TeamDME! Electronic Payment Agreement
This addendum to the Software License Agreement relates exclusively to the Electronic Payment Services.

1. Services. This service allows CUSTOMER to apply payments automatically  for various payors (Medicare, Medicaid and Commercial) using Electronic Remittance Advice files from payors in ANSI 5010 (835) format.

2. Indemnification. TEAMDME! and CUSTOMER agree to indemnify and hold the other harmless against any and all claims, damages, expenses, and costs, including, without limitation, extracontractual damages, court costs, attorney's fees, punitive and exemplary damages, resulting from or arising out of any errors or omissions in either party’s performance under this Agreement. The parties hereby agree this indemnification shall apply to all services provided pursuant to this Agreement and shall survive the termination of this Agreement.

3. Force Majeure. Neither party shall be liable for damages or have the right to terminate this Agreement for any delay or default in performing hereunder if such delay or default is caused by conditions beyond its control including but not limited to acts of God, wars, insurrections and/or any other cause beyond the reasonable control of the party whose performance is affected (including mechanical, electronic, communication, telecommunication or internet failure or failure of CMS).

4. Fee Schedule
Medicare, Cost: Free (when using TeamDME! Gateway or other approved clearinghouse)
Medicaid/Commercial, Cost: $0.05 per Claim Line processed.
Sign in to Google to save your progress. Learn more
Company Name *
Account Number (See Payable, Table, Vendor, Information or on your last Invoice) *
Your Name *
Your Title *
Email Address *
Do you agree to the above terms, including indicated charges and are you authorized by your company to sign this Agreement? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report