Item H2
BOARD OF GOVERNORS
FIRE AND AMBUALNCE DISTRICT 1
AGENDA ITEM SUMMARY
Meeting Date: April 20. 2005
Division:
County Administrator
Bulk Item: Yes
No X
Department: Fire Rescue
Staff Contact Person: Camille Dubroff
AGENDA ITEM WORDING: Request to waive the purchasing policy requiring two or more written
quotes for goods and services not to exceed $25,000 in costs and enter into a Contract with Advanced Data
Processing, Inc. (AD PI) and Board of Governors, Fire and Ambulance District 1 of Monroe County Florida for
rescue ambulance billing and related professional services for three (3) years, June 1, 2005 through May 31,
2008, with the option to renew for two (2) additional one year periods.
ITEM BACKGROUND: This item will rescind item C 17 that was approved at the March 16, 2005
Board of County Commissioners meeting. Item C 1 7 was erroneously placed on the BOCC agenda and
did not get heard by the Board of Governors. The existing contract with ADPI expires on June 1,2005.
Changing contractors at this time would be extremely difficult for the following reasons. In October of2003,
Monroe County Fire Rescue (MCFR) purchased and began implementation of EMS Pro (now RescueNet), a
comprehensive EMS data management system. This automated system efficiently integrates patient billing,
medical quality assurance, state reporting, and record keeping. ADPI has successfully been using the same
program for a few years, and has been working closely with MCFR to do the same. The process of going from
an old antiquated system to this new automated system can take up to 2 years for complete implementation.
Currently, MCFR has successfully completed phase I ofthe implementation process, which is purchasing and
installing basic hardware and software, and training all field personnel to input data into the new system. We
are now moving to phase II, which is purchasing and installing additional software allowing for electronic
reporting and transmittal of data without the use of paper reports. Once complete, this final step will allow
ADPI to work directly with our contracted collection agency, Focus Financial, to electronically send delinquer
accounts and obtain payments on those accounts in a more efficient and timely manner. Changing contractors
during this implementation process would create many challenges and would not be cost effective.
PREVIOUS RELEVANT BOG ACTION: Previous Contracts and Addendums approved in the past.
CONTRACT/AGREEMENT CHANGES: Enter into a Contract for Three (3) years effective June 1,
2005 through May 31, 2008 with option to renew for two (2) additional one year periods.
STAFF RECOMMENDATIONS: Approval.
TOTAL COST: 7% of total collections and $11.40
per Medicaid account ($23.928.87-FY 2004)
BUDGETED: Yes X
No
COST TO COUNTY: same as above
SOURCE OF FUNDS: Collections from billing
REVENUE PRODUCING: Yes
No X AMOUNT PER MONTH_ Year
APPROVED BY:
County Atty YES
Clark O. Martin, Jr.
Not Required_
AGENDA ITEM #
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION:
DISPOSITION:
Revised 2/05
Included
MONROE COUNTY BOARD OF GOVERNORS
CONTRACT SUMMARY
Contraci with, Advanced Data Processing Inc, Contract #
(ADPI) Effective Date: June 1,2005
Expiration Date: May 31, 2008
COnLract PurposeIDescri ption:
Approval to enter into a contract with Advanced Data Proce:;sing, Inc, for
Rescue Ambulance Billing and Related Professional services. This contract will be for three (3) years with
the option to renew for two (2) additional one year periods,
Contract Manager~ Clark n Martin Jr. 6010 Fire Rescue! SlOp #14
(Name) (Ext.) (Department/SlOp #)
for HaeC mcetinJ!; on AprH 20, 2005 Agenda Deadline;, Ape 11_ 5. 2005
CONTRACT COSTS
Tot.al Dollar Value of Contract: 7% of
Monthly collections ana $11.40 pcr
M~icaid account.
Current Year Portion: 79'( of
Monthlv collections and
$11.40 per Medicaid
account.
($23,928,87 FY 2004)
Budgeted') YeslSJ No 0
Grant: S
County Match: $
Account Codes;
13001-530340
- - - -
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Estimated Ongoing Costs: $_!yr
(Not included in dollar value above)
ADDITIONAL COSTS
For:
(ee:. maintenance, utilities. janitorial, salaries, etc,)
CONTRACT REVIEW
Division Director
-(I
Date In
blO,!)7
Ch[mges
Needed
YesD NoD
YesO Nd
11/ ~5' Dale Out
J. -It;: () r
J q.-zD
~-/I-os
Risk Management
MQS
O-M,B,/Purchasing 0#5' YesD N~ /
;2,);9)5 YesD Now/
Note: This item was erroneously
put UIl the MCirch agenda
CCllUlty Anomey
Comments:
."lTln pl."li"'i"rl h"fnrp I h~ 1',r)C'('
O\H3 Form Revised 2/27/01 Mer #1
CONTRACT BETWEEN
THE COUNTY OF MONROE
AND
ADVANCED DATA PROCESSING, INC.
FOR RESCUE AMBULANCE BILLING AND RELATED PROFESSIONAL
SERVICES
TIllS CONTRACT, hereinafter "CONTRACT OR AGREEMENT" made and entered into this
day of . 2005 by and between MONROE COUNTY, a political
subdivision of the State of Florida, with principal offices located at 490 63rd Street, Marathon,
FL 33050, hereinafter referred to as the "COUNTY", and ADVANCED DATA
PROCESSING, INC., a Delaware corporation with principal offices located at 520 NW 165
Street, Suite 201, Miami, Florida 33619, hereinafter referred to as "CONTRACTOR":
WITNESSETH:
WHEREAS, MONROE COUNTY intends to enter into an agreement for the provision of
rescue ambulance billing and related professional services by the CONTRACTOR to
MONROE COUNTY; and,
WHEREAS, the CONTRACTOR represents that it is capable and prepared to provide such
Services:
NOW THEREFORE, in consideration of the promises contained herein, the parties hereto
agree as follows:
ARTICLE 1 - EFFECTIVE DATE
The effective date of this Agreement shall be after the approval of MONROE COUNTY Board
of County Commissioners and effective for a three (3) year term from June 1. 2005 through
May 3 L 2008, with the option to renew for two (2) additional one year periods, subject to
cancellation as provided herein. MONROE COUNTY'S performance and obligation to pay
under this contract, is contingent upon an annual appropriation by the Board of County
Commissioners.
ARTICLE :1 - SERVICE TO BE PERFORMED BY CONTRACTOR
The CONTRACTOR shall perform the services as specifically stated in the Scope of Services
(Attachment A) without requirement for the issuance of any additional work orders. Additional
services may be issued in the form ofa Work Order. Each Work order will set forth a specific
Scope of Services, amount of compensation, deliverables and completion date and shall be
subject to the approval of MONROE COUNTY. CONTRACTOR shall perform no additional
services until any applicable Work Order is obtained from MONROE COUNTY and
countersigned by the CONTRACTOR.
ARTICLE 3 - COMPENSATION
MONROE COUNTY shall pay CONTRACTOR in accordance with Attachment B,
Compensation for Services, which is attached hereto and incorporated by reference as part of
this Agreement.
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ARTICLE 4 .. STANDARD OF CARE
CONTRACTOR shall exercise the same degree of care, skill, and diligence in the performance
of Services as is ordinarily provided by a professional CONTRACTOR, offering services for
local governments in South Florida, under similar circumstances and CONTRACTOR shall, at
no additional cost to MONROE COUNTY, re-perform services which fail to satisfY the
foregoing standard of care.
ARTICLE 5.. INDEMNIFICATION
CONTRACTOR shall indemnify and hold harmless MONROE COUNTY, its officers, and
employees from liabilities, damages, losses and costs, including, but not limited to reasonable
attorney's fees, to the extent caused by the negligence, recklessness or intentional wrongful
misconduct of CONTRACTOR and persons employed or utilized by CONTRACTOR in the
performance of this agreement. Except as specifically provided herein, this agreement shall not
require the CONTRACTOR to indemnify MONROE COUNTY, its officers, and employees
from any liability, damage, loss, claim, action, Of proceeding.
Any costs and expenses, including attorney's fees, appellate, bankruptcy or defense counsel
fees incurred by MONROE COUNTY to enforce this Indemnification Clause shall be borne by
the CONTRACTOR. This Indemnification Clause shall continue indefinitely and survive the
cancellation, termination, expiration, lapse or suspension of this agreement.
ARTICLE 6 .. INDEPENDENT CONTRACTOR
The CONTRACTOR is an independent contractor and not an employee or agent of MONROE
COUNTY except that CONTRACTOR shall be authorized as an agent as follows: To the
extent necessary to fulfill its billing and collection efforts under this Agreement, the
CONTRACTOR is authorized to execute the following types of standard forms and
correspondences only: probate filings; letters to patients or their representatives verifying that
an account is paid in full; forms verifying the tax-exempt status of MONROE COUNTY; and
insurance filings and related forms. The CONTRACTOR has no authority to sign any other
document's except as specifically authorized by MONROE COUNTY.
CONTRACTOR undertakes performance of the Services as an independent contractor and
shall be wholly responsible for the methods of performance. CONTRACTOR shall work
closely with MONROE COUNTY in performing Services under this Agreement.
The CONTRACTOR shall retain full control over the employment, direction, compensation
and discharge of all persons assisting in the performance of service by CONTRACTOR. The
CONTRACTOR shall be fully responsible for all matters relating to payment of employees,
including compliance with Social Security, withholding tax and all other laws and regulations
governing such matters. The CONTRACTOR shall be responsible for its own acts and those
of its agents and employees during the term of this contract. The CONTRACTOR shall not
receive any MONROE COUNTY benefits, stipend or privileges afforded by MONROE
COUNTY employees.
ARTICLE 7 .. COMPLIANCE WITH LAWS
In performance of the Services, CONTRACTOR will comply with applicable regulatory and
other applicable requirements including federal, state, and loca1laws, rules regulations, orders,
codes, criteria and standards.
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ARTICLE S.. INSURANCE
During the performance of the Services under this Agreement, CONTRACTOR shall procure
and maintain the following insurance polices, and provide originals or certified copies of all
policies, and such coverage shall be written by an insurance company authorized to do business
in Florida.
WORKERS COMPENSATION
The CONTRACTOR shall procure and maintain, for the life of this Contract! Agreement,
Worker's Compensation Insurance covering all its employees with limits meeting all
applicable state and federal laws. This coverage shall include Employer's Liability with limits
meeting all applicable state and federal laws. This coverage shall extend to any agent of
CONTRACTOR that does not have their own Workers' Compensation and Employer's
Liability Insurance. Thirty (30) days notice of cancellation, lapse or material modification is
required and must be provided to MONROE COUNTY via Certified Mail.
COMMERCIAL GENERAL LIABILITY
The CONTRACTOR shall procure and maintain, for the life of this Contract! Agreement,
Commercial General Liability Insurance. This coverage shall be on an "Occurrence" basis.
Coverage shall include Premises and Operations: Independent Contractors' Products and
Completed Operations and Contractual Liability. This policy shall provide coverage for death,
personal injury or property damage that could arise directly or indirectly from the performance
of this Agreement.
The Minimum Limits of Coverage shall be $1,000,000 per occurrence, Combined Single Limit
for Bodily Injury Liability and Property Damage Liability with a $10,000 deductible.
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS must be named as an
additional insured. The additional insured requirement is waived if Owners and Contractors'
Protective Coverage is also provided, or required. Thirty (30) days written notice must be
provided to MONROE COUNTY via Certified Mail in the event of cancellation.
BUSINESS AUTOMOBILE LIABILITY
The CONTRACTOR shall procure and maintain, for the life of the Contractl Agreement,
Business Automobile Liability Insurance.
The minimum limits of coverage shall be $1,000,000 per occurrence, Combined Single Limit
for Bodily injury Liability and Property Damage Liability. This coverage shall be an "Any
Auto" or "Comprehensive Form" type policy.
In the event that the CONTRACTOR does not own any vehicles, we will accept hired and non"
owned coverage in the amounts listed above. In addition, we will require an affidavit signed by
the CONTRACTOR indicating the following:
Advanced Data Processing. Inc. does not own any vehicles.
In the event we acquire any vehicles throughout the term of this Contract! Agreement,
Advanced Data Processing.. Inc. agrees to purchase" Any Auto" or Comprehensive Form
coverage as of the date of acquisition.
CONTRACTORS Signature:
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Thirty (30) days written notice must be provided to MONROE COUNTY via Certified Mail in
the event of cancellation, lapse or material modification of any coverage required by this
agreement.
PROFESSIONAL LIABJLITYIERRORS AND OMMISSIONS INSURANCE
CONTRACTOR shall provide Professional Liability Insurance, including errors and omissions
for all services provided under the terms of this agreement with minimum limits of $1, 000,000
dollars per occurrence; or claims made form with "tail coverage" extending three (3) years
beyond the term of the agreement. Proof of "nil coverage" must be submitted with the invoice
for final payment. In lieu of "tail coverage", Contractor may submit annually to MONROE
COUNTY current Certificate of Insurance proving claims made insurance remains in force
throughout the same three (3) year periods.
CRIME POLICY
CONTRACTOR shall provide a Crime Policy in the amount of $500,000. Coverage to be
provided shall include the following; Theft - Per Loss Coverage; Forgery or Alteration;
Inside the Premises - Theft of Money and Securities; Inside the Premises - Robbery or Safe
Burglary of Other Property; Outside the Premises; Computer Fraud; Funds Transfer Fraud; and
Money Orders and Counterfeit Paper Currency.
SUPPLEMENTAL PROVISIONS
1. The insurance coverage and conditions afforded by this policy( s) shall not be suspended,
voided, canceled or modified, except after thirty (30) days prior written notice by Certified
Mail Return Receipt Requested, has been given to the MONROE COUNTY department
that originated this contract.
2. Certificates of Insurance meeting the specific required provision specified within this
Contract! Agreement shall be forwarded to the MONROE COUNTY department that
originated the contract, and approved prior to the start of any work or the possession of
any MONROE COUNTY property or the commencement of services, as application.
SQBCONTRACTOR'S INSURANCE
The CONTRACTOR shall require each of his SUBCONTRACTORS to take out and maintain
during the life of his subcontract the same insurance coverage's required of the successful
CONTRACTOR Each SUBCONTRACFOR shall furnish to the successful CONTRACTOR
two copies of the Certificate of Insurance, and successful CONTRACTOR shall furnish one
copy of the Certificate to MONROE COUNTY.
NON-W AlVER OF IMMUNl1Y
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the County
and the Contractor 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 County be required to contain any provision for waiver.
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ARTICLE 9 . MONROE COUNTY'S RESPONSmlLITIES
MONROE COUNTY, during the term of this Agreement, shall:
MONROE COUNTY shall supply the <<Run Report" attached hereto identified as Exhibit A to
CONTRACTOR with the necessary patient information on a timely basis for those patients that
have been transported by Fire-Rescue Services and in sufficient detail to support diagnosis and
procedure coding and make reasonable efforts to provide patient demographic information
necessary for accurate patient identification including name, address, social security number,
date of birth, and telephone number.
MONROE COUNTY shall provide CONTRACTOR with its approved billing policies and
procedures including fee schedules and collection protocols. MONROE COUNTY shall be
responsible for engaging any third party collection service for uncollectible accounts after
CONTRACTOR has exhausted its collection efforts.
MONROE COUNTY shall make reasonable efforts to timely process refunds identified by
CONTRACTOR for account overpayments.
MONROE COUNTY shall provide a Lock Box address to CONTRACTOR and will instruct
Lock Box to forward all Lock Box documents to CONTRACTOR for processing.
MONROE COUNTY shall provide for CONTRACTOR to have daily bank balance reporting
capabilities via internet access with bank.
MONROE COUNTY shall comply and cooperate with CONTRACTOR in all matters to
ensure proper compliance with all Federal, State and local laws rules and regulations as
applicable to the services being contracted for.
ARTICLE 10. TERMINATION OF AGREEMENT
During the time of this Agreement either party may terminate this Agreement for convenience
by first giving to other party at least thirty (30) days prior written notice. In the event the acts
constituting default are a violation of law, CONTRACTOR shall be subject to immediate
tennination. Notwithstanding the provisions above, the COUNTY shall not have any right to
cancel this contract without cause.
Upon tennination, the CONTRACTOR shall submit an invoice(s) to MONROE COUNTY in
an amount( s) representing fees for services actually performed or obligations incurred to the
date of effective tennination for which the CONTRACTOR has not been previously
compensated. Upon payment of all sums found due, the COUNTY shall be under no further
obligation to the CONTRACTOR, financial or otherwise.
ARTICLE n - NONDISCLOSURE OF PROPRIETARY INFORMATION
CONTRACTOR shall consider all information provided by MONROE COUNTY and all
reports, studies calculations, and other documentation resulting from the Contractor's
performance of the Services to be proprietary unless such information is available from public
sources or is a public record under Florida law. CONTRACTOR shall not publish or disclose
proprietary information for any purpose other than the performance of the Services without the
prior written authorization of MONROE COUNTY or in response to legal process or orders of
a court of competent jurisdiction.
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Public Access. The County and Contractor shan allow and permit reasonable access to, and
inspection of, all documents, papers, letters or other materials in its possession or under its
control, which are public records and which are subject to the provisions of Chapter 119,
Florida Statutes, and made or received by the County and Contractor in conjunction with this
Agreement; and the County shan have the right to unilaterally cancel this Agreement upon
violation of this provision by Contractor.
ARTICLE 12 - UNCONTROLLABLE FORCES
Neither MONROE COUNTY nor CONTRACTOR shall be considered to be in default of this
Agreement if delays in or failure of perfonnaflCe shall be due to Uncontrollable Forces, the
effect of which, by the exercise of reasonable diligence, the non-performing party could not
avoid. The term "Uncontrollable Forces" shall mean any event which results in the prevention
or delay of performance by a party of its obligations under this Agreement and which is
beyond the reasonable control of the non-performing party. It includes, but is not limited to
fire, flood, earthquakes, stonns, lightning, epidemic, war, riot, civil disturbance, sabotage, Acts
of God and governmental actions.
Neither party shall, however, be excused from performance if non-performance is due to forces
which are preventable, removable, or remediable and which the non-perfonning party could
have, with the exercise of reasonable diligence, prevented, removed, or remedied with
reasonable dispatch. The non-performing party shall, within a reasonable time of being
prevented or delayed from performance by an uncontrollable force, give written notice to the
other party describing the circumstances and uncontrollable forces preventing continued
performance of the obligations of this Agreement.
ARTICLE 13.. GOVERNING LAW AND VENUE
This Agreement shall be governed by the laws of the State of Florida. Any and all legal action
necessary to enforce the Agreement will be held in Monroe County and the Agreement will be
interpreted according to the laws of Florida.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the County and Contractor agree that venue
will lie in the appropriate court or before the appropriate administrative body in Monroe
County, Florida.
The County and Contractor agree that, in the event of conflicting interpretations of the terms or
a term of this Agreement by or between any of them the issue shall be submitted to mediation
prior to the institution of any other administrative or legal proceeding.
ARTICLE 14.. MISCELLANEOUS
14.1 Non Waiver
A waiver by either MONROE COUNTY or CONTRACTOR of any breach of this Agreement
shall not be binding upon the waiving party unless such waiver is in writing and duly signed by
both patties to this agreement. In the event of a written waiver, such a waiver shall not affect
the waiving party's rights with respect to any other or further breach. The making or
acceptance of a payment by either party with knowledge of the existence of a default or breach
shall not operate or be construed to operate as a waiver of any subsequent default or breach.
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14.2Severability
The invalidity, illegality, or unenforceability of any provision of this Agreement, or the
occurrence of any event rendering any portion or provision of this Agreement void or voidable,
shall in no way affect the validity or enforceability of any other portion or provision of the
Agreement. Any void or voidable provision shall be deemed severed from the Agreement and
the balance of the Agreement shall be construed and enforced as if the Agreement did not
contain the particular portion or provision held to be void. The parties further agree to reform
the Agreement to replace any stricken provision with a valid provision that comes as close as
possible to the intent of the stricken provision.
The provisions of this section shall not prevent the entire Agreement from being held void
should a provision which is of the essence of the Agreement be determined to be void by a
court of competent jurisdiction.
14.3 Political Campaigns
During the term of this Agreement, the CONTRACTOR or any employee or associate, shall
not be involved in any political campaign for MONROE COUNTY elective office nor make
financial contribution to any such campaign.
14.4 Contractor R<<onls
Contractor 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 County or Clerk determines that monies paid to
Contractor pursuant to this Agreement were spent for purposes not authorized by this
Agreement, the Contractor shall repay the monies together with interest calculated pursuant to
Sec. 55.03, FS, running from the date the monies were paid to Contractor.
14.5 Attorney's Fees and Costs
The County and Contractor 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.
14.6 Binding Effect
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the
benefit of the County and Contractor and their respective legal representatives, successors, and
assigns.
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14.7 Authority
Each party represents and warrants to the other that the execution, delivery and perfonnance of
this Agreement have been duly authorized by all necessary County and corporate action, as
required by law.
14.8 Claims for Federal or State Aid
Contractor and County agree that each shall be, and is, empowered to apply for, seek, and
obtain federal and state funds to further the purpose of this Agreement; provided that all such
applications, requests, grant proposals, and funding solicitations shall be approved by each
party prior to submission.
14.9 Adjudication of Disputes or Disagreements
County and Contractor agree that all disputes and disagreements shall be attempted to be
resolved by meet and confer sessions between representatives of each of the parties. If no
resolution can be agreed upon within 30 days after the first meet and confer session, the issue
or issues shall be discussed at a public meeting of the Board of County Commissioners. If the
issue or issues are still not resolved to the satisfaction of the parties, then any party shall have
the right to seek such relief or remedy as may be provided by this Agreement or by Florida
law.
14.10 Cooperation
In the event any administrative or legal proceeding is instituted against either party relating to
the formation, execution, performance, or breach of this Agreement, County and Contractor
agree to participate, to the extent required by the other party, in all proceedings, hearings,
processes, meetings, and other activities related to the substance of this Agreement' or provision
of the services under this Agreement. County and Contractor specifically agree that no party to
this Agreement shall be required to enter into any arbitration proceedings related to this
Agreement.
14.U Nondiscrimination
County and Contractor 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. County or Contractor
agree to comply with all Federal and Florida statutes, and aU local ordinances, as applicable,
relating to nondiscrimination. These include but are not limited to: 1) Title VI of the Civil
Rights Act of 1964 (pL 88-352) which prohibits discrimination on the basis of race, color or
national origin; 2) Title IX of the Education Amendment of 1972, as amended (20 USC ss.
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 s. 794), which prohibits discrimination
on the basis of handicaps; 4) The Age Discrimination Act of 1975, as amended (42 USC ss.
6101-6107) which prohibits 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 91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42
USC ss. 690dd-3 and 290ee-3), as amended, relating to confidentiality of alcohol and drug
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abuse patent records; 8) Title vm of the Civil Rights Act of 1968 (42 USC s. 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 s. 1201 Note), as maybe amended from time
to time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Ch.
13, Art. VI, prohibiting discrimination on the bases of race, color, sex, religion, disability,
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.
14.12 Covenant of No Interest
County and Contractor 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 only interest of each is to perform and receive benefits as recited in this
Agreement.
14.13 Code of Ethics
County agrees that officers and employees of the County recognize and will be required to
comply with the standards of conduct for public officers and employees as delineated in
Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of
gifts; doing business with one's agency; unauthorized compensation; misuse of public position,
conflicting employment or contractual relationship; and disclosure or use of certain
information.
14.14 No SoIicitationlPayment
The County and Contractor warrant that, in respect to itself, it has neither employed nor
retained any company or person, other than a bona fide employee working solely for it, to
solicit or secure this Agreement and that it has not paid or agreed to pay any person, company,
corporation, individual, or firm, other than a bona fide employee working solely for it, any fee,
commission, percentage, gift, or other consideration contingent upon or resulting from the
award or making of this Agreement. For the breach or violation of the provision, the
Contractor agrees that the County shall have the right to terminate this Agreement without
liability and, at its discretion, to offset from monies owed, or otherwise recover, the full
amount of such fee, commission, percentage, gift, or consideration.
14.15 Privileges and Immunities
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
County, when performing their respective functions under this Agreement within the territorial
limits of the County 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 County.
14.16 Legal Obligations and Responsibilities: Non-Delegation of Constitutional or
Statutory Duties
This Agreement is not intended to, nor shall it be construed as, relieving any participating
entity from any obligation or responsibility imposed upon the entity by law except to the
9
extent of actual and timely performance thereof by any participating entity, in which case the
performance may be offered in satisfaction of the obligation or responsibility. Further, this
Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the
constitutional or statutory duties of the County, except to the extent permitted by the Florida
constitution, state statute, and case law.
14.17 Non-Reliance by Non-Parties
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement
to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service
or program contemplated hereunder, and the County and the Contractor agree that neither the
County nor the Contractor or any agent, officer, or employee of either shall have the authority
to inform, counsel, or otherwise indicate that any particular individual or group of individuals,
entity or entities, have entitlements Of benefits under this Agreement separate and apart,
inferior to, or superior to the community in general or for the purposes contemplated in this
Agreement.
14.18 Attestations
Contractor agrees to execute such documents as the County may reasonably require, to include
a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement.
14.19 No Personal Liability
No covenant or agreement contained herein shall be deemed to be a covenant or agreement of
any member, officer, agent or employee of Monroe County in his or her individual capacity,
and no member, officer, agent or employee of Monroe County shall be liable personally on this
Agreement or be subject to any personal liability or accountability by reason of the execution
of this Agreement.
14.20 Execution in Counterparts
This Agreement may be executed in any number of counterparts, each of which shall be
regarded as an origina~ all of which taken together shall constitute one and the same
instrument and any of the parties hereto may execute this Agreement by singing any such
counterpart.
14.21 Section Headings
Section headings have been inserted in this Agreement as a matter of convenience of reference
only, and it is agreed that such section headings are not a part of this Agreement and will not
be used in the interpretation of any provision of this Agreement.
ARTICLE 15.. INTEGRATION AND MODIFICATION
This Agreement is adopted by MONROE COUNTY and CONTRACTOR as a final, complete
and exclusive statement of the terms 'of the Agreement between MONROE COUNTY and
CONTRACTOR. This Agreement supersedes all prior agreements, contracts, proposals,
representations, negotiations, letters or other communications between MONROE COUNTY
and CONTRACTOR pertaining to the Services, whether written or oral.
The Agreement may not be modified unless such modifications are evidenced by an
amendment in writing signed by both MONROE COUNTY and CONTRACTOR.
10
ARTICLE 16.. SUCCESSORS AND ASSIGNS
MONROE COUNTY and CONTRACTOR each binds itself and its director, officers, partners,
successors, executors, administrators, assigns and legal representatives to the other party to this
Agreement. Any assignment, sale, pledge or conveyance of this contract by CONTRACTOR
must be previously approved in writing by MONROE COUNTY, whose consent will not be
unreasonably withheld.
ARTICLE 17.. CONTINGENT FEES
The CONTRACTOR warrants that it has not employed or retained any company or person,
other than a bona fide employee working solely for the CONTRACTOR to solicit or secure
this Agreement and that it has not paid or agreed to pay any person, company, corporation,
individual or firm, other than a bona fide employee working solely for the CONTRACTOR,
any fee, commission, percentage, gift or any other consideration contingent upon or resulting
from the award or making of this Agreement.
ARTICLE 18.. TRUTH-IN-NEGOTIATION CERTIFICATE
Execution of this Agreement by the CONTRACTOR shall act as the execution of a truth-in-
negotiation certificate certifying that the fees and costs used to determine the compensation
provided for in this Agreement are no higher than those charged to other customers of
CONTRACTOR for the same or substantially similar service, provided that the customer is of
comparable size and demographic.
ARTICLE 19 - OWNERSHIP OF DOCUMENTS
CONTRACTOR shall be required to work in harmony with other CONTRACTOR'S relative
to providing information requested in a timely manner and in the specified form. Any and all
documents, records, disks, original drawings, or other information shall become the property of
MONROE COUNTY upon completion for its use and distribution as may be deemed
appropriate by MONROE COUNTY. Failure to turn over such documents within seven (7)
days of when requested may be cause for MONROE COUNTY to withhold any payments due
CONTRACTOR or to enforce this clause by legal remedies.
ARTICLE 20 .. NOTICE
Any notice, demand, communication, or request required or permitted hereunder shall be in
writing and delivered in person or sent by certified mail, postage prepaid as follows:
As To MONROE COUNTY
MONROE COUNTY
FireIRescue Services Department
490 63rd Street
Marathon, FL 33050
Attention: Chief Clark O. Martin, Jr.
11
As To CONTRACTOR:
Advanced Data Processing, Inc.
500 NW. 165 Street Road Suite 101
Miami, Florida 33169
Attention: Brad Williams, Vice President, Finance
Notices shall be effective when received at the address specified above. Changes in the
respective addresses to which such notice may be directed may be made from time to time by
any party by written notice to the other party. Facsimile is acceptable notice effective when
received, however, facsimiles received (i.e. printed) after 5:00 p.m. or on weekends or
holidays, will be deemed received on the next business day. The original of the notice must
additionally be mailed as required herein.
Nothing contained in this Article shall be construed to restrict the transmission of routine
communications between representatives of CONTRACTOR and MONROE COUNTY.
IN WITNESS WHEREOF, MONROE COUNTY Board of County Commissioners, at a
regular meeting thereof, by action of MONROE COUNTY Board of County Commissioners
and directing the foregoing be adopted, has caused these presents to be signed, and it's seal to
be hereunto affixed, and ADVANCED DATA PROCESSING, INC. has executed this contract
all as of the day and year first above written.
(SEAL) BOARD OF COUNTY COMMISSIONERS OF
ATTEST' DANNY 1.. KOLHAGE, CLERK MONROE COUNTY
By:
By:
Deputy Clerk
Mayor
ADVANCED DATA PROCESSING, INC.
By:
Doug Shaman
Title: President and CEO
President (or other duly authorized
Officer)
Approved by MONROE COUNTY on
,2005, Item #
12
ATTACHMENT A
I. ScoDe of Work
The CONTRACTOR shall provide MONROE COUNTY with timely and accurate
complete medical billing and accounts receivable management services for MONROE
COUNTY'S rescue ambulance billing services and related professional services in
accordance with the responsibilities outlined as follows:
A. Initial Patient Treatment and Information
1. On a Case by case basis, MONROE COUNTY will respond to patients requiring
immediate medical treatment and emergency medical transportation services. Upon treating
each patient, MONROE COUNTY shall provide the CONTRACTOR with patient information
identified on the "Run Report" attached hereto as Exhibit A. CONTRACTOR shall be solely
responsible for retrieving insurance information and any additional patient information which
was not identified on the "Run Report" provided by MONROE COUNTY. CONTRACTOR
shall utilize "Run Report" information and any additional information retrieved by
CONTRACTOR to file proper patient billing and insurance information. CONTRACTOR shall
establish arrangements with hospitals to obtain/verify patient insurance and contact
information. CONTRACTOR shall contact the U.S. Post Office's National Change of Address
(NCOA) files or other similar services to obtain the correct billing addresses and phone
numbers for patients that have left the area, or whom have invalid information.
2. CONTRACTOR shall reconcile the number of patients that are transported for
emergency medical services with those received. The CONTRACTOR shall report
discrepancies to MONROE COUNTY within three (3) business days of receipt.
3. As requested by MONROE COUNTY, CONTRACTOR shall provide MONROE
COUNTY'S Fire Rescue Services Paramedics Personnel with training on the gathering of
necessary information to be adhered on Run Reports for the purpose of assisting
CONTRACTOR with the proper submission and processing of patient data.
B. Patient Billing
1. CONTRACTOR shall mail an invoice to each patient for emergency
transportation service at current rates set forth by MONROE COUNTY as follows:
$500.00 for Basic Life Support (BLS)
$500.00 for Advance Life Support One (ALSI)
$600.00 for Advance Life Support Two (ALS2)
$200.00 for Stand by (Special Event)
$9.00 per mile
The aforementioned rates shall be subject to change at MONROE COUNTY'S
discretion at any time throughout the term of the agreement, MONROE COUNTY agrees to
notify CONTRACTOR a minimum of seven (7) days prior to any rate changes.
2. CONTRACTOR shall provide patients with a comprehensive statementlinvoice
including a courtesy return payment envelope. The front of the statement shall describe all
charges and payments. The reverse side of the statement shall have clearly marked entry blocks
13
for information needed to file private insurance claims. CONTRACTOR shall file claims and
send an invoice to all self.pay patient/payors with return envelope and address as specified by
MONROE COUNTY within five (5) days of receipt of incident information.
CONTRACTOR shall be responsible for sending a total of six invoices. CONTRACTOR
shall send the second invoice at thirty-five days, third invoice at sixty.five days, fourth invoice
at ninety-five days, fifth invoice at one hundred twenty-five days and sixth notice at one
hundred fifty.tive days. In the course of time that the six invoices are sent to patient/payor,
CONTRACTOR shall provide follow-up on rejected and inactive claims and establish payor
remittance accounts and procedures. Unless insurance payment is pending, CONTRACTOR
shall on a monthly basis send all accounts that have not had activity for twelve (12)
months or more a Pre.Collection Letter. These accounts have thirty (30) days to respond to the
CONTRACTOR. Once the thirty (30) days has expired, the CONTRACTOR shall send
MONROE COUNTY a list of all accounts along with a complete processing history once
collection efforts are exhausted. These uncollectible accounts will be forwarded by the
CONTRACTOR onto a third party collection agency named by MONROE COUNTY for
further attempts at collecting.
3. Within MONROE COUNTY established guidelines, CONTRACTOR shall
negotiate and arrange modified payment schedules for patients unable to pay full amount when
billed.
4. CONTRACTOR shall process refund requests within the month following an
overpayment and provide MONROE COUNTY with documentation substantiating each refund
requested.
5. Where CONTRACTOR has found no method of payment for a patient after all
insurance avenues are exhausted including State Medicaid and local HRS or municipal
programs, such cases will be submitted to MONROE COUNTY in writing for final resolution
along with appropriate documentation (i.e. hospital credit status, credit file information,
activity file). At the instruction of MONROE COUNTY, CONTRACTOR shall write off any
amounts or make any adjustments to a bill, including, but not limited to; patient disputes
regarding mileage, special handling charges or the bill in its entirety.
6. CONTRACTOR shall provide MONROE COUNTY with real.time read only
electronic look-up access of CONTRACTOR'S patient data and billing information system.
CONTRACTOR shall provide the facilities to receive patient billing information from
MONROE COUNTY electronically. CONTRACTOR- This may be done through email or
other method that meets Patient Privacy requirements.
C. Patient Filing
1. CONTRACTOR shall file all insurance claim forms for all patients based upon
information received from the Run Report and research performed by CONTRACTOR.
CONTRACTOR shall provide prompt submission of required paperwork to Medicare,
Medicaid, Insurance Companies or Third Party Payors for claims, reviews, resubmission,
provider agreements and other as required within 72 hours after receiving the requested "Run
Report" from MONROE COUNTY. CONTRACTOR shall submit secondary insurance
provider claims after the primary insurance provider has paid. As necessary, CONTRACTOR
shall re-file Medicare, Medicaid or Insurance claims to obtain payment. CONTRACTOR
shall maintain responsibility for obtaining missing or incomplete insurance information.
14
CONTRACTOR shall process all third party reimbursements within one week after receipt of
appropriate billing information from primary payor.
2. CONTRACTOR shall utilize the most up-to-date knowledge and information
with regard to coding requirements and standards and proper preparation of electronic and
paper insurance filings to ensure compliance with applicable Federal, State and local
regulations.
D. Maintaining Records
1. CONTRACTOR shall maintain records in an electronic format that is readily
accessible by MONROE COUNTY and meets all federal and state requirements for
maintaining patient medical records.
2. CONTRACTOR shall maintain appropriate accounting procedures for
reconciling all deposits, receivables, billings, patient accounts, adjustments and refunds.
3. CONTRACTOR shall facilitate proper security of confidential information and
further shred and dispose of materials containing such information.
4. CONTRACTOR shall implement and comply with a Compliance Plan consistent
with the intent and activities included in the U.S. Office of Inspector General (OIG)
Compliance Program Guidance for Third Party Medical Billing Companies 63 FR 70138;
(December 18, 1998).
5. CONTRACTOR shall retain all accounts for a minimum of twelve (12) months
(unless otherwise specified by mutual agreement).
6. CONTRACTOR shall ensure that all required documentation and agreements
with payors (e.g. Medicare, Medicaid, Champus, etc.) are filed and maintained and that
MONROE COUNTY is kept apprised of important changes to industry regulations.
7. CONTRACTOR shall be knowledged of different industry insurance plans and
shall ensure MONROE COUNTY that every billable claim is pursued accordingly by
CONTRACTOR.
8. CONTRACTOR shall advise MONROE COUNTY on statutes and industry
regulations which would affect emergency transportation service rates.
E. Customer Service:
1. CONTRACTOR shall provide a toll free telephone number for patients with
CONTRACTOR'S own facilities and workforce. CONTRACTOR'S toll free telephone
number must he a dedicated phone number only for accounts from MONROE COUNTY.
CONTRACTOR shall provide a designated liaison for patient/payor concerns.
2. CONTRACTOR shall conduct all written and verbal communication in the most
professional manner. The CONTRACTOR shall never in any way represent themselves in a
way that might be interpreted as intimidating or threatening.
3. CONTRACTOR shall respond within three (3) business days of any verbal or
written requests made by Patients andlor MONROE COUNTY for information or records.
CONTRACTOR shall assist patients that are not able to speak the English language.
Difficult calls such as, but not limited to: special insurance issues, taxpayer questions, irate
15
calls shall be handled in a professional manner by a supervisor employed with
CONTRACTOR'S firm.
4. CONTRACTOR shall provide all customer inquiry services and prepare
additional third-party claims or patient payment arrangements based on this information
exchange.
5. At MONROE COUNTY'S request, CONTRACTOR shall provide survey
questionnaires or mail inserts to patients. CONTRACTOR shall mail requested citizen
satisfaction surveys.
6. CONTRACTOR shall provide for facilities to permit dial-up access to retrieve
patient data and billing information.
F. Audits
1, CONTRACTOR shall provide access to MONROE COUNTY for all requested
information in order for MONROE COUNTY to perform appropriate and periodic audits.
MONROE COUNTY will provide CONTRACTOR with reasonable notice for any planned
audit and CONTRACTOR shall conduct audit during normal business hours.
G. Monthly Reports
Unless otherwise indicated, CONTRACTOR shall provide the following reports on a
monthly basis as identified and prescribed by MONROE COUNTY. Monthly reports shall
be produced after the month's closing and provided to MONROE COUNTY no later than the
tenth of each month.
1. Ambulance Unit Report: On a monthly basis, CONTRACTOR shall provide a
report of number of calls and gross billed by ambulance unit for the current period.
2. Ambulance New Billing Report: CONTRACTOR shall produce a report
showing all billing (new charges) processed alpha sorted by Last Name and summarized total
billing for period. CONTRACTOR shall add column for date received from MONROE
COUNTY. .
3. Ambulan~ Payment Report: CONTRACTOR shall provide a batch oriented
listing of all payments processed including check number and type of payment (self pay,
Medicare, Medicaid, private insurance).
4. Gross Collection Statistics Summary: CONTRACTOR shall provide a running
summary ofInterfacility transactions including monthly amount billed, collected, Percentage
collected, number of Accounts and Gross Billed.
5. Schedule of Transport Charges & Collections: CONTRACTOR shall provide a
running month summary of charge, payment and adjustments for the closingmonth period
showing gross and net collection percentages for each period. Information provided shall be for
last five fiscal years only.
6. Report of Accounts Receivable: CONTRACTOR shall provide a summary for
period ending of Accounts Receivable showing gross billing, payments received/processed,
reflected write-offs and adjustments, reversals and ending balance.
16
7. Monthly Billing and Collection Summary: CONTRACTOR shall produce a
report showing receivables as applied to month running or original billed month. Information
provided shall be for last five fiscal years only.
8. Insurance Receivable Report: CONTRACTOR shall provide a summary of billed
month the number of patient bills having an outstanding insurance balance. This will show
the balance and number of bills outstanding by class.
9. Collection by Financial Class: CONTRACTOR shall provide a running month
summary for the closing month period of collections by Payor Class (Self-Pay, Medicare,
Medicaid and Private Insurance). CONTRACTOR shall denote billing numbers for each
category and total. Information provided shall be for last five fiscal years only.
10. Collection Schedule: CONTRACTOR shall provide a running summary of
collected amounts to include monthly, fiscal and cumulative amounts.
11. Ambulance Billing Adjustments-Write Offs-Rev~sals: CONTRACTOR shall
provide a running summary showing all adjustments, write-offs and reversals from Medicare,
Medicaid and Insurance.
12. Report of Accounts Receivable Removed: CONTRACTOR shall provide a report
showing Accounts sent to Collections with Original Amount Billed, Payments made, Adjusted
Amounts and Balance owed. These accounts will have had no activity for 12 months or more.
This report will only be provided on the months that the CONTRACTOR sent accounts to
collections.
13. Report by Incident Date: CONTRACTOR shall provide a report by account detail
of all accounts outstanding to include Original Amount billed, Adjusted Amount, and Balance
due.
14. Monthly Refund Schedule: CONTRACTOR shall provide a report by account
detail of associated payments reflecting an overpayment and necessary refund to be processed.
n. Health Insurance Portability and Accountability Act of 1996 (HIP AA)
The CONTRACTOR shall comply with the privacy regulations pursuant to Public Law
104-191 of August 21, 1996, known as the Health Insurance Portability and
Accountability Act of 1996, Subtitle F - Administrative Simplification, Sections 261, et
seq., as amended ("HIP AA")) to protect the privacy of any personally identifiable
protected health information ('"PIll") that is collected, processed or learned as a result of
the Billing Services provided hereunder.
A CONTRACTOR shall not use or further disclose PIll except as permitted herein or
required by law.
B. CONTRACTOR shall use appropriate safeguards to prevent use or disclosure of PIll
except as permitted herein.
C. CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that is
known to CONTRACTOR, its agents or subcontractors of a use or disclosure of PIll by
the CONTRACTOR, its agents or subcontractors.
17
D. CONTRACTOR shall report to MONROE COUNTY any use or disclosure of pm
not provided for by this Agreement of which the CONTRACTOR, its agents or subcontractors
become aware.
E. CONTRACTOR shall ensure that any agents or subcontractors to whom the
CONTRACTOR provide pm or who have access to pm, agree to the same restrictions and
conditions that apply to the CONTRACTOR with respect to such pm.
F. CONTRACTOR shall make pm available to MONROE COUNTY and to the
individual who has a right of access as required under HIPAA within 30 days of the c~quest by
MONROE COUNTY regarding the individual.
G. CONTRACTOR shall incorporate ally amendments to pm when notified to do so by
MONROE COUNTY.
H CONTRACTOR shall provide an accounting of all uses or disclosures of pm made
by the CONTRACTOR its agents or subcontractors as required under the HIP AA privacy rule
within sixty (60) days.
1. CONTRACTOR shall make their internal practices, books and records relating to the
use and disclosure of pm available to the Secretary ofthe Department of Health and
Human Services for purposes of detennining the CONTRACTOR'S, its agents' and
subcontractors' and MONROE COUNTY'S compliance with HIPAA.
1. CONTRACTOR shall at the termination of the agreement, return or destroy all pm
received from, or created oc received by the CONTRACTOR, its agents or subcontractocs
on behalf of MONROE COUNTY and if return is infeasible, ensure that the protections of
this Agreement ' will extend to such pm.
K. The specific uses and disclosures of pm that may be made by the CONTRACTOR,
its agents or contractors on behalf of MONROE COUNTY include:
1. Preparation of invoices to patients, earners, insurers and others responsible for
payment or reimbursement of the services provided by MONROE COUNTY to its patients.
2. Preparation of remindec notices and documents pertaining to collections of
overdue accounts.
3. The submission of supporting documentation to carriers, insurers and other
payers to substantiate the health care services provided by MONROE COUNTY to its patients
or to appeal denials of payment for same.
4. Other uses or disclosures of pm as permitted by the HIIPAA privacy rule.
5. Mail HIP AA Notice of Privacy Practices to all emergency transport patients
within the timeframe allowed under the HIP AA and FIJP AA rules.
6. Mail subpoenas, attorney's requests to Fire Rescue immediately upon receipt
18
ATTACHMENT B
L Compensation for Services
The CONTRACTOR shall provide to MONROE COUNTY a monthly invoice
representing fees for the services provided computed as:
A. Seven percent (7%) of all monies collected by the CONTRACTOR, excluding
Medicaid accounts, during the previous month. In compliance with Florida Statute 409.913
(9), the CONTRACTOR shall include in the same invoice an amount of$II.40 per Medicaid
account for providing all billing services related to such accounts processed in the previous
month.
D. Price shall include but not be limited to; all stationery, fax forms, envelopes, mailings,
postage and. telecommunications/phone facilities/charges.
E. Price for services does not include the cost of "Locked-box" service. The COUNTY
shall bear the cost of the Locked-box.
The "Locked-box service selected shall be at the sole discretion of MONROE
COUNTY and shall provide a secure postal address and box for receipt of all correspondence
(especially including all insurance and patient payments, correspondence and benefits
determination and denials). The "Locked-box" service will on a daily basis perform the
following:
I. Open all mail (except clearly marked returned-mail).
2. Make a copy of every check and attach copy with original document
accompanying each check.
3. Deposit all receivables into ,designated MONROE COUNTY account.
4. Prepare and provide a daily deposit slip totaling and accounting for all
receivables deposited for the identified day.
5. Mail (daily) to the CONTRACTOR separated bundles of; copies of checks
attached to supporting documents, other correspondence and, returned-mail along with
deposit slip.
6. Mail (daily) to MONROE COUNTY copies of checks and daily deposit slip.
7. Mail (monthly) to MONROE COUNTY reconciliation of account.
F. CONTRACTOR shall maintain daily deposit control sheets and original
documentation.
19
490 63rd Street
Marathon, FL 33050
Run Number:
Patient Name:
Date of Service:
Monroe County Fire Rescue
Phone# (305) 289-6004
Shift:
Station:
Nature of Call:
Location:
Outcome:
Received:
Rescue:
Unit ID:
Crew #1:
Crew #2:
Crew #3:
Level of Care:
Destination:
Dispatched:
Enroute:
Arrive:
Pt Contact:
Pt. Transported:
Depart
At Dest:
Resp Delay:
At Scene
it Dest Mileage:
Name:
SSN:
DOB:
Sex:
Weight:
Phone:
Home Address:
Mailing Address:
INITIAL INFORMATION
Patient Found:
Chief Complaint:
Cause of Injury:
Relevant Past History:
Medications:
Time ~
f!!.!n
~ ETC02 CaD Refill
ECG
GCS
~ft
RJgl:!t
I of 4
Printed on: 01107/2005 at 12:22
FIRE RESCUE REPORT
Monroe County Fire Rescue
490 63rd Street
Marathon, FL 33050
Run Number:
Patient Name:
Date of Service:
Documented By:
Phone# (305) 289-6004
.\SS ESSi\ IE N TS
'.I
Bodv Area
Assessment
Bodv Area
Assessment
~~------------,
INn: I{V ENTIONS
TIme
Treatment
Descrlotlon
Further Details
'\'.\RR'\ II\'E
SICN,\ ruR[S
Time
~
Disclaimer
I, , authorize any holder of medical or other information about me to release to the Social Security
AlimimSh"ation and Health Care Financing Administration or its intermediaries or carriers, or any private insurance
company any information needed for this or a related medical claim,
I permit a copy oflhis authorization to be used in place of the original and request payment of medical insurance
benefits to the party who accepts assignment. I personally guarantee payment of any charges not covered by health care
benefits. According 10 Medicare regulations. your ambulance h"ansport and related services are subject to review under
the Medicare program, The purpose of this review is to determine whether or not your transport and related services
meet the guidelines for Medicare payment. If it is determined, under the Medicare Program guidelines that your
transport and related services were not medically necessary, or that non.covered services were provided 10 you, ilien,
please be advised that you are personally responsible fOf payment of the transport or the non-covered services.
Furthermore, I hereby acknowledge thaI I have been provided with a copy of Monroe County's Notice of Privacy
Practices on this date,
Signature
2 of 4
Printed on: 01/07/2005 at ] 2;22
.... ..
FIRE RESCUE REPORT
Monroe County Fire Rescue
490 63rd Street
Marathon, FL 33050
Run Number:
Patient Name:
Date of Service:
Time
~
Be QA Review
Disclaimer
I have reviewed this report for completeness and accuracy,
Signature
(,RE\\ SI<;:\',\Tl1IU:S
Crew # Crew 1 Name
Certification Sianature
Crew # Crew 2 Name Certification
Slcmature
~ Crew 3 Name Certification
Signature
3 of 4
Printed on; OIJ071200S at 12:22
FIRE RESCUE REPORT
Monroe County Fire Rescue
490 63rd Street
Marathon, FL 33050
Run Number:
Patient Name:
Date of Service:
Documented By:
Phone#(305) 289-6004
BILLF\C I\H)R\I \T10,\
Guarantor
Address
SSN
Relation
Send Bill To
Insured?
Employed?
Work Related?
Insurance
Insurance
Company
State
Insured's Name
Polley Number
CH ,\IHa.:S
4 of 4
Printed on: 0 I 107/2005 at 12:22