Transition From MSA Administrators (MSAA) to CareGuard Member Terms & Conditions

The following terms and conditions are incorporated into the Ametros Medicare Set-Aside / Future Medical Allocation Professional Administration Member Agreement. Please read the foregoing terms and conditions carefully. They  outline duties, obligations and responsibilities of both you and Ametros.

1. RIGHTS AND RESPONSIBILITIES OF CAREGUARD

   CareGuard agrees to act on behalf of Member solely with respect to the proper disbursements and accounting of expenses from the Account according to the Professional Administration MSA Requirements. Notwithstanding anything to the contrary contained in this Agreement, CareGuard’s sole duties and responsibilities to Member hereunder shall commence on the later of the execution by the Member of this Agreement and the deposit of the Member’s funds in a Bank and are limited to the following:

   A	Place funds in an interest-bearing Account in a Bank on behalf of Member.
   B	If applicable, make authorized injury-related payments from the Account on Member’s behalf in accordance with the payment fee schedules and reimbursable rates under the MSA Regulations.
   C	Keep accurate records of the disbursements and additions to the Account and report those to Member; including reporting to the Centers for Medicare & Medicaid Services on Member’s behalf, if applicable.

   Member acknowledges and agrees that (i) as between Member and CareGuard, Member is not restricted in choice of provider for care related to Member’s injury and can seek care from any provider in the United States, subject to any restrictions set forth in Member’s Settlement Agreement, if any; provided, however that Member may be required to pay a provider directly and be reimbursed out of the Account upon submission of an invoice to CareGuard, (ii) Member will receive a benefit from negotiated volume discounts, (iii) CareGuard will make reasonable efforts to negotiate fee schedules and secure discounts on medical services and supplies on Member’s behalf, (iv) CareGuard may, from time to time, receive placement or other fees or benefits from Third Parties, including but not limited to, a Bank or one or more medical network partners in connection with the services that it provides. If CareGuard negotiates a specific price for a specific item or service on behalf of a Member, CareGuard will pass through to the Member that specifically negotiated price. For purposes of providing the services set forth in this Agreement and complying with its terms and conditions, including without limitation, making payments from the Account, Member hereby appoints and constitutes CareGuard as Member’s true and lawful attorney-in-fact.

2. RIGHTS AND RESPONSIBILITIES OF MEMBER

   Member represents and agrees:

   A	To provide CareGuard with Member’s W-9 Information and to notify CareGuard of any changes or enrollment in any Medicare plan.
   B	To provide the MSA or medical settlement funds to CareGuard if they have received them personally.
   C	To provide CareGuard with any necessary information that CareGuard may need to prepare reports and pay Medicare-covered and injury-related medical bills, including authorization necessary to communicate with health care providers providing services to Member, and to communicate with the Centers for Medicare & Medicaid Services on behalf of Member.
   D	To forward any injury-related and covered out of pocket receipts for reimbursement.
   E	Report any records discrepancy to CareGuard within sixty (60) days of the transaction date.