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Home My WebLink About20130930RESOLUTION RE: APPROVE APPLICATION FOR TIER I EMERGENCY MEDICAL SERVICES LICENSE AND AUTHORIZE CHAIR TO SIGN - POUDRE VALLEY HOSPITAL WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, pursuant to Section 7-2-100 of the Weld County Code, the Weld County Department of Public Health and Environment and the Weld County Emergency Medical/Trauma Service Council have reviewed the application of the Poudre Valley Hospital for a Tier I Emergency Medical Services License and recommend approval, and WHEREAS, after review, the Board deems it advisable to approve said Application for a Tier I Emergency Medical Services License, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the application of the Poudre Valley Hospital for a Tier I Emergency Medical Services License be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that approval of the License is conditional upon execution of appropriate Mutual Aid Agreements. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said license. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 15th day of April, A.D., 2013. BOARD OF COUNTY COMMISSIONERS WELD C COLORADO Weld County Clerk to the Board BY: AP Deputy Cle ; to t Boar D AS `! • RM: 0 lb -UL11 Attorney Date of signature APR 2 q 2013 William F. Gar Freeman LEL- rbara Kirkmey Chair r CO-(IL (rte`'` r, ' SGw,u,,A, coo (AyE) (AYE) (NAY) 2013-0930 HL0042 Memorandum TO: Board of County Commissioners FROM: Dr. Mark Wallace -` G DATE: April 10, 2013 SUBJECT: Poudre Valley Hospital EMS 2013 Application for EMS Services Poudre Valley Hospital EMS, located at 2315 E Harmony Road Suite 200, Fort Collins, Colorado, has applied for an Ambulance Service license pursuant to Chapter 7, of the Weld County Code (WCC). Chapter 7 pertains to Emergency Medical Services. The Department has reviewed this application and has deemed the ambulance service to have met all applicable licensure application requirements found in Chapter 7. As such, I am recommending for licensure. The Weld County Emergency Medical/Trauma Service (EM/TS) Council reviewed this application on March 20, 2013. The Council recommended (see attached) that Poudre Valley Hospital receive a Tier I license. 2013-0930 A J W U Z cc Et H Z ro a U m� A Od. W_0 "' o v o I Z Z Cr) Z J z z o I N Q c Q D U M A W� Q Y. >- m w 0 H OO ? v 2 la J E a A d "' d o f0 J w m ik z o W z O 5 p w ti s_ a0~ J J H Z m a E Z J 0 r^ w a Q �l R- • ce N Ad oX �z m l— et O I- I - 2 A a O > cc w U a Z ° m� o ° O uII: w = 0- 444444444444444 A N ZA S. in O A b.0 Z U o ;,LU W �; z \ 0 A ~ v J U \ Z Z N J U > 0 N A W Oa Ew 0 z cc CV m Q; `n W U - w°la U 0 v Q Z Q Q CEL O U O Q Q w ai A u ° O Z < E \ Luc � J-1 J_o a m U Wm DQ \ D in C a w 10. w Z \ U U N vl J \ N r \ 1\\ 11 1 1 1\ 1\\\ Ill 1 ISSIONERS Tier I: Licensure authorizing for Primary, as defined in Section 7-1-30 of the Weld County Code. WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWF36R58EB25618 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWF36R68ED13130 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment II 13 Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWF36R38EB25617 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. rJ J Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWF36R78EB25619 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment k1 Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 3D6WF4ELXBG574309 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. (11 Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: IFDWF3GR3AEB38114 ^ MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle(Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWF36RXSED13129 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle(Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDXE45FX3HA31598 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle(Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: WDAPF3CCXC9504702 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDXE45F43HB28716 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment c) Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWE30F5XHA26893 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDAF4HR7AEA90177 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment i ) GI Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDSS34P96HB20607 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment L4�(3 Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWF36R49EA60827 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1GKFK16K5N.I728454 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment Date Must Be Posted In Vehicle WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle(Ambulance) This Certifies: POUDRE VALLEY HOSPITAL EMS Motor Number: 1FDWX37R38ED13131 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Director, Weld County Department of Public Health and Environment tli'iil3 Date Must Be Posted In Vehicle DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 N. 17h Avenue Greeley, CO 80631 Web: http://www.co.weld.cc.usiDppartments/HealthEnvIronmentfindax.html Health Administration Public Heath & Clinical Ernironmentat Health CommunIcation, Emergency Preparedness Vital Records Services Services Education & Planning & Response Tele:970304.B410 Tole: 970.304.6420 Tele: 970.334.6415 Tee: 970.304.6470 Tete:970304.6420 Fax: 970.304.8412 Fax: 970.304.8418 Fax: 970.304.8411 Fax. 970.304&152 Fax: 970.304.6489 Our .fai on' Together w,th the mmte-rd+es we serve, we ere working to make Weld County the healthiest place ta Pura, learn, worn and play. March 15, 2013 Barry Schaefer Chair Weld County Emergency Medical/Trauma Service Council Via email: bschaefer@plattevalleyfire.org SUBJECT: Poudre Valley Healthcare EMS Application 2013 NOTICE OF EMERGENCY MEDICAL SERVICES LICENSE APPLICATION TO THE WELD COUNTY EMERGENCY MEDICAL/TRAUMA SERVICE COUNCII, The Weld County Department of Public Health and Environment has received and is in process of reviewing an Emergency Medical Service License Application from Poudre Valley Healthcare. Attached to this document are the Ambulance Service license Application, and Maps of its proposed Service Area. On behalf of the Board of County Commissioners, the Department is requesting the Emergency MedicaVTrauma Service Council review the attached documents in accordance with Section 7-2-100.B.5. of the Weld County Code (enumerated below). The Department will forward your recommendation to the Commissioners. Below are the most applicable portions of the code: Weld County Code, 7-2-100.B.5 The recommendation of the Weld County Emergency medicaUTrauma Service (EM/TS) Council as to whether or not the issuance of the license will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. The EM/IS Council shall also provide: a. Recommended Service Area. b. Recommended Tier of License. Weld County Code, 7-2-10. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners, except as provided in Section 7-2-80 below. The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: Tier I: Licensure authorizing for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier II: Licensurc authorizing for transports of patient(s) to and from licensed medical facilities. This licensure does not provide for Primary Care, as defined hi Section 7-I -30 of this Chapter. Tier III: Licensure authorizing for Standby Service, as defined in Section 7-1-30 of this Chapter. A. The Board of County Commissioners reserves the right to amend these rules and regulations and any other individual conditions of licensing as applied to any particular license, as needed in keeping with its legislative function and in order to implement the policy of the State of Colorado that the regulation and control of ambulance licenses is in the exclusive purview of the boards of county commissioners. Persons or firms seeking application and approval of any ambulance license under this Chapter acknowledge that Weld County may contract with specific ambulance service provider(s) which will serve the emergency ambulance need of Weld County and participating municipalities. Please forward the Councils recommendation to the Department. Please do not hesitate to call me should you have any questions. Sincerely, Kevin Antuna Environmental Health Specialist Environmental Health Services Recommended Level of Service: Recommended Service Area: Tier 2 Tier 3 Poudre Valley Healthcare (UCH) has current contracts with the Johnstown Fire Protection District, Milliken Fire Protection District, and the Windsor -Severance Fire Protection District for service. The also provide service to areas in western Weld County that the Poudre Fire Authority responds to. They also have a base of operations at 6906 West 10th Street in Greeley. Will the service contribute to an efficient, effective, and coordinated emergency medical response to residents of the County? Council's recommendation: Council reviewed the need for this application based on the area of Weld County that Poudre Fire Authority responds to, and also the need to backfill the current contracts with the three Fire Districts. They also have future growth in their immediate plan in the Timnath area. Council unanimously agreed to support this application of a Tier 1 license. Other EMTS Council recommendations or comments: None Recommendation By' Recommendation Date: 51.21/3 ® Poudre Valley Hospital UNIVERSITY OF COLORADO HEALTH Dr. Mark Wallace. MD Weld County Department of Public Ilealtlt and I]Iv ironment 1555 North 17°i Ave. Greeley. CO 80631 Dr. Wallace. I have attached a completed application and all required County. Colorado. I believe you will find that our stall. location all comply with the requirements outlined for a County Code. • EMERGENCY MEDICAL SERVICES 372013 documentation for a Tier I ambulance license in Weld Vehicles. records. insurance, protocols. equipment and Vier I scrVice in the recently revised Chapter 7 of the Weld Areas of Weld County n here we have contracts to provide primary care include the Windsor Severance Fire Rescue District. Milliken Fire Protection District and Johnstown Fire Protection District. An integral piece ofcovertee fur these areas will be the ability to utilize our ambulance stationed at the Greeley Emergency and Surgical Center at 6906 101h St. in Greeley. this trait is in a position to etticienth hacklill those tire protection districts when their resources become depleted and to coordinate their response with other responding units on those calls vv here there is a need for multiple ambulances. Attached vim will find a request to coyer that portion of the Poudre Fire Protection District that extends into Weld Counts along I lighwav Id. Historically we were frequent Iv requested to respond to this area by Weld County due to distance from their resources and the proximit\ of our eastside station. Since this area falls between districts we are covering. the PFA has requested us to respond on medicals there. Our station at 6906 Wm St. in Greeley has been in use since 1126 12. that portion of Milliken Station I that we will operate out of is ready now, and space is currently hieing remodeled I'hr us at Windsor Severance Station I the occupation on 515. 13. Space allocated for us at Johnstown Station 1 will be used for vehicle and equipment storage for now. with the possibility of stationing crews there as call volume increases. I Think it is apparent that by partnering w ill) carious lire protection districts. strategicalh positioning our resources and having crews dedicated to covering these areas. PVII [MS ya ill increase the effectiveness of emergency medical responses in Western Weld County. thank you for your consideration in this matter. and feel tree to contact me with any questions. Sincctyb). Steven Main Manager. Poudre Valley Hospital EMS 3509 S. Mason r Fort Collins. Colorado 80525 Cell: (970)391-9827 [mail: sett i1pvhs.org Page 2 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 171h Avenue Greeley, CO 80631 Web vwvvv_weld heaith.era Health Administration Public Health & Clinical Vital Records Services Tele. 970.3046410 Tele970.3046420 Fax: 970.304 6412 Fax 970 304 6416 Environmental Health Services Tele' 970 304 6415 Fax 970 304 6411 Communication, Education & Planning Tele 970 304 6470 Fax: 970 304 6452 Public Health Emergency Preparedness & Response Tele' 970.304.6420 Fax 970.3046469 Our vision Together with the communities we servewe are working to make Weld County the healthiest place to Iwelearn, work and play. AMBULANCE SERVICE LICENSE APPLICATION Name of Ambulance Service: Pa/tire L%& ltc3 9 s p1 3' Owner: Date of application: 3- 8'- 13 Name: i avdrG `%Q tL �'�'/�l Late- rk�` Address: 1, _25 2-1 c r _0 Rd 5ti _2-L)D Phone Number: 9'10 -_„2 -_3,2. -_42s - Operations Manager: ,,( Name: SS/Il - A.,_l3✓(4L4_0' Address: �S2Lri S fl1a/saki Svi'-J Phone Number: _71:0 Email: Email: _9 _ Pursuant to Section 7-2-150 of Weld County Code Ordinance, any change of ownership requires a new application for ambulance service license. (For Office Use Only) Date Received: 1 Documents Checked: Remarks: Approved Recommended (YIN): Date Referred to B.O.C.C.: / / Licensing Agent Phone Number: �� V'%S - kJu0 Please read carefully : Page 3 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a I 0% ownership interest (if applicable): Fetid!, aile __ Tb ar&, is _ gev14rJ U t f C Waco — N -k Crick) f What area of Weld County wit G`TGG /t`''SC i b Iv\, I tt f;- - r .t. _wider 'kite vutb«fia I be served by this company? Please attach a map indicating the service area. e'•.) . � I- i f r krS c TTH- 5 r . i 1. r L, Urk C A rt� _rIC? j I low many ambulances do you operate? 1; Location and description of the place(s) horn which this ambulance service will operate. If there are more than two locations, attach a separate sheet with the above information. Location 81: Street Number: City: Location 112: Street Number: City: Medical Director: Name: S to I -4 —ac kt State: Phone: State: Phone: OctvIL _ tc(Rstcci y D Mailing Address: /c -Ay -S 2i,,yt4 Aug c'?C.5 /� � .( // Li"L/ Ai j, C.L. 7-2-170 Annual renewal. All licenses and permits shall be renewed annually, shall expire on December 3 I of the year issued, and shall not be renewed until the application has been approved by the Department. All applications for renewal of licenses and permits shall he made not later than sixty (60) days prior to the date of expiration. The Department shall notify, by certified mail, return receipt requested, each licensee of the renewal requirements of this section within ninety (90) days prior to the date of expiration (Weld County Code Ordinance 2007-8) 7-2-18(1 Change of Medical Director An ambulance service mist report any change of medical director, including name, address and telephone number, to the Director within fifteen (15) calendar days of such change. (Weld County Code Ordinance 2007-8) Page 5 I HEREBY CERTIFY THAT I AM AUTI IORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN TI IIS APPLICATION IS TRUE l'O 'HIE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION. IN ADDITION, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WEI.D COUNTY CODE CHAPTER 7, INCLUDING, BUT NOT LIMITED TO, SECTION 7-S-10, WHICI I ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTIIFR EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMMIINAI. PROSECUTION. S_o attire of Applicant S fay Lam, ide Date 34/ .,., SUBSCRIIVJ.: AND AFFIRMED BEFORE MET , - DAY I v\AN- 1C 20 15 , IJ>H I'i IF COUNTY OF LYl`i.- - . STAT PU0 pr N 0" o� "�mlaslonE EYE,t44,�� wo.(AR)- ? � ,, — - CS -- tore of Notary UNIVERSITY of COLORADO HEALTH Weld County, Dept of Public Health and Environment 1555 North 17th Avenue Greeley, CO 80631 March 8, 2013 To Whom It May Concern: Pursuant to the requirements of Section 7-3-50 and 7-2-90 of the Weld County Ordinance, Poudre Valley Hospital Ambulance Service (owned and operated by Poudre Valley Hospital) attests to the following: • No employees of Poudre Valley Hospital Ambulance Service have had any criminal complaints or convictions, including Class I or II traffic violations within the past twelve (12) months. Each employee's criminal background check and motor vehicle records have occurred within 45 days of submittal of this application. • Poudre Valley Hospital Ambulance Service has not had any judgments entered against us within the past twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. Sincerely, Brenda L Harstad, RN CHC Ethics/Compliance & Privacy Officer University of Colorado Health Page 6 AMBULANCE VEHICLE PERMIT LIST Name of Ambulance Service: Application Year: ;tO/ j [ Vehicle # elk lit ll / /1 T !/rr%_ Year: Make: Model: 4 Wheel Drive (Y/N): _ _Manufacturers Identification Number (V.I.N.): Colorado State License Number (Registration No.): Motor Vehicle Chassis Number: Registered with the State of Colorado as an emergency vehicle (Y/N): Date Ambulance placed in service: Normal Location of Ambulance: Vehicle # Year: Make: Model: 4 Wheel Drive (Y/N): Manufacturers Identification Number (V.I.N.): Colorado State IAcense Number (Registration No.): Motor Vehicle Chassis Number: Registered with the State ofColorado as an emergency vehicle (Y/N): _ Date Ambulance placed in service: / Normal Location of Ambulance: Vehicle # Year: Make: Model: Identification Number (V.I.N.): 4 Wheel Drive ()/N): Manufacturers Colorado State License Number (Registration No.): Motor Vehicle Chassis Number: Registered with the Slate ofColorado as an emergency vehicle (Y/N): Date Ambulance placed in service: Normal Location of Ambulance: 1 r Mode ViN License :`license Name Titled inservi Emergtcy�; Phis # 'Expiration Under , _ Title #: Services are GMC 1GKFK16K5NJ728454 104UGR 5/31/2013 Health IncI I. 2011 06N679659 2663A N 00 NNNNN 5 fCO 00 W CDN Q N 0 06N662900 I 2675A 06N694303 I 2677A a0 CO NNNN N 0 a 0 0a) CO r 0) O co 0) 0 f0 N 0 CO v0) O 0 0 0 m CO 0 0 N- 0 m CO U, 0 06N662904 06N662907 m M r CO Z 0 0 0 M CO Z CO O 0 0) Z 0 0 0 W CID Z 0 0 O N CO 0 N 0) 0) OD O N CO 0 N CO O N CO 0 N CO O N CO O N 0) 0 N 0 O N 0 O N r O NN N O Poudre Valley Healthcare In c Poudre Valley Health Care Inc Poudre Valley Health Care I nc Poudre Valley Health Ca I re nc Poudre Valley Health Care I , nc Poudre Valley Health Care I nc Poudre Valley Health C I are nc Poudre Valley Health Care Inc Poudre Valley Health Care Inc Poudre Valley Health Care Inc Poudre Valley Health Core In c Poudre Valley Health Care, Inc Poudre Valley Health Care Inn Poudre Valley Hn,lthrnro Inr 1 3 ) CO O NNNNN CO N N 0 CO N CO 0 CO iii CO 0 CO N CO 0 CO in 2008 Ford 1FDWF36R78EB25619 101 UGR 5/31/2013 2008 Ford 1FDWF36R68ED 13130 093UGR 5/31/2013 2008 Ford 1FDWF36RX8ED13129 094UGR 5/31/2013 Ford 1FDWX37R38ED13131 095UGR 5/31/2013 2009 Ford 1FDWF36R49EA60827 102UGR 5/31/2013 1220 F-450 XLT 4X4 FrazerType 1 14' Gen Mod 2010 Ford 1FDAF4HR7AEA90177 089UGR 5/31/2013 Ford 1FDWF3GR3AEB38114 096UGR 5/31/2013 2011 DODGE 3D6WF4ELXBG574309 088UGR 5/31/2013 2012 Mercedes WDAPF3CCXC950489P 116UGR 5/31/2013 2013 Poudre Valley Hospital EMS FLEET 1 FDSS34P96HB20607 087UGR 1FDXE45FX3HA31598 092UGR 1 FDWE30F5XHA26893 098UGR 1FDWF36R38EB25617 099UGR 1 FDWF36R58EB25618 1000GR r.• D LL D LL U lL 0 u_ V lL 3 R type of ri De # " Aiame Pf PVH EMS Fi EET Xea TEMS , TEMS/AMB 1220 GMC Suburban 4x4 1992 f00) 00 N COM 0 N 0) 0) N 0 NN N 0 O N O Wheeled Coach Crusader Wheeled Coach E-450 Amb Wheeled Coach E-450 Amb F-350 XLT Frazer Type I 12" Gen Mod F-350 XLT Frazer Type I 12" Gen Mod F-350 XLT Frazer Type 112" Gen Mod F-350 XLT Frazer Type 112" Gen Mod F-350 XLT Frazer Type 112" Gen Mod DODGE RAM 350 typel 12' Gen Mod Mercedes Type III Amb (AEV) MED1 AMBULANCE 1220 MED2 AMBULANCE 1220 MED4 AMBULANCE 1220 MED9 I AMBULANCE I 1220 Med 12 I AMBULANCE I 1220 Y'' Med 14 AMBULANCE I 1220 NMed 15 AMBULANCE 1220 n u.r. rp'. F Med 16 AMBULANCE 1220 O NNNNNNN N O N O O AMBULANCE AMBULANCE AMBULANCE AMBULANCE AMBULANCE AMBULANCE AMBULANCE Med 17 Med 18 Med 19 Med 20 N C) N i Med22 CO -C) N 2 X JR' at COLORADO INSURA14CE IDENTIFICATION CARD CO!APAlIY NV.VBER COl1PAlry 16535 Zurich American Insurance Co COMYERCInL O PERSONAL POLICY NUMBER BAP947490301 EFFECTIVE DATE EXP;RATION DATE 06/01/12 05/01/13 YEAR 11XEl!CDEL 1992 Gh1C Suburban VEHRLEIDEIR6ICAT2454IBER 1GKFK16K5NJ728454 Brow n & IBrown of Colorado, Inc Tyler 13, Allen 4532 Boardwalk Dr, Suite 200 Port Collins, CO 80523 INSURED r Poudro Valley Health Care Inc. 2315 E. Harmony Rd., Suite 200 Fort Collins, CO 80528.8620 BI and PD Coverage Provided SEE IIAPCRTANr1:oi10E ON REVERSE SIDE THIS CARD MUST BE KEPT IN TI lE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accldenls to your Agenl/Company as soon as possible. Obtain the following Information: 1, Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORD 10 CO (1007103) O ACORD CORPORATION 10r 2031. All HOE, rc tnep. PVHEA.1 JD YEAR AtAHEIMCDEl 2003 Ford (MED1) Brown &ABrown ISSUING Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 INSURED r Poudro Valley Health Care Inc 2316 E. Harmony Rd, Suite 200 Fort Collins, Co 80528-8620 L COLORADO INSURANCE IDENTIFICATION CARD COAIPAjY MIUMPER COMPAPr r� COMMRCIAL 16635 Zurich American Insurance Co. (PEg50NAl PIXICYtlUA'e ER EFFECTIVE OATE EXPIRATION DATE BAP047490301 05/01/12 05/01/13 VEHICLE IDENTIFICATION NUMBER 1FDXE45F43HB28716 81 and PD Coverage Provided SEE ItfPORTA I NOTICE On REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain The following Information: 1. Name and address of each driver, passenger and witness. 2, Name of Insurance Company and policy number for each vehicle Involved. ACORO $0 Co (2007/03) OAC0R0 CORPORATION 2005.200T. All RgAb !n erad, PVHEA.1 JD 2006 Ford (EMS2) • Brown & lBr wn ISSUING Inc Tyler B, Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 ersvaEO r Poudre Valley Health Caro Inc 2315 E. Harmony Rd„ Suite 200 Fort Collins, CO 80628.8620 COLORADO INSURANCE IDENTIFICATION CARD C0VEANYNUOER COMPANY 16535 Zurich American Insurance ERC!Rl � PERSO:7At e CO POIICY MAWR BAP947490301 EFFECTIVE DATE EXPIRATION DATE 05/01/12 05/01/13 YEAR ,MAKERAODEL YEIECIE IDE/17IFICATR)N NUM bER 1FOSS34P96HB20607 E31 and Pb Coverage Provided SEE 14IPO.RrATT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report al/ accidents to your Agent/Company as soon as possible. Obtain the following Informailon: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle involved. ACORD !0 CO 11007/03) OACCAD CORPORATION 20062107. All rights restric Q. • / 11 PVHEA-1 3D COLORADO INSURANCE IDENTIFICATION CARD COMPANY NUMBER COMPANY IX COMMERCIAL 16535 Zurich American Insurance Co. POLCY RULIB ER BAP947490301 YEAR MARE'M0CEL 2003 Ford E450(MED AO EIIC=O!.IPANY ISSUING CARD Brown & Brown of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Sulfa 200 Fort Collins, CO 80625 INSURED r Poudro Valley Health Cara Inc 2315 E. Harmony Rd., Sidle 200 Fort Collins, CO 80528.8620 L PERSONAE. EFFECTIVE DATE EAPIRA7ION DATE 06/01/12 05/01/13 VEt11CL E IOEUTIFICATIO$ NUMBER 1FOXE45FX3HA31598 SI and PD Coverage Provided SEE IMPORTANT NOTICE ON REVERSE SICE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agen&Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehlc!e involved. ACORD 50 CO 12007/91) O ACORO CORPORA1ION 20:.1097. MI rfeh Is resorted, PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD COUPAM' HOVER COMPANY I X ) COMMERCIAL I j PER$QUAL 16635 Zurich American Insurance Co, POtiCY tJU.41aER EFPECTNE DATE EXPIRATION DATE YEAR PAREMODEL 1999 Ford ACED Wheolcoa AccBrown & Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Sullo 200 Fort Collins, CO 80525 InSURED r Poudro Valley Health Caro Inc 2315 E, Harmony Rd., Suite 200 Fort Cal/Ins, CO 80528.8620 0AP947490301 05/01112 05/01/13 PEI4TCI E IDEInIFICATION NU119ER 1FDWE30F5XHA26893 BI and PD Coverage Provided SEE IMPORTATR NOTICE ON REVERSE SIDE THIS CARD MUST pE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Cornpany as soon as possible, Obtain the following Informalion: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORD 10 CO (20011J) OACOAD CORPORATION 2016 1J02. All ',gilts as erne. I 41 PVIIEA.1 JD COLORADO INSURANCE IDENTIFICATION CARD CO4PAIJY ?WIDER COMPANY I n1 16535 CQVPE,Rf.IAI I IPERSONAL Zurich American Insurance Co, POLICY NURSER EFFECTIVE DATE EXPIRATION DATE BAP947490301 05/01/12 05/01/13 YEAR MARM,IODEL VEHICLE IDENTIFICATION WAVER 2008 Ford F350 1FOWF36R38EB25617 Brown &A Brown of Colorado, Inc Tyler B, Allen 4532 Boardwalk Or, Suite 200 Fort Collins, CO 80525 INSURED C Poudre Valley Health Caro Inc 2315 E. Harmony Rd., Salto 200 Fort Collins, CO 80528.6620 BI and PD Coverage Provided SEE IMPORTANTNOTICE ON REVERSE SIDE THIS CARD MUST RE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT; Report all accidents to your Agent/Company as soon as possible. Obtain The following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORD IS CO11001!011 OAC0RDC0RP0,RAD0N 2°DI2007. All1 hb nnrvIe. yvi I PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD PVHEA•1 JD MOM A NUMBER COMPANY 16535 POLICY BIMBE.R BAPs474s0301 YEAR MARE/M0O3L 2008 Ford F350 Brown &4�Broitn ISSUING Inc Tyler D. Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80526 vs VRED r Poudro Valley Health Caro Inc 2315 E. Harmony Rd., Suite 200 Fort Collins, CO 80528.8620 Zurich American insurance Co.ERCIAL �PERSOSUL EFFECTIVE COE EXPIRATIOU DATE 05/01/12 05/0i/13 V II;CLE IDEA76ICATION NUMBER IFDIA/E36R58E$25618 BI and PD Coverage Provided see WORMY !TWICE OOr RE cRSEE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenVCompany as soon as possible. Oblaln the following Information: 1. Name and address of each driver, passenger and tidiness. 2. Name of Insurance Company and policy number for each vehicle Involved AcoRO So CO 0007/0)2 ACCNO OOAPORA7IDR 2006.2021. Ail tlehb rc) ems, COLORADO INSURANCE IDENTIFICA TIDN CARD PVIIEA•1 JD YEAR MAKETIODET 2008 Ford F360 Brown $ Drown of Colorado, Inc Tyler B. Allan 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 INSURED r Poudre Valley Health Care Inc 2315 E. Harmony Rd., Suite 200 E Fort Collins, CO 80628.8620 COMPANYNUMBER COMPANY X 16535 CONIMZurich American Insurance eao.A Co �P�aso;:AL FOUST NUMBER BAP047490301 EFFECTIVE DATE EO51O1IONDOE 05/01/12 05/01/13 VEIICLE IDENTIFICATION 11051058 1FDWF36R78EB2561e BI and PD Coverage Provided SEE IMPORTANT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT; Report all accidents to your Agenl/Company as socn as possible. Obtain the following Information: 1. Name and address of each driver, passenger and tininess. 2. Name o/ Insurance Company and policy number for each vehicle Involved. ACORD SD Co 120076071 OACORO CORPORATION 2006.2007. AU d2AU I. sINed. X7/5 COLORADO RISURANCti IDENTIFICATION CARD COMPANY MBER COMPANY 16535 MIUZurich American Insurance Co.ER�pL ` PERSONAL POLICY NUMBER EFFECTIVE OATS EXPIRATION BAP94749030} 05/01/12 05/01OA7E 05/01/13 YEAR MAYEAIODEl VEHICLE IDEV(NICATIONLIUtwER 2008 Ford F3502wd 1FDWF36R68ED13130 Brown & BroISSUING ne of Colorado, Inc Tyler a Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 00525 'WORE() r Poudre Valley Health Care Inc 2315 E, Harmony Rd., Stifle 200 Fort Collins, CO 80528.8620 E RI and PD Coverage Provided SEE IMPORT/1a NOTICE ON REVERSE SIOE /7i/ 6. THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenUCcmpany as soon as possible. Obtain the }olloviing Information: 1. Name and address of each driver, passenger and witness, 2. Name of Insurance Company and policy number fcr each vehicle Involved. ACORn SO CO (1Pi7101) OAC0RD CORPORATION l0061C07, A'! ,lg,1,y PVHEA•1 JD CCNPRIYuUVBER 16535 POLICY /I@ER PAP947490301 YEAR A!AI(&).!0Da 2008 Ford F350 2wd AGBrown & Brown of Colorado Tyler E3. Allen Inc 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80625 INSURED r COLORADO INSURANCE IDENTIFICATION CARD CO'PAJW X COIIRERCtR Zurich American Insurance Co. Rourke Valley Ilealih Care Inc 2315 B, Harmony Rd., Sulfa 200 t. Fort Collins, CO 80628.8620 L-) PERSONAL EFFECTIVE CATE EXPIRATION CATE 05/01/12 05/01/13 VEHICLE IDE:rtIFICAT10:rhlllde E.R 1FDWF36RX8ED13129 81 and PD Coverage Provided SEE IMPORT/31g r(O110E C; I REVERSE SIDE THIS CARD MUST 8E KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain The following Informallon: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORO !J CO 1J2r1J2) DACORO FDRPORA710;l 2JGl4CJr, Alltl9 Mb serve 0. I Al? PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD CO'APANY NU!t8ER C0MPMEY (yj 16535 I n I COMMERCIAL r I PER50llRl Zurich American Insurance Co. PCYI0Y DUMPER BAP94740030f E05/011E DATE E05/01IDN DATE 05/01112 05/01/13 YEAR 1.'AR6M00Et VEIuC(E lDEfmFlCATVON NUMEER 2008 Ford SupCab 4 Brown & 1Drowll n of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Sulfa 200 Fort Collins, CO 80525 IfSURED r Poncho Valley Health Care Inc 2315 E, Harmony Rd., Suite 200 LFort Collins, CO 80528.8620 1FDWX37R38ED13131 SI and PD Coverago Provided SEE IMPORTANT NOTICE Oil REVERSE SIDS THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenUCompany as soon as possible, Obtain the following Information: 1. Name and address of each driver, passenger and witness, 2. Name of Insurance Company and policy number (or each vehicle Involved. ACORO EP CO (1C0La11 OA00R0 C0RP0RATI0D taar.taa), AU sight; ru rrvr0. PVHEA-1 JD CONPA)rr NEMOER 16535 PONCINIUMEER DAP947490301 YEAR I.'.AREA/ODEL 2009 Ford F350 AGENBrown &Brown of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Salto 200 Fort Collins, CO 80525 INSURED r Poudre Valley Health Care Inc 2315 if. Harmony Rd., Suite 200 Fort Collins, CO 80528.8620 COLORADO INSURANCE IDENTIFICATION CARD COMPAl(y COMMERCIAL Zurich American Insurance Co,➢ERseuaL Ix EFFECTIVE DATE EXPIRATION CATE 05/01/12 05/01/13 TENICI E IDEImfCAT10N NUMBER 1FDWF36R49EA60827 SI and PD Coverage Provided 5 EE IMPORTANT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenVCompany as soon as possible, Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number fcr each vehicle Involved, ACORO TO CO n007I01) OACORD CORPORATION IOCI:COT. All ,fp as Tanned. PVHEA•1 JD YEAR MAEY.ODR 2010 Ford F.45 Brow n &t Brown of SIADDColorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 INSURED r Pondro Valley Health Caro Inc 2315 E. Harmony Rd., Salto 200 Fort Collins, CO 80528.8620 COLORADO INSURANCE IDENTIFICATION CARD COMPANY IIUPBER COMPAUY f X 16535 Zurich American Insurance Co.EtcAL PERSONAL Pat ICY ❑UA!DSR BAP947499301 EFFECTIVE CATE EXPIRATIOD DATE 06/01/12 05/01/13 VEHICLE IDEDVICATION HU.IIDER 1FOAF4HR7AEA90177 BI and PD Coverage Provided SEE IMPORTANT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenUCompany as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORO 00 CO ROOM) — O ACORO CORPORATION IGEA2007, All ABU4 moved. PVHEA•1 JD YEAR I'ALMCDEL 2010 Ford Frasier Brown & Brown of Colorado, Inc Tyler B, Allen 4532 Boardwalk Or, Sulfa 200 Fort Collins, CO 80525 INSURED Poudro Valley Health Caro Inc 2315 E, Harmony Rd., Buffo 200 C- Fort Collins, CO 80528-0620 COLORADO INSURANCE IDENTIFICATION CARD COMPANY7/UY8ER COMPANY 16535 1 } Zurich American Insurance COMMERCIAL e CoCo�PERSONAL XI POLICY NUMBER BAP947490301 E5ECIn'E CATE EXP/RATION DATE 05 /01112 05/01/13 VEHICLE IDEUrIRCATIOU NUMBER 1EDWF3GR3AEB38114 BI and PD Coverage Provided SEE IMPORTANT NOTICE OH REVERSE EIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible, Obtain the following Information: 1. Name and address of each driver, passenger and witness, 2. Name of Insurance Company and policy number for each Vehicle Involver(. ACORO $0 CO (2007/01) OAC0R0 OOREORATIO!f 20064007. All light, rcssn.J, Al L/ PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD COMPANY NUMBER COMPANY16535 X COMMERCIAL Zurich American Insurance Co. PCtICY NUMBER BAP947.I90301 YEAR MAKE/MODEL 2011 Dodge Ram350 ACElCYCO PANY ISSUWO CARO Brown & Brown of Coto rado, Inc Tyler B. Alton 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 INSURED Poudre Valley Health Caro Inc 2315 E. Harmony Rd„ Sulto 200 Fort Collins, CO 805288620 EFF EC tare DATE 05/01/12 1 PER50ITAt EXPIRATIO22 PATE 05/01/13 VEHICLE IOENTIFICAT1O22 NUMBER 3D6VJF4ELXBG574309 BI and PD Coverage Provided SEE IMPORTANT NOTICE O.•2 REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. Aeon, JO CO 22COR09l OACORO C0R➢ORATIOR 20062092. All rfgpb res nvd. )7)1 2 z PVHEA•1 JD BAP947490301 06/01/12 06/01/13 COLORADO INSURANCE IDENTIFICATION CARD X) YEAR MAHE!.ICO.EL 2012 Mercedes Ambulant AGENCY/COMPANY rown &A Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Sulto 200 Fort Collins, CO 80526 IrisuaEn r Poudro Valley Health Care Inc 2316 E. Harmony Rd., Suite 200 Fort Collins, CO 80628.8620 L VEHICLE IDENTIFICAT10NN@d,ER WD`PF3CC9C9604702 BI and POCovorago Provided SEE IEIPCRTMT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND COMPANY NUMBER COMPANY COMMERCIAL 11 PERSONAL 16635 Zurich Amorican Insurance Co. PCLICY NUSIBEA EFFECTIVE DATE EXPIRATION DATE IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and vrilness, 2. Name of Insurance Company and policy number for each vehicle Involved. ACOft0 50 Co (200fl0J) OACORO CORPORAJID112005.2O 7. All 1191111 re lsnwd. NI.�� PVHEA•1 LD F\'HEA ACORD,. CERTIFICATE OF LIABILITY INSURANCE c 3/2E/201? 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER-IFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED EY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject fo the terms and conditions of the policy, certaIn poilcles may -squire an endorsement. A statement on this ce; tificate does not confer rte hts to the certificate holder In lieu of such endorsement(s). PRODUCER Flood & Peterson Ins., Inc. P. O. Box 578 Greeley, CO 83622 970355-0123 N AME:" ik°' Nikki Mosbrucker PHONE 970 265.7123 , i c, no. 970 505-6323 (U0 No, EMI: " aooaless. nWindrmosbrucker@floodandpeterson.com IA °°..`Rine I IRSURERISI AFFORDING COVERAGE NAIL d INSURED Poudre Valley health Care, Inc, I dba Poudre Valley Health System 2315 E Harmony Road, Suite 209 Fort Collins, CO 30525.8620 I INSURER A: Conic Companies IN$UFEP.e : Safety National Casualty Compan INSURER C: INSURER o: INSURER II : INSURER F: LUV_r'LcJ THIS IS TO CF IFYTHA I HE rOLICIES Or INSURANCE LISTED BELOW HAVE BEEN IU' TO THE INsUHED NAMED AOV FORME POLICY PERIOD INDICATED. NOBVITNSTANDI S ANY REOUI EM'f•' TERM OR CONDITION OF ANY CONTRACT OR OTHERDOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR HAY PERTAIN, THE INSURANCE AFFORDED 3Y THE POLICIES DESCRIBED HEREIN IS SIJE:ECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SiCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED EY PAID CLAII.MS. )764:I noon_ SNci( oLIC:5FF 0 TYPE OFIk5UP.ANC$ tuse, „n'n I POLICY NU h ER 16 00'YYP'l IMM 1'EXP ;Ts OD"'Y`-9I A GENERAL LIABILITY . COMMERCIAL =MEP J,9_ITY I LiCC0008522 I i14 Retro Cate: 5/1/1954 0./0.1201210 (^1/2013 EACH OCCURRENCE Isi 000,000 IA n: ,i.N _° 1s5C Q,0o0 [ REM lea ozcrre,rn) D ',Any one person) 'SS OOO X CLANS -MADE I XI OCCUR : PERSONA!:ADM INJURY 151,000,000 HMalpractice GENET GGREGATE 53,000,000 _ I L lability PRODUCTS - CO6PIOP AGO 51,000.000 GENT AGGREGATE LIMAITAPP'_IES PER: I Pa Fort 1��= h!x I S ACr ON.081LE JABILR" AIN AUTO i ALL OWNED AUTOS I SCHEDULED AUTOS HIRED AUTOS �-yI NON -OWNED AUTOS COMBINED SINGLE Llid :) (Es aroden$ 150010' INJURY Per persnnl I S j ROOT'S INJURY Per a=ldenl) I $ PROPERTY DAMAGE (Per =den') 5 i 5 A I x, UMBRELLAUA9 IF"-tl oocuR EXCESS UAE El CLANS-IJADE I UCC000°293 [ b410112012„14101/2013 EA.CY OCCURRENCE 1515,000,000 AGGREGATE i 115,000,000 I $ DEDUCTIBLE RETEM1TICN $ I$ B I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRI_ 0RTARTUDED? CUTPODp IFFI5EPn.ln'ER cLUCaop N, (Mandatory In NH) eyez, ate under DESCRIPTION OE DEERSSONG Foot' NfA I3P40)43656 oXcess CoverageEt. IEXC ,34/0112912I0410112018 X Ilf•ol hrc i I4RH. EL. EACH ACCIDENT $1,000,000 OISELase-�ENI=LOY2E, 61,000.000 E L DISTAFF . POLICY LIMIT 151,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach AC ORO 1 at, Additional Remanre Schedule, II more Spaw sreoulred) Health Professional Liability - Persons Included (if applicable): Professional employees of the named insured, other than physicians (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION tC,redentialing Information Only Poudre Valley Health Care, Inc. Fort Collins, CD 80523 SHOULD ANY OF THE ABOVE ❑ESCRISED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTt'V_ ACORD 25 /2009109) 1 of 2 F.`6552Y4d5545D1 I_SS-200? ACORD CORPORATIONS All He -hl_= resen'ed. The ACORD name and logo are registered marks o' ACCRD NIK DESCRIP t LONS (Continued from Pace 1) ?rofesslcnal students of the named insured, other than residents Volunteers of the named insured, other lhsn phUsicians and residents AMS 25,3 (2009:09) 2 of 2 $68z 902/M66490'i OP ID: JD ACC_J' F F. 0 C------ E` IDENCE OF PROPERTY INSURANCE GA LE HAILED^TT". 05114/2012 T?.E THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE OF PROPERY INSURANCE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE EY TEE POLICIES BELOW. AFFORDED AGENCY HONE 9?0-682-i T47 In/c Nc, `:, cola=ANY Great Northern Insurance Co. 15 Mountain View Road Warren, NJ 07059 Brown 52 & BoardwalkBrown Inc 4532 Dr, Suite 200 Fort Collins, CO 80525 Tyler B. Allen r S73_454 `165 I oFt,=rs. iwe, u�: COD=_: 55243 I SUE coos: AGENCY FVHEA,i .,LISTID[:' warmer) sD Poudre 'Valley Health Care Inc 2315 E. Harmony Rd., Suite 200 Fort Collins. CO 50525-8633 _O <AL'M9'_P. IPOLICY NUMBER 1'25633405 F erescffs OA EXPIRATION DATE CONTINUED UNTIL E,0; ER E 05101/92 Oon J53 I I, r�+�N�IwATao lFcvaao THIS REPLACES FPJO; EVIDENCE_ DATED: PROPERTY INFORMATION I.00AION.'D E SCRIFTI ON For schedule of locations on file THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ED NAMED ABOVE OR THE POLICY Y PERIOD INDICATED. DESCRIBED D WHICHTHN I` NO?VJTHSIANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT T OR OTHER DOCUMENT IFJ POLICIES RESPECT EVIDENCE OF PROPERTY INSURANCE MAY DE ISSUED OP. MAY PERTAIN. THE INSURANCE AFFORDED S'JBJ_CT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OE SUCH POLICIES. S. LIMITS SHOWN MAY RAVE BEEN REDUCED BY PAID CLAIMS COVERAGE INFORMATION COVERAGE I DEEMS I FORMS AMOUNT CF INS'JPJ,NCE CE DuCTIe'_E Blanket Building, EPP /Specie; Form/Reu' Cost 550000000 LOSS LIMIT Included 25,000.00I 24.DP BIFEE REMARKS (Inoludinc Special Conditions) CANCELLATION THE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE. THEREOF, 1 _HE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE ADDITIONAL INTEREST NAMED BELOW, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ADDITIONAL IN, crc_o NAPE AND ADDRESS Poudre Valley Haalth Systems 2355 E. Harmony Rd., Sutie 203 Fed Collins, CO 80525 I,!O,'TG AGUE I 'LOSS PAVES _0AN! k • ADTSTIONA'_ INS USED r.umc;EIED REPEESENTAT'E ACORD 27 (2006107i i ACORD CORPORE.TION 18532006. All rights resen'ed- The ACORD name end logo are registered marks of ACORD L i iLE L [C I E THIS EVIDENCE L.F F O __, INSLflANCE ID ISSUES. Lo ISATTED OF TOPIAATION GLL.. : _ O- . HT .IPs N...HE ADD!TOI: !NTEREST NAMET _S EVIDEAPSOFP -.3dardvoddt Dr, S. 'Port Collins, CD 80525 Tyler 5. ;.11ec = 15243 PVHEA_ 15 Lisuotrlr' 181aonen, 110 57058 rir_ Yolley Hens -ti Core "5 E. 'E;arTony n_ Su;! _00 For', Collins, CO ., °20 8__0 405 05/01/._ 25101/12. PROPERTY INF0Rt ATIOH Ter schedu;e or Idc0fions EN 1 SLED T II - _'R T ICY r i rD PCI =_. THE FCi liar _ ,lN "r.C C FIRDPEPFE 1' THE 5TILIEDE5 LIBJ_C1 TT ALL THE 5-151,15 I. _-.ND SENSITIENS DE _'._IEN, PODEIES Iri.l C0A'=PAGE INFORMATION ISIanDELEAAHiinn, SOP lee is 1 Gep' Cost SIZE .50070030' insIurlerl 00 '.EIN:ASK5 So vial C_nditionsl CANCELLATION SHOULD ANY O 01 DESSCHSED POLICIES9 t D SEFLPOS _ PI ISN NEO IF IN R . MILIv"' VC' 4I_ DAYS FJRI .. _N IJ il E TO T ADDITIONAL '_P. IIN''9_ c _1 .,. FAILLIDS i'AAIL SUCH ASTISS SHALL,. I OP LIABILITY OF ANY 11102 UPON nE INSURED, ITS A. N, S SD FOEFFESEDIATIVES. ADDITIONAL IN Pour e .sIC 8:dcith)'tons 2315 E. Dcondcroy Rd., StIlts cn Font Co:Ho5, CO 805_8 c-. r4a of IsiSE F I ° Ir r r I I i ES• S UsI F '.•IC r - t THIS ESELCOLS''FIO L I S II - LO COMET:TOTE I.C. SE . ISSOHES JIT. -I .LED PoSERESEOT.E.TE"E OR 0E00000E, E CEFI_L _r _c.. I .rnTt.l .7�Eell tIta iomcl 5,Gll, ,.,i r Tllr LE, cool, nom. -I 00 _ o o/... ubjeCtto ziie :errs oitlo_ :1 We pall. e..ain pc uc : Lv' r=� ercr , t. n::.n I I ..I'Ica' ass . cc IEi .s ceOificate r er in b:eu of such elforostoc-ntls t. c. I_ SER IIl5URERr :usJF: F.J x0038 HEUEEa::. CEET!H. E iJL'It45En: !',=A:SI0it 'r" IL'IBER T.=E OF IltSURL I(CE GENERA! _iLo'l:11' I !Er 'WEEi !°!J o0LL1 l IW.:EERR I __T: SOlso OEEosS s is =„5LhJTOS i..'_ -�] �O - J:YEFELLS 'L'SS !p_rt! _ . CI00 , !Toll S500 L. OLLIWS s AND LPLOVERS' ' LITI' °I r n 'SIN I EACH S CIDEJT m_ 1 V R. O 5 l..-ve siEsoils„.10/ .- T Dish $250, 000 C. 0! ..Cr. IFIC-.i= `O GL,1 SS_'__-TiCi. F [ EnOL'LE E.TL. _SCRIEE] 3_:,= .E Et- ��_ :EFFESE' TFv OfPFOECLCER, AHDTHE C_. I. -.T- -..o_r:. -: n,s Ics-_ holier In I��_, 1, e- 1 ,a Peterson InsInc_ I Fro -O i2a Moshruci:ei 970 255-7123 ._ FLc71,2533i3353 _".s `,alley rkef_i,, :Er& .c. 05a POLRjfc -�, �a1�!T-s.. -.315 = Ha; mart r;0-201:1 SHre. 202 _., COIIIns. CC, 3.,5_--22_0 CERT 1=KTE I:JH,EEft YISI01f P!LI'v?EF:: THIS IS Tee TITY Tn:.T THE FILTH D_I t - T2 - 1 GP. .'JP -__ :IS n.. J F 1 ....F PER:THEON. I:5 J T-,8 _ DE_ ,. _-.'_ _r I-,... I_7r= r� ip a tI s — I I o ICY I -. 1_11.1.17S. ,- L O .:22 0 !201 I CFO 1?01 f r -cu 1J__ ;.500.000 1 5539.01[3 Fi. __e. ! r F.,:F 1F1,000.000 J 15/1 In _ r _ e .003.903 r sl.000.000 I I 1 1.-_: _i_=Sr, I c n azEiceit EE' L ,. 00.3 IX UCC:0059293 ,./ -;. SS 71'N 150. ^J C MSS_ a LIABILITY F lees c 7 �e un I -r in NFU JOl Or; I u.!' '_'EI .Erue :-.__ 1 rIS,Dr.1@„C100 05.000,000 5'.043055 04,_';i=104101/2;9131 X 1 E erac,e 42;.l I>1.000,000 T-1- __I si .D00,000 s..Ee I -I;n'T Ii1.000.000 J emc,a 1 - :eIF .,ar,r1 Eerii=isate = t � 0r 1 ELSE 9F, EH, 1'-.� 43 2064.111, ,10:01 - Idit'i T J. THISEILLS)/ - -_0-, I ._ PILLS)/ ;�� _�F .._. _ !J nsd ;71.0 -=d DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, Colorado 80631 Web: http://www_weldhealth.org Health Administration Vital Records Telex 970 304 6410 Fac 9703046412 Public Health & Clinical Services l ale 970 304 6420 lax 970 304 6410 Public Health Envirnnmantal Health Communication, Emergency Preparedness Sep/Ices Education & Planning & Response Tele: 970 3046415 Te o 9703046470 Tee 970 304 6420 Fax 9/04146411 F.J% 970 304 6452 Par. 970.3646409 Our oslnn: I ogelhenvith the vornireinales roes w3 aret int/ to rleAe Weld Coenty the lealtllesf place In U.) learn nore ant play Memorandum Date: February 6, 2013 To: Commissioners From: Mark E. Wallace, MD, MPH — Director Re: Ambulance License Appeal, Poudre Valley Hospital EMS The Department of Public Health and Environment has reviewed the "Appeal of Denial of Ambulance Service License Application Submitted by Poudre Valley Hospital EMS", dated January 21, 2013. The appeal was submitted in response to the Department denying Poudre Valley Hospital EMS (PVH EMS) application for an Ambulance Service License. The Ambulance Service License was denied in a letter dated December 21, 2012, to Steve Main at PVH EMS, from the Director of the Weld County Department of Public Health & Environment, Dr. Mark E. Wallace. The letter of December 21, 2012, outlined two reasons for denial: #1. PVH EMS does not have its primary base of operation located in Weld County, as required by the definition of "ambulance service license," found in Section 7-1-30 of the Weld County Code, and, #2. PVH EMS is not providing "primary care" in Weld County, as defined in said Section 7- 1-30, because it does not have an agreement or contract with Weld County to do so. PVH EMS has attempted to address the two deficiencies noted above. Each item is addressed separately below: PVH EMS Response to #1: On page 2, item 6., of their appeal request, PVH EMS indicates that they have "...established its primary base of operation for its Weld County ambulance service at 6906 Tenth Street, Greeley, Colorado 80634, an address located within the County." WCDPHE position: As PVH EMS has indicated their primary base of operation is in Weld County the Department no longer has issue with this deficiency. PVH EMS Response to #2: On page 2, item 7, of their appeal request, PVH EMS indicates that they "...are presently negotiating, or has entered into, ambulance and emergency medical service agreements with the Windsor -Severance, Johnstown, and Milliken Fire Protection Districts (the "Fire Districts"). Each of the Fire Districts is located within the County. See Exhibit D." Page 1 of 2 WCDPHE position: PVH EMS has not provided the WCDPHE any agreement or contract to provide emergency medical service related to this license application. Had PVH EMS provided an agreement or contract with a Fire District or municipality, the Department would consider this deficiency to be satisfactorily addressed. However, Exhibit D did not include a contract or agreement with the Fire Districts, only a Affidavit of Steve Main. The Department does not consider Mutual Aid agreements adequate to fulfill this deficiency. The Department contends that this deficiency has not been adequately addressed. WCDPHE Recommendation: Issue a Tier I license with a condition limiting emergency medical service to Mutual Aid response. Please do not hesitate to contact me should you have any questions or concerns. S cerely, Mark E. Wallace, MD, MPH Executive Director and Health Officer Page 2 of 2 ® Poudre Valley Hospital UNIVERSITY OF COLORADO HEALTH kc% in Artma \\ cad Count) I)cp:trtmcni or Public I Iealth and Ism ironmenn 1555 North I7th Arc. (;reels. Ct1 80631 EMERGENCY MEDICAL SERVICES 201? Ke' V1 C do not hale vehicles assigned it, particular ,lotions In I nil Collin, or (irecles. Our locutions and a potential number nl. unahulances loeared di each ,lotion are us IiJlo�r c I-Poudre Valley Hospital 1024 South I. cma, At C.: I lospital udmin ishutinn elnhu antic supplies. support son ices I bet Collin.. Co. 80524 2-PVH EMS Administrative Office and South FY Station: 3309 S. ,Alison St.:; I. 5. 4: 10 Ambulance*. ambulance adminktr:nion and trainim. amhulancc supplies Pore Collins. CO 80525 3 -West EC Station 415 S. Rnan St.: 1 Amhulance Fort Collin.. ( O 80521 4 -East EC Station 013 h:, AI' rile St.: 2 1mhulanecs and I IILAIS \mbulance I oft Collin:. CO 80524 5 -Harmony EC Station: 21271-. I lanuon Rd.: I Ambulance I on. C ollins. CO 80528 6 -Accounting Office: 2315 I_ I Emon. Rd. Suit: 22110: Su Anthulunccs Port Guilin.. Co_ 811528 7 -The Greeley Emergent.) & Surgical ('enter Station: I ,Amhulanee. umhuluuc. training_ ambulance supplies 601)6 10th St. Greek.. CO 8063-I 8- \\ incisor Fire Dept.. Sta. I: - Amhulan ces 1,AJed. 12 IS). amhtd:mce supplies 100 7th St. VA ind90r C't) 80_5511 9 -Milliken Fire Dept. Sta. I: I Ambulance Aled 161_ ambulance supplies 11)1 S. Irene Arc Milliken. ( t) 80543 10 -Johnstown Fire Dept.: I Ambulance I \led la used as a lrsen c unit) Supen .or tehicle- I)odec I'.I 100 I clop Ace. Inhnlorcn. CU 80534 I hanks and if coo need inure inlrrmution. please eel free to contact 1ne. Judith A. Brauer]. Super isor or I A IS Operations Poudre Valle> I lospia I., MS 3509 S. ,AJason St -1 I t Collins CO 81525 O-197012232-1751 ('4970)301 9826 'Na'erfie Id is Lit Fort Collins �Qp E Piiecore Frgllsh r.,; Ranch fvMeado,,;s i f 3 f• Linden `'ark a ilfiC y Rd Z 47- r• ;;• -pi--' ••. try 4 l. 7• IY R. J F It_ Cr. '192 I Centerra FL -13 Loveland Re..: 18 14# .3t SE C 7 Rrrth4-;m1 — :::otid ri z a7 392 Cc Rd 8.0 Co Rd 74 I - • •Windsor Fiscr Ridge �.a Pay 6CI Cc• Rd 54 C; JOhns.%SWfl C. t.C Rc C+C u C- CL4J I2 # t�df�krn 392 I Co Rd `NCR r_° 'fi A' 4„ co Ra 430 .,o-thst 7 , •ar 20t t Si r Oh'1' 1` i t - m March 7, 2013 udre i e Authority Steve Main Manager PVH Emergency Services 1024 S. Lemay Ave. Fort Collins, CO 80524 Dear Steve, 102 Remington Street Fort Collins, CO 80524 Phone: 970-221-6570 Fax: 970-416-2809 Internet: www.poudre-fire.org Poudre Fire Authority is committed to provide prompt emergency services to all areas of our district. The far eastern area of PFA's jurisdiction, which is in Weld County, is currently not in the response areas of Poudre Valley Hospital EMS. Poudre Fire Authority is requesting auto aid response from Poudre Valley Hospital EMS for all emergency medical related incidents requiring an ambulance response in the areas designated in the attached map referencing the following 19 CAD zones: P06JAP P06JTP P06KTP P06LHP P06NAP P06NOP P06NTP P06PHP P06PTP P06MTP P06MTP P06MTP P08NTP P08MTP P08KTP If you have additional questions, please call me at 970-416-2861. Mike Gress Operations Chief Poudre Fire Authority 102 Remington St. Fort Collins, CO 80524 P06LTP P06NHP P06PAP P08NAP P08QTP 61. av0 J1TNno3 al3M :,ARLSOr4G� RK DR 6 4 CL co O d —atio XINTICi=N CL cD O 0 7 co O n t2 17-- CD d O 0 H I� E1 aV08AIITn0OTAM WELD COUNTY ROAD f U 56TIVbti l 4 0- C Sb; a. gri - U O c\ war,O EDGE O NIA CO 0 n_ sl el :t it i_ TY BO/11),i CL [--- o0 v CL c 0 0 c v \\�'ib;,,�} uirl Poudre fire A lhordy Rnpour Area* m 1741 C�wnr Auto,Aid with PlM EMS J p.i Poore Are Aut6orily Boundary line apques t Map of: 6906 W 10th St Greeley. CO 80634-9726 10th St 3» 1 rriatpgypst v;2l:.i. 500ft 200m Notes 6906 10th St Greeley Emergency and Surgery Center W 10th St sus 34 .•.°! 19th ©2013 Mapauest - Portions ©2013 N+h'TEO I Terms I Privacy O2013 MapQuesr. Inc. Use of directions and maps ra subject to the MapQuest Terms of Use We make no guarantee of the accuracy of therr content, road conditions or route usability You assume all risk of use '' t.},'9r;rs Windsor -Severance Fire Rescue POIVALLEY 4IREP 0tYRUN Xfs,;ICI ]ON7WNFXRR� N5TYYWry E(RF I:RMR ECON DISTRICT I TIFF ill Ill F! ItPRmEI,IONX ICT LOON FIRE RR TN:NON WE6.ICI is F If ION COLOk .,_i ,�.LI f l is _Ii E lid\ .�.,-.., _- . Milliken Fire Protection District CO AMBULANCE SERVICES AGREEMENT THIS AMBULANCE SERVICES AGREEMENT is entered into on January I 2013, to be effective as of May 1, 2013 120 days from the entrance into the agreement (the "Effective Date") by and between POUDRE VALLEY HEALTH CARE, INC. D/B/A POUDRE VALLEY HOSPITAL, a Colorado non-profit corporation ("PVH") and WINDSOR -SEVERANCE FIRE PROTECTION DISTRICT, a Colorado Title 32 special district ("Windsor -Severance"). A. PVHS is engaged in the business of operating Poudre Valley Hospital, an acute care hospital with its principal place of business at 1024 South Lemay Avenue, Fort Collins, Colorado (the "Hospital" or "PVH"). PVH provides emergency medical services at medical incidents to patients in Larimer and Weld Counties through its ambulance services. B. Windsor -Severance has the authority under Colorado Secs 32-1-103(7), C.R.S. and 32-1- 1002(1)(e)(I), C.R.S. to provide for ambulance services to patients in its district. Pursuant to these statutes, Windsor -Severance desires to contract with PVH for qualified personnel to provide emergency medical services as part of ambulance services ("Contract Services"). PVH has the staff and equipment to provide the requisite Contract Services to Windsor - Severance. The parties desire to enter into this Agreement in order to provide a full statement of their respective responsibilities in connection with the delivery of services from PVH to Windsor - Severance. ACCORDINGLY, PVH and Windsor -Severance agree to the following: JOINT RESPONSIBILITIES 1.1 No Windsor -Severance employee shall be deemed to be an employee of PVH, nor shall any employee of PVH be deemed to be an employee of Windsor -Severance. 1.2. Both parties shall work collaboratively to ensure the most efficient use of the resources at the scenes of medical requests for services. Both agencies shall ensure that they work from a similar standard operating procedure with the goals of high quality and efficient patient care as well as safety of all responders. 1.3 Both parties shall work together to obtain and maintain current mutual aid agreements from surrounding agencies. 1.4 Both parties shall work in conjunction to ensure that customers receive the highest quality care and that patients are satisfied with such care. Both parties shall work towards quantifying levels of customer satisfaction. PVH RESPONSIBILITIES 2.1 Vehicle Donation: PVH agrees to transfer ownership of two ambulances and one command vehicle (see 2.1.1) to Windsor -Severance. PVH agrees to pay for all maintenance on the vehicles for the remainder of the 2013 calendar year. As of January 1, 2014 all maintenance and any replacement costs for ambulances will be the sole responsibility of Windsor -Severance Page I 2.1.1 Med 12 2008 Ford F-350 XLT with Frazer Type I Generator Powered Module VIN- 1FDWF36R38EB25617, Med 15 2008 Ford F-350 XLT with Frazer Type I Generator Powered Module VIN - 1 FDWF36R78EB25619, 2004 Dodge Ram 1500 Pick-up w/topper VIN - 1 D7HU18D24S617775 2.2 Crew: PVH agrees to provide the following personnel to be deployed: 2.2.1 Standard Deployment Level 3 call: 2.2.1 (a) Windsor Station 1 (located at 100 N. 7th Street) ALS Primary Response Ambulance 2.2.1 (b) Windsor Station 1- Single Resource Captain Ambulance 2.2.1 (c) Milliken Station 1- ALS Primary Response Ambulance 2.2.2 Single Response Level 2 call: 2.2.2 (a) Either primary Ambulance responds to 911 call 2.2.2 (b) Windsor ALS Primary Response Ambulance flexes to open district (if initial call was in Milliken/Johnstown District). 2.2.3 Double Response Level 1 call: 2.2.3 (a) Remaining Ambulance will post in Iron Mountain Area 2.2.4 Triple Response 2.2.4 (a) Mutual Aid Agreement with PVH EMS or Thompson Valley EMS or Banner Northern Colorado Medical Center EMS 2.2.5 Additional Resources to be Concerned: 2.2.5 (a) 40 hour supervisor (single response capability in a non -transport capable vehicle) 2.3 Response Area: The Response Areas for the Windsor -Severance district shall be divided into three areas, the "Urban Response Area", the "Suburban Response Area" and the "Rural Response Area". The Urban Response Area is defined as the area encompassed by North by WCR 72, East by WCR 21, South by WCR 62, and West by WCR 13. The Suburban Response Area is defined as Ptarmigan Area and includes the area encompassed by North of Highway 392 and West of WCR 13/LCR 1, and North by WCR 78, East by WCR 25, South by Highway 34, by West WCR 25. The Rural Response Area is considered all areas not defined by The Urban Response Area and The Suburban Response Area but in the Windsor - Severance district. 2.4 Response Time Expectations: Response Time is defined as the time period between when the ambulance first gained enough information to respond (i.e. dispatch time) and the time a properly equipped and staffed unit arrives at the scene defined as "wheels stopped". PVH agrees that the Response Time for the Urban Response Area shall be eight minutes and fifty-nine seconds (8:59) or less in ninety percent (90%) of Emergent Calls. Emergent calls are defined as calls as defined by Emergency Medical Dispatch Protocols; i.e. Echo, Delta, Charlie or Emergency Medical Dispatch Designation. PVH agrees that the Response Time for the Suburban Response Area shall be eleven minute and fifty-nine seconds (11:59) or less in ninety percent (90%) of Emergent Calls. PVH agrees that the Response Time for the Rural Response Area shall be nineteen minutes and fifty-nine seconds or less in ninety percent (90%) of Emergent Calls. In the event of a Concurrent Response, defined as any additional call for service while the primary ALS ambulance is assigned to a request for service or released up till 15 minutes Page 2 after arrival at a receiving facility if transported. 2.5 Exemption to Response Times: If the Response Times exceed the defined Response Times in Section 2.4, PVH may apply for a Concurrent or Surge Exemption and it will be granted if PVH can demonstrate: 2.5.1 It meets the definition of a Concurrent Request 2.5.2 There are no lost unit hours during the timed period 2.5.3 Time on Task at receiving facility does not exceed agreed terms. Time on task includes all time from dispatch up to 15 minutes after arrival at a receiving facility as defined in section 2.7. 2.5.4 The Deployment Plan was followed. Deployment plan shall adjusted by representatives of Windsor -Severance and PVH as necessary. 2.5.5 There were no routing delays 2.5.6 PVH can demonstrate a continuing effort to mitigate late responses. 2.6 Weather and other exemptions to Response Times: A blanket exemption may be granted by the Fire Chief or his/her delegate for the following: 2.6.1 Individual Weather Exemption: May be requested by the crews responding on the basis of road/weather conditions (i.e. poor visibility or icy roads, etc.). This request must be made by the crew to the dispatch services. 2.6.2 Train or other unexpected road closure. 2.6.3 Bad address or other inaccurate dispatch information out of the control of the responding crew. 2.7 Time on Task: PVH shall complete patient turnover and ambulance clean/restock within fifteen (15) minutes and be en -route back to its assigned district. This time on task may be extended depending on extenuating circumstances (i.e. Full Trauma Teams, Cardiac Arrest, etc...) Crew will detail this information. 2.8 Education: PVH agrees to provide continuing medical education (CME) to the staff at Windsor -Severance. Topics will include all CME required to complete the National Registry recertification. PVH agrees to provide the following courses; Pre - Hospital Trauma Life Support, Pediatric Education for Pre -Hospital Professionals, and Advanced Medical Life Support thru UCH clinical Education Department; course tuition for all classes will be covered by the Northeast RETAC provided funds are available. 2.8.1 All PVH EMS Personnel assigned to Windsor -Severance will maintain Colorado Department of Public Health and Environment Certification, National Registry Certification as well as Pre -Hospital Trauma Life Support, Advanced Medical Life Support and Pediatric Advanced Life Support or equivalent course within 1 year. 2.9 Make available PVH Ambulance Driver Training to Fire Personnel 2.10 National Registry Affiliation: Windsor -Severance employees who maintain National Registry certification will be encouraged to affiliate with PVH EMS to ease the process of recertification. 2.11 Key Performance Indicators: PVH agrees to comply with the Key Performance Indicators as described on Exhibit A attached and incorporated into this Agreement. Page 3 2.12 Quality Assurance and Quality Indicators: PVH shall conduct regular Quality Assurance of EMS Patient Care Reports. PVH will also conduct frequent After Action Reports to improve continuity of patient care. PVH shall conduct targeted reviews of certain call types across the service areas based on services provided (i.e. spinal immobilization, pain management, etc.) These reviews will be used to ensure that care delivered to Windsor -Severance meets and exceeds nationally accepted benchmarks. 2.13 Medical Supplies: PVH shall provide durable medical equipment for each ambulance under this Agreement. The durable medical equipment to be Examples of equipment provided includes: (I) cot, (ii) monitor/defibrillator, (iii) stair chair, (iv) suction, (v) split boards, (vi) road safety driver monitoring system, (vii) laptop to be used for Computer Aided Dispatch (CAD) purposes and any other durable medical equipment required by state, county or local statutes. PVH shall provide disposable medical supplies used by Windsor -Severance on calls for service to include any disposable supply, which is currently stocked on the ambulance. PVH shall provide medical oxygen used on calls for service. PVH shall insure oxygen cylinders will be delivered to stations where PVH crews are quartered and PVH crews shall trade out empty cylinders with Windsor -Severance crews. 2.14 Crew Station Duties: PVH agrees to insure that the crew performs the station duties as a member of the team and as a resident of the station. The PVH EMS Captain shall insure that the EMS crew completes all duties. 2.15 Communications. PVH shall purchase and maintain 800mHz pack -sets for each ambulance. 2.16 Fuel for Vehicles. PVH is responsible for all fuel necessary for all vehicles donated to Windsor -Severance. 2.16 PVH shall provide a Certificate of Insurance to Windsor -Severance upon request. The Certificate of Insurance shall provide proof of: a. general liability; General liability coverage shall be for not less than $1,000,000 (one million dollars) per occurrence and $3,000,000 (three million dollars) per aggregate. PVH employees are not entitled to Worker's Compensation benefits from Windsor - Severance. 2.17 PVH shall abide by the terms of the Business Associate Agreement as attached and incorporated herein as Exhibit B. WINDSOR -SEVERANCE RESPONSIBILITIES 3.1 Performance problems of PVH employees placed with Windsor -Severance will be documented and reported to PVH immediately. 3.2 Windsor -Severance shall be responsible for providing suitable living and workspaces at all ambulance stations. These include, equipment, furniture, connectivity, phone, etc. The parties agree to work together to provide connectivity to the PVH intranet or other network connectivity. Page 4 3.3 Windsor -Severance shall ensure PVH has an 800mHz letter of permission to operate on their channel as well as appropriate dispatch software installed on each ambulance laptop. INDEMNIFICATION 4.1 Windsor -Severance agrees to indemnify, defend, and hold harmless PVH from and against any and all claims, judgments, costs, liabilities, damages, and expenses, including attorney fees whatsoever arising from any acts or omissions in the provision of services by Windsor -Severance under this Agreement. 4.2 PVH agrees to indemnify, defend, and hold harmless Windsor -Severance from and against any and all claims, judgments, costs, liabilities, damages, and expenses, including attorney fees whatsoever arising from any acts or omissions in the provision of services by PVH's employees under this Agreement. 5. PAYMENT AND BILLING. Beginning on the Effective Date, PVH agrees to pay Windsor -Severance one dollar ($1.00) per loaded mile, payable quarterly. TERM AND TERMINATION 6.1 The term of this Agreement shall be from the Effective Date through December 31, 2018. 6.2 This Agreement may he terminated without cause by PVH or Windsor -Severance upon 30 (thirty) days written notice of termination to the other party. If termination occurs within the first three hundred sixty-five days of PVH assuming provision of EMS in the district, Windsor -Severance will he liable for the start-up capital costs incurred by PVH. 6.3 Windsor -Severance may terminate this agreement immediately when quality of care or patient safety is deemed by Windsor -Severance to be at unreasonable risk due to acts or omissions by PVH. 6.4 This Agreement may not be assigned, delegated or transferred by either party without the written consent of the other 6.5 This Agreement may not be modified, except by written agreement executed by the Parties, provided if PVH deems modification necessary to comply with IRS requirements, 42 U.S.C. 1320a -7b or 42 U.S.C. 1395nn or other applicable laws, PVH may modify this Agreement to the extent necessary to comply with the applicable law. 7. REGULATORY COMPLIANCE 7.1 OBLIGATION SUBJECT TO ANNUAL APPROPRIATION. In so far as the financial obligations of the District as contained herein may be deemed to be multi -year financial obligations under Article X, Section 20 of the Colorado Constitution, such obligations shall be subject to annual appropriation of funds by the Windsor - Page 5 Severance governing board. Notwithstanding anything herein to the contrary, in the event of non -appropriation, Windsor -Severance shall have the right to terminate this Agreement at the end of its then current fiscal year without penalty or other legal consequence. Notice of such intended non -appropriation shall be given by Windsor -Severance at the earliest possible point in time during the preparation of its annual budget for the ensuing fiscal year, but in no event less than December 1 of the then current fiscal year. 7.2 in performing this Agreement, the parties agree to comply with all applicable state and federal laws. This Agreement shall be construed in accordance with the laws of the State of Colorado. Independent Contractor Relationship 8.1 In performance of this Agreement, it is mutually understood and agreed that the PVH is at all times acting and performing as an independent contractor for the contract services. PVH will determine the method, and means of performing the Contract Services. The sole interest and responsibility of Windsor -Severance is to ensure that the Contract Services shall be in accordance with applicable law, recognized standards of professional practice and the terms of this Agreement. 8.2 PVH shall have the right to perform the Contract Services for individuals or entities other than Windsor -Severance during the term of this Agreement. Access to Documentation For the purpose of implementing Section 1861 (v)(1)(I) of the Social Security Act, as amended, and any written regulations thereto, Windsor -Severance agrees to comply with statutory requirements governing the maintenance of documents to verify the cost of services rendered under this Agreement as follows: 9.1 Until the expiration of four years after the furnishing of such services pursuant to this Agreement, Windsor -Severance shall make available, upon written request to PVH and/or the Secretary of Health and Human Services, or upon request to the Comptroller General, or any of their duly authorized representatives, the contracts, books, documents and records of such Windsor -Severance that are necessary to certify the nature and extent of such costs, and, 10. Notice All notices and other communications that either party may desire or may be required to deliver to the other party may be delivered in person or by depositing the same in the United States mail, postage prepaid, certified or registered mail, or by electronic facsimile, addressed or delivered as follows: If to PVHS: Attention: President/CEO Poudre Valley Hospital 1024 South Lemay Avenue Fort Collins, CO 80524 With a copy to: PVHS Legal Department 2315 E. Harmony Rd., Ste. 200 Fort Collins, CO 80528 Fax: (970) 237-7094 Page 6 FAX (970) 495-7663 If to Windsor -Severance: Fire District: Windsor Severance Fire Rescue Attn: Fire Chief 100 71h Street Windsor, CO 80550 Either party may change the address to which notices are to be delivered by giving notice herein provided. Any notice shall be deemed to have been given if hand delivered or sent by electronic facsimile, as of the date delivered or transmitted, or if mailed as provided herein, on the third day after mailing. 11 Governing Law This Agreement shall be governed by and construed under the laws of the State of Colorado. 12. Modification and Waiver This Agreement can be amended only with a written agreement executed by the parties at the time of the modification. No breach of any provision hereof can be waived unless in writing. Waiver of any one breach of any provision hereof shall not be deemed a waiver of any other breach of the same or any other provision hereof. 13. Severability If any one or more of the terms, provisions, promises, covenants or conditions of the Agreement or the application thereof to any person or circumstance shall be adjudged to any extent invalid, unenforceable, void or voidable for any reason whatsoever, by a court of competent jurisdiction, or shall be determined by the ruling or interpretations of a Governmental agency or new legislation, to cause either party to perform an act which threatens its governmental provider or tax status, then such terms shall be deemed stricken from this agreement, and each and all of the remaining terms, provisions, promises, covenants and conditions of this Agreement or their application to other persons or circumstances shall not be affected thereby and shall be valid and enforceable to the fullest extent permitted by law. Notwithstanding the aforesaid, should the severance have the effect of materially altering the meaning of this Agreement, this Agreement shall be void. 14. Interpretation No provision in this Agreement is to be interpreted for or against any party because that party or that party's legal representative drafted such provision. 15. Disclosure Neither party to this Agreement will disclose to anyone, without the other party's prior written permission, the nature or content of any oral or written communication, or any information gained from the inspection of any record(s) or document(s) submitted to each party under this Agreement, including the terms of this Agreement, information obtained Page 7 from corporate or personal records or documents; and neither party will permit inspection of any papers or documents related to this engagement without the other party's prior written consent. 16. Assignment party. Neither party may assign this Agreement without the prior written consent of the other 17. Entire Agreement This Agreement embodies the entire agreement and understanding between the parties with respect to the subject matter of this Agreement and supersedes all prior and contemporaneous oral and written agreements with respect hereto. Pagc 8 (CommissloNLxpirafon Date) IN WITNESS HEREOF, the Parties have caused this Agreement to be executed by their authorized officers as evidenced by their signatures below. For "Windsor -Severance Date. _ t_ J the PCP a/ . 04i3 TAX/SS ID Number: S1� (�7�5 & 1 (Please provide W-9; this document can be found at http_//www.irs.gov/pub/irspdf/fw9,pdf) State of Colorado City of CIT,w-{{ l� County of,lf,rL� _ II // e foregoing rostrum nt wa acknowledged before me on this ( day of /I/ 2Ceby h (N (Notary Se@pvi' FOR POUDRE VALLEY HEALTH CARE, INC. D/B/A POUDRE VALLEY HOSPITAL -- l 4' vin Ung0l, FACHE, President/CEO ouc{f�e Valley Hospital 5 I 1 /''!l Da State of Colorado City of c . (co, County The/foregoing instrument was acknowledged before me on this �l_L.V fk-+^r• f (name). 1 (�r„ c)Urt ( I (Notary Signature) (Commission Expiration Date) day of ._,�� 201 Eby (Notary Seal) Page 9 EXHIBIT A Key Performance Indicators Key Performance Indicators (KPI) will be reported to an oversight board on a monthly basis and annual basis, KPIs to be reported shall include: Requests for Service: A report outlining requests for service, sorted by call type Response Times: see Section 2.4 and 2.5 for specific standards Destination Report: A report outlining Hospital Destinations Training: A report of all education and training provided to the Windsor -Severance staff. After Action Reports: A report of all after actions reports conducted by PVH crew and Windsor - Severance staff. Additional Activities: A report of additional activities to include; Fire Standbys, Community Paramedicine Activities, Special Event Coverage, etc Average Call Costs: A report of geographically adjusted call costs will be presented. Page 10 EXHIBIT B BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ("Agreement") is effective this 1st day of May 2013 ('Effective Date"), by and between WINDSOR -SEVERANCE FIRE PROTECTION DISTRICT ("WINDSOR -SEVERANCE") and POUDRE VALLEY HEALTH CARE, INC., D/B/A POUDRE VALLEY HOSPITAL a Colorado non-profit corporation ("Business Associate"). RECITALS WHEREAS, the parties have executed an agreement or agreements whereby Business Associate provides independent contractor services to WINDSOR -SEVERANCE, and Business Associate receives, has access to or is subject to the federal regulations issued pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") and codified at 45 C.F.R. parts 160 and 164 ("HIPAA Rules"); WHEREAS, the HIPAA Rules require WINDSOR -SEVERANCE to enter into a contract with Business Associate in order to mandate certain protections for the privacy and security of Health Information, and those Regulations prohibit the disclosure to or use of Health Information by Business Associate if such a contract is not in place; WHEREAS, Business Associate acknowledges that effective January 1, 2010, as a business associate, it is responsible to comply with the HIPAA Security and Privacy regulations pursuant to Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH), including Sections 164.308, 164.310, 164.312 and 164.316 of title 45 of the Code of Federal Regulations. NOW, THEREFORE, in consideration of the foregoing, and for other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties agree as follows: DEFINITIONS 1.1 "Disclose" and "Disclosure" mean, with respect to Health Information, the release, transfer, provision of access to, or divulging in any other manner of Health Information outside Business Associate's internal operations or to other than its employees. 1.2 "Health Information" means information that (i) relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual; (ii) identifies the individual (or for which there is a reasonable basis for believing that the information can be used to identify the individual); and (hi) is received by Business Associate from or on behalf of WINDSOR -SEVERANCE, or is created by Business Associate, or is made accessible to Business Associate by WINDSOR -SEVERANCE. 1.3 "Individually Identifiable Health Information" shall mean information that can be used to identify the individual, such as a name or social security number. 1.4 "Protected Health Information" shall mean Health Information and Individually Identifiable Health Information in any medium whether electronic or otherwise. Page 1 I 1.5 "Security Incident" shall mean the attempted or successful unauthorized access, use disclosure, modification, or destruction of information or interference with system operations in an information system. 1.6 "Security Rules" shall mean the security standards for the protection of electronic protected health information at 45 CFR Part 164, Subpart C and amendments thereto. 1.7 "Services" has the same meaning as in the Services Agreement. 1.8 "Use" or "Uses" mean, with respect to Health Information, the sharing, employment, application, utilization, examination or analysis of such Information within Business Associate's internal operations. 1.9 All capitalized terms not defined in this section shall have the meanings ascribed to them in 45 C.F.R. Part 160 and Part 164, subparts A and E pursuant to the Health Insurance Portability and Accountability Act of 1996. OBLIGATIONS OF BUSINESS ASSOCIATE 2.1 Permitted Uses and Disclosures of Health Information. Unless otherwise specifically provided in this Agreement or authorized in writing by WINDSOR -SEVERANCE, and except as required or permitted by law, Business Associate hereby agrees (a) to keep all PHI confidential and in its possession except as necessary to provide the services under the Services Agreement; (b) to restrict access to PHI to those employees of Business Associate or other workforce members under the control of Business Associate who are actively and directly participating in providing the Services and who need to know such information in order to fulfill such responsibilities ("Business Associate Representatives"); (c) not to copy or duplicate any PHI except as necessary to provide the services under the Services Agreement; (d) to treat any and all copies of, and notes, memoranda, analyses, compilations, abstracts, synopses, studies of other material produced from PHI as PHI; (e) to communicate only with the authorized representatives of PVHS conceming PHI; (f) not to use any PHI for any purpose other than the purpose for which such PHI was provided in connection with providing the services under the Services Agreement; and (g) not to use PHI in any manner that would violate the HIPAA Rules if WINDSOR - SEVERANCE were providing the services under the Services Agreement or in any other manner that may be detrimental to WINDSOR -SEVERANCE. 2.2 Uses and Disclosures of PHI for Business Associate Operations. Business Associate may use PHI, if necessary, for the proper management and administration of Business Associate or to carry out the legal responsibilities of Business Associate. Business Associate may disclose PHI for its proper management and administration or to carry out its legal responsibilities if the disclosure is required by law, or if Business Associate obtains reasonable written assurances from the Person to whom PHI will be disclosed that: (a) PHI will be held confidentially and used or further disclosed only for the purpose for which it was disclosed to such Person or only as required by law; and (b) such Person will notify Business Associate of any instances of which it becomes aware in which the confidentiality of PHI was breached. 2.3 Adequate Safeguards for Health Information. Business Associate warrants that it shall implement and maintain appropriate administrative, physical and technical safeguards in compliance with the HIPAA Rules and any other relevant laws or regulations to prevent the Use or Page 12 Disclosure of Health Information in electronic or any other form that it creates, receives, maintains or transmits under this Agreement, in any manner other than as permitted by this Agreement. 2.4 Reporting Non -Permitted Use or Disclosure Business Associate shall report to WINDSOR -SEVERANCE each Use or Disclosure that is made by Business Associate, its employees, representatives, agents or subcontractors that is not specifically permitted by this Agreement, including any Security Incident involving Health Information as required by the Security Rules. The initial report shall he made by telephone call to the appropriate representative at WINDSOR -SEVERANCE within forty-eight (48) hours from the time the Business Associate becomes aware of the non -permitted Use or Disclosure, followed by a full written report to the Privacy Officer no later than ten (10) business days from the date the Business Associate becomes aware of the non -permitted Use or Disclosure. Business Associate shall take (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. 2.5 Business Associate's Notification. Business Associate's notification to WINDSOR - SEVERANCE pursuant to Section 2.4 of this Agreement shall include the following: • Identification of the nature of the non -permitted use or disclosure of other breach; • Identification of the PHI used, accessed or disclosed; • Identification of who made the non -permitted use or received the non -permitted disclosure; • Identification of what corrective action Business Associate took or will take to prevent further non -permitted uses or disclosures; • Identification of what Business Associate did or will do to mitigate any negative effect of the non -permitted use or disclosure; and • Provide such other information, including a written report, as WINDSOR - SEVERANCE may reasonably request. 2.6 Sub -Contractors and Agents- Business Associate will ensure that any and all Persons who have access to PHI by or through Business Associate, including (without limitation) the Business Associate Representatives, agrees to the same restrictions and conditions that apply to Business Associate hereunder. 2.7. Availability of Internal Practices, Books and Records to Government Agencies. Business Associate agrees to make its internal practices, books and records relating to the Use and Disclosure of Health Information available to the Secretary of the federal Department of Health and Human Services (the "Secretary") for purposes of determining WINDSOR-SEVERANCE's compliance with the HIPAA Rules. Business Associate shall immediately notify WINDSOR - SEVERANCE of any requests made by the Secretary and provide WINDSOR -SEVERANCE with copies of any documents produced in response to such request. 2.8. Access to and Amendment of Health Information. Business Associate shall, to the extent WINDSOR -SEVERANCE determines that any Health Information constitutes a "designated record set" under the HIPAA Rules, (a) make the Health Information specified by WINDSOR - SEVERANCE available to the individual(s) identified by WINDSOR -SEVERANCE as being entitled to access and copy that Health Information, and (b) make any amendments to Health Information that are requested by WINDSOR -SEVERANCE. Business Associate shall provide such access and make such amendments within the time and in the manner specified by WINDSOR - SEVERANCE. Page 13 2.9 Accounting of Disclosures. Upon WINDSOR-SEVERANCE's request, Business Associate shall provide to WINDSOR -SEVERANCE an accounting of each Disclosure of Health Information made by Business Associate or its employees, agents, representatives or subcontractors ("Disclosure"). Any accounting provided by Business Associate under this Section 2.9 shall include: (a) the date of the Disclosure; (b) the name, and address if known, of the entity or person who received the Health Information; (c) a brief description of the Health Information disclosed; and (d) a brief statement of the purpose of the Disclosure. For each Disclosure that could require an accounting under this Section 2.9, Business Associate shall document the information specified in (a) through (d), above, and shall securely maintain that documentation for six (6) years from the date of the Disclosure. 2.10 Availability for Audit. Business Associate shall make its internal practices, books. and records relating to the Use and Disclosure of PHI received from WINDSOR -SEVERANCE, or created or received by Business Associate on behalf of WINDSOR -SEVERANCE available to the Secretary for purposes of the Secretary determining WINDSOR-SEVERANCE's compliance with the Privacy Rule. In the event that Business Associate is requested by the Secretary to make available its books, records and documents relating to WINDSOR -SEVERANCE compliance with the Privacy Rule, Business Associate will: to the extent not prohibited by law, notify WINDSOR - SEVERANCE within 2 business days. 2.11 Obligation of WINDSOR -SEVERANCE. WINDSOR -SEVERANCE shall notify Business Associate of any current or future restrictions or limitations on the use of Health Information that would affect Business Associate's performance of the Services, and Business Associate shall thereafter restrict or limit its own uses and disclosures accordingly. 2.12. Security Standards. Business Associate will: (a) Implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf of WINDSOR -SEVERANCE. (b) Ensure that any agent, including a subcontractor, to whom Business Associate provides such electronic PHI agrees to implement reasonable and appropriate safeguards to protect it; and (c) Report to WINDSOR -SEVERANCE any security incident affecting WINDSOR - SEVERANCE of which Business Associate becomes aware in accordance with the Security Rules. 2 13. Notification of Breach of Unsecured Protected Health Information_ Business Associate will: (a) Except as provided in 45 C.F.R. § 164.412, report immediately to PVHS after it becomes aware of any Breach of Unsecured Protected Health Information and promptly provide to WINDSOR -SEVERANCE (i) a list of all Individuals whose Unsecured Protected Health Information has been, or is reasonably believed by the Business Associate to have been, accessed, acquired, used, or disclosed during the Breach, and (ii) any other available information that WINDSOR - SEVERANCE is required to include in notifications to such Individuals pursuant to 45 C.F.R. § 164.404(c); and Page 14 (b) Cooperate with WINDSOR -SEVERANCE in making any requisite notifications to Individuals and the Secretary as a result of any Breach of tJnsecured Protected Health Information, including paying for the cost of notification to Individuals, and of media notification if the legal requirements for media notification are triggered by the circumstances of such breach, provided that Business Associate shall not initiate any such notifications without approval of WINDSOR -SEVERANCE. 2.14 Term and Termination. The term of this Agreement shall be the same as the term of the Services Agreement. In addition to and notwithstanding the termination provisions set forth in the Services Agreement, both this Agreement and the Services Agreement may be terminated immediately upon written notice by WINDSOR -SEVERANCE to Business Associate if WINDSOR - SEVERANCE determines, in its sole discretion, that Business Associate has violated any material term of this Agreement or any provision of the Privacy Standards or Security Standards or applicable federal or state privacy law relating to the obligations of Business Associate under this Agreement. Business Associate's obligations under Sections 2.1 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.10, 2.12, and 2.13 shall survive the termination or expiration of this Agreement. 2.15. Disposition of Health Information Upon Termination or Expiration. Upon termination or expiration of this Agreement and the Services Agreement, Business Associate shall either return or destroy, in WINDSOR-SEVERANCE's sole discretion and in accordance with any instructions by WINDSOR -SEVERANCE, all Health Information in the possession or control of Business Associate or its agents and subcontractors. However, if Business Associate determines that neither return nor destruction of Health Information is feasible and notifies WINDSOR - SEVERANCE in writing of that determination, Business Associate may retain Health Information provided that Business Associate (a) continues to comply with the provisions of this Agreement for as long as it retains Health Information, and (b) further limits Uses and Disclosures of Health Information to those purposes that make its return or destruction unfeasible. Upon termination or expiration of this Agreement, Business Associate will give to WINDSOR -SEVERANCE copies of all documents in Business Associate's possession or control that are required to be maintained by or on behalf of WINDSOR -SEVERANCE by the HIPAA Rules or the Security Rules other than what Business Associate is permitted or required by law to retain. 2.16. No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement. 2.17. Use of Subcontractors and Agents. Business Associate shall require each of its agents and subcontractors that receive Health Information from Business Associate to execute a written agreement obligating the agent or subcontractor to comply with all the terms of this Agreement, including appropriate and comparable safeguards, as defined in Section 2, above. 2.18. Relationship to Services Agreement Provisions. In the event that a provision of this Agreement is contrary to a provision of the Services Agreement, the provision of this Agreement shall control. Otherwise, this Agreement shall be construed under, and in accordance with, the terms of the Services Agreement. 2.19 Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits WINDSOR -SEVERANCE to comply with the HIPAA Rules. 2.20 Amendment. The parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for WINDSOR -SEVERANCE to comply with the requirements of the HIPAA Rules. Page IS 2.21 Waivers. No delay or omission by WINDSOR -SEVERANCE in exercising any rights or remedies under this Agreement or applicable law shall impair such right or remedy or be construed as a waiver of any such right or remedy- Any single or partial exercise of a right or remedy shall not preclude further exercise of that right or remedy or the exercise of any other right or remedy No waiver shall be valid unless in writing signed by the party to be bound. Page 16 AMBULANCE SERVICES AGREEMENT THIS AMBULANCE SERVICES AGREEMENT is entered into on January 26_, 2013, to he effective as of 120 days from the entrance into the agreement (the "Effective Date") by and between POUDRE VALLEY HEALTH CARE, INC. D/B/A POUDRE VALLEY HOSPITAL, a Colorado non-profit corporation ("PVH") and JOHNSTOWN FIRE PROTECTION DISTRICT, a Colorado Title 32 special district ("Johnstown"). A. PVHS is engaged in the business of operating Poudre Valley Hospital, an acute care hospital with its principal place of business at 1024 South Lemay Avenue, Fort Collins, Colorado (the "Hospital" or "PVH"). PVH provides emergency medical services at medical incidents to patients in Larimer and Weld Counties through its ambulance services. B. Johnstown has the authority under Colorado Secs 32-1-103(7), C.R.S. and 32-1- 1002(1)(e)(I), C.R.S. to provide for ambulance services to patients in its district. Pursuant to these statutes, Johnstown desires to contract with PVH for qualified personnel to provide emergency medical services as part of ambulance services ("Contract Services"). C. PVH has the staff and equipment to provide the requisite Contract Services to Johnstown. D. The parties desire to enter into this Agreement in order to provide a full statement of their respective responsibilities in connection with the delivery of services from PVH to Johnstown. ACCORDINGLY, PVH and Johnstown agree to the following: 1. JOINT RESPONSIBILITIES 1.1 No Johnstown employee shall be deemed to be an employee of PVH, nor shall any employee of PVH he deemed to he an employee of Johnstown. 1.2. Both parties shall work collaboratively to ensure the most efficient use of the resources at the scenes of medical requests for services. Both agencies shall ensure that they work from a similar standard operating procedure with the goals of high quality and efficient patient care as well as safety of all responders. 1.3 Both parties shall work together to obtain and maintain current mutual aid agreements from surrounding agencies. 1.4 Both parties shall work in conjunction to ensure that customers receive the highest quality care and that patients are satisfied with such care. Both parties shall work towards quantifying levels of customer satisfaction. 2. PVH RESPONSIBILITIES 2.1 Vehicles: PVH agrees to transfer ownership of one ambulance and one command vehicle (see 2.1.1) to Johnstown. PVH agrees to pay for all maintenance on the vehicle for the remainder of the 2013 calendar year. As of January 1, 2014 all maintenance and any replacement costs for ambulances will be the sole responsibility of Johnstown. The balance of the extended warranty on the ambulance chassis will be transferred to Johnstown. In exchange for the transfer of Page 1 ownership, PVH will receive crew quarters and bay space in the Johnstown fire station for the five year term of the agreement. 2.1.1 Med 14 2008 Ford F-350 XLT with Frazer Type I Generator Powered Module VIN- 1FDWF36R58EB25618, 2004 Dodge Ram 1500 Pick-up w/topper VIN- 1D7HU18D24S617775 2.2 Crew: PVH agrees to provide the following personnel to be deployed: 2.2.1 Standard Deployment Level 3 call: 2.2.1 (a) Windsor Station 1 (located at 100 N. 7th Street) ALS Primary Response Ambulance 2.2.1 (b) Windsor Station 1- Single Resource Captain Ambulance 2.2.1 (c) Milliken Station (located at 101 S. Irene Ave) 1- ALS Primary Response Ambulance 2.2.2 Single Response Level 2 call: 2.2.2 (a) Either primary Ambulance responds to 911 call 2.2.2 (b) Windsor ALS Primary Response Ambulance flexes to open district (if initial call was in Milliken/Johnstown District). 2.2.3 Double Response Level 1 call: 2,2.3 (a) Remaining Ambulance will post in Iron Mountain Area 2.2.4 Triple Response 2.2.4 (a) Mutual Aid Agreement with PVH EMS (Fort Collins) or Thompson Valley EMS or Banner Northern Colorado Medical Center paramedic services. 2.2.5 Additional Resources to be Concerned: 2.2.5 (a) 40 hour supervisor (single response capability in a non -transport capable vehicle) 2.3 Response Area: The Response Areas for the Johnstown district shall be divided into three areas, the "Urban Response Area", the "Suburban Response Area" and the "Rural Response Area". The Urban Response Area is defined as the area encompassed by North by WCR 52, East by the border between Johnstown and Milliken Fire Protection District (approx. HWY 257), South by WCR 42, and West by WCR 13 and 1-25. The Suburban Response Area is defined as Northmoor Area and includes the area encompassed by North by WCR 44, East by WCR 13, South by WCR 42, by West WCR 11 and the area West of 1-25 within the Johnstown Fire Protection District, including the Gateway Industrial Development. The Rural Response Area is considered all areas not defined by The Urban Response Area and The Suburban Response Area but in the Johnstown district. Areas within the Johnstown FPD that lie within the Thompson Valley EMS district shall not be included in the defined response area. 2.4 Response Time Expectations: Response Time is defined as the time period between when the ambulance first gained enough information to respond (i.e. dispatch time) and the time a properly equipped and staffed unit arrives at the scene defined as "wheels stopped". PVI-I agrees that the Response Time for the Urban Response Area shall be eight minutes and fifty-nine seconds (8:59) or less in ninety percent (90%) of Emergent Calls. Emergent calls are defined as calls as defined by Emergency Medical Dispatch Protocols; i.e. Echo, Delta, Charlie or Emergency Medical Dispatch Designation. PVH agrees that the Response Time for the Suburban Response Area shall be eleven minute and fifty-nine seconds (11:59) Page 2 or less in ninety percent (90%) of Emergent Calls. PVH agrees that the Response Time for the Rural Response Area shall be nineteen minutes and fifty-nine seconds or less in ninety percent (90%) of Emergent Calls. In the event of a Concurrent Response, defined as any additional call for service while the primary ALS ambulance is assigned to a request for service or released up till 15 minutes after arrival at a receiving facility if transported. 2.5 Exemption to Response Times: If (he Response Times exceed the defined Response Times in Section 2.4, PVH may apply for a Concurrent or Surge Exemption and it will be granted if PVH can demonstrate: 2.5.1 It meets the definition of a Concurrent Request 2.5.2 There are no lost unit hours during the timed period 2.5.3 Time on Task at receiving facility does not exceed agreed terms. Time on task includes all time from dispatch up to 15 minutes after arrival at a receiving facility if trasported as defined in section 2.7. 2.5.4 The Deployment Plan was followed. Deployment plan shall adjusted by representatives of Johnstown and PVH as necessary. 2.5.5 There were no routing delays 2.5.6 PVH can demonstrate a continuing effort to mitigate late responses. 2.6 Weather and other exemptions to Response Times: A blanket exemption may be granted by the Fire Chief or his/her delegate for the following: 2.6.1 Individual Weather Exemption: May be requested by the crews responding on the basis of road/weather conditions (i.e. poor visibility or icy roads, etc.). This request must be made by the crew to the dispatch services. 2.6.2 Train or other unexpected road closure. 2.6.3 Bad address or other inaccurate dispatch information out of the control of the responding crew. 2.7 Time on Task: PVH shall complete patient turnover and ambulance clean/restock within fifteen (15) minutes and be en -route back to its assigned district. This time on task may be extended depending on extenuating circumstances (i.e. Full Trauma Teams, Cardiac Arrest, etc...) Crew will detail this information. 2.8 Education: PVH agrees to provide continuing medical education (CME) to the staff at Johnstown. Topics will include all CME required to complete the National Registry recertification. PVH agrees to provide the following courses; Pre -Hospital Trauma Life Support, Pediatric Education for Pre -Hospital Professionals, and Advanced Medical Life Support thru UCH clinical Education Department; course tuition for all classes will be covered by the Northeast RETAC provided funds are available. 2.8.1 All PVH EMS Personnel assigned to Johnstown will maintain Colorado Department of Public Health and Environment Certification, National Registry Certification as well as Pre -Hospital Trauma Life Support, Advanced Medical Life Support and Pediatric Advanced Life Support or equivalent course within 1 year. 2.9 Make available PVH Ambulance Driver Training to Fire Personnel 2.10 National Registry Affiliation: Johnstown employees who maintain National Registry certification will be encouraged to affiliate with PVH EMS to ease the process of recertification. Page 3 2.11 Key Performance Indicators: PVH agrees to comply with the Key Performance Indicators as described on Exhibit A attached and incorporated into this Agreement. 2.12 Quality Assurance and Quality Indicators: PVH shall conduct regular Quality Assurance of EMS Patient Care Reports. PVH will also conduct frequent After Action Reports to improve continuity of patient care. PVH shall conduct targeted reviews of certain call types across the service areas based on services provided (i.e. spinal immobilization, pain management, etc.) These reviews will he used to ensure that care delivered to Johnstown meets and exceeds nationally accepted benchmarks. 2.13 Medical Supplies: PVH shall provide durable medical equipment for each ambulance under this Agreement. The durable medical equipment to be Examples of equipment provided includes: (I) cot, (ii) monitor/defibrillator, (iii) stair chair, (iv) suction, (v) split boards, (vi) road safety driver monitoring system, (vii) laptop to be used for Computer Aided Dispatch (CAD) purposes and any other durable medical equipment required by state, county or local statutes. PVH shall provide disposable medical supplies used by Johnstown on calls for service to include any disposable supply, which is currently stocked on the ambulance. PVH shall provide medical oxygen used on calls for service. PVH shall insure oxygen cylinders will be delivered to stations where PVH crews are quartered and PVH crews shall trade out empty cylinders with Johnstown crews. 2:14 Crew Station Duties: PVH agrees to insure that the crew performs the station duties as a member of the team and as a resident of the station. The PVH EMS Captain shall insure that the EMS crew completes all duties. 2.15 Communications. PVH shall purchase and maintain 800mHz pack -sets for each ambulance. Serious communications issues shall be identified by the oversight committee and addressed. 2.16 Fuel for Vehicles. PVH is responsible for fuel necessary to operate vehicles deeded by PVH to Johnstown for the duration of the agreement. 2.17 PVH shall provide a Certificate of Insurance to Johnstown upon request. The Certificate of Insurance shall provide proof of: a. general liability; General liability coverage shall be for not less than $1,000,000 (one million dollars) per occurrence and $3,000,000 (three million dollars) per aggregate. PVH employees are not entitled to Worker's Compensation benefits from Johnstown. 2.18 PVH shall abide by the terms of the Business Associate Agreement as attached and incorporated herein as Exhibit B. 2.19 PVH personnel assigned to Johnstown shall respond in Johnstown's ambulance to the scene of a medical incident as directed by either Johnstown or a dispatch center. If patient transport is warranted, PVH personnel shall operate Johnstown's ambulance to effect such transport. Johnstown personnel shall normally not be utilized as ambulance attendants or drivers except when unusual circumstances warrant such duties, Page 4 3. JOHNSTOWN RESPONSIBILITIES 3.1 Performance problems of PVH employees placed with Johnstown will be documented and reported to PVH immediately. 3.2 Johnstown shall be responsible for providing suitable living and workspaces at their station as well as bay space for parking the ambulance. These include, equipment, furniture, connectivity, phone, etc. The parties agree to work together to provide connectivity to the PVH Intranet or other network connectivity. 3.3 Johnstown shall ensure PVH has an 800mHz letter of permission to operate on their channel as well as appropriate dispatch software installed on each ambulance laptop. 4. INDEMNIFICATION 4.1 Johnstown agrees to indemnify, defend, and hold harmless PVH from and against any and all claims, judgments, costs, liabilities, damages, and expenses, including attorney fees whatsoever arising from any acts or omissions in the provision of services by Johnstown under this Agreement. 4.2 PVH agrees to indemnify, defend, and hold harmless Johnstown from and against any and all claims, judgments, costs, liabilities, damages, and expenses, including attorney fees whatsoever arising from any acts or omissions in the provision of services by PVH's employees under this Agreement. 5. PAYMENT AND BILLING. Beginning on the Effective Date, PVH agrees to pay Johnstown twenty four cents ($0.24) per mile, payable annually. 6. TERM AND TERMINATION 6.1 The term of this Agreement shall be from the Effective Date through December 31, 2018. 6.2 This Agreement may be terminated without cause by PVH or Johnstown upon 30 (thirty) days written notice of termination to the other party. 6.3 Johnstown may terminate this agreement immediately when quality of care or patient safety is deemed by Johnstown to be at unreasonable risk due to acts or omissions by PVH. 6.4 This Agreement may not be assigned, delegated or transferred by either party without the written consent of the other. 6.5 This Agreement may not be modified, except by written agreement executed by the Parties, provided if PVH deems modification necessary to comply with IRS requirements, 42 U.S.C. 1320a -7b or 42 U.S.C. 1395nn or other applicable laws, Page 5 PVH may modify this Agreement to the extent necessary to comply with the applicable law. 7. REGULATORY COMPLIANCE 7.1 OBLIGATION SUBJECT TO ANNUAL APPROPRIATION. In so far as the financial obligations of the District as contained herein may be deemed to be multi -year financial obligations under Article X, Section 20 of the Colorado Constitution, such obligations shall be subject to annual appropriation of funds by the Johnstown governing board. Notwithstanding anything herein to the contrary, in the event of non -appropriation, Johnstown shall have the right to terminate this Agreement at the end of its then current fiscal year without penalty or other legal consequence. Notice of such intended non -appropriation shall be given by Johnstown at the earliest possible point in time during the preparation of its annual budget for the ensuing fiscal year, but in no event less than December 1 of the then current fiscal year. 7.2 In performing this Agreement, the parties agree to comply with all applicable state and federal laws. This Agreement shall be construed in accordance with the laws of the State of Colorado. 8. Independent Contractor Relationship 8.1 In performance of this Agreement, it is mutually understood and agreed that the PVH is at all times acting and performing as an independent contractor for the contract services. PVH will determine the method, and means of performing the Contract Services. The sole interest and responsibility of Johnstown is to ensure that the Contract Services shall he in accordance with applicable law, recognized standards of professional practice and the terms of this Agreement. 8.2 PVH shall have the right to perform the Contract Services for individuals or entities other than Johnstown during the term of this Agreement. 9. Access to Documentation For the purpose of implementing Section 1861 (v)(1)(I) of the Social Security Act, as amended, and any written regulations thereto, Johnstown agrees to comply with statutory requirements governing the maintenance of documents to verify the cost of services rendered under this Agreement as follows: 9.1 Until the expiration of four years after the furnishing of such services pursuant to this Agreement, Johnstown shall make available, upon written request to PVH and/or the Secretary of Health and Human Services, or upon request to the Comptroller General, or any of their duly authorized representatives, the contracts, books, documents and records of such Johnstown that are necessary to certify the nature and extent of such costs, and; 10. Notice All notices and other communications that either party may desire or may be required to deliver to the other party may be delivered in person or by depositing the same in the Page 6 United States mail, postage prepaid, certified or registered mail, or by electronic facsimile, addressed or delivered as follows: If to PVHS: Attention: President/CEO Poudre Valley Hospital 1024 South Lemay Avenue Fort Collins, CO 80524 FAX (970) 495-7663 If to Johnstown: Fire District: Johnstown Fire Protection District Attn: Fire Chief 100 Telep Johnstown, CO 80534 With a copy to: PVHS Legal Department 2315 E. Harmony Rd., Ste. 200 Fort Collins, CO 80528 Fax: (970) 237-7094 Either party may change the address to which notices are to be delivered by giving notice herein provided. Any notice shall be deemed to have been given if hand delivered or sent by electronic facsimile, as of the date delivered or transmitted, or if mailed as provided herein, on the third day after mailing. 11. Governing Law This Agreement shall be governed by and construed under the laws of the State of Colorado. 12. Modification and Waiver This Agreement can be amended only with a written agreement executed by the parties at the time of the modification. No breach of any provision hereof can be waived unless in writing. Waiver of any one breach of any provision hereof shall not be deemed a waiver of any other breach of the same or any other provision hereof. 13. Severability If any one or more of the terms, provisions, promises, covenants or conditions of the Agreement or the application thereof to any person or circumstance shall be adjudged to any extent invalid, unenforceable, void or voidable for any reason whatsoever, by a court of competent jurisdiction, or shall be determined by the ruling or interpretations of a Governmental agency or new legislation, to cause either party to perform an act which threatens its governmental provider or tax status, then such terms shall be deemed stricken from this agreement, and each and all of the remaining terms, provisions, promises, covenants and conditions of this Agreement or their application to other persons or circumstances shall not be affected thereby and shall be valid and enforceable to the fullest extent permitted by law. Notwithstanding the aforesaid, should the severance have the effect of materially altering the meaning of this Agreement, this Agreement shall be void. 14. Interpretation Page 7 No provision in this Agreement is to he interpreted for or against any party because that party or that party's legal representative drafted such provision. 15. Disclosure Neither party to this Agreement will disclose to anyone, without the other party's prior written permission, the nature or content of any oral or written communication, or any information gained from the inspection of any record(s) or document(s) submitted to each party under this Agreement, including the terms of this Agreement, information obtained from corporate or personal records or documents; and neither party will permit inspection of any papers or documents related to this engagement without the other party's prior written consent. 16. Assignment Neither party may assign this Agreement without the prior written consent of the other party. 17. Entire Agreement This Agreement embodies the entire agreement and understanding between the parties with respect to the subject matter of this Agreement and supersedes all prior and contemporaneous oral and written agreements with respect hereto. Page R By: Date: IN WITNESS HEREOF, the Parties have caused this Agreement to be executed by their authorized officers as evidenced by their signatures below. For "Johnstown" Teel TAX/SS ID Number: (Please provide W-9; this document can be found at http://www.irs.gov/puhtirs-pdflfw9,pdf) State of Colorado City of County of kx_) C\ } The foregoing instrument was acknowledged before me on this 9(f)dayof FIht11i 20JJhy l� Y11' 1I7� (name). in AO, (Notary Seal) (IJot.ry ig -ddf ) i Z'OI. J (Commis ion EOration Dale) FOR POUDRE VALLEY HEALTH CARE, INC. D/B/A POUDRE VALLEY HOSPITAL By: ACHE, President/CEO Pou r. Val) -y Hospital 11-2 Date State of Colorado City of fort CCA._ YIS County of 1.G‘_y i {Y Q C (l/ ,, The foregoing instrument was acknowledged before me on this /_. (> day of.J--'-y\, 2tl3by VIVI Dan/ 1�VI (name). il (Notary Signature) 11II-21 x0 1I (Commission Expiration Date) J-(0 d/ (Notary Seal) Page 9 My Commission Expires 08/31/2069 EXHIBIT A Key Performance Indicators key Performance Indicators (KPI) will be reported to an oversight board on a monthly basis and annual basis, I<Pls to be reported shall include: Requests for Service: A report outlining requests for service, sorted by call type Response Times: see Section 2.4 and 2.5 for specific standards Destination Report: A report outlining Hospital Destinations Training: A report of all education and training provided to the Johnstown staff. After Action Reports: A report of all after actions reports conducted by PVH crew and Johnstown staff. Additional Activities: A report of additional activities to include; Fire Standbys, Community Paramedicine Activities, Special Event Coverage, etc Average Call Costs: A report of geographically adjusted call costs will be presented. Communications: Communication issues Page 10 EXHIBIT B BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ("Agreement") is effective this 15th day of May 2013 ("Effective Date"), by and between JOHNSTOWN FIRE PROTECTION DISTRICT ("JOHNSTOWN") and POUDRE VALLEY HEALTH CARE, INC., D/B/A POUDRE VALLEY HOSPITAL a Colorado non-profit corporation ("Business Associate"). RECITALS WHEREAS, the parties have executed an agreement or agreements whereby Business Associate provides independent contractor services to JOHNSTOWN, and Business Associate receives, has access to or is subject to the federal regulations issued pursuant to the Health Insurance Portability and Accountability Act ("FIIPAA") and codified at 45 C.F.R. parts 160 and 164 ("HIPAA Rules"); WHEREAS, the HIPAA Rules require JOI-INSTOWN to enter into a contract with Business Associate in order to mandate certain protections for the privacy and security of Health Information, and those Regulations prohibit the disclosure to or use of Health Information by Business Associate if such a contract is not in place; WHEREAS, Business Associate acknowledges that effective January 1, 2010, as a business associate, it is responsible to comply with the HIPAA Security and Privacy regulations pursuant to Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH), including Sections 164.308, 164.310, 164.312 and 164.316 of title 45 of the Code of Federal Regulations. NOW, THEREFORE, in consideration of the foregoing, and for other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties agree as follows: DEFINITIONS 1.1 "Disclose" and "Disclosure" mean, with respect to Health Information, the release, transfer, provision of access to, or divulging in any other manner of Health Information outside Business Associate's internal operations or to other than its employees. 1.2 "Health Information" means information that (i) relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual; (ii) identifies the individual (or for which there is a reasonable basis for believing that the information can be used to identify the individual); and (Hi) is received by Business Associate from or on behalf of JOHNSTOWN, or is created by Business Associate, or is made accessible to Business Associate by JOHNSTOWN. 1.3 "Individually Identifiable Health Information" shall mean information that can be used to identify the individual, such as a name or social security number. 1.4 "Protected Health Information" shall mean Health Information and Individually Identifiable Health Information in any medium whether electronic or otherwise. Page 11 1.5 "Security Incident" shall mean the attempted or successful unauthorized access, use disclosure, modification, or destruction of information or interference with system operations in an information system. 1.6 "Security Rules" shall mean the security standards for the protection of electronic protected health information at 45 CFR Part 164, Subpart C and amendments thereto. 1.7 "Services" has the same meaning as in the Services Agreement. 1.8 "Use" or "Uses" mean, with respect to Health Information, the sharing, employment, application, utilization, examination or analysis of such Information within Business Associate's internal operations. 1.9 All capitalized terms not defined in this section shall have the meanings ascribed to them in 45 C.F.R. Part 160 and Part 164, subparts A and E pursuant to the Health Insurance Portability and Accountability Act of 1996. OBLIGATIONS OF BUSINESS ASSOCIATE 2.1 Permitted Uses and Disclosures of Health Information, Unless otherwise specifically provided in this Agreement or authorized in writing by JOHNSTOWN, and except as required or permitted by law, Business Associate hereby agrees (a) to keep all PI -II confidential and in its possession except as necessary to provide the services under the Services Agreement; (b) to restrict access to PHI to those employees of Business Associate or other workforce members under the control of Business Associate who are actively and directly participating in providing the Services and who need to know such information in order to fulfill such responsibilities ("Business Associate Representatives"); (c) not to copy or duplicate any PHI except as necessary to provide the services under the Services Agreement; (d) to treat any and all copies of, and notes, memoranda, analyses, compilations, abstracts, synopses, studies of other material produced from PHI as PHI; (e) to communicate only with the authorized representatives of PVHS concerning PHI; (f) not to use any PHI for any purpose other than the purpose for which such PHI was provided in connection with providing the services under the Services Agreement; and (g) not to use PHI in any manner that would violate the HIPAA Rules if JOHNSTOWN were providing the services under the Services Agreement or in any other manner that may he detrimental to JOHNSTOWN. 2.2 Uses and Disclosures of PHI for Business Associate Operations. Business Associate may use PHI, if necessary, for the proper management and administration of Business Associate or to carry out the legal responsibilities of Business Associate. Business Associate may disclose PHI for its proper management and administration or to carry out its legal responsibilities if the disclosure is required by law, or if Business Associate obtains reasonable written assurances from the Person to whom PHI will be disclosed that: (a) PHI will be held confidentially and used or further disclosed only for the purpose for which it was disclosed to such Person or only as required by law; and (b) such Person will notify Business Associate of any instances of which it becomes aware in which the confidentiality of PHI was breached. 2.3 Adequate Safeguards for Health Information. Business Associate warrants that it shall implement and maintain appropriate administrative, physical and technical safeguards in compliance with the HIPAA Rules and any other relevant laws or regulations to prevent the Use or Page 12 Disclosure of Health Information in electronic or any other form that it creates, receives, maintains or transmits under this Agreement, in any manner other than as permitted by this Agreement. 2.4 Reporting Non -Permitted Use or Disclosure. Business Associate shall report to JOHNSTOWN each Use or Disclosure that is made by Business Associate, its employees, representatives, agents or subcontractors that is not specifically permitted by this Agreement, including any Security Incident involving Health Information as required by the Security Rules. The initial report shall be made by telephone call to the appropriate representative at JOHNSTOWN within forty-eight (48) hours from the time the Business Associate becomes aware of the non -permitted Use or Disclosure, followed by a full written report to the Privacy Officer no later than ten (10) business days from the date the Business Associate becomes aware of the non -permitted Use or Disclosure. Business Associate shall take (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. 2.5 Business Associate's Notification. Business Associate's notification to JOHNSTOWN pursuant to Section 2.4 of this Agreement shall include the following: • Identification of the nature of the non -permitted use or disclosure of other breach; • Identification of the PHI used, accessed or disclosed; • Identification of who made the non -permitted use or received the non -permitted disclosure; • Identification of what corrective action Business Associate took or will take to prevent further non -permitted uses or disclosures; • Identification of what Business Associate did or will do to mitigate any negative effect of the non -permitted use or disclosure; and • Provide such other information, including a written report, as JOHNSTOWN may reasonably request. 2.6 Sub -Contractors and Agents. Business Associate will ensure that any and all Persons who have access to PHI by or through Business Associate, including (without limitation) the Business Associate Representatives, agrees to the same restrictions and conditions that apply to Business Associate hereunder. 2.7. Availability of Internal Practices Books and Records to Government Agencies. Business Associate agrees to make its internal practices, books and records relating to the Use and Disclosure of Health Information available to the Secretary of the federal Department of Health and Human Services (the "Secretary") for purposes of determining JOHNSTOWN's compliance with the HIPAA Rules. Business Associate shall immediately notify JOHNSTOWN of any requests made by the Secretary and provide JOHNSTOWN with copies of any documents produced in response to such request. 2.8. Access to and Amendment of Health Information. Business Associate shall, to the extent JOHNSTOWN determines that any Health Information constitutes a "designated record set" under the HIPAA Rules, (a) make the Health Information specified by JOHNSTOWN available to the individual(s) identified by JOHNSTOWN as being entitled to access and copy that Health Information, and (b) make any amendments to Health Information that are requested by JOHNSTOWN. Business Associate shall provide such access and make such amendments within the time and in the manner specified by JOHNSTOWN. Page 13 2.9 Accounting of Disclosures. Upon JOHNSTOWN's request, Business Associate shall provide to JOHNSTOWN an accounting of each Disclosure of Health Information made by Business Associate or its employees, agents, representatives or subcontractors (Disclosure"). Any accounting provided by Business Associate under this Section 2.9 shall include: (a) the date of the Disclosure; (b) the name, and address if known, of the entity or person who received the Health Information; (c) a brief description of the Health Information disclosed; and (d) a brief statement of the purpose of the Disclosure. For each Disclosure that could require an accounting under this Section 2.9, Business Associate shall document the information specified in (a) through (d), above, and shall securely maintain that documentation for six (6) years from the date of the Disclosure. 2.10 Availability for Audit. Business Associate shall make its internal practices, books, and records relating to the Use and Disclosure of PHI received from JOHNSTOWN, or created or received by Business Associate on behalf of JOHNSTOWN available to the Secretary for purposes of the Secretary determining JOHNSTOWN's compliance with the Privacy Rule. In the event that Business Associate is requested by the Secretary to make available its books, records and documents relating to JOHNSTOWN compliance with the Privacy Rule, Business Associate will, to the extent not prohibited by law, notify JOHNSTOWN within 2 business days. 2.11 Obligation of JOHNSTOWN. JOHNSTOWN shall notify Business Associate of any current or future restrictions or limitations on the use of Health Information that would affect Business Associate's performance of the Services, and Business Associate shall thereafter restrict or limit its own uses and disclosures accordingly. 2.12. Security Standards. Business Associate will: (a) Implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf of JOHNSTOWN. (b) Ensure that any agent, including a subcontractor, to whom Business Associate provides such electronic PHI agrees to implement reasonable and appropriate safeguards to protect it; and (c) Report to JOHNSTOWN any security incident affecting JOHNSTOWN of which Business Associate becomes aware in accordance with the Security Rules. 2.13. Notification of Breach of Unsecured Protected Health Information. Business Associate will: (a) Except as provided in 45 C.F.R. § 164.412, report immediately to PVHS after it becomes aware of any Breach of Unsecured Protected Health Information and promptly provide to JOHNSTOWN (i) a list of all Individuals whose Unsecured Protected Health Information has been, or is reasonably believed by the Business Associate to have been, accessed, acquired, used, or disclosed during the Breach, and (ii) any other available information that JOHNSTOWN is required to include in notifications to such Individuals pursuant to 45 C.F.R. § 164.404(c); and (b) Cooperate with JOHNSTOWN in making any requisite notifications to Individuals and the Secretary as a result of any Breach of Unsecured Protected Health Information, including paying for the cost of notification to Individuals, and of media notification if the legal requirements for media notification are triggered by the circumstances of such breach, provided that Business Associate shall not initiate any such notifications without approval of JOHNSTOWN. Page 14 2.14 Term and Termination. The term of this Agreement shall be the same as the term of the Services Agreement. In addition to and notwithstanding the termination provisions set forth in the Services Agreement, both this Agreement and the Services Agreement may be terminated immediately upon written notice by JOHNSTOWN to Business Associate if JOHNSTOWN determines, in its sole discretion, that Business Associate has violated any material term of this Agreement or any provision of the Privacy Standards or Security Standards or applicable federal or state privacy law relating to the obligations of Business Associate under this Agreement. Business Associate's obligations under Sections 2.1 2.2, 2.3, 2.4, 2.5, 2.6, 2,7, 2.8, 2.10, 2,12, and 2.13 shall survive the termination or expiration of this Agreement. 2.15. Disposition of Health Information Upon Termination or Expiration. Upon termination or expiration of this Agreement and the Services Agreement, Business Associate shall either return or destroy, in JOHNSTOWN's sole discretion and in accordance with any instructions by JOHNSTOWN, all Health Information in the possession or control of Business Associate or its agents and subcontractors. However, if Business Associate determines that neither return nor destruction of Health Information is feasible and notifies JOHNSTOWN in writing of that determination, Business Associate may retain Health Information provided that Business Associate (a) continues to comply with the provisions of this Agreement for as long as it retains Health Information, and (b) further limits Uses and Disclosures of Health Information to those purposes that make its return or destruction unfeasible. Upon termination or expiration of this Agreement, Business Associate will give to JOHNSTOWN copies of all documents in Business Associate's possession or control that are required to be maintained by or on behalf of JOHNSTOWN by the HIPAA Rules or the Security Rules other than what Business Associate is permitted or required by law to retain. 2.16. No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement. 2.17. Use of Subcontractors and Agents. Business Associate shall require each of its agents and subcontractors that receive Health Information from Business Associate to execute a written agreement obligating the agent or subcontractor to comply with all the terms of this Agreement, including appropriate and comparable safeguards, as defined in Section 2, above. 2.18. Relationship to Services Agreement Provisions. In the event that a provision of this Agreement is contrary to a provision of the Services Agreement, the provision of this Agreement shall control. Otherwise, this Agreement shall be construed under, and in accordance with, the terms of the Services Agreement. 2.10 Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits JOHNSTOWN to comply with the HIPAA Rules. 2.20 Amendment. The parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for JOHNSTOWN to comply with the requirements of the HIPAA Rules. 2.21 Waivers. No delay or omission by JOHNSTOWN in exercising any rights or remedies under this Agreement or applicable law shall impair such right or remedy or be construed as a waiver of any such right or remedy. Any single or partial exercise of a right or remedy shall not preclude further exercise of that right or remedy or the exercise of any other right or remedy. No waiver shall be valid unless in writing signed by the party to be bound. Page 15 AMBULANCE SERVICES AGREEMENT THIS AMBULANCE SERVICES AGREEMENT is entered into on January IS , 2013, to he effective as of 120 days from the entrance into the agreement (the "Effective Date") by and between POUDRE VALLEY HEALTH CARE, INC. D/B/A POUDRE VALLEY HOSPITAL, a Colorado non-profit corporation ("PVH") and MILLIKEN FIRE PROTECTION DISTRICT, a Colorado Title 32 special district ("Milliken"). A. PVHS is engaged in the business of operating Poudre Valley Hospital, an acute care hospital with its principal place of business at 1024 South Lemay Avenue, Fort Collins, Colorado (the "Hospital" or "PVH"). PVH provides emergency medical services at medical incidents to patients in Larimer and Weld Counties through its ambulance services. B. Milliken has the authority under Colorado Secs 32-1-103(7), C.R.S. and 32-1-1002(1)(e)(I), C.R.S. to provide for ambulance services to patients in its district. Pursuant to these statutes, Milliken desires to contract with PVH for qualified personnel to provide emergency medical services as part of ambulance services ("Contract Services"). C. PVH has the staff and equipment to provide the requisite Contract Services to Milliken. D. The parties desire to enter into this Agreement in order to provide a full statement of their respective responsibilities in connection with the delivery of services from PVH to Milliken. ACCORDINGLY; PVH and Milliken agree to the following: 1. JOINT RESPONSIBILITIES 1.1 No Milliken employee shall he deemed to be an employee of PVH, nor shall any employee of PVH be deemed to be an employee of Milliken. 1.2. Both parties shall work collaboratively to ensure the most efficient use of the resources at the scenes of medical requests for services. Both agencies shall ensure that they work from a similar standard operating procedure with the goals of high quality and efficient patient care as well as safety of all responders. 1.3 Both parties shall work together to obtain and maintain current mutual aid agreements from surrounding agencies. 1.4 Both parties shall work in conjunction to ensure that customers receive the highest quality care and that patients are satisfied with such care. Both parties shall work towards quantifying levels of customer satisfaction. 2. PVH RESPONSIBILITIES 2.1 Vehicle Donation: PVH agrees to transfer ownership of two ambulances and one command vehicle (see 2.1.1) to Milliken. PVH agrees to pay for all maintenance on the vehicles for the remainder of the 2013 calendar year. As of January 1, 2014 all maintenance and any replacement costs for ambulances will be the sole responsibility of Milliken 2.1.1 Med 16 2008 Ford F-350 XLT with Frazer Type I Generator Powered Module VIN-1FDWF36R68ED13130 Page 1 2.2 Crew: PVH agrees to provide the following personnel to be deployed: 2.2.1 Standard Deployment Level 3 call: 2.2.1 (a) Windsor Station 1 (located at 100 N. 7th Street) ALS Primary Response Ambulance 2.2.1 (b) Windsor Station 1- Single Resource Captain Ambulance 2.2.1 (c) Milliken Station (located at 101 S. Irene Ave) 1- ALS Primary Response Ambulance 2.2.2 Single Response Level 2 call: 2.2.2 (a) Either primary Ambulance responds to 911 call 2.2.2 (b) Windsor ALS Primary Response Ambulance flexes to open district (if initial call was in Milliken/Milliken District). 2.2.3 Double Response Level 1 call: 2.2.3 (a) Remaining Ambulance will post in Iron Mountain Area 2.2.4 Triple Response 2.2.4 (a) Mutual Aid Agreement with PVH EMS (Fort Collins) or Thompson Valley EMS or Banner Northern Colorado Medical Center EMS 2.2.5 Additional Resources to be Concerned: 2.2.5 (a) 40 hour supervisor (single response capability in a non -transport capable vehicle) 2.3 Response Area: The Response Areas for the Milliken district shall be divided into three areas, the "Urban Response Area", the "Suburban Response Area" and the "Rural Response Area'. The Urban Response Area is defined as the area encompassed by North by WCR 52, East by WCR 27 and 77"' Ave, South by WCR 42, and West by the border between Johnstown and Milliken Fire Protection District (approx. HWY 257),. The Suburban Response Area is defined as the Hill -N -Park /Dos Rios/Arrowhead Area and includes the area in the Milliken Fire Protection District encompassed by North by WCR 54, East by WCR 33, South by WCR 50, by West WCR East by 77th Ave. The Rural Response Area is considered all areas not defined by The Urban Response Area and The Suburban Response Area but in the Milliken district. 2.4 Response Time Expectations: Response Time is defined as the time period between when the ambulance first gained enough information to respond (i.e. dispatch time) and the time a properly equipped and staffed unit arrives at the scene defined as "wheels stopped". PVH agrees that the Response Time for the Urban Response Area shall be eight minutes and fifty-nine seconds (8:59) or less in ninety percent (90%) of Emergent Calls. Emergent calls are defined as calls as -defined-by Emergency Medical Dispatch- Protocols; i.e. Echo, Delta, Charlie or Emergency Medical Dispatch Designation. PVH agrees that the Response Time for the Suburban Response Area shall be eleven minute and fifty-nine seconds (11:59) or less in ninety percent (90%) of Emergent Calls. PVH agrees that the Response Time for the Rural Response Area shall be nineteen minutes and fifty-nine seconds or less in ninety percent (90%) of Emergent Calls. In the event of a Concurrent Response, defined as any additional call for service while the primary ALS ambulance is assigned to a request for service or released up till 15 minutes after arrival at a receiving facility if transported. Page 2 2.5 Exemption to Response Times: If the Response Times exceed the defined Response Times in Section 2.4, PVH may apply for a Concurrent or Surge Exemption and it will be granted if PVH can demonstrate: 2.5.1 It meets the definition of a Concurrent Request 2.5.2 There are no lost unit hours during the timed period 2.5.3 Time on Task at receiving facility does not exceed agreed terms. Time on task includes all time from dispatch up to 15 minutes after arrival at a receiving facility as defined in section 2.7. 2.5.4 The Deployment Plan was followed. Deployment plan shall adjusted by representatives of Milliken and PVH as necessary. 2.5.5 There were no routing delays 2.5.6 PVH can demonstrate a continuing effort to mitigate late responses. 2.6 Weather and other exemptions to Response Times: A blanket exemption may he granted by the Fire Chief or his/her delegate for the following: 2.6.1 Individual Weather Exemption: May be requested by the crews responding on the basis of road/weather conditions (i.e. poor visibility or icy roads, etc.). This request must be made by the crew to the dispatch services. 2.6.2 Train or other unexpected road closure. 2.6.3 Bad address or other inaccurate dispatch information out of the control of the responding crew. 2.7 Time on Task_ PVH shall complete patient turnover and ambulance clean/restock within fifteen (15) minutes and be en -route back to its assigned district. This time on task may be extended depending on extenuating circumstances (i.e. Full Trauma Teams, Cardiac Arrest, etc...) Crew will detail this information. 2.8 Education: PVH agrees to provide continuing medical education (CME) to the staff at Milliken. Topics will include all CME required to complete the National Registry recertification. PVH agrees to provide the following courses; Pre -Hospital Trauma Life Support, Pediatric Education for Pre -Hospital Professionals, and Advanced Medical Life Support thru UCH clinical Education Department; course tuition for all classes will he covered by the Northeast RETAC provided funds are available. 2.8.1 All PVH EMS Personnel assigned to Milliken will maintain Colorado Department of Public Health and Environment Certification, National Registry Certification as well as Pre -Hospital Trauma Life Support, Advanced Medical Life Support and Pediatric Advanced Life Support or equivalent course within 1 year. 2.9 Make available PVH Ambulance Driver Training to Fire Personnel 2.10 National Registry Affiliation: Milliken employees who maintain National Registry certification will he encouraged to affiliate with PVH EMS to ease the process of recertification. 2.11 Key Performance Indicators: PVH agrees to comply with the Key Performance Indicators as described on Exhibit A attached and incorporated into this Agreement. 2.12 Quality_ Assurance and Quality Indicators: PVH shall conduct regular Quality Assurance of EMS Patient Care Reports. PVH will also conduct frequent After Action Reports to improve continuity of patient care. PVH shall conduct targeted reviews of certain call types across the service areas based on services provided Page 3 (i.e. spinal immobilization, pain management, etc.) These reviews will be used to ensure that care delivered to Milliken meets and exceeds nationally accepted benchmarks. 2.13 Medical Supplies: PVH shall provide durable medical equipment for each ambulance under this Agreement. The durable medical equipment to be Examples of equipment provided includes: (I) cot, (ii) monitor/defibrillator, (iii) stair chair, (iv) suction, (v) split boards, (vi) road safety driver monitoring system, (vii) laptop to be used for Computer Aided Dispatch (CAD) purposes and any other durable medical equipment required by state, county or local statutes. PVI- shall provide disposable medical supplies used by Milliken on calls for service to include any disposable supply, which is currently stocked on the ambulance. PVH shall provide medical oxygen used on calls for service. PVH shall insure oxygen cylinders will he delivered to stations where PVH crews are quartered and PVH crews shall trade out empty cylinders with Milliken crews. 2.14 Crew Station Duties: PVH agrees to insure that the crew performs the station duties as a member of the team and as a resident of the station. The PVH EMS Captain shall insure that the EMS crew completes all duties. 2.15 Communications. PVH shall purchase and maintain 800mHz pack -sets for each ambulance. 2.16 Fuel for Vehicles. PVH is responsible for all fuel necessary for all vehicles donated to Milliken. 2.16 PVH shall provide a Certificate of Insurance to Milliken upon request. The Certificate of Insurance shall provide proof of: a. general liability; General liability coverage shall he for not less than $1,000,000 (one million dollars) per occurrence and $3,000,000 (three million dollars) per aggregate. PVH employees are not entitled to Worker's Compensation benefits from Milliken. 2.17 PVH shall abide by the terms of the Business Associate Agreement as attached and incorporated herein as Exhibit B. 2.18 PVH personnel assigned to Milliken shall respond in Milliken's ambulance to the scene of a medical incident as directed by either Milliken or a dispatch center. If patient transport is warranted, PVH personnel shall operate Milliken's ambulance to effect such transport. Milliken personnel shall normally not be utilized as ambulance attendants or drivers except when unusual circumstances warrant such duties. 3. MILLIKEN RESPONSIBILITIES 3.1 Performance problems of PVH employees placed with Milliken will be documented and reported to PVH immediately. 3.2 Milliken shall be responsible for providing suitable living and workspaces at all ambulance stations. These include, equipment, furniture, connectivity, phone, etc. The parties agree to work together to provide connectivity to the PVH intranet or Page 4 other network connectivity. 3.3 Milliken shall ensure PVH has an 800mHz letter of permission to operate on their channel as well as appropriate dispatch software installed on each ambulance laptop. 4. INDEMNIFICATION 4.1 Milliken agrees to indemnify, defend, and hold harmless PVH from and against any and all claims, judgments, costs, liabilities, damages, and expenses, including attorney fees whatsoever arising from any acts or omissions in the provision of services by Milliken under this Agreement. 4.2 PVFI agrees to indemnify, defend, and hold harmless Milliken from and against any and all claims, judgments, costs, liabilities, damages, and expenses, including attorney fees whatsoever arising from any acts or omissions in the provision of services by PVH's employees under this Agreement. 5. PAYMENT AND BILLING. Beginning on the Effective Date, PVH agrees to pay Milliken one dollar ($1.00) per loaded mile, payable quarterly. 6. TERM AND TERMINATION 6.1 The term of this Agreement shall be from the Effective Date through December 31, 2018. 6.2 This Agreement may be terminated without cause by PVH or Milliken upon 30 (thirty) days written notice of termination to the other party. If termination occurs by Milliken within the first three hundred sixty-five days of PVH assuming provision of EMS in the district, Milliken will be liable for the start-up capital costs incurred by PVH. 6.3 Milliken may terminate this agreement immediately when quality of care or patient safety is deemed by Milliken to be at unreasonable risk due to acts or omissions by PVH. 6.4 This Agreement may not be assigned, delegated or transferred by either party without the written consent of the other. 6.5 This Agreement may not be modified, except by written agreement executed by the Parties, provided if PVH deems modification necessary to comply with IRS requirements, 42 U.S.C. 1320a -7b or 42 U.S.C. 1395nn or other applicable laws, PVH may modify this Agreement to the extent necessary to comply with the applicable law. 7. REGULATORY COMPLIANCE 7.1 OBLIGATION SUBJECT TO ANNUAL APPROPRIATION. In so far as the financial obligations of the District as contained herein may be deemed to be multi -year Page 5 financial obligations under Article X, Section 20 of the Colorado Constitution, such obligations shall be subject to annual appropriation of funds by the Milliken governing board. Notwithstanding anything herein to the contrary, in the event of non -appropriation, Milliken shall have the right to terminate this Agreement at the end of its then current fiscal year without penalty or other legal consequence. Notice of such intended non -appropriation shall be given by Milliken at the earliest possible point in time during the preparation of its annual budget for the ensuing fiscal year, but in no event less than December 1 of the then current fiscal year. 7.2 In performing this Agreement, the parties agree to comply with all applicable state and federal laws. This Agreement shall be construed in accordance with the laws of the State of Colorado. 8. Independent Contractor Relationship 8.1 In performance of this Agreement, it is mutually understood and agreed that the PVH is at all times acting and performing as an independent contractor for the contract services. PVH will determine the method, and means of performing the Contract Services. The sole interest and responsibility of Milliken is to ensure that the Contract Services shall he in accordance with applicable law, recognized standards of professional practice and the terms of this Agreement. 8.2 PVH shall have the right to perform the Contract Services for individuals or entities other than Milliken during the term of this Agreement. Access to Documentation For the purpose of implementing Section 1861 (v)(1)(I) of the Social Security Act, as amended, and any written regulations thereto, Milliken agrees to comply with statutory requirements governing the maintenance of documents to verify the cost of services rendered under this Agreement as follows: 9.1 Until the expiration of four years after the furnishing of such services pursuant to this Agreement, Milliken shall make available, upon written request to PVH and/or the Secretary of Health and Human Services, or upon request to the Comptroller General, or any of their duly authorized representatives, the contracts, books, documents and records of such Milliken that are necessary to certify the nature and extent of such costs, and; 10. - --- Notice All notices and other communications that either party may desire or may be required to deliver to the other party may be delivered in person or by depositing the same in the United States mail, postage prepaid, certified or registered mail, or by electronic facsimile, addressed or delivered as follows: If to PVHS: Attention: President/CEO Poudre Valley Hospital 1024 South Lemay Avenue With a copy to: Page 6 PVHS Legal Department 2315 E. Harmony Rd., Ste. 200 Fort Collins, CO 80528 Fort Collins, CO 80524 Fax: (970) 237-7094 FAX (970) 495-7663 If to Milliken: Fire District: Milliken Fire Protection District Attn: Fire Chief 101 S. Irene Ave Milliken, CO 80543 Either party may change the address to which notices are to be delivered by giving notice herein provided. Any notice shall be deemed to have been given if hand delivered or sent by electronic facsimile, as of the date delivered or transmitted, or if mailed as provided herein, on the third day after mailing. 11. Governing Law This Agreement shall be governed by and construed under the laws of the State of Colorado. 12. Modification and Waiver This Agreement can be amended only with a written agreement executed by the parties at the time of the modification. No breach of any provision hereof can be waived unless in writing. Waiver of any one breach of any provision hereof shall not be deemed a waiver of any other breach of the same or any other provision hereof. 13. Severability If any one or more of the terms, provisions, promises, covenants or conditions of the Agreement or the application thereof to any person or circumstance shall be adjudged to any extent invalid, unenforceable, void or voidable for any reason whatsoever, by a court of competent jurisdiction, or shall be determined by the ruling or interpretations of a Governmental agency or new legislation, to cause either party to perform an act which threatens its governmental provider or tax status, then such terms shall be deemed stricken from this agreement, and each and all of the remaining terms, provisions, promises, covenants and conditions of this Agreement or their application to other persons or circumstances shall not be affected thereby and shall be valid and enforceable to the fullest extent permitted by law. Notwithstanding the aforesaid, should the severance have the effect of materially altering the meaning of this Agreement, this Agreement shall be void. 14. Interpretation No provision in this Agreement is to be interpreted for or against any party because that party or that party's legal representative drafted such provision. 15. Disclosure Neither party to this Agreement will disclose to anyone, without the other party's prior written permission, the nature or content of any oral or written communication, or any information gained from the inspection of any record(s) or document(s) submitted to each Page 7 party under this Agreement, including the terms of this Agreement, information obtained from corporate or personal records or documents; and neither party will permit inspection of any papers or documents related to this engagement without the other party's prior written consent. 16. Assignment Neither party may assign this Agreement without the prior written consent of the other party. 17. Entire Agreement This Agreement embodies the entire agreement and understanding between the parties with respect to the subject matter of this Agreement and supersedes all prior and contemporaneous oral and written agreements with respect hereto. Page 8 IN WITNESS HEREOF, the Parties have caused this Agreement to be executed by their authorized officers as evidenced by their signatures below. For "Milliken": �7 J /1J�,rk_F �lc�rr1 3 Date: /-/b'.?Of -5 TAX/SS ID Number: S `�" ^ t ( 583 (-96 (Please provide W-9; this document can be found at http_//www.irs.gov/pub/irs_pdf/fw9.pdf) State of\ Colorado city of--)A-111I:t Y1 County of \x `Q.\ o The foregoing instrument was acknowledged before me on this id day o f31 fl 2013 by \Act km's (name). (Nola Sign lure) <131 I Zo v3 (Commission Expiration Dale) (Notary Seal) FOR POUDRE VALLEY HEALTH CARE, INC. D/B/A POUD E VALLEY HOSPITAL By: Date State of Coi orado City of County of E, President/CEO Hospital Lt 1YYlo-r �1The foregoing instrument was acknowledged before me on this' I day of` let V-, 20I3hy Un. Tr (name). // 7eidestei\s/ (otary Signature) l I /t3(DOlf_I� (Commission Expiration Date) (Notary Seal) 2cy3 My Comrmssbn Explre$ 08/31/2009 Page 9 EXHIBIT A Key Performance Indicators Key Performance Indicators (KPI) will be reported to an oversight board on a monthly basis and annual basis, KPIs to be reported shall include: Requests for Service: A report outlining requests for service, sorted by call type Response Times: see Section 2.4 and 2.5 for specific standards Destination Report: A report outlining Hospital Destinations Training: A report of all education and training provided to the Milliken staff. After Action Reports: A report of all after actions reports conducted by PVH crew and Milliken staff. Additional Activities: A report of additional activities to include; Fire Standbys, Community Paramedicine Activities, Special Event Coverage, etc Average Call Costs: A report of geographically adjusted call costs will be presented. Page 10 EXHIBIT B BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ("Agreement") is effective this 1st day of May 2013 ("Effective Date"), by and between MILLIKEN FIRE PROTECTION DISTRICT ("MILLIKEN") and POUDRE VALLEY HEALTH CARE, INC., D/B/A POUDRE VALLEY HOSPITAL a Colorado non- profit corporation ("Business Associate"). RECITALS WHEREAS, the parties have executed an agreement or agreements whereby Business Associate provides independent contractor services to MILLIKEN, and Business Associate receives, has access to or is subject to the federal regulations issued pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") and codified at 45 C.F.R. parts 160 and 164 ("HIPAA Rules"); WHEREAS, the HIPAA Rules require MILLIKEN to enter into a contract with Business Associate in order to mandate certain protections for the privacy and security of Health Information, and those Regulations prohibit the disclosure to or use of Health Information by Business Associate if such a contract is not in place; WHEREAS, Business Associate acknowledges that effective January 1, 2010, as a business associate, it is responsible to comply with the HIPAA Security and Privacy regulations pursuant to Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH), including Sections 164.308, 164.310, 164.312 and 164.316 of title 45 of the Code of Federal Regulations. NOW, THEREFORE, in consideration of the foregoing, and for other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties agree as follows: DEFINITIONS 1.1 "Disclose" and "Disclosure" mean, with respect to Health Information, the release, transfer, provision of access to, or divulging in any other manner of Health Information outside Business Associate's internal operations or to other than its employees. 1.2 "Health Information" means information that (i) relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual; (ii) identifies the individual (or for which there is a reasonable basis for believing that the information can be used to identify the individual); and (iii) is received by Business Associate from or on behalf of MILLIKEN, or is created by Business Associate, or is made accessible to Business Associate by MILLIKEN. 1.3 "Individually Identifiable Health Information" shall mean information that can be used to identify the individual, such as a name or social security number. 1.4 "Protected Health Information" shall mean Health Information and Individually Identifiable Health Information in any medium whether electronic or otherwise. ]'age 11 1.5 "Security Incident" shall mean the attempted or successful unauthorized access, use disclosure, modification, or destruction of information or interference with system operations in an information system. 1.6 "Security Rules" shall mean the security standards for the protection of electronic protected health information at 45 CFR Part 164, Subpart C and amendments thereto. 1.7 "Services" has the same meaning as in the Services Agreement. 1.8 "Use" or "Uses" mean, with respect to Health Information, the sharing, employment, application, utilization, examination or analysis of such Information within Business Associate's internal operations. 1.9 All capitalized terms not defined in this section shall have the meanings ascribed to them in 45 C.F.R. Part 160 and Part 164, subparts A and E pursuant to the Health Insurance Portability and Accountability Act of 1996. OBLIGATIONS OF BUSINESS ASSOCIATE 2.1 Permitted Uses and Disclosures of Health Information. Unless otherwise specifically provided in this Agreement or authorized in writing by MILLIKEN, and except as required or permitted by law, Business Associate hereby agrees (a) to keep all PHI confidential and in its possession except as necessary to provide the services under the Services Agreement; (b) to restrict access to PHI to those employees of Business Associate or other workforce members under the control of Business Associate who are actively and directly participating in providing the Services and who need to know such information in order to fulfill such responsibilities ("Business Associate Representatives"); (c) not to copy or duplicate any PHI except as necessary to provide the services under the Services Agreement; (d) to treat any and all copies of, and notes, memoranda, analyses, compilations, abstracts, synopses, studies of other material produced from PHI as PHI; (e) to communicate only with the authorized representatives of PVHS concerning PHI; (f) not to use any PHI for any purpose other than the purpose for which such PHI was provided in connection with providing the services under the Services Agreement; and (g) not to use PHI in any manner that would violate the HIPAA Rules if MILLIKEN were providing the services under the Services Agreement or in any other manner that may be detrimental to MILLIKEN. 2.2 Uses and Disclosures of PHI for Business Associate Operations. Business Associate may use PHI, if necessary, for the proper management and administration of Business Associate or to carry out the legal responsibilities of Business Associate. Business Associate may disclose PHI for its proper management and administration or to carry out its legal responsibilities if the disclosure is required by law, or if Business Associate obtains reasonable written assurances from the Person to whom PHI will he disclosed that: (a) PHI will he held confidentially and used or further disclosed only for the purpose for which it was disclosed to such Person or only as required by law; and (b) such Person will notify Business Associate of any instances of which it becomes aware in which the confidentiality of PHI was breached. 2.3 Adequate Safeguards for Health Information. Business Associate warrants that it shall implement and maintain appropriate administrative, physical and technical safeguards in compliance with the HIPAA Rules and any other relevant laws or regulations to prevent the Use or Page 12 Disclosure of Health Information in electronic or any other form that it creates, receives, maintains or transmits under this Agreement, in any manner other than as permitted by this Agreement. 2.4 Reporting Non -Permitted Use or Disclosure. Business Associate shall report to MILLIKEN each Use or Disclosure that is made by Business Associate, its employees, representatives, agents or subcontractors that is not specifically permitted by this Agreement, including any Security Incident involving Health Information as required by the Security Rules. The initial report shall be made by telephone call to the appropriate representative at MILLIKEN within forty-eight (48) hours from the time the Business Associate becomes aware of the non -permitted Use or Disclosure, followed by a full written report to the Privacy Officer no later than ten (10) business days from the date the Business Associate becomes aware of the non -permitted Use or Disclosure. Business Associate shall take (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. 2.5 Business Associate's Notification. Business Associate's notification to MILLIKEN pursuant to Section 2.4 of this Agreement shall include the following: • Identification of the nature of the non -permitted use or disclosure of other breach; Identification of the PHI used, accessed or disclosed; Identification of who made the non -permitted use or received the non -permitted disclosure; Identification of what corrective action Business Associate took or will take to prevent further non -permitted uses or disclosures; Identification of what Business Associate did or will do to mitigate any negative effect of the non -permitted use or disclosure; and Provide such other information, including a written report, as MILLIKEN may reasonably request. 2.6 Sub -Contractors and Agents. Business Associate will ensure that any and all Persons who have access to PHI by or through Business Associate, including (without limitation) the Business Associate Representatives, agrees to the same restrictions and conditions that apply to Business Associate hereunder. 2.7. Availability of Internal Practices Books and Records to Government Agencies. Business Associate agrees to make its internal practices, books and records relating to the Use and Disclosure of Health Information available to the Secretary of the federal Department of Health and Human Services (the "Secretary") for purposes of determining MILLIKEN's compliance with the HIPAA Rules. Business Associate shall immediately notify MILLIKEN of any requests made by the Secretary and provide MILLIKEN with copies of any documents produced in response to such request. 2.8. Access to and Amendment of Health Information. Business Associate shall, to the extent MILLIKEN determines that any Health Information constitutes a "designated record set" under the HIPAA Rules, (a) make the Health Information specified by MILLIKEN available to the individual(s) identified by MILLIKEN as being entitled to access and copy that Health Information, and (h) make any amendments to Health Information that are requested by MILLIKEN. Business Associate shall provide such access and make such amendments within the time and in the manner specified by MILLIKEN. Page 13 2.9 Accounting of Disclosures. Upon MILLIKEN's request, Business Associate shall provide to MILLIKEN an accounting of each Disclosure of Health Information made by Business Associate or its employees, agents, representatives or subcontractors ("Disclosure'). Any accounting provided by Business Associate under this Section 2.9 shall include: (a) the date of the Disclosure; (b) the name, and address if known, of the entity or person who received the Health Information; (c) a brief description of the Health Information disclosed; and (d) a brief statement of the purpose of the Disclosure. For each Disclosure that could require an accounting under this Section 2.9, Business Associate shall document the information specified in (a) through (d), above, and shall securely maintain that documentation for six (6) years from the date of the Disclosure. 2.10 Availability for Audit. Business Associate shall make its internal practices, books, and records relating to the Use and Disclosure of PHI received from MILLIKEN, or created or received by Business Associate on behalf of MILLIKEN available to the Secretary for purposes of the Secretary determining MILLIKEN's compliance with the Privacy Rule. In the event that Business Associate is requested by the Secretary to make available its books, records and documents relating to MILLIKEN compliance with the Privacy Rule, Business Associate will, to the extent not prohibited by law, notify MILLIKEN within 2 business days. 2.11 Obligation of MILLIKEN. MILLIKEN shall notify Business Associate of any current or future restrictions or limitations on the use of Health Information that would affect Business Associate's performance of the Services, and Business Associate shall thereafter restrict or limit its own uses and disclosures accordingly. 2.12. Security Standards. Business Associate will: (a) Implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf of MILLIKEN. (b) Ensure that any agent, including a subcontractor, to whom Business Associate provides such electronic PHI agrees to implement reasonable and appropriate safeguards to protect it; and (c) Report to MILLIKEN any security incident affecting MILLIKEN of which Business Associate becomes aware in accordance with the Security Rules. 2.13. Notification of Breach of Unsecured Protected Health Information. Business Associate will: (a) Except as provided in 45 C.F.R. § 164.412, report immediately to PVHS after it becomes aware of any Breach of Unsecured Protected Health Information and promptly provide to MILLIKEN (i) a list of all Individuals whose Unsecured Protected Health Information has been, or is reasonably believed by the Business Associate to have been, accessed, acquired, used, or disclosed during the Breach, and (ii) any other available information that MILLIKEN is required to include in notifications to such Individuals pursuant to 45 C.F.R. § 164.404(c); and (b) Cooperate with MILLIKEN in making any requisite notifications to Individuals and the Secretary as a result of any Breach of Unsecured Protected Health Information, including paying for the cost of notification to Individuals, and of media notification if the legal requirements for media notification are triggered by the circumstances of such breach, provided that Business Associate shall not initiate any such notifications without approval of MILLIKEN. Page 14 2.14 Term and Termination. The term of this Agreement shall he the same as the term of the Services Agreement. In addition to and notwithstanding the termination provisions set forth in the Services Agreement, both this Agreement and the Services Agreement may he terminated immediately upon written notice by MILLIKEN to Business Associate if MILLIKEN determines, in its sole discretion, that Business Associate has violated any material term of this Agreement or any provision of the Privacy Standards or Security Standards or applicable federal or state privacy law relating to the obligations of Business Associate under this Agreement. Business Associate's obligations under Sections 2.1 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.10, 2.12, and 2.13 shall survive the termination or expiration of this Agreement. 2.15. Disposition of Health Information Upon Termination or Expiration. Upon termination or expiration of this Agreement and the Services Agreement, Business Associate shall either return or destroy, in MILLIKEN's sole discretion and in accordance with any instructions by MILLIKEN, all Health Information in the possession or control of Business Associate or its agents and subcontractors. However, if Business Associate determines that neither return nor destruction of Health Information is feasible and notifies MILLIKEN in writing of that determination, Business Associate may retain Health Information provided that Business Associate (a) continues to comply with the provisions of this Agreement for as long as it retains Health Information, and (b) further limits Uses and Disclosures of Health Information to those purposes that make its return or destruction unfeasible. Upon termination or expiration of this Agreement, Business Associate will give to MILLIKEN copies of all documents in Business Associate's possession or control that are required to be maintained by or on behalf of MILLIKEN by the HIPAA Rules or the Security Rules other than what Business Associate is permitted or required by law to retain. 2.16. No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement. 2.17. Use of Subcontractors and Agents. Business Associate shall require each of its agents and subcontractors that receive Health Information from Business Associate to execute a written agreement obligating the agent or subcontractor to comply with all the terms of this Agreement, including appropriate and comparable safeguards, as defined in Section 2, above. 2.18. Relationship to Services Agreement Provisions. In the event that a provision of this Agreement is contrary to a provision of the Services Agreement, the provision of this Agreement shall control. Otherwise, this Agreement shall be construed under, and in accordance with, the terms of the Services Agreement. 2.19 Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits MILLIKEN to comply with the HIPAA Rules. 2.20 Amendment. The parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for MILLIKEN to comply with the requirements of the HIPAA Rules. 2.21 Waivers. No delay or omission by MILLIKEN in exercising any rights or remedies under this Agreement or applicable law shall impair such right or remedy or be construed as a waiver of any such right or remedy. Any single or partial exercise of a right or remedy shall not preclude further exercise of that right or remedy or the exercise of any other right or remedy. No waiver shall be valid unless in writing signed by the party to be bound. Page 15 Hello