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HomeMy WebLinkAboutC17-059 Mountain Family Health Centers VasectomiesAGREEMENT FOR PROFESSIONAL SERVICES BETWEEN EAGLE COUNTY, COLORADO AND MOUNTAIN FAMILY HEALTH CENTERS FOR THE PROVISION OF FAMILY PLANNING HEALTH CARE SERVICES THIS AGREEMENT ("Agreement") is effective as of 02/21/2017 , by and between Mountain Family Health Centers, a Colorado nonprofit corporation (hereinafter "Consultant" or "Contractor") and Eagle County, Colorado, a body corporate and politic (hereinafter "County"). RECITALS WHEREAS, the County, through its Department of Health and Human Services ("PH") works to promote the health, safety and welfare of County residents of all ages; and WHEREAS, the County uses outside providers and professionals to enhance the ability of County to promote such health, safety and welfare; and WHEREAS, County desires to hire the Consultant to perform the Services defined below in paragraph 1; and WHEREAS, Consultant is authorized to do business in the State of Colorado and has the time, skill, expertise, and experience necessary to provide the Services; and WHEREAS, this Agreement shall govern the relationship between Consultant and County in connection with the Services. AGREEMENT NOW, THEREFORE, in consideration of the foregoing and the following promises Consultant and County agree as follows: 1. Services. Consultant agrees to diligently provide all services, labor, personnel and materials necessary to perform and complete the services described in Exhibit A ("Services") which is attached hereto and incorporated herein by reference. The Services shall be performed in accordance with the provisions and conditions of this Agreement. a. Consultant agrees to furnish the Services no later than December 31, 2017 and in accordance with the schedule established in Exhibit A. If no completion date is specified in Exhibit A, then Consultant agrees to furnish the Services in a timely and expeditious manner consistent with the applicable standard of care. By signing below Consultant represents that it has the expertise and personnel necessary to properly and timely perform the Services. C17-059 b. In the event of any conflict or inconsistency between the terms and conditions set forth in Exhibit A and the terms and conditions set forth in this Agreement, the terms and conditions set forth in this Agreement shall prevail. C. Consultant agrees that it will not enter into any consulting or other arrangements with third parties that will conflict in any manner with the Services. 2. County's Representative. The Public Health Department's designee shall be Consultant's contact with respect to this Agreement and performance of the Services. 3. Term of the A reeg�ment. This Agreement shall commence upon the date first written above, and subject to the provisions of paragraph 11 hereof, shall continue in full force and effect through the 31st day of December, 2017. 4. Extension or Modification. This Agreement may not be amended or supplemented, nor may any obligations hereunder be waived, except by agreement signed by both parties. No additional services or work performed by Consultant shall be the basis for additional compensation unless and until Consultant has obtained written authorization and acknowledgement by County for such additional services in accordance with County's internal policies. Accordingly, no course of conduct or dealings between the parties, nor verbal change orders, express or implied acceptance of alterations or additions to the Services, and no claim that County has been unjustly enriched by any additional services, whether or not there is in fact any such unjust enrichment, shall be the basis of any increase in the compensation payable hereunder. In the event that written authorization and acknowledgment by County for such additional services is not timely executed and issued in strict accordance with this Agreement, Consultant's rights with respect to such additional services shall be deemed waived and such failure shall result in non-payment for such additional services or work performed. 5. Compensation. County shall compensate Consultant for the performance of the Services in a sum computed and payable as set forth in Exhibit A. The performance of the Services under this Agreement shall not exceed $625 Contractor shall not be entitled to bill at overtime and/or double time rates for work done outside of normal business hours unless specifically authorized in writing by County. a. For reimbursement Contractor must submit invoices quarterly. Invoices shall include a description of Services performed. 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. Payment will be made for Services satisfactorily performed within thirty (30) days of receipt of a proper and accurate invoice. All invoices shall include detail regarding the hours spent, tasks performed, who performed each task and such other detail as County may request. All invoices may be mailed or delivered in-person to the following address to ensure proper payment. Invoices may also be securely emailed to phinvoices@ea lg ecounty.us Eagle County Public Health and Environment Business Office z Eagle County HHS Prof Sery Final 5/14 551 Broadway Post Office Box 660 Eagle, CO S 1631 b. Any out-of-pocket expenses to be incurred by Consultant and reimbursed by County shall be identified on Exhibit A. Out-of-pocket expenses will be reimbursed without any additional mark-up thereon and are included in the not to exceed contract amount set forth above. Out-of-pocket expenses shall not include any payment of salaries, bonuses or other compensation to personnel of Consultant. Consultant shall not be reimbursed for expenses that are not set forth on Exhibit A unless specifically approved in writing by County. C. If, prior to payment of compensation or reimbursement for Services 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 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 set forth in this Agreement, then upon written notice of such determination and request for reimbursement from County, Consultant shall forthwith return such payment(s) to County. Upon termination or expiration of this Agreement, unexpended funds advanced by County, if any, shall forthwith be returned to County. d. 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. Contractor shall provide the County with progress reports upon County's request; or Contractor shall furnish progress reports as more specifically set forth in the attached Exhibit A. e. County will not withhold any taxes from monies paid to the Consultant hereunder and Consultant agrees to be solely responsible for the accurate reporting and payment of any taxes related to payments made pursuant to the terms of this Agreement. 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 Consultant in respect of any period after December 31 of any year, without an appropriation therefor by County in accordance with a budget adopted by the Board of County Commissioners in compliance with 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). 6. Sub -consultants. Consultant acknowledges that County has entered into this Agreement in reliance upon the particular reputation and expertise of Consultant. Consultant shall not enter into any sub -consultant agreements for the performance of any of the Services or additional services without County's prior written consent, which may be withheld in County's sole discretion. County shall have the right in its reasonable discretion to approve all personnel assigned to the subject project during the 3 Eagle County HHS Prof Sery Final 5/14 performance of this Agreement and no personnel to whom County has an objection, in its reasonable discretion, shall be assigned to the project. Consultant shall require each sub -consultant, as approved by County and to the extent of the Services to be performed by the sub -consultant, to be bound to Consultant by the terms of this Agreement, and to assume toward Consultant all the obligations and responsibilities which Consultant, by this Agreement, assumes toward County. County shall have the right (but not the obligation) to enforce the provisions of this Agreement against any sub -consultant hired by Consultant and Consultant shall cooperate in such process. The Contractor shall be responsible for the acts and omissions of its agents, employees and sub -consultants or sub -contractors. 7. Insurance. Contractor agrees to provide and maintain at Contractor's sole cost and expense, the following insurance coverage with limits of liability not less than those stated below: a. Types of Insurance. i. Workers' Compensation insurance as required by law. ii. Auto coverage with limits of liability not less than $1,000,000 each accident combined bodily injury and property damage liability insurance, including coverage for owned, hired, and non -owned vehicles. iii. Commercial General Liability coverage to include premises and operations, personal/advertising injury, products/completed operations, broad form property damage with limits of liability not less than $1,000,000 per occurrence and $2,000,000 aggregate limits. This policy shall be endorsed to include coverage for physical/sexual abuse and molestation. iv. Professional liability insurance with prior acts coverage for all Services required hereunder, in a form and with an insurer or insurers satisfactory to County, with limits of liability of not less than $1,000,000 per claim and $2,000,000 in the aggregate. In the event the professional liability insurance is on a claims -made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this Agreement. Continuous coverage will be maintained during any applicable statute of limitations for the Services. b. Other Requirements. i. The automobile and commercial general liability coverage and such other coverage as indicated above shall be endorsed to include Eagle County, its associated or affiliated entities, its successors and assigns, elected officials, employees, agents and volunteers as additional insureds. ii. Consultant's certificates of insurance shall include sub -consultants as additional insureds under its policies or Consultant shall furnish to County separate certificates and endorsements for each sub -consultant. All coverage(s) for sub -consultants shall be subject to the same minimum requirements identified above. Consultant and sub -consultants, if any, shall maintain the foregoing 4 Eagle County HHS Prof Sery Final 5/14 coverage in effect until the Services are completed. In addition, all such policies shall be kept in force by Consultant and its sub -consultants until the applicable statute of limitations for the Services has expired. iii. Insurance shall be placed with insurers duly licensed or authorized to do business in the State of Colorado and with an "A.M. Best" rating of not less than A -VII. iv. Consultant's insurance coverage shall be primary and non-contributory with respect to all other available sources. Consultant's policy shall contain a waiver of subrogation against Eagle County. V. All policies must contain an endorsement affording an unqualified thirty (30) days' notice of cancellation to County in the event of cancellation of coverage. vi. All insurers must be licensed or approved to do business within the State of Colorado and all policies must be written on a per occurrence basis unless otherwise provided herein. vii. Consultant's certificate of insurance evidencing all required coverage(s) is attached hereto as Exhibit B. Upon request, Consultant shall provide a copy of the actual insurance policy and/or required endorsements required under this Agreement within five (5) business days of a written request from County, and hereby authorizes Consultant's broker, without further notice and authorization by Consultant, to immediately comply with any written request of County for a complete copy of the policy. viii. Consultant shall advise County in the event the general aggregate or other aggregate limits are reduced below the required per occurrence limit. Consultant, at its own expense, will reinstate the aggregate limits to comply with the minimum limits and shall furnish County a new certificate of insurance showing such coverage. ix. If Consultant fails to secure and maintain the insurance required by this Agreement and provide satisfactory evidence thereof to County, County shall be entitled to immediately terminate this Agreement. X. The insurance provisions of this Agreement shall survive expiration or termination hereof. xi. The parties hereto understand and agree that the County is relying on, and does not waive or intend to waive by any provision of this Agreement, the monetary limitations or rights, immunities and protections provided by the Colorado Governmental Immunity Act, as from time to time amended, or otherwise available to County, its affiliated entities, successors or assigns, its elected officials, employees, agents and volunteers. xii. Contractor is not entitled to workers' compensation benefits except as 5 Eagle County HHS Prof Sery Final 5/14 provided by the Contractor, nor to unemployment insurance benefits unless unemployment compensation coverage is provided by Contractor or some other entity. The Contractor is obligated to pay all federal and state income tax on any moneys paid pursuant S. Indemnification. The Consultant shall indemnify and hold harmless County, and any of its officers, agents and employees against any losses, claims, damages or liabilities for which County may become subject to insofar as any such losses, claims, damages or liabilities arise out of, directly or indirectly, this Agreement, or are based upon any performance or nonperformance by Consultant or any of its sub -consultants hereunder including claims for bodily injury or personal injury including death, or loss or damage to tangible or intangible property; and Consultant shall reimburse County for reasonable attorney fees and costs, legal and other expenses incurred by County in connection with investigating or defending any such loss, claim, damage, liability or action. This indemnification shall not apply to claims by third parties against the County to the extent that County is liable to such third party for such claims without regard to the involvement of the Consultant. This paragraph shall survive expiration or termination hereof. 9. Ownership of Documents. All documents prepared by Consultant in connection with the Services shall become property of County. Consultant shall execute written assignments to County of all rights (including common law, statutory, and other rights, including copyrights) to the same as County shall from time to time request. For purposes of this paragraph, the term "documents" shall mean and include all reports, plans, studies, tape or other electronic recordings, drawings, sketches, estimates, data sheets, maps and work sheets produced, or prepared by or for Consultant (including any employee or subcontractor in connection with the performance of the Services and additional services under this Agreement). 10. Notice. Any notice required by this Agreement shall be deemed properly delivered when (i) personally delivered, or (ii) when mailed in the United States mail, first class postage prepaid, or (iii) when delivered by FedEx or other comparable courier service, charges prepaid, to the parties at their respective addresses listed below, or (iv) when sent via facsimile so long as the sending party can provide facsimile machine or other confirmation showing the date, time and receiving facsimile number for the transmission, or (v) when transmitted via e-mail with confirmation of receipt. Either party may change its address for purposes of this paragraph by giving five (5) days prior written notice of such change to the other party. COUNTY: Eagle County, Colorado Attention: Jennie Wahrer 551 Broadway Post Office Box 660 Eagle, CO S 1631 Telephone: 970-328-2604 Facsimile: 970-855-848-8829 E -Mail: jennie.wahrer@eaglecounty.us s Eagle County HHS Prof Sery Final 5/14 With a copy to: Eagle County Attorney 500 Broadway Post Office Box 850 Eagle, Co 81631 Telephone- 970-328-8685 Facsimile: 970-328-8699 E -Mail: atty@eaglecounty.us CONSULTANT: Ross Brooks, Executive Director Mountain Family Health Centers 1905 Blake Ave., Suite 101 Glenwood Springs Colorado, 81601 Telephone: 970-945-2840 E -Mail: rbrooks@mountainfamilv.l 11. Termination. County may terminate this Agreement, in whole or in part, at any time and for any reason, with or without cause, and without penalty therefor with seven (7) calendar days' prior written notice to the Consultant. Upon termination of this Agreement, Consultant shall immediately provide County with all documents as defined in paragraph 9 hereof, in such format as County shall direct and shall return all County owned materials and documents. County shall pay Consultant for Services satisfactorily performed to the date of termination. 12. Venue, Jurisdiction and Applicable Law. Any and all claims, disputes or controversies related to this Agreement, or breach thereof, shall be litigated in the District Court for Eagle County, Colorado, which shall be the sole and exclusive forum for such litigation. This Agreement shall be construed and interpreted under and shall be governed by the laws of the State of Colorado. 13. Execution by Counterparts; Electronic Signatures. This Agreement may be executed in two or more counterparts, each of which shall be deemed an original, but all of which shall constitute one and the same instrument. The parties approve the use of electronic signatures for execution of this Agreement. Only the following two forms of electronic signatures shall be permitted to bind the parties to this Agreement: (i) Electronic or facsimile delivery of a fully executed copy of the signature page; (ii) the image of the signature of an authorized signer inserted onto PDF format documents. All documents must be properly notarized, if applicable. All use of electronic signatures shall be governed by the Uniform Electronic Transactions Act, C.R.S. 24-71.3-101 to 121. 14. Other Contract Requirements. a. In rendering the Services hereunder, Contractor shall comply with the highest standards of customer service to the public. Contractor shall provide appropriate supervision of its employees to ensure the maintenance of these high standards of customer service and professionalism are maintained. 7 Eagle County HHS Prof Sery Final 5/14 The performance of such obligation shall be determined at the sole discretion of County. In the event County finds these standards of customer service are not being met by Contractor, County may terminate this Agreement, in whole or in part, upon seven (7) days' notice to Contractor. b. Consultant shall be responsible for the completeness and accuracy of the Services, including all supporting data or other documents prepared or compiled in performance of the Services, and shall correct, at its sole expense, all significant errors and omissions therein. The fact that the County has accepted or approved the Services shall not relieve Consultant of any of its responsibilities. Consultant shall perform the Services in a skillful, professional and competent manner and in accordance with the standard of care, skill and diligence applicable to Consultants performing similar services. This paragraph shall survive termination of this Agreement. C. Consultant represents and warrants that it has the expertise and personnel necessary to properly perform the Services and covenants that its professional personnel are duly licensed to perform the Services within Colorado. d. Consultant agrees to work in an expeditious manner, within the sound exercise of its judgment and professional standards, in the performance of this Agreement. Time is of the essence with respect to this Agreement. e. This Agreement constitutes an agreement for performance of the Services by Consultant as an independent contractor and not as an employee of County. Nothing contained in this Agreement shall be deemed to create a relationship of employer-employee, master -servant, partnership, joint venture or any other relationship between County and Consultant except that of independent contractor. Consultant shall have no authority to bind County. f. Consultant represents and warrants that at all times in the performance of the Services, Consultant shall comply with any and all applicable federal and state laws, codes, rules and regulations. g. Contractor shall comply with the Civil Rights Act of 1964 and Section 504, Rehabilitation Act of 1973, concerning discrimination on the basis of race, color, sex, age, religion, political beliefs, national origin or handicap. h. This Agreement contains the entire agreement between the parties with respect to the subject matter hereof and supersedes all other agreements or understanding between the parties with respect thereto. i. Consultant shall not assign any portion of this Agreement without the prior written consent of the County. Any attempt to assign this Agreement without such consent shall be void. j. This Agreement shall be binding upon and shall inure to the benefit of the parties hereto and their respective permitted assigns and successors in interest. Enforcement of this Agreement and all rights and obligations hereunder are reserved solely for the parties, and not to any third party. s Eagle County HHS Prof Sery Final 5/14 k. No failure or delay by either party in the exercise of any right hereunder shall constitute a waiver thereof. No waiver of any breach shall be deemed a waiver of any preceding or succeeding breach. 1. The invalidity, illegality or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision hereof. M. Consultant shall maintain for a minimum of three years, adequate financial and other records for reporting to County. Consultant shall be subject to financial audit by federal, state or county auditors or their designees. Consultant authorizes such audits and inspections of records during normal business hours, upon 48 hours' notice to Consultant. Consultant shall fully cooperate during such audit or inspections. n. The signatories to this Agreement aver to their knowledge, no employee of the County has any personal or beneficial interest whatsoever in the Services or Property described in this Agreement. The Consultant has no beneficial interest, direct or indirect, that would conflict in any manner or degree with the performance of the Services and Consultant shall not employ any person having such known interests. o. The Consultant, if a natural person eighteen (IS) years of age or older, hereby swears and affirms under penalty of perjury that he or she (i) is a citizen or otherwise lawfully present in the United States pursuant to federal law, (ii) to the extent applicable shall comply with C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 15. Prohibitions on Government Contracts. As used in this Section 15, the term undocumented individual will refer to those individuals from foreign countries not legally within the United States as set forth in C.R.S. 8-17.5-101, et. seq. If Consultant has any employees or subcontractors, Consultant shall comply with C.R.S. 8-17.5-101, et. seq., and this Agreement. By execution of this Agreement, Consultant certifies that it does not knowingly employ or contract with an undocumented individual who will perform under this Agreement and that Consultant 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 Services under this Agreement. a. Consultant shall not: i. Knowingly employ or contract with an undocumented individual to perform Services under this Agreement; or ii. Enter into a subcontract that fails to certify to Consultant that the subcontractor shall not knowingly employ or contract with an undocumented individual to perform work under the public contract for services. s Eagle County HHS Prof Sery Final 5/14 b. Consultant has confirmed the employment eligibility of all employees who are newly hired for employment to perform Services under this Agreement 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- htlp://www.dhs.gov/xprevprot/programs/ge 1185221678150.shtm C. Consultant 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 Consultant obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an undocumented individual, Consultant shall be required to: i. Notify the subcontractor and County within three (3) days that Consultant has actual knowledge that the subcontractor is employing or contracting with an undocumented individual; 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 undocumented individual; except that Consultant shall not terminate the contract with the subcontractor if during such three (3) days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an undocumented individual. e. Consultant 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. 5-17.5-102(5). f. If Consultant violates these prohibitions, County may terminate the Agreement for breach of contract. If the Agreement is so terminated specifically for breach of this provision of this Agreement, Consultant shall be liable for actual and consequential damages to County as required by law. g. County will notify the Colorado Secretary of State if Consultant violates this provision of this Agreement and County terminates the Agreement for such breach. 10 Eagle County HHS Prof Sery Final 5/14 IN WITNESS WHEREOF, the parties have executed this Agreement the day and year first set forth above. COUNTY OF EAGLE, STATE OF COLORADO, By and Through Its COUNTY MANAGER Ulm Bryan Tree Interim County Manager CONSL Tm. BK.. a=,,..,e.,aea,e.aa .......... Y� Print Name: Ross Brooks Title: CEO 11 Eagle County HHS Prof Sery Final 5/14 EXHIBIT A SCOPE OF SERVICES, SCHEDULE, FEES 1. Services: 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 B. 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 10 Clients that are referred by the County during the term of this Agreement. Contractor shall not perform any vasectomies for Clients who have not properly signed the consent form attached hereto as Exhibit B. 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 ISO days passing between the date of informed consent and the date that the vasectomy procedure is performed. If the physician performing 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. 2. Schedule: This contract will be effective January 1, 2017 to December 31, 2017. 3. Fees: During the term of this Agreement, Eagle County will reimburse on a quarterly basis Contractor for the costs associated with the vasectomy procedure, as identified above, in an amount not to exceed $625for 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 B; payment will not be made unless the County receives the required consent form. An assistant physician fee is not reimbursable for any sterilization procedures. 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. Payment for any unexpected complications or additional visits or services beyond those described in the Scope 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. 12 Eagle County HHS Prof Sery Final 5/14 The total cost of this Agreement shall not exceed $3,750 absent an amendment to this agreement signed by both parties. 13 Eagle County HHS Prof Sery Final 3114 EXHIBIT B FDM hppMWd: Old El W. M7-0 Nola EtPla'a7n [ME: l w3l wl B CONSENT FOR STERILI-ATICIN NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL ORWI THHOLDINO OF ANY BENEFITS PROVIDED B" PRCCRAMS DR PRC,IECTS RECEIVING FEDERAL FUNDS. ■ CONSENT TO STERILLZATION ■ 1 ha we acted for arId mWved IFlo nnA an abc d stE IUAkon torn _ When I nest asked v Cir' ar Mc 1Cl the rlralmadn, I N3S Din 1191 me ded6kor1 Id De stermd % am- pledEly up 10 me. I Ym bald mat 1 ooltn 4&d not to De mao Lmd rf I ne- ew real m Be sell mod, my [L -C n W I nd1 alredt rrl'f 11g111D Td11 re ENE or:eamen I WI not osE Dry help D<narF011t8 nim KWwrra mmmng Federal hrlde, eudl are Telpomry hb&Wbimce for Neeilp raNleb {TANP) or MedMxAd Mat I an naw WmN or ror-&ww I fray bKmme elle. I UNO ER STAND TFIAT TME STEM LJ 7AT1014 MLnST 8E CDNSI DE RED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DD 14 CT WANT TO 13 EC DME PREGNANT, 13EAR CHILDREN 0R FATHER CHILDREN. I wab laid "ut ltrx kKrporay m&ftcl5 W bkdl carrbol that are avdlaINe and DnAd be prawlded 1D me wNd1 w11 allow me to bear or railer a CNId In ine 711112- I r0W IEJ 00 ed MOM! 2lem3tive& and aw3 n 1d nC "ItZCd I understrrd that I will be sLn-bDad try an vpmAcn krrorm am a . The ftmnlata, rkka SPKWType u opelaw and 11envllla� acs[datE!d with Ow operation belle been e q tae ed m me. All my gw%to rs have been arrarered m my "'—�— I lnnerstana Llai t'he DplrMDn wil nDi De none WMI at *30 3D days aver I sdgl ms Turn. I Illldastand m2b I Can drwip my rnIrid a any u7lhe and Id" rrR deckldn at Dry rime not M be stebltreel wlI nd aSLA In the YMtYloddfng of arty neliffm Dl madem Nmce* pr mow by T9derdlly Ilnded ploglams. I am at h= 211 "as Dr age anti MBS Cam D n: LWLe HelenY rumm ar m y a w flee -0l I m be Stmoized by oyf a method fallen - My' c lie m nwwerd elpkres IM clay&tun tie dale of my a tekw- I af86 05rZAMI W CIA M4AR P 411 VIS IWM and Dr" r112dCa1 n3oolds abol the operaBon b Represerrlatives of the 9eparbrerd nr FleaAh and Henral Serhmr, re Ernployea. or progwm or proles wKsad by me DI{r &Tt aid orwVfor laws nll rig rr Feft9I ws More DtselYed. I haw a recehed a oM of M form. Date You ale rr%wcb5o 1D no ply Ale rdlo%" rnar"n, ru it is nd re - aft " arW �iaae Mwjo iy � 10❑ Ftpal'C a LUMD ❑AtnE9Nan IN&W drAWrid NINE ❑ Not Nspanca LAVA ❑ArA3n ❑ Ella= drAflhall AMKr- r1 ❑ Natre HaMalar or DmErPadac Islander Livm* ■ INTERPRETER'S STATEMENT ■ Ian Irlprprebr I& provided t asaU the hdvldual m be s4llI zed I nam tansmod the IMrM3n7r1 11rd X6109! MM@rAEd clary m d -A In- d0ckial to be slYdlsd by tie person DbUriing Vi carrtent. I haaa alsD read hkm97erme corwern farm In Ian MEMp ar'ld 00WIM 1% MMMIS 115 'IMRW. Td me nest of My knv le4e and belkel hlakhe wde abcd tk ehgllwwt}w. kLvwettfs a'w-lux Dare 1111-l5-BE7 { FN12y ■ STATEMENT OF PERSON OBTANNtmCOMSEINT ■ 6amre zigred the ❑ wan roan, I curbed m mrmrwr me natlrm orraenitmbon Dp Mar me rad ma h Is farm hhnded to be a Thal and In e)+ Ible pDdedrm and the dls[amldrt, dshs arld berletG 8.Wallen M1m it I [wed me 111CM1.9 1D De UNIMM = Stamm InKaH Cr birth carrtrd are wealable MEh are lempbray- I coil ned that stEtlliza- Val k. df qw: because H 16 1p m nerrL I hrorrned me hdvkduN be be 6terllmed trot N wrw oorment Dari be 7Ntld'd4M at arty Ime and ma 1wsw wit rdn Vose any nEiati seMdas or afy Deng prowtded by Federal fu nds- Tdthe ]651 E1r UT 11H)UM GJe Dela bE4er the VO4MMI lD Ie 6>Pf112ed 16 at leas 21 yam do wd appeals menial cam pFmm Fwsl a kncwmgy and rAolwrWly requsbed 1D be skdb5A and appeal to d7dan;Und rhe h3lrfe and cuwkgMwes or me pfon-aur. Sr Mil a a Perin obeli" Grnscrd Date ■ PRYSICWYSSFATEMENT ■ Shard) before I pedumed a sierltratldn cp abm upon on Nana od AqA Uwf Dare or SABILROW I explained b hkrawr the name ar the sled=ft oMatom , 1110 6ct CIA It 16 Spec* 4ypedrmen dorl hl�rlded th N=_ a (I hal and IwvE%ble puDedlre and the d5e-0rllrulb, asks and nerlFrr7 mm= W ai IL I CDIn6ded the IIICMM31 1D to MC= D7at ww"tIve m -tri= of Nrm mntrd a2 atataNe min kA are lempmW- I emplalned that sb3Ilz& t1T11 is drie eni becam It h& perrm n -a t I InrDRn ed the IndM 1.9 to be slEd med Les IYrridr ponEarrl Can be 7N tidrd'w a arty nm,- am ala r"* not lose wry he" se N*5as or beneM provided by Feral Md& To re deal Or my VIDWedx ala teller me ravlalaI LU be abKllmed is X least 21 yu ra Na and appears men taIy d1811p4LLM WS; he tllowirlgry a -d vDkrrtalyr regwsbd to be 6bMlzed and appeared to rnderslard the na ure and mw—gwyw.e6 W me pr�- VIIIsirw1cros lar use oT wNir n mi pmegaihle Liss the ni51 paaglape Deow EnTept h1 LIe Case Cr p2rTlaL/e neive rY or HMY1jEf q almfrl I l7a angery "where 11e 5fflizal an is pgrorrn-a le&&rm .lD dayE aner ma dale or the Indfdn zara &gralfs Dn me CLrlfiErrt tonin. In Lose Dass. mE senald paagrapt MR* m161 De eyed. Moss on the p3ra- TFap11wr" 16 not t*el'L) 17] RI le319 30 dap name pa...... lo"een rile date Or elle Illd'.aum-d skjnature on 71s Dx*ern ralrn aryl the dais Die 6benitzkbn ww MaUrned 41 Tris atwI=do was wDimea less Clan 3D"tat mDre man 72 banes iter me date or me bedeck"& "rabre on nils tslstrrt rtrm because a Rte fDIWWng drarntanoes {crea applk:aUe Iia and ill in Wormaevn regheebd): ❑ Premaliffe ON10Pfy Inlwfdl9'a a wcm-ddale ardeneary: ❑ E mmpricy odomhna sl� jo1=,D.a dPLYlRhswioE �.4Xshcrarrk S7gnahxe Celle 14 Eagle County HHS Prof Sery Final 5/14 Fmm Ap dz& 0M2 Nx ogw offs CONSENTIMIENTO PARA Lel ESTERIL17-ACION F#M: LA AEGIS" DE NO ESTERILIZARSE OUE USTED PUEL7E TUNIAR EN GUALQIAER WMEV0. NO GALISAFLA EL AETIRDOLA AETEN01ON DE NING LIN DEN EFICI0OUE LE SEAPRO PCACONADD PDR PRDGRAMAS 0PRQYEC70S QUE RECIDEN FCNDDS FEDERALES. ■ CDNSENMENTO PAPA =RUZACI6N ■ 1b he aclLdmamb y he radLido In bum& an de - u d via a*" m emmit D*n. cuan m maw mwLL9cHm see irxmwin ms djemm qua N do*,U de ser egi.AI ad e& oynoelamerrhe role. Ma dF jean qm yo pad fa 6E ddr no aar S✓ decidc m sstadltzr n% ml maumn rmn mman ml ms m" d rerttir rmtamisrmm o cu daam my 409 eel el Rani No pe mere rtguia ea=enm c Mwennoz as p rag wm p9doc &XS don sofaa6 fade rales, raise CYrrl b x F D. G O MebmkL qme re2ha-a=m3nte9 para W imm" se eIEgIsla. ENTrNDO QUr LA- E5TTP;ILIZACIBN SE C4NSIDE A LWAOPE7k AcON P mmAmrE E E Innry msinLE. vc HE ❑ECICi1cc OLm mD GUERm7 GLUM VR EMRAA,4La DA, NO UJIERO TE AER 4 J a NO GUEM PRDCHEAH iHL1CU Me IrUmar01L qm me pmm &deem pmp4rty nu 0roe Rg mas dE aril mn- oepdmin dkq o qua son Ferrp-r - y qua penrmrdn q ue pLmda t£r-mr o pmcmar hips En ei Ndum- He •.,••h•-. ado sAm opE[wm r he daddmdo sereslemCma m .En Uvia- que sere e51ermawc. po* maolo- Oe ura q* W3 n [m nama Mie nan mpmjD las mu=s, Ic6 ml mgcs y Im nmr7nblme im a.am mn e ONmadm. Han resp4mmdldm 3 �ffwne m a U4as ms PMOMmL EnbErrma q.VE Is uparad7n nD se mumm4 Masts q!E ratan p®am 3D dram LL7rmb mrFirna, a pr -Ur de la Wha en La qua dims erg FDw& Enl a qua pLmdo cErnUw de 044 sn maelquler mmonem-rlo y qua ml declelOm sn amhgLier mmrmevdn de no aer ..6bgflll-._a.,,a nmr resuhara En la ral9ndan de Derdndm9 b s9relcics n'mas prapp=&3m a Tram -W pmvglama9 qua Rcwfm 1m xm Iederam. Termpo p f Io mends 21 afos y nad N! lb,par medlo de La peaerr rli m" RimrmK&flIerrib de ml WeY&Fdedperasw aBmmvo pmsr par al m9 do Lwnada km mraenum em 1wca 1 D dies a pars r OE m ivcm en la que 11 Rna, am ODD-MLLMb. 16111 6n der• M OO Ififf tmmLEfdm para qua a9 praserde 9SU Fo-rrna y otos e godermbe mdd bm setre la open" ri Flepresmmm s dal Dspwamenm 09 saw y Swws-97C1a- lea. D Fnmpi9ed¢9 de R Nrwflama D prvyndb2 RUPUsd129 p3F ee8 aaparmrnerrm pew sNo pma q -me pmmederm debm mher d m hen am" in L39 lego&raderalae. HewatIdo Lanamxpla de -Bela Forma huLs' fd& - A $ Se niop pmopuFDb me a EUukmL3 Inromaddn, pmgm-m rm es obligatorb v*EIP4 GYar Fwe PuWe sEyw a Wgwi ❑ Higpwm D Liao ❑ tmdfgera m ner=w a Immdlgena Oe .wa= ❑ No hhmrm o WHO ❑ s ❑ Naga c simmiada m ❑ Nat A6& Hmawerl u olrao dleadd PtEDTM ❑ mamco ■ DEadm UTAa16N DEL INTtRPRETE ■ SI me hen pmpo-ckmw1D Im se-vidcE de un In19" pma &&Fahr a b pamsorma gpla K -m Boers mGa: H81maO11bim 1a Mtff n y = CmX SSM q.VE Wfbaan Efml9 9E re Man pmsw*Kb a la psrama q2e sera 9aisml�damb pa 91 Mtimhiduo qua he, obbwkb ti&Le ca_rraerdmlenta- 7ern6idn le he lLi a &UNL3 In Forma de oor,eenitnkwAn en Noir& r113 he erpLado e1 arrrimmIdD 43 ata fomma A ml reside a&ter y erLerm7err 6 E1 to m91tY om d®le 9Np i mu rt. HHS -97-1 {11 (2009 DECL4RACIbM DE LA PERS0RA 4UE DBTIEME CONS ENTIMlEWrG ■ Anma mE gue 0-�aWP-MS? Ismwo la roma de Carnendmhxdo pna In EsbALmdbn. k hg aq,llcadc s slum It® be la npemom para to 99* m9nal. el iwc-FD da qua EI me9mamx 09 mw p*=mmnID 9e 11 n e WpwE-Wb1e, y WE rrmbleetlar, log rlebgm9 y log b&*Ddv9 awxiWcr. mn e50e prooedri-IDL tie amro4mb a b pmeom rue Sera ecb31It3M que hay c1hpodUm flad9 ffwaws w almowKapdeml qw Ean 1KTxa1EE. Le n9 algimtla qua g e6mmmim as Ole om pm * em wmzmeYm61 Le ha e a g para ma W m991 sea mbbda qw puede ml rar mm ammeatl Worts arm mam&kFm1Lr mu marls y q me dWA no perdma n N an aervl- do de salud o b9naldo propuffcIeffLElb don EI pnhuu-* de brmdm rade mim A ml M*F AK -FT , la per6onaque 5Meet9 [Z.a lane p 3F la ffnerms 21 areas de wind y preoe eer mrmer,fatnerrb oNnpsabwL- E 1641 he anazwo mn uNmBanlemao -m fiarra n par fere Ymerr m ser a5 M LzII -d y puma wNno-er a nou am m b191 ":edrnm13 y sme oxtseW� X— A� i pmmmsamr mjw ah— marm vui ■ DECLAFIAC16N DEL N&WO ■ Pnlldwrium a realty la Op31Er]r7rm para is EObE111IadOn 2 fmmmmhrraA purser. rum an . Le ap" 9 &rata 105 WMIES Be ftdiada? dem W-tcmn para 1n emmrorm del aechr de que fcc�rJSguv i�9) ae to pmcadL-nIErr c. mon Ln meaulimb fi91 E Inrmimalhla y Iaa mdaAm Lcs rleaga9 y fns bereildos a9 =U- = s mn alltEL opamcm- Lo wDrngt E 13 pe rang q-eserea eaie Fllzadav qua hay dnpcd Gies mshos nme mms ee ane..rm'a3p que amn 1mpo-rarea Le emgalgLmB que a mmnl- 103= ea daarenle perque es parmanermm. Le anima a Is Mom gn aerfa E wlma03 sue pcdla mel lar s wren- WMW M Mo*" MMa SMy qua elaa111c pfr.Ena ry-j;Ln SFM..e sox O rm ig m aerL311rto pmdpxncrra d0 0[n el p 2'•] rc os k4 aRr. Awill rmeMEE"ryenl:E- er.hapiramaguesEr3eEIEAU.—claneato nm 21 emit de adad y pmeme go r Fwnt tarda no rr 7e l E m2. E11a-N ha 9o- IcR mbemom drnkg-Asdema,r. yrisme90urdadsaeededlzadaaypens& amammm N mmmmmaaa y las mmrsa� co nSL8. p MLxm I m WN:L Irre INX231rea para tea ROEMIEM mle pWIBX 9 Banka: 42nI13 a par- ffsk 1 q.me se pmeaErta a c4m wa dft waLpbm p era rmLsoE O E pan. FMMI Lmm Y arug emmm m de Enle mgerlde cv3w serf maeL�Oo Ia esRmmc mm a warm S W30 OW UeSPA9 da le W& an la q2E L9 P3130M n mini Ia FORT ea C xoErrttmmLa'rhr penia La E9W I WKCrL Pam meas mrd mmtllw el pdrmlL 2 mpe m p mewrLEL m13 ad" b3L Tact -c oon Lnm3 % el pdndo q me m Be apl}re. � Id] Han Lmansmnldo par b means ad dos -helm L3 red,& m la qre In pmmmaama b" Beta Form a k C w15"IT lento r e radia en le gmme M FB3= b enfimomdSn- I21 La ap2m " para In &Hiemvan m sa mw a mmmc ms 20 0m m parr a mas de T2 hOres, ompuft da Is vans on to qua L9 p 9m mme reels Is PmT dE Qxra and mlerrs: Uaw a lets vp *nm afOJm""-' paique ftcmiaaprbpamayawm H Inrorm acm regaenda]: ❑ Pam premaur0 Eed1a p favism dE Pam. ❑ Clrug fa abdwntlal ds Urgermal3 rIX59U AE QXIV5Ul": ¢Fane dmf mrdr4 pods) rar:c"ra>f,a m rr 15 Eagle County RHS Prof Sery Final 5/14 EXHIBIT C Insurance Certificate ss Eagle County HHS Prof Sery Final 5/14 MOUNFAM-01 BLEWIS '4cQ�zo CERTIFICATE OF LIABILITY INSURANCE DATE(MIJUDDYYYY) 6r6r2016 _ THIS CERTIFICATE 15 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 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 en dorsement(s). PRODUCER A NAME., AssuredPartners of Colorado, LLCM 3D3 Tli-1800 FAX 4600 S. Ulster Street #1400 .� W Nb)-' (303) 290-0884 Denver, CO B0237 dAAIL oss: INSURED Mountain Family Health Centers Attn: Ms. Annette Franta. CFO 1905 Blake Avenue #101 Glenwood Springs, CO B1601 INSURER A : Liberty Mutual !!SURER B: Pinnacol Assurance !!SURER C : Philadelphia Insurance Co INSURER D: INSURER E INSURER F: 1111176T+i►►:1:TNN dId176TAfs;2.u1Ly�1:14: :ax■►Wrala>tatuLy�i:1:1: 190 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. Eagle, CO B1631 INSR TYPE INSURANCEA1313L LTR SUER INSD WVD POLICY EFF POLICY NUMBER MWDDYYYY POLICY EXP MMIDWY LIMITS A x COMMERCIAL GENERAL UABILrrY EACH OCCURRENCE $ 11000,000 CLAIMS-MADEI-XI OCCUR BZ5{16}56117851 06l0il2016 06/01/2017 PREMOE TO RENTED ISES E"'currence $ 11000,000 MED EXP (Anyone person] $ 15,000 PERSONAL&ADV INJURY $ 11000,000 GE N'L AGG R EGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT P�] LOC PRODUCTS - COMPIOP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILrrY COM BIN ED SING LE UMIT Ea acadW $ 11000,000 BODILY INJURY (Per person) $ A ANY AUTO B'ZS(16)56117B51 06/01/2016 06!0112017 ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Pe raaddent] $ PROPERTY DAMAGE xx NON -OWNED HIRED AUTOS AUTOS Per aopdent X UMBRELLA UAB x OCCUR EACH OCCURRENCE $ 11000,000 A EXCESS UAB CLAIMS -MADE USO(16)56117B51 06/01/2016 0fi1011M17 AGGREGATE $ DED I X I RETENTION$ 10,000 $ 11000,000 WORKERS COMPENSATION PER OTH- STATUTE ER AND EMPLOYERS' LABILITY Y IE 1461272 06.;01.;2016 B ANY PROPRIETOR;PARTNERXECUTIVE 06.;01.;2017 E.L. EACH ACCIDENT $ 11000,000 OFFICER;MEMBER EXCLUDED? NIA (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ 11000,000 If yes, describe under DESC RIPTIDN OF 0PERAT 10NS beiow E.L. DISEASE - POLICY LIMIT 1 $ 11000,000 A Property B'ZS(16)56117B51 06/01/2016 06/01/2017 $500 4,074,600 C Directors & Officers PHSD104B310 06/01/2016 06/01/2017 11000,000 DESCRIPTION OF OPE RATIO NSI LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may beattachad It mare space Is required) Eagle County, Its associated or affiliated entitles, Its successors and assigns, elected officials, employees, agents and volunteers are Additional Insureds under the commercial general liability and automobile liability policies of insurance, ATI MA. r'-FRTIFIr_OTF Hni inFR r_ONr_FI I OTION C 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014,+01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Eagle County ACCORDANCE WITH THE POLICY PROVISIONS. POB 6C Eagle, CO B1631 AUTHORIZED REPRESENTATIVE C 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014,+01) The ACORD name and logo are registered marks of ACORD