10/01/1975 AgreementS
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AGREEMENT FOR BAKER ACT
MATCHING FUNDS
THIS AGREEMENT made this lst. day of October, 1975, by and between
the COUNTY of MONROE, hereinafter referred to as C6WEY , and FLORIDA
KEYS MENTAL HEALTH BOARD, INC., District # 23, hereinafter referred
to as District;
For and in consideration of the mutual covenants 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, and the County also
agrees to reimburse the District one hundred (100) percent of total District
expenditures for transportation costs, incurred by eligible clients,
who are transported from the contracted Baker Act in -patient facilities
to South Florida State Hospital, as billed to the District on the Transportation
Billing Form MHDB-I-BA. This cost is not to exceed a total reimbursement of
$15,000.00 during the period beginning October 1, 1975 and ending September 30,1976.
(2) The District agrees to provide to the County on a regular basis
a copy of the Summary Record of Bills Paid (DMH-BA-99a) from which
reimbursement due the District can be calculated, however, copies of
individual client bills will not be availble 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 controlledconditions to qualified quditors for audit purposes. The
Baker Act Matching Funds
Page 11
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, 1976,
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 outstanding costs incurred prior to the
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
maximun 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
Mayor and Chairman of the Board
Title
AT ST:
Clerk
B`.
President, Florida Keys Mental Health
Title Bd.