Exhibits - (Rev. 5, 08-30-02)

180 - Exhibits - (Rev. 5, 08-30-02) A1-1435 Exhibit 1 - Form CMS-1521 - - See CMS Forms page. Exhibit 2 - Form CMS-1522 - - See CMS Forms page. Exhibit 3 - Intermediary Benefit Payment Report - - See CMS Forms page. Exhibit 4 -Authorization Agreement for Electronic Funds Transfer PROVIDER/PHYSICIAN PROVIDER/PHYSICIAN NAME____________________ ID NUMBER___________________ I hereby authorize (Insert Contractor Name), hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my ( ) Checking ( ) Savings account (select one) indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. DEPOSITORY NAME _____________________ BRANCH _____________________ CITY ______________________ STATE ______ ZIP ____________ TRANSIT NUMBER ____________ ACCOUNT NUMBER ____________ This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on said notice of termination. NAME ________________________ TITLE _____________________ (PLEASE PRINT) SIGNED X ______________________ DATE _____________ Exhibit 5 - Addendum to Medicare Bank Agreement The parties have executed this Agreement for the Medicare A(B) Bank Accounts using the Checks Paid Method of Letter of Credit Financing and desire to add changes to the existing agreement currently in force. These changes are necessitated by the implementation by (Insert Contractor Name) of the Electronic Funds Transfer (EFT) method of paying providers effective (Insert Date). This change in payment method is under the direction of the Centers for Medicare and Medicaid Services (CMS) as an initiative to increase the uniformity and efficiency of the provider payment process. Also, item number 10 below, although not related to EFT, is incorporated into the bank agreement to insure that no excessive earnings credits accumulate during the period of the bank agreement. The parties hereby agree to the following terms and conditions that shall be considered an integral part of the bank Agreement: 1. The rates as reflected on the Schedule of Bank Processing Charges shall be in effect for the term of this Agreement. 2. This Agreement, with all its provisions and covenants, shall continue in force from year to year after the expiration of such term; provided, however, that notification to terminate or renegotiate has not been given by any party as specified in the Agreement executed on (Insert Date). 3. All references to checks in the original Agreement shall hereby mean checks and/or Electronic Funds Transfers (EFTs). 4. The Fiscal Intermediary (Carrier) is obligated to obtain, retain, and provide copies of provider authorizations, particularly with regard to the rights, liabilities, and responsibilities of Medicare contractors and financial institutions under Regulation E. 5. The nature, format and medium of entries, or entry information is to be furnished to the originating bank in writing by the Fiscal Intermediary (Carrier) prior to entering into an EFT arrangement. 6. The Fiscal Intermediary (Carrier) and the originating bank shall negotiate the level of security to be established for delivering the payment data from the Fiscal Intermediary (Carrier) to the originating bank, such as transmittals with authorized signatures, and the method used to verify authenticity of telecommunicated data, prior to entering into an EFT arrangement. 7. The Fiscal Intermediary (Carrier) shall specify the time when funds are to be provided to the originating bank prior to entering into an EFT arrangement. 8. The Fiscal Intermediary (Carrier) and the originating bank shall agree to the deadline for reversals, corrections, or changes by the Fiscal Intermediary (Carrier) of entries or entry information furnished to the originating bank prior to entering into an EFT arrangement. 9. In those cases where the Fiscal Intermediary's (Carrier's) Medicare bank is unable to originate EFT transactions, the Medicare bank may subcontract certain functions. The Medicare bank agrees that none of the functions to be performed under the Tri-partite agreement shall be subcontracted without prior written approval of the Fiscal Intermediary (Carrier) and the CMS. Any such approved subcontract shall contain the language of the Examination of Records Clause contained in the bank agreement (Covenant 3). 10. If Line 7 of Page 1 of the Quarterly Time Account Adjustment Schedule reflects any positive balance, the contractor shall immediately forward supporting documentation and a check made payable to CMS for that amount to: Send a copy of the check and transmittal letter to: Centers for Medicare & Medicaid Services Office of Financial Management 7500 Security Boulevard Baltimore MD 21244-1850