HFMA Peer Review Application

Thank you for your interest in HFMA’s Peer Review Program. The following application information is required to begin the HFMA Peer Review Initial Screening process.

If you have any questions, please contact Sandy Neuenkirchen, HFMA Peer Review Manager, at [email protected].

To submit your application, visit Peer Review and select “Start Your Application Today.”

COMPANY KEY CONTACT INFORMATION

  • Name
  • Title, Company
  • Phone Number, Email
  • Street, City, State, Zip

COMPANY INFORMATION

  • What is your company’s mission?
  • Describe your company’s history.
  • Identify your company’s ownership type and describe the organizational structure.
Sole ProprietorshipNon Profit Corporation
C-CorporationGeneral Partnership
S-CorporationLimited Liability Partnership
Private Limited Liability CompanyOther: please describe
Public Limited Liability Company

Please email a copy of your most recent 2 years of annual financial statements (which include Income Statement,
Balance Sheet & Statement of Cash Flow) to [email protected].

  • Describe your company’s market reputation and customer penetration.
  • List any associations or other business affiliations that your company currently recognizes.

PLEASE SELECT THE APPROPRIATE CHOICE, EITHER PRODUCT OR SERVICE.

  • Product – A product is a tangible assets the healthcare organization is purchasing from you. The healthcare
    origination is responsible for using the product.
  • Service – Services are intangible, as a vendor, you provide the reporting or support for the healthcare organization.

PRODUCT/SERVICE DESCRIPTION

  • Solution name.
  • Summarize the features.

Please email a detailed brochure to [email protected].

  • Identify any significant complaints/litigation/investigations relating to your company’s healthcare products/services. For this purpose, a “significant” matter is one that requires substantial attention (ten or more hours) from the company’s internal or outside legal counsel.
  • Please provide the product/service gross revenue for the past 2 years.
  • Summarize the problem that your solution would solve for HFMA members.
  • Describe the pricing structure.
  • Through which channels would members be able to purchase the product? (check all that apply).
Internet formMailed order form
Toll-free telephone numberIn-person sales staff
Faxed order formOther: please describe
  • Outline how the purchase would be fulfilled.

CUSTOMER SERVICE

  • What is your customer service philosophy?
  • Describe how your company measures its customer service success.

COMPETITION

Please email a list of your competitors with a summary of comparisons to [email protected].

  • What makes your company unique compared to your competitors?

PEER REVIEW PROGRAM VALUE

  • In your opinion, what value does Peer Review bring to HFMA members?
  • What value would Peer Review have on your company?

LICENSE AGREEMENT TERMS

Once approved, HFMA Peer Review program includes a royalty fee varying from $20,000 – $50,000 per year with an initial term of three years. The royalty fee is determined by your peer reviewed product/service structure and choice of Tier 1 or Tier 2 program benefits. HFMA uses a portion of these funds to drive awareness in the marketplace of the Peer Review program and its value.

  • Is your firm comfortable with this type of licensing relationship with HFMA?
    • Yes

Once approved, the licensing agreement includes insurance provisions requiring that during the term and for a period of five years thereafter, your organization shall maintain at its sole expense a standard Comprehensive General Liability Insurance Policy written by a company licensed to do business in the United States that covers your organization’s errors and omissions under the licensing agreement, provides standard products and advertiser’s liability coverage, and general liability coverage that is adequate to indemnify and defend HFMA. The minimum amount of insurance is $2 million per occurrence and $5 million aggregate.

  • Is your firm comfortable with these requirements?
    • Yes
  • What special pricing would be available for HFMA members? (Not a requirement to participate in the program.)
  • What is your timeframe for the Peer Review Process?

PEER REVIEW APPLICATION TERMS

CONFIDENTIALITY

Obligations. The parties understand and agree that, in connection with the activities contemplated herein and in the Exhibits hereto, each party will be exposed to confidential information of the other party including, but not limited to, mailing lists, databases, discussions, details and other materials (collectively, the “Confidential Information”). In order to protect information identified, either verbally or in writing as Confidential Information, or which, by its nature would reasonably be considered Confidential Information, including but not limited to mailing lists, each party hereby promises that, except as otherwise provided herein, it will not make copies of, discuss, disclose, or otherwise disseminate, or assist or permit others to copy, discuss, disclose, or otherwise disseminate, any Confidential Information and it will not use the Confidential Information for any purpose whatsoever except directly in connection with it’s activities pursuant to this application. Further, the parties understand and agree that the above promise of confidentiality will be in effect during the application process and at all times thereafter.

Damages. Each party acknowledges that a breach of this promise of confidentiality could result in irreparable damages to the other party and its mission for which a remedy at law will be inadequate, and each party agrees that this promise may be enforced by an injunction. Each party agrees to pay the other party’s reasonable costs and expenses, including attorneys’ fees, if the other party brings an action against for breach of this promise of confidentiality and prevails in such action.

Exceptions. For purposes of this confidentiality clause, the parties acknowledge and agree that the term “Confidential Information” does not include information which: (1) is or becomes generally available to the public; (2) is already in the unrestricted possession of the party as of the date of application; (3) is lawfully disclosed to the party by a third party without restrictions on its use or disclosure; (4) is approved in writing by the other party for disclosure; (5) is independently developed by one party without reference to or use of the Confidential Information of the other party; or (6) is required to be disclosed pursuant to a requirement of a governmental agency or law so long as the party provides the other party with notice, to the extent allowed by law, of such requirement prior to any such disclosure.

INDEMNIFICATION

Each party agrees to, and hereby does, indemnify and hold harmless the other party, its directors, officers, employees, members, and representatives from all losses, liabilities, demands, damages (including personal and bodily injury), claims, suits, judgments, costs and expenses (including but not limited to reasonable attorneys’ fees), which any of them may incur by reason of, in connection with, or arising out of: (i) the acts or omissions of the indemnifying party, its employees, officers, agents or representatives in connection with this Peer Review Application; (ii) the design, development, manufacture, servicing, advertising, marketing, distribution, licensing or sale of any goods or services by the indemnifying party; (iii) the misuse by the indemnifying party of the intellectual property or proprietary rights of the other party; or (iv) the other party’s use of the intellectual property or proprietary rights of the indemnifying party in the manner contemplated by this Peer Review Application, or as otherwise approved by the indemnifying party.

  • Applicant Firm
  • Applicant Name
  • Date

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