Item C32
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: February 18. 2004
Sulk Item: Yes [8J No D
Division: ManaQement Services
Department: Administrative Services
AGENDA ITEM WORDING: Approval of subcontract for Saker Act and Marchman Act
transportation services between Guidance Clinic of the Middle Keys and Jessrica. Inc.
as an attachment to the contract between Monroe County and Guidance Clinic of the
Middle Keys.
ITEM BACKGROUND: The copv of this contract was not available at the time the
contract between Monroe County and the Guidance ylinic was approved. althouQh it
was referred to in the contract as Attachment D. ThEjse services were subcontracted
last fiscal year as well. under the same terms. A cop~ of the contract approved in Oct.
2003 is attached. with the relevant portions underlinep.
PREVIOUS RELEVANT BOCC ACTION: approval of contract at October 2003 meetinQ.
CONTRACT/AGREEMENT CHANGES: n/a
STAFF RECOMMENDATION: Approval.
TOTAL COST: 750.964,00 (total contract)
BUDGETED: Yes [8J No D
SOURCE OF FUNDS: $528K - ad
valorem; 86K - fine and fort. fund; 137K-
fuel tax rev.
COST TO COUNTY: 750.964.00 (total
contract)
REVENUE PRODUCING: Yes D No [8J
AMOUNT PER MONTH
YEAR
APPROVED BY: COUNTY A TTY D OMB/PURCHASING D RISK MANAGEMENT D
~. t2~
, Sheila A. Barker
DOCUMENTATION: INCLUDED: D TO FOllOW: D NOT REQUIRED: D
(,32-
DIVISION DIRECTOR APPROVAL:
DISPOSITION:
AGENDA ITEM #:
AGREEMENT
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 the GUIDANCE CLINIC OF THE MIDDLE KEYS, INC.,
hereinafter referred to as "Provider."
WHEREAS, the Board and the Provider desire to enter into an agreement wherein the
Board contracts for services from the Provider for the rendering of mental health services to the
citizens of the Middle Keys, Monroe County, Florida, and
WHEREAS, the Board is vested and charged with certain duties and responsibilities relating
to the mental health and guidance of the citizens of Monroe County, and
WHEREAS, such services have been rendered by the Provider in the past and have been
invaluable to the citizens of the Middle Keys, and
WHEREAS, it is proper and fitting to enter into an agreement for services to be rendered in
the forthcoming fiscal year 2003-2004, 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 and obligations of the
Board, shall reimburse the Provider for a portion of the Provider's expenditures for Baker Act
hospital, physician and crisis stabilization services, as billed by the Provider, for clients qualifying
for such services under applicable state and federal regulations and eligibility determination
procedures, and for Baker Act transportation services, non-Baker Act mental health services and
substance abuse treatment. This cost shall not exceed a total reimbursement of SEVEN
HUNDRED FIFTY THOUSAND, NINE-HUNDRED, SIXTY-FOUR, AND NO/100 DOLLARS
($750,964.00), during the fiscal year 2004, payable as follows:
a) Pay to the Provider the sum of FORTY-TWO THOUSAND, THREE-HUNDRED, FIFTY-
ONE, AND NO/100 DOLLARS ($42,351.00) for Community Transportation Coordinator services.
b) Pay to the Provider the sum of FIVE-HUNDRED TWENTY-EIGHT THOUSAND,
NINETEEN, AND NO/100 DOLLARS ($528,019.00) for Baker Act Inpatient, Residential Detox, and
Mental Health/Substance Outpatient counseling services and community mental health and
substance abuse services.
c) Pay to the Provider the sum of EIGHTY-SIX THOUSAND, TWO-HUNDRED EIGHTY-
SEVEN, AND NO/100 DOLLARS ($86,287.00) for residential treatment services, including
detoxification, long-term substance abuse treatment, and long-term psychiatric treatment
services.
d) Pay to the provider the sum of NINETY-FOUR THOUSAND, THREE HUNDRED,
SEVEN, AND NO/100 DOLLARS ($94,307.00) for Baker Act transportation.
2. TERM. This Agreement shall commence on October 1, 2003, and terminate
sePte~e,~j 30, 2004; unless earlier terminated pursuant to other provisions herein.
(~. / PAYMENT. Payment will be paid monthly as hereinafter set forth. Baker Act
Billing Summary Forms, certified monthly financial and service load reports will be made available
to the Board to validate the delivery of services under this contract. The monthly financial report
is due in the office of the Clerk of the Board no later than the 15th day of the following month.
Pavment for Baker Act and Marchman Act transportation services shall be made accordinq to the
rate schedule set forth in Attachment D, sub;ect to the maximum amounts set forth in Paraqraph
1. d. above. After the Clerk of the Board pre-audits the certified report, the Board shall
reimburse the Provider for its monthly expenses. However, the total of said monthly payments in
the aggregate sum shall not exceed the total amount shown in Article 1, above, during the term
of this agreement. To preserve client confidentiality required by law, copies of individual client
bills and records shall not be available to the Board for reimbursement purposes but shall be
made available only under controlled conditions to qualified auditors for audit purposes. The
organization's final invoice must be received within sixty days after the termination date of this
contract shown in Article 2 above.
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 rendering counsel in the matter of mental health and guidance to the citizens of the
Middle Keys, Monroe County, Florida. The Provider shall provide these services in compliance with
Florida Statutes Chapter 394. Said services shall include, but are not limited to, those services
described in Provider's Details of Specific Program for Which Funding is Requested, attached
hereto as Exhibit C and incorporated herein. Baker Act and Marchman Act transportation services
which are covered under this aqreement mav be subco'ltracted. but are subiect to the rates set
forth in Attachment D. and the limitations above. The sl:Jbcontractor shall be subiect to all of the
conditions of this contract. includinq but not limited to insurance and hold-harmless reqUirements.
as is the Provider.
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 HARML~~ The Provider covenants and agrees
to indemnify and hold harmless Monroe County Board of County Commissioners from any and all
claims for bodily injury (including death), personal inoury, and property damage (including
property owned by Monroe County) and any other los~es, damages, and expenses (including
attorney's fees) which arise out of, in connection with, o~ 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 extent of liability is in no way limited to, reduced, or
lessened by the insurance requirements contained elsewhere within this agreement.
7. INDEPENDENT CONTRACTOR. At all 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, r~les 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.
COUNTY:
COMPLIANCE WITH COUNTY GUIDELINES. The PROVIDER must furnish to the
(a) evidence of the organization's SOl(c)(3) status;
(b) a list of the organization's Board of Directors of which there must be five or more;
(c) evidence of annual election of Officers and Directors;
(d) an annual audited financial report;
(e) a copy the organization's Corporate Bylaws, which must address the organization's
mission, board and membership composition, election of officers, and so on;
(f) 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;
(g) cooperation with County monitoring visits;
(h) 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.
(i) 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.
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 and/or licensure of the Provider's program and staff.
11. INSURANCE.As a pre-requisite of the services supplied under this contract, the
Provider shall obtain, at its own expense, general liability and professional liability insurance to
cover its activities.
12. 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.
13. 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. Baker Act and Marchman Act
transportation services mav be subcontracted. as set forth in Paraqraph 4. above. This aqreement
shall be incorporated bv reference into anv assiqnment and anv assiqnee shall complv 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.
14. 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 times, 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.
15. 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 and 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.
16. 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
1100 Simonton Street
Key West, FL 33040
and
Monroe County Attorney
PO Box 1026
Key West, FL 33041
For Provider:
Dr. David Rice, Executive Director
Guidance Clinic of the Middle Keys, Inc.
3000 41st Street
Marathon, Florida 33050
17. 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.
18. 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.
19. 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.
20. 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.
21. 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
Deputy Clerk
By
Mayor/Chairman
GUIDANCE CLINIC OF THE MIDDLE KEYS, INC.
(Federal ID No. )
By
Director
By
President
A+to.vkm-e.1\.tf D
At,
'~ l1i'
GUIDANCE CLINIC OF THE MIDDLE KEYS, INC.
300041~ STREET,OCEAN
MARATHON, FL 33050
(v) 305/289-6150/ (f) 305/289-6158
deb.barsell@gcmk.org
,,;~~%'~'\
l~"'OP\P}
~, ./
.,~#~.
August 15, 2003
Darren Guttman
Jessrica Corporation
800 14th Street
Key West, FL 33040
RE: LETTER OF AGREEMENT
Dear Mr, Guttman:
The Guidance Clinic of the Middle Keys, Inc. (GCMK), hereby enters into an agreement
with Jessrica Corporation to provide coordination and transportation services for Baker
Act/Marchman Act (BAlMA) clients throughout Monroe County and to/from Miami-Dade
County as required. The effective term of this agreement is October 1, 2003-
September 30, 2004.
GqMK will supply Jessrica with two Chevrolet Caprices meeting Jessrica maintenance
specifications; one to be stationed in Key West at a Jessrica location and one to be
stationed in Marathon at GCMK headquarters. A BAlMA backup vehicle (Ford Crown
Victoria) will be stationed at GCMK at Safeport located at 301 White Street in Key
West. Jessrica will have access to this backup vehicle in the event that either of the
two Caprices is out of service.
GCMK will pay for the fuel and maintenance of the three vehicles used for BAlMA
transportation. Jessrica will coordinate the maintenance for the Caprice located in Key
West. Invoices for routine maintenance (labor and parts) on the Caprice will be
forwarded to GCMK Transportation Coordinator for payment. Jessrica will not charge
an extra fee for coordinating the maintenance of the vehicle. Jessrica must obtain prior
approval from the GCMK Transportation Coordinator to initiate major vehicle repairs.
GCMK will coordinate the maintenance for the Caprice located in Marathon and the
Crown Victoria located in Key West.
GCMK will maintain insurance on the two Caprices and one backup Crown Victoria
assigned to BAlMA transportation service. Jessrica will be named as an "additional
insured" for these three cars, Jessrica will report and document accidents involving
GCMK vehicles and incidents involving clients to the proper authorities and immediately
thereafter contact GCMK.
All Jessrica drivers operating GCMK vehicles will hold a Class D Florida Driver's
License and be approved for GCMK insurance coverage. Upon execution of this
1
Partially funded by the Florida Department of Children & Families, District 11
~'('HI(L'pnEN
~ &. FAMILIES
agreement, Jessrica will fax to GCMK Transportation Coordinator a current list of
drivers - including a copy of the driver's license and social security number for each
driver - for approval to operate GCMK vehicles. Prior to adding a driver, Jessrica will
fax to GCMK Transportation Coordinator or designee a copy of the driver's license and
social security number of the person. GCMK will initiate procedures to add the driver to
GCMK vehicle insurance. Jessrica cannot use the driver until it has received written
notification that the driver has been added to the GCMKinsurarice coverage.
Additionally, Jessrica will fax a copy of picture identific~tion and social security number
for each escort to GCMK Transportation Coordinator or designee. Jessrica cannot use
the escort until it has received written notification that the escort has been approved by
GCMK.
GCMK will supply Jessrica with a cell phone. Jessrica will follow the transportation
protocol and complete the documentation provided as Attachment 1-3 herein.
The following fee structure is established for the perioq of the agreement:
Client Picku Point CIi' nt Dro -off Point
Key West Key West
Key West Marathon
.Marathon Key West
Marathon Marathon
Marathon Ke L:ar 0
Marathon Miami-Dade County
Ke Lar 0 Miami-Dade Count
Ke West Miam -Dade Count
GCMK Preauthorization Required for AN Trips Below
Approval for below fees will be granted only when the Marathon BAlMA vehicle is engaged with another
BAlM A tri that would reclude another icku within reasonable eriod of time.
Maximum Car Client Pickup Jessrica
# Roundtri s* Location Point CIi nt Dro -off Point Pa ment
3 .!J Ii ./ Key West Marathon & North Key Largo $225
5 lJt4If,{ Key West Marathon & North Miami-Dade Count $350
2 .,(~'r' Monroe County Be and Miami-Dade $480
*To be renegotiated in April 2004 if necessary.
Maximum
# Roundtri s*
r'\fb
298 ~~tflt
40
Jessrica
Pa ment
$130
$130
$130
$130
$130
$250
$250
$350
23
Timely payment for services rendered is ensured by adherence to the following
invoicing procedures:
· Jessrica will submit two statements/invoices per month; one covering the trips
made from the first through the fifteenth and one covering trips made from the
sixteenth through the end of the month. Jessrica will send statements/invoices
to GCMK within 5 business days after the end of the billing period.
· Jessrica will include required documentation with each statement/invoice.
· Jessrica statements/invoices for BAlM A trips will be submitted to the attention of
GCMK Stabilization Unit Director.
2
Partially funded by the Florida Department of Children & Families, District 11
~L('HILDREN
I2J &. FAMILIES
. GCMK Stabilization Director will review statement/invoice, mediate any
discrepancies with Jessrica, and forward approved invoice to GCMK Finance
Department.
. GCMK will mail payment to Jessrica within 7 working days (Finance Department)
upon receipt of statement/invoice by the Stabilization Unit Director.
This agreement will begin on October 1, 2003 and will terminate on
September 30, 2004. The agreement can be cancelled by either party with 60 days
written notice.
GCMK and Jessrica enter into this agreement including Attachments 1-3 by affixing
signatures below:
Iz~,',",,<- ( (
Debbie Barsell, MSW, CAP
Executive Vice President, GCMK
/)
~
Darren Guttman
Jessrica Corporation
Attachments:
1. GCMK Transportation Protocol
2. GCMK Transportation Record and Payment Authorization Sheet
3. Statement
**Pending County funding Approval.
3
Partially funded by the Florida Department of Children & Families, District 11
~'C'Hi'LDREN
\2l & FAMILIES
12/15/2003 16:58 FAX 3052896158
GeMK
~ 002/005
ATTACHMENT 1
GUIDANCE CLINIC OF THE MIDDLE KEYS TRANSPORTATION PROTOCOL:
THE TRANSPORTATION OF BAKER ACT AND MARCHMAN ACT CLIENTS
A. Client Related Rules:
1. All clients will be transported with a driver and an escort (who may also be a driver.)
2. All drivers and escorts must be approved by the Transportation Department of the
GCMK prior to accepting a driving assignment.
3. Client transportation within Monroe County may be conducted with a driver and an
escort. .
4. Client transportation outside of Monroe County mtiJst be made with 2 drivers.
5. Client must be observed for any unusual behaviors including hurting self/others Gi
sudden medical conditions. Report/respond to conditions immediately. Nurse on Duty.
Do not go after the client.
6. At the time of pick up for a Baker Act or Marchman Act client, a driver must obtain the
original Baker Act or Marchman Act paper work from the Pick Up facility. If the original
paper work is not available the driver must immediately report this information to the
GCMK Nurse on Duty for further direction.
7. A female client requires a female escort or a female driver.
8, A parent is not allowed to travel in the Baker Act vehicle with a Baker Act or Marchman
Act minor. Parents may follow in another car.
9. Only one client may be transported at a time in the Baker Act vehicle.
10. Clients are not to smoke in the car_
11. Clients are not to be placed in handcuffs or any type of restraints for any reason by a
driver or escort.
12.A client's movement is not to be impeded with anyphysical restraint unless directed by
a nurse/MDllaw enforcement officer.
13.lf a client is violent during transport and poses a treat to safety, stop the vehicle and call
911, than notify the Nurse on Duty of the situation.
14.A client shall not be left alone in the vehicle for any reason.
15. Client is encouraged to use restroom facilities prior to departure. If the trip is generated
from Key West and a stop is required. the GCMK may be used for that purpose.
16.A client may use aluminum/metal cans. Bottle caps must be removed prior to client use.
Clients may not have any metal utensils or other hard products such as pencils or pens.
17.A client may not shop during a stop. All efforts sh041d be made to avoid stops. If a stop
is required, it should be short and without delay,
18.lf a client must use a public facility, the client must be escorted to the restroom and the
driver must remain outside the restroom door until the client leaves the restroom. The
driver will remain in conversation with client while the client is in the restroom.
B. Coordination of Transportation Rules:
1. Transportation arrangements for Baker Act and Marchman Act clients are under the
direction of the Unit Nurse on Duty/GCMK per contractual arrangements with Jessrica
Corp. No other agency is authorized to contact Jessrica directly for transportation.
rev. 09/18/02
Created on 9/18/2002 12: 39 PlvHrailspoltation Rules
1
12/15/2003 16:58 FAX 3052896158
GeMK
~ 003/005
2. All trips will be made within the approved fee structure.
3. All trips will be made using the closest vehicle and the shortest distance unless
preauthorization is obtained from the Unit Nurse on Duty at the GCMK.
4. Clients may be picked up at only approved locations. The GCMK Nurse on Duty will
communicate the pick up location. Approved locations will include:
Hospitals Detention Facility
Mental Health Clinics Anchor Away
Safeport With a GCMK staff member
5. At Depoo: Call security with phone located on the first floor.
6. At GCMK: Use the "Call" button on the intercom box next to the elevator.
7. At GCMK, staff members will place the client in the vehicle for departure and will assist
the client from the vehicle at time of arrival.
8. The facility responsible for the departing client for a trip longer than 2 hours shall
provide a brown bag snack. All minors shall be supplied with a snack for any trip over 1
hour.
9. If a driver determines a client is too dangerous to transport, the GCMK Nurse on Duty
must be notified. The Nurse shall make arrangements for alternative transportation.
10. If a client absconds at time of or during transport, immediately report the information to
the GCMK Nurse on Duty. Do not go after the client.
11. "Jail Hold" clients from the Monroe County Detention Facility shall be picked up from
the Sallyport area only. To access the Sallyport area, the driver must drive the car
within 1 foot of the Sallyport entrance. If the door does not open, the escort must use
the speaker mounted on the wall next to the Sallyport entrance to request entrance.
Once inside, Detention Facility staff will bring the client to the car. When the client is
inside the car and the doors are locked, the Sallyport area exit doors will open.
12. The driver/escort must determine from the Pick Up facility if the client has been
searched and encourage staff to conduct a search prior to transport. If the client is not
searched prior to transport, the driver must communicate this information to the Duty
Staff Member prior to opening the client door at the Designation point.
13. Driver/escort must respond to the pick up point within 1 hour and 15 minutes.
C. Reimbursement related rules
1. All cancelled and otherwise diverted trips will be reported on the Transportation
Record and Payment Authorization Sheet.
2. Daily inspection checklist will be maintained for all Baker Act vehicles and sent
monthly to the GCMK Transportation Coordinator.
3. Transportation Record and Payment Authorization Sheets and a Statement of services
rendered will be faxed to the Stabilization Unit Director on the first and sixteenth of
each month.
4. If the driver arrives without the original Baker or Marchman Act paperwork, Jessrica
will obtain the paper work without charge to the GCMK.
rev, 09/18/02
Created on 9/1812002 '12'39 PMTransportatio.n Rules
2
12/15/2003 17:01 FAX 3052896158
GCMK
~ 004/005
ATTACHMENT 2
GUIDANCE CLINIC OF THE MIDDLE KEYS
3000 41ST ST. Ocean
Marathon, FL 33050
Voice 305.289-6150. Fax 305-289-6157
TRANSPORTATION RECORD AND PAYMENT AUTHORIZATION SHEET
Transportation Type:
o Baker Act
o Marchman Act
Date:
Client Name:
Time Caned:
Time of Pick Up:
Time of Drop Off:
Time van returned to Duty:
Vehicle: 0 KW Caprice
o Mar Caprice
o Crown Vic
Place of Pick Up:
(Where did you pick up the Client: Facility Name/City)
Authorized Staff Signature at Pick Up Facility:
Time:
Destination:
(Where did you take the Client: Facility Name/City)
Authorized Staff Signature at Designation Facility:
(Staff member accepting client)
Time:
Driver Name:
Escort Name:
Beginning Miles:
Pick Up Miles:
Drop Off Miles:
Ending Miles:
FOR GCMK USE ONLY:
Amount to be paid:
Stabilization Unit Director Signature:
12/15/2003 17:02 FAX 3052896158
GCMK
~ 005/005
ATTACHMENT 3
Statement
Date:
Jessrica Corp.
800 Catherine St.
Key West, Florida 33040
Stabilization Unit Director
Guidance Clinic of the Middle Keys
3000 41 st St. Ocean
Marathon, FL 33050
Re: Baker Act and Marchman Act transportation
The following is a break down- for trips from
to
Date Name Pick Up Cost Vehicle
Designation 1 2 3
TOTAL
GCMK CFO Signature
Jessrica Corp Representative Signature