Download Advanced Life Support Affiliation Agreement

This template is for ALS services wishing to enter into an agreement with a hospital OTHER than their
Affiliate Hospital for the purpose of obtaining medications. This document WILL NOT meet the
requirements for the ALS Affiliation Agreement. See separate template for that purpose.
As with any contract, all parties should seek the advice of their legal counsel prior to signing.
Advanced Life Support Medication Agreement
This Agreement made and entered into on the ___#___day of ___month_____, 20____,
between __Name of Service__; herein known as the Service and __Name of Hospital__;
herein known as the Hospital.
Preamble:
 The purpose of this Agreement is to allow for a procedure to obtain medication
replacement at a hospital of patient destination with which the service does not
have an ALS Affiliation Agreement;
 The Service maintains an ALS Affiliation Agreement with a hospital that is
licensed to provide medical control; and
 The Service is licensed to provide pre-hospital Advanced Life Support (ALS)
Emergency Medical Services (EMS), and its Emergency Medical Technicians
(EMTs) are certified at the appropriate ALS level of care to allow the Service to
deliver ALS at its level of licensure; and
 The Hospital is licensed or certified by the Department pursuant to MGL c 111,
§51 or other applicable law, with an emergency department.
THE PARTIES AGREE AS FOLLOWS:
The Hospital Agrees:
To provide medications (and linens) to the Service in order to replenish the
Service’s supply following a patient transport to the Hospital;
To maintain the Medication Exchange Form (See Appendix A), for ten (10) years;
To provide monthly invoices to the Service that indicates the ambulance patient
care report numbers and documents a one-for-one replacement;
Not to submit bills to third-party payers for medications replaced;
To charge the Service only for the amount equal to the cost incurred by the
Hospital for the replaced medication.
The Service Agrees:
To complete a Hospital provided Medication Exchange Form (See Appendix A),
including the patient care report number;
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To provide a copy of the ambulance patient care report for all patients transported
to the Hospital and for all patients for whom medication replacement was provided;
To submit bills to third-party payers for medications that the Service provides to the
patient which are replenished by the Hospital.
Both Parties Agree:
The amounts charged and paid hereunder have been determined by the Parties, after
good faith and arms-length negotiations, to be fair market compensation for the value of
services rendered and medications replenished. No amount paid hereunder is
intended to be, nor shall it be construed to be, an inducement or payment for referral
of patients by the Service to the Hospital or by the Hospital to the Service. In addition,
the amounts charged hereunder do not include any discount, rebate, kickback or other
reduction in charge, and are not intended to be, nor shall they be construed to be, an
inducement or payment for referral of patients by the Service to the Hospital or by the
Hospital to the Service.
To adhere to the policies and procedures for medication replacement and
reimbursement as specified within this agreement.
To be responsive to the other party‘s concerns and needs, acting in a timely manner
to resolve all problems and meet reasonable needs.
Term:
This Agreement shall expire no later than 24 months from the date this Agreement was
entered into, as reflected on the first page herein, or on ___#___day of ___month_____,
20____.
Early Termination:
This Agreement may be terminated prior to the expiration date agreed to herein by
either the Hospital or the Service, with __XX time period_ prior notice, with/without
cause.
___________________________
_______________________
Hospital Chief Executive Officer Signature
(Please print legibly)
___________
Date
___________________________
Hospital Pharmacist
(Please print legibly)
_______________________
Signature
____________
Date
___________________________
Service Chief Executive Officer
(Please print legibly)
_______________________
Signature
___________
Date
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