05/01/1975 Agreement.t 2
AGREEMENT FOR BAKER ACT
MATCHING FUNDS
THIS AGREEMENT made this 1st day of May, 1975, by and between the
COUNTY OF MONROE, hereinafter referred to as County, and FLORIDA
KEYS MENTAL HEALTH BOARD, INC., District 23, hereinafter referred
to as District;
For and in consideration of the mutual covenenants made herein,
the parties hereby agree as follows:
1. The County agrees to reimburse the District twenty-five (25)
per cent of total District expenditures for Baker Act hospital and
physician services, as billed to the District on state approved
Baker Act Billing Forms (DMH BA 97) for clients qualifying for
such services under applicable state and federal regulations and
eligibility determination procedures, but not to exceed a total
reimbursement of $ 5000.00 during the period beginning May 1, 1975
and ending September 30, 1975.
2. The District agrees to provide to the county on a regular basis
a copy of the Summary Record of Bills Paid (DMH BA 99A1, from which
reimbursement due the District can be calculated, however, copies
of individual client bills will not be available for inspection
by the County for reimbursement purposes in order to comply with
regulations safeguarding the patient'.s right to confidentiality.
Copies of individual client bills are kept on file in the District
business office and will be made available under controlled conditions
to qualified auditors for audit purposes. The District further
agrees to provide to the County any Baker Act statistical data
normally available to the District and to make an annual report
to the County on the expenditure of County funds for the above
specified purposes.
This agreement shall terminate at 11:59 P.M., September 30, 1975, and
the County shall not be liable under the terms of this agreement for
any liability incurred after the time of termination, however the
County shall be liable for any outstanding costs incurred prior to
termination of this agreement provided the District submits to the
County the required Summary Record of Bills Paid within three (3)
weeks of the date of termination of this agreement, provided however
that the maximum amount of reimbursement specified above is not
exceeded. This agreement may also be terminated by either party
upon thirty (30) days written notice delivered by certified mail
to the party receiving notice of termination.
County warrants or checks written for reimbursement to the District
shall be made payable to the Florida Keys Mental Health Board, Inc..
By B
Title
ATTE T :
ERK
President, Mental Heal= Ba.
Title