Free agency agreement 30Free agency agreement 30Free agency agreement 30
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Agency Agreement
This Agency Agreement (this “Agreement”) is entered into this _____ day of
_______________, 20__ by and between____________________________________________
(“Provider”) and Physicians Contracting Organization of Texas, a Texas non-profit corporation
WHEREAS, Provider is duly licensed (or if Provider is a Legal Entity, the members of
such entity are duly licensed) to provide medical services in the State of Texas, whose license(s)
is (are) without limitation or restriction, and who desire(s) to contract with private insurers, health
maintenance organization or other payors to provided professional medical services to person
covered by payors’ plans;
WHEREAS, the Company is in the business of negotiating provider contracts with Payors
on behalf of physicians; and
WHEREAS, Provider desires to appoint PCOT as its agent and attorney in fact for the
negotiation and execution of certain provider contracts; and
WHEREAS, PCOT desires to act as the agent and a