6. 07/17/2013 AgreementCLERK OF CIRCUIT COURT & COMPTROLLER
MONROE COUNTY, FLORIDA
DATE: July 24, 2013
TO: Sheryl Graham, Director
Social Services
FROM: Vitia Fernandez, D. C. �(
At the July 17, 2013, Board of County Commissioner's meeting the Board granted approval and
authorized execution of Item C45 for Monroe County Bayshore Manor to re- enroll in a Provider
Agreement for participation in the Title XIX Institutional Florida Medicaid Program.
Enclosed is a duplicate original of the above - mentioned for your handling. Should you have any
questions, please feel free to contact my office.
cc: County Attorney
Finance
File
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500 Whitehead Street Suite 101, PO Box 1980, Key West FL 33040 Phone: 305 - 295 -3130 Fax: 305 -295 -3663
3117 Overseas Highway, Marathon, FL 33050 Phone: 305 -289 -6027 Fax: 305- 289 -6025
88820 Overseas Highway, Plantation Key, FL 33070 Phone: 852 -7145 Fax: 305- 852 -7146
1/3,111
J A W A
FLORIDA AGENCY FOR HEALTHCARE ADMHNIETRATION
RICK SCOTT Better Health Care for all Floridians
GOVERNOR
PRV- 9051- D/XX/0196956022/1
MONROE COUNTY BAYSHORE MANOR
BAYSHORE MANOR
5200 COLLEGE RD
KEY WEST FL 33040 -4302
Dear Administrator:
ELIZABETH DUDEK
SECRETARY
uiiiiiiiniiimiiuWUn
June 4, 2013
Your current Institutional Medicaid Provider Agreement for participation in the Title XIX Medicaid
Program will expire 08/30/2013.
A new Institutional Florida Medicaid Provider Agreement must be signed before 08/30/2013 in
order to continue participation in the Medicaid program. Failure to complete this process may
result in termination of your provider number.
Verify the entity's name and tax id number on the last page of the agreement for
accuracy. Please have the provider agreement signed by the facility owner(s) or an
authorized representative, and fax to HP Provider Reenrollment at 866- 270 -1497. Or, mail
to:
For Regular Mail: For Overniaht or_Exoress Delive
HP Enterprise Services, LLC HP Enterprise Services, LLC
Provider Reenrollment Provider Reenrollment
PO Box 13800 2671 W Executive Center Cir Ste 100
Tallahassee, FL 32317 -3800 Tallahassee, FL 32301 -5020
If you have any questions, please call HP Enterprise Services Provider Enrollment at
1-800- 289 -7799 option 4.
Sincerely,
0
Angela Ramsey, Acting Chief
Medicaid Contract Management
cc: Provider File
Headquarters
2727 Mahan Drive, MS#22
Tallahassee, Florida 32308
AHCA.MyFlonda.com
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Medicaid Contract Management
2562 Executive Center Circle E
Montgomery Bldg., Suite 100
Tallahassee, FL 32301
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PROVIDER REENROLLMENT APPLICATION
This application is to be submitted for the purposes of establishing continuing eligibility to receive direct or indirect payment for services rendered to
recipients of the Florida Medicaid Program.(See the Provider Re-enrollment Application Guide available at www.mymedicaid-florida.com for full instructions.)
Provider ID: 1401599
Provider Name: MONROE COUNTY BAYSHORE MANOR
Doing Business As(D/B/A):
(Optional) MoIJROE. Cl fy eatSOCIAL5E1 vIc s/ /SHD -EMAk1O _
Tax ID: FEIN 596000749 / I
1. Contact Information
List the person who the Medicaid fiscal agent should communicate with if there are questions about the re-enrollment application package.
Name SHER-y l RANAM
Telephone Number ( 305 ) L�2_ 5 lO
Area Code
E-Mail Address Q faharyl_5ktr-�/) (D, �1 bi,\(Decouni'1-
2. Change of Ownership
/ f
Indicate whether there has been a change of ownership since the provider ID listed above was issued. If yes,attach a copy of the bill of sale,stock
transfer,or lease agreement and complete the requested information regarding the previous owner.
❑ Yes DK No
Previous Provider Name Provider Number Federal Tax ID Date of CHOW
3. Owners and Operators Information
Florida Medicaid requires all individuals listed below to undergo fingerprinting unless specific exemptions are met.
(See the Provider Re-enrollment Application Guide for details on submitting fingerprints or requesting consideration of an exemption.)
If you are
a An Individual Provider Who Bills Medicaid Through A Group Membership: If you bill solely through a group membership and do not
submit claims or receive payment directly from Medicaid,list only yourself and the requested information.
OR
b An Individual Provider Who Bills Medicaid Directly: If you submit claims to Medicaid and receive payments directly,list yourself,your
financial records custodian,your medical records custodian,and all individuals who hold signing privileges on your depository account,
and the requested information for each.
OR
c A Provider Group or other Business Entity:List all shareholders(five percent or more ownership),all partners of your business and
subcontractors AND all individual officers,directors,managing employees,the financial and medical records custodian(s),and all
individuals who hold signing privileges on the depository account,and the requested information for each.NOTE:If a subcontractor is
declared,you must also disclose if the provider entity or any of the individuals listed have an ownership of 5%or more in that
subcontractor.Attach an additional sheet if needed.
Name Title 'Relationship `SSN *DOB License# *%Owner
('denotes required field) (see notes below) (if applicable)
Courti-y OvE124(I/1E7JT
NOTE.Select one or more horn the following list when indicating each owner and operator's relationship to the applicant.Owner,Partner,Shareholder,Sub-Contractor,Officer,Director,Managing
Employee,Financial Records Custodian(FRC),Medical Records Custodian(MRC),EFT Autlwnzed Individual,Spouse,Parent,Child,or Sibling.
DEFINITIONS: Officers are deemed to be officers of the corporation or company-such as the President or Vice President,directors are members of the company's board of directors,and.
managing employees are members of the company's management team.If you have a'Director of Therapy Services'or'Director of Clinical Services,'these persons would quality as managing
employees for Medicaid purposes
Visit www.myrnedicaid-florida.com or call 1-800-289-7799,Option 4 for assistance
Provider ID:1401599
4. Owra riraBq Operator's History
Answer aN sections,a-f,of this question and attach any required documentation. •
Have you,or any of the individuals listed in#3 above ever:
a) Been convicted of a felony, had adjudication withheld on a felony,pled nolo ❑ Yes No
contendere to a felony,or entered into a pre-trial agreement for a felony?
If yes,list the name(s)of the individuals(s)and provide a copy of the administrative complaint and final disposition.
Name:
b) Had any disciplinary action taken against any business or professional license held ❑ Yes No
in this or any other state or surrendered a license in this or any state?
If yes,list the name(s)of the individual(s)and the date of the action. Provide a copy of the final disposition. Attach documentation from the
proper authorities that approved the reinstatement of the license.
Name: Date:
c) Been denied enrollment,been suspended or excluded from Medicare or Medicaid in ❑ Yes No
any state,or been employed by a corporation,business or professional association
that has ever been suspended or excluded from Medicare or Medicaid in any state?
If yes,list the name(s)and provider number(s)of the individual(s)and provide a copy of any documents related to the suspension or
exclusion.
Name: Provider Number:
d) Had suspended payments from Medicare or Medicaid in any state,or been employed ❑ Yes X No
by a corporation,business or professional association that ever had suspended
payments from Medicare or Medicaid in any state?
If yes,list the name(s)and provider number(s)of the individual(s)and provide a copy of any documents related to the suspended payments.
Name: Provider Number:
e) Owes money to Medicaid or Medicare that has not been paid? ❑ Yes X No
If yes,list the name(s)and provider number(s)of the individual(s)and provide a copy of any documentation related to the debt
Name: Provider Number:
f) Have ownership in any other Medicaid enrolled business? ❑ Yes EN No
If yes,list the name and Medicaid provider number of the other Medicaid enrolled business. Attach additional pages if necessary.
Name: Provider Number: c
zr.
Certification Statement
1 understand that the filing of materially incomplete or false information with this enrollment request is a third degree felony under Section 409.920(2)( Florida Statutes
and is sufficient cause for termination from the Florida Medicaid Program;that false claims,statements,documents,or concealment of material facts be pMecufed
under applicable federal and state laws;that I am responsible for the information presented on this application and that the information is true,accura nd Ali ete;
and,that it is my responsibility to notify Medicaid's fiscal agent of any future changes to the information on this application including,but nollimited to,ughangq.gt
address,group affiliation,ownership,officers,directors,tax identification number,or EFT bank account. Furthermore,I agree to abide by the provisions of th011pider
agreement from the date it is effective per Section 409 ),Florida Statutes. O
es
JA Ii 2oi3
Si re of Pvider or Registered Trent Date
C-ec e . N M gybe-,
Name of Pro ' er or Registered Age Title
(Please Type or Print Legibly)
OE COU A Ot=iNEY
Keep a copy of the application and all required documentation for your files and mail originals to: P VE FORM
For Regular Mail: For Ovemight or Express Delivery:
HP Enterprise Services HP Enterpnse Services PEDR
Provider Enrollment ,� c Provider Enrollment AS 0 TY ATTORNEY
PO Box 13800 ; 2671 W Executive Center Cir Ste 100 1 � �
Tallahassee,FL 32317-3800 r Tallahassee FL 32301 natP
Visit www.mymedicaid-florida.com or call 1-800-289-7799,Option 4 for assistance.
AHCA Form 2200-0004(May 2010) APPLICATION Page 2
AMY HEAVILlN,C RK
BY,
DEPUTY CLERK
Background Screening Quick Reference Guide If
Background Screening
Each applicant seeking to participate in the Medicaid program must submit a complete set of fingerprints for each
person declared on an initial or renewal application for the purpose of conducting a criminal history record check.
Details of the requirements are documented in the Florida Medicaid Provider Enrollment Guide for Completing
Application located in the Enrollment Forms section in the public Web Portal at the following URL:
http://mymedicaid-florida.com under Public Web Portal > Enrollment.
In an effort to streamline the background screening process, AHCA is now encouraging providers to use vendors
offering electronic fingerprint scanning services. This process avoids the traditional fingerprint card process where
finger prints are"rolled" in ink onto an FBI fingerprint card and mailed hard copy with a check for processing. This
improves accuracy with fewer rejections(no ink smudges)and improves timeliness of the background investigation (BI)
process.
This enhancement to the process allows providers to enroll without mailing any hard copy documentation. Rather, with
electronic scanning of fingerprints handled by approved vendors, applicants may submit their application and all
remaining supporting documents through the online Enrollment Wizard located at the following URL:
http://mymedicaid-florida.com, under Public Web Portal > Enrollment> Enrollment Wizard.
The following provides detailed information on how to take advantage of this new option:
Level of Screening Required
Provider applicants to Florida Medicaid require a Level 2 screening which involves a fingerprint check of state and
federal criminal history information conducted through the Florida Department of Law Enforcement(FDLE)and the
Federal Bureau of Investigation (FBI).
Submission of Fingerprints
All provider applicants are encouraged to submit their fingerprints electronically.
Forms of Electronic Screening
The most common form of electronic screening involves use of a LiveScan device which is a type of
equipment used to directly capture fingerprints through a scanning function. Persons being screened place
their hands directly on the scanner for reading. Fingerprint scanning using a LiveScan device provides faster
results and generally costs less than hard card scanning as there is less handling involved. LiveScan capture
also produces a better quality print, so has a lower rejection rate of illegible prints(no ink smudging, etc).
There are several options for LiveScan capture, including:
• LiveScan vendors approved to submit fingerprint requests through the Florida Department of Law
Enforcement(FDLE). These vendors generally require advanced online reservations or
appointments and charge a fee for use of the LiveScan in addition to the FDLE screening fee of
$40.50. LiveScan devices are available at specific locations or through mobile services where the
vendor will either come to the provider location (based on certain volumes and fees)or another
pre-arranged location. LiveScan vendors are independent businesses and each must be contacted
in advance to determine fees, services, and enrollment requirements. For more information
regarding LiveScan vendors, see Florida LiveScan Vendor List for contact information, locations and
pricing, and the FDLE LiveScan Site. The Florida LiveScan Vendor List is available at the following
URL: http://ahca.myflorida.com, under Medicaid Health Quality Assurance > Licensing and
Regulation.
1 I Background Screening Quick Reference Guide
Background Screening Quick Reference Guide
• The Agency for Health Care Administration has contracted with Cogent Systems to provide
electronic fingerprint services for health care providers licensed through the Agency. Cogent
Systems has statewide locations and will provide LiveScan services for a screening fee of$40.50
plus a processing fee of$11.00 per transaction for a total screening fee of$51.50 per individual. The
fee is due at the time of screening unless other payment arrangements have been made with
Cogent. For a list of Cogent locations, visit the Cogent Web site at the following URL:
http://www.cogentid.comMindex_ahca.htm.
Please note, this process is specifically set up for license related activities for AHCA's Health Quality
and Assurance division responsible for provider licensing. This is a different division and process
than AHCA's Medicaid Enrollment process. This is important to understand should applicants choose
to work with Cogent for capture of their fingerprints for Medicaid provider enrollment purposes.
To ensure the results of your screening are delivered to Florida Medicaid and not to AHCA's Division
of Health Quality Assurance, be sure to use the correct account number, or ORI, assigned to Florida
Medicaid. The ORI which should be used for Medicaid Enrollment and Re-Enrollment is FL922013Z.
• LiveScan devices(machines) may be purchased/leased by providers who wish to handle their own
fingerprint capture. Several businesses offer machines(sale or lease); however, it is important to
assure that any selection is approved for submission through FDLE, and all requirements of
fingerprint submission are met. For more information visit the AHCA's background screening page at
the following URL: http://ahca.myflorida.com, under Health Quality Assurance> Licensing and
Regulation > Background Screening.
LiveScan Requirements
Please have the following information available at the time of screening:
• A valid picture ID
• Indicate the AHCA#, which is either:
• the Application Tracking Number(ATN), for new applicants and associated parties; or,
• the Medicaid Provider ID, for renewing applicants and associated parties.
• All information regarding the the person to be screened, including:
• Full Name
• Address
• Social Security Number
• Date of Birth
• Race
• Sex
• Height
• Weight
NOTE: Incomplete information may result in rejection of screening requests.
Please communicate to the LiveScan vendor your screening is for Florida Medicaid Provider Enrollment and should be
submitted on behalf of Florida Medicaid at ORI FL922013Z.
Cost of Screening
FDLE charges$40.50 for a Level 2 background screen ($24.00 for the state portion and $16.50 for the national
portion). The additional cost of electronic screening varies based on the vendor chosen.
Total cost= $40.50 +electronic print processing fee
2 1 Background Screening Quick Reference Guide
n INSTITUTIONAL
V MEDICAID PROVIDER AGREEMENT if
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The Provider agrees to participate in the Florida Medicaid program under the following terms and
conditions:
(1) Discrimination. The parties agree that the Agency for Health Care Administration (agency)may make
payments for medical assistance and related services rendered to Medicaid recipients only to a person or
entity who has a provider agreement in effect with the agency, who is performing services or supplying
goods in accordance with federal, state, and local law, and who agrees that no person shall, on the
grounds of sex, handicap, race, color, national origin, other insurance, or for any other reason, be
subjected to discrimination under any program or activity for which the provider receives payment from
the agency.
(2) Quality of Service. The provider agrees that services or goods billed to the Medicaid program must
be medically necessary, of a quality comparable to those furnished by the provider's peers, and within the
parameters permitted by the provider's license or certification. The provider further agrees to bill only for
the services performed within the specialty or specialties designated in the provider application on file
with the agency. The services or goods must have been actually provided to eligible Medicaid recipients
by the provider prior to submitting the claim.
(3) Compliance. The provider agrees to fully comply with all state and federal laws, rules, regulations,
and statements of policy applicable to the Medicaid program, including the Medicaid Provider Handbooks
issued by the agency, as well as all federal, state, and local laws pertaining to licensure, if required, and
the practice of any of the healing arts.
(4) Term and signatures. The parties agree that this is a voluntary agreement between the agency and
the provider, in which the provider agrees to furnish services or goods to Medicaid recipients. Provided
that all requirements for enrollment have been met,this agreement shall remain in effect for three(3)
years from the effective date of the provider's eligibility unless otherwise terminated. With respect to
reenrolling providers, the agreement shall remain in effect for three(3)years from either the date the
most recent agreement expires or the date the provider signs the renewal agreement, which ever date is
earlier, unless otherwise terminated. This agreement shall be renewable only by mutual consent. The
provider understands and agrees that no agency signature is required to make this agreement valid and
enforceable.
(5) Provider Responsibilities. The Medicaid provider shall:
(a) Possess at the time of the signing of the provider agreement, and maintain in good standing
throughout the period of the agreement's effectiveness, a valid professional, occupational,facility or other
license pertinent to the services or goods being provided, as required by the state or locality in which the
provider is located, and the Federal Government, if applicable.
(b) Maintain in a systematic and orderly manner all medical and Medicaid-related records the agency
requires and determines are relevant to the services or goods being provided.
(c) Retain all medical and Medicaid-related records for a period of five (5)years to satisfy all necessary
inquiries by the agency.
(d) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients
and comply with all state and federal laws pertaining to confidentiality of patient information.
(e) Send, at the provider's expense, all Medicaid-related information, which may be in the form of
records, logs, documents, or computer files, and other information pertaining to services or goods billed to
the Medicaid program, including access to all patient records and other provider information if the
provider cannot easily separate records for Medicaid patients from other records to the Attorney General,
the Federal Government, and the authorized agents of each of these entities.
(f) Bill other insurers and third parties, including the Medicare program, before billing the Medicaid
program, if the recipient is eligible for payment for health care or related services from another insurer or
person and comply with all other state and federal requirements in this regard.
(g) Report and refund any moneys received in error or in excess of the amount to which the provider is
entitled from the Medicaid program within ninety(90)days of receipt.
MPA Institutional(March 2013) 1 of 4
(h) Be liable for and indemnify, defend, and hold the agency harmless from all claims, suits,judgments,
or damages, including court costs and attorney's fees, arising out of the negligence or omissions of the
provider in the course of providing services to a recipient or a person believed to be a recipient to the
extent allowed by in and accordance with section 768.28, F.S. (2001), and any successor legislation. •
(i) Provide proof of liability insurance at the option of the agency and maintain such insurance in effect for
any period during which services of goods are furnished to Medicaid recipients.
(j) Accept Medicaid payment as payment in full, and not bill or collect from the recipient or the recipient's
responsible party any additional amount except, and only to the extent the agency permits or requires,
co-payments, coinsurance, or deductibles to be paid by the recipient for the services or goods provided.
This includes situations in which the provider's Medicare coinsurance claims are denied in accordance
with Medicaid policy.
(k) Comply with all of the requirements of Section 6032 (Employee Education About False Claims
Recovery)of the Deficit Reduction Act of 2005, if the provider receives or earns five million dollars or
greater annually under the State plan.
(I) Submit,within thirty-five (35)days of the date on a request by the Secretary or the Medicaid agency,
full and complete information about the ownership of any subcontractor with whom the provider has had
business transactions totaling more than $25,000 during the twelve(12) month period ending on the date
of the request; and any significant business transactions between the provider and any wholly owned
supplier, or between the provider and any subcontractor, during the five (5)year period ending on the
date of the request.
(m) Employ only individuals who may legally work in the United States, either U.S. citizens or foreign
citizens who are authorized to work in the U.S, in compliance with the Immigration Reform and Control
Act of 1986 which prohibits employers from knowingly hiring illegal workers.
(n) Utilize the U.S. Department of Homeland Security's E-Verify Employment Eligibility Verification
system to verify the employment eligibility of all persons employed by the provider during the term of this
Contract to perform employment duties within Florida and all persons (including subcontractors)assigned
by the provider to perform work pursuant to this Contract. The provider shall include this provision in all
subcontracts it enters into for the performance of work under this Contract.
(o) Attest that all statements and information furnished by the prospective provider before signing the
provider agreement shall be true and complete. The filing of a materially incomplete, misleading or false
application will make the application and agreement voidable at the option of the agency and is sufficient
cause for immediate termination of the provider from the Medicaid program and/or revocation of the
provider number.
(p) Agree to notify the agency of any changes to the information furnished on the Florida Medicaid
Provider Enrollment Application including changes of address, tax identification number, group affiliation,
depository bank account, and principals. For this purpose, principals includes partners or shareholders of
five(5) percent or more, officers, directors, managers, financial records custodian, medical records
custodian, subcontractors, and individuals holding signing privileges on the depository account, and other
affiliated person.
(q) Agree to notify the agency within five(5) business days after suspension or disenrollment from
Medicare. Failure to notify may result in sanctions imposed pursuant s.409.908(24)and the provider
may be required to return funds paid to the provider during the period of time that the provider was
suspended or disenrolled as a Medicare provider.
(r) Search the List of Excluded Individuals/Entities (LEIE), located at
http://www.oig.hhs.gov/fraud/exclusions.asp, and the Agency's final order database, located at
http://apps.ahca.myflorida.com/dm web, monthly to determine whether any employee or contractor has
been excluded. Providers will notify the Agency immediately any exclusion information discovered. Civil
monetary penalties may be imposed against Medicaid providers and managed care entities who employ
or enter into contracts with excluded individuals or entities to provide items or services to Medicaid
recipients.
(6) Agency Responsibilities. The agency shall:
(a) Make timely payment at the established rate for services or goods furnished to a recipient by the
provider upon receipt of a properly completed claim.
(b) Not seek repayment from the provider in any instance in which the Medicaid overpayment is
attributable solely to error in the state's determination of eligibility of a recipient.
(7) Change of Ownership. A Medicaid provider agreement may be revoked, at the option of the agency,
as the result of a change of ownership of any facility, association, partnership, or other entity named as
the provider in the provider agreement.
MPA Institutional(March 2013) 2 of 4
. (a) If the provider sells or transfers a business interest or practice that substantially constitutes the entity
named as the provider in the provider agreement, or sells or transfers a facility that is of substantial
• importance to the entity named as the provider in the provider agreement, the provider is required to
maintain and make available to the agency Medicaid-related records that relate to the sale or transfer of
the business interest, practice, or facility in the same manner as though the sale or transaction had not
taken place, unless the provider enters into an agreement with the purchaser of the business interest,
practice, or facility to fulfill this requirement.
(b) In the event of a change of ownership, the transferor remains liable for all outstanding overpayments,
administrative fines, and any other moneys owed to the agency before the effective date of the change of
ownership. In addition to the continuing liability of the transferor, the transferee is liable to the agency for
all outstanding overpayments identified by the agency on or before the effective date of the change of
ownership. The term "outstanding overpayment"includes any amount identified in a preliminary audit
report issued to the transferor by the agency on or before the effective date of the change of ownership.
In the event of a change of ownership for a skilled nursing facility or intermediate care facility, the
Medicaid provider agreement shall be assigned to the transferee if the transferee meets all other
Medicaid provider qualifications. In the event of a change of ownership involving a skilled nursing facility
licensed under part II of chapter 400, liability for all outstanding overpayments, administrative fines, and
any moneys owed to the agency before the effective date of the change of ownership shall be determined
in accordance with s. 400.179.
(c) At least 60 days before the anticipated date of the change of ownership, the transferor shall notify the
agency of the intended change of ownership and the transferee shall submit to the agency a Medicaid
provider enrollment application. If a change of ownership occurs without compliance with the notice
requirements of this subsection, the transferor and transferee shall be jointly and severally liable for all
overpayments, administrative fines, and other moneys due to the agency, regardless of whether the
agency identified the overpayments, administrative fines, or other moneys before or after the effective
date of the change of ownership. The agency may not approve a transferee's Medicaid provider
enrollment application if the transferee or transferor has not paid or agreed in writing to a payment plan
for all outstanding overpayments, administrative fines, and other moneys due to the agency. This
subsection does not preclude the agency from seeking any other legal or equitable remedies available to
the agency for the recovery of moneys owed to the Medicaid program. In the event of a change of
ownership involving a skilled nursing facility licensed under part II of chapter 400, liability for all
outstanding overpayments, administrative fines, and any moneys owed to the agency before the effective
date of the change of ownership shall be determined in accordance with s. 400.179,if the Medicaid
provider enrollment application for change of ownership is submitted before the change of ownership.
(8) Termination for Convenience. This agreement may be terminated without cause upon thirty (30)days
written notice by either party.
(9) Interpretation. When interpreting this agreement, it shall be neither construed against either party nor
considered which party prepared the agreement.
(10) Governing Law. This agreement shall be governed by and construed in accordance with the laws of
the State of Florida and both parties concur that this agreement is a legal and binding document and is
fully enforceable in a court of competent jurisdiction.
(11) Amendment. This agreement, application and supporting documents constitute the full and entire
agreement and understanding between the parties with respect to their relationship. No amendment is
effective unless it is in writing and signed by each party.
(12) Severability. If one or more of the provisions contained in this agreement or application shall be
invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall
not in any way be affected or impaired.
(13) Agreement Retention. The parties agree that the agency may only retain the signature page of this
agreement, and that a copy of this standard provider agreement will be maintained by the Director of
Medicaid, or his designee, and may be reproduced as a duplicate original for any legal purpose and may
also be entered into evidence as a business record.
(14) Funding. This contract is contingent upon the availability of funds.
(15) Assignability. The parties agree that neither may assign their rights under this agreement without
the express written consent of the other.
A chief executive officer(CEO), president, or administrator may sign this agreement in lieu of all
principals. Failure to sign the agreement will make the agreement and provider number voidable by the
agency.
MPA Institutional(March 2013) 3 of 4
The signatory hereto represents and warrants that they have read the agreement, understand it, and are
authorized to execute it on behalf of their respective principals. This agreement becomes null and void
upon transfer of assets; change of ownership; or upon discovery by the agency of the submission of a
materially incomplete, misleading or false provider application unless subsequently ratified or approved
by the agency.
IN WITNESS WHEREOF, the undersigned representative has caused this agreement to be duly
executed under the penalties of perjury and now affirms that the foregoing is true and correct.
CleOr /2. (Utuc M AI o� Z4 Y44'5°1-Nlail n % 26i3
(Legibly pint name of signator Title Signature Date
(SEAL) WC
ATTEST:MAY HEAVILIN,
BY, Please Complete The Following Information: .
DEPt ITY CLERIC
Provider's Name: MONROE COUNTY BAYSHORE MANOR
DBA Name: MONRDE cow, SOLI ALS 3/j GE$/j ySi-10(LE MANOR,
Tax Identification Number: 596000749
National Provider Identifier:
Florida Medicaid Identification Number: 1401599
(For new applicants the Medicaid ID will be entered by the fiscal agent upon approval of the
application.)
Taxonomy Code: (Optional)Effective Date of This Agreement: 7 p
/t'f 20/3
Termination Date of This Agreement: 8/3/J.20 /4,
C. ---
M OE COUN Al rtNcY
PR VED FARM
PEDRO . MERCADO
ASSISTANT UN
e rl 1 i 3
MPA Institutional(March 2013 4 of 4