Persivia

Enrollment Portal

Please provide the following information to complete your Enrollment:

Organization Name *

Organization Phone *

Organization Address *

Effective From *

Tax ID *

Contact Email *

Registration / License State *

No. of Beds

Affiliated Hospital(s):

Organization Registered As *

Limited Liability Company

Corporation

Sole Proprietor

Partnership

Name and NPI of the Providers

Order Schedule

THIS ORDER SCHEDULE is dated ____________, (the “Effective Date”), between ____________________________ (“Customer”) a [Limited Liability Company] located at _______________________________, and Persivia,Inc. located at 4 Mount Royal Ave, Marlborough, MA 01752, a Delaware corporation, or its assigns (“Persivia”) each a “Party”.

Background

Persivia is a healthcare analytics company that provides Population Health Management software tools and services. Persivia provides advanced software and employs or contracts with physicians, non-physician practitioners, clinical staff, and other auxiliary personnel (collectively, “Clinical Staff”) to provide population health management tools and services.

The Customer is either: (i) an individual physician who is duly licensed under the applicable statutes and regulations of the State of __ (the “State”), to practice medicine in the State; or (ii) an entity that lawfully employs or contracts with duly licensed physicians to practice medicine under the laws of the State.

Customer wishes to engage Persivia to provide access to its BPCI-A solution solely in connection with Customer's services for Prime Healthcare.

The term of this Order Schedule commences on the date hereof and shall continue in effect until either Party notifies the other Party in writing that it has elected to terminate this Order Schedule.

There are no fees associated with this Order Schedule. However, if Customer desires to use the BPCI-A solution in connection with any provider or facility other than Prime Healthcare then Customer shall be required to enter into a separate Order Schedule with Persivia where fees may apply.

Additionally, if Customer desires to purchase any of Persivia's other solutions (i.e. Population Health Management software tools, MIPS eCQM and CPIA analytics and reporting, CPC+ eCQM reporting, Chronic Care Management (CC), Annual Wellness Visit (AWV) and other services) then Customer shall be required to enter into a separate Order Schedule with Persivia where fees may apply.

This Order Schedule is issued pursuant to, is governed by and is subject to the terms and conditions of the Persivia Master Services Agreement, a copy of which is found at http://persivia.com/resources/terms-of-services (click on Contract Terms Document link at the bottom of the page) ("the Master Agreement"). Capitalized terms used but not defined herein shall have the meaning set forth in the Master Agreement. By checking the "I accept" button below, Customer is agreeing to be bound by the provisions of the Master Agreement.

I accept the above Terms and Conditions and Certify that I am authorized to enroll on behalf of our Organization *

First Name *

Last Name *

Job Title *

Phone Number *