PROVIDER GUIDELINES
The HearTEK leasing program is not intended to replace any of the existing channels through
which the patient may obtain hearing aids; retail, insurance, traditional financing, and all other
channels still exist. The HearTEK Leasing program is developed for those individuals who may
have difficulty with either a substantial initial payment or down payment; who are credit
challenged; or who simply are on fixed incomes and wish to make monthly payments.
The following summarizes the process:
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Patient may be referred through HearTEK marketing or directly from a provider office as
a referral through the HearTEK Leasing program.
HearTEK enrolls the patient in the leasing program over the phone or online at
www.hearTEKleasing.com/apply
Medly Lending completes the review and approval process. Upon approval a draft lease
is transmitted to the consumer for review and acceptance.
Provider selects the hearing aid in conjunction with the patient and their preferred
payment level and recommend through HearTEK. (The initial formulary includes three
manufacturers: Phonak, Unitron, and GNResound.) Your other forms should be faxed or
sent to HearTEK.
Professional fees are paid in full at 90 days from order date. (Provided the patient has
made the required first three monthly payments.)
Leasing prices cover only hearing aids and not accessories.
The HearTEK Leasing program is summarized as follows:
Patient
Monthly Lease
$49.99
$79.99
$99.99
$149.99
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Technology
Level
Basic
Standard
Advanced
Premium
Provider
Professional Fee
$250
$500
$750
$750
The standard lease term is 30 months. At the end of the lease term, then patient may
buy the product for a final payment.
The patient may buy out the lease and keep the hearing aids at any time during the 30
months, for a residual payment. (Medly lending will provide that final calculation.)
Every 18 months, the patient may trade the hearing aids in or up to the latest version of
that level of technology, or to an increased technology level. A new lease starts with
each trade up. (Trading up is not mandatory) A new professional fee is paid also.
The patient may terminate the lease and return the hearing aids at any time.
We believe that the HearTEK leasing program provides another option through which patients
can affordably obtain hearing technology and amplification through the established channels of
professional audiology and dispensing. If you have questions or require more information
regarding the program, please do not hesitate to call HearTEK leasing at 1-844-586-9403, or
email to [email protected].
Version 09/16
HearTEK PROVIDER AGREEMENT FORM
This Provider Participation Agreement is between HearTEK Leasing (HearTEK) and the undersigned hearing care Provider ("Provider").
HearTEK is a hearing aid leasing program that arranges for the financing of hearing aids and related services through a subscription leasing program. This provider agreement (the “Agreement”) dated ___________ (the “Effective Date”), is entered by and between
____________________________(“Provider”) and HearTEK Leasing (“HearTEK”).
RECITALS
WHEREAS, HearTEK is in the business of leasing hearing aids to consumers through approved providers and clinics;
WHEREAS, Provider is in the business of dispensing hearing aids to consumers;
WHEREAS, Provider wishes to enter into this Agreement with HearTEK and become an authorized HearTEK provider in order to provide
HearTEK leasing’s alternative financing platform to consumers; and
WHEREAS, Provider agrees and acknowledges that HearTEK’s alternative financing platform (the “Leasing Platform”) is a highly regulated
transaction and that Provider shall, at all times, use best efforts and practices when providing the Leasing Platform to consumers.
NOW, THEREFORE, in consideration of the foregoing premises and of the mutual covenants and agreements contained herein, the
Parties hereby agree as follows:
1.
Provider is licensed and certified in the locations indicated below to provide audiological, hearing aids, and related hearing healthcare services and wishes to utilize the HearTEK leasing program for selected patients.
2.
Upon signing the Provider Agreement Form, Provider agrees to the set terms and fees of HearTEK as described in the provider guidelines.
Should HearTEK make any changes to the terms and conditions, then Provider shall be notified before referral of patients under these new
conditions.
3.
All billing and reimbursements will be performed per the HearTEK Provider Guidelines. The Provider shall complete forms as defined and
send them to HearTEK. HearTEK will bill and collect all funds for services and products defined in the HearTEK leasing program. HearTEK
will reimburse Provider for professional services per the guidelines and schedules. All billings and reimbursements shall be subject to the
indemnification provisions set forth in section 7 below.
4. Provider shall not discriminate against any patient in the provision of Services on account of race, sex, color, religion, marital status, nationorigin, ancestry, age, physical or mental handicap, health status, disability, need for medical care, sexual preference, veteran’s status or
status as an HearTEK referred customer.
5.
Provider shall at all times maintain, at Provider’s sole cost, a policy of professional malpractice liability insurance with a licensed insurance
company in amounts per claim and in the aggregate which are generally accepted as satisfactory in such areas in which Provider practices.
6.
In the performance of this agreement, the parties shall at all times be acting and performing as independent contractors. Subject to the
terms of this agreement, neither party shall have nor exercise any control or discretion over the patient/ provider interaction Nothing herein
shall be construed to create between HearTEK and Provider the relationship of employer/employee, partners or joint venturers.
7.
Each party agrees to defend themselves and each of their shareholders, directors, employees, agents and representatives against any and
all liabilities, losses, settlements, claims, demands and expenses of any kind which may arise out of the performance or the omission of any
act or responsibility pursuant to this agreement as the applicable Provider contract, including, without limitation, any dispute with any TPP
beneficiary for defamation, malpractice, fraud or negligence or other cause of action.
8.
This agreement may be terminated by either party at any time, without cause, upon 30 days prior written notice to the other party. Termination of this agreement shall not affect the payment obligations of the parties with respect to services rendered prior to the date of termination.
9.
The validity, interpretation and performance of this agreement shall be governed by and construed in accordance with the laws of the state
of California. Any controversy arising out of or relating to this agreement or its breach will be settled by arbitration in accordance with the
rules of the American Arbitration Association, and judgment upon the award rendered by the arbitrator may be entered to in any court having
jurisdiction. Such arbitration shall occur within the county in which Provider's principal practice is located unless otherwise agreed. The
arbitrator may in any such proceeding award attorney's fees and costs to the prevailing party. HearTEK and Provider agree that the prevailing party in any legal dispute between them shall be entitled to payment of its reasonable attorney’s fees.
I/We have read the above information on the financing option through the HearTEK leasing program and agree to provide professional
services under the terms and conditions as a provider. I understand there is no cost to sign up, and I may terminate at any time with
30 days notice. PLEASE SIGN AND EMAIL TO [email protected] FAX BACK TO 909-718-8457
Practice Name: __________________________________________________ Dispensing License # __________________________
Audiologist Name (s):____________________________________________ Audiology License #
_______________________________
TAX ID# ___________________________ Office Contact : _________________________________
Practice Address: _________________________________________________________________________________________________
Phone: __________________________ Fax : _______________________________ Email: ________________________________________
Authorized (Print) _____________________________ ______________ Signature:___________________________
Title
____________
Date
4
HEARING AID RECOMMENDATION
T: 844-586-9403
F: 909-718-8457 E: [email protected]
Date:
Provider Office:
Patient Information:
Name:
Address:
T:
T:
Ins. Plan Name:
Subscriber #
F:
Contact:
Information Needed for Authorization:
Ear(s) to be Fit
□
Right
□
DOB:
Group #
Group Code:
Left
□
Both
Manufacturer:
□
Phonak
□ Unitron
□ Resound
Style:
□
BTE
□ BTE (Open Ear) □ BTE Rite □ Full Shell/ITE □ LP
□ HS □ ITC □ MC □ CIC
Model: _____________________________________________
SPECIFY OPTIONS
(FEES MAY APPLY)
□
□
Volume Control
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Telecoil
Directional Microphone
□
□
□
Easyphone
□ Other____________________
Auto T-Coil
Remote Control ___________________
I hereby accept the responsibility for the recommended instrument(s) specified above.
1.
2.
3.
4.
I understand that I have a 45 day trial period
If my hearing aid is lost during the trial period I do not have the option of returning them
In many cases the manufacturer provides coverage for loss and I will be assisted in having them replaced. A
manufacturer replacement fee will apply which I will be responsible to pay
Should I decide to return the hearing aids during the trial period, I will receive a refund.
5.
I understand that hearing aids may improve my hearing but will not correct it to normal levels.
6.
I understand the provider will make every effort to optimize my hearing improvement within the limits of my residual
hearing ability and the hearing device design and circuit characteristics
I accept the terms and conditions outlined in this agreement.
___________________________ _____________________________________
Patient Signature
Patient Name (Please Print)
Date
___________________________ _____________________________________
Provider Signature
Provider Name (Please Print)
_____________
License #
_____________
Date