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Name*

First Last

Title*

Practice Name*

Practice Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have additional bill to and/or ship to addresses?*

Yes
No

Address 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address 3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address 4

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Enter Email Confirm Email

Add the following accounts*

Widex
Oticon
Resound
Starkey
Signia

Widex Account Number

Oticon Account Number

Resound Account Number

Starkey Account Number

Signia Account Number

Do you want to sign up for manufacturer loyalty programs where applicable?*

Yes
No

I hereby authorize my accounts to be affiliated with Fuel Medical Group & Pivot Hearing. I have granted the Officers of Fuel Medical Group and Pivot Hearing access to account management information on my behalf. Please provide to them at their request whatever information they may require to administer our relationship, including but not limited to (1) duplicates of invoices, (2) refund and exchange confirmations and (3) account summaries. These arrangements should remain in effect for all of my orders unless and until you receive written notification from me. Please contact me if you require any additional authorization.*

Yes, I hereby authorize my accounts to be affiliated with Fuel Medical Group & Pivot Hearing.

This Memorandum of Understanding (“MoU”) is effective as of ( “Effective Date”) by and between Fuel Medical Group a Washington Limited Liability Company (hereinafter “Fuel Medical”) in partnership with Pivot Hearing and , hereinafter “Associate”). WHEREAS, Fuel Medical and Pivot Hearing have formed, and are the administrators of, a networks of elite hearing care providers (hereinafter “The Fuel Medical Group and/or Pivot Hearing”); WHEREAS, Associate is an elite hearing care provider; WHEREAS, Fuel Medical, Pivot Hearing, and Associate are interested in establishing a mutually beneficial business relationship; WHEREAS, from time-to-time, Fuel Medical and Pivot Hearing may, subject to certain conditions, desire to offer to Associate business advisory services and discounts for products that will be purchased directly from manufacturing partners that are affiliated with Fuel Medical and Pivot Hearing; NOW THEREFORE, the parties agree to the following:
1. Associates will be able to purchase products and equipment from Fuel Medical and Pivot Hearing’s manufacturing partners at negotiated pricing on accounts that are affiliated with Fuel Medical and/or Pivot Hearing. The accounts will be set up upon the execution of the Manufacturer’s Release form. The Associate is not obligated to purchase any set percentage of product through Fuel Medical or Pivot Hearing’s manufacturing partners. The Associate only agrees to work in good faith with Fuel Medical and Pivot Hearing’s manufacturing partners, receive product training and utilize such products when they are determined by the Associate, in their sole-discretion, to be the best for their patient’s needs. Fuel Medical and Pivot Hearing advocate the provision of covered services only when they are determined to be a medical necessity.
2. From time to time, Fuel Medical and Pivot Hearing will provide the Associate with business advisory services, in connection with the Associate’s practice, which may or may not include Marketing, Human Resources Support, Financial Analysis, Professional Development & IT Systems management. All of the services provided by Fuel Medical and Pivot Hearing are upon request by the Associate. The Associate will not be required in any way to adopt or adhere to any of the advisory services given by Fuel Medical or Pivot Hearing and therefore, Fuel Medical and Pivot Hearing will not be liable, in any way, for the performance of the Associate’s practice.
3. This Agreement shall be effective as of the Effective Date and shall remain in effect until terminated. Either party may terminate this Agreement at any time without cause by giving the other party thirty (30) days prior written notice of the termination.
4. The parties may have executed a Mutual Non-Disclosure Agreement (the “NDA”). If a NDA was executed, a copy of which shall be attached hereto as Exhibit B and are herein incorporated by reference. The provisions of such NDA shall survive any termination of this Agreement. The parties may have also executed a Business Associate Agreement. If a Business Associate Agreement was executed, a copy of which shall be attached hereto as Exhibit C.

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