Sunny Day Hospice
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. 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.
B. PROVIDER shall supply Ambulance Service only if ordered by a duly authorized representative of AGENCY.
A. 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
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.
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.
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.
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.
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.
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 Call Us Medical Transport
12 Dirt Road Post Office Drawer S
Winthrop, NC 00201 Winthrop, NC 00201
7
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.