HomeMy WebLinkAboutDoc 315 - Svcs Agrmt - Harold Sexton - HealthDeschutes 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 July 21, 2014
Please see directions for completing this document on the next page.
DATE: July 08, 2014
FROM: Nancy Mooney, Contract Specialist Phone: 322-7516
Health Services--Behavioral Health Division
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2014-315, personal services contract
between Harold Sexton, M.D. and Deschutes County Health Services.
PUBLIC HEARING ON THIS DATE? No
BACKGROUND AND POLICY IMPLICATIONS:
Dr. Harold Sexton will provide behavioral health services as a Medical Director for the
department. The Medical Director provides oversight, medical direction, guidance and
policy planning to the Health Services Department. Dr. Sexton will write standing orders,
develop and implement protocols for clinical direct services and prevention activities. He
will provide medical supervision and consultation to staff and participate in direct patient
services as needed. Dr. Sexton will assist with quality assurance and oversight to the
activities of each program area.
County will provide monthly payments to Dr. Sexton (upon receipt of invoice) on a fee-for
service basis of $150 per hour for a maximum of twenty (20) hours per week. Dr. Sexton
will pay a monthly rent of $250 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 $150,000
RECOMMENDATION & ACTION REQUESTED:
Behavioral Health requests approval.
ATTENDANCE: Lori Hill, Behavioral Health Program Manager
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 June 09,2014 I
Department: [Health Services, Behavioral Health I
Contractor/Supplier/Consultant Name: I Harold Sexton, M.D.
Contractor Contact: I Harold Sexton I Contractor Phone #: I 541-324-0396
Type of Document: Personal Services Contract
Goods and/or Services: Harold Sexton, M.D. is contracted to be the Medical Director for
Deschutes County Health Services Department.
Background & History: Dr. Harold Sexton will provide behavioral health services as a Medical
Director for the department. The Medical Director provides oversight, medical direction,
guidance and policy planning to the Health Services Department. Dr. Sexton will write standing
orders, develop and implement protocols for clinical direct services and prevention activities.
He will provide medical supervision and consultation to staff and participate in direct patient
services as needed. Dr. Sexton will assist with quality assurance and oversight to the activities
of each program area.
Deschutes County will provide monthly payments to Dr. Sexton upon receipt of invoice for
services provided. Dr. Sexton will pay monthly rent of $250 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, 2014 I Ending Date: [JUne 30,2015
Annual Value or Total Payment: I Maximum compensation is $150,000. I
~ Insurance Certificate Receivecl (check box,--.....,-_-.
Insurance Expiration Date: [September 20,2014
Check all that apply:
D RFP, Solicitation or Bid Process
D Informal quotes «$150K)
~ Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37)
6/9/2014
Funding Source: (Included in current budget? I:8J 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 I:8J No
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
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: IL-_--'
Phone#:D
Departmental Contact and Title: Nancy Mooney, Contract Specialist
Phone #: I 541-322-7516 I
Deputy Director Approval: ~Q~ a-
Signature
~Department Director APprova':ifar. L
Signature
Distribution of Document: Return both originals to Nancy Mooney, Behavioral
Health Department.
Official Review:
County Signature Required (check one): D BOCC D Department Director (if <$25K)
)(~dministrator (if >$25K but <$150K; if >$150K, BOCC Order No. _____
Legal Review l6'O <~ Date /av-3 o.-(,V
Document Number 2014-315 ~~~~-----
6/9/2014
REVIEWED
L ~fYLGAL COUNSEL
For Recording Stamp Only
DESCHUTES COUNTY SERVICES CONTRACT
CONTRACT NO. 2014-315
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 Dr. Harold Sexton, MD, 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, 2014. 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, 2015, 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 1-8 and Exhibits 1 through 8.
CONTRACTOR DATA AND SIGNATURE
Contractor Address: 1652 NW Summit Dr., Bend, OR 97701
Federal Tax 10# or Social Security #:
Is Contractor a nonresident alien? DYes D No
Business DeSignation (check one): D Sole Proprietorship D Partnership
D Corporation-for profit D Corporation-non-profit D Other, describe: LLC
A Federal tax 10 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 10 number or, if none, the Social Security number provided above.
is Contract including the attached Exhibits. I understand this Contract and agree to be bound by its
Contractor shall also sign Exhibits 3, 4, 6, 7 and 8.
IM.IV'
Signature ~I $e)(\tvt
Name (please print) Date
DESCHUTES COUNTY SIGN TURE
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 County Commissioners.
Dated this ___ of ________, 2014 Dated this 1/ of fJ lU1f--,2014
TAMMY BANEY, Chair
ANTHONY DEBONE, Vice Chair
ALAN UNGER, Commissioner
Page 1 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
ut.; -~0 1 4 - 3 15
.
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. Contractor shall submit monthly invoices for work performed. Contractor shall use the invoice template provided (see
Exhibit 1 B).
f. Prior to approval or payment of any billing, County may require and Contractor shall provide any information, not
available within County electronic systems, which County deems necessary to verify work has been properly performed
in accordance with the Contract.
g. Should County discover Contractor is committing or has committed "fraud and abuse" as those terms are defined in OAR
410-120-0000, either through an audit or other means, County may recover funds paid to Contractor under this Contract. If
federal authorities demand the repayment of federal funds received under this Contract and Contractor has been found
willfully committing "fraud and abuse" as those terms are defined in OAR 410-120-0000, County may recover funds paid to
Contractor under this Contract and any fines or penalties charged to County as a result of Contractor's actions. If the State
of Oregon, disallows or requests repayment for any funds paid to Contractor under this Contract due to Contractor willfully
committing "fraud and abuse" as those terms are defined in OAR 410-120-0000 .. County may recover funds paid to
Contractor under this Contract in addition to any fines or penalties charged to County as a result of Contractor's actions. In
the event that the County determines that Contractor is responsible for the repayment of any funds paid to the Contractor,
in addition to any fines or penalties charged to the County due to Contractor willfully committing "fraud and abuse",
Contractor agrees to make such payment within ten (10) days of notification by County.
h. 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.
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.
Page 2 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
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.
6) County may immediately terminate this Contract if County finds that Contractor is committing or has
committed "fraud and abuse" as those terms are defined in OAR 410-120-0000.
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.
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.
Page 3 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
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.
1. 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.
12. Insurance. Contractor shall provide insurance in accordance with Exhibit 2 attached hereto and incorporated by
reference herein.
Page 4 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
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 Contractors 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. In addition to the obligations imposed upon by Exhibit 7, 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, Client, 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, Client, 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 either a Business
Associate Agreement or a Confidentiality Agreement, whichever is applicable, 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 Clients which are funded in whole or in part under this Contract. Contractor
shall maintain the confidentiality of Clients 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 Client's 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. Meaningful Use. "Meaningful Use" is the set of standards defined by the Centers for Medicare & Medicaid Services
(CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to
earn incentive payments by meeting specific criteria.
a. Working as a Contractor for County, Contractor understands that County is implementing a health information
technology system to comply with the Electronic Health Record (EHR) Incentive program, created by the American
Page 5 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
Recovery and Reinvestment Act, Pub. L 111-5. Contractor agrees to assist County in meeting the obligations and
objectives set forth in 42 CRF Part 495 and to take such steps as necessary to allow County to realize the benefits of
the EHR Incentive Program, including but not limited to participating in the Medicaid EHR Incentive Program as an
Eligible Professional, using Certified EHR technology, and providing attestations of adoption, implementation,
upgrading and meaningful use of such technology as requested or required by County or other federal or state
authority.
17. Access to Records. To the extent not otherwise provided for by internal County systems, 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 Product") 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.
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
Page 6 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
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 Contractors 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 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 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.
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.
Page 7 of 8 -Behavioral Health ·Personal Services Contract No. 2014-315
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 and electronically by the e-mail address provided and delivered as
follows:
To Contractor: To County:
Dr. Harold Sexton, MD Jane Smilie
1652 NW Summit Dr. Deschutes County Health Services
Bend, OR 97701 2577 NE Courtney Dr.
Bend, Oregon 97701
Email: halsexton99@gmail.com 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 646A.600 et seq.).
30. Survival. All rights and obligations shall cease upon termination or expiration of this Contract, except for the rights and
obligations set forth 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
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 8 of 8 -Behavioral Health -Personal Services Contract No. 2014-315
EXHIBIT 1
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014-315
STATEMENT OF WORK, COMPENSATION
PAYMENT TERMS and SCHEDULE
1. Contractor shall perform the following work:
Contractor shall provide Medical Services as a Medical Director in accordance with OAR's 309-032-1505(68,
73 and 74); and 309-032-1530(2); and 309-032-1535 and Medical Director for Deschutes County Alcohol
and Drug Program according to OAR 309-032-1540. 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 ("OHA"). 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 definitions, laws, and regulations as defined in this Exhibit 1 of this Contract, 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 309-032-1500
through OAR 309-032-1565, which is incorporated into this Contract herein by reference or required by law
to be so incorporated. Deschutes County policy is found on the Deschutes County Intranet in the Health
Services Department's "Policies and Procedures".
DEFINITIONS
1. Client means an individual who is currently enrolled in a County program and is receiving services provided
by or on behalf of County.
2. Clinical Assessment means the process of obtaining all pertinent biopsychosocial information, as identified
by the individual, family and collateral sources, for determining a diagnosis and to plan individualized
services and supports.
3. Coordinated Care Organization (CCO): Local networks of all types of health providers working together as
one entity to deliver care for people in the Oregon Health Plan. Care is coordinated at every pOint from
where services are delivered to how the bills are paid. PacificSource Community Health Solutions, Inc. has
been designed by OHA as the CCO for the Central Oregon region.
4. Culturally Competent: The capacity to provide services in an effective manner that is sensitive to the culture,
race, ethnicity, language and other characteristics of an individual. Such services may include, but are not
limited to, use of bilingual and bicultural staff, provision of services in culturally appropriate alternative
settings, and use of bicultural paraprofessionals as intermediaries with professional staff.
5. Fraud and Abuse: "Fraud" is defined as intentional deception or misrepresentation made by a person with
the knowledge that the deception could result in some unauthorized benefit to him/herself or some other
person. It includes any act that constitutes fraud under applicable federal or state law (OAR 410-120-0000).
Fraud occurs if Contractor intentionally falsifies information or deceives County and/or Medicaid/Medicare for
the purpose of obtaining money or property. "Abuse" (410-120-0000) means provider practices that are
inconsistent with sound, fiscal, business or medical practices and result in unnecessary costs to County
and/or Medicaid/Medicare, improper payment, or services that aren't medically necessary. Inappropriate
practices that begin as abuse can evolve into fraud. Medicare and Medicaid Fraud and Abuse Prevention
Training Program can be obtained using the following URL: http://www.cms.gov/Outreach-and
EducationlTraining/CMSNationaITrainingProgram/Downloads/2014-Medicare-and-Medicaid-Fraud-and
Abuse-Prevention-Workbook. pdf.
6. Individual service record or service record or clinical record means the documentation, written or electronic,
regarding an individual and resulting from entry, clinical assessment, orientation, service and support
planning, services and supports provided, and service conclusion.
7. Medically appropriate means services and medical supplies required for prevention, diagnosis or treatment
of a physical or mental health condition or injuries and which are:
a. Consistent with the symptoms of a health condition or treatment of a health condition;
Page 1 of 5 -Exhibit 1 -Personal Service Contract No. 2014-315
b. Appropriate with regard to standards of good health practice and generally recognized by the relevant
scientific community and professional standards of care as effective;
c. Not solely for the convenience of an individual or a provider of the service or medical supplies; and;
d. The most cost effective of the alternative levels of medical services or medical supplies that can be
safely provided to an individual.
A. SERVICES TO BE PERFORMED
1) Contractor agrees to be designated as Deschutes County Mental Health Medical Director for behavioral
health and alcohol and drug programs and perform the following:
a. Review Health Services behavioral health clinical policies, and provide consultation to the
Behavioral Health Deputy Director. Assist department in the identification and implementation of
best practices for clinical services
b. Review and provide consultation regarding the Health Services Strategic Plan and periodic updates,
helping to identify Health Services highest priority behavioral health development and improvement
goals.
c. Approve all medical protocols for the alcohol & drug treatment program as required by OAR 309
032-1540.
d. Provide clinical consultation and coordination with other contracted Deschutes County Health
Services psychiatrists and nurse practitioners.
e. Serve as leader of the Medical Team. Provide administrative and clinical supervision of the Medical
team.
f. In addition to providing Medical Supervision as described above, provide consultation as needed to
clinical staff including Qualified Mental Health Associates and Professionals (QMHA and QMHP)
and nursing staff.
g. Within available time, serve as a liaison to the medical community, the Well ness Education Board of
Central Oregon (WEBCO) and other entities as assigned.
h. May be assigned to participate in local community meetings, hospital medical staff meetings,
advisories, and forums related to the program area.
2) Contractor shall provide Medical Services 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.
3) Orders for medication, laboratory and other medical procedures shall be recorded for each Client 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 in County's EHR.
4) 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
f. Medication records which contain;
a. Observed side effects including laboratory findings, and
b. Medication allergies and adverse reaction.
Page 2 of 5 -Exhibit 1 -Personal Service Contract No. 2014-315
5) Contractor shall provide Medical Supervision. Medical Supervision means an LMP's review and approval,
at least annually, of the Clinical Assessment and the medical appropriateness of services and supports
identified in the service plan for each Client receiving mental health services for one or more continuous
years.
6) 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.
7) Contractor shall use County's EHR and legibly document all Client 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
Clients.
8) Contractor shall facilitate communication with the "Primary Care Provider" and county providers, via
telephonic and/or written methods, for each Client seen including Contractor initiated changes in
medication regimen, pertinent chart notes and other information to coordinate a high quality of Client
care. Contractor will comply with all privacy and security regulations under the Health Information
Portability and Accountability Act (HIPAA).
9) 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.
10) Contractor shall provide County a billing statement on a monthly basis which notes the quantity of hours
worked each day. Contractor shall submit the final monthly billing statement for the fiscal year 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.
11) Contractor will give advanced notice to County of planned and/or anticipated absences and assist County in
arranging psychiatric coverage when absences exceed one (1) week. Contractor shall alert County as
soon as possible in the event of unanticipated absence.
12) Contractor shall maintain all requirements to perform services as a LMP according to OAR 309-032
1505 (68), Medical Director in accordance with OAR's 309-032-1505(68, 73 and 74);and 309-032
1530(2); and 309-032-1535, and Medical Director for Deschutes County Alcohol and Drug Program
according to OAR 309-032-1540, which includes maintaining license as a physician within the state of
Oregon.
13) Contractor shall assist County in meeting "Meaningful Use" obligations and to take such steps as
necessary to allow County to realize the benefits of the EHR Incentive Program, including but not limited to
participating in the Medicaid EHR Incentive Program as an Eligible Professional, using Certified EHR
technology, and providing attestations of adoption, implementation, upgrading and meaningful use of such
technology as requested or required by County or other federal or state authority. Contractor will
consistently use EHR in a way that Meaningful Use data may be quantified and reported.
14) Contractor shall screen and assess Clients for tobacco use, and offer tobacco cessation resources to
Clients choosing to quit.
15) Effective Date of Amendment. This Contract shall take effect as soon as executed by the Parties, but no
later than July 1, 2014 All other provisions of the Contract shall continue in full force and effect for the
duration of the Contract.
Page 3 of 5 -Exhibit 1 -Personal Service Contract No. 2014-315
B. REGULATIONS & DUTIES
Contactor shall comply with all applicable provisions of that certain 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 billing statement following the end of each calendar month, but no later than
thirty (30) days following the end of the calendar month. Contractor shall utilize the format previously
stipulated, example provided in Exhibit 1B of this Contract.
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 billing statement 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:
I
I
I
I
J
Contractor: Accounts Payable: Notices & Contracts:
• Dr. Sexton Deschutes Coun!y Health Services Deschutes County Health Services •
1652 NW Summit Dr. . 2577 NE Courtney Drive 2577 NE Courtney Drive
Bend, OR 97701 Bend, OR 97701 Bend, OR 97701
Attn: Loretta Gertsch Attn: Nancy Mooney
Phone: 541-322-7544 Phone: 541-322-7510 Phone: 541-322-7516
Fax: 541-322-7565 Fax: 541-322-7565 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 Client Contractor provides services for.
3. Consideration. 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 $150 per hour. The maximum number of hours
Contractor is authorized to work under this Contract is twenty (20) hours per week unless authorized by
the Behavioral Health Deputy Director.
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. For any direct services Contractor may provide, if OHA 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 OHA disallows or requests repayment.
d. For any direct services Contractor may provide, in the event that OHA determines that County or Contractor
is responsible for the repayment of any funds owed to OHA by Contractor, Contractor agrees to make such
payment within ten (10) days of notification by County or OHA of said determination by OHA.
c. Upon County Department Director or Behavioral Health Deputy Director's approval, Contractor shall be
entitled to reimbursement for expenses as set forth in Exhibit 5. Contractor shall use the Expense
Reimbursement Form provided in Exhibit 1 A.
Page 4 of 5 -Exhibit 1 -Personal Service Contract No. 2014-315
d. Contractor shall obtain Professional Liability insurance that specifically covers Medical Director services.
County and Contractor shall split the cost (50/50) of the Professional Liability insurance coverage
obtained. County will reimburse Contractor upon receipt of proof of coverage and the invoice therefor up
to a maximum of $3,000.
4. The maximum compensation.
a. The maximum compensation under this Contract is $150,000 plus County's share of the cost of
Professional Liability insurance coverage for Medical Director.
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) 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 andlor insurance.
c. Rent. Contractor agrees to pay the County monthly rent of $250.00 in return for the County providing the
Contractor office space, meeting space (subject to availability), 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 5 of 5 -Exhibit 1 -Personal Service Contract No.2014-315
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-----
EXHIBIT 1A
EXPENSE REIMBURSEMENT FORM
Employee: Department:
Expenses From (Date): To (Date):
PRIVATE VEHICLE MILEAGE
By ITPI signature below I certify that ITPI personal vehk:1e insurance COll1>lies with Oregon financial responsibility requirerrents.·
Date Destination and/or Purpose Miles
New nileage rate effective January 1st, 2013
(from other side)
(from other side)
(from other side)
Signature of Employee: *
Signature of
Total Miles Traveled
1/1/2013 Mileage Reirnb. Rate
Total Mileage Reimbursement
Total Meal Expense
Total Lodging Expense
Total Miscellaneous Expense
TOTAL REIMBURSEMENT
Date:
___0_._56_5_
Dept. Head or Designee: Date:
Page 1 of 2 -Exhibit 1A -Personal Service Contract No.2014-315
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MEAL AND LODGING EXPENSES (attach rate sheet)"
MEAL REIMBURSEMENT<> LODGING
Receipts
Required
GSA Maxirrum
Applies+
...
DATE JUSTIFICATION FOR REIMBURSEMENT*'
Business purpose, location (city) & nalros of those
attending
Partial Day Reimbursement
=I
0
r FULL DAY
RElMB
BKFST.
Actual up to
20%
allowance
LUNCH
Actual up to
3O"A.
allowance
DINNER
Actual up to
50%
allawance
·
·
-
-
·
·
-
·
·
-
·
-
·
-
-
-
-
-
.. GSA per diem tables available at www .policyw orks .gov/perdiem Total Meals:
<> See paragraph 11 (sections a & b) of Reirrburserrent Policy for guide.nes. Total Lodging: ____
*' Include copy of approved Out of State Travel Authorization Form if applicable.
+See paragraph 13 of Reirrburselront Policy for exceptions.
MISCELLANEOUS EXPENSES
Fares, Parking, Gas Purchases for County Vehicles. Etc. (receipts required)
DATE DESCRIPTION OF EXPENDITURE AMOUNT
Total Miscellaneous Expense:
Page 2 of 2 -Exhibit 1A -Personal Service Contract No.2014-315
EXHIBIT 1B
INVOICE TEMPLATE
CE
Dr. Harold Sexton, MD
T Deschutes County Health Services o
2577 NE Courtney Drive
Bend, OR 97701
Attn: loretta Gertsch
DATE:
Contract No. 2014-315
I
I
....
DATE
I
I
i
I
BALANCE DUE
. -.-.--',
TOTA.t(t
I
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Contractor Signature:____________
Authorizing Signature:___________
Page 1 of 1 Exhibit 1B -Personal Service Contract No.2014-315
EXHIBIT 2
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014-315
INSURANCE REQUIREMENTS
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: Dr. Harold Sexton. MD
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.
[8] Rejluired by County o Not required ~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 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.
[8] Required by County o Not required by County (One box must be checked)
Page 1 of 2 -Exhibit 2 -Personal Services Contract No. 2014-315
Automobile 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 ~ 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.
Risk Management review Date
-4L
Page 2 of 2 -Exhibit 2 -Personal Services Contract No. 2014-315
EXHIBIT 3
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014·315
CERTIFICATION STATEMENT FOR CORPORATION ~"
OR INDEPENDENT CONTRACTOR
NOTE: Contractor Shall Complete A or B in addition to C below:
A. CONTRACTOR IS A CORPORATION LIMITED LIAB1LITY COMPANY OR A PARTNERSHIP.
I certify under penalty of perjury that Contractor is a [check one]: o Corporation 0 Limited Liability Company 0 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 equjpment; (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 of 2 -Exhibit 3 -Personal Services Contract No. 2014-315
7. Contractor h
required Sl tracts.
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
not discriminated against minority, women or small business enterprises in obtaining any
Page 2 of 2 -Exhibit 3 -Personal Services Contract No. 2014-315
EXHIBIT 4
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014-315
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):
Ud'SOLE PROPRIETOR
• Contractor is a sole proprietor, and
• Contractor has no employees, and
• Contractor shall not hire employees to perform this Contract.
D CORPORATION· FOR PROFIT
• Contractor's business is incorporated, and
• All employees of the corpora60n 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.
D 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.
D 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 demoli60n of an improvement to real property or appurtenances thereto.
D 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
aI/ 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 complicate Consult with County Counsel before an exemption request is
accepted from a contractor who shall perform construction work.
_"-.sa&vt
Contractor Printed Name ,nI • Contractor Signat, hrtZtJ ,~mJ-T~
Contractor Title Date II
Page 1 of 1 -Exhibit 4 -Personal Services Contract No. 2014-315
EXHIBITS
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014-315
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 (Le. 5:00 p.m.).
Page 1 of 2 -Exhibit 5 to Personal Services Contract No. 2014-315
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. 2014-315
I
I
Exhibit 6
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014w315
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 U) 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," 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, 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.
Page 1 of 7 -Exhibit 6 to Personal Services Contract No. 2014-315
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:
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
Page 2 of 7 -Exhibit 6 to Personal Services Contract No. 2014-315
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 System For Award Management (SAM) "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 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
Page 3 of 7 -Exhibit 6 to Personal Services Contract No. 2014-315
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 Contractor's
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 (B).
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. 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.
e. 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 e1. 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.
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
Page 4 of 7 -Exhibit 6 to Personal Services Contract No. 2014-315
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;
(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:
Page 5 of 7 -Exhibit 6 to Personal Services Contract No. 2014-315
(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, if
Contractor denies individual admission on the basis of lack of capacity, refer the individual to another
provider of tuberculosis Services.
(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
Page 6 of 7 -Exhibit 6 to Personal Services Contract No. 2014-315
L
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.
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 CUent 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 el. seq., and Contractor shall comply with those restrictions.
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, Contra or shall comply with the confidentiality requirements of 42 CFR Part 2.
+
Date: 10 ~ignature: ~~~:t:=====~____Title \\till
Contrac r: ":!~
Page 7 of 7 Exhibit 6 to Personal Services Contract No. 2014-315
Exhibit 7
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014-315
CONFIDENTIALITY AGREEMENT
1. INTRODUCTION
This Confidentiality Agreement (the "Agreement") is entered into as of July 1, 2014 by and between
Harold Sexton, M.D., ("Contractor") and Deschutes County ("County").
WHEREAS, in connection with the performance of the Services, Contractor may receive from the
County or otherwise have access to certain information that is required to be kept confidential in accordance with
the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder, as may
be amended from time to time (collectively, "HIPAA"); and
WHEREAS, as a part of the American Recovery and Reinvestment Act, the federal Health Information
Technology for Economic and Clinical Health Act (the "HITECH Act") was signed into law, imposing certain
privacy and security obligations on Covered Entities in addition to the obligations created by the Privacy
Standards and Security Standards; and
WHEREAS, the HITECH Act revises many of the requirements of the Privacy Standards and Security
Standards concerning the confidentiality of Protected Health Information (PHI) and Electronic Protected Health
Information (EPHI), including extending certain HIPAA and HITECH Act requirements directly to business
associates; and
WHEREAS, the HITECH Act requires that certain of its provISions be included in Contractor
Agreements, and that certain requirements of the Privacy Standards be imposed contractually upon Covered
Entities as well as Contractors;
Therefore, in consideration of the foregoing premises and the mutual covenants and conditions set forth
below and in the agreement between Contractor and County for Contractor's provision of services, intending to
be legally bound, agree as follows.
2. DEFINITIONS
2.1 "Disclosure" means the release, transfer, provision of access to, or divulging in any other manner, of
PHI, outside Contractor's organization, i.e., to anyone other than its employees who have a need to
know or have access to the PHI.
2.2 "Electronic Protected Health Information" or "EPHI" means protected health information (as defined
below) that is transmitted, stored, or maintained by use of any electronic media. For purposes of this
definition, "electronic media" includes, but is not limited to, memory devices in computers (hard drives);
removable/transportable digital memory media (such as magnetic tape or disk, removable drive, optical
disk, or digital memory card); the internet; the extranet; leased lines; dial-up lines; private networks; or e
mail.
2.3 "Protected Health Information" or "PH" means information transmitted by or maintained in any form or
medium, including demographic information collected from an individual, that (a) relates to the past,
present, or future physical or mental health or condition of an individual; the provision of health care to
an individual, or the past, present, or future payment for the provision of health care to an individual; (b)
individually identifies the individual or, with respect to which, there is a reasonable basis for believing that
the information can be used to identify the individual; and (c) is received by Contractor from or on behalf
of County, or is created by Contractor, or is made accessible to Contractor by County.
2.4 "Secretary" means the Secretary of the United States Department of Health and Human Services or any
other officer or employee of the Department of Health and Human Services to whom the authority
involved has been delegated.
Page 1 of 4 Exhibit 7 to Personal Services Contract No. 2014-315
2.5 "Services" means the LMP Services provided by Contractor and identified in the Personal Services
Contract to which this Exhibit 7 is attached.
2.6 "Use" (whether capitalized or not and including the other forms of the word) means, with respect to PHI,
the sharing, employment, application. utilization. transmission, examination. or analysis of such
information to, from or within Contractors organization.
3. AGREEMENT
Contractor shall:
3.1 not use PHI except as necessary to provide the Services or provide oversight as necessary to the role of
Medical Director.
3.2 not disclose PHI to any third party without County's prior written consent.
3.3 not use or disclose PHI except as required by law.
3.4 implement appropriate safeguards to prevent unauthorized use or disclosure of PHI.
3.5 comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information, to
prevent use or disclosure of EPHI other than as provided for by this Agreement.
3.6 mitigate, as much as possible, any harmful effect of which it is aware of any use or disclosure of PHI in
violation of this Agreement.
3.7 promptly report to County any use or disclosure of PHI not permitted by this Agreement of which
Contractor becomes aware.
3.8 make its internal practices. books, and records (including the pertinent provisions of this Agreement)
relating to the use and disclosure of PHI, available to the Secretary for the purposes of determining
County's compliance with HIPAA.
3.9 return to County. or destroy, any PHI of County still in Contractors possession upon conclusion or
termination of the Services.
3.10 ensure that any subcontractors that create. receive, maintain. or transmit PH I on behalf of the Contractor
agree to the same restrictions. conditions. and requirements that apply to the Contractor with respect to
security and privacy of such information.
3.11 make PHI available to County as necessary to satisfy County's obligation with respect to individuals'
requests for copies of their PHI. as well as make available PHI for amendments (and incorporate any
amendments, if required) and accountings.
3.12 make any amendment(s) to PHI in a deSignated record set as directed or agreed to by the County
pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy County's obligations under
45 CFR 164.526.
3.13 to the extent the Contractor is to carry out one or more of County's obligation(s) under Subpart E of 45
CFR Part 164, comply with the requirements of Subpart E that apply to the County in the performance of
such obligation(s).
3.14 If Contractor (a) becomes legally compelled by law, process, or order of any court or governmental
agency to disclose PHI, or (b) receives a request from the Secretary to inspect Contractor's books and
records relating to the use and disclosure of PHI. Contractor, to the extent it is not legally prohibited from
so doing, shall promptly notify County and cooperate with County in connection with any reasonable and
appropriate action County deems necessary with respect to such PHI.
Page 2 of 4 -Exhibit 7 to Personal Services Contract No. 2014-315
3.15 If any part of Contractor's performance of business functions involves creating, receiving, storing,
maintaining, or transmitting EPHI:
A. implement administrative, physical, and technical safeguards that reasonably and appropriately
protect the confidentiality, integrity, and availability of EPHI that it creates, receives, stores,
maintains, or transmits on behalf of County, in accordance with the requirements of 45 CFR Part
160 and Part 164, Subparts A and C; and
B. report to County any security incident relating to the EPHI that Contractor maintains for County.
4. HIPAA DATA BREACH NOTIFICATION AND MITIGA'rlON
4.1 Contractor agrees to implement reasonable systems for the discovery and prompt reporting of any
"breach" of "unsecured PHI" as those terms are defined by 45 C.F.R. §164.402 (hereinafter a "HIPAA
Breach"). The parties acknowledge and agree that 45 C.F.R. §164.404, as described below in this
Section, governs the determination of the date of a HIPAA Breach. Contractor will, following the
discovery of a HIPAA Breach, notify County immediately and in no event later than seven business days
after Contractor discovers such HIPAA Breach, unless Contractor is prevented from doing so by 45
C.F.R. §164.412 concerning law enforcement investigations.
4.2 For purposes of reporting a HIPAA Breach to County, the discovery of a HIPAA Breach shall occur as of
the first day on which such HIPAA Breach is known to the Contractor or, by exercising reasonable
diligence, would have been known to the Contractor. Contractor will be considered to have had
knowledge of a HIPAA Breach if the HIPAA Breach is known, or by exercising reasonable diligence
would have been known, to any person (other than the person committing the HIPAA Breach) who is an
employee, officer or other agent of the Contractor. No later than seven business days following a HIPAA
Breach, Contractor shall provide County with sufficient information to permit County to comply with the
HIPAA Breach notification requirements set forth at 45 C.F.R. §164.400, et seq.
4.3 Specifically, if the following information is known to (or can be reasonably obtained by) Contractor,
Contractor witl provide County with: (i) contact information for individuals who were or who may have
been impacted by the HIPAA Breach; (ii) a brief description of the circumstances of the HIPAA Breach,
including its date and the date of discovery; (iii) a description of the types of unsecured PHI involved in
the HIPAA Breach; (iv) a brief description of what the Contractor has done or is doing to investigate the
HIPAA Breach, mitigate harm to the individual impacted by the HIPAA Breach, and protect against future
HIPAA Breaches; and (v) a liaison (with contact information) so that Contractor may conduct further
investigation concerning the HIPAA Breach. Following a HIPAA Breach, Contractor will have a
continuing duty to inform County of new information learned by Contractor regarding the HIPAA Breach,
including but not limited to the information described herein.
4.4 Data Breach Notification and Mitigation Under Other Laws. In addition to the requirements above,
Contractor agrees to implement reasonable systems for the discovery and prompt reporting of any
breach of individually identifiable information (including but not limited to PHI, and referred to hereinafter
as "Individually Identifiable Information") that, if misused, disclosed, lost or stolen, Contractor believes
would trigger an obligation under one or more State data breach notification laws (each a "State
Breach") to notify the individuals who are the subject of the information.
4.5 Breach Indemnification. Contractor shall indemnify, defend and hold County harmless from and against
any and all actual losses, liabilities, damages, costs and expenses (collectively, "Information Disclosure
Claims") arising directly from (i) the use or disclosure of Individually Identifiable Information (including
PHI) in violation of the terms of this Agreement or applicable law, and (ii) any HIPAA Breach of
unsecured PHI and/or any State Breach of Individually Identifiable Information. Contractor will assume
the defense of any Information Disclosure Claim; County may partiCipate, at its expense, in the defense
of such Information Disclosure Claim. Contractor shall not take any final action with respect to any
Information Disclosure Claim without the prior written consent of County.
Page 3 of 4 -Exhibit 7 to Personal Services Contract No. 2014-315
5. OTHER PROVISIONS
5.1 A breach under this Agreement shall be deemed to be a material default in Contractor's agreement with
Deschutes County to provide Services .
5.2 Contractor authorizes termination of this Agreement by County if County determines Contractor has
violated a material term of this Agreement.
5.3 Upon conclusion or termination of the Services, Contractor shall promptly return or destroy all PHI that
Contractor maintains in any form and retain no copies of such information . If the return or destruction of
such PHI is not feasible, the obligations under this Agreement shall continue in effect for so long as
Contractor retains such information, and any further use or disclosure of such PHI shall be limited to
those purposes that make the return or destruction of the PHI infeasible.
5.4 To the extent there are any inconsistencies between this Agreement and the terms of any other
agreement, either written or oral, between County and Contractor, the terms of this Agreement shall
prevail.
Deschutes County:
BY" ~k
r Signature
Name: Dr Harold Sexton Name : Jane Smilie
Type Name Type Name
Title : Medical Director Title : Director ~~~~---------------
Page 4 of 4 -Exhibit 7 to Personal Services Contract No . 2014-315
Exhibit 8
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2014-315
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. 2014-315
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. 2014-315
I
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 aU 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:
(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;
(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
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 under this
Contract. These laws, regulations and executive orders are incorporated by reference herein to the
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
Oregon 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
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, aU 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.
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. 2014-315
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 aU 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 ("Indemnitee") 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 aUeged 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.
Page 4 of 4 -Exhibit 8 to Personal Services Contract No. 2014-315
SEXTHA1 ~PID' AZ..~
THIS IS TO CERTIFY lHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING AN'( REQUIREMENT. TERM OR CONDITION OF Nf( CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS
CERTIFJCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDmONS OF SUCH POlfCIES. LIMITS SHOWN MAY HAVE BEEN REDUCEOBY PAID CLAIMS. r-r: "TYPe OF tlSURANCe i .." .. I ........ PI"II~NUMIllg ~!J.Ir!I<.'~!;!'r UIltTli
GENERAL IJABILITY EACH OCC~ReNCE $ 2,000,00.-72SBW rr9349 DO 09118113 09118114 I ~~le~~encel 1,000,00A 1l00lvt.ti<C1At. GEt>.ERAI..lll'BlllTY $
___ ClAIMS-MADE W OCCUR MED EXP (My 0119 pen;0I1) $ 10,001
PERSONAL & ICV INAJRY $ 2,000,001-GEtERALAGGREGATE $ 4,000.001-~'LAGGREn LIMIT J>PFlI.
n
PER: PR<XIUCTS· COM?IOP AOO $ 4,000,00
POLICY . ~ Loe $
AUTOMOBILE LIABILITY-, lea acci~~'M>U:!.IMII S
IWYPUTO BODILY 1tU.RY IPor pet'JOO) $
--:ALL OWI-ED . r-SCi-£OlA.ED BODILY IN..U<Y (Per ecddOlll) $-AUTOS I--JIJJTOS
NQN.0'0AIr£0 IlP8";'aCCide~ $-HIREDPUTOS r-JIJJTOS
$
UhIllRELlA UAB tjOCCUR EACH 0CCtfA:NCE •-exCESSUAB ClAIMS-MAOE AGGREGATE $
. DED I I s Is
WORKERS COMPENSATION , WCSlA1Uo.1 IO",W"
ANt) &MPLO'tERS' LIABLITY V I N
ANVPROPRl:TOIWARlNERIEXECUl111E 0 NJA E.L. EACH ACCIDENT $
OFFttRlMEMBER EXCLlA:lED?
IMlndatolll1n NH) E.L.OISEASE-EAfM"LOYEE $
~~~~~ERAllONS boiow EL DISEASE· POLICY LIMIT ,
A Business Pers Prop 72 sew rr9349 DO 09118113 09118114 BPP ',001
~ESCRIPTION OF OP6RAnONS I LOCATlONS I VEHICLES (AbCh ACORD 101. AddIIIonaJ Rema/ks Schtdule,lt more spaef Ie recpr.CO
he Oregon Health AuthOrity, State of Oregon, Deechutee Coun~. its
p'fflcers. aMents, emplpyees. and volunteers are hereby Included as ~ditiona Insured subject to the tenns and conditions of the policy.
!'-ocation: 2571 NE Courtney Drive, Bend, OR 91701
'...... HOLDER _
ACORD· CERTIFICATE OF LIABILITY INSURANCE I DATI; (loWIlCIVYY\')
~ 08126113
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THe CERTIFICATE HOLDER. THIS
CERTifiCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CoveRAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTe A CONTRACT BETWEEN THE ISSUING INSURER(S., AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate helder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVeD, subject to
the tenns and condllons of the polley, certain poldes may require an endorsement. A statement CiI1 this certificate doe5 not confer rights to the
certificate holder Jnlleu ofsuch end st. .
PRODUCER 800-243~ 9!8~ OfIIce en-58S-5011~6 Ryan Dr., SE
Salem, OR 97301
Sarah Wolfenbarger
1=~1
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INS~S}AFFORDING COVERAGE . HAle,
tlSUtERA: The Hartford
INSURED Harold Sexton, MD
1506 NE 1st Street
Bend. OR 97701
INSlftERB:
INSUReRC;
INSUREl'tO:
INSURStE:
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~OXERAGES CERTIFICAn..NUMBER: REVISION NUMBER:
The Oregon Healtb Authority,
State of Oregon, Deschutes
County
2577 NE Courtney Drive
Bend, OR 97701
•••_ ... I_ATION
SHOULD ANY OF THE ABOve DESCRIBED POUCIES BE CAHca.LeD 81!JlORE
THE EXPIRAnON DAT! THEREOF, NonCE INILL Be DELIVERED IN
ACCORDANCE WITH TIE POllCV PROVISIONS, "'
AUlliORIZED REf'flESENTAllVE
Sarah Wolfenbarger
-@1988.2010ACORDCORPORATION. All nghta reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER: 72 SBW IT9349
BUSINESS LIABILITY I.IMITS OF INSURANCE
LIABILITY AND MEDICAL EXPENSES $2,000,000
MEDICAL EXPENSES· ANY ONE PERSON $ 10,000
PERSONAL AND ADVERTISING INJURY $2,000,000
DAMAGES TO PREMISES RENTED TO YOU $1,000,000
ANY ONE PREMISES
AGGREGATE LIMITS
PRODUCTS.cOMPLETED OPERA nONS $4,000,000
GENERAL AGGREGATE
EMPLOYMENT PRACTICES LIABILITY
COVERAGE: FORM SS 09 01
EACH CLAIM LIMIT $ 10,000
DEDUCTIBLE· EACH CLAIM LIMIT
NOT APPLICABLE
AGGREGATE LIMIT $ 10,000
RETROACTIVE DATE: 09182013
This Employment Practices Liability Coverage contains claims made coverage. Except as may be otherwise
provided herein, specified coverages of this insurance are limited generally to liability for injuries for which claims are
first made against the insured while the insurance is in force. Please read and review the insurance carefully and
discuss the coverage with your Hartford Agent or Broker.
The Limits of Insurance stated in this Declarations will be reduced. and may be completely exhausted. by the payment
of "defense expense" and. in such event, The Company will not be obligated to pay any fu rther "defense expense" or
sums which the insured is or may become legally obligated to pay as "damages".
BUSINESS LIABILITY OPTIONAL
COVERAGES
REI MBURSEMENT OF LEGAL EXPENSES $5,000
COVERAGE FOR COURT OR REVIEW
BOARDS
FORM: SS 40 75
Fonn SS 00 02 1206 Page 005 (CONTINUED ON NEXT PAGE)
Process Date: 08/15/13 Policy Expiration Date: 09/18/14
BUSINESS LIABILITY COVERAGE FORM
F. OPTIONAL ADDITIONAL INSURED
COVERAGES
If listed or shown as applicable in the Declarations,
one or more of the following Optional Additional
Insured Coverages also apply. VIlhan any of these
Optional Additional Insured Coverages apply,
Paragraph 6. (Additional Insureds When Required
by Written Contract, Written Agreement or Permit)
of Section C., Who Is An Insured, does not apply
to the person or organization shown in the
Dedarations. These coverages are subject to the
terms and conditions applicable to Business
Liability Coverage in this policy, except as
provided below:
1. Additional Insured· Deslgnated Person Or
Organization
WHO IS AN INSLIRED under Section C. is
amended to include as an additional insured
the person(s) or organization(s) shown in the
Declarations, but only with respect to liability
for "bodily injurY', "property, damage" or
"personal and adVertising injury" caused, in
whole or in part, by your acts or omissions or
the acts or omissions of those acting on your
behalf:
a. In the performance of your ongoing
operations; or
b. In connection with your premises owned
by or re nted to you.
2. Additional Insured· Managers Or Lessors
Of Premises
a. WHO IS AN INSURED under Section C. is
amended to include as an additional insured
the person(s) or organization(s) shown in the
DeclaratiOns as an Additiona! Insured
Designated Person Or Organization; but only
with respect to liability arising out of the
ownerShip, maintenance or use of that part of
the premises leased to you and shown in the
Declarations.
b. With respect to the insurance afforded to
these additional insureds, the following
additional exclusions apply:
This insurance does not apply to:
(1) Any "occurrence" which takes place
after you cease to be a tenant in that
premises; or
(2) Structural alterations, new
construction or demolition operations
performed by or on behalf of such
person or organization.
Page 18 of 24
3. Additional Insured • Grantor Of Franchise
WHO IS AN INSURED under Section C. is
amended to include as an additional insured
the person(s) or organization(s) shown in the
Declarations as an Additional Insured
Grantor Of Franchise, but only with respect to
their liability as grantor of franclhise to you.
4. Additional Insured • Lessor Of Leased
Equipment
a. WHO IS AN INSURED under Section C. is
amended to include as an additional
insured the person(s) or organization(s)
shown inthe Declarations as an Additional
Insured -Lessor of Leased Equipment,
but only with respect to liability for "bodily
injury", "property damage" or "personal
and advertising injury" caused, In whole or
in part, by your maintenance, operation or
use of equipment leased to you by such
person(s) or organization(s).
b. With respect to the insurance afforded to
these additional insureds, this insurance
does not apply to any "occurrence" which
takes place after you cease to lease that
equipment.
5. Additional Insured • Owners Or Other
Interests From Whom Land Has Been
Leased
a. WHO IS AN INSURED under Section C. is
amended to include as an additional
insured the person(s) or organization(s)
shown in the Declarations as an Additional
Insured -Owners Or Other Interests From
Whom Land Has Been Leased, but only
with respect to liability ariSing out of the
ownership, maintenance or use of that part
of the land leased to you and shown in the
Declarations.
b. With respect to the insurance afforded to
these additional insureds, the follOwing
additional exdusions apply:
This insurance does not apply to:
(1) Any "occurrence" that takes place
after you cease to lease that land; or
(2) Structural alterations, new
construction or demolition operations
performed by or on behalf of such
person or organization.
6. Additional Insured • State Or Political
Subdivision -Permits
a. WHO IS AN INSURED under Section C. is
amended to include as an additional
insured the state or political subdivision
shown in the Declarations as an Additional
Form SS 00 08 04 05
POLICY NUMBER: 72 SBW IT9349
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFUllY.
ADDITIONAL INSURED -MANAGER/LESSOR
LOCATION 001 BUILDING 001
THE OREGON HEALTH AUTHORITY
THE OREGON HEALTH AUTHORITY I STATE OF OREGON, DESCHUTES COUNTY I ITS
BEND OR 97701
t
J
Form IH 1200 11 85 T SEQ. NO. 001 Printed In U.S.A. Page 001
Process Date: 08/15/13 Expiration Date: 09/18/14
I
ADMrnRALINSURANCECOMWANY PHYSICIANS, SURGEONS & DENTISTS
PROFESSIONAL LIABILITY POLICY A STOCK COMPANY
(herein called "the Company")
DECLARATIONS
(CLAIMS-MADE FORM)
Policy No.: E0000024S61-01 RenewallRewrite of:
"This is. evidence of .Insurance procured andI ''Named Insured" and Mailing Address developed Under the Oregon surplus lines laws. It
IS NOT covered by the pl'OYi~ofORS 734.510 to
HAROLD C. SEXTON, M.D. . 734..710 relating to the Oregon ~~Guaranty
331 NW RIVERSIDE ~on. If the tnllirer ......~gtbl.in.urance
becomes Insolvent. the OregOaIlnsurance ~uarantyBEND, OR 97701 Association has no obligation to p8y CIafn'Is under
this evidence of Insurance,"
Worldwide Facilities, inc. -Ucense t1Q01824S3
"POLICY PERIOD": From 0111312014 to 01113/2015 At 12:01 A.M. Standard Timeat the address ofthe "Named Insured" as stated herein
In consideration ofthe payment ofpremium, in reliance upon the statements herein Qr attached hereto, and subject to all ofthe
tenns of this policy, the Company agrees with the ''Named Insured" as follows:
Item I: "Named Insured's" Business:
Medical Director -Administrative and Supervisory Duties Only ~ For Qeschutes County Health Services
Item II: Coverage: Physicians, Surgeons and Dentists Professional Liability
Item III: Limits ofLiability:
$1,000,000 Each "Claim"
$3,000,000 Aggregate
Item IV: Deductible:.· $2,500 . Per Claim (including "claim expenses") .
. .
. . . .
Item V: . "Retroactive Date": 01113/2014 Oregon &.wPIua unes Tax & Fees
Premium: $ 5.000.00
Company Fee: $ 0.00
Item VI: Premium: $5,000.00 Not Subject to Audit Broker Fee: $ 250.00$0.00 Terrorism Premium Inspection Fee; $ P,OO$5,000.00 Total Premium 2% state Tax: $ 105.00
SlSe: $ 15.00
0.3% Rre MarshaJ $ 15,75Item VII: Forms attached at inception:
See Schedule ofForms AI 00 180398 NOTICE
Except to such extent 18 may otherwise be provided herein, the coverage of this
policy Is limited generally to liability for only those claims that are first made against
the Insured while the policy 18 In force. Please review the policy carefully and discuss
the coverage thereunder with your insurance agent or broker
A SIGNED COpy OF THE "NAMED INSURED'S" APPLICATION FOR THIS POLICY IS MADE A PART HEREOF, AT
INCEPTION.
This policy is not binding unless countersigned by Admiral Insurance Company or it's Authorized Representative. I
Countersigned On: ___....;.0..:.;.11,.;;.10;::./2;;;.;0:..::1~4 ____ &J:~AUtJU:rizedS.~RepresentatiVeAt: ___~Se~a..:.;.ttl=e~,W~A~____
IiBERKLEY COMPANY.DE 2030 0703 I,l