EXT014 ACA Medical Service Provider Confirmation

__________________________________________confirmsthatourorganization(pleasecircle):

ProviderOrganisationName

HasreadandunderstandstheMedicalServicesPolicy,Version2.02,and

InprovidingservicestoACAanditsaffiliatedcommittees,meetsACA’sminimumrequirementsassetoutin theCOR017MedicalServicesPolicy,Version2.02.

ThisformisvaliduntiltheendoftheACAFinancialSeason(being31Decembereachyear),inwhichitis signed.

Signed:..............................................................................

Name:..............................................................................

Position:..............................................................................

Company:..............................................................................

Date:..............................................................................

IacknowledgethatIhavecommunicatedwiththeaboveMedicalServicesProviderandamsatisfiedthatthe aboveproviderunderstandstheminimumrequirementsassetoutintheCOR017MedicalServicesPolicy

Signed:..............................................................................

Name:..............................................................................

Position:..............................................................................

Committee:..............................................................................