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HomeMy WebLinkAboutC12-367 Mountain Family Health CentersAGREEMENT BETWEEN EAGLE COUNTY AND MOUNTAIN FAMILY HEALTH CENTERS FOR THE PROVISION OF FAMILY PLANNING HEALTH CARE SERVICES This Agreement ("Agreement") is entered into this ` day of 20 1-`-, between Eagle County, Colorado ("County"), and Mountain Family Health Centers, a Colorado nonprofit corporation with its principal place of business at 1905 Blake Ave., Suite 101, Glenwood Springs, Colorado 81601 ("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. AGREEMENT 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 4 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 W -M— 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, 2013 and shall terminate on June 30, 2013. 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 $2,500 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, 2013 must be submitted by July 6, 2013, 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 by the United States Department of Homeland Security. Information on applying for the E -verify program can be found at: ht!p://www.dhs.jzov/xprevprot/programs/gc—1 185221678150.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 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 Agreement is 4 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: Eagle County Public Health Director PO Box 660 Eagle, CO 81631 (970)328-8819 CONTRACTOR: Mountain Family Health Centers 1905 Blake Ave., Suite 101 Glenwood Springs, CO 81601 970-945-2840 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 Tyne 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 attorney fees, 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 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 31 st 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 Eagle County Manager By: eith Montag, Eagle Count yager MOUNTAIN FAMILY HEALTH CENTERS By: 7A L/ Title: �i T Iyc P ( V cC ' l Lid STATE OF COLORADO ) ss County of P ) / _ , Th oing as acknowledged before me this day ot��4G`�` , 20 by Y00kJ Witness my hand and official seal. My commission expires: 07/3 �1-3 tary Public BONNIE REIFF NOTARY PUBLIC STATE OF COLORADO My Commission Expires 07/30/2013 EXHIBIT A Form Approved: OMB No. M7-0166 E.xpV=n date. 1231Q012 CONSENT FOR STERILIZATION NOTICE: YOUR DECISION ATANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. ■ CONSENT TO STERILIZATION ■ I have asked Tor and received Inbnnatiam about sleriization fiorn . When 111W asked Doctor or Clinic Ta the ln1DrMabW, I was told thall the decision m be Ster9lzed I6 cerin- pletely up to me. 1 was told that I could decide oar to be slerlIM. tr I de- cide not to be sterilized., my dedslon vAl not affect my right b lirtlre care or ireatmenvt I wit not lore any help or benefits Trom programs recermg Federal funds, such as Temporary A6616tarice for needy Families JAW) or Medicaid that I am now getting or Ibr *rich I may become etlgibie. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. l HAVE DECIDED THAT 1 DO NOT WANT TO BECOME PREGNANT. BEAR CHILDREN OR FATTIER CHILDREN. I was lold about, those temporary methods Or bon Conlvl mat are avallade and could be provided b me A"Ch *111 allow me ID hear oriather a CNN in We Nbxe. I have rejected these alternatives and chosen to be slerli2ed I understand that I *ill be serrzed by an operation known as a . The c1scr mlarls, risks Spstd)y 7)Fe of Opefauan and benefits associated WM lie operalon have been eiValrhed tD me. All my quesbats have been answered to my satistaclorL I understand Vial the operation WII not be done until at least thirty days after 1 sign Us Tam. I widerstand anal 1 can ctwge my mind at any tme and that my decision at any time not to be Sterilized wit not result In the wtmholding or any benefits or medical senuRti pmAwd by federally rinsed programs I am at feast 21 years or age and was ban on: Rahe 1. , hereby consent army bwm Tree *tl to be steriltzecl bf Doacr:r CAnr by a methDd called . My :.loco yoe consent euflres tad days mfr the date or my sigrat re below. I also consent to the release or this form and Mier medical reccra5 about the operation to: Repmsenta2'.*G or the Depatrnent or Health and Human Services. Of Employees or programs or potted Ttntled by Ste DeWirieni W. only Tor delerMng 7 Federal laws were observed. I haze feeerved a copy or this form. SvMwLire Date You are requested to Supply the Wowing information, but it 16 not re - *We t iEMOy and Race Desi Von) ipfeam cWck) Ewaflr Race )mark ane of snore): ❑ Hispanic or Latino ❑ American Indian or Kaska Native ❑ Not Hispanic or Lahti ❑ Asian ❑ Black orAllran American ❑ Native Hawaiian of Otis Pacific Islander ❑ Winne ■ INTERPRETER'S STATEMENT ■ IT an Interpreter is prmsded to assist ire Mm" to be stenitzed: I have Sra filaled the information and ad ore preseriled orally 1b 1ne :n- dtvldual ID be slertized by She person dbtaklrig 1116 conserlL t There also read Nmlw the consent lrm to language and explaned Is txrnents to hinvher. To lie 1heA or my knrrw/edge and belief he"she understood this elptanalcn. fnferp~a Srgnarvre pie HHS-W7ID&la) ■ STATEMENT OF PERSON OBTAINING CONSENT ■ Berae signed the Name or 9M.Plualf arise" corm, t explained to hklvrier the nature or 6tenizanon operaion the fact mal It is Speciry Type orOper.0- trhnded ib be a conal and IrrevxsslUWe procedure and the discomforts, risks arid benefits associated wnh It I counseled the IndlMuail ib be steriCed that altemabve me20d5 of birth control are aralLabie which are tenpexary. I explained mat stertiza- bcn Is ARererd because it 16 permanent I informed the Ind. -421 to be sterilized that NVIer odnsent can be withdrawn at any time and that he'she will not lose any hear serrces or any tenents prlw/aed by Federal funds. To the best or my Immiedge and beiler lie Irdlvklual b be sV nIzed is at least 21 years bid and appears mentally cofrpeterr, He, ;ne knowingly and vofurntarily requested to be sterilized and appears to urlcoewand the nature and consequences Ofthe pfocedu -- ;.grhatune of Persm Obmaln rq Caner¢ Dare Address ■ PHYSICIAN'S STATEMENT ■ t7naCy oefae I performed a steratzabon operation upon on MmeOrinWAdum' Dare orSI-Wraw. I eVaned to hrnmher I ne nature of the sterilization Operation , the W toot Itis Specify 7ype of f}7K23Ur.' Intended to be a final and rrrevefVt%e prtoedure and the discmrrorts, risks and benefits associated wrh it I counseled tie Individual to be stemmed stat alternative melmods of birth control are available which are tenperay. i eapUlned Inst stedlza- don 16 dinerem becaU6e It I3 p ermallent I Informed the trOvldual to be WRrtuzed Chat PA&Iher consent can be wtthdrawn at any time and that lieshe wit no lose any heath services or beneflffi proOoi d by Federal Ands. To the best or my knowledge and belief the MIvtdual to be stertmiz6d Is at least 21 years bid and appears mentally competent Hei-,he knowingly, and volUn anly requested m be SteriiZed and appeared ly Inoer6t3ntl lie nabre arty consequences Cfthe procedure. 11n6Wctlons for use or anemattva final paraWaph: Use the Tkst parigapn oelow except In the case or premaclre dell wy or emergency abdominal Surgery where the ste-milzahon Is performed less man 30 days after the date of the Individuars signature cn me consent tam. In triose bases, the second paragraph below must be used. Cross out the para- graph which I6 not used) (1) At lean thrly days nw.* passed between the day or the individuals Signature on '"S consent form old the date the sterlrzalon was penorme2 12J This 6terbzatial was perbmhed less than 30 days but more than 72 rlomrs after the dam or the mdivhtuart sign—O re on Us consent tam because or twe rOWOng Circumstances (check applicable box and ell In rttormar5or, requested): ❑ Prernare delivery Indt lduars expeciea date or wNerY ❑ Emergency abdominal surgery tdewnw acumsllarnces} P.oyalclan,:i S.graanre Caw *cane aprohudn: OMB Na �a7r-o1r>E. CONSENTIMIENTO PARA LA ESTERILIZAC16N NOTA: LA DECISION DE NO ESTERILIZARSE OUE USTED PUEDE TOMAR EN CtJALOUIER MDMENTO, NO CAUSARA EL RETIRO OLA RETENGION DE NINGUN 13ENEFICIOOLIE LE SEA PRDPORCIONADO POR PROGRAMAS O PROYECTOS OUE RECIBEN FONDOS FEDERALES. ■ CONSENTUENTO PARA ESTERILIZAC16N ■ lb No SalUtaoo y he re.9bldo Infomaukin de socre la eEtem=cW, CLwdo hldainleme saWtd alta inWrnuwttN1, Me dgeron que a daczon da ser aslenlizaam eE compiewierne mia. Me dl- feNn qw yD poafa W-dW no ser aalertlzadalo. SI dBckic no erterdtzarme, ml claclsk)n no alectar8 ml Oeracno a red6!r tratamlerrtD a cldarioa rn,40- oDs an at =m. No perdera ri guna asrsitencl3 o benafUcs as programer patrocJrados con icrtdm taderedas. Was mono AF a C. a Medcaid, qua recto acUalmente o para bE cuatea said elegbe. ENTIENDO CUE LA £STERN IZACION SE CONSIDERA UNA OPER- AmN PERMANENTE E CRR! YERSi13L£. YO HE DECIDIDO me ND CriJVIC 0110AR £MBARAZADA. NO OUIERO TFNER "UDS O ND OU040 PPOCREAR HLICS Ale In rmaron qua me pueden prcpcimionar ams mWodoa de arreon- cepadn disperibies que son lerporalee y que pernitbran que puWa taper a procrear rtlios an al rVWro. He recnazado eaters opcionea y he deciakro ser estaritza vo- EnCarldo qua sera esaruzadaue poi medlo de bn3 opera tri Cam "n cordo Me Nan erpicado las mcWAm. los neegos y m Denanrbs asoaamg con la opemWA. Han rmpon46o satlstactonarnenle a lode✓ itis pregmas. Endendo q.Je la DperarhJn no se reaizara mists qoa ha an pesam 3D Chas, cm o mimeo, a parer de a facia an la que mrne alta Forma. Engerrda qoe poach csmtlar DE opinion an cuaqular momerm y que mi decision an a bluer mamento de no ser astan[tzacarc nc resurara an a WenCI n de benshcbs o seNCIDS mddlcca pmpercIOWDE a trWaS de progamas qua recben Moos Weralm. Tango poc Io mems 21 efts y rad N: mas ono) 'd1 , par madb Ce a prEaerta day rri mnserdrnlerdo de rnl Iibre VojW W para Ser astemacivo pod Off ai MMID tarn&JC W consenCrniento lance 16.1 Was a perp de a recc:!-a err Is qua Orme We Tamt4on doy ml comerttmierm para qua se presents, esta Forma y ons e>Pede a, MIWiCOS Soixe la Dp3rQW a RepresenwLes Cat Daperlamento cia Sala y Sardoos Socha- Ias, c Empleacios CIS prCgrrtnas D proyactce lnanclaaas por are DeoarI mart, perp sola para qoe puedan Celerrnhw sl se nan aarrrpddo tag Wyss rederalas. He mabicto una coplla ch aeta Forma lam: I ) (da..mm aria) Se nage pr*oporckina a sigdente Infomrawf% usque no as Wkiatono nacenc:(Der "17naerareyorganeC7cvJ CMgenatrtc¢ raze Imarque-VIP'r(q-A ❑ HLgralc o attic ❑ mfgera arrlammo o Indigena W Alaska ❑ No nispar m c la M ❑ ASIODO ❑ Negro c alroarrericam ❑ Nmra) de Hawaii u eras was del PBc1mo ❑ Rama ■ DECLARAC16N DEL INTERPRETE ■ SI se Nan proporcbnado Im sarvldoe de un Irderprete para asWUr a a persona que sera ealerlizacia: He mduclao la toonnad0f, y Ica consefos qoe vematmenie se le trap presemado a a persona qua sera erfemizaaa G por era Inahlma que IM actafUdo Bate crosentmiento. TandNen le ne Ie;r7D a 9166 a Forma de ooneeriTnierm an 11orna y a ne erTrlradc el ccnentCo de BEta lrxrrla. A MI major Saber y amender, etael ha erdendgc esta aVicacion. (bmu (fade) HHS -097-1 f11120W) ■ DECLARACION DE LA PERSONA OUE OBTIENE CONSENTIMIENTO ■ Ames de que th—b- do ) llrmara a ;:oma do Corserom'ecito para a £stentzacift Is ne axpli_ado a eila,'e W. Males Oe a cpara" Para a estaritzad0n, N neon Oe que el reaultado W ante proceamianto as finsi a Ine eMbie, y las moles!las, los qsW y dos nanatrclos asodados con Me proceotrumc. He aoonseWD a a persona qua sera esiOtlzaaa que ray dispa-f An CIMS 11161DWS as snIWXXr ebWn qoe Son lerrlpCraISS. LE he expli:ado que a asler0mOW as anererm3 porgoe as permarenta. _e he aq*mdo a is Pena qua sera esviii:ada que p,edd ram su mrlsendmww an walquier rnanemo y qis enwel no pemera ntgan saM- du W sa)ja o Danamo ppr�opoaickneilo coni ei pc-odrNo as ionom tederme. A rel metOr eraser y enUrKW. a persona qua sera astanitzaaa tene por io rnenoa 21 anee Cs adad y pereee ser mantatneede corrpetentE. Eaid1 na solcnadc con conoctniam oe rama y poi [lore vciurcad ser amervzadaio y parsce enrender la naToraleza (jet pmcearnisnio y sus wiserwnclm, thane do Jr pmam gua obmna Wcmcandnrmru) IT-* 119t7 f d --6n) ■ DECLARAC16N DEL MEDICO ■ PfE &Terre a raallzar is opemaw para a astc5'lllzad6n a (.nonbra ab pars osranimdaN an . Le ar*q.16 a Weta los daWas as jFaalra Ca "avkmw) esta openaUon pea a esterllm:m oar h emo de qua ra.�mcngw "da goaraern) as un prmca<drnlamc con ran r8SUra01 7M a In'WEIMde, y W rA Waa. W. nesgoa y Ice oanendos asouancs con asta operaclon. Le amrrseie a la persona qle Sena ea33nnram qua hay dtaporibies tiros melodcs de andccruapGdn que Bon terperalas. Le errpiqud que a eatem- lzaddn as ddemnte, perqua as parmar a lL. Le trf una a a peracna qu3 sena asnatararda qua podia mrar su co sen- tntieem an aatquer mcrrrarto y que sura[ ns, perneria nngul servldc de saw 6 rurtgrxl berg -U. propordcnmo can 91 patrowu as bmus fedarsies. A nd mepr saber y erande-, a persona que sera eslertlzada Cera a to merm 21 altos as, elan y parece Set mentaim. rata cofr.W M. OWN na Bo - con mriodmierm as rausa y [are vuumad ser astarllzadau y pereax entiender at procedrmerto y las Domeaknelas 63 sere DPOO CIRIW J ;IIV ucIIDnea pare COD alterrfstrxe Oe parrWM TWISIM: L"Moa 9 P911 TOO1 qua se pmsuta a ccrllm ao6n, excepto para cases de panic prematiro y dngla awomm da ernergerda amao se he reatz3m a asartz"n a merm da 30 das eesp as da a recta er1 a qua a perwis Sinno'a Farna d3 Catsentritienb para 1,; F9lenli sjj Parra asoa cascs. utme at pvm. b 2 que rase preserna mars adeianta T.Cta con uta % el pErrarb qoa no ser aplfaua. j1) Han Itanm9nde par b menc i 30 alas ernre a We on la que a persona Irmo asca Forma de CcnEenlmHnto y Is. Tata an is que se TaWz6 a esteritzar. {2J La opera" para la asmi[zadon se r"Im a mangy cia 30 oar. pero a mas aE 72 irons, asWim da a Wo an a qua la persona Irmo Is Farina de Cortserdmlerrra dealde a las S/Wlentes circursancas {marque W casia apropiada y 65WW a Ir.rormacWn requerldai: ❑ Panopremauro Fecha prarlsta de parin: ❑ Cirugra aWMrral a3 urgTWA (OeSC= as WOWS We ): Ifrmo � mddcu♦ Ifmdw/ EXHIBIT B PROOF OF INSURANCE (Certificate of insurance to be inserted as Exhibit B) MOUNFAM-01 DMOORE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENEFF D OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, (ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require anent. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER TPeliton Insurance4600 S. Ulster Street #1400 Denver, CO 80237 Exc:(303) 771-1800 FAa/c No : (303) 290-0884 INSURED Mountain Family Health Centers Attn: Ms. Annette Franta, CFO 1905 Blake Avenue #101 Glenwood Springs, CO 81601 A: Pinnacol Assurance B: C: D: 190 COVERAGES'NsuRER F: CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INDICATED. NOTWITHSTANDING INSURED NIAMOED ABOVE FOR THE POLICY PERIOD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN WITH RESPECT TO HEREIN IS SUBJECT TO WHICH THIS INSR ALL MAY HAVE BEEN REDUCED BY PAID CLAIMS. THE TERMS, LTR TYPE OF INSURANCE ADDL GENERAL LIABILITY UBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY 34SBAVT9917EACH 10/3/2012 OCCURRENCE $ 1,000,01 CLAIMS -MADE � OCCUR 10/3!2013 PREMISES Ea occurrence a 300,01 MED EXP (Any one person) $ 10,01 PERSONAL &ADV INJURY $ 1,000,01 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,0( X POLICY PRO- LOC PRODUCTS -COMP/OPAGG $ 2,000,0( AUTOMOBILE LIABILITY $ COMBINE SINGLE SINGLE LIMIT ANY AUTO 34SBAVT9917 10/3/2012 10(3/2013 ALL OWNED SCHEDULED EOa BODILY INJURY (Per person) $ 1,000,00 AUTOS AUTOS X NON -OWNED HIRED AUTOS X BODILY INJURY (Per accident) $ AUTOS PROPERTY DAMAGE PER ACCIDENT $ UMBRELLA LIAB OCCUR $ EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ DED RETENTION$ AGGREGATE g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N 1461272 $ V1IC STATU- OTH- LIMES OFFICER/MEMBER EXCLUDED? ❑ N/A 6/1/2012 6/1/2013 (Mandatory in NH) E.L. EACH ACCIDENT $ 500,00( If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYE $ 500,00( E.L. DISEASE. Pnl lry i ua a CA^ nnw DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Eagle County HHS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN POB 660 ACCORDANCE WITH THE POLICY PROVISIONS. Eagle, CO 81631 AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05)©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1. ISSUE DATE: 8/28/2012 2a. FTCA DEEMING NOTICE NO.: 1-F00000109-12-01 DEPARTMENT OF HEALTH AND 2b. Supersedes: [ ] 3. COVERAGE PERIOD: FROM: 1/1/2013 THROUGH: 12/31/2013 HUMAN SERVICES HEALTH RESOURCES AND SERVICES 4. NOTICE TYPE: Renewal ADMINISTRATION 5a. ENTITY NAME AND ADDRESS:' Mountain Family Health Center WKSA POST OFFICE BOX 9 NEDERLAND, CO 80466-0009 NOTICE OF DEEMING ACTION FEDERAL TORT CLAIMS ACT AUTHORIZATION: Federally Supported Health Centers Assistance Act 6. ENTITY TYPE: Grantee (FSHCAA), as amended, Sections 224(g) -(n) of the Public Health Service (PHS) Act, 42 U.S.C. § 233(g) -(n) 7. EXECUTIVE DIRECTOR: David Adamson 8a. GRANTEE ORGANIZATION: Mountain Family Health Center 8b. GRANT NUMBER: H80CS00830 9. THIS ACTION IS BASED ON THE INFORMATION SUBMITTED TO, AND AS APPROVED BY HRSA, AS REQUIRED UNDER 42 U.S.C. § 233(h) FOR THE ABOVE TITLED ENTITY AND IS SUBJECT TO THE TERMS AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING: a. The authorizing program legislation cited above. b. The program regulation cited above, and, c. HRSA's FTCA-related policies and procedures. In the event there are conflicting or otherwise inconsistent policies applicable to the program, the above order of precedence shall prevail. 10. Remarks: The check box [x] in the supersedes field indicates that this notice supersedes any and all active NDAs and rescinds any and all future NDAs issued prior to this notice. Electronically signed by Jim Macrae, Associate Administrator for Primary Health Care on: 8128/2012 8:24:23 AM FTCA DEEMING NOTICE NO.: GRANT NUMBER: 1-F00000109-12-01 H80CS00830 Mountain Family Health Center POST OFFICE BOX 9 NEDERLAND, CO 80466-0009 Dear David Adamson: The Health Resources and Services Administration (HRSA), in accordance with the Federally Supported Health Centers Assistance Act (FSHCAA), as amended, sections 224(g) -(n) of the Public Health Service (PHS) Act, 42 U.S.C. §§ 233(g) -(n), deems Mountain Family Health Center to be an employee of the PHS, for the purposes of section 224, effective 1/1/2013 through 12/31/2013. Section 224(a) of the PHS Act provides liability protection under the Federal Tort Claims Act (FTCA), 28 U.S.C. §§ 1346(b), 2672, or by alternative benefits provided by the United States where the availability of such benefits precludes a remedy under the FTCA, for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by PHS employees while acting within the scope of such employment. This protection is exclusive of any other civil action or proceeding. Coverage extends to deemed entities and their (1) officers; (2) governing board members; (3) full- and part-time employees; and (4) contractors who are licensed or certified individual health care practitioners providing full-time services (i.e., on average at least 32'/2 hours per week for the entity for the period of the contract), or, if providing an average of less than 32'/ hours per week of such service, are licensed or certified providers in the fields of family practice, general internal medicine, general pediatrics, or obstetrics/gynecology. Volunteers are neither employees nor contractors and therefore are not eligible for FTCA coverage under FSHCAA. This Notice of Deeming Action (NDA) is also confirmation of medical malpractice coverage for both Mountain Family Health Center and its covered individuals as described above. This NDA, along with documentation confirming employment or contractor status with the deemed entity, may be used to show liability coverage for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by PHS employees while acting within the scope of such employment. In addition, FTCA coverage is comparable to an "occurrence" policy without a monetary cap. Therefore, any coverage limits that may be mandated by other organizations are met. This action is based on the information provided in your FTCA deeming application, as required under 42 U.S.C. § 233(h), with regard to your entity's: (1) implementation of appropriate policies and procedures to reduce the risk of malpractice and litigation; (2) review and verification of professional credentials and privileges, references, claims history, fitness, professional review organization findings, and licensure status of health professionals; (3) cooperation with the Department of Justice (DOJ) in the defense of claims and actions to prevent claims in the future; and (4) cooperation with DOJ in providing information related to previous malpractice claims history: Deemed health centers must continue to receive funding under Section 330 of the PHS Act, 42 U.S.C. § 254b, in order to maintain coverage as a deemed PHS employee. If the deemed entity loses its Section 330 funding, such coverage will end immediately upon termination of the grant. In addition to the relevant statutory and regulatory requirements, every deemed health center is expected to follow HRSA's FTCA-related policies and procedures, which may be found online at http://www.bphc.hrsa.gov. For further information, please contact your HRSA Project Officer as listed on your Notice of Grant Award or the Bureau of Primary Health Care (BPHC) Help Line at 1-877-974-2742 or bphchelpline@hrsa.gov. 1. ISSUE DATE: 10/27/2011 2a. FTCA DEEMING NOTICE NO.: 1-F00000109-11-01 2b. Supersedes: [ ] 3. COVERAGE PERIOD: FROM: 1/1/2012 THROUGH: 12/31/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH RESOURCES AND SERVICES 4. NOTICE TYPE: Renewal ADMINISTRATION Z` Wt{ Sa. ENTITY NAME AND ADDRESS: Mountain Family Health Center POST OFFICE BOX 9 NEDERLAND, CO 80466-0009 NOTICE OF DEEMING ACTION FEDERAL TORT CLAIMS ACT AUTHORIZATION: Federally Supported Health Centers Assistance Act 6. ENTITY TYPE: Grantee (FSHCAA), as amended, Sections 224(8)-(n) of the Public Health Service (PHS) Act, 42 U.S.C. § 233(g) -(n) 7. EXECUTIVE DIRECTOR: David Adamson 8a. GRANTEE ORGANIZATION: Mountain Family Health Center 8b. GRANT NUMBER: H80CS00830 9. THIS ACTION IS BASED ON THE INFORMATION SUBMITTED TO, AND AS APPROVED BY HRSA, AS REQUIRED UNDER 42 U.S.C. § 233(h) FOR THE ABOVE TITLED ENTITY AND IS SUBJECT TO THE TERMS AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING: a. The authorizing program legislation cited above. b. The program regulation cited above, and, c. HRSA's FICA -related policies and procedures. In the event there are conflicting or otherwise inconsistent policies applicable to the program, the above order of precedence shall prevail. 10. Remarks: The check box [x] in the supersedes field indicates that this notice supersedes any and all active NDAs and rescinds any and all future NDAs issued prior to this notice. Electronically signed by Jim Macrae, Associate Administrator for Primary Health Care on: 10/27/2011 8:13:30 AM FTCA DEEMING NOTICE NO.: GRANT NUMBER: k 1-F00000109-11-01 H80CS00830 kiiA Mountain Family Health Center POST OFFICE BOX 9 NEDERLAND, CO 80466-0009 Dear David Adamson: The Health Resources and Services Administration (HRSA), in accordance with the Federally Supported Health Centers Assistance Act (FSHCAA), as amended, sections 224(g) -(n) of the Public Health Service (PHS) Act, 42 U.S.C. §§ 233(g) -(n), deems Mountain Family Health Center to be an employee of the PHS, for the purposes of section 224, effective 1/1/2012 through 12/31/2012. Section 224(a) of the PHS Act provides liability protection under the Federal Tort Claims Act (FTCA), 28 U.S.C. §§ 1346(b), 2672, or by alternative benefits provided by the United States where the availability of such benefits precludes a remedy under the FTCA, for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by PHS employees while acting within the scope of such employment. This protection is exclusive of any other civil action or proceeding. Coverage extends to deemed entities and their (1) officers; (2) governing board members; (3) full- and part-time employees; and (4) contractors who are licensed or certified individual health care practitioners providing full-time services (i.e., on average at least 32'/ hours per week for the entity for the period of the contract), or, if providing an average of less than 32% hours per week of such service, are licensed or certified providers in the fields of family practice, general internal medicine, general pediatrics, or obstetrics/gynecology. Volunteers are neither employees nor contractors and therefore are not eligible for FTCA coverage under FSHCAA. This Notice of Deeming Action (NDA) is also confirmation of medical malpractice coverage for both Mountain Family Health Center and its covered individuals as described above. This NDA, along with documentation confirming employment or contractor status with the deemed entity, may be used to show liability coverage for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by PHS employees while acting within the scope of such employment. In addition, FTCA coverage is comparable to an "occurrence" policy without a monetary cap. Therefore, any coverage limits that may be mandated by other organizations are met. This action is based on the information provided in your FTCA deeming application, as required under 42 U.S.C. § 233(h), with regard to your entity's: (1) implementation of appropriate policies and procedures to reduce the risk of malpractice and litigation; (2) review and verification of professional credentials and privileges, references, claims history, fitness, professional review organization findings, and licensure status of health professionals; (3) cooperation with the Department of Justice (DOJ) in the defense of claims and actions to prevent claims in the future; and (4) cooperation with DOJ in providing information related to previous malpractice claims history. Deemed health centers must continue to receive funding under Section 330 of the PHS Act, 42 U.S.C. § 254b, in order to maintain coverage as a deemed PHS employee. If the deemed entity loses its Section 330 funding, such coverage will end immediately upon termination of the grant. In addition to the relevant statutory and regulatory requirements, every deemed health center is expected to follow HRSA's FTCA-related policies and procedures, which may be found online at http://www.bphc.hrsa.gov. For further information, please contact your HRSA Project Officer as listed on your Notice of Grant Award or the Bureau of Primary Health Care (BPHC) Help Line at 1-877-974-2742 or bphchelpline@hrsa.gov.