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HomeMy WebLinkAboutDoc 286 - Agrmt - Smith Medical PartnersDeschutes 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 June 6, 2012 DATE: May 18, 2012 FROM: Kathy Christensen, Clinical Program Supervisor, Health Services, 322-7407 Nancy England, Contract Specialist, Health Services, 322-7516 TITLE OF AGENDA ITEM: Consideration of Board Signature of Document #2012-286, contract between Smith Medical Partners t.· and Deschutes County Health Services, Public Health Division. I PUBLIC HEARING ON THIS DA"rE? No. BACKGROUND AND POLICY IMPLICATIONS: Deschutes County Health Services, Public Health Division is preparing an Invitation to Bid (ITB) for the pharmaceuticals that the department needs to purchase. Public Health has enrolled in the 340b Prime Vendor Program, established by the Health Resources and Services Administration (HRSA) to increase the discounts already offered under the Section 340B of the U.S. Public Health Service Act. The program provides discounts on outpatient drug purchases to 340B covered entities such as public hospitals, community health centers, Title X grantees and other safety-net healthcare providers serving low income and uninsured patients. While Public Health is preparing the ITB, the department needs to order contraceptives from a vendor that will offer the 340B pricing. Smith Medical Partners offers the products at the 340B pricing and free shipping. Public Health wishes to order from Smith Medical Partners in the interim of accepting bids from other vendors for pharmaceutical products. Public Health may choose to continue ordering pharmaceuticals through Smith Medical Partners if it is determined through the ITB process that they are the best vendor for the products the department needs. IFISCAL IMPLICATIONS: ~ Contraceptive items priced at the HRSA 340B Program rates. Rates are set by the HRSA and change i I on a quarterly basis. RECOMMENDATION & ACTION REQUESTED: Approval and signature of Document #2012-286, contract between Smith Medical Partners and Deschutes County Health Services, Public Health Division is requested. i rATTENDANCE: Kathy Christensen, Clinical Program Supervisor , DISTRIBUTION OF DOCUMENTS: Executed documents to Nancy England, Contract Specialist f I I 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 May 8,2012 1 Department: 1 Health Services, Public Health Department Contractor/Supplier/Consultant Name: 1 Smith Medical Partners 1 Contractor Contact: 1 Brad Russell Type of Document: Personal Services Contract Goods and/or Services: Smith Medical Partners provides a full range of pharmaceuticals, injectables, vaccines and a highly competitive generics portfolio. Background & History: Smith Medical Partners can provide contraceptives at Health Resources and Services Administration (HRSA) 340B pricing. The 340B Prime Vendor Program was established to increase the discounts already offered under Section 340B of the U.S. Public Health Service (PHS) Act. The program provides deep discounts on outpatient drug purchases to 340B covered entities such as public hospitals, community health centers, Title X grantees, and other safety-net health care providers serving low income and uninsured patients. These are the lowest possible prices on pharmaceuticals and the maximum a vendor can charge. Deschutes County will be ordering contraceptive products from Smith Medical Partners at the 340B prices. Items will be shipped to Deschutes County locations for free. Agreement Date: 1 May 8,2012 End Date: 1 OPEN Annual Value or Total Payment: 1 Contraceptives items priced at the HRSA 340BI IProgram rates.1 [Z] Insurance Certificate Received check box) Insurance Expiration Date: Janua 15,2013 Check all that apply: D RFP, Solicitation or Bid Process D Informal quotes «$150K) [Z] Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37) (Contracting with Vendor while creating an ITB.) 519/2012 ,. t I t Funding Source: (Included in current budget? k8J Yes o No If No, has budget amendment been submitted? DYes o No Is this a Grant Agreement providing revenue to the County? 0 Yes ~ No Special conditions attached to this grant: Deadlines for reporting to the grantor: IL--__ If a new FTE will be hired with grant funds, confirm that Personnel has been notified that it is a grant-funded position so that this will be noted in the offer letter : 0 Yes 0 No Contact information for the person responsible for grant compliance: Name : D Phone#:D Departmental Contact and Title: Nancy England, Contract Specialist Phone #: I 541-322-7516 I Department Director Approval: ---~_ 5 .\\'t2~~r=-/____ DateS~ Distribution of Document: Nancy England, Deschutes County Health Services Department. Official Review: County Signature Required (check one): ~ SOCC R Department Director (if <$25K) o Administrator (if >$25K but <$150K; if >$150K, SOCC Order No. _____ Legal Review ~~ Date 0 I 7 -('2­ Document Number 2012-286 ~~~~------- 5/9/2012 - ---- ,,:-_ !. " "1, C. I .J.,',Smith Medical Partners '.',':;:. ! ';','.:, l -:. '.'1 Ney¥ Customer Application Process Step 1 Complete and sign the New Account Application, Terms &Conditions and Customer Profile Forms. Step 2 If the address on the State or DEA License does not match the shipping address specified on the application, please complete the Letter of Direction. Step 3 If the facility is a member of a Group Purchasing Organization (GPO), please complete the GPO and Contract Designation Form. Step 4 Submit forms and copies of the physician's State License and DEA Registration via fax at 630.227.9220 or email allscanneddocumentstoinquire@smpspecialty.com. For assistance or questions, please contact us at 800.292.9653. 02172011 Pa ge 1 of 9 DC -20 12-28 Account Number _______ Bill to Account Number _______Smith Medical Partners New Account Application ~countName Destbu!cS Lal~ H<alln SeC{l'Ubate ______________ ll£jPrimary Account DSecondary Account Estimated Monthly Volume $ ____________ Specialty 3'10n Ti±).(_ X Representative Name 1::>rad R\A <.>><:11 Physician Information _==_=_-==_____= ___============-=".".""""'_____ Name ______________________ DEA Number _______________ Expiration Date ___________ State License Number Expiration Date ___________ Billing & Shipping==____-====-_-==-_~__'!"fFi~~~~!!"lII"li_--====-=iy\tl(::(O\P\e Ad6kZ,s:e:S Bill To]:::;e<;.e.\:-.ales LJ)lAnti lim lin <;£rV,{J )Ship To DeS.h, g.I($ C . .C;u,011i lien I-tb ~rJ ,(eS-~ Address ?-6'1+ A1£~ (O..Adh4f U. Address a5j:} Nt (ru("-t~ 1;)("\)(e.. City, State, Zip Deca\ I 0"-q'".:1-70l City, State. Zip 1?end I 0 e... '13301 AlP Contact i,'c~ 6\:=tJ. W 'j\\:rTO He.aHb Se{)(!'ceS -~~hoSd\ Geo\U' Phone '?2L/ /-3 Q1.?\ -is£;, Ptdd.a=t; s " i I J.. :2w 8ib 5.-;-. l3ef'd Order Contact \-\o\'M ~'-\(;),w'-:>~ -54/',3JJ-l'I'J'J. Cri~\.LStgt', tiP: \2.e.ctN'\Qad) De. q:fJ-6lo Rec\lrtO\xl c(7,dUtf)()-fact-behb~c... c.ec(5L·ern'@-~8rt ______________ Trade References Vendor Name Account Number Address City State Zip------­ Phone Fax Email Vendor Name Account Number Address Zip _______City State Phone Fax Email Vendor Name Account Number Address City State Zip------­ Phone Fax Email 02172011 Page 20f9 I Account Number ________ Bill to Account Number ________Smith Medical Partners Payment Terms OStatement IB'invoice Choose Tenns 015 Day ~o Day OEmail ____________________________OMaii Payment Authorization ""======-===========_==================== OCheck Faxx (Pre-Pay Account) OElectronic Funds Transfer I authorize Smith Medical Partners, LLC, hereafter Company, to initiate debit entries, and if necessary, credit entries and adjustments for any debt entries made in error, to the checking account indicated below, at the depository named below. hereafter Depository. Branch __________________Depository Name _____________ City ________________ State _______ Zip code ______ Routing Number _____________ Account Number ______________ Tax Identification Number ______________________________ Frequency of Draft o Daily (As Ordered) OSemi-Monthly OMonthly The authorization is to remain in force and effect until Company has received written notification from the undersigned Customer of its termination in such time and in such manner as to afford Company and Depository a reasonable opportunity to act on it. Signature ________________________ Date ______________ Printed Name Title _____________ 02172011 Page 3 of9 Account Number ___________________ , Smith Medical Partners Account Name ________________________________ __ Sales Representative _______________________________ Te~ms ~ Condition~ _ .. _', oJ_ TERMS AND CONDITIONS These terms and conditions shaD apply to all purchases and sales of Products between Cuslomer and Smilh Medical Partners, LLC (SMP). Customer agrees that these terms and conditions may be modined at any time and from time to time by SMP, but no modificalion will apply to Customer retroactively. PURCHASES Customer will submit orders for pharmaceutical a"d other products (Products) to SMP, which orders are subject to acceptance by SMP. Customer agrees to pay for said PrOducts ordered by Customer in accordance with these terms and conditions. SMP shall fulfill Products ordered by Customer and accepted by SMP (to the extent SMP has Products in inventory for allocation to Customer). Customer shall take title to Products at the time of deHvery to Customer and shall be responsible for risk of loss to Products upon such delivery. Customer hereby agrees and understands that SMP may at any time and from time to time cancet all deliveries and suspend any orders (whether in route or otherwise) and reclaim any deliveries made if SMP determines in its sole discretion that the sale or delivery of any Products may be contrary to or violate any SM P policy, any law or any agreement with or request of any governmental authority or otherwise not be in the best interests of SMP. In the event that SMP in its sole d iscretion authorizes deliveries on such terms as it may determine in its sole discretion aher any such cancellation. suspension Or reclamation, such shall not constitute a waiver of this Section for any future enforcement purposes. PRICING Pricing for ProdUClS Wlil equal the price set ior1h from time to time by SMP. SMP has no duiy to pass through any rebate or discount to Customer. SHtPPING SMP ships Products free of charge wilhin the United States with a $500.00 minimum order. For orders less than $500.00, a $15.00 shipping and handflng fee will be applied. Notwithstanding the foregoing (a) non· refrigerated items shipped for next-day delivery are subject to a $30.00 Shipping and handling fee, (b) all CLASS 2 narcotic orders Will be charged a $15.00 shipping am handling fee. and (c) all Saturday deliveries are charged a $30.00 shipping and handling fee . For all shipments made outside of the 48 contiguous states there is a $50.00 shipping charge. PAYMENT TERMS Statement Payment Program ~There will be two billing periods por month. The first period will be from the 1st through the 15 th at the month. and payment for purchases during such period will be due by the 25th of that month. The second perio d will be from the 16th through the end of the month , and payment for purchases during such period will be due by the 10th of the following month. ~Payment for purchases from the 1 st through the end 01 the month will be due and payable by the 10th of the following month. Invoice Payment Program .L5.:.Q.ay; All invoices are due 15 days from the invoice biiling elate except for special dating o«ers authori zed by SMP. which are due 15 days from the special billing date stated on the invoice -,6. ~All inVOiCes are due 30 days from the invoice billing elate except for special dating oNers authorized by SMP, which a re due 30 elays from the special billing date stated on the invoice. DC Ii 5 S~1 e.C-><t'" ~;s .. oPTla1 . "All checkS shoutd be made payable to Smith Medical Partners. Remittance should be mailed to: 21950 Network Ptace. Chicago . IL 60673-1219. Electronic Funds Transfer Electronic Funds Transfer (EFT) is another paymem option aveiable through SMP. EFT requires an Authorization Agreement for Pre-Authorization Payment form which will grve SMP authorization to automatically initiate debit entries for invoice amounts from checking a=unt indicated on the form. Statements reflecting account actrvity will be mailed out semi-monthly or monthly. Semj-Monthly EFT: Amount due will be drafted the 15th and 30lh of the month. All purchases billed by H. D. SmithlSMP from the 1st through the 15th of the month are due and payable on the last day of the month via Electronic Funds Transfer. NI purchases billed by H. D_ SmithlSMP trom the 16th through the end of the month are due and payable on the 15th day of the following month via Electronic Funds Transfer. Monthly EFT: Amount due wn/ be drafted on the 10th of each month. All purchases billed by H. D. Sm~hlSMP for the calendar month are due and payable on the 10th day of the fOllowing month via Electronic Funds Transter. Daily EFT: Amount due will be drafted within 24 hours after order is placed via Electronic Funds Transfer. Accelerated Payment Incentives: Accelerated payment incentives are available for EFT or CheckFaxx payment terms. Amounts of incentives may vary relative to market conditions. Details and amounts of incentives are available upon request. Past Due Balance: Without limittng other remedies available to SMP. past due invoices are subject to a 2% service charge per month and future shipments may be suspended until past due invoices are paid in full. C redi t Card payments may be subiect to a service fee based on order size and method of payment. Customer shall be responsible to pay ar,y and all costs and ex penses incurred by SMP (including. without Iimi1ation. reasonable attorneys' fees) in connection with collecting amounts due 10 SMP. Price Changes: Due to manufacturer price increases. prices are subject to change without notice. SMP w~1 attempt to notify Customer when poSsible CheckFaxx: To reduce processing & handling time, for one-time prepayment payment by check, or for repeat purchases of the same dollar amounts, SMP also accepts check-by-Iax using the CHECKFAXX system . CHECKFAXX works by attaching a copy of the check and faxing to SMP_ Funds are withdrawn by using the routing and account number on the check. A copy of the depos~ sflp wHI be mailed to the customer for their record s. All checks should be made payable to Smith Medical Partner s . RETURN POLICY o All claims must be made to SMP within 48 hours of rec eipt of Product . o For aft returns. please call SMP to request a Return Authorization Form and pre-paid return shipping labels. o All expired ContrOlled Substances are non-returnable. Ptease refer to DEA Form 41. o Products ordered in error are returnable and will incur a 25% restOCking fee. o Products shipped in error by SMP or saleable items (returned within 30 days and/or at least 6 months prior to the expiration date) w,lI receive 100% credit. o Manufacturer'S return policies will apply to all outdated, damaged or seasonal merchandise. o Unauthorized returns will not be eligible for credit. CHARGEBACKS PHS & GPO priCing will reflect a markup for Distribution and Administration services. Customer hereby agrees to indemnify and hold SMP harmless in the event thai! there is any change in the status of customer's right to receive contract pricing. Customer hereby agrees to immediately pay SMP the ~;f· T ~l--~'-02172011 ·--rO~~ Page40f9 LEGAL COUNSEL Account Number __________________ _ ~r~\.Smith Medical Partners Account Name ___________________________________ Sales Representative ________________________ Terms & Conditions Continued amount stated by a re-biD showing the higher pricing of the Product delivered, which is the result of a manufacturer chargeback for any reason. BLANKET CERTIFICATE OF RESALE Customer certifies that if tangible personal property hereafter purchased is for purposes of resale, Customer assumes liability for payment of Retailer'S Occupation Tax, Service Occupation, Sales Tax or Use Tax with respect to receipts from the resale of this property to users or consumers. This certificate shall be considered a part of each oreler which Customer shall give, unless such order specifies otherwise. CREDIT REFERENCE AUTHORIZATION Customer hereby authorizes SMP to conduct such investigation as SMP shall in tts sale discretion deem necessary to verify the information supplied by Customer on the credit application and to verify Customer's credit worthiness and hereby agrees to release all persons, connpanies' or corporatiOns using or supplying such information, including SMP, from any claims and/or losses that may result there from. DISCLAIMER Notwithstanding anything to the contrary contained herein, Customer acknowledges and agrees. on behalf of itself and each of its affiliates and other purchasers, that SMP is not the manufacturer of any Products. SMP (on behalf of itself and its affiliates) disclaims all warranties. express or implied, including those of merchantability, non-infringement and fitness for a particular purpose, and no oral or written information provided by SMP or its aHiliates or their respective employees or other representatives have created or will create any warranty. In no event wi" SMP or its affiliates be liable for any claims. causes of action. obligations, liability, liens, indebtedness. debts. judgments. damages (of any kind and nature), losses, costs. expenses, and fees (including. without limitation, reasonable attorney, expert, and accountant lees) (Losses). including. without limitation. bodily injury or death, resulting from an individual's use of the Products, except to the extent caused by lhe negligence or willful misconduct of SMP, In no event shall SMP or its affiliates be liable for any special. indirect, incidental, exemplary, punitive or consequential damages (including, without limitation, lost profits) even if Customer has been advised of such damages. LIMITATION OF LIABILITY Customer's exclusive remedy for a defective Product shall be the replacement of such defective Product, and SMP's liabiltty for any Losses resulting from any defective Product shall be limited to the purchase price of such Product. FORCE MAJEURE SMP shall not be liable for any failure or delay in performance under these terms and conditions to the extent said failure or delay is caused conditions beyOrd its reasonable control including, but not limited to, Acts of God, wars or civil commotion, destruction of facilities or materials by fire, earthquake. storm or other natural disaster. labor disputes or shortages, product or materia! shortages. transportation delays or breakdowns or other delivery disruption. GOVERNING LAW These terms and conditions between Customer and SMP shall be governed by and construed in accordance with the feclerallaws of the United States of America and internal laws of the State of !IIinois applicable to contracts made and to be performed in Illinois (vvithout regard to the principle of conflict 01 laws applicable under Illinois law). Customer and SMP agree that it is their intent that to the fullest extent permitted by law. the laws of the State of Illinois shall govern the parties' agreement. CONTRACTUAL DISPUTES To the maximum extent permitted by law. Customer hereby agrees that an actions or proceedings arising in connection with this agreement or any course of conduct, course of dealing. statements (whether written or oral) or actions of SMP or Customer in respect thereof (whether sounding in tort or contract or otherwise) shall be tried and determined exclusively in the state courts located in the Circuit Court of Sangamon County. State of Illinois or in the Untted States District Court for the Central District of Illinois, or, at the sole and exclusive discretion of SMP, in any other court located in the State of Illinois or outside the State of Illinois, in which SMP shall initiate legal or equitable proceedings. To the maximum extent permitted by law, Customer hereby expressly waives any rights it may have to assert the doctrine in any intrastate or interstate proceeding of Forum Non Conveniens or to object to venue to the extent any proceeding is brought by SMP to enforce this contract. CUSTOMER AGREES THAT THE SOLE AND EXCLUSIVE VENUE FOR ANY PROCEEDING INITIATED BY CUSTOMER SHALL BE THE CIRCUIT COURT OF SANGAMON COUNTY. STATE OF ILLINOIS. OR THE U.S. DISTRICT COURT, CENTRAL DISTRICT OF IWNOIS. To the maximum extent permitted by law. Customer hereby expressly and irrevocably submits to the personal jurisdiction of the courts of the State of lilincis and of the U.S. District Court for the Central District of Illinois for the purpose of any and all litigation ariSing under this agrtement or any other document. and irrevocably agrees to be bound by any judgment rerdered thereby in connection with such litigation. In the event that litigaLor. arises from a contractual dispute, Customer further agrees to stipulate in wrrting that, at SMP's option, any depositions may be taken by telephone, videoconference or other electroniC means in accordance with Illinois or federal court rules, as applicable. Customer further irrevocably consents to the service of process of the complaint and summons in any such litigation by certified or registered mail. postage prepaid. at the address of Customer provided herein. SECURITY STATEMENT H. D. Smith and Smith Medical Partners hereby reserve the right to demand that any advances of merchandise on credit be secured by appropriate security agreements, and/or personal guarantees. The undersigned: (1) Acknowledges that the agreement has been read and reviewed; (2) Represents that the person Signing this agreement has the authority to bind Applicant to the terms and conditions set forth herein (n Applicant is a corporation, attach a corporate resolution); (3) Warrants, covenants and agrees that all of the information provided to H. D. Smith and Smith Medical Partners is true and correct; and (4) Agrees to pay and perform all of the obligations of App!icant or Customer included in the agreement according to the stated terms. Date _________________Signature (Physician or Agent) ______________ Print Name _____________________ Title ________________ 02172011 Page 5019 FIRST ADDENDUM TO SMITH MEDICAL PARTNERS, LLC "TERMS & CONDITIONS" OF SMITH MEOICAL PARTNERS, LLC NEW ACCOUNT APPLICATION This First Addendum to the Smith Medi<;:al Partners, LLC Terms and Conditions is between Smith Medical Partners, LLC ("SMP") and Deschutes County, by and :between Deschutes County Health Services, a political subdivision of the State of Oregon, 2577 NE Courtney Drive, Bend, OR 97701, hereinafter referred to as "Customer." For good and valuable consideration, the receipt and sufficiencry of which is hereby acknowledged, SMP, has entered into an agreement with Customer to supply contraceptives (manufactured by others independent of SMP) (Deschutes County Contract Number 2012-). In addition to the Smith Medical Partners, LLC Terms and Conditions, the parties agree as follows: ~ INDEMNITY & INSURANCE. 1. INDEMNITY a. Each party {"Indemnifying Partyn shall defend, save, hold harmless and indemnify the other party ("Indemnified Party") and its officers, employees and agents from and against all claims, suits, actions, losses, damages, liabilities costs and expenses directly resulting from the activities of the Indemnifying Party or its officers, employees, contractors, or agents under this agreement. b. The Indemnifying Party shall have control of the defense and settlement of any claim that is subject to subparagraph a of this Section; however neither the Indemnifying Party nor any attorney engaged by such party shall defend the claim in the name of Indemnified Party, nor purport to act as legal representative of the Indemnified Party or any of its departments or agencies without first receiving from the Jndemnified party's legal counsel, in a form and manner determined appropriate by the Indemnified Party's legal counsel, authority to act as legal counsel for the Indemnified Party, nor shall the Indemnifying Party settle claim on behalf of the Indemnified Party without the approval of the Indemnified party's legal counsel. 2. INSURANCE a. Each party shall at all times maintain in force at the party's expense, the following insurance coverage: not less than $1,000,000 combined single limit, commercial general liability insurance per occurrence and $3,000,000 in the aggregate. Insurance coverage must apply on a primary or non-contributory basis and be in effect for the term of this agreement. Coverage shall include personal injury, bodily injury, advertising injury, property damage, premises, operations, completed operations and contractual damages. Each party shall be responsible for its deductible or self-insured retention. 3. The provisions of this First Addendum are in addition to and do not supersede any provision in the Smith Medical Partners, LLC Terms and Conditions. Dated this ___ of ______-'--_, 2012 S@8K dg,,~~ePl, Oiret;tor, Deschutes Couilty Health Services Addendum 1 -Terms anc! CQndi~iOflS -Smith M~qical Partnerii a,greement, Deschutes County Contract No. 2012-cR8~ f I Date ________ ~coornNUm~r _________Smith Medical Partners Accoont Name _________________ I I I I I I I___ Drugs dispensed pursuant to invalid prescriptions are deemed not for legitimate medical purpose, therefore, illegal. CustomerSuNey======________===_==__~____=___=============== Are the dispensing practitioners licensed to practice medicine in the jurisdictions to which the prescription drugs are being shipped? 0 Yes 0 No What is your total monthly pharmaceutical purchase amount in dollars from all suppliers? ___________ What percentage of your overall pharmaceutical purchases from all suppliers each month are controlled substances? ___ What percentage of your total Smith Medical Partners purchases are controned substances? _________ If a large amount of a specific controlled substance will be purchased, please list the product(s) and explanation Do you purchase controlled substances from other wholesalers? 0 Yes 0 No If yes. please list other wholesalers ~____________________________ , Sales Representative ________________ Date Account Opened ______ Customer Profile Business Background==========-~======-=======____==_ Company Name ______________________________________________ Doing Business N;, _________________________________ Type of Business _______________ Number of Prescribing Practitioners ________ Address __________________________________________ City ________________ State ________ Zip code ______ DEA Registration Number _____________ Expiration Date ____________ State Ucense Number Expiration Date _____________ State Controlled Substance Ucense Number Expiration Date _____________ Customer Profile ~=__......_____====__-==___......____====__ Smith Medical Partners has the statutory obligation to exercise due diligence and maintain effective controls against diversion into other than legitimate medical channels. Therefore. our customers must also maintain effective controls to prevent the dispensing of prescription drugs based on prescriptions that are written for other than legitimate medical purposes. DEA Guidelines ===___~_======__= ___= ____====_ Please initial to indicate agreement. ___ Prescriptions can only be issued for a legitimate medical use by a doctor acting in the usual course of professional practice and prescriptions not issued in the usual course of professional practice are not valid. Has any supplier restricted your purchases of controlled substances? 0 Yes 0 No If yes, please explain _________________________________ Page 1 of4 08032011 I Oat9 ________ Account Number _________Smith Medical Partners _______________Ac~ntName Sales Representative ________________ Customer Profile Continued. Legal __________-==-________________-=======__===-______________ Has applicant. officer, owner, member, partner, physician or irrrnediate family member (spouse. Child, sibling) of the aforementioned been convicted of a felony or misdemeanor. excluding minor traffic conviction? _____Ifyes. explain: _________________________________ Has any sanction or disciplinary action been taken regarding any license, permit or registration issued to the applicant. officer, owner. member, partner, physician or immediate family member (spouse. child. sibling) involving the operation or ownership of a clinic? _____Ifyes, give state and status: ___________________________ I do hereby swear that no Intemet Sales of Pharmaceutical products of my business have occurred in or out of the United States and my business also maintains controls to prevent the dispensing of prescription drugs based on prescriptions that are written for other than legitimate rnedical purposes and \/>Iill notify the distributor prior to conducting Intemet prescription fulfillment. 1 do hereby swear. depose and say that my business does not engage in any wholesaia distribution of pharmaceutical products. In accordance with 28 USC 1748. I declare and affirm. under the penalties for perjury. that the foregoing representations are true and correct. Signature ___________________________ Date _____________ I Printed Name Tltl6 ____________ i 08032011 Page 2 Of 4 Account Number _______ Smith Medical Partners Account Name _____________ Sales Representative _____________ Letter of Direction State Medical License Information ~====_==================_ State License Number ____________ Expiration Date _____________ Facility or Physician Name ____________________________ Address ________________ City. State, Zip _____________ I DEA License Information======__.......___.......____......._____......._ .....___"""""" I DEA Number ______________ Expiration Date _____________ I Please complete this information if it varies from the State information supplied above: Facility or Physician Name ____________________________ Address ________________ City, State, <-.11-'------------­ Mail to the attention of =============~================= Smith Medical Partners 960 Lively Boulevard I Wood Dale,IL 60191 Please indicate the physical shipping address for CLASS 1* pharmaceuticals """"""""""''''''''''''''''''''''=== Company Name ______________ Account Number ____________ Address City, State, Zip _____________ 'CLASS 2, 3, 4 and 5 pharmaceuticals must be shipped to address on the DEA certificate. Signature ______________________ Date ___________ Printed Name Title ___________ 02172011 Page8of9 Account Number ________ Account Name _______________Smith Medical Partners Sales Representative _______________ GPO and Contract Designation Form AccountName~~~lfih4 dkatm ~~ Address w~.r....l.-L3--L~---t..:~:.I...\"..._~~~~u...Lo::~~..I.a..>__ City, State. ZiP::5erd1 b g, 9'±:to I DEA Number HIN Number 3408 ID f"pq 13-C? I[ I Hereby Certify ~__=-~===~========~__=_==--__= Smith Medical Partners is my wholesaler to provide product under the following contract or contracts: Primary GPO Secondary GPO ________________ For existing customers, please note if a GPO is being removed: ____________________ Contract pricing will be determined by: ~8est price among all contracts or DPre-determined priority order of contracts II\dditional approvals reqUired.} Class of Trade D Retail Pharmacy o Closed Door Pharmacy D Institution D Physician Office D Long Term Care Facility D Specialty Facility o Surgery Center D Pain Management Clinic D Substance Abuse Clinic DMaiiOrder o Home Infusion [jd-Government Facility D Other _____________ Business Description or Additional Comments ________________________ Ust any individual or tier contracts: Manufacturer Product(s) Agreement Type 1. 2. 3. 4. 5. 6. If a pricing discrepancy Is Identified by SrIlth Medical Partners, a partnerlng buying group, a Smith Medical Partners supplier or a customer, Smith Medical Partners will credit and/or rebill Customer upon verification of the discrepancy, subject to Smith Mecical Partners Return Goods Policy. Since Smith Medical Partners. under contractual pricing. often sens merchandise to CUstomer at a price below whOleSale acquisition cost and must receive supplier chargeback to recover the cost of merchandise. supplier determinations of group or item eligibility for CUstomer are binding on both Smith Medical Partners and CUstomer. Aqustments of any pricing extended to CUstomer for which Customer Is subsequently determined to be heliglble is the responsibility of CUstomer. Contract group pricing will be effective upon validation with the GPO and/or manufacturer. The person signing this agreement has the authority to bind CUstomer to the terms and conditions set forth herein (if Customer is a corporation, attach corporate resolution). Unless otherwise permitted by law. signature of this declaration constitutes a representation by you and your company that product received at contract prtcirg wiD be used only for its own use as defined in Abbott Laboratooes v. Portland Retail Druggist ASSOCiation. 425 U. S. 1 (1976). Any other use of these prodlCts will constitute cause for immediate termination of this account. Signature __________________ Oate ____________________ Printed Name TItle ____________________ Sales Representative Signature Oat6'____________________ Submission must be within 60 days of signature date. E-mail Signed fomn to membership@hdsmith.com with a copy of the DEA License and Enrollment Checklist. 02172011 Page 90f9 , I OPID: CB DATE (MMIODlYYVYjCERTIFICATE OF LIABILITY INSURANCE 01/19/12I 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 INSURERIS). AUTHOR/ZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 217 -546-6900 Nicoud Insurance 217-546-7034481 Ash Grove Ste B. PO 13078 Springfield, /L 62791-3078 Timothy J. Nicoud. Jr. INSURED H D Smith Wholesale Drug Co. & Smith Medical Partners LLC & Major Value & Independent Holding Co LLC & Complete Care Pharmacy 3063 Fiat Avenue SnriJ"1nfi",M Il 62703 CONTACT NAME: PHONE FAX ._~~~~L ___________.._ ......._.~_xc!AI"'C:.t.,'-"Nou):'--__._ : ADDRESS: '~bOUCER IIjiosco-OJ;B..IP.",,~:...;;,..c.,.;;.......;;.._.. _ •........_.._________ INSURER(S) AFE..9RDlNG C9Y!'~!!.E.._m_'___-l-_--,N.::.AI=.::C:"':#'---1 ~!;IlI1,E~".~CincjnnC:l!i Insurance Com~C:lny' 10677 INSURER B: Cincinnati In«!~l1j:tYC:;I:),!!~;..;a___n-'Y'--_____i_'. ..__... _ J.!!~B!~£~I!~""ClAmeri.(;C:l.. ___m ___ •••••••••••••.m.m.m_ • •••••••••••••••••••••••••• .1!:!!;!!I~.I:~D.:........~______ .......... ____.. . ..... •.•_..._.m __·m ..m__ _ ~ER~E: ·········m___m________ . INSURERF; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N01WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PERSONAL & ADV:cI::.:NJ""U::,:Rc:...Y--;•....:$:.........___1c..:.,00c...:...:0c..:..O.:...O:...:.1 AG.G.~~.q,A..!!'. ...... .LS. ..2!()()~!~!_ -COMPlOP AGG I $ i EACH OCCURRENCE AGGREGATE I i WCSTATU-i X • TORY LIMIT!>! $ 2,000,00 $ 1mil/3mi 1.000,00 U::L.:..E.'J.l:CH ACCIDENT $ I EL DISEASE -EA EMPLOYE $ ""~m.-..----"":::-:::.::..:.=:1_..:...---__-'----l i E.L DISEASE· POLICY LIMIT !Excess I~f: TYPE OF INSURANCE i GENERAL UABIUTY A ')(1 COMMERCiAl GENERAl LIABILITY . [J ClAIMS-MADE jJ OCCUR A AlL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS UMBRELLA UAB EXCESS LIAS DEDUCTIBLE X . RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY A ANY PROPRlETORJPARTNERlEXECUTIVE B OFFICERIMEMBER EXCLUDED? (Mandatory in NHI If yes, descril.le under DESCRIPTION OF OPERATIONS below i ICOP2315677 ic0A2315677 ICCC1154820 C1911316 WC1861218 01/15/12 01/15113 01/15/12 01115113 01/15/12 01115113 01/15/12 01/15113 01/15/12 01/15113 C jExCeSS over Umb MAXA3EC300000137 01/15/12 01/15/13 iowrumb !AbDLrSOB~---~~~~~u...aER -·····T LIMITS EACH OCCURRENCE i $ ••_ .._...._.!.'..~!~.'l. g~~~~J~~~""""1 : $ 500,00 MED EXP (My one P"!:."""L.....:;..::$'--___...:1..:.0'-',O..:.0CCj DESCRlP110N OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Add~lonai Remarl<s Schedule, if more Sp.ilC8 is required) Roger Mood SmHh and Beverly Smith are excluded from Workers Compensation RE: 950 and 960 Lively Blvd, Wood Dale,IL 60191. Wood Dale Wheeling,LLC fowner), American Realty AdvisorsJadvlsor)and CBRE {property manager) are Included as additional insureds un er the general liability as their interest rna a ar. CERTIFICATE HOLDER CANCELLATION CBRE1-1 SHOULD ANY OF lliE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRAnON DATE THEREOF, NOnCE WIlL BE DELIVERED INCBRE ACCORDANCE WITH THE POUCY PROVISIONS.Jacqueline B Raimondo 20 N Martingale Road,Suite 100 Schaumburg, IL 60173 AUTHORIZED REPRESENTATIVE /tv-fltdal: © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD