Memorandum of Agreement

Between

(Insert name of STD Clinic)

and

(Insert name of Health Care Agency to provide clinical services)

I. Parties of the Memorandum:
A. STD Clinic:
(Insert name of STD Clinic)
/ B. Health Care Agency:
(Insert name of Health Care Agency)
Project Manager or Designee:
Division/Department:
Address:
City, State, Zip Code:
Phone: ( )
Fax: ( )
Primary Contact Person’s E-mail: / Project Manager or Designee:
Division/Department:
Address:
City, State, Zip Code:
Phone: ( )
Fax: ( )
Primary Contact Person’s E-mail:

II.Purpose

The purpose of this memorandum of agreement (MOA) is to specify the agreements of the [Insert STD Clinic]and the [Insert Health Care Agency] as participants in acollaborative effort to improve health outcomes for patients attending the STD Clinic.The STD Clinic and the Health Care Agency (HCA) may be different agencies or different departments within the same agency. Per this agreement, the STD Clinic will provide STD testing, diagnosis and treatment. The HCA will agree to acceptpatientreferrals from the STD Clinic for medical services beyond the clinical scope of the STD Clinic. The STD Clinic will agree to accept referrals from the HCA for services within the clinical scope of the STD Clinic.

III.Terms of the Memorandum

This MOA shall be effectiveas of the date of ______. Amendments to,or termination of this memorandum will not be considered to be binding untilagreed to by both parties and signed in writing.

Either party may terminate this Agreement 30 days prior with written notification to the other party.

  1. Health Care Agency Responsibilities

AHealth Care Agency(HCA) is defined in this MOAas an acute care hospital, hospital satellite, clinic, clinic satellite, ambulatory surgical center, or community health center licensed by the Department of Public Health.

The participating HCA will:

  1. Assign a HCA Project Manager responsible for communicating with the designated STD Clinic Project Manager to oversee the collaboration between the HCA and STD Clinic.
  2. Within _____ months of contract initiation, in partnership with the STD Clinic, ensure systems are in place to receive referrals from STD Clinic and ensure patients receiveclinical services in a timely manner.
  3. Ensure that any and all patient data shared between agencies complies with federal privacy and security standards, is HIPAA compliant, and maintains the confidentiality of all patient information.
  4. The HCA will bill patients for these services according to their established policies and procedures.

V. STD Clinic Responsibilities

A STD Clinic is defined in this MOA as an agency funded to provide STD testing, diagnosis, and treatment.

The participating STD Clinic will:

  1. Assign a STD Clinic Project Manager responsible for communicating with the designated HCA Project Manager to oversee the collaboration between the STD Clinic and HCA.
  2. Within ______months of contract initiation, in partnership with the HCA, develop and coordinate an organized patientreferral and tracking system with the HCAto ensure patients receive clinical services in a timely manner.
  3. Ensurethat any and all patient data shared between agencies complies with federal privacy and security standards, is HIPAA compliant, and maintains the confidentiality of all patient information.
  4. The STD Clinic will bill patients for these services according to their established policies and procedures.

VII. Approval

THIS MEMORANDUM OF AGREEMENT,is executed by the persons signing below who warrant that they have the authority to execute the MOA.

STD Clinic
Project Manager or Designee:Type Name / Date
Health Care Agency
Project Manager or Designee:Type Name / Date

______
*STDTAC/Jan. 2014. Thank you to Roberta Moss, Moss Healthcare Consulting, for her contributions to this document.

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