02/18/2004 Agreement
Gled( 0I11Ie
Gimul Goun
Danny L. Kolhage
Phone: 305-292-3550 Fax: 305-295-3663
Memnrandum
To:
James Roberts,
County Administrator
Attn:
Maria Z. Fernandez, Administrator
Group Insurance
Isabel C. DeSantis,. .OJ
Deputy Clerk jY"
From:
Date:
Monday, April 19, 2004
The fOllowing items were approved by the Board at their February 18, 2004
meeting:
Amendment to Administrative Services Agreement between Monroe County and
Acordia National for monthly claim administrative fees for dental and vision coverage.
This amendment is required effective January 1, 2004 as our dental and vision coverage
is no longer provided by Acordia National therefore eliminating the need for
administrative fees, except for the handling of runout claims.
./
Employer-Provider Network and Utilization Review and Case Management
Services Agreement between Monroe County and Keys Physician-Hospital Alliance
effective March 1, 2004 through February 28,2005.
Enclosed please find duplicate originals of the sUbject documents for your
handling.
Copies: Finance
County Attorney
t/ File
EMPLOYER-PROVIDER NETWORK
AND
UTILIZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
TillS AGREEMENT is entered into as of this first day of MARCH 2004 by and between
Keys Physician-Hospital Alliance ("KPHA") and the County of Monroe ("County"), hereon
referred to as "Employer".
RECITALS
WHEREAS, the KPHA has established a network of participating health care providers,
which providers, pursuant to the terms and conditions of provider agreements with KPHA, have
agreed to deliver medical services in a cost effective manner to persons covered under the health
benefit plans and policies of Employer.
WHEREAS, KPHA has agreed to provide utilization review and case management services
to Employer and personnel, dependents, Cobra beneficiaries and eligible retirees covered under
the health benefit plans and policies of Employer.'
WHEREAS, Employer administers the health care benefit plans and has the express
authority, by signing this Agreement, to bind the Employer to all of the terms and conditions of
this Agreement.
WHEREAS, Employer desires and agrees to offer KPHA Provider Network to persons
covered under the Employers health benefits plans;
Now, THEREFORE, the parties agree as follows:
1. RECITALS. The foregoing recitals are hereby incorporated by reference and made a
substantive part hereof.
2. LIST OF PARTICIPATING PROVIDERS. KPHA shall provide Employer with a list of
Participating Providers, to include hospitals, physicians, dentists, pharmacies, and other
ancillary health services, and shall provide Employer with periodic updates of the Network
roster of Participating Providers from time to time. Such updates will be at least semi-
annually and in such a printed format as distributable to persons covered under the
Employers health benefits plans.
OUT-OF COUNTY PROVIDERS. KPHA agrees to negotiate and contract with
"Dimension Network" in Dade, Broward and Palm Beach Counties for discounted fee
arrangements with physicians, hospitals, and other ancillary health services as needed for the
benefit of the Employer. If the "Dimension Network" is not utilized, or becomes
unacceptable to the Employer, KPHA will propose other alternative arrangements for such
out of county services.
KPHA agrees to negotiate and contract with or work collaboratively with a national network
for discounted fee arrangements with physicians, hospitals, and other ancillary health
services as needed for the benefit of the Employer. If the current network is not utilized, or
becomes unacceptable to the Employer, KPHA will propose other alternative arrangements
for such out of county services.
3. UTILIZATION MANAGEMENT AND QUALITY ASSURANCE. KPHA shall provide
for Employer Utilization Review services to include
· Review of inpatient admissions and of continued hospital stay
· Discharge planning
· Data collection and reporting
· Review of supportive or treatment services
· Review of office visits, ambulatory surgery and diagnostic or other outpatient services
· Participation in the review of billing practices and appropriateness of charges of network
providers in conjunction with the Claims Administrator if requested
· Large Case Management services
The monthly capitation fee for such services will be $1.35 per employee per month. This fee
will be payable by the County to KPHA by the 20th of each month beginning on the 20th day
of March, 2004. The number of enrollees will be determined on the 1st business day of each
month.
KPHA shall provide for Large Case Management services for a fee of $55.00 per hour on an
as-needed basis. Large Case Management services may be pre-approved by the County on a
case by case basis and billings for such fees incurred shall be provided monthly with details
of all charges.
Utilization Review and Large Case Management services will be performed according to pre-
set protocols developed in conjunction with the claims administrator's (Acordia National)
standards and will be documented in the claims administrators' computer system.
4. WELLNESS PROGRAMS AND OTHER EDUCATIONAL SERVICES. KPHA shall
design and implement with the coordination of Employer's staff, the W orksite Wellness
Program and other similar services to the Employer and Covered Persons to promote healthy
lifestyles and preventative health care. The Worksite Wellness Program will include, at no
additional charge to Employer or Covered Persons, a health risk assessment for each
employee and may include, for a charge by a Participating Provider, Health Physical
Packages. Health Pair coordination and implementation or other services as negotiated and
deemed to promote healthy lifestyles and preventative health care may also be included in
this service.
2
5. PARTICIPATING PROVIDER COMPENSATION. Employer shall compensate
Participating Providers for covered services minus any plan participant responsibilities.
Employer has the responsibility for implementation of the applicable claims payment
submitted by Participating Providers for services rendered or for any billing or other function
related to the health care services provided by Participating Providers to Covered Persons.
All claims for covered services, whether payable by the Employer or a Covered Person will
receive a discount off of provider billed charges as specified in Attachment A. This discount
will be rescinded if an appropriately documented and non-contested claim is not paid to the
Participating Provider within thirty (30) days of being received by the claims administrator
(Acordia National).
NON-APPROPRIATIONS CLAUSE. Monroe County's performance and obligation to
pay under this contract is contingent upon an annual appropriation by the BOCC. Monroe
County may not deny payment for valid and accurate claims properly submitted and rendered
during the plan year.
PROVIDER REIMBURSEMENT TERMS. Physician VCR charges will be based upon
the "P.H.C.S" fee schedule, formerly known as "HIAA". The above agreed upon discount
will be applied to the billed charge, not to exceed the VCR charge for a service.
KPHA further agrees that no other self-insured employer contracting with KPHA will be
provided with better overall terms than what is being here agreed. If however, better terms
are provided to another self-insured employer contracting with KPHA, such terms will also
be extended to the Employer.
CLEAN CLAIM. A "Clean Claim" means a claim submitted by the Provider/Hospital that
has been properly and accurately completed on the appropriate paper or electronic claim
form, HCFA 1500 and/or VB 92 together with any information that was requested in writing
by Acordia National within 15 days of Acordia National's receipt ofa claim.
NOTIFICATION OF CLAIM STATUS. Payor/Plan shall notify Provider/Hospital within
15 days of receipt of a claim that said claim is not considered "Clean" and reasons therefore.
Failure to do so shall deem the claim being considered "Clean" and set for timely payment.
DISPUTED CLAIMS. If the Payor/Plan does not object in writing to a claim within 15
days of receipt by the Payor/Plan, the claim will be considered clean and complete. If the
Payor/Plan disputes any portion of the billing for services rendered, Payor/Plan will promptly
seek to resolve the dispute and return the claim to the regular processing status. Should the
claim remain in dispute for more than 30 days, Payor/Plan will pay the Provider/Hospital
90% of the fees as outlined in the "Provider Agreement Amendment! Reimbursement
Addendum" within 7 days with payment for the remaining 10% subject to the outcome of
the dispute. Those items requiring further resolution prior to the remaining payment shall be
reconciled by the Payor/Plan and the ProviderlHospital and the appropriate payments or
adjustments made within 60 days.
3
6. COVERED PERSON IDENTIFICATION. Employer shall supply Covered Persons with
identification cards or other means of identification which clearly identifies KPHA, reflects
the Covered Person's coverage under the applicable Employers health benefit plan, and
reflects the Covered Person's eligibility to receive services from Participating Providers in
accordance with the terms of this Agreement. Employer shall also provide such other
services as may be required in order for Participating Providers promptly to verify the status
of individuals as Covered Persons, the terms of the Covered Person's health care benefits,
including but not limited to the applicable terms of coverage, deductible status and co-
insurance.
7. NETWORK EXCLUSIVITY. During the course of the agreement Employer agrees not to
participate or enter agreements to utilize other provider networks other than that agreed upon
with KPHA and the Employer. Employer during the term of this Agreement shall not seek to
negotiate with individual network members for care or services outside of contractual
provisions without prior notification to KPHA.
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator (Acordia
National) and County of Monroe (employer) all records and other data relating to both the
network and utilization review and case management services for the purposes of periodic
audits of KPHA's services. Information/data will be maintained, as required, to assure
confidentiality and compliance with all applicable regulations.
9. RESPONSIBILITY FOR HEALTH CARE SERVICES. Employer agrees that KPHA
shall not have any responsibility or liability for any act, omission, or decision related to
medical services rendered by Participating Providers to a Covered Person.
10. TERM. This Agreement shall continue in effect for one (1) year from the date first above
written. Thereafter, the Agreement shall renew for two (2) consecutive one (1) year terms.
KPHA agrees to provide the Employer with at least ninety (90) days written notice of the
intent to terminate, non-renew, or amend this Agreement. The Employer agrees to provide
KPHA with at least ninety (90) days written notice of the intent to terminate or non-renew
this agreement. Any modification of the terms of this agreement may occur upon the mutual
agreement of the parties.
BREACH AND CURE. Notwithstanding the foregoing, this Agreement may be terminated
by either party upon a material breach of this Agreement by the other party, providing that
the breaching party does not cure the breach within thirty (30) days following receipt of a
written notice from the non-breaching party specifying the nature of the breach and
requesting that it be cured.
11. GENERAL PROVISIONS.
A. THIRD PARTIES: The terms and provisions of this Agreement are for the benefit of
the parties hereto and are not intended to provide any other person with any right or cause
of action on account thereof
4
B. NOTICES: Any notice required to be given pursuant to the terms and provisions thereof
shall be in writing and shall be hand-delivered, with return receipt thereof, or sent by
certified or registered mail, return receipt requested and first-class postage prepaid to the
addresses as follows:
Employer: County of Monroe
Manager- Employee Benefits
Gato Building
1100 Simonton Street, Room 2-268
Key West, Florida 33040
KPHA: Keys Physician-Hospital Alliance
c/o Lower Florida Keys Physician Hospital Organization, Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Nicki Will, Secretary
C. ASSIGNMENT: This Agreement may not be assigned, subcontracted, delegated,
transferred by either party without the express written consent of the other party, and any
attempted assignment, subcontract, delegation or transfer shall be void.
D. INDEPENDENT CONTRACTORS: None of the provisions of this Agreement are
intended to create, nor shall be deemed to, or construed to create any relationship
between KPHA and Employer other than that of independent entities contracting with
each other hereunder solely for the purposes of effecting the provisions of this
Agreement. Neither of the parties hereto, nor any of their respective officers, directors, or
employees shall be construed to be the agent, employee, or representative of the other.
E. GOVERNING LAW: This Agreement shall be governed in all respects by the laws of
the State of Florida without regard to Florida's choice of law statutes or decisions. Any
action by any party, whether at law or in equity, relating to this Agreement shall be
commenced and maintained, and venue shall be proper, only in Monroe County, Florida.
F. ORDINANCE 10-1990: KPHA warrants that it has not employed, retained or otherwise
had acted on his behalf any former County officer subject to the prohibition in Sec. 2 of
Ordinance no. 10-1990 or any County officer or employee in violation of sec. 3 of
Ordinance 10-1990, and that no employee or officer of the County had any interest,
financially or otherwise, in KPHA except for such interest, permissible by law and fully
disclosed by affidavit attached hereto. For breach or violation of this paragraph, the
County may, in its discretion, terminate this agreement 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 or employee.
5
G. CONFLICT OF INTEREST: KPHA assures the County that to the best of its
knowledge information and belief, the signing of this agreement does not create conflict
of interest.
H. OWNERSHIP OF INFORMATION: All Utilization Review and Case Management
documents which are prepared in the performance of this agreement are to be, and shall
remain, the property of the County and shall be transferred to the County or to a
replacement Utilization Review/Case Management service provider upon request and no
later than thirty (30) days after termination of this agreement. Any patient identifying
information shall not be disclosed without written consent of the patient.
1. INSURANCE REQUIREMENTS: KPHA is required to maintain the types of
insurance identified in Attachment B.
J. SEVERABILITY: If any provision of this Agreement is held to be illegal, invalid, or
unenforceable, under present or future laws effective during the term hereof, such
provision shall be fully severable. In such event, this Agreement shall be construed and
enforced as if the illegal invalid or unenforceable provision had never been a part hereof,
and the remaining provisions shall remain in full force and effect unaffected by such
severance- provided that if the illegal, invalid or unenforceable provision is material to
the overall purpose and operation of this Agreement, then this Agreement shall terminate
upon the severance of such provision.
K. COUNTERPARTS: This Agreement and any amendment hereto may be executed in
multiple originals, all counterparts together constituting one and the same instrument.
L. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all the
terms and conditions agreed upon by the parties hereto regarding the subject matter of
this Agreement and supersedes any prior Agreements, promises, negotiations, or
representations either oral or written, relating to the subject matter of this Agreement.
M. HOLD HARMLESS: KPHA shall indemnify and hold the County harmless from and
against any and all losses, penalties, damages, professional fees, including attorney fees
and all costs of litigation and/or judgment arising, out of any willful misconduct or
negligent act, error or omission of KPHA incidental to the performance of this agreement
or work performed thereunder. This indemnity shall extend to amounts the County
becomes legally obligated to pay and shall be limited by any sovereign immunity limit
applicable to the underlying claim plus costs of litigation.
In witness wherof, the Employer and KPHA have caused this Agreement to be executed by
their respective corporate officers, effective as ofthe first day of March 2004.
6
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Employer:
By:
Its:
Board of County Commissioners
of Monroe County, Florida
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Attachment A
Reimbursement Schedule
*KPHA Members
75% of billed charges with the cap of the 90th percentile of the P.H.C.S.
(formerly known as HIAA) Fee Schedule.
*In County Providers (IPN)
75% - 85% of billed charges with the cap of the 90th percentile of the
P.H.C.S. (formerly known as HIAA) Fee Schedule.
Out-of-County Providers (IPN) 70% of billed charges with the cap of the 90th percentile of the P.H.C.S.
(formerly known as HIAA) Fee Schedule.
Dimension Providers
Dimension NetworkFee Schedule.
MultiPlan Providers
MultiPlan Network Fee Schedule.
Fisherman's Hospital
75% of billed charges.
Lower Keys Medical Center
75% of billed charges.
*HCPS codes shall be reimbursed at 75% of billed charges.
A list of specific providers and discount percentages will be provided to Acordia National by KPHA for
implementation.
y- 1'4-:'."(
Date
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Robin Lockwood, M.D. ...
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2> - .lU -4-
Date
8
1996 Edition
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
General Insurance Requirements
for
Other Contractors and Subcontractors
As a pre-requisite of the work governed, or the goods supplied under this contract (including the
pre-staging of personnel and material), the Contractor shall obtain, at hislher own expense,
insurance as specified in any attached schedules, which are made part of this contract. The
Contractor will ensure that the insurance obtained will extend protection to all Subcontractors
engaged by the Contractor. As an alternative, the Contractor may require all Subcontractors to
obtain insurance consistent with the attached schedules.
The Contractor will not be permitted to commence work governed by this contract (including
pre-staging of personnel and material) until satisfactory evidence of the required insurance has
been furnished to the County as specified below. Delays in the commencement of work,
resulting from the failure of the Contractor to provide satisfactory evidence of the required
insurance, shall not extend deadlines specified in this contract and any penalties and failure to
perform assessments shall be imposed as if the work commenced on the specified date and time,
except for the Contractor's failure to provide satisfactory evidence.
The Contractor shall maintain the required insurance throughout the entire term of this contract
and any extensions specified in the attached schedules. Failure to comply with this provision
may result in the immediate suspension of all work until the required insurance has been
reinstated or replaced. Delays in the completion of work resulting from the failure of the
Contractor to maintain the required insurance shall not extend deadlines specified in this contract
and any penalties and failure to perform assessments shall be imposed as if the work had not
been suspended, except for the Contractor's failure to maintain the required insurance.
The Contractor shall provide, to the County, as satisfactory evidence of the required insurance,
either:
· Certificate of Insurance
or
· A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non-renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving
the Contractor from any liability or obligation assumed under this contract or imposed by law.
Administration Instruction
#4709.3
14
ATTAClDlENT B
1996 Edition
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on all policies, except for Workers' Compensation.
Any deviations from these General Insurance Requirements must be requested in writing on the
County prepared form entitled "Request for Waiver of Insurance Requirements" and
approved by Monroe County Risk Management.
Administration Instruction
#4709.3
ATTACHMENT lr
. .
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
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 of the 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.
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.
wel
Administration Instruction
#4709.3
88
A'lTACHMENT B
1996 Edition
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician HOsDital Alliance
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$500,000 per Occurrence/$l,OOO,OOO Aggregate
PR02
Administration Instruction
#4709.3
78
ATTACHKENT B
1996 Edition
VEIDCLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
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 Vehicles
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
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
VL2
Administration Instruction
#4709.3
ATTACIIKENT B
82
1996 Edition
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
The Contractor shall purchase and maintain, throughout the term of the contract, Employee
Dishonesty Insurance which will pay for losses to County property or money caused by the
fraudulent or dishonest acts of the Contractor's employees or its agents, whether acting alone or
in collusion of others.
The minimum limits shall be:
$10,000 per Occurrence
ED!
Administration Instruction
#4709.3
45
ATrACHKENT B
1996 Edition
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall 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
· Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 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 of twelve
(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.
GL2
Administration Instruction
#4709.3
A'l'TACHMENT B
55
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. "
A'l'TACHKENT B
ETHICS CLAUSE
Contractor 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 or employee.
NON-COLLUSION AFFIDAVIT
~oO\r. loG"({ 9J(X)d (J' . (J of the city
t
~bf w e~~ according to law on my oath, and under
penalty of perjury, depose and say that;
I,
of
1) I am '\Zt~\o \' () lot J(<..A.k )Od I fY',0. ,the bidder making the
Proposal for the project described as follows:
2) The prices in this bid have been arrived at independently without collusion, consultation,
communication or agreement for the purpose of restricting competition, as to any matter relating to such
prices with any other bidder or with any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this bid have not
been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid
opening, directly or indirectly, to any other bidder or to any competitor; and
4) No attempt has been made or will be made by the bidder to induce any other person,
partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition;
5) The statements contained in this affidavit are true and correct, and made with full
knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in
awarding contracts for said project.
STATE OF ~ty lOa..
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DATE
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COUNTY OF -(Y\Q(\{l )e
(Signature of Bidder)
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PERSONALLY APPEARED BEFORE ME, the undersigned authority,
~()b\h l UL.,~~ol "'. ~ho, after first being sworn by me, (name of individual
I
signing) affixed his/her signature in the space provided above on this
~ day of ~^ .t.h
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NOTARY PUBLIC
, 2001'~
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My commission expires:
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\ Notary Public . ItDl err Florida
.;: 1oty~~_.\1DOll
Cornmm''''oll ., D0113312
80l1ded fly N.!Ionill Notary AIIn.
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
JtllC>v"- C:..~
1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that
will be taken against employees for violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of
maintaining a drug-free workplace, any available diug counseling, rehabilitation, and employee assistance
programs, and the penalties that may be imposed upon employees for drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that are under bid a
copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notify the employees that, as a condition of working on the
commodities or contractual services that are under bid, the employee will abide by the terms of the
statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any
state, for a violation occurring in the workplace no later than five (5) days after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or any employee who is so convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this
section.
As the person authorized to sign the statement, I certify that this firm complies fully with the above
requirements.
~~
Bidder's Signature
3- - .J.e-~
Date
~~
OMB - MCP#5