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HomeMy WebLinkAboutC21-144 Quality Health Network 1 Product/Services Order Exhibit B Addendum of QHN eCommerce Agreement Quality Health Network: Product/Services Order Form. Revised 11, 2016 Executed by: _______________________________________________ Authorized Participant Signature Date Participant / Customer Information Name: eCommerce Agreement Date: Contact: Contact phone: Contact email: QHN Services & Licenses for Access Access includes : Basic HIE services, QHN Direct, Pt. Summary Rate / Fees Quantity Total Setup, implementation & training: Travel expense (mileage at IRS allowed rate, current rate: $0. ) QHN technical services: Statement of Work (SOW) detail below. This Order is a supplement to Exhibit B of the eCommerce Agreement executed between QHN and Participant. Subtotal: Total amount due: Notes: Signature below authorizes delivery of products and services listed pursuant to eCommerce Agreement. . This Product/Services Order contains Confidential and Proprietary Information of Quality Health Network, Inc. and is intended solely for use by the Healthcare Participant or its agents. Valid for 30 days from: Printed name: _______________________________________________ Printed name / title Amounts will be due under this Order when Specified work is complete. Work is considered complete when system is available for productive use. License and Services Fees are delivered pursuant to the eCommerce Agreement with QHN. Special Fee Schedules may apply for special situations. Travel & out-of-pocket expenses are invoiced to Participant as incurred. Add-on Users to be invoiced per then current QHN fee schedule. QHN is not responsible for any Participant vendor fees that may apply. DocuSign Envelope ID: 6B5C4659-7B2A-41AF-920B-A3965A158CAB $150 $0 CO (-$0) 81631 $150 $53$53 11/10/2020 jeff.shroll@eaglecounty.us Monthly QHN access fee $0 PO Box 660 Adjustments: N/A $203 Jeff Shroll $203 This order is to add Elena Sanchez as a user of Quality Health Network (QHN). No training will be needed. 1 1 04/19/2021 $0 (970) 328-8840 Eagle County Government Eagle 5/9/2021 County ManagerJeff Shroll C21-144