Network Provider Step 1 of 3 33% Clinic DetailsPractice name* Practice name Practice address* Address line 1 Address line 2 City County Postcode Website Therapist InformationMain contact name* Email address* Main contact number* Secondary contact number Professional registration* Registering body Registration number Additional practitioner? Yes Contact name* Email address* Primary contact number* Secondary contact number Professional registration* Registering body Registration number Session informationIt will be your responsibility to ensure that you and your practitioners have suitable liability insurance to practice.Initial assessment cost (£)* Session length (minutes)* Follow up session cost (£)* Follow up session length (minutes)* Number of practitioners along with specialities with at least 3 years post qualification experience and registered with the relevant regulatory bodies.12345678910Does your clinic accommodate disabled patients?* Yes No Do you treat patients under 18 years?* Yes No Do you have parking facilities?* Yes No Payment InformationIf you wish to change your bank details please inform us in writing or request our Bacs amendment form. It may take up to four weeks for any changes to be processed and we will verify any changes in bank details. To ensure timely payment please compete.Name on bank account* Sort code* Account number* Standards Therapists must be registered with the relevant regulatory bodies. Therapists to adhere to the GDPR and Data Protection Legislation. healthcare rm must be notified immediately upon you being made aware of any data breaches concerning our clients. Therapists must have at least three years post graduate experience. Therapists must have adequate professional indemnity insurance, public liability insurance and employers liability insurance. Therapists must have an up to date continuing professional portfolio, regular supervision and annual appraisal. healthcare rm reserve the right to see evidence of this on request. All clinics must be clean, safe and fit for purpose. Any equipment used must be safe, regularly serviced, used and stored in line with manufacturers guidelines. All therapists must adhere to standards of infection control and COSSH. healthcare rm reserve the right to inspect premises to ensure that all standards are being met. All therapists must follow evidence based practice. healthcare rm must be notified immediately if any therapist is subject to a hearing with their professional body. All therapists/clinics should have the facility to send and receive all correspondence electronically via e-mail. Reporting requirements All reports must be sent electronically and in a typed format. Hand written notes will not be accepted. You must comply with the requirements of the GDPR and Data Protection Legislation. All information sent to you from us will be encrypted via a free to view encryption service. An initial assessment report must be submitted within 2 working days of the initial assessment. Discharge / Interim reports must be submitted within 2 working days of the final authorised treatment. The initial assessment and interim/discharge reports must be submitted on the templates provided by healthcare rm. Payment terms All treatments require pre-authorisation. You will be provided with an authorisation number by secure email which will detail the exact treatment and the number of sessions authorised. The authorisation number will have the format Auth-XXXXXXXXXX. No treatment can be carried out without an authorisation and no treatment in excess of that authorisation will be funded unless a report requesting further treatment has been submitted and further authorisation granted. We will only pay the agreed pricing. Price changes need our prior agreement. Patients sent to you by healthcare rm must not be invoiced directly for treatment authorised by us. The invoice must list the treatment date of each session, allocated to the correct authorisation. Multiple sessions can be billed on one invoice providing that they are annotated with the correct authorisation number for that session. Treatments must be invoiced to us within 3 months of the session date. We reserve the right to withhold payment for invoices that are received outside of this 3 month period. We operate weekly payment runs. Invoices that are submitted correctly will be paid on the next scheduled payment run. We will make payment directly into your appointed bank account. Remittances will be emailed via secure email on the day of each payment run. Invoices which do not meet the above criteria will be rejected. DisclosureFailure to adhere to any of the specified areas within this contract could result in the removal of your service from our network. You could also be removed from the network if desired customer outcomes are not met. healthcare rm reserves all rights to the customer in the terms of the authorised treatment. By signing this agreement, you agree to the terms and conditions of this contract outlined above. This will then constitute a contract between you and Healthcare RM Ltd.Consent* Yes, I agree to the terms and conditions outlined above. Please upload your first file here.*This file should be the signed GDPR agreementAccepted file types: pdf, jpg, Max. file size: 2 MB.Please upload an additional file here.*This file should be Liability Insurance certificatesAccepted file types: pdf, jpg, Max. file size: 2 MB.Please upload an additional file here.*This file should be qualifications of cliniciansAccepted file types: pdf, jpg, Max. file size: 2 MB.Please upload an additional file here.*This file should be images of the clinicAccepted file types: pdf, jpg, Max. file size: 2 MB.