Ordinance No. 6,127920121 -3
ORDINANCE NO. 6127
AN ORDINANCE AUTHORIZING AND DIRECTING THE MAYOR TO
EXECUTE AND THE CITY CLERK TO ATTEST TO A CONTRACT WITH
ALTA REVIEW, INC. FOR CLAIMS MANAGEMENT AND UTILIZATION
REVIEW; AUTHORIZING PAYMENT BY THE CITY OF BAYTOWN OF
THE SUM OF SEVENTY -EIGHT THOUSAND AND N01100
($78,000.00) DOLLARS; AND PROVIDING FOR THE EFFECTIVE
DATE THEREOF.
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF BAYTOWN,
TEXAS:
Section 1: That the City Council of the City of Baytown,
Texas, hereby authorizes and directs the Mayor and City Clerk of
the City of Baytown to execute and attest to a contract with Alta
Review, Inc. for claims management and utilization review. A
copy of said agreement is attached hereto, marked Exhibit "A,"
and made a part hereof for all intents and purposes.
Section 2: That the City Council of the City of Baytown
authorizes payment of the sum of SEVENTY -EIGHT THOUSAND AND
N01100 ($78,000.00) DOLLARS, pursuant to the Agreement.
Section 3: This ordinance shall take effect immediately
from and after its passage by the City Council of the City of
Baytown.
INTRODUCED, READ and PASSED by the affirmative vote of the
City Council of the City of Baytown, this the 21st day of
January, 1992.
rV ERRM - T
r�mt 0. 1UTTO, Mayor
ATTEST:
EILEEN P. L, City Clerk
(TWACIO IREZ, R., City Attorney
40 C:1:81:19
s
I-
r
This Health Cara Ma
(thin "Agreement") is among ALTA Review, Inc„ a Utah
cosp x*ion CALTM tae 16azy P= am .p co
Texts corporation (the "Phan Sponsor'). and (if other than the Plan
a (the "Plan Adminis ZWe), and is for the PrOAMOU of
' t servicres to or respecii� the City of B&Ttovn - G m Benef itA-. Play
health care
(the "Plan").
1. sun= the health ire ma�'emeat g'i'bes �IW in &a s Exhibit iu accordaooe
wen w d conditiam of the Plan sad whin then fr� ar Via'
p made by the l� Sponsor or Plan �. with the SoMM
Exhibit sad all b1e ba<► and regulatiaas.
2. FIEL
The Plan Sponsor"P W or cmusa to be pald to ALTA, for the servkes proaldad under this Agreement, the fees
degaibed in the afteched Fee Exhibit.
S. TEM ' shall begin on t�..� igg�, (the "Effective Dates and and on
The 3nitlal term of this Thereafter. .this A� @W be satomatic 0W renewed far sua�esSive one-year
teW 199
nted , m the attached Standard Terms and Conditions.
periods tulles tarmi�ted as proms
4. No Pmumay Avnwmy. 1 ee Retirement income
'The parties
intend that ALTA shall not be deemed a Plan "fiduciary" under � EMP o3'
She pay Ad of 1974, as stndrded CERISA*). Accordift*, ALTA's servim shah not include the Dower to make any
decisions as to Plan polfc.y, 2 or � but stall be 11mited to the Performance of only►
those ministerial hmea ns such as the types de=ibed in Depsc'tmW of Labor Dilation ?.509.755. D-2 Grelating
to clsims proc�essiag. calcuiadon of benefits. report p oa m1°� commuaicahoas' recommendations
p� etc,} w Wn a framework of polldes. �� rules. �� and procedw=
regard'lnf of this Agreement. ALTA's
maw by the plan Sponsor or Plan Adrnie *ator. Notwithstanding any other' provision
mvices with respect to the Plan shall be subject to re�vle�ar, modification, or reversal by the Plan Sponsor or Plan
Administrator sad ALTA shall have no final drscre�onarof say Plan or
assett. sad final discretionary► authority or
authority or control over the maflr�gemetit or dispo advise �, respect to Plea assets or
�Mty over p� administration. Nor aW ALTA reWc any kivestment
have any authority or responsibility to do so.
S. Lunar moN of LLOU r. t of Flsa benefits or liabilities,
ALTA shah have no responsibi ity► • or liability for buditg the Plan. for the paysYLet1 n t of insured
or for the failure of the FM or the Plan Sponsor, to obtain or continue M=rs= eoverNe PaY�'
benefits. Basest under the Plan, ie in the P1aa. ALTA shad use its beat eEfo render the agreed 80100
on servks
Flan Sponsor or those persons named from occasional errors or delays
is a timely and a= -rate manner. but shall not be liable for xw damages resaldnf
standards) in the provision of its aexviM from its good faith application of
(witfiin the range of accepted indirslry tnedicsl necessity. or bens% or from the failure of
Plan provisions, including those concerniaf eligibatq►, co+►e►
Pin participants or bem6daries to obtain any psr*Ww health are as a result of ALTA services. Nor ahall ALTA juWre of heakh care
be liable for any recommendations concerninf stops m a o p�onsored, arranged for, or prpded through health �
or recommended by ALTA.
e oePMftM IMt ALTA WOW **NO- WA-
EXNIW A
►tfwar.I
6.
Plea for sivB AiiA . Im deim. or
ftbft
*ft ad ft
of art afar bred oo W ddw for dks a--ar odw �
des P1aa S�oamr or PLn Admiaiepfor, as Fba emir or odwwbc W At
(d) do Pha% or AMM aliened Matsu r = Lwt w, Wauft
WaWe&" ararrao002an0 wad (e) ace or omits m of AMAlu '
11 8O f* w in accordanos with da *Gcdoas of a Ppm %ormw or rm
bond oa lan' ar lieb bluft reroo�ble —0-
misdow of ALTA. bat oath dw" Sots or "deown for A!
tie -melange; Vrar3ded ALTA shy aot be refit e
5poa�or iE the Flra Shororti ace or oaaiaiow ooa�booed to kt low, Rl�b � p
� o�this�r+eeme,�t,
Ub Avamot dmatbci edBAibieaad &NWWdTa= wad Conditimt
City oftv&t f Baytm ALTA RLV� W. INC
Strart 363 N. am Howes
. s.
Te>css 77520 WdraW moustoop-TOXw 77460 6-24
1300
Br
Pft Nsmx
'fide: - •,,.r_
We, Senior Vice Pyre Umt
DMa Dft
IF n 7l lr&lN I= PIdAk SPOMolb
(Administrator)
$9"
Print N=w
Titer
Daft
fw Wi*tb Oea ds®a ttiser ts�oeipt of the PbnAdmbbtratot's wthtda tegttett 6iovfag *te termiswlim of thisAgt+eattaat; IILTA tddi
dtdNer b the Ptas Admiais<rtbt; err iba designe6 those Plffi records b its paara�aias thstare daaibed in sacb 'L11e Pia t+ecotds
• rr� bedayeeted b the forrtsrt ie wtt;dt their are atabdbed by ALTA, bst than laciude:adBesdtt lorttdd e+rplaiddiow tnd doaanestadoa
m e rxipimf b here nnmedids nae o[tbe record kjm ddos. The pbn Spomor shd ramoburse ALTAfonll cods iaearoed to
Paviditte mch records. WAN the ooabs of proms ad Pm .I dmQm mad tdtsll pay mA addidomd tttdtatdiYaareed%W fee
(wow Be I ""odd or mq" of AM bor wpptft ddidmoal idmmadw sat aoatain d in tiro No v I I m Is I T) be swat *te
remora: doatmmhtioa isrindea ayaiems or p dMiOpd or Mod by, or l mood m4 ALTS ALTA shsb base dwright b Wgtwd
thdr ate aad see by ragditiol the trmdw b coda is arch a =ON dW w0 not permit the redpied b have eosin tree of &C
pleadl tortmsios. ise bloc adw*p d the pre0ecbed bfatmWaL ALTA 61 be eWW in
rsbb a wn of Plea rsiaards at ib mta wpm
D ALTAshalt =bW& dPlmtoW& ht ibpcmm im obrm Panes I aft aM dw basebem traasbrW b thePhs
Sp=worAdmWdm oraitsartbe�rdOdpmj tie i —pe AremoL
9. CMMD MALny.
0
A ALTA may witlthold prttdpat or bene6asrY method rrlcorda err other Mborttddon from Iny pow whm ALU
d�aa *pttttis ob%ted b d4 ao aaderfederal err state aoddmdiiq► attlabts or regttlstioss.
B. ALTA Ad kW amfideadd d mn* nft to *►e ft Ms W idpa* and %mfic trbs turd Ad dbdma dteiabrmados
in ttucb rocarde pl ed ptm Omt m the wee d= v a I) a* b tht Pt,a A&ddtabr, the Ptm aom dtotr duigm or by
order of a cowl d mspdent reque>a>t HA, i ALTA m* howam; sae Plea dad for or reparlbg MI' lea iR a
mmw t Ak reaaosably a pecb wit sot dhdme ooddeslhl biormetlnn ideali� hie wi8t apec'dic Pbs pr*cipanb or bme5daries
10. I�t.Aciwpt.
IE0. ttadon bbroagbtagabst *te Flo or ALTA b obtdn Phm betalb far dmid ddms. at the wtxbm mgttestaad d the sole mdo( to Pisa a the
fbn $poaeor, ALTA dA b the g*d each is wWm its canb a mace ttabtbb b testify► dim* a b such mailer, the apprOOW phyrWm
tt PAP ttma or mY other w@bym dm+ * imtoW in vA maw gap* in dds Avtrtmt is vd* ser w d wkh a ssbpeema, & msery mgaett
,or produtibn d Momma. w other legs! procaa fiat hoemn, the " M"W droll immediRtety no* the oft pub► is *tat h MW
dderntiae whether my d tt: aoaidmtid err propriebcy dst4 reports, err albs probed statarbls tt�ay be ittduded is tirc tt The caner pto't� mq►
st Sd arm arpeasa pie Bite ooafideotid'�q► d id ddi No pvgr tf uII htee sa ob�tiam b mutest aWr Legal Process.
11. PROPRWARY AM-
Eadt parq► m thb Ae►'� � the validity of the outer ptrrtiea' aerviceaduln► irademarkx trsdmatttesr p � and �
not b my way infdw Wtoa or otherwise berm their bl i i m is meh property. Durime the terms of tltisAgretsa 4 the Pin SPMW and
AdmWsltgw rtM bare aoosaa b kbrmiidm of a ptopeiedry ttt I o W or demloped by, or licensed k4 AM bit sot IWW for
bforttttttiatooaoarabr P atd methods saed byAL1� aad olltainfnrststiom ttttvked "oan6dnttiel,'"Rp�1�'ar`aot
for pabfie �edost�' IooYectively tite'lnforrnatioai, ad of which i�are�uutsabe bALi'A The!'bm Sponsor std �t�aotb aQy wq►
dbdoft &UIMMK twbV4 or mad to may ptaon or ass for 0* m benefit SDY of the bbwabiom which they my obtda 0=0 as
C-0 l mtplaled by tiro llgtr attmt, bo gavanasatt sgeorSes as aaq►be rsqui+sd for rapor6� patposes, or m a person who las obtidoed as otdcda
nowt of aw d atowic*om regWft wdt d'Idomm ALTA, & tW ordwdw berm of this Agtemtm. may Waal acdms d*k maa w*
dem aeoteory to Rearve the aomfidmdit of the labratdok ib imtet•edoa b any kN prsoealiug ooacersot� BteIdormation'a ass
or A&Mrs Fadt "hereto acbtowledga dW the mn* st law for lqbft6lemCDtOD Of aaaathorW tun: ordisdamdrite letortttdioe
fmda Any
b tefiet aesy be ttrnW widtout bold, which e>& party does berebyweiuL �e rend in s to a� atb�r �bie
12. fit.
. ti A@Y pert►"have lire right b terennde dns Avemme by w&m m dm to ffied er Wfim
W blfe ft as of de bu'bm d &W other pro to an my momadry dd uk Loch ft ft tin b pay AI.TRs fees and
dwo or w properly provide hr or pay tdlotrd &* wilhb five Wender days after wide sodw t wu4 or the fitbm m
cotttmata b cart IW other defaak within tai a>>mdsr daysatter + notice them
.GWftMgoo, ALTAW.md* rwIl ML NowoaNruorw
0
ALTA sbaE provide dre hettlfh atro t mt unias &W bdm butody ftaforvnticie s fee is provided on &a Fee wit
A. Now t!P 5nwcsL
'imn sae m w mtmortices' ao■ittaf a w*m of; m -pecd-% eooduued slay and rehoapetre r+aoiew of tT7e me"
neestit� mstaurUorsppropeia0aoes, aEheurlfh tmd bebmlonlatre strrvioeR s,tid auy attrer ttpeci6ed rtt�lcd seevioas sorh ss
mu"ft ass =MW MK *0 MW of hapW dNsbk tmmatpeateat< end desbi pr*a&mt mw a Pm* cn
mmWemeotttervioes daft be provided o* forbeffi aenetervioes rmde><od or to be rm&red in the Unitaed States b Pfd
pa'4&4l andbeoe6dnieswithpriall"C xer�eRaidedladepla
B. &JGI W Oft CDYI M D6l ATlONB.
ALTA's he& cm =uprnat services do sot iodude i pamrfee or cetkndm of the sir of the recipimt or da
mverape atthe service coder dre Plea prevlsieot ALT1! a�gptteddesit�igrasd coverage iafornumon ip m4necdao wkh ite
hub cn aaoyttr aW serviose to-do etimt it is aware of A ntevsooe of uch ioiorrn *m to a psrdalu heft we
recipient er unite, bat tW not be obftpfed b do sa Axnp d* to tbb Aat Ad be iaduded witb At 2 tarsi
and and td deimairwdont Nor dad my eta arcoasrr�a hformadoo be pearided antD 90 bays ttfi;erALTA's receipt of
such iatormatiaa.
C. 19ff•Up S RMM
ALTA w3 mOe br sae stmdar+d employee p t�apBsh cal Spsaisb veniea provided foradddiopd tee)
per Cones- lfmplo m the Wft of Pisa bm& storntafm% &a osttitsdoa of WW= ielephoae service Of for die
parforanasoa afmr*esl, sad the ftWidomiafdedkwmd dd No wriilten orprkW naterial &wNqjAMs haft are
rmrtsp, - serviars dW be retassed or dishWW v %oatAiLTlks *rvM m atuaeat AM shall be re>t*mw Qor dre
fWmcimy sadr mtle ds at ib Hard end arstn wy eonu ft tee dams
AM Ad bete the rW b r* epos the rsoommdodaGma of we or more phpiasns licensed to prae W nad'V= bat ABTA
a* Main in the miry of physician reviewer in comecdm *6 haft are mmapanent services.
L Amem NKmtf7 cw &Vm
COaliefW viva AM& lade of dimdomry =ftrity or omhd om Pisa ttdmbistt&dM the bukh cane m=Wnmt services
povu mpreaeat >dvhory appiadoas of Pha patvMM MOOM melt neotmity, apprap uft ms, aad aher metros
tabjedeo maim mW!aeou, orrw&Wbyr$ohnSpoasorarAdmioi wft ALTAsha saberespooabisforthe mu bof
hub are provider services or for the mea Wft of sock seniors in aocardnm with appropritte medical sasdsrds or
Procedsres Deciitoas or daemerimdoos m obttds or dancer my heddr are str -dw stab Arm be erode oely by do pdw
aWar bis or her physician anti /or hospebtt.
II. DSAM CM MAMA DWff- 1xpA'MW MANAG0f W.
1. Pta adores of service:
I Preddmation of physician fees.
& Pruu futkm of all hospital admWms- Ifiduft o and cdeaaW dependency admiatiaos.
4. Admbsioon review (ell inpatimt adrriesi W.
• e coo " IWI a r► w.tm ar wgt.., rK.
Harcarreeacr.7
M BfbdM a of &e date any other"bem w bohremt: It adWklW a a baniorog b business soma iDb
poaaadoa or MUM on teas wetly, of my true in bmlauptgt ba a recxteer appoi W for k or makes a samml
lw*ebenadtof a dito % &ft 13J Effective as of the exprratioa of td file other parties than 6l) days advanae�writtea notice prior b am
re WIW term 6weofi provided &a V" gitrea
acpi dm dalm or
(4) E bavemofb edbcfvedatedwyV npoaetlad*mtb9ALTAtotbemcn berparsuaatbtbealtachedFee
B>hlbit E 8sr Plan Spoasordoes aatsoocser�lh arch a
B. Upon&eefbcdv &b4f6eateZmfaalioad*&A4r mWfw=Y 1 1
(U M pebr va pay b the otlrer parties sA moaiaa do b them under @dt Agreement winds Ihi<b► days aftrr the
dbeedvedstedtho Wmni &&
cc TheP!a► SponsorandAdmiaimratnrabaE iaomedhtdY ceae b mpumtthatAMis a M P" sedoe provide
for the Blau and stroll acme In =&M do0001% employee coram nintiom rrr*&% ► bP"% scrubs aaart
metLoda sad tedraigaet is tmy hm sad the Plan Ammar &hall dose Se NO
partieipaabt and beaa8dariea d dm larroinatioa d thin l�reeateat.
qj ALTA shall ddiMer the Pi's reoorda b the Plea a provided for under "Boob Hader �e A�eearmt I�
t►uader of the records as so requif t+ad► ALAI► sbsll line ao iurfber obli�dan m parb+n aoY
boemm AM is requested b ooadaue p waa ft daims or b perform other aer+doa for or widr raped to the Pia &tier the
dfeehve dab of the termim", bat p W to the Wda of moord% ALTA small be paid the fees provided fro such pose
to mim iim a -An in the ao" Fee Eft t
U Dts &bP* i. written a ment d dm Plea Spoosar swept to a subsid'ory a
ALTA aiaU not delgpole ib oblgpsims under this Agmammt the prior
a0essa( ALTA
19, Bmw 11i; No TM PA �.
J%A mvAat droll be biadiag upon and mare to the b a t ai dle penes haft wd their l evert v slrom» ors and permitted asecgas. ti`iotlimg b
66 Arleemed express or implied, is intended to oonfer upon any odrer person any rlAts, rwodies, or obrvadm under or by reason of this
Aveallat
15. Pim &mam Pux AMKMC M
Uaida the axtteat requires adterwis� tine term ?m Spom a or To Adrruaisblw as used m this Agrear at shalt indude any mpotadoa,
prom* mm km trustea of s trust, or odtar entity or lndividud spoaso N or admiaislcriag the Plaa at dw dme of orawtion of this
Agreaaoeot sad aba>> also eldWe each additional or onmeseor ioatvidnats or adho nevus from time b time dwing the lean of this Asmeorent
provided, howsm diet wb ac dda Agreerrreat arils for direction a atioe lobe glum to ALTA by da Ana Spomor or Ana Adm or. ALTA M
be absoWlr pro0ecded in rdyW upon any direction or notice raoelved tram the persons aecuting this Agreancat a Ptaa Spoor or Phu
A&nWdmbx
16. DMEWDW CbfMc.' L
ALTA is a+p A" dwWwWW or deemed b bead 'amp' b*e Of dw Plan as flat term is defined uWw ERU section 300) or nay
odw&X( able kdlad or slate law.
17. bm A SVI AMOMMM
'ibis Agre=A i 0oding al schedules, whbib and amendments bw to. amstimtea the eofn Agree<a d smoag the parties sad supersedes ati
prior popeads, &NMi= sad w ft by sad between the parties and rented to dhe subject matter of this Agmwmt The Agreement maybe
mmNed, emended, orsuppi =tK bdoa Ybya w ifto insaum denernted by &D parties, ac* ticfee W)m m is pmpmW byALTAsad not
o�ie�0edbby atber ire AattAdmiaistrstororP�a SpanaorahallshoatastldtbabiodiagsmacdmaEk 'the psrtiesad�rladge9ntthe Phan ondu
• G*pW 101 A1.YA HOBO aN I"WL blL HOMCCUMAM
0
ft Sponsor asst' bpe edte sd tom wpvjfmWowwftvA aftiW u of AMA far other types of servi0su► but such sweemenb da be eoa*W
and enforced now& dyfi=dlhAV"M"t.
18. SWAURM.
Ifawpm fdoncidbilusAss P,
sdditioa, do W or mwbu" pwWon fdsdt be modified so as to cmf orm to the a tedaliy p m the or" to d of
suchpwWmL
19. Fb=MAn=
mo term %i= a*ursf' frbal mem ae act d God, WIA mbasrt of other WON d *zb m9e, sm tiat uhf 4 fim *fm flood. OONIA
doersstfaml mt3oa or daibti � err besddawstt of egfdpasem�t and aagr o6tsr tams ant rsosoosbhr � die fw�oi of die pftrgr t�ttiat
susspemioa. Tfieobfapdoas ofony pnrq►=des dtbApnmoffitodterdw dodopdoa m mda mfineyp I l 6 fdbews awW dui s 6s
coattaumce of a b�aa as +e epp>•ir�bte m dui pflefat "fire fJferfad pmsrb iad ffse ffh rasoaa6le dllttaeoce m rensoaer to the m" rI a it
pndlaibla,dteiaoean�euros dionaaq+ ►e �ie 6ont acsmW 00%.butdd adbe row" loaeltb*la%wdmo tae
otberlabordid�culdeaoonha <ymib+iLdw�
X Gam UP,, JUMUC N MD VDM
To dseemmt ant o by EXUaradwkhW bg ddsAgmemed dialbepmnwd by and cm*w d underda lacer of **SMe dam'
By a%* I o"Apeemest do Piro AdmiaWramr aad Ptaa subjeetdwas I to W=d NrMcdm is dm marts of &e SWeaf Unh
ad on dot ft b the a* ap maide vase for fray afdioa h as tt fo Wpret or edforae my pwWm of this AvemmK or wM mw
okrwW v*m rider or rsdfsfe to dhf: subject matter of this AVeemmt
21. Nam.
AS mod= shall be in wrida and Ad be hxdd&e ed trassasided by to mM arse d by Mi*md or =AM C4 Mtn receipt reMiA fa
the addsYas > ca the
MociddsAvammtwion&otberW=hrisWbygmaidmm A hwWei' &ad ar Wsmpied.
asAtoe Basil be demmd dl+sea aob► �a >tctway rerdved. A astifoe freotby regifrtend or oerd6ed mdl doD be dammstd Qivm on the tksft m ofxnraf its
acted rer*orthe fib day after the date nab d as evidenced by dse smski+s miN or re jsiered sad reodpt
eoo�Aar no+ AM HaL ft Mmmgi ., rL HdAC011rRAGri
77, 31 •97 10s 43 ALTA HEALTH I- IOLIS"fON 7t 924 ' -
S Qj& aoMmued afar mmMmimt
& b►p@dW bftWd cage rAmW=t
I cybussim
10. OaftommumdudiaL
cmmasecim bepme opener
� Pba�►.au�
coroe�yA�r,► ��
Harm on Rod bmim 1�1 Keee �ep>toeemt
LNUobw Ve"Hernia
it &e wWs to prdo. troM& pli $kikne and loo
11 Haft Wm mmdm urvim vie tod im number Of nereary).
It stmdgd Ac lMly reports.
III. RNs Cats MANAGOUNr Pt.I.
1. Alleervicxapnvolded in Heaith Cami~da�anmi
2 Phyeiam iee nWtiadon Gnpntimt admiaaions only)•
N. EkM CM MANAGMiirfl' COMHEOM
1. AIl ee�vioes included is Haalth Cue Mao�neat
2
Fhy*Wimmpdsdm 6np wt xlu= iaae oey).
& pewrdfimion of the k&ywi w prow&m
Amiocen6eds cau net
An Wm*of Pedp wd kkdes Cu minim Ww flan Aer Wa)
Ar6ros w &ate Calo++os M
CclpD=w
&oachoso W Coni:"of cer&
Buniommmf► CoronaryArteiiVspby
Cardiac C tion a scan k boar "steo
Cups1 TUOW cyeOaeo w
o Cwo" 1N1 ALTA HmVk ft*$ w. MO.
' OCT 31 '91 10:44 ALTA HEALTH HOUSTON 713- 873 -5924 P. 10/18'
0
L Finn b* ibibaimcrednoM=iorbigkM&dtiamdaak"ap;rop Wk
2. Swats rr;w
HOSPUBM
• A WW for debscdm of bft anon► i.e:, dorm for eervioes dat were not ordered or were ordered but not
Presided.
Mecircet aeom* MM of dre spproprieimm of dw s imwm 646 of sft sad se:vicea b cues in wbidr
prlc0el"�m - Ind mneurrm review tmk pbm ■ sdrdatic* vdid sit cf ifie medint r=rd tQ enaare
dtst mote kbrrnsdm vu presorted *dw dmeaf the meow
I Smn WA tr4ilyfiV ts,
Vx AISMARW EINAUC RAL KUAMP POOM
1. SpeasCnoed cm mu�mt Pro+kW by PvhubW sari whb idvtowd dgpn aWor eeperietex is the bdrsviorel
sdesoes.
2 Pm wffimdm wd 000enmt oertll CWN ohevim provided in s provider's dim or based ser...
3. Sand -rd Ac Mty cwt.
eoafINI ALTr►caratMmW@ftk%
WdAOOWrnscsr
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a OCT 31 191 1044 ALTA HEALTH HOUSTON 713 - 873 -6924
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above $� Aer omw Emp om per month
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11�e moatbbr fees pavided for above s6sif be psyal� oo ar be6oro dre titb� day of each moat fa aii�i ere irna�rred, based upon
d o.mbera OpwW Employees ad the bg day of die pre o ftmoah. PqmewMbvumpmWbyamWWkaftdwWW
namber of CovmW Employees, mad gm number of Covered Woyeao wkh fw+ War depeodmt c mum, as of the and of the
peeehs moa& ALTA shdibm the right b 6e PWs bodmud om u& r bft b Coeered Lmbym dudoE Hormel k*m
hmnud upon IS hoom sbasee written notice m ver* each imm li&9 Psa msifs sa aoeoant aiwwW ALTA or an mate has
withdraad aft* to pri ft beoeft ALTA 6 adlwW to dedaat ifa ma * imes fiam sodr account as soon as die Pan moPmm
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