318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

TOWNSHIP OF WEST ORANGE THIRD PARTY BILLING FOR EMERGENCY AMBULANCE SERVICES PROPOSAL FORM The Township of West Orange is seeking an incentive based scale to maximize the collection of the billable ambulance services. An example is provided below. Example: Percentage Range of Collections by Vendor 5 % $0 to $100,000.00 10 % $101,000.00 to $200,000.00 Percentage increases to be paid by the Township would be based on total collections over a 12 month period. The undersigned hereby agrees to furnish all services, labor, materials, supervision, equipment, and other means as necessary to perform all the work in accordance with these specifications. _______ % $ 0 to 750,000.00 _______ % $ 751,000.00 to 1,000,000.00 _______ % $ 1,000,001.00 to 1,500,000.00 _______ % $ 1,551,000.00 and above ________________________________ ________________________________ Authorized Signature Print Name & Title ______________________________________ ______________________________________ Company Name Address ______________________________________ ______________________________________ Date City, State, Zip ______________________________________ Telephone Number ______________________________________ 20