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Home My WebLink About20193383.tiffRESOLUTION RE: APPROVE AGREEMENT FOR HEALTH SCREENING SERVICES AND AUTHORIZE CHAIR TO SIGN -GOOD SAMARITAN MEDICAL CENTER, LLC 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, the Board has been presented with an Agreement for Health Screening Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Good Samaritan Medical Center, LLC, commencing upon full execution of signatures, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, 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 Agreement for Health Screening Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Good Samaritan Medical Center, LLC, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 29th day of July, A.D., 2019. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, CO ORADO f• ATTEST: dime&:ei Weld County Clrk to the Board BY: APP ounty A torney Date of signature: O rbara Kirkmeyer, Chair Mike Freeman, Pro-Tem Sean P. Conway ames Steve Moreno Cc: (-1RCPR) 1'--/te- /9 2019-3383 PE0033 fir+ ,,y_ m tEcti �aY A' DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 SCL H al, II GOOD SAMARITAN July 15, 2019 Weld County 1150 "O" Street, Greeley, Colorado 80631 Re: Health Screenings Services Dear Weld County: This Letter Agreement and the attached Exhibit (collectively, the "Agreement") reflect the terms and conditions agreed to by Weld County, a body corporate and politic of the State of Colorado, by and through its Board of County Commissioners ("County") and Good Samaritan Medical Center, LLC ("Care Site") pursuant to which Care Site will provide access to certain health services for certain of County's employees ("Employees"), as an independent contractor to County during the Term (as defined below) to be effective as of July 16, 2019 (the "Effective Date"). 1. Health Screening Services. Care Site will make available to County Employees the services described in Exhibit A ("Services"). County will specify the requested Services on each Employee Authorization for Treatment Form, a form of which is attached as Exhibit B. 2. Payment. County will pay to Care Site the fees listed in Exhibit A for the Services. On an annual basis, Care Site has the right, in its discretion and upon providing County a sixty (60) day written notice, to adjust the fees in accordance with fair market value rates. Employees receiving Services who also present with other symptoms or conditions will be screened and treated in accordance with Care Site policies and legal requirements. Care Site shall bill the Employee or his/her third party payor for such services. 3. Invoices. Care Site will invoice County for Services on a monthly basis, and County will pay Care Site within thirty (30) days of receipt of Care Site's invoice. In the event County fails to make payment within the above time frame, County will be responsible for any late fees or interest charged as described in Exhibit A by Care Site in connection with outstanding amounts, as well as any other expenses incurred by Care Site in the event such outstanding amounts are referred to a collection agency. 4. Locations. Appointments for Services for eligible Employees shall be scheduled to be provided, within two (2) weeks from Employee request, and subject to availability, at Good Samaritan Medical Center, located at 200 Exempla Circle, Lafayette, CO 80026. County Page 1 of 7 2019-weldc-25125 2019-3383 DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 JL SCL Health fl r GOOD SAMARITAN acknowledges and understands that Care Site may occasionally be unable to accommodate a particular request for Services, and the services available may change from time to time. 5. County's Obligations. County represents and warrants that the Services contemplated herein, are part of the County's health benefit plan design, and that Employees will be informed of any pre -requisites to receiving Services such as obtaining a referral or visiting a primary care physician prior to presenting to Care Site to receive Services. Further, prior to sending an Employee to receive testing services under this Agreement, County will (i) fully inform such Employee of County's calcium scoring screening policy and any other applicable County health care testing and screening policies and procedures; (ii) obtain appropriate informed consent from such Employee for all testing and screenings; and (iii) provide Employee with a completed form attached as Exhibit B to present to Care Site at the time of service. County agrees to inform the Care Site of any special requirements prior to sending an Employee for the agreed upon Services. County will notify Care Site promptly of any change to County's contact information, including its invoicing address. 6. No Recuirement to Refer. No party is entering into this Agreement with an expectation or obligation that unlawful patient referrals will occur or other business will be generated between County and Care Site. This Agreement is intended to be commercially reasonable and consistent with fair market value for services rendered, and will not vary with or take into account the value or volume of referrals or other business generated by the parties. 7. Compliance with Laws. With respect to this Agreement, Care Site and County, respectively, each agrees that it is bound by and will observe and comply with all applicable local, state and federal laws, ordinances, rules and regulations during the Term of this Agreement. 8. Term and Termination. This Agreement shall commence on the Effective Date and shall continue for a term of one (1) year (the "Initial Term"). This may be terminated by either County or Care Site at any time with or without cause upon providing a thirty (30) days prior written notice to the other. County agrees to reimburse Care Site for any Services provided or expenses incurred as of the date of termination, even if payment is not due until after termination. 9. Records. County acknowledges that the Care Site is subject to compliance with the Federal Health Information Technology for Economic and Care Clinical Health Act of 2009 ("HITECH Act"), the Administrative Simplification Provisions of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), and any current and future regulations promulgated under either the HITECH Act or HIPAA. The parties acknowledge that certain records and documents created by Care Site may constitute employment records not subject to HIPAA and others may include protected health information ("PHI") as that term is defined by HIPAA. Accordingly, all medical records created by Care Site or its employees that contain PHI will remain solely the property of Care Site. Each party shall preserve the privacy and confidentiality of PHI in Page 2of7 2019-weldc-25125 DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 SCL Health GOOD SAMARITAN accordance with HIPAA and other applicable state and federal laws and the privacy and confidentiality of employment records in accordance with applicable state and federal laws. No health information, including any return -to -work evaluation, will be provided to Employer without the Employee's authorization or as required by law. 10. Confidentiality. Except as required by law or as necessary to perform its obligations hereunder, County agrees not to disclose any confidential or proprietary information relating to Care Site and its operations. County represents and warrants that it will respect the privacy of its Employees and County will not attempt to obtain any confidential health information of its Employees from Care Site unless authorized in writing by an Employee or required by law. Care Site shall endeavor to mark all or a part of any information that it does not want disclosed as "Confidential" or the like. However, the absence of such markings on any information provided hereunder shall not in any event be construed so as to remove said information from the scope of this Agreement. Care Site acknowledges that the County must comply with the Colorado Open Records Act (CORA) and Care Site acknowledges that the County cannot guarantee information that is not excepted under CORA or protected by other laws will not be disclosed. The County agrees to notify Care Site of any request for information marked as confidential, so that Care Site may pursue legal remedies to prevent such disclosure. 11. Insurance. The County is a public entity within the meaning of the Colorado Governmental Immunity Act, CRS 24-10-101, et seq., as amended ("Act"). The County shall at all times during the term of this Agreement maintain such liability insurance, by commercial policy or self- insurance, as is necessary to meet its liabilities under the Act, including workers compensation insurance that meets statutory requirements. Nothing in this Agreement shall be construed as a waiver of the protections of said Act. A party will provide to the other party a certificate of insurance from the insurer upon request, and will provide a written notice to the other party ten (10) days prior to the effective date of any reduction, cancellation, termination of or other material change in the coverages under this Section 11. County will provide to Care Site a written notice of each claim filed against County and/or its employees related to Services rendered hereunder within ten (10) days of the filing of said claim. 12. Indemnification. Each party shall be responsible for its own acts and omissions under this Agreement and shall not be responsible for the acts and omissions of the other party. Without limiting the foregoing, the parties acknowledge that County is solely responsible for ensuring that it complies with all laws related to its business and employment of its own employees including, without limitation, laws and regulations related to pre -employment screening and any health benefits plans covering County's employees. 13. Non -Discrimination. Each party agrees that it will comply with the requirements of applicable state and federal law that prohibit discrimination against qualified individuals based on Page 3of7 2019-welde-25125 DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 'tivi SCL Health Otte GOOD SAMARITAN their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on their race, color, religion, age, gender identity, sex, sexual orientation, disability or national origin. 14. Entire Agreement. This Agreement (along with all Exhibits hereto) is the entire agreement between and among Care Site and County and supersedes all previous oral and written agreements, understandings, statements and representations between and among them relating to its subject matter. This Agreement may be amended only by a written agreement that is signed by both parties and expressly refers to this Agreement. 15. Governing Law. Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 16. Third Party Beneficiaries. This Agreement is entered into for the sole benefit of County and Care Site. Nothing contained herein or in the parties' course of dealings shall be construed as conferring any third party beneficiary status on any person or entity not a party to this Agreement. 17. Electronic Signature. Each party agrees to be bound by its digital or electronic signature ("e -signature") in the form of an electronically scanned image (e.g. in pdf form), by email, or by other means of e -signature technology, and each party agrees that it shall accept the signature of the other party transmitted in such a manner. If you are in agreement with the foregoing, please countersign below and a fully executed copy will be returned to you for your files. Very truly yours, —DocuSigne by: juutiurty Nulty 3f 3EEAE 4EB434... _ Jennifer Alderfer, President [Signature page follows] Page 4 of 7 2019-weldc-25125 �I• DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 SCL Health -Iv GOOD SAMARITAN [Signature page to Health Screening Services Letter Agreement] The undersigned hereby represents and warrants that he or she is duly authorized to sign and execute this Agreement on behalf of County. AGREED TO AND ACCEPTED: WELD COUNTY: ATTEST: Weld C BY: Clerk to the Bo , rd Deputy Cle to he Bo APPROVED AS TO FUNDING: gada, Controller f APP D AS T (ORM: County Attorney 2019-weldc-25125 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO arbara Kirkmeyek, Chair Ju 2 S 2019 VED AS T • , BSTANCE: ected Official or i partment Head Page 5 of 7 Qt0/ f -, 33E3 ,3 DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 -ealth GOOD SAMARITAN EXHIBIT A Health Screening Services Agreement is solely for technical component of Calcium Scoring CT Screening tests completed at Good Samaritan Medical Center SERVICES FEES Provide the Annual Calcium Scoring Screening consisting of: A. Technical component of Calcium CT Imaging of Coronary Arteries $65.00 All payments made by the County for Health Screening Services provided pursuant to this Agreement should be directed to: For studies completed at Good Samaritan Medical Center: Good Samaritan Medical Center Attn: Hilda Dalfonso 200 Exempla Circle Lafayette, CO 80026 Page 6 of 7 2019-weldc-25125 n V • ' �&„ kr .f .5 . ity. 59•'— DocuSign Envelope ID: A96479BB-3BFA-48A8-9D9E-DB200B7462D6 SCL Health GOOD SAMARITAN KXHI ITB Authorization for Screening Form [Provided by Weld County]. Employee Name: Company Name: Company Address: Company Contact Person: Company Telephone ll: Employee has received a Primary Care Physician referral from: Weld County Department issuing authorization is: Authorizing Individual's N ame Authorizing Individual's Title Date Page 7 of 7 2019-weldc-25125 AC' ®© CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/23/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY 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(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC. 540 W. MADISON CHICAGO, IL 60661 Attn: healthcare.accountscss@marsh.com Fax: 212-948-1307 EGSMC CONTACT NAME: PHONE (A/C, No, Ext): E-MAIL ADDRESS: FAX (A/C, No INSURER(S) AFFORDING COVERAGE INSURER A : SCL Health Trust NAIC # INSURED Good Samaritan Medical Center, LLC 200 Exempla Circle Lafayette, CO 80026 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: CHI -009312996-01 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL IN$D SUBR POLICY NUMBER WVD POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL CLAIMS -MADE LIABILITY OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS AND ANYPROPRIETOR/PARTN OFFICER/MEMBER (Mandatory If yes, DESCRIPTION COMPENSATION EMPLOYERS' LIABILITY ER/EXECUTIVE EXCLUDED? in NH) describe under OF OPERATIONS below Y I N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ EL. DISEASE - POLICY LIMIT $ A Healthcare Professional Liab. (Claims Made / Shared Limits) SCL HEALTH TRUST 10/01/2018 10/01/2019 Each Incident Aggregate 1,000,000 3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION Good Samaritan Medical Center, LLC 200 Exempla Circle Lafayette, CO 80026 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kimberly J. Bailey in SC. : -- ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Hello