brought to you by
Dear Doctor and Other Healthcare Providers:
Thank you for your decision to accept Liberty HealthShare members into your service and billing system based on
the following reimbursement rates as shown on this signature form. Upon your signature and submission, Liberty
HealthShare Inc will expedite reimbursement(s) to the Provider within the agreed upon payment time period. For
questions, please contact Kimberly Pantoya, Provider Liaison, at 855-585-4237 ext. 1170.
Authorized Signature
Office Name:
Provider Tax ID:
Mailing Address:
Street:
City:
Phone:
Fax:
State:
Contact Persons Name:
Physician-Related
Office Visits:
Inpatient-Related
Services:
OutpatientRelated Services:
Zip:
Position:
Payment shall be reimbursed at Medicare rate plus 50% for prevailing area where
service is rendered within 30 days of billing receipt.
Payment shall be reimbursed at Medicare rate plus 60% for prevailing area where
service is rendered within 30 days of billing receipt.
Payment shall be reimbursed at Medicare rate plus 70% for prevailing area where
service is rendered within 30 days of billing receipt.
Authorized Signature
Date
Print Name
Title
By signature above, I approve the reimbursement schedule for all Liberty HealthShare, Inc. members as
billed by my office according to the following terms:
1. Provider agrees to accept the adjusted price for the services rendered, and to not bill the patient or other
responsible party for the discounted amount, if any.
2. Provider may bill the patient or other responsible party for any “Ineligible for Sharing” (denied) amounts
related to the services rendered.
3. All reimbursements are per the terms and conditions of the patient’s healthshare program guidelines.
After signing this form, please FAX to: Kimberly Pantoya at 216-456-8115, OR scan and attach to an
email and send to [email protected]