HomeMy WebLinkAboutDoc 274 - Agrmt - Williams - Beh Health SvcsI
Deschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org
AGENDA REQUEST &STAFF REPORT
For Board Business Meeting of August 7, 2013
Please see directions for completing this document on the next page.
DATE: July 29, 2013
FROM: Nancy Mooney, Contract Specialist Phone: 322-7516
Health Services--Behavioral Health Division
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2013-274, personal services contract
between Marc Williams, M.D. and Deschutes County Health Services.
PUBLIC HEARING ON THIS DATE? No
BACKGROUND AND POLICY IMPLICATIONS:
Marc Williams, M.D., provides behavioral health services to persons diagnosed with
serious behavioral health illness, or other behavioral or emotional disturbance posing a
danger to the health and safety of themselves or others. These services include providing
psychiatric assessments, medication prescribing and medication management, and
provision of group and individual therapy for qualifying individuals. Medical services will be
provided and documented in a legible manner consistent with professional and community
standards of care.
County will provide monthly payments to Dr. Williams (upon receipt of invoice) on a fee-for
service basis of $137.19 per hour for a maximum offorty (40) hours per week. Dr.
Williams will pay a monthly rent of $500 in return for the County providing an office,
meeting space, use of a computer, phone, e-mail and any other general office supplies
required to carry out the terms of the contract.
FISCAL IMPLICATIONS:
Maximum compensation for the duration of the contract is $230,000.
RECOMMENDATION &AC1"ION REQUESTED:
Behavioral Health requests approval.
ATTENDANCE: DeAnn Carr, Behavioral Health Deputy Director
DISTRIBUTION OF DOCUMENTS:
Executed originals to:
Nancy Mooney, Contract Specialist, Health Services
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements,
regardless of whether the document is to be on a Board agenda or can be signed by the County
Administrator or Department Director. If the document is to be on a Board agenda, the Agenda
Request Form is also required. If this form is not included with the document, the document will
be returned to the Department. Please submit documents to the Board Secretary for tracking
purposes, and not directly to Legal Counsel, the County Administrator or the Commissioners. In
addition to submitting this form with your documents, please submit this form electronically to
the Board Secretary.)
Please complete all sections above the Official Review line.
Date: I July 16, 2013 :
Department: I Health Services, Behavioral Health I
Contractor/Supplier/Consultant Name: I Marc Williams, M.D.
Contractor Contact: I Dr. Williams I Contractor Phone #: I 541-322-7572
Type of Document: Personal Services Contract
Goods and/or Services: Marc Williams, M.D. provides mental health to persons diagnosed
with serious mental health illness, or other mental or emotional disturbance posing a danger to
the health and safety of themselves or others.
Background & History: Dr. Marc Williams will provide behavioral health services as a
Licensed Medical Practitioner. These services include psychiatric assessments, medication
prescribing and medication management, and provision of group and individual therapy for
qualifying individuals. Medical services will be provided and documented in a legible manner
consistent with professional and community standards of care.
Deschutes County will provide monthly payments to Dr. Williams upon receipt of invoice for
services provided. Dr. Williams will pay monthly rent of $500 in return for the County providing
the office and meeting space, use of a computer, phone, e-mail and any other general office
supplies required to carry out the terms of the contract.
Agreement Starting Date: I July 1, 2013 I Ending Date: I June 30, 2014
Annual Value or Total Payment: I Maximum compensation is $230,000 I
Check all that apply: o RFP, Solicitation or Bid Process o Informal quotes «$150K)
r8J Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37)
7116/2013
Funding Source: (Included in current budget? rgJ Yes 0 No
If No, has budget amendment been submitted? 0 Yes 0 No
Is this a Grant Agreement providing revenue to the County? 0 Yes rgJ No
Special conditions attached to this grant: L-I_--'
Deadlines for reporting to the grantor: D
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that it is a
grant-funded position so that this will be noted in the offer letter: 0 Yes 0 No
Contact information for the person responsible for grant compliance: Name: D
Phone #:
Departmental Contact and Title: Nancy Mooney, Contract Specialist
Phone #: I 541-322-7516 I
Deputy Director Approval: } -L5-t3
Date
Department Director Approval: --""",=,'f-~------
Date
Distribution of Document: Return both 0 ginals to Nancy Mooney, Behavioral
Health Department.
Official Review:
County Signature Required (check one): ~SOCC Department Director (if <$25K)
~~~ <~}10K; if >$150K, SOCC Order No.
Legal Review . /.. J!iz)I Date]' Z i ~ I 3
Document Number .::.20=-1.:..::3:....!-2=-:7~4:--____
o Administrator (if >$25K
7/]6/2013
LEAL CdUNSEL
For Recording Stamp Only
DESCHUTES COUNTY SERVICES CONTRACT
CONTRACT NO. 2013-274
This Contract is made and entered into by and between Deschutes County, a political subdivision of the State of Oregon,
acting by and through the Deschutes County Health services Department, Behavioral Health division, hereinafter referred
to as "County", and Marc V. Williams, M.D., , hereinafter referred to as "Contractor". The Parties agree as follows:
Effective Date and Termination Date. The effective date of this Contract shall be July 1, 2013. Unless extended or
terminated earlier in accordance with its terms, this Contract shall terminate when County accepts Contractor's completed
performance or on June 30, 2014, whichever date occurs last. Contract termination shall not extinguish or prejudice County's
right to enforce this Contract with respect to any default by Contractor that has not been cured. This Contract may be
renewed or extended only upon written agreement of the Parties.
Statement of Work. Contractor shall perform the work described in Exhibit 1.
Payment for Work. County agrees to pay Contractor in accordance with Exhibit 1.
Contract Documents. This Contract includes Page 1-9 and Exhibits 1,2,3,4,5,6 and 7 and 8.
CONTRACTOR DATA AND SIGNATURE
Contractor Address: 1495 NW Quincy Dr., Bend, OR 97701
Federal Tax ID# or Social Security #: ***-**-7768
Is Contractor a nonresident alien? DYes D No
Business Designation (check one): D Sole Proprietorship o Partnership
D Corporation-for profit 0 Corporation-non-profit o Other, describe: LLC
A Federal tax ID number or Social Security number is required to be provided by the Contractor and shall be used for the
administration of state, federal and local tax laws. Payment information shall be reported to the Internal Revenue Service
under the name and Federal tax ID number or, if none, the Social Security number provided above.
I have read this Contract including the attached Exhibits. I understand this Contract and agree to be bound by its
terms. NOTE: Contractor shall also sign Exhibits 3 and 4 and, if applicable, Exhibit 6 and 7.
Signature Title
Name (please print) Date
DESCHUTES COUNTY SIGNATURE
Contracts with a maximum consideration of not greater than $50,000 are not valid and not binding on the County until
signed by the appropriate Deschutes County Department Head. Additionally, Contracts with a maximum consideration
greater than $50,000 but less than $150,000 are not valid and not binding on the County until signed by the County
Administrator or the Board of Gounty Commissioners.
Dated this l" of J vi y ,2013 Dated this of , 2013
ALAN UNGER, Chair
TAMMY BANEY, Vice Chair
ANTHONY DEBONE, Commissioner
Page 1 of 9-Behavioral Health -Personal Services Contract No. 2013-274
DC-2013-274
STANDARD TERMS AND CONDITIONS
1. Time is of the Essence. Contractor agrees that time is of the essence in the performance of this Contract.
2. Compensation. Payment for all work performed under this Contract shall be made in the amounts and manner set
forth in Exhibit 1.
a. Payments shall be made to Contractor following County's review and approval of billings and deliverables
submitted by Contractor.
b. All Contractor billings are subject to the maximum compensation amount of this Contract.
c. Contractor shall not submit billings for, and County shall not pay, any amount in excess of the maximum
compensation amount of this Contract, including any reimbursable expenses, (See Exhibit 5).
1) If the maximum compensation amount is increased by amendment to this Contract, the amendment shall be
signed by both parties and fully executed before Contractor performs work subject to the amendment.
2) No payment shall be made for any services performed before the beginning date or after the expiration date of
this Contract.
d. This Contract shall not be amended after the expiration date.
e. Unless otherwise specifically provided in Exhibit 5, Contractor shall submit monthly invoices for work performed.
The invoices shall describe all work performed with particularity and by whom it was performed and shall itemize
and explain all expenses for which reimbursement is claimed.
f. The invoices also shall include the total amount invoiced to date by Contractor prior to the current invoice.
g. Prior to approval or payment of any billing, County may require and Contractor shall provide any information which
County deems necessary to verify work has been properly performed in accordance with the Contract.
h. Expenditures of Contractor may be charged to this Contract only if they: (1) are in payment for services performed
under this Contract; (2) conform to applicable State and Federal regulations and statutes; (3) are in payment of an
obligation incurred during the period of this Contract; and (4) are not in excess of 100% of program costs. Any County
funds spent for purposes not authorized by this Contract shall be deducted from payments or refunded to County, at
County's option. Payments by County in excess of authorized actual expenditures shall be deducted from payment or
refunded to County no later than thirty (30) days after the expiration of this Contract. If Contractor fails to provide an
acceptable audit performed by a certified public accountant for federal funds received under this Contract, or if federal
authorities demand the repayment of federal funds received under this Contract, County may recover all federal funds
paid under this Contract, unless a smaller amount is disallowed or demanded. If Oregon Health AuthOrity
(Department) disallows or requests repayment for any funds paid under this Contract due to Contractors' acts or
omiSSions, Contractor shall make payment to the County of the amount disallowed or requested. In the event that the
Department determines that County is responsible for the repayment of any funds owed to the Department by
Contractor, Contractor agrees to make such payment within ten (10) days of notification by County or the Department
of said determination by the Department.
i. In the event that a statutorily required operating license or letter of approval is suspended or not extended, County's
obligation to provide reimbursement for services or program expenses hereunder related to services rendered without
the necessary license or approval will cease on the date of termination of this Contract (whether in whole or in part) or
the date of expiration or suspension of the license or letter of approval, whichever date is earlier.
3. Delegation, Subcontracts and Assignment. Contractor shall not delegate or subcontract any of the work required by
this Contract or assign or transfer any of its interest in this Contract, without the prior written consent of County.
a. Any delegation, subcontract, assignment, or transfer without prior written consent of County shall constitute a
material breach of this Contract.
b. Any such assignment or transfer, if approved, is subject to such conditions and provisions as the County may
deem necessary.
c. No approval by the County of any assignment or transfer of interest shall be deemed to create any obligation of
the County to increase rates of payment or maximum Contract consideration.
d. Prior written approval shall not be required for the purchase by the Contractor of articles, supplies and services
which are incidental to the provision of services under this Contract that are necessary for the performance of the
work.
e. Any subcontracts that the County may authorize shall contain all requirements of this Contract, and unless
otherwise specified by the County the Contractor shall be responsible for the performance of the subcontractor.
4. No Third Party Beneficiaries.
a. County and Contractor are the only parties to this Contract and are the only parties entitled to enforce its terms.
Page 2 of 9 -Behavioral Health -Personal Services Contract No. 2013-274
b. Nothing in this Contract gives or provides any benefit or right, whether directly, indirectly, or otherwise, to third
persons unless such third persons are individually identified by name in this Contract and expressly described as
intended beneficiaries of this Contract.
5. Successors in Interest. The provisions of this Contract shall be binding upon and inure to the benefit of the parties
and their successors and approved assigns, if any.
6. Early Termination. This Contract may be terminated as follows:
a. Mutual Consent. County and Contractor, by mutual written agreement, may terminate this Contract at any time.
b. Party's Convenience. County or Contractor may terminate this Contract for any reason upon thirty (30) calendar
days written notice to the other party.
c. For Cause. County may also terminate this Contract effective upon delivery of written notice to the Contractor, or
at such later date as may be established by the County, under any of the following conditions:
1) If funding from state or other sources is not obtained and continued at levels sufficient to allow for the
purchase of the indicated quantity of services as required in this Contract.
2) This Contract may be modified to accommodate the change in available funds.
3) If state laws, regulations or guidelines are modified, changed or interpreted in such a way that the services are
no longer allowable or appropriate for purchase under this Contract or are no longer eligible for the funding
proposed for payments authorized by this Contract.
4) In the event sufficient funds shall not be appropriated for the payment of consideration required to be paid
under this Contract, and if County has no funds legally available for consideration from other sources.
5) If any license or certificate required by law or regulation to be held by the Contractor to provide the services
required by this Contract is for any reason denied, revoked, suspended, not renewed or changed in such a
way that the Contractor no longer meets requirements for such license or certificate.
d. Contractor Default or Breach. The County, by written notice to the Contractor, may immediately terminate the
whole or any part of this Contract under any of the following conditions:
1) If the Contractor fails to provide services called for by this Contract within the time specified or any extension
thereof.
2) If the Contractor fails to perform any of the other requirements of this Contract or so fails to pursue the work
so as to endanger performance of this Contract in accordance with its terms, and after receipt of written notice
from the County specifying such failure, the Contractor fails to correct such failure within ten (10) calendar
days or such other period as the County may authorize.
3) Contractor institutes or has instituted against it insolvency, receivership or bankruptcy proceedings, makes an
assignment for the benefit of creditors, or ceases doing business on a regular basis.
e. County Default or Breach.
1) Contractor may terminate this Contract in the event of a breach of this Contract by the County. Prior to such
termination, the Contractor shall give to the County written notice of the breach and intent to terminate.
2) If the County has not entirely cured the breach within ten (10) calendar days of the date of the notice, then the
Contractor may terminate this Contract at any time thereafter by giving notice of termination.
7. Payment on Early Termination. Upon termination pursuant to paragraph 6, payment shall be made as follows:
a. If terminated under subparagraphs 6 a. through c. of this Contract, the County shall pay Contractor for work
performed prior to the termination date if such work was performed in accordance with the Contract. Provided
however, County shall not pay Contractor for any obligations or liabilities incurred by Contractor after Contractor
receives written notice of termination.
b. If this Contract is terminated under subparagraph 6 d. of this Contract, County obligations shall be limited to
payment for services provided in accordance with this Contract prior to the date of termination, less any damages
suffered by the County.
c. If terminated under subparagraph 6 e of this Contract by the Contractor due to a breach by the County. then the
County shall pay the Contractor for work performed prior to the termination date if such work was performed in
accordance with the Contract:
1) with respect to services compensable on an hourly basis, for unpaid invoices, hours worked within any limits
set forth in this Contract but not yet billed, authorized expenses incurred if payable according to this Contract
and interest within the limits set forth under ORS 293.462, and
2) with respect to deliverable-based Work, the sum designated for completing the deliverable multiplied by the
percentage of Work completed and accepted by County, less previous amounts paid and any claim(s) that
County has against Contractor.
3) Subject to the limitations under paragraph 8 of this Contract.
Page 3 of 9 -Behavioral Health -Personal Services Contract No. 2013-274
8. Remedies. In the event of breach of this Contract the parties shall have the following remedies:
a. Termination under subparagraphs 6 a. through c. of this Contract shall be without prejudice to any obligations or
liabilities of either party already reasonably incurred prior to such termination.
1) Contractor may not incur obligations or liabilities after Contractor receives written notice of termination.
2) Additionally, neither party shall be liable for any indirect, incidental, consequential or special damages under
this Contract or for any damages of any sort arising solely from the termination of this Contract in accordance
with its terms.
b. If terminated under subparagraph 6 d. of this Contract by the County due to a breach by the Contractor, County
may pursue any remedies available at law or in equity.
1) Such remedies may include, but are not limited to, termination of this Contract, return of all or a portion of this
Contract amount, payment of interest earned on this Contract amount, and declaration of ineligibility for the
receipt of future contract awards.
2) Additionally, County may complete the work either by itself, by agreement with another Contractor, or by a
combination thereof. If the cost of completing the work exceeds the remaining unpaid balance of the total
compensation provided under this Contract, then the Contractor shall be liable to the County for the amount of
the reasonable excess.
c. If amounts previously paid to Contractor exceed the amount due to Contractor under this Contract, Contractor
shall repay any excess to County upon demand.
d. Neither County nor Contractor shall be held responsible for delay or default caused by fire, civil unrest, labor
unrest, riot, acts of God, or war where such cause was beyond reasonable control of County or Contractor,
respectively; however, Contractor shall make all reasonable efforts to remove or eliminate such a cause of delay
or default and shall, upon the cessation of the cause, diligently pursue performance of its obligations under this
Contract. For any delay in performance as a result of the events described in this subparagraph, Contractor shall
be entitled to additional reasonable time for performance that shall be set forth in an amendment to this Contract.
e. The passage of this Contract expiration date shall not extinguish or prejudice the County's or Contractor's right to
enforce this Contract with respect to any default or defect in performance that has not been cured.
f. County's remedies are cumulative to the extent the remedies are not inconsistent, and County may pursue any
remedy or remedies singly, collectively, successively or in any order whatsoever.
g. Differences between a Contractor and County, or between contractors, will be resolved when possible at appropriate
management levels, followed by consultation between boards, if necessary. County's Director will have ultimate
responsibility for resolution of disagreements among subcontract agencies.
9. Contractor's Tender upon Termination. Upon receiving a notice of termination of this Contract. Contractor shall
immediately cease all activities under this Contract unless County expressly directs otherwise in such notice of
termination.
a. Upon termination of this Contract, Contractor shall deliver to County all documents, information, works-in-progress
and other property that are or would be deliverables had this Contract been completed.
b. Upon County's request. Contractor shall surrender to anyone County designates, all documents, research, objects
or other tangible things needed to complete the work.
10. Work Standard.
a. Contractor shall be solely responsible for and shall have control over the means, methods, techniques, sequences
and procedures of performing the work, subject to the plans and specifications under this Contract and shall be
solely responsible for the errors and omissions of its employees, subcontractors and agents.
b. For goods and services to be provided under this Contract, Contractor agrees to:
1) perform the work in a good, workmanlike, and timely manner using the schedule, materials, plans and
specifications approved by County;
2) comply with all applicable legal requirements;
3) comply with all programs, directives, and instructions of County relating to safety, storage of equipment or
materials;
4) take all precautions necessary to protect the safety of all persons at or near County or Contractor's facilities,
including employees of Contractor, County and any other contractors or subcontractors and to protect the
work and all other property against damage.
11. Drugs and Alcohol. Contractor shall adhere to and enforce a zero tolerance policy for the use of alcohol and the
unlawful selling, possession or use of controlled substances while performing work under this Contract.
Page 4 of 9 -Behavioral Health -Personal Services Contract No. 2013-274
12. Insurance. Contractor shall provide insurance in accordance with Exhibit 2 attached hereto and incorporated by
reference herein.
13. Expense Reimbursement. If the consideration under this Contract provides for the reimbursement of Contractor for
expenses, in addition to Exhibit 5, Exhibit 1 shall state that Contractor is or is not entitled to reimbursement for such
expenses.
a. County shall only reimburse Contractor for expenses reasonably and necessarily incurred in the performance of
this Contract.
b. Expenses reimbursed shall be at the actual cost incurred; including any taxes paid, and shall not include any
mark-up unless the mark-up on expenses is specifically agreed to in this Contract.
c. The cost of any subcontracted work approved in this Contract shall not be marked up.
d. Contractor shall not bill County for any time expended to complete the documents necessary for reimbursement of
expenses or for payment under this Contract.
e. The limitations applicable to reimbursable expenses are set forth in Exhibit "5," attached hereto and by reference
incorporated herein.
14. Criminal Background Investigations. Contractor understands that Contractor and Contractor's employees and
agents are subject to periodic criminal background investigations by County and, if such investigations disclose
criminal activity not disclosed by Contractor, such non-disclosure shall constitute a material breach of this Contract and
County may terminate this Contract effective upon delivery of written notice to the Contractor, or at such later date as
may be established by the County.
15. Confidentiality. Contractor shall maintain confidentiality of information obtained pursuant to this Contract as follows:
a. Contractor shall not use, release or disclose any information concerning any employee, Individual, applicant or
person doing business with the County for any purpose not directly connected with the administration of County's
or the Contractor's responsibilities under this Contract except upon written consent of the County, and if
applicable, the employee, Individual, applicant or person.
b. The Contractor shall ensure that its agents, employees, officers and subcontractors with access to County and
Contractor records understand and comply with this confidentiality provision.
c. Contractor shall treat all information as to personal facts and circumstances obtained on Medicaid eligible
individuals as privileged communication, shall hold such information confidential, and shall not disclose such
information without the written consent of the individual, his or her attorney, the responsible parent of a minor child,
or the child's guardian, except as required by other terms of this Contract.
d. Nothing prohibits the disclosure of information in summaries, statistical information, or other form that does not
identify particular individuals.
e. Personally identifiable health information about applicants and Medicaid reCipients will be subject to the
transaction, security and privacy provisions of the Health Insurance Portability and Accountability Act ("HIPAA").
f. Contractor shall cooperate with County in the adoption of policies and procedures for maintaining the privacy and
security of records and for conducting transactions pursuant to HIPAA requirements.
g. This Contract may be amended in writing in the future to incorporate additional requirements related to compliance
with HIPAA.
h. If Contractor receives or transmits protected health information, Contractor shall enter into a Business Associate
Agreement with County, which, if attached hereto, shall become a part of this Contract.
i. Individually Identifiable Health Information about specific individuals is confidential. Individually Identifiable Health
Information relating to specific individuals may be exchanged between County and OHA for purposes directly
related to the provision of Services to Individuals which are funded in whole or in part under this Contract.
Contractor shall maintain the confidentiality of Individuals records as required by applicable state and federal law,
including without limitation, ORS 179-495 to 179.507, 45 CFR Part 205, 42 CFR Part 2, any administrative rule
adopted by the Oregon Health Authority, implementing the foregoing laws, and any written poliCies made available
to Contractor by County or by the Oregon Health Authority. Contractor shall create and maintain written policies
and procedures related to the disclosure of Individual information and shall make such policies and procedures
available to County and the Oregon Health Authority for review and inspection as reasonably requested by County
or the Oregon Health Authority.
16. Reports. Contractor shall provide County with periodiC reports at the frequency and with the information prescribed by
County. Further, at any time, County has the right to demand adequate assurances that the services provided by
Contractor shall be in accordance with the Contract. Such assurances provided by Contractor shall be supported by
documentation in Contractor'S posseSSion from third parties.
Page 5 of 9 -Behavioral Health -Personal Services Contract No. 2013-274
Contractor agrees to prepare and fumish such reports and data as may be required by County and the Oregon Health
Authority, including but not limited to Individual records which contain Individual identification, problem assessment,
Individual Service and Support Plan (including any training and/or care plan), appropriate medical information, and
Individual Service Notes, including a service termination summary and current assessment or evaluation instrument
as designated by the Oregon Health Authority in the administrative rules. Contractor shall retain Individual records in
accordance with OAR 166-150-0005 through 166-150-0215 (State Archivist). Unless OAR 166-150"'()005 through
166-150-0215 requires a longer retention period, Individual records must be retained for a minimum often (10) years
from termination or expiration of this Contract. It is understood that due to the limited nature of Contractor's services
under this Contract, not all of these documents will have been prepared by Contractor and therefore need not be
furnished. Oregon Health Authority Client Process Monitoring System (CPMS) data, Community Mental Health
Provider Report, and Termination Service Recording Form shall, if necessary, be completed in accordance with
Oregon Health AuthOrity reqUirements and submitted to Oregon Health Authority through County. Contractor agrees
to, and does hereby grant County and the Oregon Health Authority the right to reproduce, use and disclose for County
or Oregon Health Authority purposes, all or any part of the reports, data, and technical information furnished to
County under this Contract. Contractor shall make available to County, Oregon Health Authority and any Individual
enrolled in and/or seeking services from Contractor as defined in Exhibit 1, of this Contract, any and all written
materials in alternate formats in compliance with Oregon Health Authority's policies or administrative rules. For
purposes of the foregoing, "written materials" includes, without limitation, all work product and contracts related to this
Contract.
17. Access to Records. Contractor shall maintain fiscal records and all other records pertinent to this Contract.
a. All fiscal records shall be maintained pursuant to generally accepted accounting standards, and other records shall
be maintained to the extent necessary to clearly reflect actions taken.
1) Contractor shall retain and keep accessible all books, documents, papers and records that are directly related
to this Contract, the funds paid to Contractor hereunder or to any services delivered hereunder, for a minimum
of six (6) years, or such longer period as may be required by other provisions of this Contract or applicable
law, following the termination or expiration of this Contract.
2) If an audit, litigation or other action involving this Contract is started before the end of the six-year (6) period,
the records shall be retained until all issues arising out of the action are resolved ..
b. County, the Oregon Health Authority, the Secretary of State's Office of the State of Oregon, the Federal
Government, and their duly authorized representatives shall have the right to direct access to all of Contractor's
books, documents, papers and records related to this Contract, the funds paid to Contractor hereunder, or any
services delivered hereunder for the purpose of conducting audits and examinations, making copies, excerpts and
transcripts. In addition, Contractor shall permit authorized representatives of County and the Oregon Health
Authority to perform site reviews of all services delivered by Contractor hereunder.
1) These records also include licensed software and any records in electronic form, including but not limited to
computer hard drives, tape backups and other such storage devices. County shall reimburse Contractor for
Contractor's cost of preparing copies.
2) At Contractor's expense, the County, the Secretary of State's Office of the State of Oregon, the Federal
Government, and their duly authorized representatives, shall have license to enter upon Contractor's premises
to access and inspect the books, documents, papers, computer software, electronic files and any other
records of the Contractor which are directly pertinent to this Contract.
3) If Contractor's dwelling is Contractor's place of business, Contractor may, at Contractor's expense, make the
above records available at a location acceptable to the County.
18. Ownership of Work. All work of Contractor that results from this Contract (the "Work Producf) is the exclusive
property of County.
a. County and Contractor intend that such Work Product be deemed "work made for hire" of which County shall be
deemed author.
b. If, for any reason, the Work Product is not deemed "work made for hire," Contractor hereby irrevocably assigns to
County all of its right, title, and interest in and to any and all of the Work Product, whether arising from copyright,
patent, trademark, trade secret, or any other state or federal intellectual property law or doctrine.
c. Contractor shall execute such further documents and instruments as County may reasonably request in order to
fully vest such rights in County.
d. Contractor forever waives any and all rights relating to Work Product, including without limitation, any and all rights
arising under 17 USC § 106A or any other rights of identification of authorship or rights of approval, restriction or
limitation on use or subsequent modifications.
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e. County shall have no rights in any pre-existing work product of Contractor provided to County by Contractor in the
performance of this Contract except an irrevocable, non-exclusive, perpetual, royalty-free license to copy, use and
re-use any such work product for County use only.
f. If this Contract is terminated prior to completion, and County is not in default, County, in addition to any other rights
provided by this Contract, may require Contractor to transfer and deliver all partially completed work products,
reports or documentation that Contractor has specifically developed or specifically acquired for the performance of
this Contract.
g. In the event that Work Product is deemed Contractor's Intellectual Property and not "work made for hire," Contractor
hereby grants to County an irrevocable, non-exclusive, perpetual, royalty-free license to use, reproduce, prepare
derivative works based upon, distribute copies of, perform and display the Contractor Intellectual Property, and to
authorize others to do the same on County's behalf.
h. In the event that Work Product is Third Party Intellectual Property, Contractor shall secure on the County's behalf and
in the name of the County, an irrevocable, non-exclusive, perpetual, royalty-free license to use, reproduce, prepare
derivative works based upon, distribute copies of, perform and display the Third Party Intellectual Property, and to
authorize others to do the same on County's behalf.
19. County Code Provisions. Except as otherwise specifically provided, the provisions of Deschutes County Code,
Section 2.37.150 are incorporated herein by reference. Such code section may be found at the following URL
address: http://www.deschutes.org/Countv-Code.aspx.
20. Partnership. County is not, by virtue of this Contract, a partner or joint venturer with Contractor in connection with
activities carried out under this Contract, and shall have no obligation with respect to Contractor's debts or any
other liabilities of each and every nature. Unless Contractor is a State of Oregon governmental agency,
Contractor agrees that it is an independent contractor and not an agent of the State of Oregon, the Oregon Health
Authority or County.
21. Indemnity and Hold Harmless.
a. To the fullest extent authorized by law Contractor shall defend (in the case of the state of Oregon and the Oregon
Health Authority, subject to ORS Chapter 180), save, hold harmless and indemnify the County, the State of
Oregon and the Oregon Health Authority, their officers, employees and agents from and qgainst all claims, suits,
actions, losses, damages, liabilities costs and expenses of any nature resulting from or arising out of, or relating to
the activities of Contractor or its officers, employees, contractors, or agents under this Contract, including without
limitation any claims that the work, the work product or any other tangible or intangible items delivered to County
by Contractor that may be the subject of protection under any state or federal intellectual property law or doctrine,
or the County's use thereof, infringes any patent, copyright, trade secret, trademark, trade dress, mask work utility
design or other proprietary right of any third party.
b. Contractor shall have control of the defense and settlement of any claim that is subject to subparagraph a of this
paragraph; however neither contractor nor any attorney engaged by Contractor shall defend the claim in the name
of Deschutes County or any department or agency thereof, nor purport to act as legal representative of the County
or any of its departments or agencies without first receiving from the County's legal counsel, in a form and manner
determined appropriate by the County's legal counsel, authority to act as legal counsel for the County, nor shall
Contractor settle any claim on behalf of the County without the approval of the County's legal counsel.
c. To the extent permitted by Article XI, Section 10, of the Oregon Constitution and the Oregon Tort Claims Act, ORS
30.260 through 30.300, County shall defend, save, hold harmless and indemnify Contractor and its officers,
employees and agents from and against all claims, suits, actions, losses, damages, liabilities costs and expenses
of any nature resulting from or arising out of, or relating to the activities of County or its officers, employees,
contractors, or agents under this Contract.
22. Compliance with provisions, requirements of funding source and Federal and State laws, statutes, rules,
regulations, executive orders and policies. See Exhibit 6.
23. Waiver.
a. County's delay in exercising, or failure to exercise any right, power, or privilege under this Contract shall not
operate as a waiver thereof, nor shall any single or partial exercise or any right, power, or privilege under this
Contract preclude any other or further exercise thereof or the exercise of any other such right, power, or privilege.
b. The remedies provided herein are cumulative and not exclusive of any remedies provided by law.
Page 7 of 9 -Behavioral Health -Personal Services Contract No. 2013-274
24. Governing Law. This Contract shall be governed by and construed in accordance with the laws of the State of Oregon
without regard to principles of conflicts of law.
a. Any claim, action, suit or proceeding (collectively, "Claim") between County and Contractor that arises from or
relates to this Contract shall be brought and conducted solely and exclusively within the Circuit Court of Deschutes
County for the State of Oregon; provided, however, if a Claim shall be brought in federal forum, then it shall be
brought and conducted solely and exclusively within the United States District Court for the District of Oregon.
b. CONTRACTOR, BY EXECUTION OF THIS CONTRACT, HEREBY CONSENTS TO THE IN PERSONAM
JURISDICTION OF SAID COURTS. The parties agree that the UN Convention on International Sales of Goods
shall not apply.
25. Severability. If any term or provision of this Contract is declared by a court of competent jurisdiction to be illegal or in
conflict with any law, the validity of the remaining terms and provisions shall not be affected, and the rights and
obligations of the parties shall be construed and enforced as if this Contract did not contain the particular term or
provision held invalid.
26. Reserved.
27. Notice. Except as otherwise expressly provided in this Contract, any communications between the parties hereto or
notices to be given hereunder shall be given in writing, to Contractor or County at the address or number set forth
below or to such other addresses or numbers as either party may hereafter indicate in writing. Delivery may be by
personal delivery, facsimile, or mailing the same, postage prepaid.
a. Any communication or notice by personal delivery shall be deemed delivered when actually given to the
designated person or representative.
b. Any communication or notice sent by facsimile shall be deemed delivered when the transmitting machine
generates receipt of the transmission. To be effective against County, such facsimile transmission shall be
confirmed by telephone notice to the County Administrator.
c. Any communication or notice mailed shall be deemed delivered five (5) days after mailing. Any notice under this
Contract shall be mailed by first class postage or delivered as follows:
To Contractor: To County:
Marc V. Williams, M.D. Scott Johnson
1495 NW Quincy Ave. Deschutes County Health Services
Bend, OR 97701 2577 NE Courtney Dr.
Bend, Oregon 97701
Phone No. 541-322-7572 Phone No. 541-322-7500
28. Merger Clause. This Contract and the attached exhibits constitute the entire agreement between the parties.
a. All understandings and agreements between the Parties and representations by either Party concerning this
Contract are contained in this Contract.
b. No waiver, consent, modification or change in the terms of this Contract shall bind either party unless in writing
signed by both parties.
c. Any written waiver, consent, modification or change shall be effective only in the specific instance and for the
specific purpose given.
29. Identity Theft Protection. Contractor and subcontractors shall comply with the Oregon Consumer Identity Theft
Protection Act (ORS 646A600 et seq.).
30. Survival. All rights and obligations shall cease upon termination or expiration of this Contract, except for the rights and
obligations setforth in Sections 4,5,8,9,15,17, 18,20-28,29 and 31.
31. Representations and Warranties.
a. Contractor's Representations and Warranties. Contractor represents and warrants to County that:
1) Contractor has the power and authority to enter into and perform this Contract;
2) This Contract, when executed and delivered, shall be a valid and binding obligation of Contractor enforceable in
accordance with its terms;
3) Contractor has the skill and knowledge possessed by well-informed members of its industry, trade or
profession and Contractor will apply that skill and knowledge with care and diligence to perform the Work in a
Page 8 of 9 Behavioral Health -Personal Services Contract No. 2013-274
professional manner and in accordance with standards prevalent in Contractor's industry, trade or profession;
4) Contractor shall, at all times during the term of this Contract, be qualified, professionally competent, and duly
licensed to perform the Work;
5) Contractor prepared its proposal related to this Contract, if any, independently from all other proposers, and
without collusion, fraud, or other dishonesty; and
6) Contractor's making and performance of this Contract do not and will not violate any provision of any applicable
law, rule or regulation or order of any court, regulatory commission, board or other administrative agency.
7) Contractor is and shall remain an independent contractor as that term is defined in ORS 670.600.
b. Warranties Cumulative. The warranties set forth in this paragraph are in addition to, and not in lieu of, any other
warranties provided.
Page 9 of 9 -Behavioral Health -Personal Services Contract No. 2013-274
EXHIBIT 1
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
STATEMENT OF WORK, COMPENSATION
PAYMENT TERMS and SCHEDULE
1. Contractor shall perform the following work:
Contractor shall provide Medical Services as a Licensed Medical Practitioner (LMP) in accordance with OAR's 309
032-1505(68) and(74);and 309-032-1530(e); and 309-032-1535. Contractor shall perform the services described and
funded by and through County's contract with the Oregon Health Authority rOHA" or "Department"). Services shall be
performed in accordance with a schedule approved by the County. Contractor shall provide Medical Services in a
manner that is in accordance with Deschutes County Health Services' Policy "Integrated Policies for Delivery of
Behavioral Health Outpatient Services and Supports" and Oregon Health Authority's "Integrated Services and
Supports Rules" OAR's 309-032-155 through OAR 309-032-1565, which is incorporated into this Contract herein by
reference.
A. SERVICES TO BE PERFORMED
For the purposes of this Contract. "Individual" means any person being considered for or receiving services regulated
by County's Integrated Policies for Delivery of Behavioral Health Outpatient Services and Supports. Definitions, laws,
regulations as defined by the OAR 309-032-1500 through OAR 309-032-1565 are incorporated by reference herein to
the extent that they are applicable to the Contract or required by law to be so incorporated.
Contractor shall provide Medical as a LMP and document services using County's Electronic Health Record (EHR)
system in a legible manner consistent with professional and community standards of care and shall include the
following:
1) Orders for medication, laboratory and other medical procedures shall be recorded for each Individual using
County's EHR and in conformance with standard medical practice. Such orders, whether written or verbal, shall be
initiated and authenticated by Contractor. Consultation and/or exchange of information with other medical
personnel who are not employed by, or under contract to, County shall be documented in the Individual Service
Record.
2} Written documentation of medications prescribed for the Individual by Contractor shall be maintained in the EHR's
Individual Service Record. Documentation for each medication prescribed follow the appropriate protocols
developed by the EHR and may include but is not limited to the following:
a) A copy or detailed written description of the signed prescription order;
b) The name of medication prescribed;
c} The prescribed dosage and method of administration;
d) The date medications were prescribed, reviewed, or renewed;
e) The date, the signature and credentials of staff administering and/or prescribing medications; and
3) Medication use record which contain:
a. Medication Individual Service Notes
b. Observed side effects including laboratory findings;
c. Medication allergies and adverse reactions; and
d. Documentation that the consumer was asked about possible adverse effects of medications, including sexual
dysfunction, and evaluation for tardive dyskinesia, when appropriate.
4) Contractor shall provide Medical Supervision in determining the medical appropriateness of rehabilitative
behavioral health services. Medical supervision shall be performed at least annually by reviewing the
Comprehensive Mental Health Assessment and approving the revised Individual Service and Support Plan.
5) Contractor shall also provide: psychiatric assessments, medication prescribing and medication management,
individual therapy, training of Primary Care Providers in the community, community education and staff
consultations at Deschutes County Health Services Department, as funded by and through County's contract with
the Oregon Health Authority.
6) Contractor shall use County's EHR and legibly document all Individual contacts including assessments, chart
notes, medication records and service conclusion summaries and service notes (unless completed by behavioral
health staff at time of service) to facilitate County accurately recording services provided to Individuals.
Page 1 of 3 -Exhibit 1 -Personal Service Contract No. 2013-274
7) Contractor shall facilitate communication with the "Primary Care Provider" and county providers, via telephonic
and/or written methods, for each Individual seen including Contractor initiated changes in medication regimen,
pertinent chart notes and other information to coordinate a high quality of Individual care. Contractor will comply
with all privacy and security regulations under the Health Information Portability and Accountability Act (HIPAA).
8) Contractor shall provide full assistance to County in billing and recovering revenue from all legal resources by
keeping all licenses and certificates current including all credentialing and certification required by state and
federal governments to provide reimbursement for services (OHP/Medicaid/Medicare, etc.) Contractor shall
provide County with copies of licenses, certificates of insurance and evidence of CME's.
9) Contractor shall provide County with a detailed billing statement on a monthly basis which notes dates of service,
number of Individuals seen, hours worked and is consistent with County requirements. Bills are to be submitted to
Accounts Payable for review and reimbursement. Contractor shall submit the final monthly detailed billing
statement no later than thirty (30) days following the end of the fiscal year. Fiscal year shall be based on the
period July 1 through June 30.
10) Contractor will give advanced notice to County of planned and/or anticipated absences and assist County in arranging
psychiatric coverage when absences exceed one week. Contractor shall alert County as soon as possible in the
event of unanticipated absence.
11) Contractor shall maintain all requirements to perform services as a LMP according to OAR 309-032-1505 (68)
which includes maintaining license as a physician within the state of Oregon.
12) Contractor shall screen and assess Individuals for tobacco use, and offer tobacco cessation resources to
Individuals choosing to quit.
13) Effective Date of Amendment. This Contract shall take effect as soon as executed by the Parties, but no later
than July 1, 2013 All other provisions of the Contract shall continue in full force and effect for the duration of the
Contract.
B. REGULATIONS & DUTIES
Contactor shall comply with all applicable provisions of that certain Financial Assistance Contract, as amended,
including applicable Service Descriptions attached thereto, effective July 1, 2013, between the Oregon Health
Authority (OHA) and Deschutes County. Contractor agrees to comply with the rules and regulations of County,
applicable provisions in the Contract between County and OHA, incorporated herein by reference, as of the
effective date of the Contract, applicable provisions of the Administrative Rules and Procedures of the OHA,
applicable Federal regulations and all provisions of Federal and State statutes, rules and regulations relating to
Contractor's performance of services under this Contract. Any act or duty of County, imposed upon County by
OHA, which, by the nature of this Contract County determines to be within the scope of this Contract and is to be
performed by Contractor, Contractor shall perform on behalf of County. No federal funds may be used to provide
services in violation of 42 USC 14402.
C. METHOD AND PLACE OF GIVING NOTICE, SUBMITTING BILLS AND MAKING PAYMENTS
Contractor shall submit a monthly invoice following the end of each calendar month, but no later than thirty
(30) days following the end of the calendar month. The report shall include a summary of services, including,
but not limited to, date of bill, amount billed, billing period including month and year and amount billed year-to
date. All notices, bills and payments shall be made in writing and may be given by personal delivery or by
mail. Contractor shall submit the final monthly report under this Contract no later than thirty (30) days
following expiration or termination of the Contract. Notices, bills, and payments sent by mail should be
addressed as follows:
Contractor: Marc V. Williams, M.D.
1495 NW Quincy
Bend, OR 97701 Phone: (541) 322-7572
Attn: Marc Williams
County: Deschutes County Health Services
2577 NE Courtney Drive
Bend, OR 97701
Attn: Loretta Gertsch Fax: (541) 322-7565
2. County Services. County shall provide Contractor, at County's expense, with material and services
described as follows:
a. County shall provide an EHR, training and technical support where Contractor will record data as
described in Paragraph 1 of this Exhibit for each specific Individual Contractor provides Services for.
Page 2 of 3 -Exhibit 1 -Personal Service Contract No. 2013-274
b. County shall provide an office or other location mutually agreed upon between the Contractor and the
County.
c. County shall provide meeting space (subject to availability), use of a computer, phone, e-mail via County
Intra-net, Electronic Health Record system, and general office supplies required to carry out the terms of
the Contract.
3. Consideration. Subject to availability of funds from OHA, County shall provide payments to Contractor
based upon Contractor's monthly billing statement, for rendering Services listed in this Contract.
a. County shall pay Contractor on a fee-for-service basis at $137.19 per hour. The maximum number of
hours Contractor is authorized to work under this Contract is forty (40) hours per week.
b. Notwithstanding any other payment provision of this Contract, should Contractor fail to submit required
reports when due, or fail to perform or document the performance of contracted Services; County shall
immediately withhold payments under this Contract.
c. Contractor shall be entitled to reimbursement for expenses as set forth in Exhibit 5 DYES 1:81 NO
[Check one]
4. The maximum compensation.
a. The maximum compensation under this Contract is $230,000.
b. Contractor shall not submit monthly billing statements for, and County shall not pay for any amount in
excess of the maximum compensation amount set forth above.
1) County may be required to modify the maximum compensation through amendment of this Contract.
If this maximum compensation amount is decreased or increased by amendment of this Contract,
the amendment shall be fully effective before Contractor performs work subject to the amendment.
2) Contractor shall notify County in writing of the impending expiration of this Contract thirty (30)
calendar days prior to the expiration date.
3) If federal or state authorities disallows or requests repayment for any funds paid under this Contract
due to Contractor's acts or omissions, Contractor shall make payment to County of the amount
disallowed or requested. In the event that federal or state authorities determines that County is
responsible for the repayment of any funds owed to state or federal authorities by Contractor,
Contractor agrees to make such payment within ten (10) days of notification by County or federal or
state authority of said determination.
4) Notwithstanding any other payment provision of this Contract, should Contractor fail to submit
required reports or documentation as outlined in this Contract, or fail to perform or document the
performance of contracted Services; County shall immediately withhold payments under this
Contract.
5) In the event that a statutorily required license or insurance is suspended or not extended, County's
obligation to provide reimbursement for Services rendered without the necessary license or
insurance will cease on the date of expiration or suspension of license and/or insurance.
c. Rent. Contractor agrees to pay the County monthly rent of $500.00 in return for the County providing the
Contractor office and meeting space, use of a computer, phone, e-mail via the County Intra-net, Electronic
Health Record system, and any other general office supplies required to carry out the terms of the Contract.
Rent is due on the last day of each month through the duration of this Contract.
5. Schedule of Performance or Delivery.
a. County's obligation to pay depends upon Contractor's delivery or performance in accordance with the
schedule listed in Exhibit 1, Paragraph 1.
b. County will only pay for completed work that conforms to the terms of the Contract.
6. Renewal. This Contract may be renewed, subject to the following conditions:
a. Renewal will be based on the County Annual Implementation Plan approved by the Department.
b. Renewal is subject to the availability of funding.
Page 3 of 3 -Exhibit 1 -Personal Service Contract NO.2013-274
EXHIBIT 2
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
INSURANCE REQUIREMENTS
I
I
i
Contractor shall at all times maintain in force at Contractor's expense, each insurance noted below. Insurance
coverage must apply on a primary or non-contributory basis. All insurance poliCies, except Professional
Liability, shall be written on an occurrence basis and be in effect for the term of this Contract. Policies written
on a "claims made" basis must be approved and authorized by Deschutes County.
Contractor Name: Marc V. Williams. M.D.
Workers Compensation insurance in compliance with ORS 656.017. requiring Contractor and all subcontractors to
provide workers' compensation coverage for all subject workers, or provide certification of exempt status. Worker'S
Compensation Insurance covers claims made under Worker's Compensation, disability benefit or any other employee
benefit laws, including statutory limits in any state of operation with Coverage B Employer's Liability coverage all at the
statutory limits. In the absence of statutory limits the limits of said Employers liability coverage shall be not less than
$1,000,000 each accident, disease and each employee. This insurance must be endorsed with a waiver of subrogation
endorsement. waiving the insured's right of subrogation against County.
Professional Liability insurance with an occurrence combined single limit of not less than:
Per Occurrence limit Annual Aggregate limit
X $1,000,000 0 $2,000,000
o $2,000,000 X $3,000,000
o $3,000,000 0 $5,000,000
Professional Liability insurance covers damages caused by error, omission, or negligent acts related to professional
services provided under this Contract. The policy must provide extended reporting period coverage, sometimes referred
to as "tail coverage" for claims made within two years after the Contract work is completed.
~ Required by County o Not required by County (one box must be checked)
Commercial General Liability insurance with a combined single limit of not less than:
Per Single Claimant and Incident All Claimants AriSing from Single Incident
X $1,000,000 0 $2,000,000
o $2,000,000 X $3,000,000
o $3,000,000 0 $5,000,000
Commercial General Liability insurance includes coverage for personal injury, bodily injury, advertising injury, property
damage, premises, operations, products. completed operations and contractual liability. The insurance coverages
provided for herein must be endorsed as primary and non-contributory to any insurance of County, its officers, employees
or agents. Each such policy obtained by Contractor shall provide the insurer shall defend any suit against the named
insured and the additional insureds, their officers, agents, or employees, even if such suit is frivolous or fraudulent. Such
insurance shall provide County with the right, but not the obligation, to engage its own attorney for the purpose of
defending any legal action against County, its officers, agents, or employees, and that Contractor shall indemnify County
for costs and expenses, including reasonable attorneys' fees, incurred or arising out of the defense of such action.
The policy shall be endorsed to name The Oregon Health Authority, State of Oregon, Deschutes County, its officers,
agents, employees and volunteers as an additional insured. The additional insured endorsement shall not include
declarations that reduce any per occurrence or aggregate insurance limit. The Contractor shall provide additional
coverage based on any outstanding claim(s) made against policy limits to ensure that minimum insurance limits required
by the the County are maintained. Construction contracts may include aggregate limits that apply on a "per location" or
"per project" basis. The additional insurance protection shall extend equal protection to County as to Contractor or
subcontractors and shall not be limited to vicarious liability only or any similar limitation. To the extent any aspect of this
Paragraph shall be deemed unenforceable, then the additional insurance protection to County shall be narrowed to the
maximum amount of protection allowed by law.
I2J Required by County o Not required by County (One box must be checked)
Page 1 of 2 -Exhibit 2 -Personal Services Contract No. 2013-274
Liability insurance with a combined single limit of not less than:
Per Occurrence
o $500,000
o $1,000,000
o $2,000,000
Automobile Liability insurance includes coverage for bodily injury and property damage resulting from operation
of a motor vehicle. Commercial Automobile Liability Insurance shall provide coverage for any motor vehicle
(symbol 1 on some insurance certificates) driven by or on behalf of Contractor during the course of providing
services under this Contract. Commercial Automobile Liability is required for contractors that own business
vehicles registered to the business. Examples include: plumbers, electricians or construction contracts . An
example of acceptable personal automobile policy is a contractor who is a sole proprietor that does not own
vehicles registered to the business.
o Required by County [8l Not required by County (one box must be checked)
Additional Requirements. Contractor shall pay all deductibles and self-insured retentions . A cross-liability clause
or separation of insured's condition must be included in all commercial general liability policies required by this
Contract. Contractor's coverage will be primary in the event of loss.
Certificate of Insurance Required. Contractor shall furnish a current Certificate of Insurance to the County with
the signed Contract. Contractor shall notify the County in writing at least thirty (30) days in advance of any
cancellation, termination, material change, or reduction of limits of the insurance coverage . The Certificate shall
also state the deductible or, if applicable, the self-insured retention level. Contractor shall be responsible for any
deductible or self-insured retention . If requested, completed copies of insurance policies shall be provided to the
County .
Date
-;1zr)3
Page 2 of 2 -Exhibit 2 -Personal Services Contract No . 2013-274
EXHIBIT 3
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
CERTIFICArlON STATEMENT FOR CORPORATION
OR INDEPENDENT CONTRACTOR
NOTE: Contractor Shall Complete A or B in addition to C below:
A. CONTRACTOR IS A CORPORATION, LIMITED LIABILITY COMPANY OR A PARTNERSHIP.
I certify under penalty of perjury that Contractor is a [check one]: o Corporation D Limited Liability Company D Partnership authorized to do business in the State of Oregon.
Signature Title Date
B. CONTRACTOR IS A SOLE PROPRIETOR WORKING AS AN INDEPENDENT CONTRACTOR.
Contractor certifies under penalty of perjury that the following statements are true:
1. If Contractor performed labor or services as an independent Contractor last year, Contractor filed federal and
state income tax returns last year in the name of the business (or filed a Schedule C in the name of the
business as part of a personal income tax return), and
2. Contractor represents to the public that the labor or services Contractor provides are provided by an
independently established business registered with the State of Oregon, and
3. All of the statements checked below are true.
NOTE: Check all that apply. You shall check at least three (3) -to establish that you are an
Independent Contractor.
A. The labor or services I perform are primarily carried out at a location that is separate from my
residence or primarily carried out in a specific portion of my residence that is set aside as the
location of the business.
B. I bear the risk of loss related to the business or provision of services as shown by factors such
as: (a) fixed-price agreements; (b) correcting defective work; (c) warranties over the services or
(d) indemnification agreements, liability insurance, performance bonds or professional liability
insurance.
C. I have made Significant investment in the business through means such as: (a) purchasing
necessary tools or equipment; (b) paying for the premises or facilities where services are
provided; or (c) paying for licenses, certificates or specialized training.
D. I have the authority to hire other persons to provide or to assist in providing the services and if
necessary to fire such persons.
E. Each year I perform labor or services for at least two different persons or entities or I routinely
engage in business advertising, solicitation or other marketing efforts reasonably calculated to
obtain new contracts to provide similar services.
Contractor Signature Date
Page 1 of2 -Exhibit 3 -Personal Services Contract No. 2013-274
C. Representation and Warranties.
Contractor certifies under penalty of perjury that the following statements are true to the best of
Contractor's knowledge:
1. Contractor has the power and authority to enter into and perform this Contract;
2. This Contract, when executed and delivered, shall be a valid and binding obligation of Contractor enforceable
in accordance with its terms;
3. The services under this Contract shall be performed in a good and workmanlike manner and in accordance
with the highest professional standards; and
4. Contractor shall, at all times during the term of this Contract, be qualified, professionally competent, and duly
licensed to perform the services.
5. To the best of Contractor's knowledge, Contractor is not in violation of any tax laws described in ORS
305.380(4),
6. Contractor understands that Contractor is responsible for any federal or state taxes applicable to any
consideration and payments paid to Contractor under this Contract; and
7. Contractor has not discriminated against minority, women or small business enterprises in obtaining any
required subcontracts.
Contractor Signature Date
Page 2 of 2 Exhibit 3 -Personal Services Contract No. 2013-274
EXHIBIT 4
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
Workers' Compensation Exemption Certificate
(To be used only when Contractor claims to be exempt from Workers' Compensation coverage requirements)
Contractor is exempt from the requirement to obtain workers' compensation insurance under ORS Chapter 656 for the following reason
(check the appropriate box):
o SOLE PROPRIETOR
• Contractor is a sole proprietor. and
• Contractor has no employees. and
• Contractor shall not hire employees to perform this Contract.
o CORPORATION· FOR PROFIT
• Contractor's business is incorporated. and
• All employees of the corporation are officers and directors and have a substantial ownership interest* in the
corporation. and
• The officers and directors shall perform all work. Contractor shall not hire other employees to perform this
Contract.
o CORPORATION· NONPROFIT
• Contractor's business is incorporated as a nonprofit corporation, and
• Contractor has no employees; all work is performed by volunteers, and
• Contractor shall not hire employees to perform this Contract.
o PARTNERSHIP
• Contractor is a partnership, and
• Contractor has no employees, and
• All work shall be performed by the partners; Contractor shall not hire employees to perform this Contract and
• Contractor is not engaged in work performed in direct connection with the construction. alteration, repair.
improvement, moving or demolition of an improvement to real property or appurtenances thereto.
o LIMITED LIABILITY COMPANY
• Contractor is a limited liability company. and
• Contractor has no employees. and
• All work shall be performed by the members; Contractor shall not hire employees to perform this Contract, and
• If Contractor has more than one member, Contractor is not engaged in work performed in direct connection with
the construction, alteration, repair, improvement. moving or demolition of an improvement to real property or
appurtenances thereto.
*NOTE: Under OAR 436-050-050 a shareholder has a "substantial ownership" interest if the shareholder owns 10% of the corporation or.
if less than 10% is owned, the shareholder has ownership that is at least equal to or greater than the average percentage of ownership of
all shareholders.
"NOTE: Under certain circumstances partnerships and limited liability companies can claim an exemption even when performing
construction work. The requirements for this exemption are complicated. Consult with County Counsel before an exemption request is
accepted from a contractor who shall perform construction work.
Contractor Printed Name Contractor Signature
Contractor TiUe Date
Page 1 of 1 -Exhibit 4 -Personal Services Contract No. 2013-274
EXHIBIT 5
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
Expense Reimbursement
1. Travel and Other Expenses. (When travel and other expenses are reimbursed.)
a. It is the policy of the County that all travel shall be allowed only when the travel is essential to the normal
discharge of the County responsibilities.
1) All travel shall be conducted in the most efficient and cost effective manner resulting in the best
value to the County.
2) Travel expenses shall be reimbursed for official County business only.
3) County shall not reimburse Contractor for any item that is not otherwise available for reimbursement
to an employee of Deschutes County per Deschutes County Finance Policy F~1,
"REIMBURSEMENT FOR MISCELLANEOUS EXPENSES AND EXPENSES INCURRED WHILE
TRAVELING ON COUNTY BUSINESS," dated 11/8/06.
4) County may approve a form other than the County Employee Reimbursement Form for Contractor to
submit an itemized description of travel expenses for payment.
5) Personal expenses shall not be authorized at any time.
6) All expenses are included in the total maximum contract amount.
b. Travel expenses shall be reimbursed only in accordance with rates approved by the County and only
when the reimbursement of expenses is speCifically provided for in Exhibit 1, paragraph 3 of this
Contract.
c. The current approved rates for reimbursement of travel expenses are set forth in the above described
policy.
d. County shall not reimburse for any expenses related to alcohol consumption or entertainment.
e. Except where noted, detailed receipts for all expenses shall be provided.
f. Charge slips for gross amounts are not acceptable.
g. County shall not reimburse Contractor for any item that is not otherwise available for reimbursement to
an employee of Deschutes County.
2. Approved reimbursements:
a. Mileage. Contractor shall be entitled to mileage for travel in a private automobile while Contractor is
acting within the course and scope of Contractor's duties under this Contract and driving over the most
direct and usually traveled route to and from Bend, Oregon.
1) Reimbursement for mileage shall be equal to but not exceed those set by the United States General
Services Administration ("GSA") and are subject to change accordingly.
2) To qualify for mileage reimbursement, Contractor shall hold a valid, current driver's license for the
class of vehicle to be driven and carry personal automobile liability insurance in amounts not less
than those required by this Contract
3) No mileage reimbursement shall be paid for the use of motorcycles or mopeds.
b. Meals.
1) Any reimbursement for meals shall be for actual cost of meals incurred by Contractor while acting
within the course and scope of Contractor's duties under this Contract.
2) For purposes of calculating individual meals where the Contractor is entitled only to a partial day
reimbursement, the following maximum allocation of the meal expenses applies:
a) Breakfast, $10;
b) Lunch, $15;
c) Dinner, $31.
3) Except in the event of necessary overnight travel as provided below, partial day meal expenses shall
be reimbursed as follows and only while Contractor is acting within the course and scope of
Contractor's duties under this Contract:
a) Breakfast expenses are reimbursable if Contractor is required to travel more than two (2) hours:
before the start Contractor's regular workday (I.e. 8:00 a.m.).
b) Lunch expenses are reimbursable only if Contractor is required to travel overnight and begins
the journey before 11 :00 am or ends the journey after 11 :00 a.m.
c) Dinner expenses are reimbursable only if Contractor is required to travel more than two (2)
hours after Contractor'S regular workday (i.e. 5:00 p.m.).
Page 1 of 2 -Exhibit 5 to Personal Services Contract No. 2013-274
4) Breakfast and dinner expenses are reimbursable during Contractor's necessary overnight travel
while acting within the course and scope of Contractor's duties under this Contract and shall not
exceed those set by the GSA. and are subject to change accordingly.
c. Lodging.
1) County shall reimburse Contractor for Contractor's actual cost of lodging necessary to provide
service to the County and shall not exceed the maximum lodge set by the GSA for Bend, Oregon.
2) Reimbursement rates for lodging are not considered "per diem" and receipts are required for
reimbursement.
d County shall not reimburse Contractor in excess of the lowest fair for any airline ticket or vehicle rental
charges.
3. Exceptions. Contractor shall obtain separate written approval of the County Administrator for any
exceptions to the expense items listed above prior to incurring any expense for which reimbursement shall
be sought.
Page 2 of 2 -Exhibit 5 to Personal Services Contract No. 2013-274
Exhibit 6
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013·
Compliance with provisions, requirements of funding source and
Federal and State laws, statutes, rules, regulations, executive orders and pOlicies.
Contractor shall comply with the following federal requirements. For the purposes of this Contract, all
references to federal and state laws are references to federal and state laws as they may be amended
from time to time.
1. Miscellaneous Federal Provisions. Contractor shall comply with all federal laws, regulations, and
executive orders applicable to the Contract or to the delivery of Services. Without limiting the generality
of the foregoing, Contractor expressly agrees to comply with the following laws, regulations and
executive orders to the extent they are applicable to the Contract: (a) Title VI and VII of the Civil Rights
Act of 1964, as amended, (b) Sections 503 and 504 of the Rehabilitation Act of 1973, as amended, (f)
the Age Discrimination in Employment Act of 1967, as amended, and the Age Discrimination Act of
1975, as amended, (g) the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended,
(h) all regulations and administrative rules established pursuant to the foregoing laws, (i) all other
applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations, and (j) all
federal law governing operation of Community Mental Health Programs, including without limitation, all
federal laws requiring reporting of Client abuse. These laws, regulations and executive orders are
incorporated by reference herein to the extent that they are applicable to the Agreement and required by
law to be so incorporated. No federal funds may be used to provide Services in violation of 42 U.S.C.
14402.
2. Equal Employment Opportunity. If this Contract, including amendments, is for more than $10,000,
then Contractor shall comply with Executive Order 11246, entitled "Equal Employment Opportunity, n as
amended by Executive Order 11375, and as supplemented in Department of Labor regulations (41 CFR
Part 60). .
3. Clean Air, Clean Water, EPA Regulations. If this Contract, including amendments, exceeds $100,000
then Contractor shall comply with all applicable standards, orders, or requirements issued under Section
306 of the Clean Air Act (42 U.S.C. 7606), the Federal Water Pollution Control Act as amended
(commonly known as the Clean Water Act) (33 U.S.C. 1251 to 1387), specifically including, but not
limited to Section 508 (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency
regulations (2 CFR Part 1532), which prohibit the use under non-exempt Federal contracts, grants or
loans of facilities included on the EPA List of Violating Facilities. Violations shall be reported to OHA,
United States Department of Health and Human Services and the appropriate Regional Office of the
Environmental Protection Agency. Contractor shall include in all contracts with subcontractors receiving
more than $100,000, language requiring the subcontractor to comply with the federal laws identified in
this section.
4. Energy Efficiency. Contractor shall comply with applicable mandatory standards and policies relating
to energy effiCiency that are contained in the Oregon energy conservation plan issued in compliance with
the Energy Policy and Conservation Act 42 U.S.C. 6201 et. seq. (Pub. L. 94-163).
5. Truth in Lobbying. By signing this Contract. the Contractor certifies under penalty of perjury that the
following statements are true to the best of the Contractor's knowledge and belief that:
a. No federal appropriated funds have been paid or will be paid, by or on behalf of Contractor, to any
person for influencing or attempting influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with the awarding of any federal contract. the making of any federal grant, the making of
any federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment or modification of any federal contract, grant, loan or cooperative agreement.
b. If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress,
Page 1 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
an officer or employee of Congress, or an employee of a Member of Congress in connection with
this federal contract, grant, loan or cooperative agreement, the Contractor shall complete and submit
Standard Form LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions.
c. The Contractor shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients and subcontractors shall
certify and disclose accordingly.
d. This certification is a material representation of fact upon which reliance was placed when this
Contract was made or entered into. Submission of this certification is a prerequisite for making or
entering into this Contract imposed by section 1352, Title 31 of the U.S. Code. Any person who ails
to file the required certification shall be subject to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
e. No part of any federal funds paid to Contractor under this Contract shall be used other than for
normal and recognized executive legislative relationships for publicity or propaganda purposes, for
the preparation, distribution, or use of any kit, pamphlet, booklet, publication, electronic
communication, radio, television, or video presentation designed to support or defeat the enactment
of legislation before the United States Congress or any State or local legislature or legislative body,
except in presentation to the Congress or any Stage or local legislature itself, or designed to support
or defeat any proposed or pending regulation, administrative action, or order issued by the executive
branch of any State or local government, except in presentation to the executive branch of any Sate
or local government itself.
f. No part of any federal funds paid to Contractor under this Agreement shall be used to pay the salary
or expenses of any grant or contract recipient, or agent acting for such reCipient, related to any
activity designed to influence the enactment of legislation, appropriations, regulation, administrative
action, or Executive order proposed or pending before the United States Congress or any State
government, State legislature or local legislature or legislative body, other than for normal and
recognized executive-legislative relationships or participation by an agency or officer of a State, local
or tribal government in policymaking and administrative processes within the executive branch of
that government.
g. The prohibitions in subsections (b) and (c) of this section shall include any activity to advocate or
promote any proposed, pending or future Federal, State or local tax increase, or any proposed,
pending, or future requirement or restriction on any legal consumer product, including its sale or
marketing, including but not limited to the advocacy or promotion of gun control.
h. No part of any federal funds paid to Contractor under this Contract may be used for any activity that
promotes the legalization of any drug or other substance included in schedule I of the schedules of
controlled substances established under section 202 of the Controlled Substances Act except for
normal and recognized executive congressional communications. This limitation shall not apply
when there is significant medical evidence of a therapeutic advantage to the use of such drug or
other substance or that federally sponsored clinical trials are being conducted to determine
therapeutic advantage.
6. HIPAA Compliance. Contractor is a Covered Entity with respect to its healthcare components as
described in OAR 943-014-0015 for purposes of the Health Insurance Portability and Accountability Act
and the federal regulations implementing the Act (collectively referred to as HIPAA), and OAR 125-055
0100 through OAR 125-055-0130. Contractor must comply with HIPAA to the extent that any Services
or obligations of Contractor arising under this Contract are covered by HIPAA. County shall determine if
County will have access to, or create and protected health information in the performance of any Service
or any other obligations under this Contract. To the extent that Contractor will have access to, or create
any protected health information to perform functions, activities, or Services for, or on behalf of a
healthcare component of OHA in the performance of any Service required by this Contract, County shall
comply and Contractor shall comply with OAR 125-055-0100 through OAR 125-055-0130 and the
following:
Page 2 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
a. Privacy and Security of Individually Identifiable Health Information. Individually Identifiable Health
Information about specific individuals is confidential. Individually Identifiable Health Information
relating to specific individuals may be exchanged between County and OHA for purposes directly
related to the provision of Services to clients which are funded in whole or in part under this
Contract. To the extent that Contractor is performing functions, activities, or services for, or on
behalf of, a healthcare component of OHA in the performance of Services required by this Contract.
Contractor shall not use or disclose any Individual Identifiable Health Information about specific
individuals in a manner that would violate OHA Privacy Rules, OAR 943-014-0000 et. seq., or OHA
Notice of Privacy Practices. A copy of the most recent OHA Notice of Privacy Practices may be
obtained by contacting OHA or by looking up form number 2090 on the OHA web site at
https:llapps.state.or.us/cf1/FORMS/.
b. Data Transactions Systems. If County and Contractor intends to exchange electronic data
transactions with a health care component of OHA in connection with claims or encounter data,
eligibility or enrollment information, authorizations or other electronic transaction, County and
Contractor shall execute an EDI Trading Partner Agreement and shall comply with OHA EDI Rules.
c. Consultation and Testing. If County or Contractor reasonably believes that the County's or
Contractor's data transactions system or other application of HIPAA privacy or security compliance
policy may result in a violation of HIPAA requirements, County or Contractor shall promptly consult
the OHA Information Security Office. County or Contractor may initiate a request for testing of
HIPAA transaction requirements, subject to available resources and the OHA testing schedule.
7. Resource Conservation and Recovery. Contractor shall comply with all mandatory standards and
pOliCies that relate to resource conservation and recovery pursuant to the Resource Conservation and
Recovery Act (codified at 42 U.S.C. 6901 et. seq.). Section 6002 of that Act (codified at 42 U.S.C. 6962)
requires that preference be given in procurement programs to the purchase of specific products
containing recycled materials identified in guidelines developed by the Environmental Protection Agency.
Current guidelines are set forth in 40 CFR Part 247.
8, Audits.
a. Contractor shall comply with applicable audit requirements and responsibilities set forth in this
Contract and applicable state or federal law.
b. Contractor shall also comply with applicable Code of Federal Regulations (CFR) and OMS Circulars
governing expenditure of federal funds. Including, but not limited to, OMS A-133 Audits of States,
Local Governments and Non-Profit Organizations.
9. Debarment and Suspension. County shall not permit any person or entity to be a contractor if the
person or entity is listed on the non-procurement portion of the General Service Administration's "List of
Parties Excluded from Federal Procurement or Nonprocurement Programs" in accordance with
Executive Orders No. 12549 and No. 12689, "Debarment and Suspension". (See 2 CFR Part 180). This
list contains names of parties debarred, suspended, or otherwise excluded by agencies, and contractors
declared ineligible under statutory authority other than Executive Order No. 12549. Contractors with
awards that exceed the simplified acquisition threshold shall provide the required certification regarding
their exclusion status and that of their principals prior to award.
10. Drug-Free Workplace. Contractor shall comply with the following provisions to maintain a drug-free
workplace: (i) Contractor certifies that it will provide a drug-free workplace by publishing a statement
notifying its employees that the unlawful manufacture, distribution, dispensation, possession or use of a
controlled substance, except as may be present in lawfully prescribed or over-the-counter medications,
is prohibited in Contractor's workplace or while providing services to OHA clients. Contractor's notice
shall specify the actions that will be taken by Contractor against its employees for violation of such
prohibitions; (ii) Establish a drug-free awareness program to inform its employees about: the dangers of
drug abuse in the workplace, County's policy of maintaining a drug-free workplace, any available drug
counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed
upon employees for drug abuse violations; (iii) Provide each employee to be engaged in the
performance of services under this contract a copy of the statement mentioned in paragraph (i) above;
(iv) Notify each employee in the statement required by paragraph (i) above that, as a condition of
Page 3 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
employment to provide services under this Contract, the employee will: abide by the terms of the
statement, and notify the employer of any criminal drug statute conviction for a violation occurring in the
workplace no later than five (5) days after such conviction; (v) Notify OHA within ten (10) days after
receiving notice under subparagraph (iv) above from an employee or otherwise receiving actual notice of
such conviction; (vi) Impose a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program by any employee who is so convicted as required by Section 5154
of the Drug-Free Workplace Act of 1988; (vii) Make a good-faith effort to continue a drug-free workplace
through implementation of subparagraphs (i) through (vii) above; (ix) Neither County, Contractor nor any
of County's or Contractor's employees, officers, agents may provide any service required under this
Contract while under the influence of drugs. For purposes of this provision, ·under the influence" means:
observed abnormal behavior or impairments in mental or physical performance leading a reasonable
person to believe the County or Contractor's employee, officer, agent has used a controlled substance,
prescription or non-prescription medication that impairs the County or Contractor, County or Contractors
employees, officers, agents performance of essential job function or creates a direct threat to OHA
clients or others. Examples of abnormal behavior include, but are not limited to: hallucinations,
paranoia or violent outbursts. Examples of impairments in physical or mental performance include, but
are not limited to: slurred speech, difficulty walking or performing job activities; and (x) Violation of any
provision of this section my result in termination of this Contract.
11. Pro-Children Act. Contractor shall comply with the Pro-Children Act of 1994 (codified at 20 U.S.C.
section 6081 et. seq.).
12. Medicaid Services. To the extent Contractor provides any service whose costs are paid in whole or in
part by Medicaid, Contractor shall comply with all applicable federal and state laws and regulation
pertaining to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 U.S.C. Section
1396 et. seq., including without limitation:
a. Keep such records as are necessary to fully disclose the extent of the services provided to
individuals receiving Medicaid assistance and shall furnish such information to any state or federal
agency responsible for administering the Medicaid program regarding any payments claimed by
such person or institution for providing Medicaid Services as the state or federal agency may from
time to time request. 42 U.S.C. Section 1396 a(a)(27); 42 CFR 431.107(b)(1) & (2).
b. Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455 Subpart (8).
c. Maintain written notices and procedures respecting advance directives in compliance with 42 U.S.C.
Section 1396(a)(57) and (w), 42 CFR 431.107(b)(4), and 42 CFR 489 subpart I.
d.
e.
Certify when submitting any claim for the provision of Medicaid Services that the information
submitted is true, accurate and complete. Contractor shall acknowledge Contractor's understanding
that payment of the claim will be from federal and state funds and that any falsification or
concealment of a material fact may be prosecuted under federal and state laws.
Entities receiving $5 million or more annually (under this Contract and any other Medicaid
Agreement) for furnishing Medicaid health care items or services shall, as a condition of receiving
such payments, adopt written fraud, waste and abuse policies and procedures and inform
employees, contractors and agents about the poliCies and procedures in compliance with Section
6032 of the Deficit Reduction Act of 2005,42 U.S.C. § 1396a(a)(68).
13. ADA. Contractor shall comply with Title II of the Americans with Disabilities Act of 1990 (codified at 42
U.S.C. 12131 et. seq.) in the construction, remodeling, maintenance and operation of any structures and
facilities, and in the conduct of all programs, services and training associated with the delivery of
Services.
14. Agency-Based Voter Registration. If applicable, Contractor shall comply with the Agency-based Voter
Registration sections of the National Voter Registration Act of 1993 that require voter registration
opportunities be offered where an individual may apply for or receive an application for public assistance.
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tPage 4 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274 l
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15. Disclosure.
a. 42 CFR 455.104 requires the State Medicaid agency to obtain the following information from any
contractor of Medicaid or CHIP services, including fiscal agents of providers and managed care
entities: (1) the name and address (including the primary business address, every business location
and P.O. Box address) of any person (individual or corporation) with an ownership or control interest
in the provider, fiscal agent or managed care entity; (2) in the case of an individual, the date of birth
and Social Security Number, or, in the case of a corporation, the tax identification number of the
entity, with an ownership interest in the provider, fiscal agent or managed care entity or of any
subcontractor in which the provider, fiscal agent or managed care entity has a 5% or more interest;
(3) whether the provider, fiscal agent, or managed care entity is related to another person with
ownership or control interest in the provider, fiscal agent or managed care entity as a spouse,
parent, child or sibling; (4) the name of any other provider, fiscal agent or managed care entity in
which an owner of the provider, fiscal agent or managed care entity has an ownership or control
interest; and, (5) the name, address, date of birth and Social Security Number of any managing
employee of the provider, fiscal agent or managed care entity.
b. 42 CFR 455.434 requires as a condition of enrollment as a Medicaid or CHIP provider, to consent to
criminal background checks, including fingerprinting when required to do so under state law, or by
the category of the provider based on risk of fraud, waste and abuse under federal law. As such, a
provider must disclose any person with a 5% or greater direct or indirect ownership interest in the
provider whom has been convicted of a criminal offense related to that person's involvement with the
Medicare, Medicaid, or title XXI program in the last 10 years.
c. OHA reserves the right to take such action required by law, or where OHA has discretion, it deems
appropriate, based on the information received (or the failure to receive) from the provider, fiscal
agent or managed care entity.
16. Special Federal Requirements Applicable to Addiction Services.
a. Women's Services. If Contractor provides A&D 61 or A&D 62 Services, Contractor must:
(1) Treat the family as a unit and admit both women and their children if appropriate.
(2) Provide or arrange for the following services to pregnant women and women with dependent
children:
(a) Primary medical care, including referral for prenatal care;
(b) Pediatric care, including immunizations, for their children;
(c) Gender-specific treatment and other therapeutic interventions, e.g. sexual and physical
abuse counseling, parenting training, and child care.
(d) Therapeutic interventions for children in custody of women in treatment, which address, but
are not limited to, the children's developmental needs and issues of abuse and neglect; and
(e) Appropriate case management services and transportation to ensure that women and their
children have access to the services in (a) through (d) above.
b. Pregnant Women. If Contractor provides any A&D Services other than A&D 70 Services, Contractor
must:
(1) Within the priority categories, if any, set forth in a particular Service Description, give preference
in admission to pregnant women in need of treatment who seek, or are referred for, and would
benefit from, such services;
(2) Perform outreach to inform pregnant women of the availability of treatment services targeted to
them and the fact that pregnant women receive preference in admission to these programs;
Page 5 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
(3) If Contractor has insufficient capacity to provide treatment services to a pregnant woman, refer
the women to another provider with capacity or if no available treatment capacity can be located,
refer the women to OHA's Addictions and Mental Health Division for referral to another provider
in the state. If capacity cannot be located, AMH will make available interim services within 48
hours, including a referral for prenatal care.
c. Intravenous Drug Abusers. If Contractor provides any A&D Services other than A&D 70 Services,
Contractor must:
(1) Within the priority categories, if any, set forth in a particular Service Description and subject to
the preference for pregnant women described above, give preference in admission to
intravenous drug abusers;
(2) Programs that receive funding under the grant and that treat individuals for intravenous
substance abuse, upon reaching 90 percent of its capacity to admit individuals to the program,
must provide notification of that fact to the State within seven days.
(3) If Contractor receives a request for admission to treatment from an intravenous drug abuser,
Contractor must, unless it succeeds in referring the individual to another provider with treatment
capacity, admit the individual to treatment not later than:
(a) 14 days after the request for admission to Contractor is made; or
(b) 120 days after the date of such request if no provider has the capacity to admit the individual
on the date of such request and, if interim services are made available not less than 48
hours after such request.
(4) For the purposes of (3) above, "Interim Services» means:
(a) Services for reducing the adverse health effects of such abuse, for promoting the health of
the individual, and for reducing the risk of transmission of disease, including counseling and
education about HIV and tuberculosis, the risks of needle sharing, the risks of transmission
of disease to sexual partners and infants, and steps that can be taken to ensure that HIV
and tuberculosis transmission does not occur;
(b) Referral for HIV or TB treatment services, where necessary; and
(c) Referral for prenatal care if appropriate, until the individual is admitted to a provider'S
services.
(d) If Contractor treats recent intravenous drug users (those who have injected drugs within the
past year) in more than one-third of its capacity, Contractor shall carry out outreach activities
to encourage individual intravenous drug abusers in need of such treatment to undergo
treatment, and shall document such activities.
d. Infectious Diseases. If Contractor provides any A&D Services other than A&D 70 Services,
Contractor must:
(1) Complete a risk assessment for infectious disease including Human Immunodeficiency Virus
(HIV) and tuberculosis, as well as sexually transmitted diseases, based on protocols established
by OHA, for every individual seeking Services from County; and
(2) Routinely make tuberculosis services available to each individual receiving Services for
alcohol/drug abuse either directly or through other arrangements with public or non-profit entities
and, jf Contractor denies individual admission on the basis of lack of capacity, refer the
individual to another provider of tuberculosis Services.
Page 6 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
(3) For the purposes of (2) above. "tuberculosis services" means:
(a) Counseling the individual with respect to tuberculosis;
(b) Testing to determine whether the individual has contracted such disease and testing to
determine the form of treatment for the disease that is appropriate for the individual; and
(c) Appropriate treatment services.
e. OHA Referrals. If Contractor provides any A&D Services other than A&D 70 services. Contractor
must. within the priority categories. if any. set forth in a particular Service Description and subject to
the preference for pregnant women and intravenous drug users described above. give preference in
A&D service delivery to persons referred by OHA.
f. Barriers to Treatment. Where there is a barrier to delivery of an A&D Service due to culture. gender.
language. illiteracy, or disability. Contractor shall develop support services available to address or
overcome the barrier, including:
(1) Providing, if needed, hearing impaired or foreign language interpreters.
(2) Providing translation of written materials to appropriate language or method of communication.
(3) Providing devices that assist in minimizing the impact of the barrier.
(4) Not charging clients for the costs of measures, such as interpreters. that are required to provide
nondiscriminatory treatment.
g. Misrepresentation. Contractor shall not knowingly or willfully make or cause to be made any false
statement or representation of a material fact in connection with the furnishing of items or Services
for which payments may be made of OHA.
h. Oregon Residency. A&D Services funded through this Contract may only be provided to residents of
Oregon. Residents of Oregon are individuals who live in Oregon. There is no minimum amount of
time an individual must live in Oregon to qualify as a resident so long as the individual intends to
remain in Oregon. A child's residence is not dependent on the residence of his or her parents. A
child living in Oregon may meet the residency requirement if the caretaker relative with whom the
child is living is an Oregon resident.
i. Tobacco Use. If Contractor has A&D Services treatment capacity that has been deSignated for
children, adolescents, pregnant women, and women with dependent children, Contractor must
implement a policy to eliminate smoking and other use of tobacco at the facilities where the Services
are delivered on the grounds of such facilities.
j. Client Authorization. Contractor must comply with 42 CFR Part 2 when delivering an Addiction
Service that includes disclosure of Client information for purposes of eligibility determination.
Contractor must obtain Client authorization for disclosure of billing information, to the extent and in
the manner required by 42 CFR Part 2, before a Disbursement Claim is submitted with respect to
delivery of an Addiction Service to that individual.
17. Community Mental Health Block Grant. All funds, if any, awarded under this Contract for MHS 20,
MHS 22, MHS 37 or MHS 38 Services are subject to the federal use restrictions and requirements set
forth in Catalog of Federal Domestic Assistance Number 93.958 and to the federal statutory and
regulatory restrictions imposed by or pursuant to the Community Mental Health Block Grant portion of
the Public Health Services Act, 42 U.S.C. 300x-1 et. seq., and Contractor shall comply with those
restrictions.
Page 7 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
18. Substance Abuse Prevention and Treatment. To the extent Contractor provides any Service whose
costs are paid in whole or in part by the Substance Abuse, Prevention, and Treatment Block Grant,
Contractor shall comply with federal rules and statutes pertaining to the Substance Abuse, Prevention,
and Treatment Block Grant, including the reporting provisions of the Public Health Services Act (42
U.S.C. 300x through 300x-66). Regardless of funding source, to the extent Contractor provides any
substance abuse prevention or treatment services, Contractor shall comply with the confidentiality
requirements of 42 CFR Part 2.
Date: Signature: ____________Title _______
Contractor: Marc V. Williams, M.D.
Page 8 of 8 -Exhibit 6 to Personal Services Contract No. 2013-274
Exhibit 7
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
CONFIDENTIALITY AGREEMENT
County will make available and/or transfer to Contractor certain Information, in conjunction with goods or
services that are being provided by Contractor to County that is confidential and must be afforded special
treatment and protection.
Contractor will have access to and/or receive from County certain Information that can be used or disclosed only
in accordance with this Agreement and the HHS Privacy Regulations.
To the extent required by 42 U.S.C. 1171 et seq. enacted by the Health Insurance Portability and Accountability
Act of 1996 and regulations promulgated thereunder, Contractor assures County that Contractor will
appropriately safeguard protected health information made available to or obtained by Contractor.
Contractor further agrees to comply with applicable laws relating fo protected health information and with respect
to any task or other activity Contractor performs on behalf of County, to the extent County would be required to
comply with such requirements.
For purposes of this Agreement, the following terms shall apply:
A. Contractor shall be considered a Contractor;
B. County shall be considered a COVERED ENTITY;
C. HHS Privacy Regulations shall mean the Code of Federal Regulations (C.F.R.) at Title 45, Sections
160 and 164;
D. Individual shall mean the person who is the subject of the Information, and has the same meaning
as the term 'individual' is defined by 45 C.F.R. 164.501; and
E. Secretary shall mean the Secretary of the Department of Health and Human Services (HHS) and
any other officer or employee of HHS to whom the authority involved has been delegated;
F. Information shall mean any health information provided and/or made available by County to
Contractor, and has the same meaning as the term 'health information' as defined by 45 C.F.R.
160.102.
Contractor agrees it shall:
1. Not use or further disclose such information other than as permitted or required by this Agreement.
Contractor shall not, except as necessary for the proper management, administration and performance
of its duties under this Agreement, use, reproduce, disclose, or provide to third parties, any confidential
document or information relating to the County, its members or to Individuals seeking services from
County or its members without the prior written consent or authorization of the County or of the
Individual. If Contractor uses such information for the purposes set forth above, it will only do so if the
disclosure is required by law or Contractor obtains reasonable assurances from the person to whom the
information is disclosed that it will be held confidentially and used or further disclosed only as required by
law or for the purpose for which Contractor disclosed it to the person. Contractor shall ensure that its
personnel, employees, affiliates and agents maintain the confidentiality of patient health information and
business information of County.
2. Not use or further disclose the information in a manner that would violate the requirements of applicable
law, if done by County;
Page 1 of 2-Exhibit 7 to Personal Services Contract No. 2013-274
3. Use appropriate safeguards to prevent use or disclosure of such information other than as provided for
by this Agreement;
4. Report to County any use or disclosure of such information not provided for by this Agreement of which
Contractor becomes aware;
5. Ensure that any subcontractors or agents to whom Contractor provides protected health information
received from County agree to the same restrictions and conditions that apply to Contractor with respect
to such information;
6. Make available protected health information in accordance with applicable law, i.e., the Code of Federal
Regulations (C.F.R.) at Title 45, Sections 160 and 164;
7. Maintain standard records, pursuant to this Agreement, and to provide such records and other
necessary information to the County as may be requested in writing and as permitted by law. Contractor
agrees that all records kept in connection with this agreement are subject to review and audit by the
County upon reasonable notice of a minimum of 14 work days from the date of written request by the
County.
8. Make Contractor's internal practices, books, and records relating to the use and disclosure of
protected health information received from County available to the Secretary of the United States
Health & Human Services for purposes of determining County's compliance with applicable law
(in all events, Contractor shall immediately notify County upon receipt by Contractor of any such
request, and shall provide County with copies of any such materials);
9. Upon termination of this Agreement, Contractor shall promptly return all protected health
information received from County. If the return of protected health information is not feasible,
Contractor shall continue the protections required under this contract to the protected health
information consistent with the requirements of this Attachment and the HIPAA privacy
standards.
Date: Signature: _____________Title _______
Contractor: Marc V. Williams, M.D.
Page 2 of 2 -Exhibit 7 to Personal Services Contract No. 2013-274
Exhibit 8
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2013-274
REQUIRED PROVIDER CONTRACT PROVISIONS
Oregon Health Authority Exhibit I of 2013-2015 Intergovernmental Agreement
1. Expenditure of Funds. Contractor may expend the funds paid to Contractor under this Contract solely
on the delivery of services as described in Exhibit 1 of this Contract ("Services"), subject to the following
limitations (in addition to any other restrictions or limitations imposed by this Contract):
a. Contractor may not expend on the delivery of Services any funds paid to Contractor under this
Contract in excess of the amount reasonable and necessary to provide quality delivery of Services.
b. If this Contract requires Contractor to deliver more than one service, Contractor may not expend
funds paid to Contractor under this Contract for a particular service on the delivery of any other
service.
c. If this Contract requires Contractor to deliver alcohol, drug abuse and addiction services, Contractor
may not use the funds paid to Contractor under this Contract for such services:
(1) To provide inpatient hospital services;
(2) To make cash payments to intended recipients of health services;
(3) To purchase or improve land, to purchase, construct or permanently improve (other than minor
remodeling) any building or other facility or to purchase major medical equipment;
(4) To satisfy any requirement for expenditure of non-federal funds as a condition for receipt of
federal funds (whether the federal funds are received under this Contract or otherwise);
(5) With respect to federal Substance Abuse Prevention and Treatment Block Grant moneys only, to
purchase services from any person or entity other than a public or non-profit entity; or
(6) To carry out any program prohibited by section 245(b) of the Health Omnibus Programs
Extension Act of 1988 (codified at 42 U.S.C. 300ee(5).
d. Contractor may expend funds paid to Contractor under this Contact only in accordance with federal
OMB Circular A-87 as that circular is applicable on allowable costs.
2. Records Maintenance, Access and Confidentiality.
a. Access to Records and Facilities. County, the Oregon Health Authority, the Secretary of State's
Office of the State of Oregon, the Federal Government, and their duly authorized representatives
shall have access to the books, documents, papers and records of Contractor that are directly
related to this Contract, the funds paid to Contractor hereunder, or any services delivered hereunder
for the purpose of making audits, examinations, excerpts, copies and transcriptions. In addition,
Contractor shall permit authorized representatives of County and the Oregon Health Authority to
perform site reviews of all services delivered by Contractor hereunder.
b. Retention of Records. Contractor shall retain and keep accessible all books, documents, papers,
and records, that are directly related to this Contract, the funds paid to Contractor hereunder or to
any services delivered hereunder, for a minimum of six (6) years, or such longer period as may be
required by other provisions of this Contract or applicable law, following the termination or expiration
of this Contract. If there are unresolved audit or other questions at the end of the six-year period,
Contractor shall retain the records until the questions are resolved.
c. Expenditure Records. Contractor shall document the expenditure of all funds paid to Contractor
under this Contract. Unless applicable federal law requires Contractor to utilize a different
Accounting system, Contractor shall create and maintain all expenditure records in accordance with
generally accepted accounting principles and in sufficient detail to permit County and the Oregon
Health Authority to verify how the funds paid to Contractor under this Contract were expended.
Page 1 of 4 -Exhibit 8 to Personal Services Contract No. 2013-274
d. Individual Records. Unless otherwise specified in this Contract, Contractor shall create and
maintain an Individual record for each Individual who receives services under this Contract. The
Individual record must contain:
(1) Individual identification;
(2) Problem assessment;
(3) Services and supports, training and/or care plan;
(4) Medical information when appropriate; and
(5) Service notes including service conclusion summary and current assessment or evaluation
instrument as designated by the Oregon Health Authority in administrative rules.
Contractor shall retain Individual records in accordance with OAR 166-150-0005 through 166
150-0215 (State Archivist). Unless OAR 166-150-0005 through 166-150-0215 requires a longer
retention period, Individual records must be retained for a minimum of ten (10) years from
termination or expiration of this Contract.
e. Safeguarding of Individual Information. Contractor shall maintain the confidentiality of Individual
records as required by applicable state and federal law, including without limitation, ORS 179.495 to
179.507,45 CFR Part 205,42 CFR Part 2, any administrative rule adopted by the Oregon Health
Authority, implementing the foregoing laws, and any written policies made available to Contractor by
County or by the Oregon Health Authority. Contractor shall create and maintain written policies and
procedures related to the disclosure of Individual information, and shall make such policies and
procedures available to County and the Oregon Health Authority for review and inspection as reasonably
requested by County or the Oregon Health Authority.
f. Data Reporting.
All individuals receiving services with funds provided under this Contract must enroll and maintain that
client's record in either:
(1) The Client Processing Monitoring System (CPMS) as specific in OHA's CPMS manual located at
http://www.oregon.gov/OHAlamh/training/cpms/index.shtml.asit may be revised from time to time;
or
(2) The Measures and Outcome Tracking System (MOTS) as specified in OHA's MOTS manual located
at: http://www.oregon.gov/oha/amh/pages/compass/electronic-data-capture.aspx, as may be revised
from time to time.
Over the next two years AMH will be closing the CPMS system and replaCing it with the MOTS system.
Providers will be notified of the change.
3. Alternative Formats of Written Materials. In connection with the delivery of Services, Contractor shall:
a. Make available to an Individual, without charge to the Individual, upon the Individual's, the County's
or the Oregon Health Authority's request, any and all written materials in alternate, if appropriate,
formats as required by the Oregon Health Authority's administrative rules or by the Oregon Health
Authority's written policies made available to Contractor.
b. Make available to an Individual, without charge to the Individual, upon the Individual's, County's or
the Oregon Health Authority's request, any and all written materials in the prevalent non-English
languages in the area served by Contractor.
c. Make available to a Individual, without charge to the Individual, upon the Individual's, County's or the
Oregon Health Authority's request, oral interpretation services in all non-English languages in the
area served by Contractor.
Page 2 of 4 -Exhibit 8 to Personal Services Contract No. 2013-274
d. Make available to a Individual with hearing impairments, without charge to the Individual, upon the
Individual's, County's or the Oregon Health Authority's request, sign language interpretation services
and telephone communications access services. For purposes of the foregoing, "written materials"
includes, without limitation, all written materials created or delivered in connection with the services
and all subcontractor contracts related to this Contract.
4. Reporting Requirements. Contractor shall prepare and furnish the following information to County and
the Oregon Health Authority when a service is delivered under this Contract:
a. Individual, service and financial information as specified in the applicable Service Description
attached hereto and incorporated herein by this reference.
b. All additional information and reports that County or the Oregon Health Authority reasonably
requests.
5. Compliance with Law. Contractor shall comply with all state and local laws, regulations, executive
orders and ordinances applicable to the Contract or to the delivery of services hereunder. Without
limiting the generality of the foregoing, Contractor expressly agrees to comply with the following laws,
regulations and executive orders to the extent they are applicable to the Contract:
I r(a) all applicable requirements of state civil rights and rehabilitation statutes, rules and regulations;
(b) all state laws governing operation of community mental health programs, including without limitation,
all administrative rules adopted by the Oregon Health Authority related to community mental health
programs; I
(c) all state laws requiring reporting of abuse of an Individual; (d) ORS 659A.400 to 659A.409, ORS
659A.145 and all regulations and administrative rules established pursuant to those laws in the
I
construction, remodeling, maintenance and operation of any structures and facilities, and in the Iconduct of all programs, services and training associated with the delivery of services under this
Contract. These laws, regulations and executive orders are incorporated by reference herein to the !
I
!extent that they are applicable to the Contract and required by law to be so incorporated. All
employers, including Contractor, that employ subject workers who provide services in the State of
tOregon shall comply with ORS 656.017 and provide the required Workers' Compensation coverage,
unless such employers are exempt under ORS 656.126. In addition, Contractor shall comply, as if it l
were County thereunder, with the federal requirements set forth in Exhibit H to the certain 2013-2015
Intergovernmental Agreement for the Financing of Community Addictions and Mental Health
Services between County and the Oregon Health Authority dated as of July 1, 2013, which Exhibit is
incorporated herein by this reference. For purposes of this Contract, all references in this Contract to
federal and state laws are references to federal and state laws as they may be amended from time
to time. I
6. Unless Contractor is a State of Oregon governmental agency, Contractor agrees that it is an
independent contractor and not an agent of the State of Oregon, the Oregon Health Authority or County
7. To the fullest extent permitted by applicable law, Contractor shall defend (in the case of the state of
Oregon and the Oregon Health Authority, subject to ORS Chapter 180), save and hold harmless the
State of Oregon, the Oregon Health Authority, County, and their officers, employees, and agents from
and against all claims, suits, actions, losses, damages, liabilities, costs and expenses of any nature
whatsoever resulting from, arising out of or relating to the operations of the Contractor, including but not
limited to the activities of Contractor or its officers, employees, subcontractors or agents under this
Contract.
8. Contractor understands that Contractor may be prosecuted under applicable federal and state criminal
and civil laws for submitting false claims, concealing material facts, misrepresentation, falsifying data
system input, other acts of misrepresentation, or conspiracy to engage therein.
Page 3 of 4 -Exhibit 8 to Personal Services Contract No. 2013-274
9. Contractor shall only conduct transactions that are authorized by the County for transactions with the
Oregon Health Authority that involve County funds directly related to this Contract.
10. Contractor(s) that are not units of local government as defined in ORS 190.003 shall obtain, at
Contractor's expense, and maintain in effect with respect to all occurrences taking place during the term
of the Contract, insurance requirements as specified in Exhibit 2 of this Contract.
11 Contractor(s) that are not units of local government as defined in ORS 190.003, shall indemnify, defend,
save and hold harmless the State of Oregon and its officers, employees and agents rlndemniteen
) from
and against any and all claims, actions, liabilities, damages, losses, or expenses (including attorneys'
fees) arising from a tort (as now or hereafter defined in ORS 30.260) caused, or alleged to be caused, in
whole or in part, by the negligent or willful acts or omissions of Provider or any of the officers, agents,
employees or subcontractors of the contractor( "Claims»). It is the specific intention of the parties that the
Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or
omissions of the Indemnitee, be indemnified by the Contractor from and against any and all Claims.
12. Contractor shall include sections 1 through 11, in substantially the form set forth above, in all permitted
Contractor contracts under this Contract.
Date: _____ Signature: ____________Title _______
Contractor:
Page 4 of 4 -Exhibit 8 to Personal Services Contract No. 2013-274
CNA
OMAICNA Physicians Protection Program
CERTIFICATE OF INSURANCE
THIS CERTIFICATE OF INSURANCE IS NOT AN INSURANCE POLICY AND IS ISSUED AS A
MATTER OF INFORMATION ONLY. IT CONFERS NO RIGHTS UPON THE HOLDER.
NAME AND ADDRESS OF INSURED: ISSUED BY: Continental Casualty Company
Marc V. Williams MD
1495 NW Quincy Ave
Bend, OR 97701
A Claims-Made Professional Liablity Policy
POLICY NUMBER POLICY PERIOD LIMITS OF LlABLITY PRIOR ACTS DATE
PSC 2074998280 08/01/12-08/01/13 1,000,000 PerClaim 04/01/2001
3,000,000 Aggregate
NAME AND ADDRESS OF CERTIFICATE HOLDER:
TO WHOM IT MAY CONCERN I
I,
This Certificate of insurance is not an insurance policy and does not amend. extend or alter the coverage afforded
by the policies listed herein. Notwithstanding any requirement, term. or condition of any contract or other document
with respect to which this Certificate of insurance 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. I
!
&
I
[
I. Photocopies of this document ~re deemed as valid as the original.
II. If the Policy, or coverage for any person, is canceled for any reason or if the terms of the policy are
changed, we will notify the First Named Insured only.
~
~m-~.~ ...~...... ~-""'---~---=-=-=-=----
AUTHORIZED REPRESENTATIVE
DATE ISSUED: July 17.2012
CNA HealthPro, 12909 SW 68th Parkway. Suite 200 Portland, OR 97223(800} 341 -3684
GSL2929XX Ed. 07 08
M1-363-8949 Sarah Shores Page2J2
Commercial Certificate of Insurance FA R MER S'
Agency
• Scott Robson
Name
• 644 NE Greenwood Ave #1 Issue Date (MMlDDIYY) 108/1612012 !& • Bend., OR 97701-4569
Address • 541-382-9111
This certificate is issued as a matter of information only and confers no rights
upon the certIficate holder. This certificate does not amend. extend or alter the
coverage afforded by the policies shown below.St. 73 Dist__0_9____Agent _3_5_4 ___
Companies Providing Coverage:
Insured Company A Truck Insurance Exchange
• WILLIAMS, MARC I..m:r
Name • 1495 NW QUINCY AVE. Company B Farmers Insurance Exchange
I..ct1cr& • BEND, OR 97701 Company C Mid-Century Insurance Company
Address 1..i.1;1tr D
Company
1..i.1;1tr
Coverages
This is to certify that the policies of insurance listed below have been issued to the insured named above for the policy period indicated. NotwithSlanding
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.
Co. Type or Insurance PUN b Policy Flfective IPolicy Expiration , Polley Umits1Jr. 0 ey urn er Date (t.-lMllllllYV) Date (MM/l.)lllYV)
~--1-~-----------------+-----~-----~-------------+-----------+--------------r-----------~General AggregateB General Uability $ 2,000,000
Products-Comp/OPS08/0912013034978089 08/09/2012
K Commercial General Aggregate $ 1,000,000Liability
Personal &
K • Octw:rence Version Advertising Injury $ 1,000,000
Each Occurreoce $Contractual-Incidental Fire Damage 1,000,000
Only
(Any one Hre) $ 75,000
Owners & Contractors Prot Medical Expense
(Anyone penon) $ 5,000
~--~-+-----------------+-----------------~----------+-----------r-~--~-------+'----------~
Combined SingleAutomobile liability Limit $All Owned Commercial
Autos
Bodily Injury
(per person) $Scheduled Autos
Bodil 1,1Hired Autos Y .J}ltlIT) $(peraooucntNon-Owned Autos
Property Damage $Garage Liability
Garage A!B'egate $
LimitUmbrella liability $
WOlters' Compensation Statutory
Each Accident $
and Disease. Each Employee $
Employers' liability Disease -Policy Limit $
~--~~----------------~---------------~-----------~----------~--------------~------------Description of Operations/VehlcleslRestrictions/Special items:
1128 NWHARRIMAN ST, BEND, OR 97701
Certificate Holder Cancellation
Should any of the above described policies be cancelled before the expiration date• DESCHUTES COUNTY, ITS OFFICERS
Name thereof. the issuing company will endeavor to mail 30 days written notice to the• AGENTS, EMPLOYEES, VOLUNTEER~
certificate holder named to the left. but failure to mall such notice shall Impose no& • 1130 NW HARRIMAN ST., obligation or liability of any kind upon the company. its agents or representatives.Address • BEND, OR 97701
Sarah 1_ Shores
Authorized Representative
'=-56:-'2:-4-:-:92:----4-94-:-----------::::C-op-y-:D::::-:-istri--:T·b-u~tlon-:-;:Se,-m---:-c-e-:::::Ce,-n-t-er-:C=-o~p·-y-a-nd-;--""7A-ge-n-:t';-s-;:;C:-O-py-----------~1iOl
POLI<';:V NUMBER: 03497"80-89
THIS ENDORSEMENT CHANGES THE PO~CY. PLEASE READ IT
ADomONAL INSVRED • QESIGNATED PE
OR ORGANIZATION
.:
H This endorsement modifies Insurance provided under the fOllowing:
:1 '
BUSINESSOWNER8 POLICY
Name Of Person Or Organization:
DESCHUTES COUNTY, ITS OFFICERS
AGEJlTS, ,BKPLOYBES, VOLUIlTEERS
... Information required to complete this Schedule, If not shown on this endors
DeclaratIons.
The following Is added to Paragraph C. Who •• .An
In8Uf8CI In the Buslnessowners Liability Coverage
Form:
4f.. Any person or organization shown In the Sched
ule Is also an Insured, but only with r••pect to
liability artslng out of your ongoIng operations
or premises owned by or rented to you.
,
"
BUSINE889WNER8
CAREFULLY.
SON
ment, will be shown In the
BP04 48 0197 Page 1 of1 0