12/15/2010 AgreementDANNYL. KOLHAGE
CLERIC' OF THE CIRCUIT COURT
DATE: January 14, 2011
TO: Teresa Aguilar
Employee Services
ATTN. • Christine Diaz
FROM: Isabel C. DeSantis, D. C.
At the December 15, 2010, Board of County Commissioner's meeting the Board
approved Item C26 to piggyback on a competitively bid Contract between Monroe County
Sheriff and Key West Urgent Care to provide employment post -offer physicals.
Enclosed is a fully executed electronic copy of the above -mentioned for your handling.
Should you have any questions please do not hesitate to contact this office.
cc: County Attorney email
Finance email
File
AGREEMENT
MONROE COUNTY
CONTRACT FOR
EMPLOYMENT PHYSICAL SERVICES
EXHIBIT 1
Scope of Services -
a
Attachment A
2010 Contract for Medical Services (4 pages) ......
N
Attachment B
Written Permission from Monroe County Sheriff's office W r
o 0
Attachment C
Written Permission from Key West Urgent Care, Inc.
Attachment D
Report of Medical History to be reviewed by Physician
Attachment E
Report of Medical Examination to be completed by Physician
THIS AGREEMENT ("Agreement") is made and entered into this 15th day of December, by
MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florida, whose address
is 1100 Simonton Street, Key West, Florida 33040 and Key West Urgent Care
("CONTRACTOR"), whose address is 1501 Government Road, Key West, FL 33040.
Section 1. SCOPE OF SERVICES
CONTRACTOR shall do, perform and carry out in a professional and proper manner certain
duties as described in the Scope of Services — Exhibit 1 — which is attached hereto and made a
part of this agreement.
CONTRACTOR shall provide the scope of services in Exhibit Al for COUNTY. CONTRACTOR
warrants that it is authorized by law to engage in the performance of the activities herein
described, subject to the terms and conditions set forth in these Agreement documents. The
CONTRACTOR shall at all times exercise independent, professional judgment and shall
assume professional responsibility for the services to be provided. Contractor shall provide
services using the following standards, as a minimum requirement:
A. The CONTRACTOR shall maintain adequate staffing levels to provide the
services required under the Agreement.
B. The personnel shall not be employees of or have any contractual relationship
with the County. To the extent that Contractor uses subcontractors or
independent contractors, this Agreement specifically requires that
subcontractors and independent contractors shall not be an employee of or
have any contractual relationship with County.
C. All personnel engaged in performing services under this Agreement shall be fully
qualified, and, if required, to be authorized or permitted under State and local law
to perform such services.
Section 2. QUALIFICATIONS NECESSARY OF CONTRACTOR
The CONTRACTOR must provide an adequate staff of experienced personnel, capable of
and devoted to the successful accomplishment of work to be performed under any
contract with the County.
Section 3. COUNTY'S RESPONSIBILITIES
3.1 Provide all best available information as to the COUNTY'S requirements for the
Scope of Services described in Exhibit 1 to this Agreement.
3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters
concerning said services.
Section 4. TERM OF AGREEMENT
4.1 The initial Agreement term will be effective December 15, 2010 until September 30,
2013.
4.2 This Agreement shall be in effect until the expiration date or until either party gives
the other notice of cancellation in accordance with the terms set forth below.
Section 5. COMPENSATION
Compensation to CONTRACTOR will be in the amount of $50 per employment physical.
Section 6. PAYMENT TO CONTRACTOR
6.1 Payment will be made according to the Florida Local Government Prompt Payment Act.
Any request for payment must be in a form satisfactory to the Clerk of Courts for Monroe
County (Clerk). The request must describe in detail the services performed and the
payment amount requested. The CONTRACTOR must submit invoices to the
appropriate offices marked Group Insurance. The respective office supervisor and the
Director of Employee Services, who will review the request, note his/her approval on the
request and forward it to the Clerk for payment.
6.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe
County Board of County Commissioners.
Section 7. CONTRACT TERMINATION
Either party may terminate this Agreement because of the failure of the other party to perform its
obligations under the Agreement. COUNTY may terminate this Agreement with or without
cause upon thirty (30) days notice to the CONTRACTOR. COUNTY shall pay CONTRACTOR
for work performed through the date of termination.
Section 8. CONTRACTOR'S ACCEPTANCE OF CONDITIONS
A. CONTRACTOR hereby agrees that he/she has the personnel, equipment, and other
requirements suitable to perform this work and assumes full responsibility therefore.
B. The passing, approval, and/or acceptance by COUNTY of any of the services furnished
by CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with
the terms of this Agreement, and specifications covering the services.
C. CONTRACTOR agrees that County Administrator or his designated representatives may
visit: CONTRACTOR'S facility (ies) periodically to conduct random evaluations of
services during CONTRACTOR'S normal business hours.
D. CONTRACTOR has, and shall maintain throughout the term of this Agreement,
appropriate licenses and approvals required to conduct its business, and that it will at all
times conduct its business activities in a reputable manner. Proof of such licenses and
approvals shall be submitted to COUNTY upon request.
Section 9. NOTICES
Any notice required or permitted under this agreement shall be in writing and hand delivered or
mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the
following:
To the COUNTY: Employee Services Director
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
To the CONTRACTOR: Dr. John Ray VanTuyl, MD
Key West Urgent Care
1501 Government Road
Key West, FL 33040
Section 10. RECORDS
CONTRACTOR shall maintain all books, records, and documents directly pertinent to
performance under this Agreement in accordance with generally accepted accounting principles
consistently applied. Each party to this Agreement or their authorized representatives shall
have reasonable and timely access to such records of each other party to this Agreement for
public records purposes during the term of the agreement and for four years following the
termination of this Agreement. If an auditor employed by the COUNTY or Clerk determines that
monies paid to CONTRACTOR pursuant to this Agreement were spent for purposes not
authorized by this Agreement, the CONTRACTOR shall repay the monies together with interest
calculated pursuant to Section 55.03 of the Florida Statutes, running from the date the monies
were paid to CONTRACTOR.
Section 11. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010 AND 020-1990
The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its
behalf any, former County officer or employee subject to the prohibition of Section 2 of
Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 020-1990. For breach or violation of this provision the COUNTY may, in its
discretion, terminate this agreement without liability and may also, in its discretion, deduct from
the agreement or purchase price, or otherwise recover the full amount of any fee, commission,
percentage:, gift, or consideration paid to the former County officer or employee.
Section 12. CONVICTED VENDOR
A person or affiliate who has been placed on the convicted vendor list following a conviction for
public entity crime may not submit a bid on a Agreement with a public entity for the construction
or repair of a public building or public work, may not perform work as a CONTRACTOR,
supplier, subcontractor, or CONTRACTOR under Agreement with any public entity, and may not
transact business with any public entity in excess of the threshold amount provided in Section
287.017 of the Florida Statutes, for the Category Two for a period of 36 months from the date of
being placed on the convicted vendor list.
Section 13. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES
This Agreement shall be governed by and construed in accordance with the laws of the State of
Florida applicable to Agreements made and to be performed entirely in the State.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR agree that
venue shall lie in the appropriate court or before the appropriate administrative body in Monroe
County, Florida.
Section 14,. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the application thereof to any
circumstance or person) shall be declared invalid or unenforceable to any extent by a court of
competent jurisdiction, the remaining terms, covenants, conditions and provisions of this
Agreement, shall not be affected thereby; and each remaining term, covenant, condition and
provision of this Agreement shall be valid and shall be enforceable to the fullest extent permitted
by law unless the enforcement of the remaining terms, covenants, conditions and provisions of
this Agreement would prevent the accomplishment of the original intent of this Agreement. The
COUNTY and CONTRACTOR agree to reform the Agreement to replace any stricken provision
with a valid provision that comes as close as possible to the intent of the stricken provision.
Section 15., ATTORNEY'S FEES AND COSTS
The COUNTY and CONTRACTOR agree that in the event any cause of action or administrative
proceeding is initiated or defended by any party relative to the enforcement or interpretation of
this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, and court
costs, as an award against the non -prevailing party. Mediation proceedings initiated and
conducted pursuant to this Agreement shall be in accordance with the Florida Rules of Civil
Procedure and usual and customary procedures required by the Circuit Court of Monroe
County.
Section 16. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the
benefit of the COUNTY and CONTRACTOR and their respective legal representatives,
successors, and assigns.
Section 17. AUTHORITY
Each party represents and warrants to the other that the execution, delivery and performance of
this Agreement have been duly authorized by all necessary County and corporate action, as
required by law.
Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
COUNTY and CONTRACTOR agree that all disputes and disagreements shall be attempted to
be resolved by meet and confer sessions between representatives of each of the parties. If the
issue or issues are still not resolved to the satisfaction of the parties, then any party shall have
the right to seek such relief or remedy as may be provided by this Agreement or by Florida law.
This Agreement shall not be subject to arbitration.
Section 19. COOPERATION
In the event any administrative or legal proceeding is instituted against either party relating to
the formation, execution, performance, or breach of this Agreement, COUNTY and
CONTRACTOR agree to participate, to the extent required by the other party, in all
proceedings, hearings, processes, meetings, and other activities related to the substance of this
Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR
specifically agree that no party to this Agreement shall be required to enter into any arbitration
proceedings related to this Agreement.
Section 20. NONDISCRIMINATION
COUNTY and CONTRACTOR agree that there will be no discrimination against any person,
and it is expressly understood that upon a determination by a court of competent jurisdiction that
discrimination has occurred, this Agreement automatically terminates without any further action
on the part of any party, effective the date of the court order. The parties agree to comply with
all Federal and Florida statutes, and all local ordinances, as applicable, relating to
nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of
1964 (PL 88-352) which prohibits discrimination in employment on the basis of race, color,
national origin; 2) Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-
1683, and '1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the
Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the
basis of handicaps: 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101-
6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and
Treatment ,Act of 1972 (PL 29-255), as amended, relating to nondiscrimination on the basis of
drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42
USC ss. 690dd-3 and 290ee-3) as amended, relating to confidentiality of alcohol and drug
abuse patient records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC ss. 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The
Americans with Disabilities Act of 1990 (42 USC s. 1201), as may be amended from time to
time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter
13, Article VI, which prohibits discrimination on the basis of race, color, sex, religion, national
origin, ancestry, sexual orientation, gender identity or expression, familial status or age; and 11)
any other nondiscrimination provisions in any Federal or state statutes which may apply to the
parties to, or the subject matter of, this Agreement.
Section 21,. COVENANT OF NO INTEREST
COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not
acquire any interest, which would conflict in any manner or degree with its performance under
this Agreement, and that only interest of each is to perform and receive benefits as recited in
this Agreement.
Section 22„ CODE OF ETHICS
COUNTY agrees that officers and employees of the COUNTY recognize and will be required to
comply with the standards of conduct for public officers and employees as delineated in Section
112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing
business with one's agency; unauthorized compensation; misuse of public position, conflicting
employment or contractual relationship; and disclosure or use of certain information.
Section 23. NO SOLICITATION/PAYMENT
The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor
retained any company or person, other than a bona fide employee working solely for it, to solicit
or secure this Agreement and that it has not paid or agreed to pay any person, company,
corporation, individual, or firm, other than a bonafide employee working solely for it, any fee,
commission, percentage, gift, or other consideration contingent upon or resulting from the award
or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR
agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at
its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee,
commission, percentage, gift, or consideration.
Section 24. PUBLIC ACCESS
The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection
of, all docurnents, papers, letters or other materials in its possession or under its control subject
to the provisions of Chapter 119, Florida Statutes, and made or received by the COUNTY and
CONTRACTOR in conjunction with this Agreement; and the COUNTY shall have the right to
unilaterally cancel this Agreement upon violation of this provision by CONTRACTOR.
Section 25. NON -WAIVER OF IMMUNITY
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the
COUNTY and the CONTRACTOR in this Agreement and the acquisition of any commercial
liability insurance coverage, self-insurance coverage, or local government liability insurance
pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor
shall any Agreement entered into by the COUNTY be required to contain any provision for
waiver.
Section 26. PRIVILEGES AND IMMUNITIES
All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules
and pensions and relief, disability, workers' compensation, and other benefits which apply to the
activity of officers, agents, or employees of any public agents or employees of the COUNTY,
when performing their respective functions under this Agreement within the territorial limits of
the COUNTY shall apply to the same degree and extent to the performance of such functions
and duties of such officers, agents, volunteers, or employees outside the territorial limits of the
COUNTY.
Section 27,. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non -Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor
shall it be construed as, relieving any participating entity from any obligation or responsibility
imposed upon the entity by law except to the extent of actual and timely performance thereof by
any participating entity, in which case the performance may be offered in satisfaction of the
obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed
as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except to
the extent permitted by the Florida constitution, state statute, and case law.
Section 28. NON -RELIANCE BY NON-PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to
enforce or attempt to enforce any third -party claim or entitlement to or benefit of any service or
program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither
the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the
authority to inform, counsel, or otherwise indicate that any particular individual or group of
individuals, entity or entities, have entitlements or benefits under this Agreement separate and
apart, inferior to, or superior to the community in general or for the purposes contemplated in
this Agreement.
Section 29. ATTESTATIONS
CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require,
including, but not being limited to, a Public Entity Crime Statement, an Ethics Statement, and a
Drug -Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non -Collusion
Agreement.
Section 30. NO PERSONAL LIABILITY
No covenant or agreement contained herein shall be deemed to be a covenant or agreement of
any member, officer, agent or employee of Monroe County in his or her individual capacity, and
no member, officer, agent or employee of Monroe County shall be liable personally on this
Agreement or be subject to any personal liability or accountability by reason of the execution of
this Agreement.
Section 31,. EXECUTION IN COUNTERPARTS
This Agreement may be executed in any number of counterparts, each of which shall be
regarded as an original, all of which taken together shall constitute one and the same instrument
and any of the parties hereto may execute this Agreement by signing any such counterpart.
Section 32.. SECTION HEADINGS
Section headings have been inserted in this Agreement as a matter of convenience of reference
only, and it is agreed that such section headings are not a part of this Agreement and will not be
used in the interpretation of any provision of this Agreement.
Section 33. INSURANCE POLICIES
33.1 General Insurance Requirements for Other Contractors and Subcontractors.
As a pre -requisite of the work governed, the CONTRACTOR shall obtain, at his/her own
expense, insurance as specified in any attached schedules, which are made part of this
contract. The CONTRACTOR will ensure that the insurance obtained will extend protection to
all Subcontractors engaged by the CONTRACTOR. As an alternative, the CONTRACTOR may
require all Subcontractors to obtain insurance consistent with the attached schedules; however
CONTRACTOR is solely responsible to ensure that said insurance is obtained and shall submit
proof of insurance to COUNTY. Failure to provide proof of insurance shall be grounds for
termination of this Agreement.
The CONTRACTOR will not be permitted to commence work governed by this contract until
satisfactory evidence of the required insurance has been furnished to the COUNTY as specified
below. Delays in the commencement of work, resulting from the failure of the CONTRACTOR
to provide satisfactory evidence of the required insurance, shall not extend deadlines specified
in this contract and any penalties and failure to perform assessments shall be imposed as if the
work commenced on the specified date and time, except for the CONTRACTOR's failure to
provide satisfactory evidence.
The CONTRACTOR shall maintain the required insurance throughout the entire term of this
contract and any extensions specified in the attached schedules. Failure to comply with this
provision may result in the immediate suspension of all work until the required insurance has
been reinstated or replaced and/or termination of this Agreement and for damages to the
COUNTY. Delays in the completion of work resulting from the failure of the CONTRACTOR to
maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been
suspended, except for the CONTRACTOR's failure to maintain the required insurance.
The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the required
insurance, either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non -renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as
relieving the Contractor from any liability or obligation assumed under this contract or imposed
by law.
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on general liability and vehicle liability policies.
33.2 General Liability Insurance Requirements For Contract Between County And
Contractor
Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
• Premises Operations
• Bodily Injury Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
33.3 Workers' Compensation Insurance Requirements
Prior to commencement of work governed by this contract, the CONTRACTOR shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
33.4 Professional Liability Requirements
Recognizing that the work governed by this contract involves the furnishing of advise or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$1,000,000 per occurrence and aggregate
Section 34. INDEMNIFICATION
The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the
COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions,
Officers, and the Employees, and any other agents, individually and collectively, from all fines,
suits, claims, demands, actions, costs, obligations, attorneys fees, or liability of any kind arising
out of the sole negligent actions of the CONTRACTOR or substantial and unnecessary delay
caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and
answerable for any and all accidents or injuries to persons or property arising out of its
performance of this contract. The amount and type of insurance coverage requirements set
forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this
paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs attendant to
acts attributable to the sole negligent act of the CONTRACTOR.
At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor
and not an employee of the Board of County Commissioners. No statement contained in this
agreement shall be construed so as to find the CONTRACTOR or any of his/her employees,
contractors, servants or agents to be employees of the Board of County Commissioners for
Monroe County. As an independent contractor the CONTRACTOR shall provide independent,
professional judgment and comply with all federal, state, and local statutes, ordinances, rules
and regulations applicable to the services to be provided.
The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan,
supporting data, and other documents prepared or compiled under its obligation for this project,
and shall correct at its expense all significant errors or omissions therein which may be
disclosed.. The cost of the work necessary to correct those errors attributable to the
CONTRACTOR and any damage incurred by the COUNTY as a result of additional costs
caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply
to any maps, official records, contracts, or other data that may be provided by the COUNTY or
other public or semi-public agencies.
The CONTRACTOR agrees that no charges or claims for damages shall be made by it
for any delays or hindrances attributable to the COUNTY during the progress of any
portion of the services specified in this contract. Such delays or hindrances, if any, shall
be compensated for by the COUNTY by an extension of time for a reasonable period for
the CONTRACTOR to complete the work schedule. Such an agreement shall be made
between the parties.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the
day of 20_.
(SEAL)
Attest: DANNY L. KOLHAGE, CLERK
OF MONROE COUNTY, FLORIDA
By
Deputy Clerk
(CORPORATE SEAL)
ATTEST:
By
PP�oc,►�D �45 To
BOARD OF COUNTY COMMISSIONERS
by
Mayor/Chairman
KEY WEST URGENT CARE
b
T tle: L/
EXHIBIT 1
SCOPE OF SERVICES
SPECIFICATIONS
The services are to be provided on an as needed basis during the normal business hours of
the Contractor. The Contractor shall provide post -offer physicals at the rate of $50 per
physical. The forms to be reviewed and completed by the Contractor are attached to this
agreement (Attachments D and E).
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO.010-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
en -f C. a
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"...warrants that he/it has not employed, retained or otherwise had act on his/her behalf any
former County officer or employee in violation of Section 2 of Ordinance No. 010-1990 or any
County officer or employee in violation of Section 3 of Ordinance No. 010-1990. For breach or
violation of this provision the County may, in its discretion, terminate this Agreement without
liability and may also, in its discretion, deduct from the Agreement or purchase price, or
otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration
paid to the Former County officer or employee."
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MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION MANUAL
Indemnification and Hold Harmless
For
Other Contractors and Subcontractors
The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury (including death), personal
injury, and property damage (including property owned by Monroe County) and any other
losses, damages, and expenses (including attorney's fees) which arise out of, in connection
with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any
tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its
Subcontractors in any tier, their employees, or agents.
In the event the completion of the project (to include the work of others) is delayed or
suspended as a result of the Contractor's failure to purchase or maintain the required insurance,
the Contractor shall indemnify the County from any and all increased expenses resulting from
such delay.
The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification
provided for above.
The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements
contained elsewhere within this agreement.
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
KEY WEST URGENT CARE
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized
self -insurer, the County shall recognize and honor the Contractor's status. The Contractor may
be required to submit a Letter of Authorization issued by the Department of Labor and a
Certificate of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
KEY WEST URGENT CARE
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Professional Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$_100,000 _ per Person
$_300,000 per Occurrence
$_ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION MANUAL
WAIVER OF INSURANCE REQUIREMENTS
There will be times when it will be necessary, or in the best interest of the County, to deviate
from the standard insurance requirements specified within this manual. Recognizing this
potential and acting on the advice of the County Attorney, the Board of County Commissioners
has granted authorization to Risk Management to waive and modify various insurance
provisions.
Specifically excluded from this authorization is the right to waive:
• The County as being named as an Additional Insured — If a letter from the Insurance
Company (not the Agent) is presented, stating that they are unable or unwilling to name
the County as an Additional Insured, Risk Management has not been granted the
authority to waive this provision.
And
• The Indemnification and Hold Harmless provisions
Waiver of insurance provisions could expose the County to economic loss. For this reason,
every attempt should be made to obtain the standard insurance requirements. If a waiver or a
modification is desired, a Request for Waiver of Insurance Requirement form should be
completed and submitted for consideration with the proposal.
After consideration by Risk Management and if approved, the form will be returned, to the
County Attorney who will submit the Waiver with the other contract documents for execution by
the Clerk of the Courts.
Should Rises; Management deny this Waiver Request, the other party may file an appeal with the
County Administrator or the Board of County Commissioners, who retains the final decision -
making authority.
NON -COLLUSION AFFIDAVIT
I, Rrte� Oq & of the city of KeU tt,)esf according to law on
my oath, and under pe alty of perjury, depose and gay that
1. 1 am V t 0 e jQ Fe S of the firm of
'ethe bidder making the
Prop sal for the projrol"&t
escribed in th Request for Proposals for
o t A and that I executed the said
proposal with full authority to 00 so;
2. The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting
competition, as to any matter relating to such prices with any other bidder or with
any competitor;
3. Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be
disclosed by the bidder prior to bid opening, directly or indirectly, to any other
bidder or to any competitor; and
4. No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose
of restricting competition; and
5. The statements contained in this affidavit are true and correct, and made with full
knowledge that Monroe County relies upon the truth of the statements contained in
this affidavit in awarding contracts for said project.
(Si na ure)
i
Dat
STATE OF:�� lXlti
COUNTY OF: Y Y l m r o L
Subscribed) and sworn to (or affirmed) before me on
(date) by _ - JUvf VMy
(name of affiant). He/She is
�s�onallknown me or has produced
(type of identification) as identification
PAJ a '� " �' -/
NOTARY PUBLIC
My Co "-Cx PAMELAL. PUMAR
crs lRkWPublic - State of Florida
* " 6 My Commission Expires Nov 27. 2011
.•
Commission # DD 737309
°%F•°,`,F �d''� Bonded Through National Notary Assn.
DRUG -FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies
that:
(Name of Business)
1. Publishes a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace
and specifying the actions that will be taken against employees for violations of such
prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the business'
policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation,
and employee assistance programs, and the penalties that may be imposed upon
employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual services that
are under bid a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a condition
of working on the commodities or contractual services that are under bid, the employee
will abide by the terms of the statement and will notify the employer of any conviction of,
or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or
of any controlled substance law of the United States or any state, for a violation
occurring in the workplace no later than five (5) days after such conviction.
5. Imposes a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program if such is available in the employee's community, or
any employee who is so convicted.
6. Makes a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with the
above requirements.
(Si na ure)
Date:
STATE OF: 01 & k
COUNTY OF: 1M0& f d=
Subscribed and sworn to (or affirmed) before me on 1 1 (date) by
(name of affiant). H e is personally known
to me or has produced
(type of ident' 'cation) as identification.
NOTARY PUBLIC
My Commission Expir
a�"""•. PAMELAL. PUMAR
•o�►R� A�4's
Notary Public -State of Florida
My Commission Expires Nov 27, 2011
V' Commission # DD 737309
,`` Bonded Thmunh N,,Nn'r'nt1rv4
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following a conviction for
public entity crime may not submit a bid on a contract to provide any goods or services to a
public entity, may not submit a bid on a contract with a public entity for the construction or repair
of a public building or public work, may not submit bids on leases of real property to public
entity, malt not be awarded or perform work as a contractor, supplier, subcontractor, or
CONTRACTOR under a contract with any public entity, and may not transact business with any
public entifiy in excess of the threshold amount provided in Section 287.017, Florida Statutes, for
CATEGORY TWO for a period of 36 months from the date of being placed on the convicted
vendor list."
I have read the above and state that neither ri t? f Van 1 (Respondent's name)
nor any Affiliate has been placed on the convicted vendor list w*th6 the last 36 months.
(SigrTat re)
Datet�
STATE OF: �fl DIZI\(x�
COUNTY OF: Moln
Subscribed and sworn Iffirmed) before me on 1 1
(date) by _ (name of affiant). a/She is personally known to me
or has produced
(type of
identification) as identification.
n
NOTARY PUBLIC
My Commission Expires:
+""""'• PAME7. PUMAR
Notary Public - State of Florida
# • • e My Commission Expires Nov 27, 2011
Commission # DD 737309
Bonded Through National Notary Assn.
INSURANCE REQUIREMENTS
Worker's Compensation $ 100,000 Bodily Injury by Acc.
$ 500,000 Bodily Inj. by Disease, policy Imts
$ 100,000 Bodily Inj. by Disease, each emp.
General Liability, including $ 300,000 Combined Single Limit
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
Professional Liability $250,000 per Occurrence and
Including errors and omissions $750,000 Aggregate
The Monroe County Board of County Commissioners shall be named as Additional
insured on general liability policy.
CONTRACT FOR
EMPLOYMENT PHYSICAL SERVICES
KW URGENT CARE 2010
ATTACHMENT A
2010 Contract for Medical Services
(ECO NEAP 3 0 2010,
Monroe County Sheriff's Office and Key West Urgent Care
1-Purpose: The Monroe Country,
the State of Florida, requires medical efrviceeshfor itsce S'temployees.
Key West ),apolitical subdivision of
a Florida corporation doing business as Key West Urgent Careis qua fled and Urgent Care,
Ito provide those services to MCSO. This Contract states the terms of the agreement
t
between the parties. g
g
. Parties: The parries to this Contract are MCSO and Key West Urgent Care.
mailing address and points of contact for the parries are: The
Donna Moore, Executive Director of Human Resources
Monroe County Sheriffs Office
5525 College Road
Key West, Florida 33040
Telephone: (305) 292 7044
Facsimile: (305) 292 7159
Dr. John Ray VanTuyl, MD
Key West Urgent Care
-C� ---I'583"Government Road
Key West, FL 33040
U Telephone: 305-295-7550
Facsimile:
VJ EIN:
3-Term: The term of this Contract begins the day when both parries have s'
ends September 30, 2013. Igned it It
4-Early Termination for Convenience of the parties: Contract for any reason after providing sEither party May terminate (60) days advance written ter ate this
other party,
notice to the
5-Services and Fees: A list of the services Key West Urgent Care agrees to
the fees MCSO agrees to pay for each service, is con provide, and
titled "Medical Services Provided by Key West Urgent Care and Fees fors Exhibit A
Service
G-Invoicing And Payment: Key West Urgent Care will submit invoices and b
MCSO on a monthly basis. e paid by
Page 1 of 1
7-Representations of Key West Urgent Care
A -Audit trail• Key West Urgent Care agrees to maintain and make available
irecords sufficient to permit a proper audit of its performance of this Contract.
B-Debarment: Key West Urgent Care represents that it has never had a contract
bid or proposal rejected, suspended, or cancelled due to any allegation of a failure to
comply with any federal, state or local government law or regulation regarding '
competitive bidding or auditing or accounting standards.
C-Insurance: Key West Urgent Care represents that all physicians providing
services under this contract are covered by medical malpractice insurance in amounts
sufficient for hospital admission in the State of Florida. Certificates of insurance for
Key West Urgent Care and each medical professional are attached to this Contract an
by reference made a part hereof. Key West Urgent Care will main d
malpractice coverage during g fain existing
g the term of this Contract. Key West Urgent Care must
Provide written notice to MCSO of any change of coverage, terms, or carrier.
8-Indemnification: Key West Urgent Care agrees to hold harmless, indemnifyand
defend the Monroe County Sheriffs Office, Sheriff Robert P. Peryam and his
predecessors and successors in office, and each and every one of his deputies,
employees, and attorneys from any and all loss, damage, claim or judgment arisingout
of the provision of services pursuant to this Contract.
9-Prohibition Against Assignment: Neither party shall assign all or any portion of its
duties or rights under this Contract without the prior written consent of the other
P
10-Independent Status: Key West Urgent Care is an independent contra r it
nor any of its personnel are employees or agents of MCSO. Neither Key West Neither
Care nor its personnel will make any statement or representation on behalf of MCS
O.
16-Paragraph Headings Not Dispositive: The parties agree that the headings given the
Paragraphs and other subdivisions of this Contract are for ease of reference onl and
are not dispositive in the interpretation of Contract language. y
17-No Presumption Against Drafter: The
freely negotiated by both parties, and that,Parties agree that this Contract has been
interpretation, validity, or enforceabilityy dispute over the meaning,
Provisions, there shall be no Presumption fwhatsoever aataiin t i he its terms or
their having drafted this Contract or any portion thereof. either Perry by virtue of
Page 2 of 2
u
1 S-Governing Law and Venue: This Contract shall be construed, interpreted
and
governed by the laws of the State of Florida. Venue for any litigationarisin g outt of t '
Contract will be in Monroe County, Florida. g hrs
19-Entire Agreement: This Contract expresses the complete and final understanding
the parties hereto, that any and all negotiations and representations not inclu of
or referred to herein are hereby abrogated and that this Contract cannot be changed,
included herein
modified or vaned except by a written instrument signed by all parties hereto. There
no private" or "side agreements." here are
20-Authority of Signatories: The persons signing this Contract represent that
authority to bind their principles its terms. t they
UNDERSTOOD .AND AGREED TO THI'5,-)_(0 DAY OF
KEY WEST URGENCA, 2010.
T' S
M4OE COUN � ^�a FF'S
By. z�' "_J b G , OFFICE
Authorized represe five r Au orized representative
1
Printed name and titre
Witnesses as to Key W
Page 3 of 3
Printed name and title
Medical Services Provided & Fees for Service
-.
Ph sical ----
-
Key West Urgent Care
- — ----
--- ------------
EKG ----�
--
--- ---$5---
TB Test ------ -- --
- _..-----
--- 0 -- -
-------------------
U
$30-
- -- - --------- ---
$10
Complete Blood count (CBC)
$40
Comprehensive Metabolic Panel
--
(CMP)
------------
Drug Test (10 Panel)
----
--- 40
--- --
$50
Drug Test Collectlon only
--------. _
1
B Vaccination
*Fitness for Duty $90/no charge if done with
*Consultation with Sheriff ----- Physical -- --
Designee
---
N vmerry iriesplrator test) $50
*Range of Motion Test
*Audiogram - --- ---
*Hep B Surface Antibody-- $15
*If Applicable ---
Tote- Cost - _-
CONTRACTFOR
EMPLOYMENT PHYSICAL SERVICES
KW URGENT CARE 2010
.ATTACHMENT B
Sherift
SUBSTATIONS
Freeman Substation
20950 Overseas Hwy.
Cudjoe Key, FL 33042
(305)745-3184
FAX (305) 745-3761
Marathon Substation
3103 Overseas Hwy.
Marathon, FL 33050
(305) 289-2430
FAX (305) 289-2497
Islamorada Substation
87000 Overseas Hwy.
Islamorada, FL 33036
(305)853-7021
FAX (305) 853-9372
Roth Building
50 High Point Roa
Tavernier. FL 33070
(305) 853-3211
FAX (305) 853-3205
DETENTION CENTERS
Key West Det. Center
5501 College Road
Key West, FL 33040
(305) 293-7300
FAX (305) 293-7353
Marathon Det. Facility
3981 Ocean Terrace
Marathon, FL 33050
(305)289-2420
FAX (305) 289-2424
Plantation Det. Facility
53 High Point Road
Plantation Key, FL 33070
(305)853-3266
FAX (305) 853-3270
October 26, 2010
.Monroe County Sheriff's Office
Robert T Teryam, Sheriff
5525 Coffege Road
Key ` Vest, 'Florida 3.3040
(305) 292-7000 TAX.- (305) 292-7070 1-800-273-COTS
4L'ttllu . kysso. net
Dr. John Ray VanTuyle
Attention: Jante VanTuyle — Officer Manager
]Key West Urgent Care
1501 Government Road
]Key West, FL 33040
RE: Monroe County Board of County Commissioners
Dear Mrs. VanTuyle:
Please be advised that the Monroe County Sheriff's Office (MCSO) is authorizing
the Board of County Commissioners (BOCC) to utilize the services outlined in the
MCSO contract with Key West Urgent Care.
The Monroe County Sheriff's Office will not be responsible for payment for services
rendered to BOCC employees and/or applicants. Billing for services for BOCC
employee and/or applicants should be sent to:
Board of County Commissioners
Teresa Aguiar, Employee Services Director
1.100 Simonton Street — Room 2-268
Key West, FL 33040
Please contact me if you have any questions or require additional information at
(305) 2927044.
SPECIAL OPERATIONS ,
�� cerely,
P.O. Box 500975
Marathon, FL 33050
(305) 289-2410 r
FAX (305) 289-2498
AVIATION DIVISION I)Onn A. Moore, Executive Director
10100 Overseas Hwy.
Marathon, FL 33050
(305) 289-2777
FAX (305) 289-2776 cc: Teresa Aguiar, Employee Services Director
COMMUNICATIONS
2796 Overseas Hwy.
Marathon, FL 33050
(305) 289-2351 t t t t
FAX (305) 289-2493 iL 1 3A ea 11,,
AwediWicu Camotiuiam
CONTRACTFOR
EMPLOYMENT PHYSICAL SERVICES
KW URGENT CARE 2010
ATTACHMENT C
Aguiar-Teresa
From: Janet Van Tuyl 0lv_kwuc@belIsouth.net]
Sent: Monday, November 08, 2010 1:57 PM
To: Aguiar-Teresa
Subject: RE: Physicals
Teresa,
We are happy to perform physicals for the BOCC under the same contract as agreed to with the MCSO. The
attached physical will be completed with the exception of #18 (we will be able to remark on any dental disease
or defect),# 19A(4),B,C,D,E,F, #29,00, #31, #32, #34, #36, #37, #38, #41. These portions were not agreed to
with the MCSO or were not requested by the BOCC. This physical will be done for $50 each. If a urine drug
screen is required it will be an additional $50 each. Let me know if this needs to be changed in any way.
Thank you for your business,
Janet Van Tuyl
Key West Urgent Care, Inc.�-
1501 Government Road
Key West, FL .33040
Phone:305-295-7550
Fax:305-296-3-010
Email: ilv_kwuc(ic;bellsouth.net �D
l�
--- On Mon, 11/8/t0, Aguiar-Teresa<Aguiar-Teresa(&NonroeCounty-FL.Gov> wrote:
From: Aguiar-Teresa<Aguiar-TeresaAMonroeCounty-FL.Gov>
Subject: RE: Physicals
To: "'Janet Van Tuyl"' <jlv kwucgbellsouth.net>
Date: Monday, November 8, 2010, 12:31 PM
Hello Janet: I'm going to give your office a call as well in case you don't get this email. I can't do 9am in the morning. I
have to take my father for an 8:30 appt that Ijust was informed of.
If you can do the afternoon of Tuesday or anytime Wednesday that would be great. Sorry about that. Please let me know.
From: Janet Van Tuyl [mailto:jlv_kwuc@bellsouth.net]
Sent: Thursday, November 04, 2010 10:57 AM
To: Aguiar-Teresa
Subject: Physicals
Teresa,
Please give me a call when you get back in the office regarding the BOCC physicals. I have questions
regarding what you want to do about the chest xrays, vision tests, audiometry, and lab tests.
1
Thank you,
Janet Van Tuyl
Key West Urgent Care, Inc.
1501 Government Road
Key West, FL 33040
Phone:305-295-7550
Fax: 305-296-3010
Email: ilv kwucrcOellsouth.net
Please take a moment to complete our Customer Satisfaction Survey:
http://monroecofl,.virtualtownhall.net/Pages/MonroeCoFL WebDocs/css Your feedback is important to
us!
Please note: Florida has a very broad public records law. Most written communications to or from the
County regarding, County business are public record, available to the public and media upon request.
Your e-mail communication may be subject to public disclosure.
CONTRACTFOR
EMPLOYMENT PHYSICAL SERVICES
KW URGENT CARE 2010
ATTACHMENT D
NO. OF ATTACHED SHEETS:
DAT OF XA
MEDICAL RECORD REPORT OF MEDICAL HISTORY
fil This information is for official and medics y-con i ential use only and will not be re eased to unauthorized persons
1. NAME OF PATIENT IL ast, first, middle! 12. IDENTIFICATION NUMBER 7-Position
TT HOME STREET ADDRESS /Street or RFD; City or Town; State; and ZIP Code) 15. EXAMINING FACILITY
M.
6. PURPOSE OF EXAMINA
7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)
a. PRESENT HEALTH
b. CURRENT MEDICATION
REGULAR OR INTERM.
c. ALLERGIES (Include insect bites/stings and common foods/
—d.
HEIGHT
le. WEIGHT
B. PATIENT'S OCCUPATION
9. ARE YOU ec one
13 RIGHT HANDED LEFT HANDED
12mll l/[MU:1::101Is &1a11Lill ;16Y1111,11111:fi
CHECK EACH ITEM
YES
NO
DON'T
KNOW
CHECK EACH ITEM
YES
NO
DON'T
KNOW
CHECK EACH ITEM
YES
NO
DON'T
KNOW
Household contact with anyone
with tuberculosis
Shortness of breath
Bone, joint or other deformity
Pain or pressure in chest
Loss of finger or toe
Tuberculosis or positive T B test
Chronic cough
Painful or "trick' shoulder
or elbow
Blood in sputum or when
coughing
Palpitation or pounding heart
Heart trouble
i
Recurrent back pain or any
back injury
Excessive bleeding after injury or
dental work
High or low blood pressure
Cramps in your legs
"Trick" or locked knee
Suicide attempt or plans
Frequent indigestion
Foot trouble
Sleepwalking
Stomach, liver or intestinal trouble
Nerve Injury
Wear corrective lenses
Gall bladder trouble or
gallstones
Paralysis (including infantile)
Eye surgery to correct vision
Epilepsy or seizure
Lack vision in either eye
Jaundice or hepatitis
Car, train, sea sickness
Wear a hearing aid
Broken bones
-or -air
Frequent trouble sleeping
Stutter or stammer
Adverse reaction to medication
Depression or excessive worry
Wear a brace or back support
Skin diseases
Loss of memory or amnesia
Scarlet fever
Tumor, growth, cyst, cancer
Nervous trouble of any sort
Rheumatic fever
Hernia
Periods of unconsciousness
Swollen or painful joints
Hemorrhoids or rectal disease
Parent/sibling with diabetes,
cancer, stroke or heart disease
Frequent or severe headaches
Frequent or painful urination
Dizziness or fainting spells
ing since age 12
X-ray or other radiation therapy
Eye trouble
tone or blood in urine
Chemotherapy
Hearing loss
albumin in urine
;Kd
Asbestos or toxic chemical
exposure
Recurrent ear infections
transmitted diseases
Chronic or frequent colds
ain or loss of weight
Plate, pinor rod in any bone
Severe tooth or gum trouble
Eating disorder (anorexia bulimia,
etc.)
Easy fatigability
--�
Sinusitis
Been told to cut down or
criticized for alcohol use
Hay fever or allergic rttmrtis
Arthritis. Rheumatism, or
Bursitis
Head injury
Used illegal substances
Asthma
Thyroid trouble or goiter
Used tobacco
NSN 7540-00-181-836EI a 141mumill rWi lvl 7a (l o-eol
Previous edition not usable Prescribed by ICMR/GSA
FIRMR (41 CFR) 201 9 202-1
11 . FEMALES ONLY
CHECK EACH ITEM
YES
NO
DON'T
KNOW
DATE OF LAST MENSTRUAL
PERIOD
N/A
DATE OF LAST PAP SMEAR
N/A
DATE OF LAST MAMMO-
GRAM
N/A
Treated for a female disorder
N
Change in menstrual pattern I N/
CHECK EACH ITEM. IF "YE. EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER.
ITEM
12. Have you been refused employment or been unable to hold a job or
stay in school because of:
a. Sensitivity to chemicals, dust, sunlight, etc.
b.Inability to perform certain motions.
C. Inability to assume certain positions.
d.Other medical reasons (If yes, give reasons.)
13. Have you ever been treated for a mental condition? (If yes, specify
when, where, and give details-)
14. Have you ever been denied life insurance? (If yes, state reason and
give details.!
15. Have you had, or have you been advised to have, any operation.
Of yes, describe and give age at which occurred.)
16. Have you ever been a patient in any type of hospital? W yes,
specify when, where, why, and name of doctor and complete address
of hospital.]
17. Have you consulted or been treated by clinics, physicians, healers,
or other practitioners within the past 5 years for other than minor
illnesses? Of yes, give complete address of doctor, hospital, clinic, and
details.)
18. Have you ever been rejected for military service because of
physical, mental, or other reasons? (it yes, give date and reason for
rejection.)
19. Have you ever been discharged from military service because of
physical, mental, or other reasons? Of yes, give date, reason, and
type of discharge, whether honorable, other than honorable, for
unfitness or unsuitability.!
20. Have you ever received, is there pending, or have you ever applied
for pension or compensation for existing disability? (If yes, specify
what kind, granted by whom, and what amount, when, why.!
22, Have you ever been diagnosed with a learning disability? (If yes,
give type, where, and how diagnosed.)
23 1IST ALL. IMMIJNI7ATIONS RFCFIVFD
certify that I havi -reviewed the foregoing information supplied y me and that it is true and compete tote best of my knowledge. I authorize any of the doctors, ospita s,
or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I
understand that falsificaWn of information on Government forms is punishable by fine and/or imprisonment.
NAME OF EXAMINEE
DA
NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY",
25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shalt comment on all positive answers in Items 7 through 11. Physician may
develop by interview any additional medical history deemed important, and record any significiant findings here.)
DATE
STANDARD FORM 93 (REv. 6-96) BACK
CONTRACT FOR
EMPLOYMENT PHYSICAL SERVICES
KW URGENT CARE 2010
ATTACHMENT E
DATE OF EXAM
MEDICAL RECORD REPORT OF MEDICAL EXAMINATION
1, LAST NAME - FIRST NAME - MIDDLE NAME 2. IDENTIFICATION NUMBER 3. Position
4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code)
5. EMERGENCY CONTACT (Name and address otconlad)
6. DATE OF BIRTH
7. AGE
8. SEX
9. RELATIONSHIP OF CONTACT
FEMALE MALE
10 PLACE OF BIRTH
11. RACE NIC
AMERICAN INDIAW HISPANIC HISPAASIAN/PACIFlC
1-1 WHITE BLACK gLASKA NATIVE WHITE BLACK ISLANDER
12a. AGENCY
12b. ORGANIZATION UNIT
13. TOTAL YEARS GOVERNMENT SERVICE
a. MILITARY
b. CIVILIAN
14. NAME OF EXAMINING FACILITY OR EXAMINER. AND ADDRESS
15. RATING OR SPECIALTY OF EXAMINER
16, PURPOSE OF EXAMINATION
MAL
(Check each item In appropriate column, enter "NE' if not evaluated.)
kMOR.
MAL
NOR-
MAL
(Check each item In appropriate column, enter "NE" it not evaluated.)
MAL
A. HEAD, FACE, NECK AND SCALP
O. PROSTATE (Over40 or clinically Indicated)
B. EARS - GENERAL. (INTERNAL CANALS)
(Auditory acuity under items 39 and 40)
P. TESTICULAR
R. ENDOCRINE SYSTEM
C. DRUMS (Perforation)
D. NOSE
S. G-U SYSTEM
E. SINUSES
T. UPPER EXTREMITIES (Strength, range of motion)
F. MOUTH AND THROAT
U. FEET
G. EYES - GENERAL (Visual acuity and m1ractlon under items 28, 29, and 36)
V. LOWER EXTREMITIES (Except reel) (Strength, range ofmotion)
H. OPTHALMOSCOPIC
W. SPINE, OTHER MUSCULOSKELETAL
I. PUPILS (Equally andreaction)
X. IDENTIFYING BODY MARKS, SCARS, TATTOOS
J. OCULAR MOTILITY (Associated parallel movements nystagmus)
Y. SKIN, LYMPHATICS
K. LUNGS AND CHEST
Z. NEUROLOGIC (Equilibrium tests under item 41)
L. HEART (Thrust, size, rhythm, sounds)
AA. PSYCHIATRIC (Specify any personally deviation)
M. VASCULAR SYSTEM (Varicosities, etc.)
N. ABDOMEN AND VISCERA (Include hernia)
NOTES: (Describe everyabnormality in detab. Enter p3rrMent item number nefore earn comment L onunue m nem x arK, uaro awrwrrur �r�r� „ r,aw�,r.r
18. DENTAL (Place appropriate symbols. shown In examples, above or below number of upper and lower teeth.)
00
n Restorada 1
i
an- X Missng
1122
33 Replaced 1 2 —
Fixed
Partial
Teeth 3
31
es
Teeth 3il 3 Teeth
pantures
DeNr rres
R
L
1
1 2 3 4
5
6 7 a
9 10
11 12
13 14 15 16
E
G
32 31 30 29
28
27 26 25
24 23
22 21
20 19 18 17
F
H
T
T
REMARKS AND ADDITIONAL
DEFECTS AND DISEASES
19. TEST RESULTS (Copies of results are preferred as attachments)
A. URINALYSIS (1) SPECIFIC GRAVITY B. CHEST X-RAY OR PPD (Place, date, nlm number and result)
(2) URINE ALBUMIN (4) MICROSCOPIC No 00
(3) URINE SUGAR
C SYPHILIS SEROLOGY (Specify test used D. EKG E. BLOOD TYPE AND RH F. OTHER TESTS
and mulls) O lop I
FACTOR 00 14o
8& 126
De"ned using Perform Pro, WHSrD1OR, Jan 97
STANDARD FORM 68 (Rev 10-94) (EG)
Prescribed by GSA/ICMR FIRMR (41 CFR) 201.9 202-1
NAME j IDENTIFICATION NUMBER ( NO. OF SHEETS ATTACHED
MEAS
FI
20 HEIGHT
21 WEIGHT
22. COLO��R�2
4.BUILD
SLENDER MEDIUM HEAW OBESE
25. TEMPERATURE
26, BLOOD PRESSURE (Arm at heart level)
27. PULSE (Arm at heart level)
A
SITTING
SYS.
B.
RECUM
BENT.)
%H:ji:
NG
j
A. SITTING
B.RECUMBENT
C. STANDING
(3 mMs)DIAS
D. AFTEREXERCISE
E. 2 MINS. AFTER
.
28. DISTANT VISION
29. REFRACTION f4 0
30. NEAR VISION No
RIGNT 201 CORR. TO 20l
BY S. CX
CORR. TO BY
LEFT201 CORR TO201
BY S. CX
CORR. TO BY
77. HtTEROPHORIA(SNecnY(Jisranoo) N
ESO EXO R.H. L.H. PRISM DIV. PRISM CONV. PC PO
CT
32. ACCOMMODATION NO
33 COLOR VISION (Test used and result)
34. DEPTH PERCEP 60
(Test used and score)
UNCORRECTED
RIGHT LEFT
CORRECTED
35. FIELD OF VISION
36. NIGHTVISION (Test used and score)
W D
37. RED LENS TEST
NO
38. 1NTRAOCULAR TENSION
RIGHT LEFT
RIGHT LEFT
39. HEARING
40. AUDIOMETER
41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)
Q
250
SW
1000
2000
3000
6000
0—
RIGHT WN f15SV 115 266 512 1024 2048 2896 4009960 6144 8192
LEFT WN /15SV 115 RIGHT
LEFT
42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY
(Use addRbnal sheets it necessary)
43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with Rem numbers)
44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)
45A. PHYSICAL PROFILE
P
U
L
H=
S
46. EXAMINEE
A.
&
(Check)
IS QUALIFIED FOR In accordance with
IS NOT QUALI FIED FOR descri Lion
attached job
45B. PHYSICAL CATEGORY
47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER
A
B
C
E
48. TYPED OR PRINTED NAME OF PHYSICIAN
SIGNATURE
49 TYPED OR PRINTED NAME OF PHYSICIAN
SIGNATURE
50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)
SIGNATURE
51. TYPED OR PRINTED NAME OFREVIEWING OFFICER OR APPROVING AUTHORI
SIGNATURE
STANDARD FORM 88 (Rev. 10-94) BACK
® I
A� CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/Y
1/13/2011
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 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
The Porter Allen Company, Inc.
513 Southard Street.
CONTACT
NAME:
(305)294-2542 FVCNo:(305)296-7985 PHONE
E-MAIL
ADDRESS:
PRODUCERCUSTOMEEt IDN00005487
INSURERS AFFORDING COVERAGE
NAIC #
Key West FL 33040
INSURED
INSURERAMount Vernon Fire Ins. Co
INSURER B :
INSURER C :
Key West Urgent Care
INSURER D :
1501 Goverment Rd
INSURER E :
INS
Key West FL 33040
Key
COVERAGES a,r=rc r lrrvm i L., --- — -
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.
rA
TYPE OF INSURANCE
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCUR
ADDLSM
POLICY NUMBER
BP2008504C
POLICY EFF
MM/DD/YYYY
6/15/2010
POLICY EXP
MM/DD/YYYY
6/15/2011
LIMITS
EACH OCCURRENCE
OCCURRENCE
$ 1,000,000
DAMAGE
PREMISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
l
GEN'L AGGREGATE LIMIT APPLIES PER:
RO LOC
X I POLICY PRO-
$
AUTOMOBILE
LIABILITY
ANY AUTO
i
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
ALL OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
SCHEDULED AUTOS
HIRED AUTOS
_. ��
I I
NON -OWNED AUTOS
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATIONER
WC STATU- OTH-
E.L. EACH ACCIDENT
$
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE❑
E.L. DISEASE - EA EMPLOYE
$
OFFICERNEMBER EXCLUDED?
(Mandatory In NH)
N / A
E.L. DISEASE - POLICY LIMIT
1 $
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, tf more space Is required)
MEDICAL OFFICE - EMERG]ENCY CARE CLINIC
IEM
MONROE COUNTY BOARD OF COUNTY COMMISSIONE
1100 SIMONTON STREET
KEY WEST, FL 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
REPRE f NTATIV E
4�IZABETH FREEMAN
ACORD 25 (2009/09)
INS025 (200909) The ACORD name and logo are registered marks of ACORD
RMK
® DH10
A CERTIFICATE OF LIABILITY INSURANCE
DAI E IMM'DD'VYYYI
12-01-20P4
THIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATEIS
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 policylies) must be endorsed. If SUBROGATIONIS 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).
PROWLER
CONTACT
NAME:
PAYCHEX INSURANCE AGENCY INC
PHONE n c. Ner (8 8 8) 4 4 3 - 6112
A/C No Extl
210705 P: () - F: (888)443-6112
E-MAIL
ADDRESS
P O BOX 33015
PRODUCER -- —
SAN ANTON I O TX 78265
CUSTOMER ID a;_
INSURER(S) AFFORDING COVERAGE NAIL N
INSURED
INSURER A: Twin City Fire Ins Co _
9459
INSURER B
KEY WEST URGENT CARE INC
1501 GOVERNMENT RD .
INSURER c
KEY WEST FL 33040
INSURER
INSURER E
INSURER F
AG ES CERTIFICATE NUMBER: REVISION NUMBER:
COVER
CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO
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.
---
-- i- --------- --__.. - - --- DDLBUPR -------- _._ POLY EFF POU6Y EXP.._.
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/OD/YYYY) (MM/DD/YYYYI LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
GENERAL LIABILITY
PREMISES IEa occurrence)
$__.__,_.
MED EXP Any one person)
_COMMERCIAL
1 CLAIMS -MADE L—I OCCUR
S
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
S
QLN'L
1
AGGRE ATE LIMIT AF'PLI S PER:
POLICY I PRO- [ LOCJLQI
PRODUCTS - COMPIOP AGG
S
S
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
S
_
Ea accident)
ANYAUTO
BODILY INJURY IPer person)
$
ALL OWNED AUTOS
BODILY INJURY IPer accident)
S
SCHEDULED AUTOS
PROPERTY DAMAGE
$
HIRED AUTOS
(Per accident)
S
NON -OWNED AUTOS
S
UMBRELLA L/AB OCCUR
EACH OCCURRENCE
EXCESS L/AB CLAIMS -MADE
AGGREGATE
S
DEDUCTIBLE
-
S
-1
RETENTION $
$
WORKERS COMPENSATION
WC STAU
O_R_Y_ IM_ITS
AND EMPLOYERS' LIABILITY Y
_X_ _ _O_ERTH_
E.L. EACH ACCIDENT
$ 100, 000
ANY PROPRIETOR'PARTNER'EXECUTIVE
Yl
N/A
E.L. DISEASE -EA EMPLOYE
S 100, 000
AOFFICERIMEMBEREXCLUDED?
(Mandstory b NH)
76 WEG NZ0324
05/09/2010
05/09/2011
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$5 0 0 0 0 0
i
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101. Addlbna/ Remarks Schedule, K mole +Pete is required)
Those usual to the Insured's Operations.
ULK I It-IL,A I E FIULUEH I.,MNY ,CLLM I IUIM
MONROE COUNTY BOCC
1100 SIMONTON ST
KEY WEST, FL 33040
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
" 1 y36U-LUU& AUUHU GUHNUHA I IUIV. All rlgnTs reserves.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
First Professionals Insurance Company
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
Lower Keys Health System, Inc. (Form. Florida Keys Mem. Hosp
Attn: Medical ,Staff Office
5900 Junior College Road
Key West, FL 33040
POLICY INFORMATION
Named Insured:
John Ray Van Tuyl, M.D.
Policy Number:
IN072567
Policy Period:
05/01/2010 to 05/01/2011
Retroactive Date:
05/01/2005
Limits of Liability: $250,000 per claim/$750,000 aggregate
Classification: Physician - Minor Surgery (NOC)
Memorandum of Insurance Issue Date: 02/12/2010
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way
whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231-4033; or
Phone (904) 354-5910, (800) 741-3742; or Facsimile (904) 358-6728.
lauv /4M/Z-L
Authorized Representative
FPIGMP1.-103-1I. (12/09)
1000 Riverside Suite 800 • Jacksonville, Florida 32204 • (904) 354-5910 • 1-800-741-1742 • Fix (904) 358-6728
P.O. Box 44033 0 Jacksonville, Florida 32231-4033 0 u,%ti•a-.firstprolessionals.cc,m