Provider Application

Provider Information
Business Phone, Fax and Email
Communication comfirming your submission will be sent to this email address.
Business Address
Provider Staff
Click Add button to provide Name and email for primary provider and support staff
Include all staff that will require access to MyPHTS.
Provide NPI numbers for all licensed health practictioners.


First Name
Last Name
Email
Phone Number
Primary Provider
NPI Number

CARE PARTNER REGISTRATION AND SPONSOR APPLICATION AND REGISTRATION AGREEMENT

CARE PARTNER REGISTRATION: If you received a Care Partner registration invitation code from a MyPHTS Sponsor, your organization is being registered as a Care Partner. Care Partners are other providers of healthcare services to a Care Coordination Member that are licensed physicians or other qualified healthcare professional, qualified healthcare practice, or qualified health plan.

Care Partners are invited by their MyPHTS Sponsor for treatment purposes. Treatment purposes are defined under HIPAA as the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another. HIPAA rules permit both the use and disclosure of personal health information (PHI) for treatment purposes without patient consent.

Care Partner registration is free and permits viewing of Care Coordination Reports only.

You may upgrade your Care Partner membership to Sponsor membership at any time by applying for a Sponsor registration. Sponsor members are able to invite care coordination members, invite care partners, and use MyPHTS care management and care coordination services.

SPONSOR APPLICATION OR REGISTRATION: If your organization is submitting or has submitted an application to register as a Sponsor and received a Sponsor registration code, your organization is being registered as a Sponsor defined in PHTS Terms and Conditions.

Sponsor registration is not free. Sponsor accepts MyPHTS Application services and agrees to be charged MyPHTS subscription fees. Sponsor understands PHTS reserves the right to change any MyPHTS subscription fees.

PHTS is NOT a medical provider nor is it a medical organization. PHTS may use and disclose Provider PHI as needed to perform the Services for or on behalf of Provider under the Provider Terms and Conditions. PHTS shall use and disclose Provider PHI only as permitted or required by the Provider Terms and Conditions, the terms of the Business Associate Agreement, or required by law and only to the extent that such use and disclosure would not violate the Privacy Regulation, Security Regulations or HITECH Act if performed by PHTS. Provider shall not request PHTS to use or disclose Provider PHI in any manner that would not be permissible under the Privacy Regulation, Security Regulations or HITECH Act.

Whether being registered as a Care Partner or a Sponsor, your organization understands MyPHTS is a communication tool. MyPHTS is NOT a medical provider nor is it a medical organization. As a communication tool, MyPHTS educational information should not be construed as medical diagnosis or advice or independent medical judgement or treatment. MyPHTS does not guarantee a patient care outcome nor does it guarantee any billable service or charge. Neither Care Partner registration invitations nor Sponsor registration invitations should be construed as a referral(s) for any healthcare service or an inducement for a referral of any healthcare service to any organization or individual. Neither Care Partner registrations nor Sponsor registrations should be construed as being offered based on the volume or value of any referrals or business to any organization or individual.

Your organization is responsible for understanding and adhering to pertinent health plans or state and or federal regulatory and compliance rules and laws.

I and my organization:
  • Accept PHTS Terms and Conditions.
  • Accept PHTS Business Associate Agreement.
  • Accept PHTS Privacy Policy
  • Attest submission of our organization’s sponsor application or sponsor registration or care partner registration as applicable for creation of login access and use of the PHTS web application will not violate applicable federal privacy regulations.
  • Agree not to use to use MyPHTS service to violate the federal Anti-Kickback Statute which prohibits soliciting or inducing referrals to generate federal health care program business.
  • Agree not to use to use MyPHTS service to violate the Stark Law which prohibits referrals to an entity or entities in which I have a financial interest unless an exception applies and which also prohibits claims submissions for services from prohibited referrals.
  • Agree to indemnify, hold harmless and defend PHTS, its affiliates, and members, directors, officers, employees, stockholders, representatives, or agents, of any of the foregoing (that is PHTS and its affiliates) from any and all third party claims, liability, damages and/ costs(including but not limited to reasonable attorney fees and expenses) arising from (i) your improper use of this website (ii) your failure to comply with any of these PHTS Terms and Conditions for Sponsors as contained in this document (iii) your Care Coordination Member(s) failure to comply with PHTS Terms and Conditions for Members (iv)your infringement of any intellectual property whatsoever of any person or entity (v) or the infringement or use by any other user of your account, of any intellectual property or other right of any person or entity.
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