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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
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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
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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
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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
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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
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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.
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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.
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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.
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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.
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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
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Print Name: Ross Brooks
Title:
CEO
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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.
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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.
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Eagle County HHS Prof Sery Final 3114
EXHIBIT B
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CONSENT FOR STERILI-ATICIN
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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