE CROSS BLUE SHIELD OF ALABAMA
WebMD Office Real-Time Carrier Enrollment Form 01/04
5
From:WEBMD:MEMPHIS
8436688
07120/2004 15:43 /1578 P .(00/012
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