EmailMe Form - Independent Contractor Application and Agreement

Independent Contractor Application

Office Manager

Billing Administrator

Licensed Mental Health Professional

Please Select Box and Click What You Interested In!

Date of Completing This *

MM / DD / YYYY

Portfolio Website

Upload Your CV / Resume *

Make Sure you add your state date as date you completed form FamilyCounselingSanDiego.Com, Inc. as your most current Job. Also add your NPI, CAQH, Licensed Number in your Resume/CV

Upload Your License Insurance make sure it is up to day and does not expire within next 3 months or renew it prior to submitting it to us. *

Word or PDF Documents Only

Upload Your CAQH Report. Google CAQH as all clinicians should be on CAQH. *

Word, TIFF, JPG, DOC or PDF Documents Only

Upload Your W-9 with FamilyCounselingSanDiego.Com Inc as company so we can get you your 1099 end of year for taxes. Google W-9 PDF form to get this right form. *

Word, TIFF, JPG, DOC or PDF Documents Only

HR FILE DATA PLEASE BE ACCURATE

Please check our data twice.

Name *

First Last

MUST ENTER DATA

Email *

MUST ENTER DATA

Mobile Phone *

### - ### - ####

MUST ENTER DATA

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

MUST ENTER DATA

Insurance Name, ID#, Date of expiration

Check your data twice.

Why clients do you enjoy seeing and willing to work with in practice?

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What computer experence do you have? What makes you special in your practice? Have you written any books?

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Medicaid Number # (Not Required)

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SSN ID Required for 1099 to be setup correctly *

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CAQH# and Date of last Attestation

If you do not have one get it soon and email me me CAQH#, User Name, Password.

What do you expect from us? What is your main concerns? What special talents do you bring to the practice? *

Please tell us what hours you can keep, family issues that could interfere with duties.

What is the name, relationship, phone numbers of EMERENCY Contact person?

It is Important to have an Emerency Contact Person!!!!

GENERAL TERMS AND CONDITIONS

1. APPROVAL: This Agreement is of no force or effect until signed by both parties and approved by the Walter P Martin Chief Operations Officer, if required. Contractor may not commence performance until such approval has been obtained.

2. AMENDMENT: No amendment or variation of the terms of this Agreement shall be valid unless made in writing, signed by the parties and approved as required. No oral understanding or Agreement not incorporated in the Agreement is binding on any of the parties.

3. ASSIGNMENT: This Agreement is not assignable by the Contractor, either in whole or in part, without the consent of FamilyCounselingSanDiego.Com, Inc. in the form of a formal written amendment.

4. AUDIT: Contractor agrees that the awarding department, the Walter P Martin Chief Operations Officer, or their designated representative shall have the right to review and to copy any records and supporting documentation pertaining to the performance of this Agreement. Contractor agrees to maintain such records for possible audit for a minimum of three (3) years after final payment, unless a longer period of records retention is stipulated. Contractor agrees to allow the auditor(s) access to such records during normal business hours and to allow interviews of any employees who might reasonably have information related to such records. Further, Contractor agrees to include a similar right of FamilyCounselingSanDiego.Com, Inc. to audit records and interview staff in any subcontract related to performance of this Agreement. (Gov. Code §8546.7, Pub. Contract Code §10115 et seq., CCR Title 2, Section 1896).

5. INDEMNIFICATION: Contractor agrees to indemnify, defend and save harmless FamilyCounselingSanDiego.Com, Inc., its officers, agents and employees from any and all claims and losses accruing or resulting to any and all contractors, subcontractors, suppliers, laborers, and any other person, firm or corporation furnishing or supplying work services, materials, or supplies in connection with the performance of this Agreement, and from any and all claims and losses accruing or resulting to any person, firm or corporation who may be injured or damaged by Contractor in the performance of this Agreement.

6. DISPUTES: Contractor shall continue with the responsibilities under this Agreement during any dispute.

7. TERMINATION FOR CAUSE: FamilyCounselingSanDiego.Com, Inc. may terminate this Agreement and be relieved of any payments should the Contractor fail to perform the requirements of this Agreement at the time and in the manner herein provided. In the event of such termination FamilyCounselingSanDiego.Com, Inc. may proceed with the work in any manner deemed proper by FamilyCounselingSanDiego.Com, Inc.. All costs to FamilyCounselingSanDiego.Com, Inc. shall be deducted from any sum due the Contractor under this Agreement and the balance, if any, shall be paid to the Contractor upon demand.

8. INDEPENDENT CONTRACTOR: Contractor, and the agents and employees of Contractor, in the performance of this Agreement, shall act in an independent capacity and not as officers or employees or agents of FamilyCounselingSanDiego.Com, Inc.. You are required to attend yearly Culturally Confidence Classes, Legal and Ethical Class every 2 years.

9. RECYCLING CERTIFICATION: The Contractor shall certify in writing under penalty of perjury, the minimum, if not exact, percentage of post consumer material as defined in the Public Contract Code Section 12200, in products, materials, goods, or supplies offered or sold to FamilyCounselingSanDiego.Com, Inc. regardless of whether the product meets the requirements of Public Contract Code Section 12209. With respect to printer or duplication cartridges that comply with the requirements of Section 12156(e), the certification required by this subdivision shall specify that the cartridges so comply (Pub. Contract Code §12205).

10. NON-DISCRIMINATION CLAUSE: During the performance of this Agreement, Contractor and its subcontractors shall not deny the contract’s benefits to any person on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran status, nor shall they discriminate unlawfully against any employee or applicant for employment because of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran status. Contractor shall insure that the evaluation and treatment of employees and applicants for employment are free of such discrimination. Contractor and subcontractors shall comply with the provisions of the Fair Employment and Housing Act (Gov. Code §12900 et seq.),
the regulations promulgated thereunder (Cal. Code Regs., tit. 2, §11000 et seq.), the provisions of Article 9.5, Chapter 1, Part 1, Division 3, Title 2 of the Government Code (Gov. Code §§11135-11139.5), and the regulations or standards adopted by the awarding state agency to implement such article. Contractor shall permit access by representatives of the Department of Fair Employment and Housing and the awarding state agency upon reasonable notice at any time during the normal business hours, but in no case less than 24 hours’ notice, to such of its books, records, accounts, and all other sources of information and its facilities as said Department or Agency shall require ascertaining compliance with this clause. Contractor and its subcontractors shall give written notice of their obligations under this clause to labor organizations with which they have a collective bargaining or other agreement. (See Cal. Code Regs., tit. 2, §11105.)

Contractor shall include the nondiscrimination and compliance provisions of this clause in all subcontracts to perform work under the Agreement. At any time drug testing can be required.

11. CERTIFICATION CLAUSES: The CONTRACTOR CERTIFICATION CLAUSES contained in the document CCC 04/2017 are hereby incorporated by reference and made a part of this Agreement by this reference as if attached hereto.

12. TIMELINESS: Time is of the essence in this Agreement such that upon signature you agree to begin working with FamilyCounselingSanDiego.Com Inc on date of signature and are bound by the laws of California and the County of San Diego.

13. COMPENSATION: The consideration to be paid Contractor, as provided herein, shall be in compensation for all of Contractor's individual, group or couples therapy work as per insurance payment contract when insurance pays. If Contractor is delayed for more then 3 days in billing and gets dad wrong or does not call to verify insurance deducible it is not FamilyCounselingSanDiego.com, inc responsibility. It the contractors responsibility to call clients whom owe money to college and get credit card which ca be processed or develop a payment plan through credit card. It is fulling the contractors responsibility to maintain billing records and submit it to insurance through electronic system in ThrerapyNotes.com system. Contractor gets 60% of gross from clients payments and insurance payments. At Contractors are not Employee's they do not have any rights as Employee have. No complaints to DOL as this is not within there area. If you have a complaint you agree to mediate with CEO, COO and Office Manager initially otherwise you are in violation of this contract and you could be fined up to $100,0000 for violation of this agreement.

14. GOVERNING LAW: This contract is governed by and shall be interpreted in accordance with the laws of FamilyCounselingSanDiego.Com, Inc. of California.

15. ANTITRUST CLAIMS: The Contractor by signing this agreement hereby certifies that if these services or goods are obtained by means of a competitive bid, the Contractor shall comply with the requirements of the Government Codes Sections set out below.
a. The Government Code Chapter on Antitrust claims contains the following definitions:
1) "Public purchase" means a purchase by means of competitive bids of goods, services, or materials by FamilyCounselingSanDiego.Com, Inc. or any of its political subdivisions or public agencies on whose behalf the Attorney General may bring an action pursuant to subdivision (c) of Section 16750 of the Business and Professions Code.
2) "Public purchasing body" means FamilyCounselingSanDiego.Com, Inc. or the subdivision or agency making a public purchase. Government Code Section 4550. In addition all work and contract obtained through FCSD's work and contracting process you can not leave for 12 months or face $300 per contract fee for the time and labor to obtain your own sole contract with payers per our company.

b. In submitting a bid to a public purchasing body, the bidder offers and agrees that if the bid is accepted, it will assign to the purchasing body all rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton Act (15 U.S.C. Sec. 15) or under the Cartwright Act (Chapter 2 (commencing with Section 16700) of Part 2 of Division 7 of the Business and Professions Code), arising from purchases of goods, materials, or services by the bidder for sale to the purchasing body pursuant to the bid. Such assignment shall be made and become effective at the time the purchasing body tenders final payment to the bidder. Government Code Section 4552.

c. If an awarding body or public purchasing body receives, either through judgment or settlement, a monetary recovery for a cause of action assigned under this chapter, the assignor shall be entitled to receive reimbursement for actual legal costs incurred and may, upon demand, recover from the public body any portion of the recovery,
including treble damages, attributable to overcharges that were paid by the assignor but were not paid by the public body as part of the bid price, less the expenses incurred in obtaining that portion of the recovery. Government Code Section 4553.

d. Upon demand in writing by the assignor, the assignee shall, within one year from such demand, reassign the cause of action assigned under this part if the assignor has been or may have been injured by the violation of law for which the cause of action arose and (a) the assignee has not been injured thereby, or (b) the assignee declines to file a court action for the cause of action. See Government Code Section 4554.

16. CHILD SUPPORT COMPLIANCE ACT: For any Agreement in excess of $100,000, the contractor acknowledges in accordance with Public Contract Code 7110, that:

a. The contractor recognizes the importance of child and family support obligations and shall fully comply with all applicable state and federal laws relating to child and family support enforcement, including, but not limited to, disclosure of information and compliance with earnings assignment orders, as provided in Chapter 8 (commencing with section 5200) of Part 5 of Division 9 of the Family Code; and

b. The contractor, to the best of its knowledge is fully complying with the earnings assignment orders of all employees and is providing the names of all new employees to the New Hire Registry maintained by the California Employment Development Department.

17. UNENFORCEABLE PROVISION: In the event that any provision of this Agreement is unenforceable or held to be unenforceable, then the parties agree that all other provisions of this Agreement have force and effect and shall not be affected thereby.

18. REQUIREMENT OF PROFESSIONAL STANDARD: As an Independent Contractor you are responsible to keep a daily log through our Google Sheets Form, You are required to enter your Intake, Treatment Plan on the first session, in addition verify signature of client completing online legal forms prior to beginning treatment or you are 100% liable for violations. In addition being complete in entering data into EMR and billing area. All notes and billing data is required within 24 hours. If clinician loses license or insurance he can no longer work with this company.

19. SMALL BUSINESS PARTICIPATION AND PARTICIPATION REPORTING REQUIREMENTS:
a. If for this Contract Contractor made a commitment to achieve small business participation, then Contractor must within 60 days of receiving final payment under this Contract (or within such other time period as may be specified elsewhere in this Contract) report to the awarding department the actual percentage of small business participation that was achieved. (Govt. Code § 14841.)
b. If for this Contract Contractor made a commitment to achieve disabled veteran business enterprise (DVBE) participation, then Contractor must within 60 days of receiving final payment under this Contract (or within such other time period as may be specified elsewhere in this Contract) certify in a report to the awarding department: (1) the total amount the prime Contractor received under the Contract; (2) the name and address of the DVBE(s) that participated in the performance of the Contract; (3) the amount each DVBE received from the prime Contractor; (4) that all payments under the Contract have been made to the DVBE; and (5) the actual percentage of DVBE participation that was achieved. A person or entity that knowingly provides false information shall be subject to a civil penalty for each violation. (Mil. & Vets. Code § 999.5(d); Govt. Code § 14841.)

20. LOSS LEADER:
If this contract involves the furnishing of equipment, materials, or supplies then the following statement is incorporated: It is unlawful for any person engaged in business within this state to sell or use any article or product as a “loss leader” as defined in Section 17030 of the Business and Professions Code. (PCC 10344(e).)

ACKNOWLEDGEMENT OF ACCEPTANCE OF ABOVE STIPULATION
E-Signature is my true signature same as if it was written on paper. Authorizing FamilyCounselingSanDiego.com, Inc. to act on my behalf with my insurance company to bill and allows FCSD to utilize an insurance billing company to assist FCSD in obtaining funds from insurance per contracts and agreeing to the legal arrangement as stated in accordance with State of California law. I declare under the penalty of perjury under the laws of the state of California that the above information are true and correct.

ACKNOWLEDGEMENT OF RECEIPT
If this signature is missing or unreadable the verification of this Secured E-Signature represents the said person completed above. By signing this form, you acknowledge receipt of the above data and agree to its statements. I acknowledge receipt of This Legal Notice of FamilyCounselingSanDiego.Com, Inc. and Agree to Follow per the laws of the state of California. *

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