PINEAPPLE SUPPORT COUNSELLING AND PSYCHOTHERAPY PROVIDER AGREEMENT

WHEREAS, THIS PROVIDER AGREEMENT (hereinafter the “Agreement”) is made by and between The Adult Industry Support Network (“Pineapple Support”) and _______________________ (“Provider”) as of _____________________ (the “Effective Date”) whereby Provider agrees to be included as a provider of counseling and/or psychotherapy services in the Pineapple Support Provider Network (the “Network”). NOW, THEREFORE, in consideration of the promises and other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties hereto agree as follows:

Provider understands that these policies are intended to protect the rights and interests of Pineapple Support clients, clarify the rights and responsibilities of Pineapple Support providers (including prompt and accurate reimbursement for services) and to ensure that Pineapple Support complies with applicable laws and its fiduciary responsibilities as a 501(c)(3) nonprofit organization. Periodically Pineapple Support may make changes in policies and procedures and when that occurs, providers will receive the changes in writing to review. Should you have any questions or objections to the changes to Pineapple Support policies, please contact us immediately. Your continued provision of services to Pineapple Support clients constitutes your acceptance of our amended policies or procedures.

ELIGIBILITY

Providers agree to:

Be registered to practice, counseling or psychotherapy by at least one of the following bodies: Health Care Professional’s Council (HCPC); British Association of Behavioral & Cognitive Psychotherapies (BABCP); British Association for Counselling and Psychotherapy (BACP); British Psychoanalytic Council (BPC); National Counselling Society (NCS); UK Council for Psychotherapy (UKCP). for the profession(s) in which they are licensed, to maintain that professional licensure, and must provide Pineapple Support with a current copy of their license(s) prior to being admitted to the network and annually thereafter. Providers will verify their license on each submitted Provider Claim Form.

Maintain professional liability insurance at all times and provide Pineapple Support with a current copy prior to admission to the network. Providers will verify their insurance status on each submitted Provider Claim Form.

Sign and return a Pineapple Support Counselling and Psychiatry Provider Agreement at the time of admission to the Pineapple Support Provider Network and at the time of any major change in Pineapple Support policies, if required.

Have an email account at which they may receive encrypted notices and requests from Pineapple Support that may include client identifying information.

Have access to the Internet in order to provide online video therapy and download forms and other important information from the Providers page on the Pineapple Support website (http://www.pineapplesupport.com).

Make a commitment to using Pineapple Support’s “Apricot” client information system for the benefit of both Provider (prompt and accurate payment) and Pineapple Support (real time data entry, timely authorization and re-enrollment).

Understand that they are independent contractors and in no way employees of The Pineapple Support Foundation.

PROVIDER HEREBY AGREES TO INDEMNIFY, DEFEND (WITH COUNSEL REASONABLY SATISFACTORY TO PINEAPPLE SUPPORT) AND FOREVER SAVE AND HOLD HARMLESS PINEAPPLE SUPPORT, ITS BOARD MEMBERS, OFFICERS, DIRECTORS, EMPLOYEES, AND VOLUNTEERS (REFERRED TO HEREIN AS THE “PINEAPPLE SUPPORT INDEMNITEES”) FROM AND AGAINST ANY AND ALL DAMAGES, CLAIMS, LOSSES, OBLIGATIONS, LIABILITIES, ACTIONS AND/OR CAUSES OF ACTION WHICH ANY OF THE SIMS INDEMNITEES SUFFERS OR INCURS TO THE EXTENT ARISING DIRECTLY OR INDIRECTLY OUT OF OR IN CONNECTION WITH (I) PROVIDER’S NEGLIGENT ACTS OR OMISSIONS AND (II) ANY CLAIM BY ANY THIRD PARTY WHICH SHALL BE INCONSISTENT WITH ANY AGREEMENT, WARRANTY, OR REPRESENTATION MADE BY PROVIDER IN THIS AGREEMENT.

PROFESSIONAL CONDUCT

Providers agree to:

Abide by all applicable codes of ethics of their profession.

Abide by current privacy laws, respect the confidentiality of Pineapple Support clients and maintain appropriate professional boundaries with clients at all times, including in the use of electronic communications and social media.

Defer all gifts from clients, regardless of monetary value, including downloads, tickets to shows, passes or other items that represent some monetary value to the client.

Not identify clients by name in email correspondence; use only the Pineapple Support ID number and first and last initial.

Respond to all contacts and inquiries by authorized Pineapple Support clients, including initial requests for appointments, on the same day if at all possible but at all times within 24 hours during the regular business week. If the contact or inquiry occurs during a weekend or holiday, a response is required before close of business on the first business day following the weekend or holiday.

Respond to all contacts and inquiries from Pineapple Support Foundation staff (via telephone, email or text) on the same day if at all possible, but at all times within 24 hours during the regular business week. If the contact or inquiry from a Pineapple Support staff member occurs during a weekend or holiday, a response is required before close of business on the first business day following the weekend or holiday. Persistent failure to respond to outreach by Pineapple Support staff will be grounds for termination from the Network.

Be available for one or more face-to-face meetings with the Clinical Director, as needed, at the provider’s office, for a duration not to exceed 45 minutes.

Use evidence based best practices, based on clinical judgment and scope of practice (as allowed by state and federal law for specific education, experience and competency) to achieve the best outcomes for Pineapple Support clients.

REFERRALS OF PINEAPPLE SUPPORT CLIENTS TO PROVIDERS

Referrals to authorized Pineapple Support providers are made based on multiple criteria, including but not limited to, a client’s specific request regarding location, gender of provider, experience with specific issues or problems of concern to a client, philosophical or spiritual preference of a client, current provider caseloads and provider availability.

While Pineapple Support makes no guarantee as to the number of referrals a provider may receive, Pineapple Support expects each new provider build up to a caseload of no fewer than two (2) Pineapple Support clients.

PROVIDERS MAY

Discontinue their relationship with Pineapple Support at any time, without explanation, by notifying Pineapple Support by email, mail, fax or phone that they no longer want to be a Pineapple Support provider 30 days prior to the desired date of termination. Provider must refer all Pineapple Support clients back to the Pineapple Support clinical staff for an assessment and new referral to a Pineapple Support provider, if needed.

Decline to accept additional referrals by notifying Pineapple Support by email, mail, fax or phone clearly delineating the period of time the referral hold status applies. A period of referral hold may be for up to six (6) months.

Share their concerns and grievances with Pineapple Support clinicians and/or the Clinical Director and expect reasonable efforts and actions to achieve resolution.

Communicate directly with the Pineapple Support clinicians and/or Clinical Director. Confidential correspondence may be forwarded to the Pineapple Support office via email. Verbal communication may be shared by contacting the Clinical Director at +34 602 459 656.

PINEAPPLE SUPPORT WILL

Set eligibility criteria for providers and retain the right to terminate a relationship with a provider if a change in criteria renders the provider ineligible.

Use the following process when Pineapple Support has a grievance with a provider:

If Pineapple Support receives a complaint about a provider, Pineapple Support will contact the provider to obtain the provider’s version of the event. If the grievance is reportable, Pineapple Support Clinical Staff will file a complaint with the appropriate licensing board of the provider. If complaints continue, recommendations will be sought through peer review (the Pineapple Support Clinical Advisory Panel). If this does not resolve the concern, Pineapple Support reserves the right to place the provider on suspension until the issue is investigated and resolved and/or terminate the relationship with the provider and reassign clients as needed.

If the issue is malpractice or clearly violates ethical practice standards, Pineapple Support reserves the right to terminate the provider immediately and reassign clients as necessary.

AUTHORIZATIONS AND SCHEDULING

Providers agree to:

Immediately notify Pineapple Support by telephone or email when they are unable to take additional clients and/or if the provider will be away from the office and unable to take referrals for a period of time.

Return contacts and inquiries from authorized SIMS clients on the same day if at all possible but at all times within 24 hours during the regular business week, and within 48 hours over a weekend or holiday. Providers may request assistance from the Pineapple Support clinical staff if they are having difficulty reaching a client.

Notify Pineapple Support if the provider receives an Authorization for Services and the referenced client does not call to schedule an appointment within two weeks of the initial authorization.

Not be reimbursed for services provided to a client without a valid Authorization for Services.

Not be reimbursed for continued services to a Pineapple Support client beyond the expiration date of the Authorization for Services. These clients must be referred back to Pineapple Support for re-authorization.

INITIAL SESSIONS

Providers agree to:

Discuss the Pineapple Support fee schedule and Provider’s policy/expectations for payment of co-pays and for missed appointments during the initial session with a SIMS client.

Collect the authorized co-pay amount from the client at the initial session and every session thereafter, unless other arrangements have been made with Pineapple Support.

Fill out and submit a Provider Service Summary (“PSS”) at intake and at termination. The PSS will include a valid DSM-5 diagnosis, at least one treatment goal and, for established clients, an assessment of progress. At these treatment junctures, claims cannot be processed for reimbursement without the Provider Service Summary.

EXCHANGE OF INFORMATION WITH OTHERS

Providers agree to:

Exchange the minimum necessary relevant information with Pineapple Support clinical staff regarding services provided to the Pineapple Support client, as indicated in the Pineapple Support Consent for Release of Information form agreed to by the client at the time of the initial request form submittal.

Exchange relevant treatment information with other authorized Pineapple Support providers providing other authorized services to the same Pineapple Support client, including psychiatric providers, and inform the Pineapple Support client of this exchange of information.

CO-PAYS AND CLAIM FORMS

Pineapple Support will:

Compensate providers according to the Apricot Counseling Claim Form.

Compensate providers only the remaining balance minus the client’s co-payment. Providers are responsible for collecting the co-pay from the client at each session. Co-pays are assessed individually, so please refer to each client’s Authorization for Services.

Not pay for missed or cancelled appointments. At the provider’s discretion and in accordance with the provider’s individually established policy, as discussed with the client during the initial session, providers may bill the Pineapple Support client for the entire cost of a missed appointment at the applicable Pineapple Support rate. Pineapple Support will not pay for an extended session, beyond the usual and customary session.

Respond to questions about claim forms or other billing procedures. Contact Pineapple Support billing-accounting staff at +34 602 459 656 or email through the http://www.pineapplesupport.com website.

TERMINATIONS OF SERVICES WITH CLIENTS

Providers agree:

When the provider and client agree to terminate therapy, or if the client disengages for any reason from therapy for more than 60 days without notice to Pineapple Support or the provider, the provider will complete the termination portion of the Provider Service Summary within 60 days of the final session.

Providers will adhere to the ethical standards of their discipline and licensing board when terminating a client, ensuring that the client is notified in writing, provided with referrals where appropriate, and, where appropriate, offering the client 30 days of continued treatment during transition to another provider. Providers will clearly document reasons for termination and efforts made to notify the client. Should the client contact the provider to schedule an appointment after services are terminated, the provider will refer the client to Pineapple Support for re-authorization. Providers will not be reimbursed for services without a valid authorization.

Representations and Warranties; Covenants. Each party hereby represents, warrants and agrees that (a) it has the full right and authority to enter into and fully perform this Agreement in accordance with its terms and that this Agreement constitutes a valid, binding and enforceable agreement of such party, (b) it shall perform its activities under this Agreement in accordance, in all material respects, with all applicable Federal, state and local laws and regulations, (c) the execution, delivery and performance of this Agreement will not violate the provisions of any agreement to which it is a party or by which it is bound and (d) in executing this Agreement it does so freely and voluntarily, that such party has consulted with or has had the opportunity to consult with independent counsel of its own choosing concerning this Agreement, and that each party has read and understands this Agreement, is fully aware of its legal effect and has entered into it freely based on such party’s own judgment. Hence, this Agreement shall not be construed against any party on the basis that such party was the drafter.

Counterparts. This Agreement may be executed simultaneously in several counterparts, each of which shall be an original, but all of which together shall constitute one and the same original.

IN WITNESS WHEREOF, the parties have executed this Agreement as of the day and year first above written.

PROVIDER THE ADULT INDUSTRY SUPPORT NETWORK

___________________________________________________________

NAME:NAME: