Item G2BOARD OF GOVERNORS OF
FIRE AND AMBULANCE DISTRICT 1
AGENDA ITEM SUMMARY
Meetin Date: December 12,2012 Division: Emmency Services
Bulk Item-.- Yes X No Department: Fire Rescue
Staff Contact Person- M
4 -N@ 289-6010
AGENDA ITEM WORDING: Re to issue a competitive solicitation ( review and evaluation of
EMS g round and air rescue transport billin and collections.
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ITEM BACKGROUND* It is desired that the count emer medical services" billin Methods be
reviewed to evaluate their efficienc and effectiveness and also determine if
revenue collected is appropriate and
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maximized. The review will include the billin and collection of medicare, Medicaid, and workers"
compensation, automobile, commercial and private pa for both air ambulance and g round ambulance
transportations.
PREVIOUS RELEVANT WG **CTION: N/A.
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CONTRACT/AGREEMENT CHANGES.* N/A.
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STAFF RECOlv#4MENDATIONS: Approval.
TOTAL COST: advertisin fees BUDGETED: Yes X No
COST TO COUNTY: 900 advertisinja fees SOURCE OFFUNDS: 11001-530340
REVENUE PRODUCING: Yes No X AMOUNT PERMONTH Year
OMBfPurchasin Risk Mana
APPROVED BY: Count Att
DOCUMENTATION: Included X
Not Re
DISPOSITION.
AGENDA ITEM #
REQUEST FOR COMPETITIVE SOLICITATION
BILLING CONSULTANT TO REVIEW AND EVALUATE
MONROE COUNTY FIRE RESCUE'S
EMS GROUND AND AIR RESCUE TRANSPORT
BILLING AND COLLECTIONS
MONROE COUNTY EMERGENCY SERVICES
BOARD OF COUNTY COMMISSIONERS AND
THE BOARD OF GOVERNORS OF FIRE AND AMBULANCE
DISTRICT 1
OF MONROE COUNTY
BOCC MEMBERS:
Mayor George Neugent, District 2
Commissioner Danny L. Kolhage, District 1
Commissioner Heather Carruthers, District 3
Commissioner David Rice, District 4,
Commissioner Sylvia Murphy, District 5
BOARD OF GOVERNORS MEMBERS:
Monroe County Mayor George Neugent, District 2
Monroe County Commissioner David Rice, District 4
Layton Mayor, Norm Anderson
Layton Councilman, Clark Snow
COUNTY ADMINISTRATOR CLERK OF THE CIRCUIT COURT
Roman Gastesi Amy Heavilin
MONROE COUNTY FIRE CHIEF
James Callahan
December 2012
Prepared by Monroe County Emergency Services
NOTICE OF REQUEST FOR COMPETITIVE
SOLICITATIONS
NOTICE IS HEREBY GIVEN that on January 16, 2013 at 3:00 P.M. the Monroe
County Purchasing Office will receive and open sealed responses for the following:
REVIEW AND EVALUATE
MONROE COUNTY FIRE RESCUE (MCFR) EMS
GROUND AND AIR RESCUE TRANSPORT BILLING
MONROE COUNTY, FLORIDA
Requirements for submission and the selection criteria may be requested from
DemandStar by Onvia at www.demandstar.com OR www.monroecountybids.com
or call toll -free at 1- 800 - 711 -1712. The Public Record is available at the Monroe
County Purchasing Office located at The Gato Building, 1100 Simonton Street,
Room 1 -213, Key West, Florida. All Responses must be sealed and must be
submitted to the Monroe County Purchasing Office.
Publication dates
Citizen (Fr) 12/14/12
Keynoter (Sa) 12/15/12
Reporter (Fr) 12/14/12
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TABLE OF CONTENTS
NOTICE OF REQUEST FOR COMPETITIVE SOLICITATION
SECTION ONE
Instruction to Respondents
SECTION TWO
Definitions
SECTION THREE
Draft Agreements (Consulting Agreement and HIPAA Business Associate Agreement)
SECTION FOUR
Submissions Form & Required County Forms
Attachment A Scope of Work
Attachment B Submission Response Form
Attachment C Non - Collusion Affidavit
Attachment D Public Entity Crime Statement
Attachment E Drug Free Workplace Form
Attachment F Lobbying &Conflict of Interest Clause- (Ethics Clause)
Attachment G Indemnification and Hold Harmless
Attachment H Insurance Documents
Attachment I Local Preference Form
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SECTION ONE: INSTRUCTION TO RESPONDENTS
1.01 DESCRIPTION
The Respondent awarded a contract shall act as a consultant to perform a review and
evaluation of Monroe County Fire Rescue's (MCFR) emergency medical services (EMS)
ground and air rescue transport billing and collections, as described more fully in the
Scope of Work, Attachment A below. The County seeks a Respondent who will review
current billing practices to determine whether they are in compliance with contracts, as
well as federal, state and local laws; and make suggestions for improvements that will
result in increases in collection. The County wishes the review to be conducted and
completed within ninety (90) days following award of contract.
This contract is subject to approval of the Monroe County Board of County
Commissioners and the Board of Governors of Fire and Ambulance District 1 of Monroe
County, Florida. All submissions must remain valid for a period of ninety (90) days from
the date of the deadline for submission stated above. The Board will automatically reject
the response of any person or affiliate who appears on the convicted vendor list prepared
by the Department of Management Services, State of Florida, under Sec. 287.133(3)(d),
Florida Statutes.
Once completed, the recommended contract will be presented to the Monroe County
Board of County Commissioners and the Board of Governors of Fire and Ambulance
District 1 for review and approval.
1.02 RFS DOCUMENTS
A. Only complete sets of RFS documents will be issued and shall be used in
preparing responses. The County does not assume any responsibility for errors or
misinterpretations resulting from the use of incomplete sets.
B. Complete sets of RFS documents may be obtained in the manner and at the
locations stated in the Notice of Request for Solicitations.
1.03 DESCRIPTION OF EMS BILLING PROGRAM
Monroe County ( "County ") is a non - chartered county established under the
Constitution and the laws of the State of Florida. The population of the County is
estimated at approximately 73,000. The Board of County Commissioners, constituted
as the governing body, has all the powers of a body corporate, including the powers to
contract; to sue and be sued; to acquire, purchase, hold, lease and convey real estate and
personal property; to borrow money and to generally exercise the powers of a public
authority organized and existing for the purpose of providing community services to
citizens within its territorial boundaries.
Fire and Ambulance District 1 ( "District ") is a municipal special taxing district set up
within Monroe County. The governing body consists of four members of the Board of
County Commissioners and the representative of one municipality.
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The County's EMS system includes ground ambulances and one air ambulance (Trauma
Star). The EMS operations on all of the ambulances are staffed and operated by Monroe
County Fire Rescue, a department within Monroe County Emergency Services division).
Ground ambulance revenues are collected by the District. Air ambulance revenues are
collected by the County.
Monroe County currently contracts with athird -party billing company Advanced Data
Processing, Inc. (d /b /a ADPI- Intermedix) to issue invoices and begin initial collections
for ground and air transports. After an initial period of time (currently seven months),
accounts are then placed with a separate third party collection company (Gila LLC d /b /a
Municipal Services Bureau) for further collection efforts. Rates for both ground and air
ambulance transports are set by Resolution of the governing body. County residents are
eligible for a fee waiver for air ambulance transports.
Monroe County Transport volume for the past eight (8) years is as follows:
Year
Ground
Air
Total Transports
2005
1449
89
1538
2006
1339
0
1339
2007
1301
83
1384
2008
1430
176
1606
2009
1406
148
1554
2010
1568
197
1765
2011
1583
237
1820
2012
1697
281
1978
1.04 DISQUALIFICATION OF RESPONDENT (Section Four contains these
forms)
A. NON - COLLUSION AFFIDAVIT: Any person submitting a solicitation in
response to this invitation must execute the enclosed NON - COLLUSION
AFFIDAVIT. If it is discovered that collusion exists among the Respondents,
the solicitations of all participants in such collusion shall be rejected, and no
participants in such collusion will be considered in future solicitations for the
same work.
B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the
convicted vendor list following a conviction for a public entity crime may not
submit a solicitation on a contract to provide any goods or services to a public
entity, may not submit a solicitation on a contract with a public entity for the
construction or repair of a public building or public work, may not submit
Solicitations on leases or perform work as a respondent, supplier, or sub
Respondent under a contract with any public entity, and may not transact
business with any public entity 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. Category
Two: $25,000.00
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C. DRUG -FREE WORKPLACE FORM: Any person submitting a solicitation or
bid in response to this invitation must execute the enclosed DRUG -FREE
WORKPLACE FORM and submit it with his solicitation. Failure to complete
this form in every detail and submit it with the solicitation or bid may result in
immediate disqualification of the solicitation or bid.
D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any person
submitting a solicitation or bid in response to this invitation must execute the
enclosed LOBBYING AND CONFLICT OF INTEREST CLAUSE and submit it
with his solicitation or bid. Failure to complete this form in every detail and
submit it with the solicitation or bid may result in immediate disqualification of
the solicitation or bid.
1.05 EXAMINATION OF RFS DOCUMENTS
A. Each Respondent shall carefully examine the RFS and other contract documents,
and inform themselves thoroughly regarding any and all conditions and
requirements that may in any manner affect cost, progress, or performance of the
work to be performed under the contract. Ignorance on the part of the Respondent
shall in no way relieve them of the obligations and responsibilities assumed under
the contract.
B. Should a Respondent find discrepancies or ambiguities in, or omissions from, the
specifications, or should they be in doubt as to their meaning, they shall at once
notify the County.
C. Examination of Specifications. Each Respondent is required before submitting a
solicitation, to be thoroughly familiar with the specifications contained herein. No
additional allowances will be made because of lack of knowledge of the
conditions. It is the responsibility of the successful respondent to ascertain if any
components of the specification are unsafe or contrary to current applicable
regulations. If any unsafe or unlawful criteria are contained herein, they shall be
thoroughly explained to the purchaser in the solicitation.
1.06 INTERPRETATIONS, CLARIFICATIONS, AND ADDENDA
Request for additional information relating to the specifications of this Request for
Competitive Solicitation shall be submitted in writing directly to:
Mary Napoli
Monroe County Fire Rescue, Administrative Assistant
490 63rd Street
Marathon, FL 33050
Fax: 305- 289 -6013
Written requests for additional information or clarification received at least seven (7)
days prior to the deadline listed in the Notice will be answered in the form of an
addendum published on DemandStar and issued to all persons who have downloaded the
RFS. Oral requests will not be answered.
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1.07 GOVERNING LAWS AND REGULATIONS
The Respondent is required to be familiar with and shall be responsible for complying
with all federal, state, and local laws, ordinances, rules, and regulations that in any
manner affect the work. Knowledge of business tax requirements and obtaining such
licenses for Monroe County and municipalities within Monroe County are the
responsibility of the Respondent. Monroe County is exempt from all local, state, and
federal sales and use taxes.
1.08 PREPARATION OF RESPONSES
Signature of the Respondent: The Respondent must sign the response forms in the space
provided for the signature. If the Respondent is an individual, the words "doing business
as ", or "Sole Owner" must appear beneath such signature. In the
case of a partnership, the signature of at least one of the partners must follow the firm
name and the words "Member of the Firm" should be written beneath such signature. If
the Respondent is a corporation, the title of the officer signing the Response on behalf of
the corporation must be stated along with the Corporation Seal Stamp and evidence of
their authority to sign the Response must be submitted. The Respondent shall state in the
response the name and address of each person having an interest in the submitting entity.
1.09 SUBMISSION OF RESPONSES
Interested firms or individuals shall submit four (4) signed originals and one (1)
complete copy [total = five (5)], of the solicitation in a sealed envelope clearly marked
on the outside with the Respondent's name and "Proposal — Billing Consultant To
Review and Evaluate Monroe County Fire Rescue's EMS Ground and Air Rescue
Transport Billing and Collections" on the outside envelope. If sent by mail or by
courier, the above - mentioned envelope shall be enclosed in another envelope addressed
to Monroe County Purchasing Department, 1100 Simonton Street, Room 1 -213, Key
West, FL 33040, which shall be received on or before 3:00 P.M. local time on January
16, 2013 at 3:00 P.M. Faxed or e- mailed Solicitations shall be automatically rejected.
1.10 CONTENT OF SUBMISSION
The solicitation submitted in response to this RFS shall be printed on 8-1/2" x 11" white
paper and bound; shall be clear and concise and provide the information requested herein.
Statements submitted without the required information will not be considered. Responses
shall be organized as indicated below. The Respondent should not withhold any
information from the written response in anticipation of presenting the information orally
or in a demonstration, since oral presentations or demonstrations may not be solicited.
Each Respondent must submit adequate documentation to certify the Respondent's
compliance with the County's requirements. Respondent should focus specifically on the
information requested.
The following information, at a minimum, shall be included in the Submittal:
A. Cover Page
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A cover page that states "Proposal — Billing Consultant To Review and Evaluate
Monroe County Fire Rescue's EMS Ground and Air Rescue Transport Billing
and Collections" The cover page should contain Respondent's name, address,
telephone number, and the name of the Respondent's contact person.
B. Tabbed Sections
This Solicitation is written around specific needs of this department. The award shall
be given to the Respondent whose Solicitation comes closest to meeting these
specifications at the most competitive price.
Tab 1. Narrative Self- Analysis
The Respondent shall provide a history of the firm and a general description of
Respondent's experience and qualifications with ground and air ambulance transport
;billing, with particular emphasis on experience with governmental entities at the state,
county or local (municipal or special district) level within the State of Florida.
Include a comprehensive statement detailing how the Respondent, if awarded a
contract, shall provide the services and deliverables identified in the Scope of Work.
Tab 2. Qualifications of Respondent
Respondent must provide proof of the following items:
A. Documentation showing that the Respondent has a minimum of ten (10) years'
experience in which ground transport and /or air transport billing services are
performed.
B. The number of years the Respondent has operated under its present name and any
prior names.
C. The number of years the Respondent has been operating and, if different, the
number of years it has been providing the services or goods called for in this
Request.
Tab 3. References
Provide the name, address, telephone number and contact name of at least three (3)
references who can provide information as to your qualifications for the same or similar
services. At least one (1) of the names must be from other governmental entities.
Provide the dates during which you have worked for each reference, and a description of
services provided.
Tab 4. Past Performance on Similar Projects
List other similar projects completed as those required in this request within the past five
(5) years. For each project, give the client's:
- Name and full address
- Telephone number and name of client contact
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- Date of initiation and completion of contract
- Summary of the services and area served
Tab 5. Litigation
Respondent must supply answers to the following questions regarding claims and
suits:
A. Has the Respondent ever failed to complete work or provide the goods for which
it has contracted? (If yes, provide details.)
B. Are there any judgments, claims, arbitration proceeding or suits pending or
outstanding against the Respondent, or its officers, managing members, or general
partners? (If yes, provide details.)
C. Has the Respondent, within the last five (5) years, been a party to any lawsuit or
arbitration with regard to a contract for services or goods similar to those
requested in the RFS? (If yes, the Respondent shall provide a history of any past
or pending claims and litigation in which the Respondent is involved as a result of
the provision of the same or similar services which are requested or described
herein.)
D. Has the Respondent ever initiated litigation against the County or been sued by
the County in connection with any contract to provide services, goods or
construction services? (If yes, provide details.)
E. State whether, within the last five (5) years, an officer, general partner, controlling
shareholder or major creditor or proposer was an officer, general partner,
controlling shareholder or major creditor of any other entity that failed to perform
services or furnish goods similar to those sought in the request for solicitation.
Tab 6. Other Information
Provide any additional information which will present evaluators with insight about the
knowledge, skills and abilities of the respondent.
Tab 7. County Forms and Licenses
Respondent shall complete and execute the forms specified below and located in Section
four in this _, as well as copies of all professional and business tax licenses, and shall
include them behind this tab.
Form
- Submission Response Form (including
acknowledgement of addenda if applicable)
- Non - Collusion Affidavit
- Public Entity Crime Statement
- Drug Free Workplace Form
- Lobbying and Conflict of Interest Clause
- Local Preference Form (if applicable)
compensation sought, and
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1.11 MODIFICATION OF RESPONSES
Written modification will be accepted from respondents if addressed to the entity and
address indicated in the Notice of Request for Solicitations and received prior to
Solicitation due date and time. Modifications must be submitted in a sealed envelope
clearly marked on the outside, with the Respondents name and "Modification to
Proposal — Billing Consultant to Review and Evaluate Monroe County Fire Rescue's
EMS Ground and Air Rescue Transport Billing and Collections ". If sent by mail or
by courier, the above - mentioned envelope shall be enclosed in another envelope
addressed to the entity and address stated in the Notice of Request for Solicitation. Faxed
or e- mailed modifications shall be automatically rejected.
1.12 RESPONSIBILITY FOR RESPONSE
The Respondent is solely responsible for all costs of preparing and submitting the
response, regardless of whether a contract award is made by the County.
1.13 RECEIPT AND OPENING OF RESPONSES
Responses will be received until the designated time and will be publicly opened.
Respondents' names shall be read aloud at the appointed time and place stated in the
Notice of Request for Competitive Solicitations. Monroe County's representative
authorized to open the responses will decide when the specified time has arrived and no
responses received thereafter will be considered. No responsibility will be attached to
anyone for the premature opening of a response not properly addressed and identified.
Respondents or their authorized agents are invited to be present.
1.14 DETERMINATION OF SUCCESSFUL RESPONDENT
The following describes the criteria to be used for analyzing and evaluating the various
solicitations.
A. Qualification:
1. Expertise /qualifications of entity and key personnel — 25 points
B. Experience:
1. Experience with EMS ground billing — 10 points
2. Experience with EMS air billing — 25 points
3. Experience in collections — 10 points
4. Governmental /municipal experience — 10 points
5. Experience in Florida with regard to ground and air transport billing and
collections — 10 points
C. Price: 5 points
D. Local preference — 5 points
NOTE In performing the evaluation, only information contained within the Respondents
written solicitation will be considered.
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1.15 AWARD OF CONTRACT
A. The County reserves the right to reject any and all solicitations, or any part of any
solicitations; to award separate contracts for the services based on geographic area
or other, and to waive any informality in any response, or to re- advertise for all or
part of the work contemplated.
B. The County also reserves the right to reject the response of a Respondent who has
previously failed to perform properly or to complete contracts of a similar nature
on time.
C. The recommendation of staff shall be presented to the Board of County
Commissioners and the Board of Governors of Fire and Ambulance District 1 of
Monroe County, Florida, for final selection and award of contract. If solicitations
are found to be acceptable to the County, written notice will be given to the
selected Respondent of the acceptance of the Respondent's solicitation and the
award of the contract to Respondent.
1.16 EXECUTION OF CONTRACT
The Respondent with whom a contract is negotiated shall be required to return to the
County four (4) executed counterpart originals of the consulting agreement and HIPAA
Business Associate Agreement shown in Section Three, below..
1.17 CERTIFICATE OF INSURANCE AND INSURANCE REQUIREMENTS
The Respondent shall be responsible for all necessary insurance coverage as indicated on
Attachment H (general liability, professional liability, vehicle liability, workers'
compensation and employer liability). Certificates of Insurance must be provided to
Monroe County within fifteen (15) days after award of contract. If the proper insurance
forms are not received within the fifteen (15) day period, the contract may be awarded to
the next selected Respondent. Policies shall be written by companies licensed to do
business in the State of Florida and having an agent for service of process in the State
award of contract of Florida. Companies shall have an A.M. Best rating of A- and a
Financial Size of VI or better. The required insurance shall be maintained at all time
while Respondent is providing service to the County.
Monroe County shall be named as Additional insured on the General Liability and
Vehicle Liability Policies.
1.18 INDEMNIFICATION
The Respondent to whom a contract is awarded shall defend, indemnify and hold
harmless the County as outlined below.
The Respondent covenants and agrees to indemnify, hold harmless and defend Monroe
County, its commissioners, officers, employees, agents and servants from any and all
claims for bodily injury, including death, personal injury, and property damage, including
damage to property owned by Monroe County, and any other losses, damages, and
expenses of any kind, including consultant's fees, court costs and expenses, which arise
out of, in connection with, or by reason of services provided by the Respondent or any of
its Subbidder(s) in any tier, occasioned by the negligence, errors, or other wrongful act or
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omission of the Respondent, its Sub- bidder(s) in any tier, their officers, employees,
servants or agents.
In the event that the service is delayed or suspended as a result of the Respondents failure
to purchase or maintain the required insurance, the Respondent 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 Respondent is consideration 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.
This indemnification shall survive the expiration or earlier termination of the contract.
1.18 LOCAL PREFERENCE
Vendors claiming a local preference according to Monroe County Ordinance 023-2009
must complete the form attached in Section Four.
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SECTION TWO:
DEFINITIONS
2.01 Definitions
Wherever used in these General Conditions or in the other contract documents the terms
below have the meanings indicated which are applicable to both the singular and the
plural thereof. The use of the terms "he ", "him ", "himself' or "his" shall refer to male
and female persons alike and should not be construed as derogatory or discriminatory to
female persons.
Purchaser — The end user of the equipment specified or the applicable purchasing agent
for Monroe County Fire Rescue and the Board of Governors of Fire and Ambulance
District 1 of Monroe County through the Board of County Commissioners of Monroe
County, Florida.
Respondent — The individual, firm, partnership, manufacturer or corporation to whom
the contract is awarded by the County and who is subj ect to the terms thereof.
Equal — Shall be taken in it is general sense and shall not mean identical. These
specifications are for the sole purpose of establishing minimum requirements for the level
of quality and standards of performance and is in no way intended to prohibit the
responder's ability to provide service in another manner he sees fit.
Note: Monroe County Fire Rescue (HCFR) shall be the sole judge of equality and this
decision shall be final.
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SECTION THREE:
DRAFT AGREEMENTS
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CONSULTING AGREEMENT
BETWEEN
THE BOARD OF COUNTY COMMISSIONERS
AND
THE BOARD OF GOVERNORS FIRE AND AMBULANCE DISTRICT I
OF MONROE COUNTY, FLORIDA
AND
FOR REVIEW AND EVALUATION
OF MONROE COUNTY FIRE RESCUE'S
EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND
COLLECTIONS
This agreement (the "Agreement ") is made and entered into this day
of , 2012 by and between the BOARD OF COUNTY COMMISSIONERS
and the BOARD OF GOVERNORS OF FIRE AND AMBULANCE DISTRICT 1,
MONROE COUNTY, a political subdivision of the State of Florida, with principal
offices located at 490 63 Street, Marathon, FL 33050 (the District and Monroe County
are hereinafter referred to collectively as the "COUNTY "), and
, (hereinafter, "Consultant" or "Business Associate "), as of
the latest of the execution dates set forth below in Section VII.
WITNESSETH:
WHEREAS, the COUNTY intends to enter into an agreement for the provision of
consulting services to analyze and recommend changes to ground and air rescue transport
billing by the Consultant to the COUNTY; and,
WHEREAS, the Consultant represents that it is capable and prepared to provide such
Services:
NOW THEREFORE, in consideration of the promises contained herein, the parties
hereto agree as follows:
1. Term: This agreement commences on , 2012, and terminates
on the earlier of (a) the delivery of the deliverables identified in Attachment A to this
Agreement or ninety (90) days after execution of the contract, whichever comes first.
2. Scope of Services: Within ninety (90) days following execution of this
Agreement, the Consultant shall provide the scope of services described in Attachment A
to this Agreement. The results shall be described in a deliverable consisting of a report
delivered both in hard copy and electronic form, summarizing the results as to each point.
The scope of services may also include the appearance at one Board of County
Commissioners /Board of Governors meeting, which may occur no later than sixty (60)
days following delivery of the report.
3. Compensation: The Consultant shall receive a total of $ as fixed
price, full and final payment for the services described in Attachment A, including all
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deliverables. There shall be no further costs or expenses allowed, including but not
limited to, travel expenses, photocopy costs, facsimile charges, overnight or regular U.S.
mail expenses, with the exception that if the attendance of the Consultant is required at a
County commission meeting, then pre- approved travel expenses will be reimbursed,
subject to rates in Florida statutes and County policy, upon presentation of a request for
reimbursement on forms provided by the County. The Consultant shall be paid after
delivery of all services identified in Attachment A, including final delivery of the final
report described above, and after presentation of a final invoice. All invoices shall be
paid in accordance with the Florida Local Government Prompt Payment Act. In the
event this Agreement is extended beyond the expiration of the County's fiscal year, this
Agreement is subject to appropriation by the COUNTY.
4. Termination: The agreement can be terminated by either party with or without
cause with ten (10) days' prior written notice. In the event the termination is without
cause, the COUNTY shall be responsible for reimbursement of compensation, on a
quantum meruit basis, up to the date of termination, in which case the Consultant will
deliver all work product produced to that time.
5. Access to Records and Auditing. Consultant understands and agrees that, unless
specifically exempted by Florida, Chapter 119, Florida Statutes, generally requires public
access to all records and documents. Monroe County shall have access, at all reasonable
times, to all books, records, correspondence, instructions, receipts, vouchers and
memoranda (excluding computer software) pertaining to work under this Agreement for
any purpose, including the purpose of conducting a complete independent fiscal audit.
Consultant shall retain all records required to be kept under this Agreement for a
minimum of five years, and for at least four years after the termination of this agreement.
Consultant shall be responsible for repayment of any and all audit exceptions which are
identified by the Auditor General for the State of Florida, the Clerk of Court for Monroe
County, the BOCC, or their agents and representatives.
6. Modification: Additions to, modification to or deletions from the provisions set
forth in this agreement shall be effective only in writing and with prior approval of the
BOCC.
7. Indemnification and Hold Harmless: The Consultant agrees to indemnify and
hold Monroe County BOCC harmless for any and all claims, liability, losses and causes
of action which may arise out of its fulfillment of the agreement. It agrees to pay all
claims and losses, including related court costs and reasonable attorneys' fees, and shall
defend all suits filed due to the negligent acts, errors or omissions of the Consultant
employees and /or agents.
8. Insurance. The coverage provided herein shall be provided by an insurer with an
A.M. Best Rating of VI or better, that is licensed to business in the State of Florida and
that has an agent for service of process within the State of Florida. The coverage shall
contain an endorsement providing sixty (60) days notice to the COUNTY prior to any
cancellation of said coverage. Said coverage shall be written by an insurer acceptable to
the COUNTY and shall be in a form acceptable to the COUNTY.
The Consultant shall obtain and maintain the following policies:
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a) General Liability Insurance
Prior to the commencement of work governed by this contract, the Respondent
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
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 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.
b) Professional Liability Insurance
Recognizing that the work governed by this contract involves the furnishing of
advice or services of a professional nature, the Respondent 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 Respondent
arising out of work governed by this contract.
The minimum limits of liability shall be:
$500,000 per Occurrence / $1,000,000 Aggregate
c) Vehicle Liability Insurance
Recognizing that the work governed by this contract requires the use of vehicles,
the Respondent, prior to the commencement of work, shall obtain Vehicle
Liability Insurance. Coverage shall be maintained throughout the life of the
contract and include, as a minimum, liability coverage for:
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• Owned, Non - Owned, and Hired Vehicles
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
The Monroe County Board of County Commissioners shall be named as
Additional Insured on all policies issued to satisfy the above requirements.
d) Workers Compensation Insurance
Prior to the commencement of work governed by this contract, the Respondent
shall obtain Workers' Compensation Insurance with limits sufficient to respond to
the applicable state statutes.
In addition, the Respondent shall obtain Employers' Liability Insurance with
limits of not less than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
e) COUNTY shall be named as an additional insured with respect to Consultant's
liabilities hereunder in insurance coverages for general liability and vehicle
liability.
fl Consultant shall require its subconsultants to be adequately insured at least to the
limits prescribed above, and to any increased limits of CONSULTANT if so
required by COUNTY during the term of this Agreement. COUNTY will not pay
for increased limits of insurance for subconsultants.
g) Within fifteen (15) days after execution of this Agreement, Consultant shall
provide to the COUNTY certificates of insurance or a copy of all insurance
policies including those naming the COUNTY as an additional insured. The
COUNTY reserves the right to require a certified copy of such policies upon
request. The Agreement shall be cancelled and treated as void from its inception if
proof of coverage is not provided.
9. Taxes The County is exempt from federal excise and state sales and use taxes.
10. Independent Contractor It is the intent of the parties hereto that the Consultant
shall be legally considered as an independent contractor and that neither it nor its
employees or agents shall, under any circumstance, be considered servants or agents of
the County and County shall at no time be legally responsible for any negligence on the
18
part of said successful responder, its employees or agents, resulting in either bodily or
personal injury or property damage to any individual, firm, or corporation.
11. Disclosure The Consultant shall be required to list any or all potential conflicts
of interest, as defined by Florida Statute 112 and Monroe County Ethics Ordinance. The
Consultant shall disclose all actual or proposed conflicts of interest, financial or
otherwise, direct or indirect, involving any client's interest which may conflict with the
interests of the County.
12. Assignment the Consultant shall not assign, transfer, convey, sublet or otherwise
dispose of this agreement, or of any or all of its right, title or interest therein, or his or its
power to execute such contract to any person, company or corporation without prior
written consent of the County.
13. Compliance With Laws: Consultant shall comply with all international, federal,
state and local laws and ordinances applicable to the work or payment for work thereof.
14. Force Maieure The Consultant shall not be liable for delay in performance or
failure to perform, in whole or in part, the services due to the occurrence of any
contingency beyond its control or the control of any of its subcontractors or suppliers,
including but not limited to weather conditions.
15. Governing Law /Venue This agreement shall be governed and construed by and
in accordance with the laws of the State of Florida and constitutes the entire agreement
between the County and Consultant. Venue of any court action filed relative to this
agreement shall lie in Monroe County, Florida.
16. Anti solicitation The Consultant warrants that no person has been employed or
retained to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage, or contingent fee and that no member of the Monroe
County government or the County has any interest, financially or otherwise in the
Consultant or its subcontractors.
17. Severability If any provision of the agreement shall be held by a Court of
competent jurisdiction to be invalid or unenforceable, the remainder of this agreement, or
the application of such provision other than those as to which it is invalid or
unenforceable, shall not be affected thereby; and each provision of the agreement shall be
valid and enforceable to the fullest extent permitted by law.
18. Notice Any notice required or permitted under this agreement shall be in writing
and hand - delivered or mailed, postage prepaid by certified mail, return receipt requested,
to the other party as follows:
For County For Consultant
Monroe County Fire Rescue Fire Chief
49063 rd Street Ocean, Suite 140
Marathon, FL 33050
(305) 289 -6006
19
19. Ethics Clause The Consultant warrants that it has not employed, retained or
otherwise had act on its behalf, any former Monroe County officer or employee in
violation of Section 2 or Ordinance No. 10 -1990 or any County officer or employee in
violation of Section 3 of Ordinance No. 10 -1990. For breach or violation of the
provision, the County may, at its discretion terminate this agreement without liability and
may also, at 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 or present County officer or employee.
20. 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
response on a contract to provide any goods or services to a public entity, may not submit
a response /bid on a contract with a public entity for the construction or repair of a public
building or public work, may not submit responses /bids on leases of real property to
public entity, may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public entity, and may not transact
business with any public entity 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.
21. General Provisions
a) Ownership of files and work product: All files and work product prepared by
Consultant or his or her firm at the expense of County (or for which County is otherwise
billed) is the property of the County. Without COUNTY's prior written approval, this
work product may not be used by Consultant or his or her firm nor disclosed by
Consultant or his or her firm to others, except in the normal course of Consultant's
representation of COUNTY in this matter.
b) Confidential /proprietary information. Consultant understands that in addition to
documents which fall under the statutory definition of public records, as part of the
review, Consultant may be viewing information and documents that are confidential and
proprietary ( "Confidential Information ") to the third party billing and collection
companies under contract to the County. By signing this agreement, Consultant
understands and agrees that (i) to protect any and all Confidential Information Consultant
receives from unauthorized access, use and disclosure; (ii) not to use the Confidential
Information for any purpose other than performing the services for County; (iii) not to
record, copy, or reproduce any Confidential Information in any form, except to the extent
necessary to perform the services for County; (iv) not to disclose the Confidential
Information to, or otherwise permit to access the Confidential Information, any third
party, including without limitation Consultant's, except as expressly provided herein or
with County's prior written consent; (v) to limit access to and use of the Confidential
Information to those of Consultant's employees who have a need to know such
information for the purpose of performing the services and have acknowledged, in a
writing which will be made available to County upon request, their individual agreement
to the terms hereof; and (vi) to take any and all other steps necessary to safeguard
Confidential Information against unauthorized access, use, and disclosure to at least the
extent Consultant maintains the confidentiality of its most proprietary and confidential
information. Consultant further agrees that no amount of money may compensate the
20
third party billing and collection companies for use and disclose of their Confidential
Information, and therefore, that the County shall be entitled to seek injunctive relief in
order to prevent disclosure of Confidential Information. If, in the event of disclosure, the
County is named in a lawsuit by the third party billing and collection companies arising
out of Consultant's disclosure, the Consultant agrees to defend and indemnify the County
for any losses arising out of Consultant's actions, including but not limited to damages,
attorneys' fees, and costs.
c) Entire Agreement. The entire agreement between the COUNTY and Consultant
with respect to the subject matter hereof is contained in this Agreement. This Agreement
supersedes all prior oral and written proposals and communications between the
COUNTY and Consultant related to this Agreement. No provision of this Agreement
shall be deemed waived, amended or modified by either party unless such waiver,
amendment or modification is in writing and signed by the party against whom the
waiver, amendment or modification is claimed. This Agreement shall be binding upon
and inure to the benefit of the parties hereto, their permitted successors and assigns.
d) In the event any administrative proceeding or cause of action is initiated or
defended by the COUNTY or Consultant relative to the enforcement or interpretation of
this Agreement, the prevailing party shall be entitled to an award of reasonable attorneys'
fees and costs.
e) Non - Discrimination. Consultant shall not discriminate, in its employment
practices and in providing services hereunder, on the basis of race, color, sex, religion,
disability, national origin, ancestry, sexual orientation, gender identity or expression,
familial status, or age, and shall abide by all federal and state laws regarding non-
discrimination. Upon a determination by a court of competent jurisdiction that such
discrimination has occurred, this Agreement automatically terminates without any further
action by the COUNTY, effective the date of the court order. Consultant is aware of the
provisions of Section 13-101 through 13-106, Monroe County Code, relating to non-
discrimination, and agrees to abide by the Code's nondiscrimination requirements.
21
IN WITNESS WHEREOF, the parties have executed this agreement the day and year
first above written.
(SEAL)
ATTEST: AMY HEAVILIN,
COUNTY CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
B B
Deputy Clerk Mayor, George Neugent
RESPONDENT: BOARD OF GOVERNORS OF FIRE AND
AMBULANCE DISTRICT I OF MONROE
COUNTY, FL
0
Print Name and Title
Date:
Mayor / Chairman
ON
BUSINESS ASSOCIATE AGREEMENT
BETWEEN
THE BOARD OF COUNTY COMMISSIONERS
AND
THE BOARD OF GOVERNORS FIRE AND AMBULANCE DISTRICT I
OF MONROE COUNTY, FLORIDA
AND
FOR REVIEW AND EVALUATION
OF MONROE COUNTY FIRE RESCUE'S
EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND
COLLECTIONS
This Business Associate Agreement (the "Agreement') is made and entered into this
day of , 2012 by and between the BOARD OF COUNTY
COMMISSIONERS and the BOARD OF GOVERNORS OF FIRE AND AMBULANCE
DISTRICT I. MONROE COUNTY, a political subdivision of the State of Florida, with
principal offices located at 490 63 Street, Marathon, FL 33050 (the District and Monroe
County are hereinafter referred to collectively as the "COUNTY "), and
, (hereinafter, "Consultant' or "Business Associate "), as of
the latest of the execution dates set forth below in Section VII.
WITNESSETH:
WHEREAS, the COUNTY intends to enter into an agreement for the provision of
consulting services to analyze and recommend changes to ground and air rescue transport
billing and collections by the Consultant to the COUNTY; and,
WHEREAS, the Consultant represents that it is capable and prepared to provide such
Services: an
WHEREAS, under federal health care privacy law it is necessary to enter into an
agreement with the Consultant regarding the treatment of protected health information
(PHI) in order to be able to share PHI with the Consultant for review and evaluation;
NOW THEREFORE, in consideration of the promises contained herein, the parties
hereto agree as follows:
I. INTRODUCTION AND GENERAL STATEMENT.
A. Business Associate has been retained by County to perform certain functions,
activities, or services (collectively, "Services ") in connection with ground and /or
air ambulance billing.
The terms and provisions of this Agreement are incorporated in and shall
supersede any conflicting or inconsistent terms and provisions of any other
agreement, to which Business Associate and County are parties, including all
23
exhibits or other attachments thereto and all documents incorporated therein by
reference.
This Agreement is intended to ensure that the Business Associate will establish
and implement appropriate privacy and security safeguards with respect to
"Protected Health Information" (as defined below) that the Business Associate
may create, receive, use, or disclose in connection with the Services to be
provided by Business Associate to County, consistent with the standards set forth
in regulations and administrative guidance with respect to the Health Insurance
Portability and Accountability Act of 1996, Public Law 104 -191 ( "HIPAA "),
including as amended by the Health Information Technology for Economic and
Clinical Health Act as set forth in Title XIII of Division A and Title IV of
Division B of the American Recovery and Reinvestment Act of 2009 ( "HITECH
Act ") .
B. Effective Date. The provisions of this Agreement shall take effect on
C. Definitions. Capitalized terms used, but not otherwise defined, in this Agreement
shall have the same meaning as those terms in the HIPAA Privacy and Security
Rules. Other defined terms include:
1. "Breach" shall have the meaning given such term in 45 C.F.R. § 164.402.
2. "Designated Record Set' shall have the meaning given such term in 45 C.F.R.
§164.501.
3. "Electronic Protected Health Information" shall have the same meaning as the
term "electronic protected health information" in 45 C.F.R. § 160.103.
4. "Individual" shall have the same meaning given such term under 45 C.F.R.
§ 160.103, and shall include a person who qualifies as a personal
representative in accordance with 45 C.F.R. § 164.502(g).
5. "Privacy Rules" shall mean the Standards for Privacy of Individually
Identifiable Health Information at 45 C.F.R. Part 160 and Part 164, subparts
A and E.
6. "Protected Health Information" (or "PHI ") shall have the meaning given to
such term in 45 C.F.R. § 160.103, limited to the information created or
received by Business Associate from or on behalf of County.
7. "Required By Law" shall have the same meaning given to such term in 45
C.F.R. §164.103.
8. "Secretary" shall mean the Secretary of the United States Department of Health
and Human Services ( "HHS ") or his designee.
9. "Security Incident' shall have the same meaning given to such term in 45
C.F.R. §164.304.
10. Health Information at 45 C.F.R. Part 160 and Part 164, subpart C.
11. "Unsecured Protected Health Information" shall have the same meaning given
to such term in 45 C.F.R. § 164.402.
12. "Security Rules" means final regulations issued by the Secretary governing
the security of electronic PHI by covered entities contained in 45 C.F.R.
parts 160, 162 and 164.
II. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
24
A. Scope of Use and Disclosure of Protected Health Information. Business
Associate agrees to not use or further disclose PHI other than as permitted or
required by this Agreement or as Required By Law.
B. Safeguard Against Misuse of Information. Business Associate agrees to use
appropriate safeguards to prevent use or disclosure of the PHI other than as
provided for by this Agreement. Furthermore, Business Associate will implement
administrative, physical, and technical safeguards (including written policies and
procedures) that reasonably and appropriately protect the confidentiality,
integrity, and availability of Electronic Protected Health Information that it
creates, receives, maintains, or transmits on behalf of the County as required by
the Security Rules. To the extent practicable, Business Associate will secure all
Protected Health Information by technological means that render such
information unusable, unreadable, or indecipherable to unauthorized individuals
and in accordance with any applicable guidance issued by the Department of
Health and Human Services under Section 13402 of the HITECH Act.
C. Duty to Mitigate. Business Associate agrees to cure or mitigate, to the extent
practicable, any harmful effect that is known to Business Associate of a use or
disclosure of PHI by Business Associate or its agents or subcontractors in
violation of the requirements of this Agreement.
D. Reporting of Violations. Business Associate agrees to notify the County, in
writing, of any use or disclosure of the PHI not provided for by this Agreement,
any Security Incident, and any Breach of County's Unsecured Protected Health
Information. This notification will be made within thirty (30) business days after
the discovery of the use, disclosure, Security Incident, or Breach. In the event of a
Breach, if a delay is requested by law enforcement under 45 C.F.R. § 164.412,
Business Associate may delay notifying the County for the applicable timeframe.
This notification will include, to the extent possible, the identification of each
individual whose Unsecured Protected Health Information has been, or is
reasonably believed by the Business Associate to have been, accessed, acquired
used or disclosed during the Breach. Business Associate will also provide the
County with any other available information that the County is required to include
in its notification to the individual under C.F.R. § 164.404(c) at the time of the
initial notification or promptly thereafter as the information becomes available.
E. Use or Disclosure to Subcontractors. Business Associate shall ensure that any
subcontractor or agent to whom it provides PHI received from, or created or
received by Business Associate on behalf of, County agrees to implement
reasonable and appropriate safeguards to protect the County's PHI. In turn,
Business Associate agrees to ensure that any such subcontractor or agent agrees,
in writing, to the same restrictions and conditions that apply through this
Agreement to Business Associate with respect to such information. Business
Associate shall provide copies of such agreements to County upon request.
F. Access, Amendment, and Accounting Responsibilities. In a mutually agreeable
time and manner, the Business Associate agrees to provide access to the PHI that
25
it maintains in Designated Record Sets to the County, or to the Individual to
whom the PHI relates in accordance with 45 C.F.R. § 164.524. Business Associate
shall have the right to charge the Individual a reasonable, cost -based fee, as
permitted by 45 C.F.R. § 164.524. The Business Associate further agrees to
document any disclosures of PHI if requested by the County in accordance with
45 C.F.R. § 164.528, and to provide such documentation to the County as it may
request from time to time. Furthermore, at the request of the County, the Business
Associate agrees to make amendments to PHI that it maintains in a Designated
Record Set as directed by the County and to incorporate any amendments to PHI
in accordance with 45 C.F.R. §164.526. Business Associate assumes no
obligation to coordinate the provision of PHI maintained by other business
associates of the County. Notwithstanding the foregoing, the County will not
request that the Business Associate use or disclose PHI in any manner that would
not be permissible under the Privacy rule if such disclosure or use were done by
the County itself.
G. Electronic Data Interchange. Inasmuch as Business Associate transmits or
receives Transactions (as that term is defined in 45 C.F.R. § 160.103) on behalf of
County, Business Associate shall comply with any applicable provisions of the
Electronic Data Interchange Requirement (as set forth in 45 C.F.R. parts 160 and
162) and shall ensure that any subcontractors or agents that assist Business
Associate in conducting Transactions on behalf of County agree in writing to
comply with the Electronic Data Interchange Requirements.
H. Availability of Books and Records. For purposes of the Secretary determining
the County's compliance with the Privacy Rules, Business Associate agrees to
make internal practices, books, and records, including policies and procedures and
PHI relating to the use and disclosure of PHI received from, or created or received
by the Business Associate on behalf of the County available (i) to the County in a
mutually agreeable time and manner, or (ii) to the Secretary in the manner
designated by the Secretary.
I. HITECH Act Business Associate Agreement Requirements. The parties intend
for this Agreement to satisfy the requirements of sections 13401 (a) and 13404 (a)
of the HITECH Act that specified security and privacy provisions requirements be
incorporated into business associate agreements. This Agreement shall be
interpreted in a manner consistent with this intention.
III. OBLIGATIONS AND ACTIVITIES OF COUNTY
A. Obligations of County. County shall inform Business Associate with respect to
the following privacy practices and restriction:
1. County shall provide Business Associate with a copy of the notice of privacy
practices that County approves /produces and has distributed in accordance
with 45 C.F.R. § 164.520, as well as any changes to such notice. Furthermore,
County shall specifically notify Business Associate of any limitation(s) in its
notice of privacy practices to the extent that such limitation(s) may affect
Business Associate's use or disclosure of PHI.
26
2. County shall provide Business Associate with any changes in, or revocation of,
permission by Individual to use or disclose PHI, if such changes affect
Business Associate's permitted or required uses or disclosures as set forth in
this Agreement or the Service Agreement.
3. County shall notify Business Associate within five (5) business days of any
restriction to the use or disclosure of PHI requested by an Individual in
accordance with 45 C.F.R. § 164.522, to the extent that such restriction may
affect Business Associate's use or disclosure of PHI. In turn, due to the wide
variety of services and clients of Business Associate, Business Associate has
limited capacity to comply with special privacy restrictions requested by
Individuals. Accordingly, County agrees that it will only accommodate such
requests to the extent required by 45 C.F.R. § 164.522(b)(1)(ii).
4. County shall notify Business Associate in advance of the time and manner in
which Business Associate must comply with requests by County with respect
to any of the obligations and activities of Business Associate set forth above
in Section II, and in all events such times and manners shall be reasonable.
5. The parties acknowledge and agree that the Privacy Rules allow County to
permit Business Associate to disclose or provide access to PHI to .County.
6. Business Associate acknowledges and agrees that the Privacy Rules allow
County to permit Business Associate to disclose or provide access to PHI to
only those employees or other persons (including third parties) under the
control of County who are described by name or position below as the persons
who are given access to PHI solely to carry out billing administration
functions that County performs for County. Accordingly, notwithstanding any
other terms and conditions of this Agreement, to the extent that the fulfillment
of its obligations under this Agreement requires Business Associate to
disclose or provide access to PHI to County or any employees or other
persons (including third parties) under the control of County, Business
Associate shall make such disclosure of or provide such access to PHI on as
follows:
a) Business Associate shall disclose or make available PHI at the direction of
County only to the following employees or other persons (including third
parties):
Any and all employees and officers of billing agency
Any and all employees and officers of collection company
Any and all employees of Monroe County Board of County Commissioners
County agrees to promptly notify Business Associate in writing of changes to
the above list. Business Associate is authorized to rely on the information
provided by County.
27
b) It is acknowledged and agreed that the Privacy Rules require County to
maintain policies and procedures to ensure that any PHI that it uses, requests,
or discloses be no more that the minimum necessary to accomplish the
intended purposes. County hereby warrants and represents that any requests
for County will be for no more than the minimum amount necessary for the
intended purpose.
c) Business Associate shall provide PHI to other business associates who assist
in administering County and are authorized by County to receive such
information for the purpose of facilitating billing and collections for the
County's ground and air ambulance program. County shall enter into and
maintain a written agreement with each agent and subcontractor or other third
party to which it directs Business Associate to disclose PHI under which such
agent, subcontractor, or other third party is legally bound by the same
restrictions with respect to PHI that apply to Business Associate pursuant to
this Agreement.
B. Permissible Requests by County. County shall not request Business Associate to
use, disclose, or handle PHI in any manner that would not be permissible under
the Privacy and Security Rules if done by the County, except for the data
aggregation or management and administrative activities of the Business
Associate.
IV. PERMITTED USES AND DISCLOSURES BY BUSINESS ASSOCIATE
A. General Use and Disclosure Provisions. Except as otherwise limited in this
Agreement, Business Associate may use or disclose PHI to perform functions,
activities, or services for, or on behalf of, County, provided that such use or
disclosure would not violate the Privacy and Security Rules if done by County, or
the minimum necessary policies and procedures of the County.
B. Specific Use and Disclosure Provisions.
1. Business Associate will make reasonable efforts to use, disclose, and to
request only the minimum amount of the County's PHI necessary to
accomplish the intended purpose of the use, disclosure or request, except that
Business Associate will not be required to comply with this minimum
necessary limitation if neither Business Associate nor the County is required
to limit its use, disclosure or request to the minimum necessary. Business
Associate and the County acknowledge that the phrase "minimum necessary"
shall be interpreted in accordance with the HITECH Act.
2. Except as otherwise limited in this Agreement, specific examples of permitted
use or disclosure of PHI by Business Associate on behalf of, or to provide
Services to, County may include, but are not limited to, reviewing billing and
collection with the objective of making recommendations for the
improvement of County's billing functions.
28
3. Business Associate may use PHI to report violations of law to appropriate
Federal and State authorities, consistent with 45 C.F.R. §164.502(j)(1).
4. Except as otherwise limited in this Agreement, Business Associate may use
PHI for the proper management and administration of Business Associate or
to carry out any present or future legal responsibilities of the Business
Associate.
5. Except as otherwise limited in this Agreement, Business Associate may use
PHI to provide Data Aggregation services to County as permitted by 42
C.F.R. § 164.504(e)(2)(i)(B).
C. Applicability. This Agreement applies with respect to any aspect of the
Agreement that involves the use or disclosure of PHI but only to the extent that
the services or transactions of Business Associate are not exempt from HIPAA
pursuant to 1179 of the Social Security Act (42 U.S.C. § 1320d -8).
V. TERM AND TERMINATION
A. Term. The term of this Agreement shall commence as of the Effective Date set
forth above in Section I.B., and shall terminate when all of the PHI provided by
County Entity to Business Associate, or created or received by Business Associate
on behalf of County, is destroyed or returned to County, or, if it is infeasible to
return or destroy PHI, protections are extended to such information, in accordance
with the termination provisions of this Section.
B. Termination for Cause. Upon County's knowledge of a material breach by
Business Associate, County (or, County, on behalf of County) shall either:
1. Provide an opportunity for Business Associate to cure the breach or end the
violation and terminate this Agreement if Business Associate does not cure
the breach or end the violation within the time specified by County or
County;
2. Immediately terminate this Agreement and any underlying agreements if
Business Associate has breached a material term of this Agreement and cure
is not possible; or
3. If neither termination nor cure is feasible, County shall report the violation
to the Secretary.
D. Effect of Termination. Upon termination of the Agreement, for any reason,
Business Associate shall return all PHI received from County, or created or
received by Business Associate on behalf of County. This provision shall apply to
PHI that is in the possession of subcontractors or agents of Business Associate.
Business Associate shall retain copies of the PHI. If Business Associate has
determined that destroying the PHI is infeasible, it shall provide County an
explanation of the conditions that make destruction infeasible. If County and
Business Associate mutually agree that destruction of the PHI is infeasible,
Business Associate shall extend the protections of this Agreement to such PHI
29
and limit further uses and disclosures of such PHI to those purposes that make the
return or destruction infeasible, for so long as Business Associate maintains such
PHI.
VI. MISCELLANEOUS
A. Regulatory References. A reference in this Agreement to a section in the Privacy
and Security Rules means the section as in effect or as amended and for which
compliance is required.
B. Governing Law. This Agreement shall be construed and enforced according to
HIPAA, and any applicable state law to the extent not preempted by HIPAA or
other federal law.
C. Complete Integration. This Agreement constitutes the entire agreement between
the parties and supersedes all prior negotiations, discussions, representations, or
proposals, whether oral or written, unless expressly incorporated herein, related to
the subject matter of the Agreement. Unless expressly provided otherwise herein,
this Agreement may not be modified unless in writing signed by the duly
authorized representatives of both parties. If any provision or part thereof is found
to be invalid, the remaining provisions shall remain in full force and effect.
D. Amendment. The parties agree to take such action as is necessary to amend this
Agreement from time to time as is necessary for County to comply with the
requirements of the Privacy and Security Rules, the Health Insurance Portability
and Accountability Act, Public Law 104 -191, and the HITECH Act.
E. Interpretation. The parties hereto acknowledge and agree that both (i) the rule of
construction to the effect that any ambiguities are resolved against the drafting
party, and (ii) the terms and provisions of this Agreement, will be construed fairly
as to all parties hereto and not in favor of or against a party, regardless of which
party was generally responsible for the preparation of this Agreement. Moreover,
any ambiguity in this Agreement shall be resolved in favor of a meaning that
permits County to comply with the Privacy and Security Rules. In the event of an
inconsistency between the provisions of this Agreement and the Privacy and
Security Rules, as may be amended from time to time, because of interpretations
by HHS, a court, or another regulatory agency with authority over the Parties, the
interpretation of HHS, such other court or regulatory agency shall prevail. In the
event provisions of this Agreement differ from those mandated by the Privacy and
Security Rules but are nonetheless permitted by such rules, the provisions of this
Agreement shall control.
F. Severability. The parties intend this Agreement to be enforced as written.
However, (i) if any portion or provision of this Agreement will to any extent be
declared illegal or unenforceable by a duly authorized court having jurisdiction,
then the remainder of this Agreement, or the application of such portion or
provision in circumstances other than those as to which it is so declared illegal or
unenforceable, will not affected thereby, and each portion and provision or this
Agreement will e valid and enforceable to the fullest extent permitted by law; and
30
(ii) if any provision, or part thereof, is held to be unenforceable because of the
duration or such provision, the County and the Business Associate agree that the
court making such determination will have the power to reduce the duration of
such provision, and /or to delete specific words and phrases, and in its reduced
form such prevision will then be enforceable and will be enforced.
G. Successors and Assigns. This Agreement will inure to the benefit of and be
binding upon the successors and assigns of County and Business Associate.
However, this Agreement is not assignable by either party without the prior
written consent of the other party, except that Business Associate may assign or
transfer this Agreement to any entity owned or under common control with
Business Associate.
H. No Third Party Beneficiaries. Business Associate and County agree that nothing
express or implied in this Agreement is intended to confer, nor shall anything
herein confer, upon any person other than Business Associate, and County, and
their respective successors or assigns, any rights, remedies, or obligations or
liabilities whatsoever.
I. Headings and Captions. The headings and captions of the various subdivisions
of this Agreement are for convenience of reference only and will in no way
modify, or affect the meaning or construction of any of the terms or provisions
thereof.
J. No Waiver of Rights, Powers, and Remedies. No failure or delay by a party
hereto in exercising any right, power or remedy under this Agreement, and no
course of dealing between the parties hereto, will operate as a waiver of any such
right, power or remedy of the party. No single or partial exercise of any right,
power or remedy under this Agreement by a party hereto, nor any abandonment or
discontinuance of steps to enforce any such right, power or remedy, will preclude
such party from any other or further exercise thereof or the exercise of any other
right, power or remedy hereunder. The election of any remedy by a party hereto
will not constitute a waiver of the right of such party to pursue other available
remedies. No notice to or demand on a party not expressly required under this
Agreement will entitle the party receiving such notice or demand to any other or
further notice or demand in similar or other circumstances or constitute a waiver
of the rights of the party giving such notice or demand in similar or other
circumstances or constitute a waiver of the rights of the party giving such notice
or demand to any other or further action in any circumstances without such notice
or demand. The terms and provisions of this Agreement may be waived, or
consent for the departure there from granted, only by written document executed
by the party entitled to the constitute a waiver or consent with respect to any other
terms or provisions of this Agreement, whether or not similar. Each such waiver
or constitute a continuing waiver or consent.
K. Indemnification. Business Associate shall indemnify and hold harmless County
from and against any and all loss, damage, or expense (including claims of
damage or liability) asserted against County by third parties and arising out of (i)
the use or disclosure of PHI by Business Associate or its agents or subcontractors
31
other than as provided in this Agreement, or (ii) a breach of Business Associate's
representations contained in this Agreement. To the extent allowed by Section
768.28, Florida Statutes, County shall indemnify and hold harmless Business
Associate from and against any and all loss, damage, or expense (including claims
of damage or liability) asserted against Business Associate by third parties and
arising out of (i) the use or disclosure of PHI by County or its agents or
subcontractors other than as provided in this Agreement, or (ii) a breach of
County's representations contained in this Agreement.
Notice. All notices, requests, consents, and other communications hereunder will
be in writing. All notices to the County shall be served on the following address:
Monroe County Fire Rescue, 490 63rd Street Ocean, Suite 140, Marathon, FL
33050. All notices to Business Associate shall be served at the following address:
L. Survival. The respective rights and obligations of Business Associate under V.C.
and VIX of this Agreement shall survive the termination of this Agreement.
M. Counterparts. This Agreement may be executed in two or more counterparts,
each of which may be deemed an original.
VII. ACKNOWLEDGEMENT AND SIGNATURES
The parties acknowledge that they have read this agreement, understand it, and agree
to be bound by its terms. Accordingly, in witness whereof, this Agreement is
executed by the parties, by their duly authorized representatives as of the date set
forth above.
(SEAL) BOARD OF COUNTY COMMISSIONERS
ATTEST: AMY HEAVILIN, OF MONROE COUNTY, FLORIDA
COUNTY CLERK
By: By:
Deputy Clerk Mayor, George Neugent
RESPONDENT: BOARD OF GOVERNORS OF FIRE AND
AMBULANCE DISTRICT 1 OF MONROE
COUNTY, FL
B B
Print Name and Title Mayor / Chairman
Date:
32
SECTION FOUR ATTACHMENTS AND FORMS:
Attachment A Scope of Work
Attachment B Submission Response Form
Attachment C Non - Collusion Affidavit
Attachment D
Public Entity Crime Statement
Attachment E
Drug Free Workplace Form
Attachment F
Lobbying &Conflict of Interest Clause- (Ethics Clause)
Attachment G
Indemnification and Hold Harmless
Attachment H Insurance Documents
Attachment I Local Preference Form
33
Attachment A
SCOPE OF WORK
As used herein, the term "contracted independent billing agency" includes both the
third party billing company and the collection agency currently under contract with
the County.
The Consultant will review and make recommendations for improvements as to all of the
following:
A. Initial Patient Treatment and Information
1. Respondent will review MCFR's records to determine whether sufficient
detail has been given in ePCRs (electronic patient care reports) to the
independent contracted billing agency to support diagnosis and procedure
coding, including insurance and patient demographic information necessary
for accurate identification including name, address, social security number,
date of birth, and telephone number. The Consultant will make any necessary
recommendations for improvement.
2. Respondent will review situations in which immediate medical treatment and
patient transport were administered without patient info being collected. In
such cases, after transporting said patients, the COUNTY requires the
contracted independent billing agency to be solely responsible for retrieving
insurance information and any additional patient information which was not
identified in the ePCR. The Consultant will make any necessary
recommendations for improvement.
B. Patient Billing
1. Rates charged by the County are set by resolution, and currently are as
follows:
Ground Ambulance:
$600.00 for Basic Life Support (BLS)
$600.00 for Advance Life Support One (ALSI)
$800.00 for Advance Life Support Two (ALS2)
Plus $12.00 per mile
Air Ambulance:
$5500.00 for Air Ambulance Transport Fee
Plus $80.00 per mile
Respondent will make recommendations on modifications to the
aforementioned fee for maximization of potential revenues from third -party
payers.
2. Respondent will review and validate whether billing agency and collection
companies are compliant in sending invoices and other billing notices
according to the time frames as agreed to in the contracts with the COUNTY.
34
Respondent will make recommendations on any improvements to billing and
initial collection processes.
C. Patient Filing
1. Respondent will review contracted independent billing agency utilization of
the most up -to -date knowledge and information with regard to coding
requirements and standards and proper preparation of electronic and paper
insurance filings to ensure compliance with applicable Federal, State and local
regulations.
D. Specifically relevant to Collections Company
1. Respondent will evaluate independent collection company collection
processes and compliance with terms of contract.
2. Respondent will recommend any modifications or improvements to the above
processes and contracts to meet best industry standards and revenue collection
maximization.
E. Respondent will provide any other recommended modifications or improvements
relative to billing, collections and revenue maximization.
All conclusions, observations and recommendations will be provided to the County in the
form of a report no later than ninety (90) days from the date of execution of the
agreement between the parties.
35
Attachment B
SUBMISSION SOLICITATION RESPONSE FORM
BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY
FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING
AND COLLECTIONS
Respondent's Name and Mailing Address:
Telephone and Fax Numbers:
Email Address
Indicate below the compensation you seek for the Scope of Service described in
Attachment A. All amounts must be written AND in number format. In case of a conflict
between the amount in words and the amount in numbers, the amount in words shall
control.
Total $
I have included:
• Submission Response Form
• Non Collusion Affidavit
• Public Entity Crime Statement
• Lobbying and Conflict of Interest Clause Form
• Drug Free Workplace Form
• Indemnification and Hold Harmless
• Local Preference Form (if applicable)
(Check mark items above, as a reminder that they are included).
I state that I am authorized to submit this proposal.
STATE OF
(Signature of Respondent)
COUNTY OF
Date
PERSONALLY APPEARED BEFORE ME, the undersigned
authority, who, after first being sworn by me, (name of
individual signing) affixed his /her signature in the space provided above on this
day of , 20
My commission expires:
NOTARY PUBLIC
36
Attachment C
NON- COLLUSION AFFIDAVIT
I, , of the
city of according to law on my oath,
and under penalty of perjury, depose and say that;
1) I am ,the respondent
making the Solicitation for the project described as follows:
2) The prices in this solicitation 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 respondent or with
any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this
solicitation have not been knowingly disclosed by the respondent and will not knowingly
be disclosed by the respondent prior to solicitation opening, directly or indirectly, to any
other respondent or to any competitor; and
4) No attempt has been made or will be made by the respondent to induce any
other person, partnership or corporation to submit, or not to submit, a solicitation 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.
STATE OF
(Signature of Respondent)
COUNTY OF
Date
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
who, after first being sworn by me, (name of
individual signing) affixed his /her signature in the space provided above on this
day of , 20
My commission expires:
NOTARY PUBLIC
OMB - MCP FORM # 1
37
Attachment D
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 solicitation on a contract to provide
any goods or services to a public entity, may not submit a solicitation on a contract with a
public entity for the construction or repair of a public building or public work, may not
submit solicitations on leases of real property to public entity, may not be awarded or
perform work as a bidder, supplier, subbidder, RESPONDENT or subRespondents under
a contract with any public entity, and may not transact business with any public entity 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."
By executing this form, I acknowledge that I /my company is in compliance with the
above.
STATE OF
(Signature of Respondent)
COUNTY OF
Date
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
who, after first being sworn by me, (name of
individual signing) affixed his /her signature in the space provided above on this
day of , 20
My commission expires:
NOTARY PUBLIC
38
Attachment E
DRUG -FREE WORKPLACE FORM
The undersigned Respondent in accordance with Florida Statute 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's
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 solicitation 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 solicitation, 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 contendre 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.
Respondent's Signature
Date
OMB - MCP FORM #5
39
Attachment F
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 10 -1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
warrants that he /it has not employed,
retained or otherwise had act on his /its behalf any former County officer or employee in
violation of Section 2 of Ordinance No. 10 -1990 or any County officer or employee in
violation of Section 3 of Ordinance No. 10 -1990. For breach or violation of this
provision the County may, in its discretion, terminate this contract without liability and
may also, in its discretion, deduct from the contract 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.
(Signature)
Date:
STATE OF
COUNTY OF
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
his /her
who, after first being sworn by me, affixed
signature (name of individual signing) in the space provided above on this day
of
20
NOTARY PUBLIC
My commission expires:
OMB - MCP FORM #4
40
Attachment G
MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
Indemnification and Hold Harmless
for
Other Respondents and subRespondents
The Responder covenants and agrees to indemnify and hold harmless Monroe County
Board of County Commissioners AND Board of Governors for District I, its servants,
agents and employees 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 consultant's fees) which arise out of,
in connection with, or by reason of services provided by the Bidder or any of its
subRespondents (s) in any tier, occasioned by the negligence, errors, or other wrongful
act or omission of The Responder or its sub - Responder 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 Responder's failure to purchase or maintain the required
insurance, the Respondent 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 Respondent 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.
Respondent's Signature
Date
41
TCS
Attachment H (1 of 4)
INSURANCE REQUIREMENTS
FOR CONTRACT
BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY
FIRE RESCUE'S (MCFR) EMS GROUND AND AIR RESCUE TRANSPORT
BILLING AND COLLECTIONS
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the commencement of work governed by this contract, the Respondent 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
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 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.
IP)
GL2
43
Attachment H (2 of =1)
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR CONTRACT
BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY
FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING
AND COLLECTIONS
BETWEEN
MONROE COUNTY, FLORIDA
AND
Recognizing that the work governed by this contract involves the furnishing of advice or
services of a professional nature, the Respondent 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 Respondent arising out of work governed by this contract.
The minimum limits of liability shall be:
$500,000 per Occurrence /$1,000,000 Aggregate
PRO2
44
Attachment H (3 of 4)
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR CONTRACT
BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY
FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING
AND COLLECTIONS
BETWEEN
MONROE COUNTY, FLORIDA
AND
Recognizing that the work governed by this contract requires the use of vehicles, the
Respondent, prior to the commencement of work, shall obtain Vehicle Liability
Insurance. Coverage shall be maintained throughout the life of the contract and include,
as a minimum, liability coverage for:
• Owned, Non - Owned, and Hired Vehicles
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
The Monroe County Board of County Commissioners shall be named as Additional
Insured on all policies issued to satisfy the above requirements.
VL2
45
Attachment H (4 of =1)
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR CONTRACT
BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY
FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING
AND COLLECTIONS
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the commencement of work governed by this contract, the Respondent shall
obtain Workers' Compensation Insurance with limits sufficient to respond to the
applicable state statutes.
In addition, the Respondent shall obtain Employers' Liability Insurance with limits of not
less than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 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 Respondent has been approved by the Florida's Department of Labor, as an
authorized self - insurer, the County shall recognize and honor the Respondent's status.
The Respondent may be required to submit a Letter of Authorization issued by the
Department of Labor and a Certificate of Insurance, providing details on the
Respondent's Excess Insurance Program.
If the Respondent participates in a self - insurance fund, a Certificate of Insurance will be
required. In addition, the Respondent may be required to submit updated financial
statements from the fund upon request from the County.
WC2
46
Attachment H (4 of =1)
MONROE COUNTY, FLORIDA
Request for Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance
Requirements, be waived or modified on the following contract.
Respondent:
Contract for:
Address of Respondent:
Phone:
Scope of Work:
Reason for Waiver:
Policies Waiver
will apply to:
Signature of Respondent:
Approved Not Approved
Risk Management
Date
County Administrator appeal:
Approved: Not Approved:
Date:
Board of County Commissioners appeal:
Approved: Not Approved:
Meeting Date:
47
Attachment I
LOCAL PREFERENCE FORM
Vendors claiming a local preference according to Ordinance 023 -2009 must complete this form.
Name of Bidder /Responder.
Date:
1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated
at least one year prior to the notice or request for bid or solicitation? (Please furnish copy. )
2. Does the vendor have a physical business address located within Monroe County from which the vendor
operates or performs business on a day to day basis that is a substantial component of the goods or services
being offered to Monroe County?
List Address:
Telephone Number:
B. Does the vendor /prime Respondent intend to subcontract 50% or more of the goods, services or
construction to local businesses meeting the criteria above as to licensing and location?
If yes, please provide:
1. Copy of Receipt of the business tax paid to the Monroe County Tax Collector by the subRespondent
dated at least one year prior to the notice or request for bid or solicitation.
2. SubRespondent Address within Monroe County from which the subRespondent operates:
Signature and Title of Authorized Signatory for
Bidder /Responder
STATE OF
COUNTY OF
Tel. Number
Print Name:
On this day of , 20 , before me, the undersigned notary public, personally appeared
known to me to be the person whose name is subscribed above or who
produced as identification, and acknowledged that he /she is the person who
executed the above Local Preference Form for the purposes therein contained.
Notary Public
Print Name
My commission expires:
Seal
48