HomeMy WebLinkAboutC12-085 VVMC Diversified Services AGREEMENT BETWEEN EAGLE COUNTY AND VVMC DIVERSIFIED SERVICES dba EAGLE CARE MEDICAL CLINIC AND NORTHSTAR UROLOGY FOR THE PROVISION OF FAMILY PLANNING HEALTH CARE SERVICES This Agreement ( "Agreement ") dated as of this f f day of i LAI, 201 is between the County of Eagle, State of Colorado, a body corporate and politic, by and through its Board of County Commissioners ( "County "), with a mailing address of 500 Broadway, Post Office Box 850, Eagle, CO 81631 and VVMC Diversified Services dba Eagle Care Medical Clinic and Northstar Urology with a mailing address of P.O. Box 40,000, Vail, CO 81658 ( "Contractor "). WITNESSETH: Whereas, the County, through its Department of Public Health, works to promote the health, safety and welfare of County residents of all ages; and Whereas, in order to promote such health, safety and welfare, the County encourages the provision of family planning health care services for County residents in need; and Whereas, the use of outside providers of such services enhances the ability of the County to promote such health, safety and welfare; and Whereas, Contractor is a provider of such a service and wishes to contract with County. Now, therefore, in consideration of the foregoing premises and the following promises, County and Contractor enter into this Agreement. I: SCOPE A. In accordance with prevailing medical standards, Contractor shall perform vasectomies for clients of Eagle County Public Health Family Planning Clinic who are over the age of 21, have been referred to Contractor by County, agree to receive services from Contractor, and who have signed the consent for sterilization form attached hereto as Exhibit A ( "Clients "). The vasectomy procedure covered under this Agreement shall include one pre - procedure consultation (exam), the vasectomy procedure (procedure), a post procedure sperm count, a post - procedure 3 month clinic visit and all associated lab work involved with the procedure. County is responsible for determining the eligibility of each Client. Contractor shall provide services for up to 13 Clients that are referred by the County during the term of this Agreement. B. Contractor shall not perform any vasectomies for Clients who have not properly signed the consent form attached hereto as Exhibit A. Contractor shall not obtain the consent of any Client who is under the influence of alcohol or other drugs, or who does not appear to be mentally competent. A 30 -day waiting period between the time of consent and the time of the procedure is required with no more than 180 days passing between the date of informed consent and the date that the vasectomy procedure is performed. If the physician performing 1 the vasectomy procedure is not the person obtaining the Client's consent, then there should be an oral explanation of the procedure and its risks and benefits so that the client has been fully informed, understands the vasectomy procedure, and has freely given consent. C. Contractor shall submit monthly reports (See Section VI.F below), in addition to monthly invoices for payment accompanied by a signed consent form for each Client served. II: TERM This Agreement shall commence January 1, 2012 and shall terminate on June 30, 2012. III: COMPENSATION A. During the term of this Agreement, Eagle County will reimburse on a monthly basis Contractor for the costs associated with the vasectomy procedure, as identified above, in an amount not to exceed $625 for each Client served by Contractor. The vasectomy cost agreed upon herein shall include all surgery costs, anesthesia, facility costs, lab fees, one pre - procedure exam, the vasectomy procedure, one post - procedure sperm count and one post - procedure 3 -month clinic visit. Contractor may not charge Clients any additional cost for the services described above. All invoices must be accompanied by a copy of a signed consent for sterilization on the form attached hereto as Exhibit A; payment will not be made unless the County receives the required consent form. B. Contractor may bill County only for the specific services provided during the previous month and may not bill in advance for services not yet provided. County will reimburse Contractor on a monthly basis for Clients served during the previous month upon receipt of properly submitted invoices by Contractor. All lab fees must be concurrent with the Medicare reimbursement rate. C. Payment for any unexpected complications or additional visits or services beyond those described in Section I of this Agreement will not be the responsibility of County. Contractor should arrange directly with the Client for payment in the event of any such unexpected complications, additional visits or additional services. Unexpected complications include, but are not limited to, bleeding problems at the incision site or internally, infection on or near the suture of incision site, problems related to the use of anesthesia, and allergic reactions to drugs. D. The total cost of this Agreement shall not exceed $8,125 absent an amendment to this agreement signed by both parties. E. For reimbursement Contractor must submit invoices by the fifth business day of each month. Invoices shall include a description of services performed for each Client during the previous month. If County is not satisfied with the completeness of a submitted invoice, County may request Contractor to either revise the invoice or provide additional information. Fees will be paid within thirty (30) days of receipt of a proper and accurate invoice from Contractor for Contractor's Services. Billings for services provided through June 30, 2012 must be submitted by July 6, 2012, in order to be eligible for reimbursement. 2 All invoices must be mailed or delivered in- person to the following address to ensure proper payment. Invoices sent by fax or email will not be accepted. Eagle County Health & Human Services Business Office 550 Broadway P.O. Box 660 Eagle, CO 81631 F. If, prior to payment of compensation, but after submission to County of a request therefore by Contractor, County reasonably determines that payment as requested would be improper because the services were not performed as prescribed by the provisions of this Agreement, the County shall have no obligation to make such payment. If, at any time after or during the Term or after termination of this Agreement as hereinafter provided or expiration of this Agreement, County reasonably determines that any payment theretofore paid by County to Contractor was improper because the services for which payment was made were not performed as prescribed by the provisions of this Agreement, then upon written notice of such determination and request for reimbursement from County, Contractor shall forthwith return such payment to County. Upon termination of this Agreement as hereinafter provided or expiration of the Term, any unexpended funds advanced by County to Contractor shall forthwith be returned to County. IV: PROHIBITIONS ON PUBLIC CONTRACT FOR SERVICES If Contractor has any employees or subcontractors, Contractor shall comply with C.R.S. § 8- 17.5 -101, et seq., regarding Illegal Aliens — Public Contracts for Services, and this Contract. By execution of this Contract, Contractor certifies that it does not knowingly employ or contract with an illegal alien who will perform under this Contract and that Contractor will participate in the E -verify Program or other Department of Labor and Employment program ( "Department Program ") in order to confirm the eligibility of all employees who are newly hired for employment to perform work under this Contract. A. Contractor shall not: (i) Knowingly employ or contract with an illegal alien to perform work under this contract for services; or (ii) Enter into a contract with a subcontractor that fails to certify to the Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under the public contract for services. B. Contractor has confirmed the employment eligibility of all employees who are newly hired for employment to perform work under this Contract through participation in the E- verify Program or Department Program, as administered 3 by the United States Department of Homeland Security. Information on applying for the E- verify program can be found at: http: / /www.dhs.gov /xprevprot/programs /gc 1185221678150.shtm C. The Contractor shall not use either the E- verify program or other Department Program procedures to undertake pre - employment screening of job applicants while the public contract for services is being performed. D. If the Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien, the Contractor shall be required to: (i) Notify the subcontractor and the County within three days that the Contractor has actual knowledge that the subcontractor is employing or contracting with an illegal alien; and (ii) Terminate the subcontract with the subcontractor if within three days of receiving the notice required pursuant to subparagraph (i) of the paragraph (D) the subcontractor does not stop employing or contracting with the illegal alien; except that the Contractor shall not terminate the contract with the subcontractor if during such three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. E. The Contractor shall comply with any reasonable request by the Department of Labor and Employment made in the course of an investigation that the department is undertaking pursuant to its authority established in C.R.S. § 8- 17.5- 102(5). F. If a Contractor violates these prohibitions, the County may terminate the contract for a breach of the contract. If the contract is so terminated specifically for a breach of this provision of this Contract, the Contractor shall be liable for actual and consequential damages to the County as required by law. G. The County will notify the office of the Colorado Secretary of State if Contractor violates this provision of this Contract and the County terminates the Contract for such breach. V. TERMINATION County or Contractor may terminate this Agreement at any time and for any reason or no reason upon written notice to Contractor specifying the date of termination, which date shall be not less than ten (10) days from the date of the notice. In the event Contractor files for bankruptcy or is declared bankrupt or dissolves, County may declare in writing that this 4 Agreement is terminated, and all rights of Contractor and obligations of County, except for payment of accrued but unpaid fees and expenses, shall terminate immediately. VI. CONTRACTOR'S DUTIES A. All funds received by Contractor under this Agreement shall be or have been expended solely for the purpose for which granted, and any funds not so expended, including funds lost or diverted for other purposes, shall be returned to County. B. Contractor shall maintain, for a minimum of 3 years, adequate financial and programmatic records for reporting to County on performance of its responsibilities hereunder. Contractor shall be subject to financial audit by federal, state or county auditors or their designees. Contractor authorizes County to perform audits or to make inspections during normal business hours, upon 48 hours notice to Contractor, for the purpose of evaluating performance under this Agreement. Contractor shall cooperate fully with authorized Public Health representatives in the observation and evaluation of the program and records. Contractor shall have the right to dispute any claims of misuse of funds and seek an amicable resolution with County. C. Contractor shall comply with all applicable federal, state and local rules, regulations and laws governing services of the kind provided by Contractor under this Agreement. D. Contractor shall assure that the service described herein is provided to the County at a cost not greater than that charged to other persons in the same community. E. Contractor shall safeguard information and confidentiality of all clients in accordance with rules of Eagle County Public Health, and the Health Information Privacy and Accountability Act. F. Contractor shall provide the County with a monthly report of services that includes: • Name of client • Client's date of birth • Dates of service and service provided • If client decided to cancel the procedure VII. NOTICE Any notice required under this Agreement shall be given in writing by registered or certified mail; return receipt requested which shall be addressed as follows: COUNTY: CONTRACTOR: Eagle County Public Health Director Contact: Tom Mars PO Box 660 VVMC Diversified Services dba Eagle, CO 81631 Eagle Care Medical Clinic and (970) 328 -8819 Northstar Urology PO Box 40,000 Vail Colorado, 81658 5 Notice shall be deemed given three (3) days after the date of deposit in a regular depository of the United States Postal Service. VIII. ASSIGNMENT Contractor shall not assign any of its rights or duties under this Agreement to a third party without the prior written consent of County. County shall terminate this Agreement in the event of any assignment without its prior written consent of County. IX. MODIFICATION Any revision, amendment or modification of this Agreement shall be valid only if in writing and signed by all parties. X. INSURANCE Insurance Type Coverage Minimums • Workers' Compensation Statutory • Employers Liability, including $500,000 Occupational Disease • Comprehensive General Liability, including $1,000,000 per occurrence, $2,000,0000 aggregate • Professional Liability Insurance $1,000,000 per occurrence Contractor shall purchase and maintain such insurance as required above and shall provide certificates of insurance in a form acceptable to County upon execution of this Agreement. XI. MISCELLANEOUS A. The relationship of Contractor to County is that of independent contractor. No agent, employee or volunteer of Contractor shall be deemed to be an agent, employee or volunteer of County. B. In the event of litigation in connection with this Agreement, the prevailing party shall be entitled to recover all reasonable costs incurred, including attorney fees, costs, staff time and other claim related expense. C. Invalidity or unenforceability of any provision of this Agreement shall not affect the other provisions hereof, and this Agreement shall be construed as if such invalid or unenforceable provision was omitted. D. Contractor shall indemnify and hold harmless County, its Board of Commissioners, and the individual members thereof, its agencies, departments, officers, agents, employees, servants and its successors from any and all demands, losses, liabilities, claims or judgments, together with all costs and expenses incident thereto which may accrue against, be charged to or be recoverable from County, its Board of Commissioners, and the individual members thereof, its agencies, departments, officers, agents, employees, servants and its successors, as a result of the acts or omissions of Contractor, its employees or agents, in or in part pursuant 6 to this Agreement or arising directly or indirectly out of Contractor's exercise of its privileges or performance of its obligations under this Agreement. E. Contractor shall comply at all times and in all respects with all applicable federal, state and local laws, resolutions, and codes. F. Notwithstanding anything to the contrary contained in this Agreement, County shall have no obligations under this Agreement after, nor shall any payments be made to Contractor in respect of any period after, August 31st of the calendar year of the Term of this Agreement, without an appropriation therefore by County in accordance with a budget adopted by the Board of County Commissioners in compliance with the provisions of Article 25, Title 30 of the Colorado Revised Statutes, the Local Government Budget Law (C.R.S. §§ 29 -1 -101 et seq.) and the TABOR Amendment (Colorado Constitution, Article X, Sec. 20). G. This Agreement shall be governed by the laws of the State of Colorado. Jurisdiction and venue for any suit, right or cause of action arising under, or in connection with this Agreement shall be exclusive in Eagle County, Colorado. H. This Agreement supersedes all previous communications, negotiations and /or agreements between the respective parties hereto, either verbal or written, and the same not expressly contained herein are hereby withdrawn and annulled. This is an integrated agreement and there are no representations about any of the subject matter hereof except as expressly set forth in this Agreement. I. This Agreement does not, and shall not be deemed or construed to, confer upon or grant to any third party or parties any right to claim damages or to bring any suit, action or other proceeding against either Contractor or County because of any breach hereof or because of any of the terms, covenants, agreements and conditions herein. J. Contractor certifies that it has read the Agreement, understands each and every term and the requirements set forth herein, and agrees to comply with the same. // SIGNATURE PAGE TO FOLLOW // In Witness Whereof, County and Contractor have executed this Agreement in triplicate on the date set forth above. Two counterparts have been delivered to County and one to Contractor. COUNTY OF EAGLE, STATE OF COLORADO, By and through the Eat - ounty Manager By: ,�t0 / - eith Montag, Eagle County a nager VVMC DIVERSIFIED SERVICES dba EAGLE CARE MEDICAL CLINIC AND NORTHSTAR UROLOGY By: 1G AA Title: SAP) COO STATE OF COLORADO ) B ) ss County of ) The fdreg wars acknowledged before me this IL( day of , , , 201 Z- Witness my hand and official seal. My commission expires: 11 Zv 1 . iagdifi Not.r ' , blic NP LA Y /7; f 6rA ' O � i • I • • , ••••A p 0 %i ' O" u_ My Commission Expires 7/21/2014 8 EXHIBIT A Form Approved: 0IB No 037 -0166 Expiration date 12!312©12 CONSENT FOR STERILIZATION NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS DR PROJECTS RECEIVING FEDERAL FUNDS. • CONSENT TO STERILIZATION • • STATEMENT OF PERSON OBTAINING CONSENT • 1 have asked Ter and receNed Tbrinatto moot steitIZabo tom Detre sg red the . When I first asked Name of axmiduaf to Ca.Ylt: consent Tome, t explained to Matra er the na:lre or sterlIzatbn opera:on Doc for Me Mfoamatbn, 1 was trot that the decision to be sterilzed Is corn- , Vie Tact mat 1 t pletety up to me. I was bolo that I cx31i0 decide not to be siertIzed_ It I de- SpecMy Type of Operator/ code not to be sterutzed, my tied goo 81:11 not alT•ct my right 10lfallre care htenced to be a final and kreyerslte procedure and the discomforts. risks or treatment I wtl .. not lose any help or benefits from programs receiving and benefit aswr -'wed wtth 3. Federal holds, such as Temporary AssIstan0e Tor Needy Farntles (TANF) I counseled tie In tvID1 l ID be stetted Mal alternative methods of or Medicaid that I am now getting or for which 1 may become eligible birth control are calla tie wNch are temporary. I explained that stenlz} I UNDERSTAND THAT THE STERILIZATION MUST EE CONSIDERED ben is dlferont becalae It pemanent l hiermed the Ihd ebzumi0 to be PERMANENT AND NOT REVERSIBLE I HAVE DECIDED THAT 1 DO sterllzed Mal hister consent can be withdrawn at any time and chat NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER haw* %Hfl ntt icee any tseam seances a any bene1115 pranded by CHII.DREN. Federal hinds. I was told about Close temporary methods of OM control that are To the best of my 53081edge and beset one Indlviduai 3o be s8rllzed Is avertable and could be provided to ms which 813 allow me to bear or father at least 21 years old and appears mentally corrpelerr HaVhe knowingy a 111ld In the future. I have reenter] these attefna5Ve8 and chosen ID be and vIXUnt3nry requested to sterilized and appears to understand the stenl¢ed nature any consequences of Me procedure. I understand that t will be sterized by an operation known as a .The rfscomtorts, asks Sagnahu( DTPer50, O07a1Jlg Consent Dare Spear/ Type Of Ope23an and tlenerts associated Wirt Ire operator have been explained to MI my questions have been answered ID my satisfaction. Fat1Ry I Iflderbt3r1 that 1110 aperalion 9111 nor be done U1tl at least 1Nrty days alter t alga the Torn. 1 Understand Tat 1 can change my mind at any tine Address and that my decision at cry time not to be steatized wit net resort In me • PHYSICIAN'S STATEMENT • withholding benefits or medical services provided by tederaly only before r performed a ste1Jtzabon operation upon P I am at least 21 years of age and was tom on Date Name orloOMOual Dare or Sterlization , hereby =sent of my own I exp mined to hIrnher Te nature cr the sterilization operetta free wet to be ster3ize0 by , the tit that tt Is DDCRY or CMI11 Specify Type of CperaDCn by a method called . My Intended to be a teal and irreversible proce1.re and the discomforts, risks Specoy ofOpperaGav and benefss associated 8th 3. consent expires 186 days torn the date of my signature below. t counseled the Individual ID be stetted That alternative methods of 1 also consent to the reease of this form and 031er n'Sedicai records birth Conrol are available which are temporary. I EatpLafned that st ilt:m- abWt the operation b: bon is different because k Is permanent Representa1' we of the Department of Heath and Human 5ervtces, I htamed the kfavltluaI to fix eaertI3 d that braider consent can a Employees DT programs a protects ended sy Te DeparLnenA or tenets withdrawn 33 b time Federal and Mat 06 she wit not lose any health services 1Ui. only for c e2nrining If Federal laws Were observed. P Y I Aare recehed a copy of this form. To the best or rrry knowledge and beset the i drvldua to be sterlized Is at least 21 yeas old and appears mentally competent He/She flowingly and vdlydariy requested to be s.Efllzed and appeared to vole -stand re Srgnatre Date nature and consequences of the prom-ohm (Instructions for Use or altemattve final paragraph: Use the first You are requested to supply the fDtrnwng kmormaidn,. but tt Is not rr paragrapn Delow, except 1n Te case tX premahre 00il pry a errergency quireot (EdWo y and Race Desgnafkrl) (please check) abdominal surges), where Ire st is performed less than '� days EfOok.ty Race (rno2 me a mare).: a?er the date of die truth /duffs 1 nature m Ir1e consent torn h those ❑ Htsparic Cr Latino ❑ Arnen A" can Indian or Naive cases, the second paragraph below must be used. Cross out the pare- El Not Hispanic or La'ho ❑ Asian graph which Is not used.) ❑ Black cc A31cal A rnellcan (1) At least thirty days ha.* passed between the dale of the hdavldual`s ❑ Native Hawallan or Other Pacific Warder slgrhatre ctrl this consent fort and the date the stcrazaion was ❑ Waite perlonned. (2) This sterllzatlon was perbnned less Tai 30 rays but more than 72 • NTERPRETER'S STATEMENT • Mire after trite date of me knteirk.ars slgna'rae on this consent Tam M al InYrpreter Is worded lo assist die m9vlDUa to be ster;ilze0: because of the Tolortng carcun stances (credit app1lcab1_ box and 33 In hlbrrnaton requested): I have translated the Information and a0v1ce presendd orally ID tie II- ❑ Premature d0Nery drvilua b be siertzed by fie person! ootatnhg Tls consent. I have also Indl.l01efs expected dale or deriver! read Nm1er the consent ban T 3pEU Language and explained its contents to hlnv1er. To the best of my ❑ Emergercyatdortira surgery (descntxcvcur races): knowledge and betel hershe understood this a tllanabo.. Mterpreters Sigma re Date Physician s Signature Dale HI-IS-687 (D5110) 9 Femme Af/oF,ada CMG No. c8 7 oiee CONSENTIMIENTO PARA LA ESTERILIZACION FarJ,adaao0mc NOTA: LA DECISION DE NO ESTERLIZARSE OUE LISTED PUEDE TOMAR EN CUALOUIER MOMENTO, NO CAIJSARA EL RETIRO 0 LA RETENCION DE NING(JN BENEFICIO QIJE LE SEA PROPORCIONADO FOR PROGRAMAS 0 PROYECTOS QUE REGIBEN FONDOS FEDERALES. • CONSENTIMIENTO PARA ESTERILIZACION • • DECLARACIbN DE LA PERSONA OUE 1t1 he sdkdato y he matte Intarrhaakin de OBTIENE CONSENTIMIENTO • Arto5 de que (roid■co odwea) f.riambfa da perms) sorts La. eaterllzaGdn. Wanda 1ltlalmerde solk3a 8618 rOorrna,cicn, me inners !a Forma 0a Ccre+era:truest° pars a Eslerltza16n, le he expoaro dye= que le 18080800808 COmfletarn8'fe wile. Me CI- a 66Iar6r 1811 deletes to 18 apera0er1 Won quo yo pads da7dlrrmsalest- ritzerie%Si deckle re7esterJtzarme, , pare 16 ml ddt151tn r1 madder$ m1 derecho a rEf.1t tratamlerlto a °Stades mead- e6L=nzzsltkn, H r io 63 qua 61 161l.Hta30 08 6516 procerjmlanto es nrsa' e 038 en ei 1uf rro. No Per dere rYrrg tens 3' o bonsn08 s de programes 6Te.rereltle, y 1815 1110l6etlas, 108 11289 s y las tenetic13s 850.061c6 can E:t palrcclnaatics can bolos federates. tales arno AS_ D. C. 0 1tea010, que procearrie ln. Isdto adtanne5fle a pare 136 melee Sere el88da_ He amuse/Ma a a persona que sera esteralzaea que Roy disparities ENTIENDO OUE LA ESTERILIZACION SE CONSIDERA UNA OPER- afros nretadda de anti on pcbn qJe stn terrylcrales_ Le ha explicate que ACKMt PERMANENTS E 1RREVEAStBLE. YO HE DECIDIDO OLr"E NO l e 1tr n 1r mewls ixeeee as p&maranle- OUIERO OJODAR EMBAFIAZADA, NO QUIERO TENOR HL)OS 0 NO Le Ile &p lead) a la parscna que sera ealenitzela que puede re ear su OUI£F10 PROCREAR HUGS. mrtsaraatlertd en tualapter rrtrneri7 y q.► 6616/11 no perdera mein sent- Me trlermaron qua me pueden ptoporclo.iar otros nalada6 de ar0anrr- d d2 saiuo 0 reeer183 efcpaclmado 0311 ei p6:trcc - e, de woc61808ralee. Ciepudn disparities que sari 6errbarrales y que perr€r1han que puede Weir A ml wept 66L16r y ent6FPder, 18 persona qua sera estenllzada t8(16 for b o procrear ri os en el Mat. He rechazalo ems apcicnes y he ambito mane 21 Mee de eied y palace 8811ertahlsnte compe1811 e. Etalel re Saf 810615818, solicttario Gar can - Janette de oriL C0 y par 10re vrrlurrad 6@r 2136rtizadsro EnflenOo IIUe 8818 estrt P011 Mad10 de 003 OPer31 c-0rledt8 y palace eatendar la nat.iral8za del procedl8ntenb y et a 0Lns8cu8r Des. COMO Ile ban e191c6do 186 nal setae lab news y k6 hsrendos 88aclad36 t] operar.Ylkl. Nan rag:drdpda salsteatanamente 8 fades rrl5 pregllf Ila6. thaw eta L paaa a Quo 5Focnu d crosonunimra) 14od1a) Ereengo que la cperaclan no se temzer3 hasty qJe Wan pesado 30 cas coma mlrrrr.3, a parilr de la teche, en fa que lame este Forme. Entleroo qJe puled winder de opinlen en =NgJer moment y que ml dec1515n @rl 06340811 maner1a de no set ester1lzata'0 no re&Jlara Era 18 relanClCn de bereft-ass a *enlace medicos praporc1J18 08 a halts to ( aauan) p10931185 que racoon tondos federates. • DECLARACION DEL MEDICO • Tsng7 par l0 merits 21 etas y lad et (dn. mas, aria) P1118nler16 a realtzar 1a ape1e1[n para [8 6680//28 11 a • par media 8613 presets day rat consentmle 8 de 118 litre ytiunl80 Para 8er ( names d3 pawn asraoLmida!o) 851811 z8ialo pot en . Le elgrgJa a 66/818 1615 delanes to ) tl'adla fry cwocat S[N) per el metcdo Unlade 6316 Operac0Cn pem la esterl8z80011 IA Ctrcenb rierin yenta 197 dlas a pa6rte d6 la tette al la que hate 6638 , dal 668020 de que d0Clrnerda. (asp abqua 6pa daoperociin) Tdnt3En dry ml corrserairnlsrea pare qua se presenle seta Fauna y dunce es 1Jn pnlce]tnlenta Car III r666JM.a671Y 81 a trreoer8ltle, y las mc1H51ias. 1015 m[pedente mEdloas sabre la ederarl& a: nesgas y los henelloa asac1a0as win e51a operaclan. Represerctantee del Department de Salad y SerAais Seals- Le amnesia a la persona qJe Sena e8lerJlzeda quo hay disparities erne Ms, t Empleados de progr 1656 t proy'e00G8 1Tenctadns par 868 m8btos de anaa ncepucn 9118 son 16rycral66. Le et tlgl:e que la 830611 - Dsrparta'nsnia, pets sale p8Ja clue pueian determhar 51 se ban rraadnes eremite partite espermarrnte. currp1do Las (eyes F6lerales. La h1ofm8 a la pensara qua eerie estanllzada qua Fade 1180181 EU 11 3n- He r6i;terS7 1.na septa eta esta Forma trriettd en aslquer mamma, y que 68a'6l no per o6413 Wait srna= to Vol a regal teret060 properrsanadd cal el palr0rl3 eta_ br13cs federal es. A ne mefpt' saber y emanate; le persona quo sera setertlzada Genre a to Icons- mends 21 ales de eta y precis 1521 me06811ienie competer . 01151 l ha aa- (frma) (eta rtes aria) sateda sin oonrrlmlEnii de caLsa y Dare valuraO ser esterlizaaib y pf rote n7ormacJ atque 5e wage Oatic g ptap6le la stgulente I .. xn no eb dandelion: I ere er prccedrrlierta y 1183 canseawanaas. to este proceOn baSe w g e prop un es ante I t000) tle pera ubo enemel:he de prorate Melee: LRllce er par - C61ge nod. Faze (masque 1569187 gcoitqu } a .g a( a oa 11619 8 turbo a to 6 a cu s ❑ sespana o raft o ❑ magma americans a I 10611 a de Alaska menus de 33 tlas esep4Je5 08 la rests en ta que ta. persa18 amd la Forma de ❑ No Madam O want ❑ AsAtilca CarEn11n1 pars. a EslerJizalcn- Para eats caws, ullIce H parra6 2gle ❑ Negro a atroarrreacxro peseta r. adelar T'.cte win ire X H paw qJe no se epll ❑ Natural de Hsnyall u eras teas dH Pecg7tO (1) Han trar1curnd3 par lo mends 37 dl3s eritre la recta en la qJe `a ID Bianco persona ntm mH d seta Forma ce 0: Ytmlert° y re lsrtla 611 la gore se maize e esterlazs0Un. • DECLARACON DEL INTERPRETE • (2) La opera:On par's la ec18rJtzaadn se real= a mance eta 3o dies, pert a wise to 72 floras, deep81e ds la leola en a qua Da parsons rang e Si se flan propercclonado los servicios de un tderprete pars wiser a la F011718 de C7re ntmlerd1 a ias tes dralrstencias (marque R&M e48 persona que 61flz3da: la max aproplarya y escrt83 a Inrc ina uetoa): 118llaOccitlo to blvrmatlin y los =seism 9118 vetternerds se le ban ❑ ?eft pfErneuro preserreed a la p8usene qua sera 6swelzalab per er 8'631.15110 quo ra Fettle pmeveta de parla Melba este conserdrolen6O. Tarntl81 le Ire Ioo3o a 88668 a Fatima ❑ Clruglla 6bdanhel eta urgsneta (Desolate his cinxnsla10las): cle o31serntni8rlo en llama y Y1 he apica10 el r04terJto cle set for'fna. A ml rrrejar setter y 8 tender, els% ha anima 8316 erpilcad1n (Lora dotinhip.croj (fwiia) (bmo d rmodc ([ydy) F1- S- 6117 -1 (11/2006) - y ru, Ail Oa ra• 10 ACUFP ©� DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 8/8/2012 8/4/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. 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DISEASE • POLICY LIMIT S � � DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES /(Attach ACORD 101, Additional Remarks Schedule, If morn space Is required) Decuctible $5,000; Extended Reporting Period 100 %; Discrimination Defense Coverage Endorsement $100,000; Contingent BUPD Endorsement with Sublimit - $500,000, Prior Acts Date: 08/08/05. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 11225146 AUTHORIZED REPRESENTATIVE VVMC Diversified Services 181 W. Meadow Dr. Vail CO 81657 yeL oats g tf ACORD 25 (2010/05) 01 8 2010 ACORD CORPO TION. All rights reserved The ACORD name and logo are registered marks of ACORD