[Name of Hospital]
[Address]
[City, State, Zip Code]
LETTER OF AGREEMENT FOR COVERAGE OF
[Clinic Name]
BY [Hospital Name]
l. Effective [Enter Date], all medical admission patients of [Clinic Name] will go to the [Hospital Name]
service when admitted to the Emergency Department, unless previous arrangements have been made.
2. Additionally, when requested by sub-specialists, [Hospital Name] will provide in-patient medical
consultations for the patients of [Clinic Name] primary care physicians (PCPs).
3. [Hospital Name] will not admit nor accept care of any patients less than 16 years of age.
4. [Clinic Name] will notify [Hospital Name] 90 days in advance of any new providers that [Clinic Name]
hires.
5. When a physician has been involved with the direct immediate care of an outpatient that requires
hospitalization, the physician will be required to contact [Hospital Name] point physician through
transfer/admit center (TAC) to inquire if [Hospital Name] will be able to provide admission to the [Clinic
Name] patient. If [Hospital Name] is available, physician will need to verbally discuss the patient's
condition with [Hospital Name] physician that will be accepting the patient.
6. PCP is responsible for providing pertinent chart notes, problem, medication & allergy list, Living
Wills/POLST forms and emergency contacts to either be sent with the patient or faxed to the
appropriate medical floor.
7. [Hospital Name] physicians (or their representatives) will be responsible for calls from the wards
regarding established in-patients that are followed by PCP as outpatients.
8. [Clinic Name] physicians are welcome to provide "social visits" to their patients when hospitalized, but
we ask that [Clinic Name] physicians do not write orders on those patients. Please feel free to bring up
management questions to the attending [Hospital Name] physician.
9. Electronic medical records from [Clinic Name] will be made accessible to [Hospital Name] physicians
from [Clinic Name].
10. Post hospitalization follow up will revert to [Clinic Name]’s physician. [Hospital Name] physicians will
provide the [Clinic Name]'s physician with a dictated discharge summary detailing the hospital course,
pertinent discharge diagnoses and medications along with suggested follow up testing. Typically, a postdischarge follow up visit will be suggested or scheduled for the patient at the time of discharge from the
hospital.
11. [Hospital Name] physicians (or their acting representatives) that provide inpatient care or are listed
as the attending physician will bill and collect for services provided to [Clinic Name]'s patients.
12. With the staffing crises of [Hospital Name] and dependent on community physicians commitment to
fill shifts, [Hospital Name] reserves the right to withdraw from this contract.
13. [Hospital Name] reserves the right to periodically re-evaluate this arrangement and discuss the need
for revisions with [Clinic Name]. [Hospital Name] will reassess their hospitalist service workload at 3
month intervals.
This Letter of Agreement between [Hospital Name] and [Clinic Name], hereby approved.
By: ____________________________________________
Date: ___________________________
[Title, Hospital Name]
By: ____________________________________________
[Title, Clinic Name]
Date: ___________________________