FEE CODE PROGRAM REGISTRATION FORM
|Given Name and Initial
|College of Physicians and Surgeons License No.
|MCP Provider No.
Participation in the Program is subject to eligibility requirements.
Within 90 days from date of physician registration, physician eligibility will be validated through both physician-provided and MCP data. On an ongoing basis, reviews, random or otherwise, will be conducted to verify continuing physician compliance with eligibility criteria.
Wherever possible, FPRP will support efforts to achieve compliance. However, where, at any time and in the sole discretion of the FPRP, it is determined that a physician is not compliant with the eligibility requirements of the Program and there is no reasonable prospect of the physician achieving such compliance, the FPRP may deny or revoke, as the case may be, a physician’s participation in the Program.
Please check the box next to the statements that apply to you.
To participate in the Program, you (the Fee-For-Service Family Physician):
Note: Checking the box in #4 below means, you currently perform the service at the stated level OR you can demonstrate a clear and consistent pattern, which, if continued, would meet the requirement(s) of the stated service level(s).
Example: You are new to practice and although you regularly provide after hours care and regularly conduct medical care visits to your own patients in their personal residences, you do not meet the annual requirement as stated in the criteria as you have only been in practice for 3 months. Are you eligible for registration?
Yes, if you can demonstrate a clear and consistent pattern, which, if continued, would meet the requirement of the stated service level, you are eligible to participate in the Program.
Note: In relation to #3 above, if, at the time the EMR process is to be initiated, you decide to withdraw, you are required to meet six (6) of the requirements in #4 above. Please contact FPRP to complete a revised registration form.
Note: If you currently do not meet Fee Code Program eligibility requirements and would like to discuss this further, please contact a member of the Family Practice Renewal team.
Terms and Conditions of Registration
Your registration in the Fee Code Program (“Program”) is subject to the terms and conditions of the agreement below (“Agreement”). To accept the terms and conditions, to be bound by them and to be eligible for registration in the Program, you must read and accept this Agreement. To accept, click on the “I agree” box below.
- Entire Agreement - The above Fee Code Program Registration Form (“Form”) is incorporated as part of this Agreement. This Agreement represents the entire understanding between the parties with respect to its subject matter.
- Validation of Eligibility Requirements - I understand that FPRP requires information from MCP about the health care I provide (“Information”) for validation of eligibility requirements stated in the Form.
- Failure to Meet Eligibility Requirements - I acknowledge that failure to meet or maintain eligibility requirements at any time will result in denial, suspension or termination of registration in the Program.
- MCP – I understand that MCP is subject to the Medical Care and Hospital Insurance Act, Access to Information and Protection of Privacy Act (ATIPPA) and the Personal Health Information Protection Act (“Legislation”).
- Disclosure to Third Parties - I understand that FPRP may disclose personal information (i.e. criteria- related activities in requirement 3, Program Eligibility) to third parties (i.e. external firm contracted to conduct eligibility compliance) that are not FPRP-affiliated if those third parties have contracted with FPRP to assist in providing products and services. In such circumstances, FPRP will take reasonable contractual measures to ensure that personal information is protected by those third parties at a level comparable to the requirements of ATIPPA.
- Consent Required - I understand that the disclosure to and the use of the Information by FPRP is necessary to participate in the Program. Should I choose not to provide consent for disclosure to FPRP of the Information I will not be eligible to participate in the Program.
- Consent Given - I hereby consent to MCP providing FPRP with the Information in accordance with the Legislation.
- Consent Revoked - I acknowledge my participation in the Program is voluntary and I may revoke my consent, and my participation, at any time, by completing the 'Revocation of Registration and Consent' Form and submitting it to FPRP.
- Changes in Program - I understand the design of the Program may be altered over time, including the conditions and fees associated with each code. I understand that in such circumstances, physicians will be notified and have the opportunity to withdraw their consent and participation by completing the ‘Revocation of Registration and Consent’ portion of the Form.
- Information True and Accurate - I confirm that I have read and understand the terms and conditions above and that the information that I have provided in the Form is true and accurate.
Date: Monday, November 25th 2019