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HomeMy WebLinkAboutC12-387 VVMC Diversified Services Agreement AGREEMENT BETWEEN EAGLE COUNTY
AND VVMC DIVERSIFIED SERVICES
dba EAGLE CARE MEDICAL CLINIC
FOR THE PROVISION OF FAMILY PLANNING HEALTH CARE SERVICES
This Agreement ( "Agreement ") dated as of this . day of �, 201 Z ; 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 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.
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
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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.
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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
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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
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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: Amy Lee
PO Box 660 VVMC Diversified Services dba
Eagle, CO 81631 Eagle Care Medical Clinic and
(970) 328 -8819 PO Box 40,000
Vail Colorado, 81658
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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.
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 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
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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, December 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 //
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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: A /� /� :.r •■
eith Montag, Eagle County a - ,ter
VVMC DIVERSIFIED SERVICES
dba EAGLE CARE MEDICAL CLINIC
:
Title:
Director of Diversified Services
STATE OF COLORADO )
ss
County of ..-6\0\\ )
The foregoing was acknowledged before me this day of NN \M. 20 12
by Aral L •
Witness my hand and official seal.
My commission expires: \ \S\ V
13;3 `%%, Notary Public
NOTARY • : y
AUK J
c ti � 9 l ••... • P
;, FOF co-
� S3ION
8
EXHIBIT A
Form Approved: 011B No. 0537 -0TE6
Egoiratbn data 12312912
CONSENT FOR STERILIZATION
NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WRNDRAWAL OR WITHHOLDING
OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
• CONSENT TO STERILIZATION • • STATEMENT OF PERSON OBTAINING CONSENT •
I have asked for and reoeNed Intm9ahcn about stenrzadon from Be/de signed the
. Men !fist asked name or irony dual
Doctor Ck'CAhac unseal form, I eaplared lo timber tn8 nature d stylization bpei3l Mn
1tr the illfo/nhaton, I 1K36 i7td Mal 1 the decision to be sterilized Is corm- , the fad Ihal It is
pietay u' to me. I was told that I ooUid decade rot to be itemized. t 1 lie- SpecXy Type c(Opera!a -.tr
Ode not ID be slanted. my decimal MI not affect rrly rtgtat to future care htended to be a final and Irreversible procedure and the discomforts, ruts
or treatment I wit not hose any help or benefits from programs receiving and benefits assetzged s11h R
Federa finds, such as Temporary Assistance tax Needy Famile6 (TANF) 1 °aniseed ire Individual to be stetted Unal alternative rnelrhotl5 a
or Meacald Mal I am now geltlig or lbr *VIM t may become eligible. birth c01443 are available wrath are temporary. I explained flat sterltza-
I UNDERSTAND THAT THE STERIL2ATION MUST BE CONSIDERED non is afferent becaiae n Is permanent 1 Ind anonym] the Indhidual to be
PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT 1 DO mimed tat rustler oonserrt oar be wtinarawn al any time and that
NOT WANT TO BECOME PREGNANT, BEAR CHILDREN Cut FATHER rffi!6tae will not Lee airy beam ser.toes or any bereft prolded by
CInLDREN. Federal Rums.
I was n1d about arose temporary methods or NM control that are To the best a my krhbwted96 and betie+r the Individual 10 be sterized Is
avalatle and could be prvattew lo me snob will allow me to bear or father at weast 21 yews to and appears werlaIy competent. Hei'Z11e inowingy
a 1711111 In the Mae. I have relented these alternatives and chosen to be and vounta'ty requested to t+e stermzed and appears t0 u tic erstand the
itemized ra;rae and consequences of the procedure.
1 understand that 1 611! be senized by an operation down as a
.The d6cbrtrRlAS, risks Sgraruie arPer oi, Obta1139 Consent ate
Spec.ry Type of Opts ali:4
and benefits a='9y'3bad rrdh Ire epenaton have been explained ID me. All
my questions Cave been answered to my sanstaCtblti Fai1Ry
I understand Ilia the operation will not be done will at least thirty days
alter 1 sign this form. 1 tndastand Mal I can c halge my mrrld at any tone Add'ess
are oat my decision at any time not to De stylized yid not result In the • PHYSICIAN'S STATEMENT •
tilidekfng of any benefits or rnedk:a sen*.ces provided by tederaiy Shorty before I performed a sterilization operation upon
tended pry
I am at east 21 years of age and was bomr on: qa
Care Name d(dntiMiciti t Date or SZerldzaboo
,. hereby Consent of my 021 I expand to hinter tie nacre or the sterilization operation
free 6111 to be sterilized by tie fad tat It Is
Doctor a Clint Specny T)pe bf Operalasr
by a method caned . \1} ntehtdecl to be a trial and Irreversible procedure and Me disdrrtNrt6, rusts
Specify Type of Operairom and benefits associated wttla t
consent expires MD days horn the date of my signature belay. 1 ahlseletl the tkihtldc 34 10 be refitted 1ha1 alternative rrie'BIDd6 of
f ��l consent t0 the re§ease wit" 1klrrrr 31x1 wheir nledca reak'LY drtia control are avalatie each are temporary. I explained tat skrtiza-
ablxrt tie operation to: lion I6 diferer1 because R Is permanent
Represernalives of the Depalrherl or Heath and Human Sentbe6, t Irtormetl the mdvlatal to be serfized Ma: Maher consent can
br Err'phkhyees b T programs br pled, tlrh by the Department be wrnrdr3rar at any brie and that haz6he wit not lose any health services
txt only for delen ruing If Federal taws were observed. a benefits prDs1 1 by Federal hinds.
t
Moe recreMed a copy of this form_ lb the best of my Lnbwledge and bale` 1Re Individual 10 be stertlzed 16
at least 21 yeas old and appears m6r1aty cxrr1 e1snL HeShe knowingly
and voluntarily requested to be slenl0b orb appeared 10 u'd'statrd the
sagraatcre Date nacre and consequences or Me procedrre.
T'rl: are requested t0 slippy re tdowmg Information, but R is riot re- Itnrt!uctiorle for use of aItemarvs anal paragraph: Use the frst
*area ( ETMICCr and Race Design:1S 1) (please check) abdominal surga' a 1 1r ire cote b poem ue performed or n 3 0 d ays
MdGlIy. Race (ma'k one or mare): abdmilnl suryr3y Winery the 6terllz Dn t6 i the c Cd Ie<66 than 3 0 days
❑ iiuparrc Of fabric ❑ American Indian Dr Alaska tlattve after the date of the indlviduers sigranre en the consent tom. n tthobe
❑ Clot HF6larlc or La-And ❑ Asian cases, second 0 graph below !host be used. Cross out die {aria-
• . ❑ alas or A3rcan America] (1) At least thtty days have passed between the dale of the nd5Atluas
•
❑ Native Hawaiian of Other Pacific dander signalise on Ids consent torn and the dale the ster5lzaIcr was
❑ Mille per/ mined
(2) This sterilization was perlrinned less than 30 days but more than 72
• INTERPRETER'S STATEMENT • rows alier the dale of the trunalaters signature on this consent form
became of the 1oirreng circumstances (check applicable boa and tit In
!Tan Irierpreter is provided to assist the ndvldual to be Sternb2d: ntor requested:
I have tarsized tie nrbrmatort and adrtoe pre elled orally to tae irk ❑ premature 064186y
dtvklual 1D be Seri1zed [xy tie person ebb/Ping IN6 consent. I have arc
Indt. °dtaf6 date delvery
read tinnier the ansent tbrm in expected d
language and explained I'S =Minis to hinter. To the best of my Emergency abdominal' 611rgrly (descrrbearcrnnssarrlces).
tnt7w1R7yv_ 3rd belief nettle undeest od this ea lalatbn.
htlErpa8ers SrpnaSUe Care Physician's Scrie re Dale
HHS-687 (65110)
9
•
•
tOrlaa Aproll i& Okla nln MIT r -0166
CONSENTI#AIENTO PARA LA ESTERILIZACIoNI F °c'aaa "' W. ' 2O013
NOTA: LA DECISX N DE NO ESTERILIZARSE OUE USTED PUEDE TOMAR EN CUALOUIER MOMENT°, NO CAUSARII EL
RETIFO 0 LA RETENCION DE NINGUN BENEFICIOOUE LE SEA PROFORCIONADO POW PROGRAMAS 0 PROYECTOS
OUE RECIBEN FONDOS FEDERALES-
■ CONSENTOIENTO PARA ESTERILIZACION • • DECLARACION DE LA PERSONA DUE
- w3 re Bella/silo y he ra.Udo Irmrmacur dE OBTIENE CONSENTIMIENTO •
Ames de qua
(acdm o dmra! promb *parson&
sotre 13 embar ttzacnr. c uan do hldaarnen a sclbtO ES0 mUrmaclen, ire frusta la Forma de Ccr¢seramlelte pare re EsterlI tn, le be eepkaoo
d(ercn qua l3 CelelCn de sEr e613ritzanaxl ee. tux 1et3mente runs. Ma d- a awe sus agates me ie cperaCGn
(oral qua ye pada 3e171ir ro ser ester-Ilzadart S1 Daci s no eeterllzarrne, , Para
ml 03c(561 n7 dlectara m aarecro a rgatrr trataralaala a Cizdaaos rnet9- es1l1Iz ]den, el remc oe que el n33Ut'ar]a de este prooedm13rto e5 Tire e
ads en al TSaro. rlc palLiere nngune asi1cncla o henelk>la6 de programas rre3e 1Ll y to "maw, lob rleEg y 4 02 C ene a c v r3 asas+x cm e,te,
patrx1redes cart tunics 1e0erai6S, tees amo AS. D. C. a Medc2, que ©1oD66hne1Mn.
radix act alrrente a para las cuale5 sera elegtfe. H acorreamie a a persons qua sera EEtenitzaaa que nay disparities
ENTE.NDO CUE LA ESfERILIZAC ION SE CONSIDERA UNA OPER- atri s it de arlaccnzpcYan que son ierrpcnale Le he Expl:aco que
AC„ON PERMANENTE E lRREVEAS1P:t0, YO HE OECIDIDO OLE No a es€ii2s. of esdnererte pat? leespermarerte.
put PO QJEDAA EMaARAZADA, NO CUIERO TENER HLOS 0 h.0 Le he i 131 Co a i6 persona qua sera e.1erlZeia que puede Wear su
IYJ1'RO PROCREAR HODS izn9antlmlerto en o alp:ler mane= y q,e ale/a rd pastes ntlgl:rl seM-
Me hfarmaran que 1112 pueden prix trans area rata/Da dE arrtun- 0C 03 Gain o Pere= praparell1rb am a p6lcctr*5 oe 1cn308 Federates.
cep= dlspcnbzs que son lerrperale6 y que perrritran que puede tenet A ml Maibr saber y e , 13 persona p.m sera ai ltzac2 terse par 3
a procrear r1JC6 ei el NJturc. He- rectazado esters opcICnee y he de010Jd0 rnencE 21 EC1DE de &dad y parer! set lr33nlarnEr to competerl E1a/91 ra
set 8518n11a:11V salakada con ccrlacm13rta rho cause y par It r3 vtlurral ter esterl'Zaaaro
ErSerde PIA sere einerilzadab par medic de Lino 0perr Lin (0012 l22 ,y par ece enterder la 112Lr313za 031 pnxs]tnlar}s y sus ansecuerclaf.
aim°
Me non apical:. 1a.5 rnete6535, los deegas y cos 0Ereacla5 a9CClams ecru
n3 cparsaon. Hari reEp3rd0o sarffiractarrErnertle a ladae Irts preigl[rta3, !Funs der Y parsma sus otrGCC y rrnsanurroxi :; ;
Eraerdc que a cperacian no 93 reatzara 1135Ya ape Mayan pasaso
313 alas, coma anima, a posh! de a Vclio en le que (lime este Forma.
Enaerdo eve quarto cattier ere oprten en cuatpler Pncmertb y que n1 ¢r+wrr
dectiaan en imakquer rnernerrc de no sat ester11zaCet n2 rawrara en re
reIerbiOn r8 0erls5cKas 0 9emd2a rn10tcc6 prepercbn ix a Pale8 ne
programs qua neaten boas *dermas. • DECLARACION DEL MEDICO •
Tenpa par to stiles 21 eras y sacs e :
(der. mss Ana, F15',l nerve o realtrar i6 open 3orl pa -a to OEfer111zaCar a
, par
me410 ae la preserrte d c y 1 11 4 (0 01 1 1 1 11 1 6 02 2 0 5 1 11 1 1 1 2 1 6 5 0 4 1 5 1 1 8 11 para se' (numb der pars arc as ranimici of
esternav]a;o par an . Le acid.* a Abate r[6 deta'le5 ere
( ml I3sd13 oV amanirr.rin,
per el rnetcd0 uAna'uC - est i ope,2cicn pea I6 eslelle 13)drl
MI ariserter3er1D yen:* 197 alas a parch de to tectla en 1a que liana 6519 , 061 hectic de que
d0ltrner10. (ssynefqua Sea ds stature u.
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8spederlte medl3ss sabre a cperea7M a 1E6gas y las tar601os as:Kailas ear est3 operacicn.
Represertantes del Deperarrento der Satz y S6rletas sects- Le aOnsejE a la persona que serla 20811111322 que hay disparities 01sts
r%. c EmpeaCas de prograrnas C proy€cloe 'anc.000s par ese Halmos de artlecnoe ucn que Son 16r9Cr3JES. Le e1glque que 13 851611 -
Csepar0513 11c, pert sole pare que pueaan aatennhar sl se ran :zecOn eE drive pop.* as pefmarent5.
wmplda 019 1eye3 16.1843135. LE Marne a a per3C08 rye Sena astern/633 cure pada labor su arisen -
He tE7t 07 tr1d (orate a?' eEta FOfmd. 2rrr64713 er meatier mernallio y qt. 84341 nc pern1113 nrrgrh serY04c oe
sew a ringin 08re1_ 0 proptt5Snaau 0181 61 pair0Crla de 53020SPeclaraee.
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mares ares 21 31106 Ce 8035 y p8re0e 98r mental male competerlx. E1L3r21 ha so-
recta
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Se nixie prdpor0me a 9g31@nte Inforrrladon. arrle.Ia net es atlgatoro Ontario:dories para use ellenlattlo lie pdrrdioe finales: Ulnae 9 par -
rla(612: fcl8RrI'cvvr 0e raza y larger Palm Taro 1492 se prsserta a carttruadcrt. Etloepta par casc8 de partc premaalro
Gr rgE1 etax: 11za (rnirque segue+ 1¢18 ?' dngta acracinna as emergenda cunao ee ha 183422elo ra esrerfzacldn a
❑ Hielape 0 Mho ❑ Macias american0 o Indigene de Alaska 'tams de 33 21x3 0mi:ties ere a Mona a erl'a we 1a persona tnnd ss Forma de
❑ No ntpans o ache ❑ ,1sdE'.b0 Ccnserlal11 - 11: awake Esleritradan Para 8806 , 12110e el ;grab 2 ;are
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❑ Sara p t ester Forma oe Cons rarnlarto y is recta en a qua 913 !Baize
i erdefl4ID.
• DECLARACION DEL INTERPRETE • 12I La 298racl0n pars 13 53335110E0211 se realize a mends de 30 31as,
pert a mss 26 72 110135, escrie3 de la tclra an a que 13 persona hrrrlo` a
Si se nail prcgcr0laray2 428 aanaC606 08 2n NT,Erp0Ere Para asl3llr a t 1o5l0 de Corealtlmlentc Cear]C a Ias sitJaren draur503nC1aa jrrlarque
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otter= este croseramlent9. Te itlen le re leer: a 64el13 la Forma
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de oorsEn5ml8rrl3 el l0knna y ie
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ala'Ll ra ernen:1/7c e51a expleadCn.
Iimu darinrd¢.swj [cads; lfrma LSO muds./ (lady,;
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1 U
EXHIBIT B
PROOF OF INSURANCE
(Certificate of insurance to be inserted as Exhibit 8)
11
ACORD ni CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDtYYYY)
/l20, 8/2/20
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: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certaln policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
p CONTACT
PRODUCER
Lockton Corn antes, LLC Denver ptatii Fax
8110 E. Union Avenue (A/C, No, Ext): INC, No):
Suite 700 E -MAIL
Denver CO 80237 ADDRESS:
(303) 414 -6000 INSURERS AFFORDING COVERAGE NAIL a ,
INSURER A: Lloyd's of London
INSURED Vail Valley Medical Center and all entities INSURER B :
1064723 P.O. Box 40000 INSURER C
Vail, CO 81658
INSURER D: -
INSURER E ;
INSURER F :
COVERAGES VAIVA01 DE CERTIFICATE NUMBER: 1 1225146 REVISION NUMBER: XXXXXXX
_ ABOVE POLICY THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED BO F. FOR R T E H _ OLI , Y PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY ��CC PAI � D �� CC � LAIMS.
LTR TYPE OF INSURANCE AN S S WVD POLICY NUMBER Iry1rry QD ►IMM1QpNYYY) LIMITS
,A, GENERAL LIABILITY N N 0810 - 0008178911 8/8/2012 8/8/2013 EACH OCCURRENCE $ XXXXXXX
DAMAGE TO RENTED XXXXXXX
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurroncel $
MO CLAIMS -MADE , OCCUR MED EXP (Any one person( $ XXXXXXX
® Prof. E&0 Prop Mgmt PERSONAL & AOV INJURY _ $ XXXXXXX
® Ea. Claim $1.000.000 GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE -- LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ XXXXXXX
POLICY 1 JE 9 - LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
NOT APPLICABLE (Ea accident) $ XXXX.XXX
ANY AUTO BODILY INJURY (Per person) $ XXXXXXX
ALL TOS AUT� 8YVNED SCH pULED BODILY INJURY (Per accident $ XXXXXXX
AU
al HIRED AUTOS A UU T A S
OS � ED (P er � ac c ide nt) DAtdAGE $ XXXXXXX
al UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ XXXXXXX
1 EXCESS LB CLAIMS -MADE NOT APPLICABLE: LAB AGGREGATE $ XXXXXXX
OED RETENTION $ $
WORKERS COMPENSATION WO(, STATU- OTH-
AND EMPLOYERS' LIABILITY v I N T O1/Y LIMITS FR
ANY PROPRIETOR/PARTNER/EXECUTIVE ( N! A NOT APPLICABLE E.L. EACH ACCIDENT $ XXXXXXX
OFFICER /MEMBER EXCLUDED?
(Mandatory in NH/ E.L. DISEASE- EA EMPLOYEE $ XXXXXXX
it Yes, de under
bESCRIP OF OPERATIONS below El. DISEASE - POLICY LIMIT ; XX.XXXXX
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES /(Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Decuctible $5.000: Extended Reporting Period 100 %; Discrimination Defense Coverage Endorsement $100,000; Contingent BI/PD 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
C
_ - 1 c e5 l tom
ACORD 25 (2010/05) 0019 8 2010 ACORD CORPO TION. All rights reserved
Tho lr:rim1 mama anti Inn." aro ronicforari marks of ACflPrl
o
•
A1C CERTIFICATE OF LIABILITY INSURANCE D ATE IYYYY)
4er...--� fl9126/2012
2012
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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MARSH USA INC. N E
1225 17TH STREET, SUITE 2100 PHOPHON FAX
DENVER, CO 80202-5534 E-ME201. FX 11 :............ ............................_.. _�._..._.._._. i .. SAIC, Ne);..._.
Attn: Denver.certrequest @marsh•com• Fax:212.948.4381 1+o.4.RE3,
INSURER(S) AFFORDING COVERAGE NAIL II
510478-WC-12••13 INSURER A , Star Insurance Company : 18023
INSURED
Colorado Hospital Association Trust INSURER B
For WC INSURER C :
7335 East Orchard Road
Suite 100 INSURER o
Englewood CO 80111 INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: SEA - 002258730.03 REVISION NUMBER:0
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUER! i ._.._.._.._._.— — ........._. POLICY EFF POLICY EXP
LTR I TYPE OF INSURANCE 1INSR WVD 1 POLICY NUMBER (MM /DDIYYYY) JMM1DD/YYYY) ' LIMITS
1 i
GENERAL LIABILITY i - E EACH OCCURRENCE I $
I DAMAGE TO RENTED
I COMMERCIAL GENERAL LIABILITY
s }...._,.. I PREMISES (Ea occu r nw,� , F$
_ _...
I CLAIMS -MADE ' OCCUR I I
MED EXP (Any one person) $
._._...__ ?PERSONAL 8 ADV INJURY $
-- —_— i - ... .... ......._.._.__'-_
I
T
1. i ...._..... .. ._... _. .......,,.� i GENERAL AGGREGATE $
GEN1. AGGREGATE LIMIT APPLIES PER: � I PRODUCTS - COMP/OP AGG ! $
r —I PRO . 1
POLICY ; ' LOC -- $
i ,IFCT I
' AUTOMOBILE LIABILITY ? t ( - COMBINED SINGLE LIMIT
€a acc don0 $
I ' ANY AUTO I # BODILY INJURY (Per person) $
1 ALL OWNED 1 SCHEDULED BODILY INJURY (Per r
_ AUTOS i _ AUTOS et a t $
NON -OWNED PROPERTY DAMAGE accident):
HIRED AUTOS [ AUTOS PeracclUentl .._. $
i
, 1 $
•
I UMBRELLA LIAR i • I I
I OCCUR i I i EACH OCCURRENCE §
EXCESS LIAB " ' .......__..
I j CLAIMS - MADE i AGGREGATE ,..,_............,_ I
..... ..... __._ _._
f ' OED I RETENTION $ ± i I T I $
WORKERS COMPENSATION ' '
j WC STATU- OTH
AND EMPLOYERS LIABILITY VIN F .SORY LIMITSI ER..,
ANY PROPRIETOR/PARTNER/EXECUTIVE N N/ A ' I F E.L. EACH ACCIDENT _ t $
OFFICER/MEMBER EXCLUDED? ' - -- ---
(Mandatory In NH) I I ; El. DISEASE EA EMPLOYEE $
I If yes, describe under � t
I DESCRIPTION OF OPERATIONS below 7 EL. DISEASE - POLICY LIMIT i $
A :Excess Workers' Compensa(ion i I WCE070574412 , 10/01112012 €10/01/2013 I Employers Liability 1,000,000
(
And Employers Liability I I ' WC Statutory for WC Act Benefits I ( i Self Insured Retention 400,000
f •
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
CERTIFICATE HOLDER CANCELLATION
Vail Valley Medical Center SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Alin: Charlie Crevling, SVP Finance/ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Gana Davis, Benefits Manager ACCORDANCE WITH THE POLICY PROVISIONS.
P,O. Box 40000
Vail, CO 81058 AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Kathleen M. Parsloe y` lit. ractalsrG
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD