Item C24
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: December 17. 2003
Bulk Item: Yes [gJ No D
Division: Manaqement Services
Department: Administrative Services
AGENDA ITEM WORDING: Approval of consent to subcontract dental services with
Rural Health Network of Monroe County. Inc.
ITEM BACKGROUND: Contract with Rural Health Network for primary health care
services includes dental services. These services are subcontracted out to Christensen
Hsu. a dentist. Oriqinal contract prohibits assiqnment or subcontractinq without
Commission approval.
PREVIOUS RELEVANT BOCC ACTION: Approval of contract Oct 2003.
CONTRACT/AGREEMENT CHANGES: consent to subcontract
STAFF RECOMMENDATION: approval
TOTAL COST: $150.000.00
COST TO COUNTY: $150.000.00
BUDGETED: Yes [gJ No D
SOURCE OF FUNDS: ad valorem taxes
REVENUE PRODUCING: Yes 0 No [gJ AMOUNT PER MONTH
YEAR
APPROVED BY: COUNTY A~MB/PU~CHASING 0 RISK MANAGEMENT 0
DIVISION DIRECTOR APPROVAL: '
. / /'~. ' " /" -) . I) .'
. , / L l. ~ (.... I, /"~ j t: L tit.. '- '-..,0
Sheila A. Barker
DOCUMENTATION: INCLUDED: [gJ TO FOLLOW: 0 NOT REQUIRED: D
DISPOSITION: AGENDA ITEM #:c.a.~
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Rural Health Network Effective Date: 10/01103
Expiration Date: 09/30/04
Contract Purpose/Description: Consent to subcontract dental services in Monroe County
Contract Manager: David P. Owens
(Name)
4482
(Ext. )
Administrative Services
(Department)
for BOCC meeting on 12/17/03
Agenda Deadline: 12/02/03
CONTRACT COSTS
Total Dollar Value of Contract: $150,000.00 Current Year Portion: $150,000.00
Budgeted? Yes XX No Account Codes: 001-04571-530340
Grant: $0.00
County Match: $0.00
Estimated Ongoing Costs: $0.00
(Not included in dollar value above)
ADDITIONAL COSTS
For:
(eg. Maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes
Date In Needed
Division Director YesD NoD
Date Out
Reviewer
Risk Management
YesDNoD
:o::::::mg I~~:::~::~ c/f;f;l!'~
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Comments:_
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OMB Form Revised 9/11/95 MCP #2
CONSENT TO SUBCONTRACT DENTAL SERVICES
This consent to subcontract is made and entered into this day of December, 2003,
between the BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA, hereinafter
referred to as "Board," and the RURAL HEALTH NETWORK OF MONROE COUNTY, FLORIDA, INC.,
hereinafter referred to as "PROVIDER."
WHEREAS, on October 15, 2003, the parties entered into an agreement whereby the
PROVIDER is to provide health-related services to the disadvantaged citizens of Monroe County (the
original agreement); and
WHEREAS, paragraph 12 of the original agreement prohibits the assignment or
subcontracting of any of the PROVIDER'S duties and obligations under the original agreement
without the consent of the Board; and
WHEREAS, the PROVIDER desires to subcontract the provision of dental services in Monroe
County to Christensen Hsu; now, therefore,
IN CONSIDERATION of the mutual promises and covenants set forth below, the parties agree
as follows:
1. The Board consents to the PROVIDER subcontracting the provision of dental services in
Monroe County to Christensen Hsu, according to the terms and conditions of the agreement between
the PROVIDER and Christensen Hsu. A copy of that agreement is attached to this consent to
subcontract agreement as Exhibit A and is hereby made a part of this consent to subcontract
agreement. The Board agrees to reimburse the PROVIDER for the survey provision of dental
services in Monroe County according to the terms set forth in Exhibit A, subject to the maximum
amounts set forth in the original agreement paragraphs one and three and subject to the PROVIDER
furnishing reimbursement documentation satisfactory to the Clerk of the Circuit Court.
2. Except as provided in this consent to subcontract agreement, paragraph one, in all other
respects the terms and conditions of the parties' original agreement remain in full force and effect.
This consent to subcontract does not release or waive the obligation of the PROVIDER to see that its
duties and responsibilities under the original agreement are satisfactorily performed.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed as of
the day and year first written above.
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By
By
Deputy Clerk
Mayor/Chairman
RURAL HEALTH NETWORK OF MONROE COUNTY, INC.
(Federal ID No. )
By
By
President
Director
MONROE COUNTY ATTORNEY
~2VED AS T M'
.'n'~~N A. TTON
c: A8S1STA~_j"i{j~^r"RNEY_
consent to subcontract - rural health
Kura! Health Network of Monroe Cu" FL, Inc.
Contract and Agreement for Dental F ' lsionals
CONTRACT AND AGREEMENT FOR DENTAL PROFESSIONALS
This agreement is made on the between the RURAL HEALTII NEIWORK OF MONROE CO., FL, INC.,
Post.office Box 4966, Key West, FL 33041-4966'";bereinafter referred to as RHNMC and
t::%r/S;7;?.A..5IdU1. A<< , hereinafter referred to as the Provider, and whose tax ID and/or social
securitynumberis 557-.35 -7265 .andwhoseaddressis.;(~ vade ~, ,~ .~~.l1 n
Now, therefore, in consideration of the mutual promises passing between the parties, there agrees as .3 ~()y [)
follows:
1. REClT AL: RHNMC was created to improve the quality of and access to health care available to the
residents of Monroe Co., FL. RHNMC desires to engage the services of the Provider and the Provider
is agreeable to rendering services for RHNMC. _
2. TERM OF AGREEMENT: RHNMC agrees to contract with the Provider from (. J ~ 3, ~ 3
unlil v'~ ~'..?a>~ and)1![Ough the following schedule: (days/hours to be - ,
worked) ,"1 ,. .s / ~ hd17/A":.. f . It is understood and agreed by
both parties that intemu ent absences by the provider for professional or other reasons shall not
necessarily alter or terminate this agreement. However, such intermittent absences shall not be .""
compensated. It is the good faith intention that this agreement will continue until otherwise ended
by either party. Any renewal agreement, as applicable, shall be in writing. Unless there are changes
in the existing contractual conditions, renewals and/or amendments may be accomplished by
attaching a statement (by signatures) the parties' agreement to renewal and/ or amend and its
duration (by dates)..
3. RIGHT TO TERMINA1E: RHNMC reserves the right to immediately terminate this agreement if the
Provider fails to perform consistently with the terms of this agreement or operate the program in
conformance with all requirements. RHNMC reserves the right to terminate this agreement if
funding sources are decreased or discontinued. Notwithstanding the above, at any time either party
may terminate this agreement by providing to the other party a minimum of thirty (30) days written
notice.
4. DUTIFS: During the term of this contract and agreement or any extension thereof, the Provider shall
p'rovide oral health care services for clients served bv RHNMC for those days and/ or hours specified
by this agreement Those services may include screenin2S/ exams. deanings, x-rays. fillings{
extractions, sealant services, dentures (partial and full), as well as "simple" ~ndodontics and
periodontal procedures. .Emer2etlCV care, infection control and oral pain management may also be
offered. By striking through any of the procedures listed above 4Uld by the initials placed beside each
strike by the Provider and the RHNMC representative, the Provider indicates his/her unwillingness
or inability to perform this/these service(s) and that RHNMC is agreeable to that/those
specification(s).. And/or, the Provider elects to provide the following lists of services and
procedures.
-=::::::::::::: ---
--------- ---------
5. LEG}\'[" REQUIREMEN1S AND DENTAL CARE PARAMETERS: The Provider expressly agrees that
he/ she shall comply fully with the licensure grant reqtPrements as set forth by the Board of Dentistry
for the State of Florida, and by the parameters reconulteI;\ded by the American Dental Association
and protocols adopted by RHNMC. These parameters will be made available in writing to the dental
professional by RHNMC. The Provider shall provide RHNMC with a copy of current licensure and
subsequent copies of all renewal of licensure, as applicable.
6. (As Applicable) COMPLIANCE WITH FS 466.0285. RHMMC and the Provider mutually agree to
abide by the stipulations contained in FS 466.0285. In that regard, the Provider shall not be
considered an employee of RHNMC, and shall act as an independent agent and licensed dental
practitioner under the laws of the State of Florida. In addition, RHNMC will not interfere, control or
direct the clinical judgment of the Provider. Finally, :RHNMC will exercise no control over any dental
1
. ,
. "
Kural Health Network of Momoe Co., FL, Inc.
Omtract and Agreement for Dental p. ~;ionals
equipmeJ,lt or materials to be used for any an d all dental procedures, but will maintain the
equipment in good working order, as directed and/or advised by the Provider.
7. DISBURSEMENT OF FUNDS: The following funds shall be allocated by RHNMC to the Provider for -
the services provided pursuant to this contract and agreement:: The full time equivalent (ftP.) of
$100,000 per year, but at 0.6 fie, or 24 hours per wee~ payable semi-monthly (15th and 31st of each
month). RHNMC and the Provider both agree that based on client or organizational need, this fte
may be increased by mutual consent, and so noted in an amendment to this document
The Provider af!:fees to sign over throu~ appropriate documentatiollt all receipts from Medicaid.
Medicare, third party insurance billinw;, FL KidCare reimbursement and FL Medi-Pass to RHNMC
for professional services performed and claimed under this agreement and in RHNMC operated
facilities.
8. RECORDS: The Provider agrees to record all information relevant oral health services performed
and consultations provided, as applicable. RHNMC will maintain and retain all such records for a
period of ten (10) years from the date of the termination of this agreement.
9. LIABILITY lNSURANCE: The Provider shall maintain his/her professionalliabilitv insurance but
such expense shall be paid bv RHNMC as a reimbursement..
10. INDEMNIFICATION: RHNMC shall indemnify the Provider and hold him/her/it harmless against
.'- all claims, actions, liabilities, judgments and settlements, including (but not limited to) personal
injury or death of any persOllt or for physical damage to or destruction of property, as well as any
and all related expenses, including attorneys' fees and other legal costs, concerning any actual or
alleged negligence, error, omissiollt or act of RHNMC or any of its employees, agents, contractors, or
designees for the duration of this contract and/ or employment, and in perpetuity.
The Provider shall indemnify and hold RHNMC harmless a~ainst all claims, actions, liabiliti~,
judgments and settlements, including but not limited to personal injury or death of any person, or for
physical damage to or destruction of property, as well as any and all related expenses, including
attorneys' fees and other legal costs, concerning any actual or alleged negligence, error, omissiollt or
act of the Provider or any ofhislher agents, employees, contractors, or designees for the duration of
this contract and in perpetuity.
11. AGENCY: The Provider shall have no authority to enter into any contract binding on RHNMC or to
create any obligations on the part of RHNMC, except as shall be specifically authorized in writing by
RHNMC.
12 DISPARAGEMENT: All parties and their agents shall refrain from making remarks to clients, other
agendes or organizations, or any other person or entity, which shall be construed as disparaging to
either of the parties, other subcontractors, or any other person connected with this project durin~ the
term of this contract and agreement or any renewal thereof.
13. POLICIES/PROCEDURES/FEDERAL PRIVACY: The Provider agrees to abide by all RHNMC
polides, procedures, and rules, including but not limited to RHNMC and federal HIP AA privacy
rules and regulations. RHNMC agrees to make its polides, procedures, rules and regulations and
periodic updates available to the Provider.
14. LEA VB TIMEi CLINIC SERVICE TIME. The Provider shall not be considered an employee of
RHNMC in compliance with state law. However, the Provider may be allowed up to 24 hours of
personal leave per year after the first six months of contract execution in the full increment of 24
hours or less. Such leave must be approved at least 30 days prior to the planned leave time by
RHNMC. The Provider may also be allowed to take as much c;lS 24 hours of sick leave for herself or
her dependent(s) per year without loss of compensation. Such leave may only be ~n after the first
six months of the contract period.
The provider shall schedule clinic services with other staff in such a way that clinic services will
fill an 8 hour work day. If services extend beyond the 8 hour period based on clinical need, the
Provider will appropriately finish the service or reschedule the client for a follow-up visit. RHNMC
shall not compensate the provider beyond the 8 hour workday schedule.
15. ENTIRE AGREEMENT: This instrument contains the entire agreement of the parties. It may not be
changed orally, but only upon an agreement in writing signed by any party against whom
2
Contract and Agreement for Dental p~ 'C~ionats
---- -.....,..-,........"'. .'
enforcement of any waiver, change, modification.. exterlSion or discharge is sought. H any prOvisions
of this agreement shall be declared invalid and unenforceable, the remainder of this agreement shall
remain in full force and effect.
16. GOVERNING AUlHORlTY: The Executive Director of RHNMC, under the authority vested in him
by the RHNMc Board of Directors, hereby delegates the RHNMC health services director with the
authOrity to execute this agreement and to negotiate with the Provider in any and matters before both
parties.
17. GOVERNlNG LAW: This agreement sha11 be construed, interpreted, governed, and enforced in and
. under the Jaws of the State of Florida.
THEREFORE, TIlE p~ 10 TIlE TERMs OF TIDS CONTRAcr AND AGREEMENT:
717. / J '7 '3{J3
Mark L. Szurek, Ph. ., / Date
For the Rural H Network of Monroe Co., FL, Ine.
~~_J~ }'~3.
(~ofCoubacting eatJI~-n..l'nmdet1/Dale /
(Please attach a copy of a CIII:ftnt auricuIum vitae, 1kensare aad proof of CIII:ftnt IiabDity inswance, as
applicable.) , '- ___
AMENDMENT :
Both parties agree that the Provider shall perform services in accord with this
agreement on and between July 16, 2003 through July 25, 2003, and on and between
August 13, 2003 through August 22, 2003. The Provider will resume contract servic~~
on September 2Q" 2003. Compensation for these intervals shall be on aupro rata
basis $48/hr.~~. n
7,7/.t7 /-F ,/.~
NMC M1fals. lr~rt.r
3
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l'
Certification for Human Service and Youth Organization Agreements
To: Monroe County Finance Department
From: Office of Grants Management
Re: Rural Health Network of Monroe County
May this serve to certify that the above-referenced organization has documentation that meets
the conditions as stated in Section 9 'Comoliance with County Guidelines' items (a) through (i):
v/' evidence of the organ~zation's 501 (c)(3) status;
v
a list of the organization's Board of Directors of which there must be five or more;
v
evidence of annual election of Officers and Directors;
v
an annual audited financial report;
a copy the organization's Corporate Bylaws, which must address the organization's
mission, board and membership composition, election of officers, and so on;
,/
/' a copy of the organization's Corporate Policies and Procedures Manual which must
include hiring policies for all staff, drug and alcohol free workplace provisions, equal
employment opportunity provisions, and so on;
~
cooperation with County monitoring visits;
~
semi-annual performance reports. These reports should include performance
measurements which will demonstrate the level of accomplishment of goals for which funding
has been provided.
1--".
other reasonable reports and information related to compliance with applicable laws,
contract provisions and the scope of services that the County may from time to time request.
Based on the agency's compliance with these contractual conditions, I recommend payment of
the requests for reimbursement.
'U ~- /J~7
/ ~,~ /'...
(( ~- t/" [t,-e-~vz--
David P. Owens, Grants Administrator
/l/ L 1'le'_3
date
U:\Admin Services\Grants\FORMS\Certification by grants admin merge.doc
AGREEMENT
Rural Health Network of Monroe County, Florida, Inc.
This Agreement is made and entered into this day of
, 2003, between the BOARD OF COUNTY COMMISSIONERS OF
MONROE COUNTY, FLORIDA, hereinafter referred to as "Board" or "County," and
RURAL HEALTH NETWORK OF MONROE COUNTY, FLORIDA, INC., hereinafter
referred to as "Provider."
WHEREAS, the Provider is a not-for-profit corporation established for the
provision of health-related services to the disadvantaged citizens of Monroe County,
and
WHEREAS, it is a legitimate public purpose to provide county-wide primary
health care, now, therefore,
IN CONSIDERATION of the mutual promises and covenants contained herein,
it is agreed as follows:
1. AMOUNT OF AGREEMENT. The Board, in consideration of the
Provider substantially and satisfactorily performing and carrying out the duties of
the Board as to providing primary health care in Monroe County, Florida, shall pay
to the Provider the sum of ONE-HUNDRED, FIFTY-THOUSAND, AND NOl100
DOLLARS ($150,000.00) for the fiscal year ending September 30, 2004.
2. TERM. This Agreement shall commence on October 1, 2003, and
terminate September 30, 2004, unless earlier terminated pursuant to other
provisions herein.
3. PAYMENT. Payment will be paid periodically, but no more frequently
than monthly as hereinafter set forth. Reimbursement requests will be submitted
to the Board via the Clerk's Finance Office. The County shall only reimburse,
subject to the funded amounts below, those reimbursable expenses which are
reviewed and approved as complying with Florida Statutes 112.061 and Attachment
A - Expense Reimbursement Requirements. Evidence of payment by the Provider
shall be in the form of a letter, summarizing the expenses, with supporting
documentation attached. The letter should contain a certification statement as well
as a notary stamp and signature. An example of a reimbursement request cover
letter is included as Attachment B.
After the Clerk of the Board examines and approves the request for
reimbursement, the Board shall reimburse the Provider. However, the total of said
reimbursement expense payments in the aggregate sum shall not exceed the total
amount shown in paragraph one during the term of this agreement.
4. SCOPE OF SERVICES. The Provider, for the consideration named
,
covenants and agrees with the Board to substantially and satisfactorily perform and
carry out the duties of the Board in providing primary health care in Monroe County,
Florida.
5. RECORDS. The Provider shall maintain appropriate records to insure
a proper accounting of all funds and expenditures, and shall provide a clear financial
audit trail to allow for full accountability of funds received from said Board. Access
to these records shall be provided during weekdays, 8 a.m. to 5 p.m., upon request
of the Board, the State of Florida, or authorized agents and representatives of the
Board or State.
The Provider shall be responsible for repayment of any and all audit
exceptions which are identified by the Auditor General of the State of Florida, the
Clerk of Court for Monroe County, an independent auditor, or their agents and
representatives. In the event of an audit exception, the current fiscal year contract
amount or subsequent fiscal year contract amounts shall be offset by the amount of
the audit exception. In the event this agreement is not renewed or continued in
subsequent years through new or amended contracts, the Provider shall be billed by
the Board for the amount of the audit exception and the Provider shall promptly
repay any audit exception.
6. INDEMNIFICATION AND HOLD HARMLESS. The Provider
covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all clai ms for bodily injury (including death),
personal injury, and property damage (including property owned by Monroe
County) and any other losses, damages, and expenses (including attorney's fees)
which arise out of, in connection with, or by reason of services provided by the
Provider occasioned by the negligence, errors, or other wrongful act or omission of
the Provider's employees, agents, or volunteers. The provider agrees to comply
with Monroe County General Insurance Requirements, as shown on Attachment C,
and agrees to carry and provide evidence of the required coverages described on
Attachments D through G.
7. INDEPENDENT CONTRACTOR. At all times and for all purposes
hereunder, the Provider is an independent contractor and not an employee of the
Board. No statement contained in this agreement shall be construed so as to find
the Provider or any of its employees, contractors, servants or agents to be
employees of the Board.
8. COMPLIANCE WITH LAW. In providing all services pursuant to this
agreement, the Provider shall abide by all statutes, ordinances, rules and
regulations pertaining to or regulating the provision of such services, including
those now in effect and hereinafter adopted. Any violation of said statutes,
ordinances, rules and regulations shall constitute a material breach of this
agreement and shall entitle the Board to terminate this contract immediately upon
delivery of written notice of termination to the Provider.
9. COMPLIANCE WITH COUNTY GUIDELINES. The Provider must
demonstrate and sustain compliance with:
(a) 501(c)(3) Registration;
(b) Board of Directors of five or more;
(c) Annual election of Officers and Directors;
(d) Annual provision of annual report to County;
(e) Corporate Bylaws;
(f) Corporate Policies and Procedures Manual;
(g) Hiring policies for all staff;
(h) Cooperate with County monitoring visits; and
(i) Semi-annual performance reports to be presented to County.
10. PROFESSIONAL RESPONSIBILITY AND LICENSING. The Provider
shall assure that all professionals have current and appropriate professional licenses
and professional liability insurance coverage. Funding by the Board is contingent
upon retention of appropriate local, state and/or federal certification andlor
licensure of the Provider's program and staff.
11. MODIFICATIONS AND AMENDMENTS. Any and all modifications of
the services and/or reimbursement of services shall be amended by an agreement
amendment, which must be approved in writing by the Board.
12. NO ASSIGNMENT. The Provider shall not assign this agreement
except in writing and with the prior written approval of the Board, which approval
shall be subject to such conditions and provisions as the Board may deem
necessary. This agreement shall be incorporated by reference into any assignment
and any assignee shall comply with all of the provisions herein. Unless expressly
provided for therein, such approval shall in no manner or event be deemed to
impose any obligation upon the Board in addition to the total agreed upon
reimbursement amount for the services of the Provider.
13. NON-DISCRIMINATION. The Provider shall not discriminate against
any person on the basis race, creed, color, national origin, sex or sexual orientation,
age, physical handicap, or any other characteristic or aspect which is not job-
related in its recruiting, hiring, promoting, terminating or any other area affecting
employment under this agreement. At all ti mes, the Provider shall comply with all
applicable laws and regulations with regard to employing the most qualified
person(s) for positions under this agreement. The Provider shall not discriminate
against any person on the basis of race, creed, color, national origin, sex or sexual
orientation, age, physical handicap, financial status or any characteristic or aspect
in its providing of services.
14. AUTHORIZED SIGNATURES. The signatory for the Provider below,
certifies and warrants that:
(a) The Provider's name in this agreement is the full name as designated
in its corporate charter, if a corporation, or the full name under which the Provider
is authorized to do business in the State of Florida.
(b) He or she is empowered to act a nd contract for the Provider; and
(c) This agreement has been approved by the Board of Directors of the
Provider if the Provider is a corporation.
,
15. NOTICE. Any notice required or permitted under this agreement shall
be in writing and hand-delivered or mailed, postage pre-paid, by certified mail,
return receipt requested, to the other party as follows:
For Board:
David P. Owens, Grants Administrator and
Gato Building
1100 Simonton Street
Key West, FL 33040
Monroe County Attorney
PO Box 1026
Key West, FL 33041
For Provider
Mark L. Szurek
Executive Director
Rural Health Network of Monroe County
Post Office Box 4966
Key West, FL 33041-4966
16. CONSENT TO JURISDICTION. This agreement shall be construed by
and governed under the laws of the State of Florida and venue for any action
arising under this agreement shall be in Monroe County, Florida.
17. NON-WAIVER. Any waiver of any breach of covenants herein
contained to be kept and performed by the Provider shall not be deemed or
considered as a continuing waiver and shall not operate to bar or prevent the Board
from declaring a forfeiture for any succeeding breach, either of the same conditions
or covenants or otherwise.
18. AVAILABILITY OF FUNDS. If funds cannot be obtained or cannot be
continued at a level sufficient to allow for continued reimbursement of expenditures
for services specified herein, this agreement may be terminated immediately at the
option of the Board by written notice of termination delivered to the Provider. The
Board shall not be obligated to pay for any services or goods provided by the
Provider after the Provider has received written notice of termination, unless
otherwise required by law.
19. PURCHASE OF PROPERTY. All property, whether real or personal,
purchased with funds provided under this agreement, shall become the property of
Monroe County and shall be accounted for pursuant to statutory requirements.
20. ENTIRE AGREEMENT. This agreement constitutes the entire
agreement of the parties hereto with respect to the subject matter hereof and
supersedes any and all prior agreements with respect to such subject matter
between the Provider and the Board.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be
executed as of the day and year first written above.
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By
By
Deputy Clerk
Mayor/Chairman
o J:]."~.~~ n
, / 1<'\'. I , __-7"Y-..-..~
., [r, .
Witness
~fl1~ }
Witness
RURAL HEALTH NETWORK OF
MONROE COUNTY, FLORIDA, INC.
(Federal 10 No. 65-0474953 )
-;1//
/j
~/
M(/1< L. Szurek, Ph.D.
By
President
UZANNE A. HUTTON
Date~_:.I~:~~~1JORNEY
ATTACHMENT A
EXPENSE REIMBURSEMENT REQUIREMENTS
This document is intended to provide basic guidelines to Human Service Organizations,
county travelers, and contractual parties who have reimbursable expenses associated with
Monroe County business. These guidelines, as they relate to travel, are from Florida Statute
112.061.
A cover letter summarizing the major line items on the reimbursable expense request needs
to also contain a notarized certified statement such as:
"I certify that the attached expenses are accurate and in agreement with the records
of this organization. Furthermore, these expenses are in compliance with this organization's
contract with the Monroe County Board of County Commissioners."
Invoices should be billed to the contracting agency. Third party payments will not be
considered for reimbursement. Remember, the expense should be paid prior to requesting a
reimbursement.
Only current charges will be considered, no previous balances.
Reimbursement requests will be monitored in accordance with the level of detail in the
contract. This document should not be considered all-inclusive. The Clerk's Finance
Department reserves the right to review reimbursement requests on an individual basis.
Any questions regarding these guidelines should be directed to 305-292-3534.
Data Processing, PC Time, etc.
The vendor invoice is required for reimbursement. Inter-company allocations are not
considered reimbursable expenditures unless appropriate payroll journals for the charging
department are attached and certified.
Payroll
A certified statement verifying the accuracy and authenticity of the payroll expense is
needed. If a Payroll Journal is provided, it should include: dates, employee name, salary or
hourly rate, total hours worked, withholding information and payroll taxes, check number
and check amount. If a Payroll Journal is not provided, the following information must be
provided: check amount, check number, date, payee, support for applicable payroll taxes.
Postage, Overnight Deliveries, Courier, etc.
A log of all postage expenses as they relate to the County contract is required for
reimbursement. For overnight or express deliveries, the vendor invoice must be included.
Rents, Leases, etc.
A copy of the rental or lease agreement is required. Deposits and advance payments are
not allowable expenses.
Reproductions, Copies, etc.
A log of copy expenses as they relate to the County contract is required for reimbursement.
The log must define the date, number of copies made, source document, purpose, and
recipient. A reasonable fee for copy expenses will be allowable. For vendor services, the
vendor invoice and a sample of the finished product are required.
Supplies, Services, etc.
For supplies or services ordered, a vendor invoice is required.
Telefax, Fax, etc.
A fax log is required. The log must define the sender, the intended recipient, the date, the
number called, and the reason for sending the fax.
Telephone Expenses
A user log of pertinent information must be remitted including: the party called, the caller,
the telephone number, the date, and the purpose of the call.
Travel Expenses
Travel expenses must be submitted on a State of Florida Voucher for Reimbursement of
Travel Expenses. Travel must be submitted in accordance with Florida Statute 112.061.
Credit card statements are not acceptable documentation for reimbursement. If attending a
conference or meeting a copy of the agenda is needed. Airfare reimbursement requires the
original passenger receipt portion of the airline ticket. A travel itinerary is appreciated to
facilitate the audit trail. Auto rental reimbursement requires the vendor invoice. Fuel
purchases should be documented with paid receipts. Taxis are not reimbursed if taken to
arrive at a departure point: for example, taking a taxi from one's residence to the airport for
a business trip is not reimbursable. Parking is considered a reimbursable travel expense at
the destination. Airport parking during a business trip is not.
A detailed list of charges is required on the lodging invoice. Balance due must be zero.
Room must be registered and paid for by traveler. The County will only reimburse the
actual room and related bed tax. Room service, movies, and personal telephone calls are
not allowable expenses.
Meal reimbursement is: breakfast at $3.00, lunch at $6.00, and dinner at $12.00. Meal
guidelines state that travel must begin prior to 6 a.m. for breakfast reimbursement, before
noon and end after 2 p.m. for lunch reimbursement, and before 6 p.m. and end after 8 p.m.
for dinner reimbursement.
Mileage reimbursement is calculated at .29 cents per mile for personal auto mileage while
on County business. An odometer reading must be included on the state travel voucher for
vicinity travel. Mileage is not allowed from a residence or office to a point of departure. For
example, driving form one's home to the airport for a business trip is not a reimbursable
expense.
Non-allowable Expenses
The following expenses are not allowable for reimbursement: capital outlay expenditures
(unless specifically included in the contract), contributions, depreciation expenses (unless
specifically included in the contract), entertainment expenses, fundraising, no n-sufficient
check charges, penalties and fines.
ATTACHMENT B
ORGANIZATION
LETTERH EAD
Monroe County Board of County Commissioners
Finance Department
500 Whitehead Street
Key West, FL 33040
Date
The following is a summary of the expenses for ( Organization name) for the time
period of to
Check # Payee Reason Amount
101 Company A Rent $ X,XXX.XX
102 Company B Utilities XXX. XX
104 Employee A PIR ending 05/14/01 XXX. XX
105 Employee B P/R ending 05/28/01 XXX .XX
(A) Total $ X.XXX.XX
(B) Total prior payments $ X,XXX.XX
(C) Total requested and paid (A + B) $ X,XXX.XX
(D) Total contract amount $ X,XXX.XX
Balance of contract (D-C) $ X.XXX.XX
I certify that the above checks have been submitted to the vendors as noted and
that the expenses are accurate and in agreement with the records of this
organization. Furthermore, these expenses are in compliance with this
organizations_ contract with the Monroe County Board of County Commissioners
and will not be submitted for reimbursement to any other funding source.
Executive Director
Attachments (supporting documentation)
Sworn to and subscribed before me this _ day of 2003
by who is personally known to me.
Notary Public
Notary Stamp
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
Mark L. Szurek, Ph.D. for the
Rural Health Network/Monroe Co.
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.o!: employee.
4 ... \
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STATE OF
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COUNTY OF
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
~Q,,/L t. J;;Z')~ who, after first being sworn by me, affixed his/her
signature (name of individual signing) in the space provided above on this
On:)
7 day of
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NOTARY PUBLIC
My commission expires:
OMB - MCP FORM #4
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following
a conviction for public entity crime may not submit a bid on a contract to provide
any goods or services to a public entity, may not submit a bid on a contract with a
public entity for the construction or repair of a public building or public work,
may not submit bids on leases of real property to public entity, 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, for
CATEGORY TWO for a period of 36 months from the date of being placed on the
convicted vendor list. "
Attachment D
] 996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Rural Health Network of Monroe Co., FL, Inc.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to Florida Statute 440.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term ofthe contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-
insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance, providing details on the Contractor's Excess Insurance Program.
Ifthe Contractor participates in a self-insurance fund, a Certificate oflnsurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
wet
Administration Instruction
#4709.3
87
Attachment E
1996 Edition
MEDICAL PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Rural Health Network of Monroe Co., FL, Inc.
Recognizing that the work governed by this contract involves the providing of professional
medical treatment, the Contractor shall purchase and maintain, throughout the life of the contract,
Professional Liability Insurance which will respond to the rendering of, or failure to render
medical professional services under this contract.
The minimum limits of liability shall be:
$250,000 per Occurrence/$750,000 Aggregate
Ifcoverage is provided on a claims made basis, an extended claims reporting period offour (4)
years will be required.
MEDl
Administration Instruction
#4709.3
66
Attachment F
1996 Edition
GENERAL LIABILITY
INSURANCE REQUffiEMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Rural Health Network of Monroe Co., FL, Inc.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life ofthe 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:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum oftwelve
(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.
GLl
Administration Instruction
#4709.3
53
Attachment G
1996 Edition
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Rural Health Network of Monroe Co., FL, Inc.
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
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 Vehides
The minimum limits acceptable shall be:
$100,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 50,000 per Person
$100,000 per Occurrence
$ 25,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfY the above requirements.
VLl
Administration Instruction
#4709.3
80