02/07/2020 Agreement ATTACHMENT A
COUIN(TY ADMINISTRATOR
CONTRACT SUMMARY FORM FOR CONTRACTS LESS THAN$50,000.00
Contract with-, on tract
Effecove Date:
Expiration Date:
Conn t Purpose/Description:
11tonturact.is Original Agree nt ontract Amendmen ension Renewal
Contract Manager: o f ik -c t c. r i It c
e) (Ext) (Dep ent(Stop )
CONTRACT COSTS
Total Dollar Value of Contract: $ CM Current Year Portion: S
(must be Ears $50,000) 1, ® (If multiyear agreement then
AMA requires Rocc approval,unless the
Budgeted?Yesgj No Account Cozies: `; -�-
Grant: S _ $
County Match: $ W
DITTO COSTS
Estimated Ongoing Costs: lyrr For:
-09tincluded in dollar value above) (e. ,Maintanancz utilizies Wait salaries etc.
CONTRACT REVIEW
Changes Date Out
Date In Needed Reviewer
Department Head f l 19 Yes[:J Nogols a
Risk Management -11-221 yesCl No 5-11-2021
O.M.B./Purchasing -- Yes[]Na -I ., oci' ® aisBo'n
,.=®isi :
County Attorney Yes[]Noy �' W` 5111/21
Comments.
CONSULTANT SERVICES AGREEMENT
BETWEEN
RB HEALTH SERVICES,INC.AND
MONROE COUNTY
WHEREAS, RB Health Partners,Inc.(hereinafter Consultant)provides certain health
care consulting services; and
WHEREAS, Monroe County (hereinafter Client), the county's new potential ALF
project; and
WHEREAS,Client wishes to engage Consultant to provide services; and
WHEREAS Consultant is willingto provide those services,
NOW THEREFORE,theParties agree as follows:
ARTICLE I
BACKGROUND
1.1 This contract is between the Client and the Consultant.
1.2 Client is responsible for the operation of the business and legally bound under this
Agreement.
1.3 Consultant, in carrying out the terms of this Agreement, may give advice based on
information given to it by Client staff. Consultant will use its best efforts to make
judgments and recommendations appropriate to the situation as described by Client
but makes no warranti es or representations that its advice shall be sufficient to solve
the problems for which it is sought.
ARTICLE 11
ENGAGEMENT
2.1 Engagement shall commence on February 7, 2020, (the "Effective Date") and shall
continue until such time as the parties agree that the purposes of the Engagement have
been accomplished or as set out below.
2.2 Either party may terminate this contract with 30-days' written notice without cause or
explanation.
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2.3 Consultant may terminate this Agreement upon 5-days' written notice if payment is
not received in accordance with the terms of this Agreement.
ARTICLE III
RESPONSIBILITIES OF FACILITY
3.1 Control of Client operations shall be retained by Client.Client,through its directors,
officers, management,employees and/or authorized representatives of any nature,
shall at all times exercise complete control over the assets and operations of the
business.By entering into this Agreement,Client does not delegate to Consultant any
ofthe powers, duties and responsibilities.
ARTICLE IV
RESPONSIBILITIES OF CONSULTANT
4.1 Consultant shall supply professional associates as necessary to carry out the terms of
this engagement.
ARTICLE V
COMPENSATION TO CONSULTANT
5.1 This Agreement is for ongoing services; however,initially for a general evaluation and
report of the county's new potential ALF project. Consultant shall charge, overall, no
more than a total of$25,000.00 including all expenses.
ARTICLE VI
INDEMNITIES
6.1 To the extent set forth in Florida Statute 768.28 Client shall protect, indemnify and
hold harmless Consultant, its employees, agent's shareholders, and officers from any
and all claims brought against Consultant and those identified herein from and against
any liability and expense of any arising from injuries and/or damages to any person or
property in connection with the services contemplated by this Agreement unless the
claim arose from the negligence or willful misconduct of Consultant.
6.2 Consultant shall protect, indemnify and hold harmless Client, its employees, agents,
shareholders, and officers from any and all claims brought against Client and those
identified herein from and against any liability and expense of any kind arising from
injuries and/or damages to any person or property in connection with the services
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contemplated by this Agreement unless the claim arose from the negligence or willful
misconduct of Client.
6.3 Consultant's advice and recommendations are intended to provide guidance to Client;
however, any final decision to act or not act is in the sole discretion of Client.
Consultant shall use its best efforts to provide sound advice and holds Consultant
harmless from any loss as the result of following Consultant's advice.
ARTICLE VII
MISCELLANEOUS
7.1 This Agreement constitutes the entire Agreement between the parties with respect to
the subject matter hereof,and shall supersede all prior agreements between the parties,
whether oral or written.
7.2 This Agreement is a negotiated agreement and the languaw used herein shall not be
construed in favor of either party in interpreting this Agreement and settling any
disputes.
73 Any amendment to this Agreement shall be in writing and signed by both parties or
shall not be enforceable.
7A This Agreement: shall be governed by the laws of the State of Florida. Any dispute
regarding this Agreement shall be resolved through the provisions set out in
Paragraph 7.13 of this Agreement.Any action brought to enforce the terms of this
Agreement shall be brought in an appropriate court or before the appropriate
administrative body in Monroe County,Florida.
7.5 Waiver of one or more provisions of this Agreement shall not act as either a continuing
waiver or the waiver of any other provision.
7.6 If any provision of this Agreement is determined to be illegal or unenforceable, it
shall be severed from this Agreement and the remainder of the Agreement shall be
enforceable unless that provision goes to the heart ofthis Agreement.Inthat case,the
parties shall use their best efforts to renegotiate the Agreement such that it is fully
legal and enforceable.
7.7 This Agreement is for the benefit of the parties hereto and is not assignable without
permission of the other party.This Agreement shall not be construed as to confer any
benefit on any third party, including but not limited to Facility residents or their
representative.
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7.8 Any written notice required herein shall be sent certified mail, return receipt
requested, to:
Cl ient:Monroe County
1100 Simonton St.
Key West,FL.33040
Sheryl L. Graham, Sr. Director, Monroe County Social Services
Consultant: RB Health Partners, Inc.
PO Box 1116
Crystal Beach, FL 34681
Robin A. Bleier, President
Notice shall be deemed to have been given when delivered with proof of delivery.
7.9 Consultant is an independent contractor and has no agency relationship with Client.
This Agreement shall not be construed to create a partnership or joint venture of any
nature. Neither party shall act as the agent of the other without specific written
agreement of the other party. Consultant shall not,by entering into or performing this
Agreement, assume liability or become liable for any of the existing or future
obligations, liabilities or debts of the Client.Consultant is not a fiduciary of Client and
has no fiduciary duty to it. Nothing herein relieves Client from the responsibility or
duties it owes its staff or others.
7.10 This Agreement may be signed in multiple counterparts and those when taken together
shall constitute this Agreement.
7.11 Paragraphs 5.1, 6.1, 6.2, and 7.13 shall survive termination ofthis Agreement.
7.12 Each party warrants to the other party that it has the right,power, legal capacity and
authority to enter into this Agreement, that the execution and delivery hereof have
been duly approved by all necessary corporate or partnership action,as the case may
be,and that entry into this Agreement and performance of its obligations hereunder
do not violate any applicable statute, ordinance, administrative ruling or any
agreement to which it is a party.
7.13 Notwithstanding paragraph 7.4, the parties agree to attempt to settle any dispute
arising out of or relating to this Agreement first by good faith discussions. Ifthat
fails, the parties agree to go to mediation with a certified mediator acceptable to both
parties.
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714 Client agrees to not recruit or hire Consultant or associates from Consultant. Ifthe Client
has an interest to possibly interview, retain,contract, and/or hire an associate,they will
contact Robin Bleier directly to discuss. Ms. Bleier will alert the associate, and should
the associate wish to make the transition and the Client desires to do so,the Client will
pay the Consultant using standard executive search fees of 25% of the hiring salary
prior to the what would become the former associate first date of transition (hire) by
Client.
7.15 Consultant shall maintain all books, records, and documents directly pertinent to
performance under this Agreement in accordance with generally accepted accounting
principles consistently applied. Each party to this Agreement or their authorized
representatives shall have reasonable and timely access to such records of each other party
to this Agreement for public records purposes during the term of the Agreement and for
four years following the termination of this Agreement. If an auditor employed by the
Client or the Monroe County Clerk of Courts determines that monies paid to Consultant
pursuant to this Agreement were spent for purposes not authorized by this Agreement,the
Consultant shall repay the monies together with interest calculated pursuant to Sec. 55.03,
FS,running from the date the monies were paid to Consultant.
7.16 The Client and Consultant agree that in the event any cause of action or administrative
proceeding is initiated or defended by any party relative to the enforcement or
interpretation of this Agreement, the prevailing party shall be entitled to reasonable
attorney's fees, court costs,investigative,and out-of-pocket expenses,as an award against
the non-prevailing party, and shall include attorney's fees, courts costs, investigative, and
out-of-pocket expenses in appellate proceedings. Mediation proceedings initiated and
conducted pursuant to this Agreement shall be in accordance with the Florida Rules of
Civil Procedure and usual and customary procedures required by the circuit court of
Monroe County.
7.17 The parties agree that there will be no discrimination against any person,and it is expressly
understood that upon a determination by a court of competent jurisdiction that
discrimination has occurred,this Agreement automatically terminates without any further
action on the part of any party, effective the date of the court order. The parties agree to
comply with all Federal and Florida statutes, and all local ordinances, as applicable,
relating to nondiscrimination. These include but are not limited to: 1)Title VII of the Civil
Rights Act of 1964(PL 88-352),which prohibit discrimination in employment on the basis
of race, color, religion, sex, and national origin; 2)Title IX of the Education Amendment
of 1972, as amended (20 USC §§ 1681-1683, and 1685-1686), which prohibits
discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as
amended(20 USC § 794),which prohibits discrimination on the basis of handicaps;4)The
Age Discrimination Act of 1975, as amended (42 USC §§ 6101-6107), which prohibits
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discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972
(PL 92-255), as amended,relating to nondiscrimination on the basis of drug abuse; 6)The
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970(PL 91616),as amended,relating to nondiscrimination on the basis of alcohol
abuse or alcoholism; 7) The Public Health Service Act of 1912, §§ 523 and 527 (42 USC
§§690dd-3 and 290ee-3),as amended,relating to confidentiality of alcohol and drug abuse
patient records; 8)Title VIII of the Civil Rights Act of 1968 (42 USC §§ 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The
Americans with Disabilities Act of 1990 (42 USC §§ 12101), as amended from time to
time, relating to nondiscrimination in employment on the basis of disability; 10) Monroe
County Code Chapter 14, Article II, which prohibits discrimination on the basis of race,
color, sex, religion, national origin, ancestry, sexual orientation, gender identity or
expression, familial status or age; and 11) any other nondiscrimination provisions in any
federal or state statutes which may apply to the parties to, or the subject matter of, this
Agreement.
7.18 Client and Consultant covenant that neither presently has any interest,and shall not acquire
any interest,which would conflict in any manner or degree with its performance under this
Agreement, and that the only interest of each is to perform and receive benefits as recited
in this Agreement.
7.19 Consultant warrants that he/it had not employed, retained or otherwise had act on his/its
behalf any former Monroe County officer or employee subject to the prohibition of Section
2 of Ordinance No. 0 10-1990 or any Monroe County officer or employee in violation of
Section 3 of Ordinance No. 020-1990. For breach or violation of this provision the Client
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 fiill amount
of any fee, commission, percentage, gift, or consideration paid to the former Monroe
County officer or employee.
7.20 Consultant must comply with Florida public records laws, including but not limited to
Chapter 119,Florida Statutes and Section 24 of article I of the Constitution of Florida. The
Client and Consultant shall allow and permit reasonable access to, and inspection of, all
documents, records, papers, letters or other"public record" materials in its possession or
under its control subject to the provisions of Chapter 119, Florida Statutes, and made or
received by the Client and Consultant in conjunction with this contract and related to
contract performance. The Client shall have the right to unilaterally cancel this contract
upon violation of this provision by the Consultant. Failure of the Consultant to abide by
the terms of this provision shall be deemed a material breach of this contract and the Client
may enforce the terms of this provision in the form of a court proceeding and shall, as a
prevailing party, be entitled to reimbursement of all attorney's fees and costs associated
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with that proceeding. This provision shall survive any termination or expiration of the
contract.
The Consultant is encouraged to consult with its advisors about Florida Public Records
Law in order to comply with this provision.
Pursuant to F.S. 119.0701 and the terms and conditions of this contract, the Consultant is
required to:
(1) Keep and maintain public records that would be required by the Client to perform the
service.
(2) Upon receipt from the Client's custodian of records, provide the Client with a copy
of the requested records or allow the records to be inspected or copied within a reasonable
time at a cost that does not exceed the cost provided in this chapter or as otherwise provided
by law.
(3) Ensure that public records that are exempt or confidential and exempt from public
records disclosure requirements are not disclosed except as authorized by law for the
duration of the contract term and following completion of the contract if the Consultant
does not transfer the records to the Client.
(4) Upon completion of the contract,transfer, at no cost, to the Client all public records
in possession of the Consultant or keep and maintain public records that would be required
by the Client to perform the service. If the Consultant transfers all public records to the
Client upon completion of the contract, the Consultant shall destroy any duplicate public
records that are exempt or confidential and exempt from public records disclosure
requirements.If the Consultant keeps and maintains public records upon completion of the
contract,the Consultant shall meet all applicable requirements for retaining public records.
All records stored electronically must be provided to the Client, upon request from the
Client's custodian of records, in a format that is compatible with the information
technology systems of the Client.
(5) A request to inspect or copy public records relating to a Client contract must be made
directly to the Client, but if the Client does not possess the requested records, the Client
shall immediately notify the Consultant of the request,and the Consultant must provide the
records to the Client or allow the records to be inspected or copied within a reasonable
time.
If the Consultant does not comply with the Client's request for records, the Client shall
enforce the public records contract provisions in accordance with the contract,
notwithstanding the Client's option and right to unilaterally cancel this contract upon
violation of this provision by the Consultant. A Consultant who fails to provide the public
records to the Client or pursuant to a valid public records request within a reasonable time
may be subject to penalties under Section 119.10, Florida Statutes.
Consultant shall not transfer custody, release, alter, destroy or otherwise dispose of any
public records unless or otherwise provided in this provision or as otherwise provided by
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law.
IF THE CONSULTANT HAS QUESTIONS REGARDING THE APPLICATION OF
CHAPTER 119, FLORIDA STATUTES, TO THE CONSULTANT'S DUTY TO
PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE
CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT (305) 292-3470,
BRADLEY-BRIAN@MONROECOUNTY-FL.GOV, MONROE COUNTY
ATTORNEY'S OFFICE, 11 I 1 12th STREET, SUITE 408, KEY WEST, FL 33040.
7.21 Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the
Client and the Consultant in this Agreement and the acquisition of any commercial liability
insurance coverage, self-insurance coverage, or local government liability insurance pool
coverage shall not be deemed a waiver of immunity to the extent of liability coverage,nor
shall any contract entered into by the Client be required to contain any provision for waiver.
7.22 All of the privileges and immunities from liability,exemptions from laws,ordinances,and
rules and pensions and relief, disability,workers' compensation, and other benefits which
apply to the activity of officers, agents, or employees of any public agents or employees of
the Client, when performing their respective functions under this Agreement within the
territorial limits of the Client shall apply to the same degree and extent to the performance
of such functions and duties of such officers, agents, volunteers, or employees outside the
territorial limits of the Client.
7.23 Consultant agrees to execute such documents as the Client may reasonably require, to
include a Public Entity Crime Statement, an Ethics Statement,and a Drug-Free Workplace
Statement.
7.24 No covenant or agreement contained herein shall be deemed to be a covenant or agreement
of any member, officer, agent or employee of Client in his or her individual capacity, and
no member, officer, agent or employee of Client shall be liable personally on this
Agreement or be subject to any personal liability or accountability by reason of the
execution of this Agreement.
7.25 Consultant shall obtain and maintain insurance coverage throughout the term of this
agreement as set forth in Exhibit A attached hereto.
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IN wi'TNCSS WHERFOF, the pa'.ties hereto have Caused this Agreement to be
executed on this 7th day of February 2020.
BOARD OF COUNTY COMMISSIONERS
OF MONROS COUNTY,FLORIDA
v 6
By TefinvU—min ,n's or
County Administrator
Witnesses for CONSULT HEALTH PARTNERS, INC.
14
ff
Robin Bieier,President
rent N� e
Date:
r�
Signat re
OE COU AP F.4-NEY
V YEI O �
Date: t �W RCADQ
SI AFL
Page 9af i
HIPAA PRIVACY & SECURITY COMPLIANCE AGREEMENT FOR BUSINESS
ASSOCIATES
THIS AGREEMENT is made as of the 7th of February, 2020, by and between Monroe
County, a political subdivision of the State of Florida (the "Covered Entity"), and RB Health
Partners, Inc., a Florida corporation (the 'Business Associate"). Covered Entity and Business
Associate shall collectively be referred to sometimes herein as the "Parties".
WHEREAS, Covered Entity is a government agency; and
WHEREAS,Business Associate is inthe business of providing services to the health
care industry and Business Associate's activities are generally described as clinical and
operational consulting; and
WHEREAS, Covered Entity wishes to continue an existing business relationship with
Business Associate that has been memorialized in a separate services agreement or
engagement which is still in effect; and
WHEREAS, the nature of the existing relationship between Covered Entity and
Business Associate may involve the exchange of Protected Health Information("PHI")as that
term is defined under the Health Insurance Portability and Accountability Act of 1996
("HIPAA") as amended by the Health Information Technology for Economic and Clinical
Health Act of 2009 ("HITECH Act"), including all pertinent regulations issued by the
Department of Health and Human Services ("HHS");
NOW THERFORE,the premises having been considered and with acknowledgment of
the mutual promises and of other good and valuable consideration herein contained, the
Parties, intending to be legally bound,hereby agree as follows:
A. Definitions.
1) Breach. "Breach" has the same meaning as this term has in §13400 of the Health
Information Technology for Economic and Clinical Health Act of 2009 ("HITECH
Act").
2) Designated Record Set. "Designated Record Set" has the same meaning as this term
has in 45 CFR §164.501.
3) Individual. "Individual" has the same meaning as this term has in 45 CFR§164.501.
4) Privacy Rule. "Privacy Rule" shall mean the Standards for Privacy of Individually
Identifiable Health Information at 45 CFR Part 160 and Part 164,Subparts A and
E, as amended by the HITECH Act.
Page 1 oof 15
5) Protected Health Information. "Protected Health Information" (or "PHI") has the
same meaning as this term has in 45 CFR §160.103 (as amended by the HITECH
Act), limited to the information created or received by Business Associate from or
on behalf of Covered Entity.
6) Required By Law."Required By Law" has the same meaning as this term has in 45
CFR §164.501.
7) Security Standards. "Security Standards" means the security standards for protection
of PHI promulgated by the Secretary in Title 45 C.F.R.
8) Unsecured Protected Health Information. "Unsecured Protected Health
Information" shall mean Protected Health Information (PHI) that is not secured
through the use of a technology or methodology specified by the Secretary in
regulations or as otherwise defined in the §13402(h)of the HITECH Act.
) Any prospective amendment to the laws or regulations referenced in this
definitional section prospectively amend this agreement to incorporate said changes
by Congressional act or by regulation of the Secretary of HHS.
B. Obligations and Activities of Business Associate. Business Associate agrees to not use
or disclose Protected Health Information other than as permitted or required by the
Agreement or as required by law.
1) Business Associate agrees to employ administrative, physical, and technical
safeguards meeting required Security Standards for business associates as Required By
Lawto prevent disclosure or use of PHI other than as allowed by this Agreement.
2) Business Associate agrees to mitigate,to the extent practicable, any harmful effect
that is known to Business Associate of a use or disclosure of PHI held by Business
Associate in violation ofthe requirements ofthis Agreement.
3) Business Associate agrees to report to Covered Entity any use or disclosure of the
Protected Health Information not provided for by this Agreement of which it becomes
aware.
4) Business Associate agrees to ensure that any agent, including a subcontractor, to
whom it provides Protected Health Information received from, or created or received
by Business Associate on behalf of Covered Entity agrees to the same restrictions and
conditions that apply through this Agreement to Business Associate with respect to
PHI.
5) Business Associate agrees, at the request of Covered Entity,to provide Covered
Entity (or a designate of Covered Entity) access to Protected Health Information in a
Designated Record Set in prompt commercially reasonable manner in order to meet
the requirements under 45 CFR§164.524.
6) Business Associate agrees to make any amendment(s) to Protected Health
Information in a Designated Record Set that the Covered Entity directs or agrees to
Page 11 of 15
pursuant to 45 CFR §164.526 at the request of Covered Entity or an Individual in a
prompt and commercially reasonable manner.
7) Business Associate agrees to make internal practices,books,and records,including
policies and procedures and Protected Health Information, relating to the use and
disclosure of Protected Health Information received from,or created or received by
Business Associate on behalf of Covered Entity available to the Covered Entity,orto
the Secretary (including official representatives of the Secretary), in a prompt
commercially reasonable manner for purposes of determining Covered Entity's
compliance with the Privacy Rule.
8) Business Associate shall, upon request with reasonable notice, provide Covered
Entity access to its premises for a review and demonstration of its internal practices
and procedures for safeguarding PHI.
9) Business Associate agrees to document such disclosures of Protected Health
Information and information related to such disclosures as would be required for
Covered Entity to respond to a request by an Individual for an accounting of disclosures
of Protected Health Information in accordance with 45 CFR §164.528.
10) Business Associate agrees to provide to Covered Entity or an Individual in a
prompt commercially reasonable manner, information collected in accordance with
this Agreement to permit Covered Entity to respond to a request by an Individual for
an accounting of disclosures of Protected Health information in accordance with 45
CFR §164.528.
C. Permitted Uses and Disclosures by Business Associate. Except as otherwise limited in
this Agreement, Business Associate may use or disclose Protected Health Information,
as follows:
1)On behalf of Covered Entity,provided that such use or disclosure would not violate
the Privacy Rule if done by Covered Entity.
2) Except as otherwise limited in this Agreement, Business Associate may disclose
Protected Health Information for the proper management and administration of the
Business Associate,provided that disclosures are required by law,or Business Associate
obtains reasonable assurances from the person to whom the information is disclosed
that it will remain confidential and used or further disclosed only as required by law
or for the purpose for which it was disclosed to the person,and the person notifies the
Business Associate ofany instancesofwhich itis aware inwhich the confidentiality of
the information has been breached.
D. Obligations of Covered Entity
1) Covered Entity shall notify Business Associate of any limitations) in its notice of
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privacy practices of Covered Entity in accordance with 45 CFR §164.520 to the extent
that such limitation may affect Business Associate's use or disclosure of Protected
Health Information.
2) Covered Entity shall notify Business Associate of any changes in,or revocation of,
permission by individual to use or disclose Protected Health Information,to the extent
that such changes may affect Business Associate's use or disclosure of Protected Health
Information.
3) Covered Entity shall notify Business Associate of any restriction to the use or
disclosure of Protected Health Information that Covered Entity has agreed to in
accordance with 45 CFR §164.522, to the extent that such restriction may affect
Business Associate's use or disclosure of Protected Health Information.
4) Covered Entity shall not request Business Associate to use or disclose Protected
Health Information in any manner that would not be permissible under the Privacy
Rule if done by Covered Entity. Nothing in this paragraph shall restrict the ability of
Business Associate to use or disclose PHI as set forth in paragraph C.2.herein.
E. Term and Termination. Term of Agreement. The Term of this Agreement shall be
effective as of the date given at the top of Page Therein, and shall terminate when all
of the Protected Health Information provided by Covered Entity to Business Associate,
or created or received by Business Associate on behalf of Covered Entity, is destroyed
or returnedto Covered Entity,or,if it is infeasible to return or destroy Protected Health
Information, protections are extended to such information, in accordance with the
termination provisions in this Section.
1) Termination for Cause. Upon Covered Entity's knowledge of a material breach by
Business Associate,Covered Entity shall either:
i) 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 Covered Entity;
ii) Immediately terminate this Agreement if Business Associate has breached a
material
term of this Agreement and cure is not possible; or
iii) If neither termination nor cure are feasible, Covered Entity shall report the
violation totheSecretary.
2) Effect of Termination.
i) Except as provided in paragraph E.2(ii) of this section, upon termination of this
Agreement, for any reason, Business Associate shall return or destroy all
Protected Health Information received from Covered Entity, or created or
received by Business Associate on behalf of Covered Entity.This provision shall
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apply to Protected Health Information that is in the possession of subcontractors
or agents of Business Associate. Business Associate shall retain no copies of the
Protected Health Information.
ii) In the event that Business Associate determines that returning or destroying the
Protected Health Information is infeasible, Business Associate shall provide to
Covered Entity notification of the conditions that make return or destruction
infeasible. Upon notification to Covered Entity that return or destruction of
Protected Health Information is infeasible, Business Associate shall extend the
protections of this Agreement to such Protected Health Information and limit
further uses and disclosures of such Protected Health Information to those
purposes that make the return or destruction infeasible, for so long
as Business Associate maintains such Protected Health Information.
F. State Law. If state law applicable to the relationship between Business Associate and
Covered Entity contains additional or more stringent requirements than federal law
for Business Associates regarding any aspect of PHI privacy,then Business Associate
agreesto comply with the higher standard contained in applicable state law.
G. Consideration. Business Associate recognizes that the promises it has made in this
Agreement shall, henceforth, be detrimentally relied upon by Covered Entity in
choosing to continue or commence a business relationship with Business
Associate.
H. Modification. This Agreement may only be modified through a writing signed by
the Parties and, thus no oral modification hereof shall be permitted. The Parties
agree to take such action as is necessary to amend this Agreement from time to time
as is necessary for Covered Entity to comply with the requirements of the Privacy
Rule and the Health Insurance Portability and Accountability Act of 1996 as
amended by the Health Information Technology for Economic and Clinical Health
Act of 2009 ("HITECH Act"), including all pertinent regulations issued by the
Department of Health and Human Services ("HHS");
1. Noticeto Covered Entity.Any notice required underthis Agreement to begiven
Covered Entity shall be made in writing to:
Monroe County
1100 Simonton St.
Key West, FL.33040
Sheryl L. Graham, Sr. Director, Monroe County Social Services
J. Notice to Business Associate. Any notice required under this Agreement to
Page 14of 15
Notice to Business Associate. Any notice required under this Agreement to
be glen Business Associate shalt be made in writing to:
RB Health Partners,
Inc.PO Box 1116
Crystal Beach,FL
34,681 Robin A. Bleier,
President
IN WITNESS WHOtEDF.the parties.hereto have caused this Agrmnent to be executed on
this 7th clay of February,2020.
OARD OF C.0UNrY com-missioNERs
OF MO OE CO ,FLORIDA
lay f4c,
ing oun mint ar
County Adrninistrator
Witnesses for CONSULT , RB HEALTHPARTNFRS..INC.
J
i tXbitntleier.Pri t
P
.Print N e
Date:-
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Si p
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Nnt Name
Bate: ,: Z
Page 15of i3
EXHIBIT A
COMMERCIAL GENERAL LIABILITY REQUIREMENTS
FOR CONTRACT BETWEEN
RB HEALTH SERVICES INC.
AND MONROE COUNTY
Prior to the commencement of work governed by this contract, the Contractor will obtain
Commercial General Liability Insurance. Coverage will 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
The minimum limits acceptable is:
$300,000 Combined Single Limit(CSL)
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 will be named as Additional Insured on
all policies issued to satisfy the above requirements.
BUSINESS AUTOMOBILE LIABILITY INSURANCE REQUIREMENTS
FOR CONTRACT BETWEEN
RB HEALTH SERVICES INC.
AND MONROE COUNTY
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
prior to the commencement of work, shall obtain Business Automobile Liability Insurance.
Coverage will 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 is:
$300,000 Combined Single Limit(CSL)
If split limits are provided, the minimum limits acceptable are:
$200,000 per Person
$300,000 per Occurrence
$200,000 Property Damage
The Monroe County Board of County Commissioners will be named as Additional Insured on
all policies issued to satisfy the above requirements.
MEDICAL PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS
FOR CONTRACT BETWEEN
RB HEALTH SERVICES INC.
AND MONROE COUNTY
Recognizing that the work governed by this contract involves the providing of professional
medical treatment,the Contractor will 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 are:
$300,000 per Occurrence/$750,000 Aggregate
If coverage is provided on a claims made basis, an extended claims reporting period of four
(4) years will be required.
WORKERS' COMPENSATION INSURANCE REQUIREMENTS
FOR CONTRACT BETWEEN
RB HEALTH SERVICES INC.
AND MONROE COUNTY
Prior to the commencement of work governed by this contract, the Contractor will obtain
Workers' Compensation Insurance with limits sufficient to respond to applicable Workers'
Compensation state statutes and the requirements of Chapter 440, Florida Statutes.
In addition, the Contractor will 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 will be maintained throughout the entire term of the contract.
Coverage will 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 may recognize and honor the Contractor's status. The Contractor
may be required to submit a Letter of Authorization issued by the Department of Labor and a
Certificate of Insurance,providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition,the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
ACIC LIO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY)
`� 1 05/11/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
FrankCrum Insurance Agency,Inc. PHONE (727)412-7765 FAX Nu: (727)608-1526
100 South Missouri Avenue E-MAIL FCIA@frankcrum.com
ADDRESS:
INSURERS AFFORDING COVERAGE NAIL#
Clearwater FL 33756 INSURERA: Lloyd's Of London
INSURED
INSURER B
RB Health Partners.Inc. INSURER C:
PO BOX:1116 INSURER D:
INSURER E
Crystal Beach FL 34681 INSURER F:
COVERAGES CERTIFICATE NUMBER: 21122 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR TYPE OF INSURANCE POLICY EFF POLICY EXP
LTR IN SD WVO POLICY NUMBER MMIDD1YYYY MMIDDIYYYY LIMITS
X COMMERCIALGENERALLIABILITY 1,000,000
EACH OCCURRENCE S
CLAIMS MADE ®OCCUR PREMISES fEa occurrence $
MEDEXPAn one pemnl, S 5,000
A ME0168922821 04/14/2021 04/14/2022 PERSONAL aADVINJURY s 1,000,000
GEN'LAGGREGATEUMITAPPLIESPER. GENERAL AGGREGATE $ 2,000,ODO
POLICY E JPEC LOC PRODUCTS•COMP/OPAGG S 1,000,0W
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE L-MIT $
Approved Risk Managem nt Ea en,
ANY AUTO BODILY INJURY(Per my $
OWNED SCHEDULED ;5&
AUTOS ONLY AUTOS BODILYINJURY(Peraccident) $
HIRED 14ON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY 5-11-2021 Per so.'.dTy
UMBRELLA LIAS OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DED I I RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETORIPARTNERIEXECUTWE N 1 A E.L.EACH ACCIDENT S
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required)
Clinical risk Medicare&operations consultingladvisors
Automatic Additional Insured for ongoing operations is included in regards to the General Liability coverage per the attached form#VVCL P0002 CW(10/14).
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Monroe County Board of County Commissioners ACCORDANCE WITH THE POLICY PROVISIONS.
1100 Simonton Street 2-257
AUTHORIZED REPRESENTATIVE
Key West FL 33040
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
DATE(MM/DD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE
O5/19/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
FrankCrum Insurance Agency,Inc. a/CNr o Ext: (727)412-7765 a/c,No): (727)608-1526
100 South Missouri Avenue E-MAIL FCIA@frankcrum.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33756 INSURERA: Lloyd's Of London 15792
INSURED
INSURER B
RB Health Partners,Inc. INSURER C:
PO Box 1116
INSURER D
INSURER E:
Crystal Beach FL 34681 INSURER F:
COVERAGES CERTIFICATE NUMBER: 19/20 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCEAUULbUbK POLICY EFF POLICY EXP
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE FX OCCUR PREM SDAMAGES Ea oNcurDrence $ 50,000
MED EXP(Any one person) $ 5,000
A ME0168922819 04/14/2019 04/14/2020 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 1'000'000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Approved Risk Management Eaaccident
ANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ElN/A E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Professional Liability Each Claim 1,000,000
A ME0168922819 04/14/2019 04/14/2020 Aggregate 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Clinical risk Medicare&operations consulting/advisors
Automatic Additional Insured for ongoing operations is included in regards to the General Liability coverage per the attached form#WCL P0002 CW(10/14).
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Monroe County Board of County Commissioners ACCORDANCE WITH THE POLICY PROVISIONS.
1100 Simonton Street 2-257
AUTHORIZED REPRESENTATIVE
Key West FL 33040
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Am
HISCOX '" General Liability Coverage Part (Occurrence)
C. Limited liability If you are a duly organized limited liability company,your members and their spouses are
companies insureds,but only with respect to the conduct of your business.Your managers are also
insureds,but only with respect to their duties as your managers.
D. Other organizations If you are an organization(including a professional corporation)other than a partnership,joint
venture,or limited liability company,your directors and officers are insureds,but only with
respect to their duties as your directors or officers.Your stockholders and their spouses are also
insureds,but only with respect to their liability as your stockholders.
E. Trusts If you are a trust,your trustees are insureds, but only with respect to their duties as your
trustees.
F. Employees Your employees are insureds,but only while in the course and scope of their employment by
you or while performing duties related to the conduct of your business.
G. Volunteer workers Your volunteer workers are insureds,but only while in the course and scope of their activities
related to the conduct of your business performed on your behalf or at your direction.
H. Real estate managers Persons(other than your employees)or organizations acting as your real estate managers are
insureds, but only with respect to their duties as your real estate managers.
I. Amateur athletic Any person representing you while participating in an amateur athletic activity you sponsor is an
participants insured. However,no such person is an insured for:
1. bodily injury to:
a. a co-participant,your employee,or your volunteer worker while also participating in
the amateur athletic activity you sponsor;or
b. you or any of your partners,members,or officers;or
2. property damage to property owned,occupied,or used by;rented to;or in the care,
custody,or control of:
a. a co-participant in the amateur athletic activity you sponsor,your employee,or your
volunteer worker;or
b. you or any of your partners, members,or officers.
J. Newly acquired or formed If there is no other similar insurance available,any organization you acquire or form during the
organizations policy period,and in which you have majority ownership or interest at the time of an occurrence
or offense covered by this Coverage Part,will qualify as an insured.This coverage is effective on
the date of acquisition or formation and is afforded only until the 180th day after you acquire or
form the organization,or the end of the policy period,whichever is earlier.
There is no coverage for the acquired or formed organization for:
1. bodily injury or property damage that occurred;or
2. personal or advertising injury arising out of an offense that was committed,
before you acquired or formed the organization.
The acquired or formed organization is an Insured only with respect to the conduct of your
business.
K. Additional insureds If you have agreed in a written contract or agreement to add them as an additional insured to a
policy providing the type of coverage afforded by this Coverage Part,the following persons or
organizations are insureds:
1. Any person or organization from whom you lease any premises,but only with respect to
liability arising out of the ownership,maintenance,or use of that part of the premises leased
to you.
However,there is no coverage for such additional insureds for any structural alterations,
new construction,or demolition operations performed by or on behalf of the additional
insured.
Includes copyrighted material of Insurance
Services Offices,Inc.,with its permission
WCL P0002 CW(10114) Page 3 of 19
Aev
H I SCOX ' General Liability Coverage Part (Occurrence)
A person or organization's status as an additional insured under this subsection 1 ends
when you cease to be a tenant in the premises.
2. Any person or organization for whom you are performing operations,but only with respect to
liability arising out of:
a. your acts or omissions or of those acting on your behalf;and
b. the performance of your ongoing operations for the additional insured.
However,there is no coverage for such additional insureds for:
a. bodily injury,property damage,or personal and advertising injury arising out of
the rendering of or failure to render any professional architectural,engineering,or
surveying services,including:
(1) the preparing,approving,or failing to prepare or approve,maps,shop drawings,
opinions,reports,surveys,field orders,change orders,drawings,or
specifications;or
(2) supervisory, inspection,architectural,or engineering activities;or
b. bodily injury or property damage occurring after:
(1) all work,including materials,parts,or equipment furnished in connection with
such work,on the project(other than service,maintenance,or repairs)to be
performed by or on behalf of the additional insured at the location of the covered
operations has been completed;or
(2) that portion of your work out of which the injury or damage arises has been put
to its intended use by any person or organization other than another contractor or
subcontractor engaged in performing operations for a principal as a part of the
same project.
A person or organization's status as an additional insured under this subsection 2 ends
when your operations for that additional insured are completed.
3. Any person or organization who sells or distributes your products(referred to in this
subsection as"vendor"), but only with respect to bodily injury or property damage arising
out of your products sold or distributed in the regular course of such vendor's business.
However,there is no coverage for such additional insureds for:
a. bodily injury or property damage for which the vendor is legally obligated to pay
damages because of liability assumed in a contract or agreement;however,this
exclusion will not apply to liability the vendor would have in the absence of such
contract or agreement;
b. any express warranty unauthorized by you;
C. any physical or chemical change in the product made intentionally by the vendor;
d. repackaging,except when unpacked solely for the purpose of inspection,
demonstration,testing,or the substitution of parts under instructions from the
manufacturer,and then repackaged in the original container;
e. any failure to make inspections,adjustments,tests,or servicing the vendor has either
agreed to make or normally undertakes to make in the usual course of business,in
connection with the distribution or sale of the product;
f. demonstration, installation,servicing,or repair operations,except such operations
performed at the vendors premises in connection with the sale of the product;
g. products which,after distribution or sale by you,have been labeled or relabeled or
used as a container, part,or ingredient of any other thing by or for the vendor;
h, bodily injury or property damage arising out of the sole negligence of the vendor for
its own acts or omissions or those of its employees or anyone else acting on its behalf;
however,this exclusion will not apply to:
Includes oopyrighled material of Insurance
Services Offices,Inc.,with its permission
WCL P0002 CW(10/14) Page 4 of 19
2013 Edideati
MONROE COUNTY,FLORIDA
REQUEST FOR WAIVER OF INSURANCE REQUIREMENTS
It is requested that the insurance requirements,as specified in the County's Schedule of hisurance
Requirements,be waived or modified on the following contract.
Contractor/Vendor: Altak .
Project or Service, j ,WWY%4b'I M 0�_
-�
Contractor/Vendor
Address&Phone ff: R9 ._!•1-�{" _ w,F,., . v ., ,
General Scope of Work _
Reason for Waiver or
Modification: w
Vol _ ass 4 -
_
Policies Waiver or •
Modification will apply to: 4 /
Signature of Conttsctor/Vendor.
Date. Approved . XX . Not Approved .,
Risk Management Signature:_.serial.,Slavik
Batt:_3...-42020_ _�w
County Administrator appcai.
Approved: Not Approved:
Date:
Board of County Commissioncrs appeal:
Approved Not Approved:
Meeting Date:
Adtnin+sintive Instruction 7500.7
r�9!
201 a Edition
MONROE COUNTY,FLORMA
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.
ContmctorNendor. !-..�-._
Project or Service: v_I U-LS t�. L [1{ HIV L C -5
ContractorNendor {�
Address&Phone#:
General Scope of Work:
Reason for Waiver or W C r 1L i`S l ()�Ul (' \C �f�U�'4�._`��1G.t1 l _� 10 qee 5
Modification:
Policies Waiver or -
Modification will apply to: Uy C r� j= _��2�1LSi� _. __..._._-._....
Signature of ContractorNendor:
Date: -)—µf J7r2J Approved X Not Approved . _
-..._._..._...._.__
Risk Management Signature: �7:)kaAa 5-18-2021
Date:
County Administrator appeal:
Approved: w Not Approved:
Date:
Board of County Commissioners appeal:
Approved: Not Approved:
Meeting Date:
Administrative Instruction 7500.7
itta
Effective with UNDERWRITERS AT LLOYD'S, LONDON
40 Administered by Hiscox Inc.
520 Madison Avenue 32nd Floor,New York,NY 10022
H I SCOX M (646)452-2353
Insurance for Professionals
DECLARATIONS
THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INSURED BY SURPLUS LINES
CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT TO THE EXTENT OF ANY
RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT UNLICENSED INSURER.
SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT
APPROVED BY ANY FLORIDA REGULATORY AGENCY.
Broker No.: US 0000014 Agency Marketing Services Inc
Certificate No.: MEO1689228.19 9800 4th Street North Suite 400
Renewal of: MEO1689228.18 Saint Petersburg, FL 33702
1. Named Insured: RB Health Partners, Inc.
Address: 137 Pennsylvania Ave
Palm Harbor, FL 34683-3434
2. Policy Period: Inception Date:04/14/2019 Expiration Date: 04/14/2020
Inception date shown shall be at 12:01 A.M. (Standard Time)to Expiration date shown above at
12:01 A.M. (Standard Time)at the address of the Named Insured.
3. General terms and WCL P0001 CW(09/14)
conditions wording: The General terms and conditions apply to this policy in conjunction with the specific wording
detailed in each section below.
4. Endorsements: E6002.1 -Florida Amendatory Endorsement, E6015.7-Lloyd's Syndicate(3624) Endorsement,
E6016.1 -Service of Suit, E6017.2-Nuclear Incident Exclusion Clause-Liability-Direct(Broad)
Endorsement, E6018.2-Applicable Law Endorsement, E6020.2-War and Civil War Exclusion
Endorsement, and E9998.2-TRIA Not Purchased Endorsement
S. Optional Extension 12/24/36 months at 75/150/225 percent of the annual premium, for eligible coverage parts.
Period:
6. Notification of Hiscox Claims
claims to: 520 Madison Avenue, 32nd floor
New York, NY 10022
Fax: 212-922-9652
Email: HiscoxClaims@Hiscox.com
Additional Notification NONE
requirements:
WCL D0001 CW(07/14) Page 1 of 3
Effective with UNDERWRITERSATP69NYPA§N�.9cNdg.goNA289060
Administered by Hiscox Inc. AGENT ADDRESS:9800 4th St.N.,Ste.400
''
520 Madison Avenue 32nd Floor,New York,NY 10022 St.Petersburg,FL 33702
H I SCOX M (646)452-2353 Prod.Agent:Matthew C.Crum
Address: 100 South Missouri Avenue
Address:Clearwater,FL 33756
This Insurance is issued pursuant to the Florida
Surplus Lines Laws.Persons Insured by Surplus
Lines Carrier's do not have the protection of
the Florida Insurance Guaranty Act to the
Insurance for Professionals extent of any recovery for the obligation of
an insolvent unlicensed carrier.
DECLARATIONS AGENT'S COUNTERSIGNATURE:
7. Policy Premium: Administration Fee: N/A State Surcharge: N/A
a.ww. .
Professionals Liability Claims-Made and Reported Coverage Part: WCLMPL P0001 CW (11-14)
Covered Professional Services: Solely in the performance of medical/healthcare consulting services(non-physician).
Professional Liability(PL): $ 1,000,000 Each Claim/$2,000,000 Aggregate
Defense of Licensing Proceedings: $ 10,000 Aggregate Limit(Separate Limit)
Subpoena Assistance: $ 10,000 Aggregate Limit(Separate Limit)
Retroactive Date: 04-14-2014
Retention: $5,000
PL Premium: $3,552
Endorsements: E6103.2-Medical Malpractice Exclusion Endorsement, E6408.1 -Care Management
Consulting Exclusions Endorsement, E6147.1 -Managed Care Exclusion Endorsement,
and E6172.2-Healthcare Consultant-Related Exclusions Endorsement
General Liability Occurrence Coverage Part: WCL P0002 CW(10/14) " �� �
General Liability(GL): $ 1,000,000 Each Occurrence/$2,000,000 Aggregate
Products and Completed $ 1,000,000 Each Occurrence Limit(Shared Limit with GL)
Operations:
Personal and Advertising Injury: $ 1,000,000 Each Claim Limit(Shared Limit with GL)
Damage to Premises: $50,000 Any One Premise Limit(Shared Limit with GL)
Medical Payments: $5,000 Each Person Limit(Separate Limit)
Retention: $5,000
GL Premium: $ 1,238
Endorsements: E6803.1 -Sexual Misconduct Exclusion Endorsement
In accordance with the authorization granted to Hiscox Inc. under Contract No. 131234HisInc2019 by certain Underwriters at Lloyd's,
London,whose names and the proportions underwritten by them can be ascertained by reference to the said Contract,which bears
the Seal of Lloyd's Policy Signing Office and is on file at the office of the said Agency and in consideration of the premium specified
herein, the said Underwriters do hereby bind themselves, each for their own part and not one for another,their heirs, executors and
administrators,to insure as follows in accordance with the terms and conditions contained or endorsed hereon.
The Certificate terms and conditions contained herein or endorsed hereon and such other provisions, agreements or conditions as
may be endorsed hereon or added hereto are hereby incorporated in this Certificate. No representative of the Underwriters shall
have the power to waive or be deemed to have waived any provision or condition of this Certificate unless such waiver, if any, shall
be written upon or attached hereto; nor shall any privilege or permission affecting the insurance under this Certificate exist or be
claimed by the Insured(s)unless so written or attached.
wcL D0001 cw(o7n4) "SURPLUS LINES INSURERS' POLICY RATES AND Page 2 of 3
FORMS ARE NOT APPROVED BY ANY FLORIDA
REGULATORY AGENCY."
Effective with UNDERWRITERS AT LLOYD'S, LONDON
Administered by Hiscox Inc.
520 Madison Avenue 32nd Floor,New York,NY 10022
H I SCOX PRU (646)452-2353
Insurance for Professionals
DECLARATIONS
IN WITNESS WHEREOF this Certificate has been signed at New York, New York
Authorized Representative
Kevin Kerridge
March 15, 2019
Hiscox Inc.
WCL D0001 CW(07/14) Page 3 of 3