Provider Contracts
We need a signed contract, business associate agreement, and payment method to send you referrals and reimburse you for uninsured and underinsured participants. We ask providers to execute the contract within 30 days of becoming an approved provider.
Please email the Project Director, Erin Henle, at ehenle@fletchergroup.org with the name and email address of the person at your organization who will execute the contract. We will send the contract to that person through Nitrosign. Please note that contracts cannot be forwarded through Nitrosign and the person receiving it must be the signer. We have included our contract template here so your team can review and share it.
Please contact Erin Henle with any questions about the timelines, payments, legal and provider responsibilities.
The Documents You’ll Need
Below are the contract and other documents you’ll need. They can be read on this page by hovering your mouse over the lower left corner of each page. You can also download the documents by clicking the appropriate “Download” button.
Provider Contract
To read the Provider Contract, here referred to as a “Services Agreement,” hover your mouse over the lower left corner of each page. To download the Services Agreement, click Download.
Fletcher-Group-Provider-Contract-FY25Business Associate Agreement
To read the Business Associate Agreement, hover your mouse over the lower left corner of each page. To download the Business Associate Agreement, click Download.
Provider-BAADirect Deposit Authorization
To read the Direct Deposit Authorization, hover your mouse over the lower left corner of each page. To download the Direct Deposit Authorization, click Download.
Direct-Deposit-Authorization-Form