Fax Completed Forms and Other Documents To:

Transcription

1 Instructions for Credit Recommendation Setup In order for OrthoBanc to complete your request for Credit Recommendations, the following documents must be obtained. Once you have completed the documents, please print and sign all necessary forms and return via fax to OrthoBanc. THESE FORMS ARE SET UP TO ALLOW YOU TO TAB AND TYPE FOR BETTER LEGIBILTY. PLEASE COMPLETE THE DOCUMENTS BY TYPING IN AS MUCH DATA AS POSSIBLE. ONCE YOU HAVE COMPLETED THE DOCUMENTS, PLEASE PRINT AND SIGN AS NECESSARY AND RETURN VIA FAX. Documents to complete and fax back to OrthoBanc: Addendum to Outsourcing Services Agreement Credit Recommendation Application Letter of Intent on Company Letterhead (Sample Attached) Customer Use and License Agreement Provide Copy of Business License Provide Copy of Owner's Drivers License Provide Copy of Current Gas or Electric Utility Bill (service address must match business address as well as business name) **Note: This service allows you to access data that is sensitive in nature. Our vendor, TransUnion, requires an on-site inspection of your practice to ensure your practice complies with their regulations. This is usually a 3-5 day process and is performed by a third-party agency hired by OrthoBanc. To avoid the inspection and speed up the approval of your account, TransUnion will allow us to waive inspection of the premises if the practice can provide a current utility bill read by a meter (gas or electric only). Otherwise, under TransUnion regulations, we must have a contracted inspector schedule a visit to your practice. **Note: If the Commercial Business Report requested by OrthoBanc does not meet TransUnion compliance requirements, a Bank Verification form will be sent for completion to ensure compliance. If in business for one (1) year or less, one of the following items must be received in addition to the requested documents above. Choose one (1) and fax to OrthoBanc. Copy of lease or proof of property ownership by business of the principal place of business Copy of bank statement addressed to the End User at its principal place of business Proof of commercial insurance under the business name shown on the application Fax Completed Forms and Other Documents To: Page 1 of 7

2 ADDENDUM TO OUTSOURCING SERVICES AGREEMENT Credit Recommendation Services This addendum amends the Outsourcing Services Agreement between OrthoBanc and Orthodontist. OrthoBanc provides a credit recommendation product the Zuelke Automated Credit Coach (ZACC). This agreement applies to practices using this recommendation product. Orthodontist hereby agrees that if credit recommendations will be used in their practice, the following terms and conditions shall apply: Before access is granted to credit recommendations, the practice must pay $149 setup fee. An on-site inspection will be conducted by a 3rd party entity to verify the orthodontist s location, business license, etc. Orthodontist agrees that any time a credit recommendation is requested, the patient/responsible party will have prior knowledge of the request. The ZACC Recommendation Service does not require a signature from the patient/responsible party but is desired. Orthodontist agrees that any time an offer is made to the patient/responsible party that, based on the credit recommendation, is less favorable than the standard offer, the orthodontist will provide an adverse action letter to the patient/responsible party. Setup Fee: $149 Primary location setup fee. $99 Setup fee for additional locations. Credit Recommendations: Individual $5.75 Individual w/zacc Credit Data Report $6.75 Please select one: ZACC ZACC with Credit Data Report ($1.00 Additional) By signing below, I authorize OrthoBanc, LLC, to debit the amount indicated above for every credit recommendation pulled by me (Orthodontist) or a member of my staff from the checking account regularly used for OrthoBanc to transact business with my practice. IN WITNESS WHEREOF, the party has executed this Addendum as of the date below. ORTHODONTIST: Signature: Printed Name: Page 2 of 7 Date:

3 Credit Recommendation Application Applicant Information Legal Name of Business: DBA: Phone: Address: City: State: Website: How long in business (Indicate Years/Months): Fax: Contact: ZIP Code: Tax ID: (Years) (Months) If you have been in business less than 1 year, please refer to the additional requirements listed on the instruction page of this application. Business Details Type of Business: Medical/Dental Practice Purpose for which Consumer Reports will be used: For a legitimate business need in connection with a business transaction that is initiated by the consumer. Business Organization Type of Organization: Sole Proprietor Partnership Corporation LLC (Provide Owner information for those owning more than 20% of the company) NOTE: Sole Proprietor or Partnerships require a personal credit report request. Prior to requesting this credit report a copy of the owner or partners' government issued Photo ID is required. The name and address on the ID must match the information supplied below for the owner(s). The credit report will be requested and reviewed by the Credit Approval Department. (Check with personal Accountant for Type of Organization classification.) Owner: Owner s Home Address: Owner City: Owner s SSN: Owner s Phone: State: ZIP Code: nd 2 Owner Information Owner # 2: Owner s Home Address: Owner City: Owner s SSN: Owner s Phone: ZIP Code: State: Signatures I authorize the verification of the information provided on this form. If I/we are a sole proprietorship or partnership, I/we authorize OrthoBanc, LLC to obtain a credit report as required by TransUnion. I authorize billing of my EFT account the one-time implementation fee, unless previously paid, and billing of every ZACC Credit Recommendation pulled by me (Orthodontist) or a member of my staff from the checking account regularly used for OrthoBanc to transact business with my practice. I have received a copy of this application. Date: Authorized Signature: Page 3 of 7

4 Sample Letter of Intent Instructions to Practice: Trans Union requires that a Letter of Intent be on your company letterhead and must be signed by an officer, owner or authorized manager of the company. Please note, all text in red is for instructional purposes only. The text will not be visible when printed. [Your Name] [Your Address] [City, State, Zip] [Date] OrthoBanc LLC Credit Recommendations Compliance Dept Northpoint Blvd. Hixson, TN To Whom It May Concern, [Type of Company] [Company Name] My company,, a Type of Company is requesting service with Trans Union to obtain credit reports. The intended use of these reports is for a legitimate business need in connection with a business transaction that is initiated by the consumer on whom the information is to be furnished and involving the extension of credit. [Number of Reports] It is my expectation that we will pull about reports per month. Most of these reports will primarily be from of Clients area. [Geographical Location] Please accept this letter of intent as my confirmation that I will use Trans Union credit reports only for the purpose listed above and that I will not access this information without specific written authorization from my customer/patient. Sincerely, Doctor Name and Signature Practice Name Page 4 of 7

5 Bank Verification Form Instructions to Practice: Please complete the Authorization Agreement and Account Information sections below and then send this form to your banker and ask him/her to complete the Bank Verification/ Signature section below and to fax the completed form to OrthoBanc at the number below. Note to Banker: The practice listed below has applied for membership in the TransUnion Credit Bureau and needs this form completed before we can process their membership. Please complete the form and fax it to us at the number listed below. Authorization Agreement I hereby authorize OrthoBanc to receive this banking verification of my account(s) at the financial institution named below. Name of Practice (on Bank Account): Address of Practice: Authorized Signature: Date: Account Information Bank/Credit Union Name: Name of Banker: Phone Number of Banker: Type of Accounts: Checking Savings What is the length of relationship between practice and bank? Bank Verification/Signature I certify that the medical/dental practice listed above has an open account in satisfactory standing with our institution. Banker s Signature: Date: Please fax completed form to Page 5 of 7

6 Customer Use and License Agreement The undersigned Customer of OrthoBanc is a medical or dental practice that desires to utilize the Zuelke Automated Credit Coach subject to the terms herein. Grant of License. OrthoBanc grants Customer a nonexclusive, personal, non-transferable license to use Credit Recommendations (ZACC) and any associated software (collectively the Licensed Product ) pursuant to the terms herein and applicable law. This license only applies to and the Licensed Product may only be used by Customer and Customer s authorized employees. Customer is responsible for all computer and communications equipment, telephone or internet access charges or other expenses necessary to utilize the Licensed Product. OrthoBanc reserves the right to change or modify the Licensed Product from time-to-time and by continuing to use the Licensed Product, Customer accepts all such changes. If any changes are not acceptable, Customer may terminate this Agreement on 60 days written notice. Credit Reports. Customer acknowledges and agrees that it must have a permissible purpose for obtaining consumer reports pursuant to the Fair Credit Reporting Act (15 U.S.C et seq.) ( FRCA ). Customer certifies its permissible purpose as (check all that apply): In connection with a credit transaction involving the consumer on whom the information is to be furnished and involving the extension of credit to, or review or collection of an account of the consumer; or For a legitimate business need in connection with a business transaction that is initiated by the consumer. Customer certifies that it shall use the consumer reports: (a) solely for Customer s certified use(s); and (b) solely for Customer s exclusive one-time use. Customer shall not request, obtain or use consumer reports for any other purpose including, but not limited to, for the purpose of selling, leasing, renting or otherwise providing information obtained under this Agreement to any other party, whether alone, in conjunction with Customer s own data, or otherwise in any service which is derived from the consumer reports obtained through OrthoBanc. The consumer reports shall be requested by, and disclosed by Customer only to Customer s designated and authorized employees having a need to know and only to the extent necessary to enable Customer to use the consumer reports in accordance with this Agreement. Customer shall ensure that such designated and authorized employees shall not attempt to obtain any consumer reports on themselves, associates, or any other person except in the exercise of their official duties. Customer shall indemnify, defend and hold harmless OrthoBanc against any claims or expenses (including attorney fees) arising out of a violation of any law applicable to Customer s use of the Licensed Product. Customer will maintain copies of all written consumer authorizations for a minimum of five (5) years from the date of inquiry. THE FCRA PROVIDES THAT ANY PERSON WHO KNOWINGLY AND WILLFULLY OBTAINS INFORMATION ON A CONSUMER FROM A CONSUMER REPORTING AGENCY UNDER FALSE PRETENSES SHALL BE FINED UNDER TITLE 18 OF THE UNITED STATES CODE OR IMPRISONED NOT MORE THAN TWO YEARS, OR BOTH. Customer acknowledges it must keep consumer report information in strict confidence, and not disclose it to any third parties; provided, however, that Customer may, but is not required to, disclose the report to the subject of the report only in connection with an adverse action based on the report. Moreover, unless otherwise explicitly authorized in an agreement between OrthoBanc and Customer for credit scores obtained from TransUnion, or as explicitly otherwise authorized in advance and in writing by TransUnion through OrthoBanc, Customer shall not disclose to consumers or any third party, any or all such scores provided under such agreement, unless clearly required by law. In the event of Customer s violation of this Agreement, the FCRA, or a change in existing law that would cause this Agreement to become illegal, OrthoBanc may, upon its election, discontinue providing this service to the Customer and cancel the Agreement immediately. Customer acknowledges that services it has subscribed to receive hereunder must be used in accordance with the Fair Credit Reporting Act, 15, U.S.C et. seq. (the FCRA ) and any state law counterparts including but not limited to the Vermont Fair Credit Reporting Statute, 9 V.S.A. 2480e (1999) (the VFCRA ). Customer acknowledges receipt of the Notice to Users of Consumer Reports, attached as Exhibit A, and agrees to review and comply with the provisions therein. In connection with Customer s continued use of the Licensed Product in relation to Vermont consumers, Customer hereby certifies that (i) it will comply with applicable provisions under Vermont law, (ii) it will order information services relating to Vermont residents that are credit reports as defined by the VFCRA, only after Customer has received prior consumer consent in accordance with VFCRA 2480e and applicable Vermont Rules, and (iii) a copy of VFCRA 2480e and applicable Vermont Rules, attached hereto as Exhibit B, were received from OrthoBanc. Page 6 of 7

7 Customer Use and License Agreement Disclaimer of Warranty: EXCEPT AS EXPRESSLY PROVIDED HEREIN, ORTHOBANC DOES NOT MAKE, AND EXPRESSLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, WITH REGARD TO THE LICENSED PRODUCT WHETHER ARISING BY OPERATION OF LAW, COURSE OF PERFORMANCE OR DEALING, CUSTOM, USAGE IN THE TRADE OR PROFESSION OR OTHERWISE, INCLUDING WITHOUT LIMITATION ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. Limitation on Liability. UNDER NO CIRCUMSTANCES AND UNDER NO LEGAL THEORY, WHETHER IN TORT, CONTRACT OR OTHERWISE, SHALL ORTHOBANC OR ITS OFFICERS, EMPLOYEES, AGENTS, REPRESENTATIVES, SUCCESSORS, OR ASSIGNS BE LIABLE TO CUSTOMER OR ANY OTHER PERSON FOR ANY INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES OR LOST PROFITS EVEN IF ORTHOBANC HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES, FURTHER, IN NO EVENT SHALL THE TOTAL LIABILITY OF ORTHOBANC EXCEED THE TOTAL OF FEES PAID TO ORTHOBANC IN THE PRECEDING TWELVE MONTH PERIOD PRIOR TO THE EVENT GIVING RISE TO THE CLAIM. IN NO EVENT WILL ORTHOBANC BE LIABLE TO CUSTOMER FOR ANY INABILITY TO COLLECT FROM PATIENTS ANY AMOUNTS OWED BY SUCH PATIENTS TO CUSTOMER DUE TO CIRCUMSTANCES OUT OF ORTHOBANC S CONTROL. ZACC Ownership/Rights. Customer acknowledges that certain aspects of the Licensed Product are owned by Zuelke & Associates, Inc. ( Zuelke ). Zuelke retains all applicable copyrights, trade secrets, patent rights, if any, and other intellectual property ownership or rights in said aspects, except the right of use licensed to Customer herein and any rights provided to OrthoBanc under its separate agreement with Zuelke. Zuelke also owns and retains all trademarks, service marks, trade names and any other names or marks used to identify Zuelke and/or any of its components described above. Customer acknowledges that this Agreement will terminate if the separate agreement between Zuelke and OrthoBanc terminates. Although Zuelke is not a party to this Agreement, and Customer has no rights against Zuelke arising under this Agreement, the parties agree that Zuelke is an intended third party beneficiary of this Agreement and the terms herein. Relation to OSA. This Agreement shall constitute an addendum to the Outsourcing Services Agreement ( OSA ). Except as maybe extended, amended or superseded by the provisions of this Agreement, the provisions of the OSA shall remain applicable and are incorporated herein by reference. Agreed to this day of, 20 Authorized Signature: Practice Name: By: Printed Name: Title: Page 7 of 7