HCL Account Authorisation Sales Intake

⚠️ Interim Sales Process

Until the Account Authorization is built into the HealthcareLive EHR platform, sales reps must complete this form and submit it to legal@healthcarelive.com. Legal will then send the completed authorization to the designated signatory for execution via DocuSign. Do not send directly to the client.

A Your Organization

Legal entity name *

DBA / Trade name

Primary contact *

Primary email *

Phone number

Business address *

Workers' comp carrier

TPA / Administrator

Est. employee count

Sales representative *

Execution date Date signed — account activates immediately

Legal contact (signatory) name & title *

Legal contact (signatory) email *

B Account Type & Billing Method — Select One — All Accounts Billed Weekly

All accounts are billed weekly, no exceptions. To avoid a weekly invoice, select Type 2 (Pay-in-Advance). If executing a separate billing agreement, select Other.

Type 1 — Pay-in-Arrears

Services billed weekly in arrears. All services Mon–Sun invoiced the following Monday. CC or ACH required — no exceptions (outside CMS-1500 carriers).

Type 2 — Pay-in-Advance

Pre-fund your account; services drawn against balance as rendered. No weekly invoice while balance is sufficient. CC or ACH recommended for auto-replenishment.

Other — Separate Agreement

FFPE Agreement, Benefits Program Agreement, On-Site Services Agreement, or Insurance Carrier arrangement. Completes Sections A, C, and Authorization only.

C Payment Method — Select One

Type 1: Credit Card / ACH required — no exceptions. CMS-1500 accepted for Insurance Carriers. Type 2: Credit Card, ACH, Check, or Wire accepted.

Credit Card or ACH (Type 1 or 2)

Processed via Stripe encrypted vault. HealthcareLive does not store card numbers. Auto-replenishment supported.

Invoice / Check / Wire (Type 2 only)

Net 30 invoice, check, or wire transfer. Allow 3–5 business days for check/wire clearing.

CMS-1500 (Type 1 / Carriers only)

Tier 1 = Injury triage. Tier 2 = Imaging and MD telemedicine. CC/ACH on file required as backup.

CMS-1500 Payor Arrangement — select one:

Option A — Split Payor: Employer responsible for Tier 1 (injury triage). TPA / Carrier responsible for Tier 2 (imaging and MD telemedicine). HealthcareLive will bill each party for their respective tier. Employer guarantees any Tier 2 amounts not settled by Carrier within applicable payment terms per the Universal Terms of Service. Option B — Carrier / TPA Pays Both Tiers: TPA / Carrier responsible for both Tier 1 and Tier 2. HealthcareLive will bill TPA / Carrier for all services via CMS-1500. Employer guarantees any unpaid balance not settled by Carrier within applicable payment terms per the Universal Terms of Service. Unpaid balances accrue interest at 1.5%/month (18%/yr).

E Payment Terms & Pre-Funded Account Setup — E2 = Type 2 Only

E1. Payment Terms — All Accounts

Payment TermsNet 30 days from invoice or service date. Customers may negotiate alternative terms in writing.

Late Payment Interest1.5% per month (18% per annum) on any unpaid balance past due date, until paid in full.

Account SuspensionHCL reserves the right to suspend if balance remains negative beyond agreed payment terms.

DiscountsNo standard discounts for pre-funding, CC/ACH on file, or volume. Custom pricing in writing only.

E2. Pre-Funded Account Setup — Type 2 Accounts Only

Opening Deposit Amount Min. $2,500 for FFS | Min. $10,000 for FFPE accounts

Replenishment Level Amount charged/transferred when trigger fires

⚠ Negative Balance Policy HealthcareLive reserves the right to suspend service coordination if the balance reaches zero before replenishment is confirmed. Services rendered while balance is at or below zero remain the Customer's full financial responsibility. Unpaid negative balances accrue interest at 1.5% per month (18% per annum) from the date services were rendered.

Replenishment TriggerFires when Current Balance falls below 20% of the Replenishment Level — no exceptions.

Balance ExpiryUnused pre-funded balances expire 365 days from deposit date. 30-day advance expiry reminder provided. Deposits non-refundable once applied.

✓ Authorization & Acceptance

Effective Date This Agreement becomes effective and binding upon execution. Either party may cancel with 30 days' written notice. By signing, the Customer confirms: (1) authorized to enter into this Agreement; (2) has read and agrees to the Universal Terms of Service at www.HealthcareLive.com/terms-of-service; (3) this Authorization establishes the account, payment method, and where applicable governs the billing arrangement; and (4) all information provided is accurate. This Agreement may be executed electronically with the same legal effect as a handwritten signature.

Customer Authorized Signatory

Signature

Print name

Title

Date

HealthcareLive Representative