Use our standard template

Fill out this form to post a contract using our standard templates. If you want to post your own template, please complete this form instead . Required fields marked with *.

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02Contracting Preference

Describe the preferred contracting method for your practice. Before we publish your contract, we will confirm your entries with you via email.

Contracting Method*

Percent of applicable Medicare fee schedule (MPFS, ASC, CLFS)

Custom

Backstop preference*

For claims billed with codes outside the applicable Medicare fee schedule.

$0 (no payment for out-of-schedule codes)Cost-Plus (actual invoice cost, plus a markup of...)Percent of billed chargesNot applicable

Negotiation preference*

Once my contract is posted, I'm open to further negotiation with employers.My submitted contract and rates will be firm and non-negotiable.

03Contact Person

Who should we reach out to about this contract to facilitate direct relationships with interested employers?

First name*

Last name*

Email*

Phone

Role*

I confirm the person listed above is authorized to oversee this contract and agrees to be contacted.*By checking this box, I authorize Cost Plus Wellness to reach me via email or phone about this contract. I understand that no contract will be posted without my confirmation.

04Anything else?

Optional. Share any other information or comments that would help us review your application.

Other information / comments

Having trouble? Contact us at feedback@costpluswellness.com

Use our standard template

01Group Info

02Contracting Preference

03Contact Person

04Anything else?