Download AGREEMENT BETWEEN SUNNY DAY HOSPICE AND CALL

AGREEMENT
BETWEEN
SUNNY DAY HOSPICE
AND
CALL-US TRANSPORT
This Agreement is entered into this 28th day of December, 2000, by and between Sunny Day
Hospice located at 12 Dirt Road, Winthrop, North Carolina 000102, the Hospice Home, located
at 101 Hospice Lake Lane, Winthrop, North Carolina, both of which are referred to in this
Agreement as "AGENCY", and Call-Us Medical Transport, referred to in this Agreement as
"PROVIDER." PROVIDER contracts office is located at Post Office Drawer S, Winthrop, NC
000201.
PROVIDER will supply to AGENCY Ambulance Services for AGENCY patients, who may
reside in a private residence, nursing facility, or the Hospice Home. PROVIDER assumes no
responsibility for the administration of health care services to AGENCY patients.
The services will be rendered within the geographical area served by both AGENCY and
PROVIDER.
1. Responsibilities of PROVIDER
1.01 Services. PROVIDER will supply Ambulance Services to AGENCY patients upon request.
A.
B.
A.
PROVIDER shall promptly furnish AGENCY with appropriate Ambulance
Service as defined in subsection (C) below. In instances where
Ambulance Service is not readily available, PROVIDER shall
immediately notify AGENCY.
PROVIDER shall supply Ambulance Service only if ordered by a duly
authorized representative of AGENCY.
PROVIDER agrees to be responsible for transport scheduling after
AGENCY patients have been referred for Ambulance Services and that
service had been authorized by an AGENCY representative.
The term "Ambulance Service" shall mean the provision of non-emergent
medical and non-medical transportation services.
B. PROVIDER agrees to assume responsibility for all maintenance and repairs
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of transportation vehicles and will have back-up vehicles with drivers
available in case of breakdown. Mileage expense shall also be the
responsibility of PROVIDER within Forsyth County AGENCY. For
transport outside of Forsyth County PROVIDER shall receive $3.00 per
mile as mileage expense reimbursement for Basic Life Support
Ambulance. This will be for loaded patient mile.
C. PROVIDER agrees to furnish information regarding services as requested
and to participate in interdisciplinary patient care planning and utilization
review as requested by AGENCY.
D. PROVIDER agrees to provide transportation for deceased AGENCY
patients, who do not have any family or funeral arrangements.
1.02 Personnel. PROVIDER will supply AGENCY with personnel who are well qualified,
properly trained and who meet the following criteria:
A. Each individual must:
1) Be certified in the State of North Carolina for the discipline in which
he or she is working and shall possess CPR certification, if required by
applicable laws, regulations, or accreditation standards.
2) Meet PROVIDER and AGENCY conditions of employment
regarding health clearance, providing of professional references, and
any other applicable hiring criteria.
3) Carry certification and CPR card, if required by applicable laws,
regulations, or accreditation standards, and present these documents
to an AGENCY representative upon request.
1.03 Employer Obligations. For personnel employed by PROVIDER, PROVIDER will
maintain direct responsibility as employer of such personnel for payment of wages and other
compensation; reimbursement of expenses; compliance with federal, state, and local tax
withholding; payment of worker's compensation, social security, unemployment, and liability
insurance sufficient to provide no less than $1,000,000/$2,000,000 coverage for all services
provided by PROVIDER; and other obligations imposed on the employer of such personnel.
Evidence of such insurance will be provided to AGENCY upon execution of this Agreement.
PROVIDER will require a certificate of insurance from each subcontractor, will forward a copy
to AGENCY upon request, and require subcontractor to give PROVIDER and AGENCY prompt
written notice of material change in that coverage.
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1.04 Patient Care Records. PROVIDER personnel will forward directly to AGENCY, when
requested, clinical notes and observations for each AGENCY patient served, to be incorporated
into the patient's record by AGENCY. The PROVIDER will maintain strict confidentiality of
the patients and the nature of any services provided and will exercise the utmost good faith with
respect to maintaining the confidentiality of the information and materials learned by virtue of
this Agreement.
1.05 State and Federal Compliance. PROVIDER will adhere to all of PROVIDER'S policies
and procedures, any applicable federal rules and regulations, and any applicable state licensure
laws and regulations for the provision of Ambulance Services.
1.06 PROVIDER Insurance. PROVIDER will maintain at its sole expense a valid policy of
insurance covering professional liability arising from the acts or omissions of PROVIDER and its
employees, agents, or representatives in an amount no less than $1,000,000/$2,000,000.
PROVIDER will forward a certificate of insurance to AGENCY upon execution of this
Agreement and will give prompt written notice of any material change in PROVIDER coverage.
Any Ambulance Service personnel subcontracted by PROVIDER are required to maintain their
own policy of insurance covering professional liability in the same amount as PROVIDER.
PROVIDER will require a certificate of insurance from each subcontractor, will forward a copy
to AGENCY, and will require subcontractor to give PROVIDER and AGENCY prompt notice of
material change in that coverage.
1.07 Non-discrimination. PROVIDER will not discriminate in provision of services with
respect to age, race, color, religion, military status, gender preference, sex, marital status, national
origin, disability, or source of payment.
1.08 Access to Records. Until the expiration of five (5) years after services are furnished under
this Agreement, PROVIDER agrees to make available, upon receipt of request from AGENCY
or from the Secretary of Health and Human Services or the U.S. Comptroller General or any of
their duly authorized representatives, this Agreement, and books, documents, and records of
PROVIDER that are necessary to certify the extent of costs incurred by AGENCY under this
Agreement.
1.09 Subcontract Records. If PROVIDER carries out any of the duties of this Agreement with
a value of $10,000 or more over a twelve-month period through a subcontract or related
organization or individual, such subcontract must contain a clause to the effect that until the
expiration of four (4) years after the furnishing of services under the subcontract, the related
organization will make available, upon request from AGENCY or from the Secretary of Health
and Human Services or the U.S. Comptroller General, or any of their duly authorized
representatives, the subcontract, and books, documents, and records of the related organization
that are necessary to verify the nature and extent of cost incurred under the subcontract.
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2. Responsibilities of AGENCY
2.01 Coordination. AGENCY will evaluate the resources of the patient and the family, and
will assume responsibility for the administration of services. A designated AGENCY employee
will notify the PROVIDER of any patients requiring Ambulance Service. Any information
obtained or reviewed in connection with the patient/family assessment or from interdisciplinary
group care conferences that affect the patient's care will be communicated to the PROVIDER by
an AGENCY employee.
2.02 Physician's Plan of Treatment. AGENCY will request from PROVIDER that Ambulance
Services be provided. Each request will be made in accordance with a plan established by the
patient's physician in cooperation with AGENCY staff. Ambulance Services provided by
PROVIDER are to be within the scope and limitations set forth in the physician's Plan of
Treatment and will not be altered in any way by Provider.
2.03 Orientation. AGENCY will provide any necessary orientation to PROVIDER personnel
who are providing Ambulance Services to AGENCY. Orientation shall include any applicable
and necessary AGENCY policies, objectives, and procedures.
2.04 Agency Professional Staff. Members of AGENCY professional staff will request services
supplied by PROVIDER, and will be available on a 24-hour basis for consultation and
supervision concerning the physician's Plan of Treatment.
2.05 Rules and Regulations. AGENCY will comply with it's policies and procedures, any
applicable federal Conditions of Participation, and any applicable state licensure laws and
regulations for the provision of health services.
2.06 AGENCY Insurance. AGENCY will maintain at its sole expense a valid policy of
insurance covering professional liability arising from the acts or omissions of AGENCY, its
agents, and its employees in the amount of $1,000,000. AGENCY will forward a copy of its
professional liability policy to PROVIDER, upon request, and will give prompt written notice of
any material change in AGENCY coverage.
2.07 Quality Assurance.
AGENCY shall develop, maintain and conduct an ongoing
comprehensive assessment to evaluate the quality and appropriateness of the Ambulance
Services provided. This will be completed by chart review, interview, and survey of patients
served. PROVIDER shall cooperate with the AGENCY conduction of Quality Assurance and
will facilitate the administration of such program in relation to purchased services.
2.08 Non-discrimination. It is AGENCY policy that it will not discriminate in employment or
provision of services with respect to age, race, color, religion, military status, gender preference,
sex, marital status, national origin, disability, or source of payment.
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3. Mutual Responsibilities
3.01 Liaison. AGENCY and PROVIDER will each designate a person who will be responsible
for coordinating the services provided under this Agreement.
3.02 Cooperation. AGENCY and PROVIDER will consult and cooperate with each other to
establish acceptable procedures for handling of requests for service, billing, and other necessary
operational matters.
3.03 Communication. AGENCY and PROVIDER recognize that prompt communications to
relay pertinent information related to patient history, drug or therapy treatment is necessary in
order for the purposes of this Agreement to be accomplished.
4. Compensation
4.01 Rates. PROVIDER will supply services under this Agreement at the following rates:
A.
All ambulance transports will be at the base rate of $_________ per transport plus a
$_____supply fee for Basic Life Support (BLS).
B. For all transports that are outside of the county that the patient is picked up from or taken to, a
charge of $______ per mile, for a Basic Life Support Ambulance, will be charged. This
will begin at the county line and will be for loaded patient miles only.
4.02 Rates Subject to Change. Contract rates will be subject to change upon thirty (30) days
advance written notice from PROVIDER to AGENCY.
4.03 Billing Schedule. AGENCY will be invoiced monthly for services that are billable to
AGENCY. AGENCY shall pay PROVIDER for services provided pursuant to this Agreement in
accordance with the following provisions:
A. All claims submitted will be by itemized billing in a form satisfactory to AGENCY
setting forth each patient transported per month. Claims submitted must be for
services rendered to eligible recipients. AGENCY will not be held financially
responsible for any transportation services that have not been requested by a duly
authorized AGENCY employee.
B. Payments by AGENCY shall be made in accordance with the schedule as outlined
in 4.01.
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C. All bills (requests for payment forms) shall be submitted to AGENCY for services
rendered. AGENCY shall pay PROVIDER within thirty (30) days following the
day on which properly completed invoices are received.
D. The PROVIDER shall look to AGENCY for payment of services for Hospice
Medicare/Medicaid patients, that were prior approved by AGENCY personnel
qualified to give such approval. For patients that are not covered by the
Medicare/Medicaid Benefit, for patients that did not seek prior approval, or for
non-covered Ambulance service, the PROVIDER will seek other 3rd party payer.
If no 3rd party payer is available the PROVIDER will bill the patient/family based
on the AGENCY contracted rate.
5. Miscellaneous Terms
5.01 Term and Termination. This Agreement will be in effect for one (1) year and will be
automatically renewed at the end of the each subsequent year unless terminated. Either party
may terminate this Agreement at any time, with or without cause, by providing at least thirty (30)
days advance written notice of the termination date to the other party. Such termination will
have no effect on the rights and obligations resulting from any transactions occurring prior to the
effective date of the termination.
5.02 Independent Contractor. PROVIDER and any subcontractor of PROVIDER are
independent contractors and shall be solely responsible for the safety and supervision of their
own employees. Although AGENCY will use the services of PROVIDER, as described in this
Agreement, AGENCY will have no control or right to control PROVIDER or its employees in
their performance of the services in this Agreement. PROVIDER will provide the services
described in this Agreement as an independent contractor, and nothing contained in this
Agreement will be construed to create a partnership, joint venture, agency, or employment
relationship between AGENCY and PROVIDER.
5.03 Assignment. This Agreement and the rights and obligations hereunder may not be
assigned to a third party, except to a parent, affiliate, or subsidiary, without the prior written
consent of the other party.
5.04 Indemnification. PROVIDER agrees to indemnify and hold harmless AGENCY, its
directors, officers, employees, and agents from and against any and all claims, actions, or
liabilities which may be asserted against them by third parties in connection with any negligent
performance of PROVIDER, its directors, officer, employees, or agents under this Agreement.
AGENCY agrees to indemnify and hold harmless PROVIDER, its directors, officers, employees,
and agents from and against any and all claims, actions, or liabilities which may be asserted
against them by third parties in connection with any negligent performance of AGENCY, its
directors, officers, employees, or agents under this Agreement.
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5.05 Notices. Any notice required under this Agreement will be in writing, will be personally
served or sent by certified mail, return receipt requested, postage prepaid, or by a recognized
overnight carrier which provides proof of receipt, and will be sent to the addresses below. Either
party may change the address to which notices are sent by sending written notice of such change
of address to the other party.
Sunny Day Hospice
12 Dirt Road
Winthrop, NC 00201
Call Us Medical Transport
Post Office Drawer S
Winthrop, NC 00201
5.06 Waiver of Breach. The waiver by either party of a breach or violation of any provision of
this Agreement will not be deemed a waiver of any subsequent breach of the same or a different
provision.
5.07 Severability. In the event that a provision of this Agreement is held to be invalid or
unenforceable, the balance of this Agreement will remain in full force and effect.
5.08 Headings. The headings of sections and subsections of this Agreement are for reference
only and will not affect in any way the meaning or interpretation of this Agreement.
5.09 Entire Contract. This Agreement constitutes the entire contract between AGENCY and
PROVIDER. Any agreements, promises, negotiations, or representations not expressly set forth
in this Agreement are of no force or effect. This Agreement may be executed in any number of
counterparts, each of which will be deemed to be in the original. No amendments to this
Agreement will be effective unless made in writing and signed by both parties. This Agreement
will be governed by and construed in accordance with the laws of the State of North Carolina.
5.10 Compliance with Laws. If any law or regulation is enacted, modified, or judicially
interpreted so that this Agreement would be found not to comply with such law or regulation, the
parties shall, upon notification of such change in the law or regulation, renegotiate the terms of
this Agreement so that it complies with such law, regulation or interpretation. In the event the
parties cannot renegotiate the terms of this Agreement, this Agreement will terminate
immediately upon either party's receipt of notice of termination from the other party.
AGENCY and PROVIDER have acknowledged their understanding of and agreement to the
mutual promises written above by executing this Agreement.
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SUNNY DAY HOSPICE
CALL-US MEDICAL TRANSPORT
BY: ____________________
Jill Nice
BY: _____________________
Joe Swift
TITLE: Chief Executive Officer
TITLE:Owner
DATE: _________________
DATE: ___________________
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