CHPSO Participating Provider Agreement

The CHPSO Participating Provider Agreement is broken down here in three parts: Participating Provider Agreement, Exhibit 3.4 (BAA) and Exhibit 8 (Out-of-State Fee Schedule).

Note: The Participating Provider Agreement and BAA must be completed for all CHPSO member hospitals.

Participating Provider Agreement

This portion of the contract is the general agreement for CHPSO and Providers. Includes Background, Definitions, General Overview, CHPSO Responsibilities, Provider Responsibilities, Responding to Requests for Information, Insurance and Indemnification, Term and Termination, Miscellaneous, and Exhibit 1.1: Definitions Section of Patient Safety Act Regulations.

Note: This form requires Provider input on pages 1, 3, 6, and 7.

Download Participating Provider Agreement

Exhibit 3.4: Business Associate Addendum (BAA)

The BAA supplements the Participating Provider Agreement as Exhibit 3.4. This addendum binds both entities as Business Associates as given meaning by the Privacy Rule, the Security Rule, and the HITECH Act.

Note: This form requires Provider input on pages 10, 15, and 16.

Download Exhibit 3.4: BAA

Exhibit 4.1: Participating Healthcare Provider List

Exhibit 4.1 is a participating healthcare provider list. List all your facilities to include in your membership.

Download Exhibit 4.1: Healthcare Provider List

Exhibit 8.1: Fee Schedule for Out-of-State Members

Out-of-state members shall pay a membership fee to CHPSO according to the Fee Schedule in Exhibit 8.1. Rates and Exhibit 8.1 can be obtained by contacting CHPSO.