Item I2
BOARD OF GOVERNORS
FIRE AND AMBULANCE DISTRICT 1
AGENDA ITEM SUMMARY
Meeting Date: March 19. 2003
Division: County Administrator
Bulk Item: Yes X No
Department: Fire Rescue
AGENDA ITEM WORDING: Requesting approval of rescission of Provider Agreement Form,
which was approved by the Board of Govemors of the Fire and Ambulance District 1 on May 15,2002.
ITEM BACKGROUND: Provider Agreement Form was originally provided with Resolution 222-
2002 to write-off patient account (Herminio Camejo); subsequently, all but the amount of $1 0.00 was
paid on the account making the Provider Agreement Form unnecessary.
PREVIOUS RELEVANT BOCC ACTION: None.
CONTRACT/AGREEMENT CHANGES: None.
STAFF RECOMMENDATIONS: Approval.
TOT AL COST: n/a
BUDGETED: Yes
No
COST TO COUNTY: n/a
SOURCE OF FUNDS:
REVENUE PRODUCING: Yes
No X
AMOUNTPERMONTH_ Year
APPROVED BY: County Atty Yes
DEPARTMENT HEAD APPROVAL:
DIVISION DIRECTOR APPROVAL:
=-:::~
James L. Roberts
DOCUMENT A TION:
Included X
To Follow_
Not Required_
DISPOSITION:
.--:--
AGENDA ITEM # .~--
Revised 1/03
Emergency Medical Services
RESOLUTION NO. 345 -2002
A RESOLUTION OF THE BOARD OF GOVERNORS OF THE
FIRE AND AMBULANCE DISTRICT 1 OF MONROE COUNTY,
FLORIDA, AMENDING RESOLUTION NO. 222-2002
WHEREAS, Monroe County Emergency Medical Services provides ambulance service; and
WHEREAS, The Board of Governors approved Resolution No. 222-2002 for the write-off of
$213.36; and
WHEREAS, it has been determined that the amount of write-off for Herminio Camejo should
have been $10.00 instead of$147.20;
.-
BE IT RESOLVED BY THE BOARD OF GOVERNORS OF THE FIRE AND
AMBULANCE DISTRICT 1 OF MONROE COUNTY, FLORIDA:'
NOW THEREFORE, the amount of write-off authorized under Resolution:No. 222-2002 shall
be amended to be $76.16.
PASSED AND ADOPTED by the Board of Governors of the Fire and Ambulance District 1 of
Monroe County, Florida, at a regular meeting of said Board held on the 21st day of
Augus t , 2002.
yes
yes
yes
y<>s
yes
...', -.' -.'
. . BOARD OF GOVERNORS OF THE
{~VXtHG;..;I,
f'..3
<::> .."
'--"
......, r-
(,I) f"Tl
r'T1
-0 0
I .."
CJ1 0
::0
-0 ::0
:x t"T1
.r:- c,"")
. . 0
N ::0
0 0
BY.
. . hr.I..:;. ~ ~U20N
f"~~ ",. .~~/~_~
~J/~'/~~82 88:15
1l4-::l::lb-4 LI:n:!
Hl...,K:J
HeRS
REALm CARE RECOVERY SYSTEMS
3151 AJnv.l.Y Ave., Building 1-3, Suite F, Costa Mesa, CA. 9Z626 · PhOll~ 714-556-4255 Fu 714-556-4280
PROVIDER AGREEMENT FORM
. Date: March 6,2002
TO: Darice,
PROVIDER: Monroe City Ems.
FAX: 305-289-6336
PHONE:
305-289-6004
PATIENT:..Camejo, Hermlnio
PATIENT ID:
590-24.-4024
Date of Service: 11/18/01
Patient Acct: 41140701
Current Billed Charges: $588.95
Group: Clarendon Kids, FL
Dear: Darice,
This agreement confinns that Monroe City EMS. #596000749 agrees to the revised $
amount for services on the above patient to be $441.75
There will be no billing to the primary payor, insured or the patient for the difference between the billed
charges and the agreed upon amount for the services rendered for this episode of care except for the insured
co-pay, deductibles and co-insurance blUed on the agreed upon amount. The provider also agr~es that the
bill will be processed by the payor subject to eligibility, co-paYment, deductibles, insurance plan limits,
maximums and utilization review requirements as defined in the patients insurance plan docwnent.
This agreement la In Ueu of any proposed audits. The above claim will qualify for prompt processing
nd ill be 15 business days.
.:t C \~~
Date
Signature Date
Authorized Representatiye of Provider
Manager
John Ralpb,
Health Care Recovery Systems
Printed Name
Title
Please sign above and FAX. to HCRS at 714-556-4280 or can me at 714-556-4255. Thank you for
your time and consideration of the claim.
f) ^ TF