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MEDICAL GROUP CONTRACT <br />This agreement is entered into by and between UnitedHealthcare Insurance Company, UnitedHealthcare <br />of Washington, Inc., and PacifiCare Life and Health Insurance Company ("Carrier", "we", "our(s)", "us") <br />contracting on behalf of itself individually and you for certain products and services we offer our <br />customers, all of which we describe in the attached Appendix 2. <br />This agreement applies to you and to your professional staff (the physicians and other professionals who <br />are your employees, or your independent contractors providing services to your patients, and who are <br />subject to credentialing by us) and the services you provide at the locations in the attached Appendix 4. <br />When this agreement refers to `you", it also refers to your professional staff. Your professional staff is <br />bound to the satne requirements of this agreement as you are. You represent to us that you have the <br />authority to bind your professional staff to this agreement. <br />With your signature, you confirm you understand the contract, the appendices, and the items referenced in <br />Appendix 1. <br />UnitedHealthcare Insurance Company Medical Group: <br />Address: Address: 205 W 5th Ave Ste I Ellensburg <br />WA, 98926 <br />Kittitas County Sheriffs Office - Jail <br />(Outreach Name) <br />Signature: Signature: <br />h_ <br />Print <br />Print Name: Name: <br />Title: Title: <br />Date: Date: _ <br />7 - A `f -;.- 5 <br />PacifiCare Life and Health Insurance Company Medical Group: <br />205 W 5th Ave Ste 1 Ellensburg <br />Address: Address: WA, 98926 <br />Signature: Signature: <br />Print <br />Print Name: Name: <br />Title: Title: <br />Date: Date: <br />UnitedHealthcare of Washington, Inc. Medical Group: <br />UfIC/SMGR.03.12. WA Parties bound to confidentiality under Section 'About data and confidentiality' <br />-2- <br />