HomeMy WebLinkAboutAgreement A-19-289 with Valley Childrens Hospital.pdf Agreement No. 19-289
;
1 AGREEMENT
I
2
i
3 THIS AGREEMENT is made and entered into this 18th day of June, 2019, by and between the
4 COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter referred to as
i
5 "COUNTY", and Valley Children's Hospital, a non-profit corporation, whose address is 9300 Valley
6 Children's Place, Madera, California 93636-8762, hereinafter referred to as"CONTRACTOR".
7 WITNESSETH:
3
8 WHEREAS, CONTRACTOR maintains an electronic medical records system and controls remote
I
9 access to their hospital systems for users who require electronic access from offsite locations.
i
10 WHEREAS, COUNTY, through its Department of Public Health, hereinafter referred to as"DPH"
I
11 maintains several programs mandated by the State of California, hereinafter referred to as"STATE", to
12 authorize payment for medical care, provide medical case management, provide medical assessments and
i
13 treatments, ensure continuity of medical care for children and youth in out-of-home placement and at risk 1
14 for entering the Child Welfare System, and to meet STATE-mandated investigation and reporting
15 requirements for certain infectious diseases; and
I
16 WHEREAS, COUNTY'S DPH has designated employees whose specific duties, within those j
1
17 STATE-mandated programs, are facilitated by access to the electronic medical records maintained by the
i
18 CONTRACTOR.
i
19 NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions herein
j
20 contained, the parties hereto agree as follows:
21 1. OBLIGATIONS OF THE CONTRACTOR AND COUNTY
I
22 A. COUNTY shall request remote electronic access to CONTRACTOR's electronic
23 medical records for designated COUNTY employees, as defined in Section 1 D.
24 B. CONTRACTOR shall grant remote electronic access of hospital systems to
25 designated COUNTY employees for the sole purpose of accessing electronic medical records j
26 necessary to completing specific State-mandated program required work duties.
27 C. To gain access, a "Valley Children's Healthcare Information Systems NOW 11i
28 Employee Remote Access Agreement", attached hereto as Exhibit A, incorporated herein by reference,
i
i
1
i
i
I
1 and hereinafter referred to as VCH Remote Access Agreement, shall be completed and submitted to
2 Valley Children's Hospital for approval.
3 D. COUNTY's DPH Director or designee shall identify designated COUNTY
4 employees to enter into a VCH Remote Access Agreement with CONTRACTOR. Authorized COUNTY
5 employees are those designated individuals who work in the following DPH Divisions/Programs:
;
,
6 California Children's Services (CCS) and Medical Therapy Program; Child Health and Disability
7 Prevention's Health Care Program for Children in Foster Care (HCPCFC); probation youth and children
8 at risk for entering the Child Welfare System; Communicable Disease Investigation (CDI) and i
9 Epidemiology (EPI) Programs; and other programs engaging in certain activities, including authorizing
i
10 payment for medical services, performing medical case management, providing health assessments
i
11 and ensuring continuity of medical care for children and youth in out-of-home placement, providing
12 medical assistance and treatment, or meeting the STATE-mandated investigation and reporting
13 infectious diseases requirements for residents of Fresno County.
14 E. COUNTY and CONTRACTOR acknowledge that COUNTY-designated
i
15 employees as of the effective date of this Agreement shall be listed in Exhibit B, "County of Fresno
16 Employees Authorized to Remote Access of Valley Children's Hospital's Electronic Medical Records", )
17 incorporated herein by reference.
18 F. COUNTY's DPH Director or designee, reserve the right at any time during the
,
t
19 term of this Agreement to add new COUNTY-designated employees to the list contained in Exhibit B.
20 Such additions shall follow the process as defined in Section 1 C of this Agreement, and upon mutual
21 approval of the COUNTY's DPH Director or designee and the CONTRACTOR. COUNTY's DPH
f
22 Director or designee, also reserves the right at any time during the term of this Agreement to delete any
23 COUNTY-designated employees contained in Exhibit B. In the event of additions or deletions to Exhibit
i
24 B, COUNTY will notify CONTRACTOR within two (2) COUNTY business days. Additions or deletions to 3
25 Exhibit B shall be attached to this Agreement and incorporated herein by this reference.
26 2. TERM
1
27 The term of this Agreement shall be for a period of one (1) year, commencing on July 1, {
I,
28 2019 through and including June 30, 2020. This Agreement may be extended for an unlimited number of
'1
-2-
1 twelve (12) month periods upon written approval of both parties no later than thirty(30) days prior to the first
2 day of the next twelve (12) month extension period. The DPH Director or designee is authorized to execute
3 such written approval on behalf of the COUNTY based on CONTRACTOR'S satisfactory performance.
4 3. TERMINATION
5 A. Non-Allocation of Funds—The terms of this Agreement, and the services to be
6 provided hereunder, are contingent on the approval of funds by the appropriating government agency.
7 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
8 terminated, at any time by giving the CONTRACTOR thirty(30) days advance written notice.
9 B. Breach of Contract- Either party may immediately suspend or terminate this
10 Agreement in whole or in part, where in the determination of the terminating party there is:
11 1) An illegal or improper use of funds;
12 2) A failure to comply with any term of this Agreement;
13 3) A substantially incorrect or incomplete report submitted to the other party;
14 4) Improperly performed service.
15 C. Without Cause - Under circumstances other than those set forth above, this
t
16 Agreement may be terminated by either party upon the giving of thirty(30) days advance written notice of
17 an intention to terminate to other party.
18 4. COMPENSATION/INVOICING
19 The process to grant COUNTY employees remote electronic access to CONTRACTOR-
20 maintained electronic records, pursuant to the terms and conditions of this Agreement, shall be performed
21 without the payment of any monetary consideration by the CONTRACTOR or COUNTY, one to the other.
22 The parties hereto acknowledge and agree that their respective covenants made to the other party and
23 benefits received from the other party under this Agreement shall form the basis of the consideration
24 exchanged between them under this Agreement.
25 5. INDEPENDENT CONTRACTOR
26 In performance of the work, duties and obligations assumed by CONTRACTOR under this
27 Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of the
28 CONTRACTOR'S officers, agents, and employees will at all times be acting and performing as an
-3-
1 independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
2 employee,joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no right
3 to control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and
4 function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
5 CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof.
i
6 CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the
7 rules and regulations, if any, of governmental authorities having jurisdiction over matters the subject
8 thereof.
9 Because of its status as an independent contractor, CONTRACTOR shall have absolutely
10 no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
11 solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
12 benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
13 matters relating to payment of CONTRACTOR'S employees, including compliance with Social Security
14 withholding and all other regulations governing such matters. It is acknowledged that during the term of this
15 Agreement, CONTRACTOR may be providing services to others unrelated to the COUNTY or to this
16 Agreement.
i
17 6. MODIFICATION
18 Any matters of this Agreement may be modified from time to time by the written consent of
19 all the parties without, in any way, affecting the remainder.
20 7. NON-ASSIGNMENT
21 Neither party shall assign,transfer or sub-contract this Agreement nor their rights or duties
22 under this Agreement without the prior written consent of the other party.
23 8. MUTUAL HOLD HARMLESS
24 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY'S request,
25 defend the COUNTY, its officers, agents, and employees from any and all costs and expenses (including
26 attorney's fees and costs), damages, liabilities, claims, and losses occurring or resulting to COUNTY in
27 connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents, or
28 employees under this Agreement, and from any and all costs and expenses (including attorney's fees and
-4-
1 costs), damages, liabilities, claims, and losses occurring or resulting to any person, firm, or corporation who
2 may be injured or damaged by the performance, or failure to perform, of CONTRACTOR, its officers,
3 agents, or employees under this Agreement.
4 COUNTY agrees to indemnify, save, hold harmless and at COUNTRACTOR's request,
5 defend the CONTRACTOR, its officers, agents, and employees from any and all costs and expenses,
6 damages, liabilities, claims, and losses occurring or resulting to CONTRACTOR in connection with the
7 performance, or failure to perform, by COUNTY, its officers, agents, or employees under this Agreement,
8 and from any and all costs and expenses, damages, liabilities, claims, and losses occurring or resulting to
9 any person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
10 of COUNTY, its officers, agents, or employees under this Agreement.
11 9. INSURANCE
12 Without limiting the parties' right to obtain indemnification, both parties shall, at its sole
13 expense, maintain in full force and effect, insurance policies or a program of self-insurance, including but
14 not limited to, an insurance pooling arrangement or Joint Powers Agreement(JPA)throughout the term of
15 the Agreement, to fund its liabilities. Coverage shall be provided for comprehensive general liability,
16 automobile liability, professional liability, and worker's compensation exposure. Evidence of Insurance,
17 Certificates of Insurance or other similar documentation shall not be required under this Agreement.
18 A. Commercial General Liability - Commercial General Liability Insurance with limits of
19 not less than Two Million Dollars ($2,000,000.00) per occurrence and an annual aggregate of Four Million
20 Dollars($4,000,000.00). This policy shall be issued on a per occurrence basis. COUNTY may require
21 specific coverages including completed operations, products liability, contractual liability, Explosion-
22 Collapse-Underground, fire legal liability or any other liability insurance deemed necessary because of the
23 nature of this contract.
24 B. Automobile Liability—Comprehensive Automobile Liability Insurance with limits of
25 not less than One Million Dollars ($1,000,000.00) per accident for bodily injury and for property damages.
26 Coverage should include any auto used in connection with this Agreement.
27 C. Professional Liabil — If party employs licensed professional staff, (e.g., Ph.D., R.N.,
28 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One
-5-
1 Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate.
2 D. Worker's Com ensation—A policy of Worker's Compensation insurance as may be
3 required by the California Labor Code.
4 E. C ber Liability—Cyber Liability Insurance, with limits not less than Two Million
5 Dollars ($2,000,000.00) per occurrence or claim, Two Million Dollars($2,000,000.00) aggregate. Coverage
6 shall be sufficiently broad to respond to the duties and obligations as is undertaken by COUNTY or
7 CONTRACTOR in this agreement and shall include, but not be limited to, claims involving infringement of
8 intellectual property, including but not limited to infringement of copyright, trademark, trade dress, invasion
9 of privacy violations, information theft, damage to or destruction of electronic information, extortion and
10 network security. The policy shall provide coverage for breach response costs as well as regulatory fines
11 and penalties as well as credit monitoring expenses with limits sufficient to respond to these obligations.
12 Additional Requirements Relating to Insurance
13 CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
14 naming the County of Fresno, its officers, agents, and employees, individually and collectively, as additional
15 insured, but only insofar as the operations under this Agreement are concerned. Such coverage for
16 additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained
17 by COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance
18 provided under CONTRACTOR's policies herein. This insurance shall not be cancelled or changed without
19 a minimum of thirty (30) days advance written notice given to COUNTY.
20 CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and
21 employees any amounts paid by the policy of worker's compensation insurance required by this
22 Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be
23 necessary to accomplish such waiver of subrogation, but CONTRACTOR's waiver of subrogation under
24 this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
25 Within Thirty (30) days from the date CONTRACTOR signs and executes this Agreement,
26 CONTRACTOR shall provide certificates of insurance and endorsement as stated above for all of the
27 foregoing policies, as required herein, to the County of Fresno, (Name and Address of the official who will
28 administer this contract), stating that such insurance coverage have been obtained and are in full force; that
-6-
I the County of Fresno, its officers, agents and employees will not be responsible for any premiums on the
2 policies that for such worker's compensation insurance the CONTRACTOR has waived its right to recover
3 from the COUNTY, its officers, agents, and employees any amounts paid under the insurance policy and
4 that waiver does not invalidate the insurance policy; that such Commercial General Liability insurance
5 names the County of Fresno, its officers, agents and employees, individually and collectively, as additional
6 insured, but only insofar as the operations under this Agreement are concerned; that such coverage for
7 additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained
8 by COUNTY, its officers, agents and employees, shall be excess only and not contributing with insurance
9 provided under CONTRACTORS policies herein; and that this insurance shall not be cancelled or changed
10 without a minimum of thirty (30) days advance, written notice given to COUNTY.
11 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
12 provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate this
13 Agreement upon the occurrence of such event.
14 All policies shall be issued by admitted insurers licensed to do business in the State of
15 California, and such insurance shall be purchased from companies possessing a current AM, Best, Inc.
16 rating of A FSC VI I or better.
17 10. AUDITS AND INSPECTIONS
18 The CONTRACTOR shall at any time during business hours, and as often as the COUNTY
19 may deem necessary, make available to the COUNTY for examination all of its records and data with
20 respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the
21 COUNTY, permit the COUNTY to audit and inspect all of such records and data necessary to ensure
22 CONTRACTOR'S compliance with the terms of this Agreement.
23 A. The COUNTY shall conduct periodic internal audits and inspections of all records
24 and data necessary to ensure COUNTY'S compliance with the terms of this Agreement.
25 B. The COUNTY shall permit the CONTRACTOR to conduct at any time during
26 business hours, periodic reviews and/or audits of data necessary to ensure COUNTY's compliance in
27 accordance with CONTRACTOR'S Information Systems NON-Employee Remote Access Agreement as
28 attached hereto as Exhibit A.
-7-
1 11. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
2 COUNTY and CONTRACTOR each consider and represent themselves as covered entities
3 as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-191
4 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law, including,
5 but not limited to, complying with California's Child Abuse or Neglect Reporting Act, or CANRA(Penal
6 Code§§ 11164 et seq.)for individuals listed on Exhibit B .
7 COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is only
8 for treatment, payment, and health care operations.
9 COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
10 PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for Economic
11 and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder by the
12 U.S. Department of Health and Human Services (HIPAA Regulations) and other applicable laws.
13 12. NON-DISCRIMINATION
14 During the performance of this Agreement, CONTRACTOR shall not unlawfully discriminate
15 against any employee or applicant for employment, or recipient of services, because of race, religious
16 creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic
17 information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, military
18 status or veteran status pursuant to all applicable State of California and Federal statutes and regulation.
19 13. NOTICES
20 The persons and their addresses having authority to give and receive notices under this
21 Agreement include the following:
22 COUNTY CONTRACTOR
Director, COUNTY OF FRESNO ATTN: Director, Information Security
23 Department of Public Health Valley Children's Hospital
P.O. Box 11687 9300 Valley Children's Place
24 Fresno, CA 93721 Madera, CA 93636-8762
25 All notices between the COUNTY and CONTRACTOR provided for or permitted under this
26 Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
27 an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
28 personal service is effective upon service to the recipient. A notice delivered by first-class United States
-8-
I mail is effective three COUNTY business days after deposit in the United States mail, postage prepaid,
2 addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
3 COUNTY business day after deposit with the overnight commercial courier service, delivery fees prepaid,
4 with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by
5 telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission
6 is completed outside of COUNTY business hours, then such delivery shall be deemed to be effective at the
7 next beginning of a COUNTY business day), provided that the sender maintains a machine record of the
8 completed transmission. For all claims arising out of or related to this Agreement, nothing in this section
9 establishes, waives, or modifies any claims presentation requirements or procedures provided by law,
10 including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government Code,
11 beginning with section 810).
i
12 14. GOVERNING LAW
13 Venue for any action arising out of or related to this Agreement shall only be in Fresno
14 County, California.
15 The rights and obligations of the parties and all interpretation and performance of this
16 Agreement shall be governed in all respects by the laws of the State of California.
17 15. SEVERABILITY
18 The provisions of this Agreement are severable. The invalidity or unenforceability of any one
19 provision in the Agreement shall not affect the other provisions.
20 16. ENTIRE AGREEMENT
21 This Agreement, including Exhibit A and B, constitutes the entire agreement between the
22 CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
23 Agreement negotiations, proposals, commitments, writings, advertisements, publications, and
24 understanding of any nature whatsoever unless expressly included in this Agreement.
25 111
26 111
27 111
28 111
-9-
I
I IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written.
3 CONTRACTOR: COUNTY OF FRESNO:
4 Valley Children's Hospital
5 &i
6 Danielle Barry
7 VP Revenue Cycle Management
8 Nathan Magsig, Chairman of the Board of f
9 Supervisors of the County of Fresno
10 '
11
12 i
ATTEST:
13 Bernice E. Seidel
Clerk of the Board of Supervisors
14 County of Fresno, State of California
15
By:
16 Deputy i
1
17
18
19
20
21 Mailing Address:
ATTN:Vice President
22 Revenue Cycle Management
9300 Valley Children's Place
23 Madera,CA 93636
24
25
26
FOR ACCOUNTING USE ONLY:
27 ORG No.: 5620
Fund: 0001
28 Subclass: 10000
-10-
" Valley Information Systems NON-
, _
hildren s Exhibit A Employee Remote Access
HEALTHCARE
Agreement �.
Valley Children's Hospital ("Children's") maintains remote access for certain Remote Users who require
an electronic connection to hospital systems from offsite locations for the purpose of providing the best
possible service to our patients.
Remote Access Agreement
1. Acceptable Use standard. Remote User agrees to read and adhere to Children's Acceptable Use
policy (AD-1001) while connected to and utilizing any information system remotely.
2. Protection of Confidential Information. Remote User agrees to protect the confidentiality,
integrity and availability of all electronic patient health information at all times. Remote User agrees
to comply with all organizational policies, state and federal laws and regulations concerning the
security and privacy of confidential information.
3. Passwords and Codes. Remote User agrees to abide by Children's Access Control Policy
regarding usernames and passwords. Remote User will NOT share passwords, codes, credentials,
or user accounts with others.
4. Appropriate Safeguards. Remote User agrees to take proper steps to ensure the security of the
device in which they connect to Children's systems remotely. Remote User agrees not to copy
information accessed remotely to local devices and or portable devices. Printing information is also
not permitted unless specific authorization has been granted.
5. Auditing and logging. Remote User agrees that his/her remote access is subject to review and/or
audit by Children's. Upon notice, Remote User agrees to return any Children's-owned portable
device for purposes of ensuring compliance with this Agreement and the policies described herein.
6. Response to Confidentiality Concerns. Remote User acknowledges that if Children's determines
in its discretion that remote access has been compromised by unauthorized parties, or that remote
access has been misused, any or all of the following actions may be taken:
a. Remote Access terminated or disabled.
b. Notification to Remote User and/or Remote User's supervisor of concerns related to remote
access.
c. Termination of this agreement.
d. Notification of the human resources department, information security officer, and/or
information privacy officer may occur.
7. Notification of Breach. During the term of this Agreement, Remote User shall notify Children's
within (24) hours of any suspected or actual breach of security, intrusion or unauthorized use of
disclosed PHI of which Remote User becomes aware. Notification will be made in the way of the
ITS Service Desk (559) 353-7300
8. Non-Disclosure Statement. Remote User acknowledges and agrees that access of information
through use of Hospital Information Systems warrants access to proprietary Hospital Information,
and that such data (information) is confidential and/or secret with ownership solely that of
Children's. Authorized individuals listed on this form who access the Hospital Information System
shall treat the data contained therein as confidential, and shall not disclose or otherwise make
available such information and data to any other person other than the affected patient or
appropriate persons involved with the medical care of the patient, except in accordance with all
applicable patient medical record and information confidentiality laws, rules and regulations and as
permitted by patient consent, contracts with Children's, or IRB authorization. Do not print or access
protected health information unless authorized to do so. Remote User agrees to abide by applicable
federal and state laws and regulations governing the privacy and security of protected health
information. Violators will be prosecuted to the full extent of the law for criminal charges and/or
Page 1 of 3
WIN a
Valley Information Systems NON-Employee
Children's Remote Access Agreement 7.18
HEALTHCARE
monetary damages and shall indemnify and hold harmless Children's against all liability resulting
from violations or alleged violations. Remote User shall ensure Children are that information shall
not be accessed through equipment at any site not previously approved by
Information Technology Services (ITS). Remote User shall immediately notify Children's
Information Systems and/or Administration of any unauthorized access via their computer system.
9. Termination of Agreement. Should the authorized user no longer require access to the system,
notification of such change shall be made within 24 hours to Children's Information Systems. Upon
termination, all protected health information shall be destroyed or returned to Children's.
Notwithstanding the foregoing, Children's reserves the right to terminate this Agreement at any time
upon at least thirty (30) days' advance notice to Remote User.
10. Training Module Agreement Statement: Remote User acknowledges and agrees that he or she
has been provided the Remote Access and Portable Device Training Module from Children's.
Remote User also acknowledges that this training module has been successfully completed prior to
obtaining access to Children's Information Systems or receipt of a Children's-owned portable
electronic device. Only the authorized individual listed on this form shall have access to Children's
Information Systems or portable device.
Page 2 of 3
" Valley Information Systems NON-Employee
Children's Remote Access Agreement 7.18
HEALTHCARE
Remote Access Agreement Acknowledgement
By completing and signing this form, you acknowledge that you have read and understand the aforementioned
agreements and all supported policies that pertain to it. All organizational policies are available upon request from
the ITS service desk (559)353-7300. To complete this form: Fill top section of this form. Please print clearly,
Incomplete or illegible forms will not be processed and may be returned, Return this page only. All other pages are
for your records.
Please complete the section . fields
BusinessProvider: Physician, Resident,Allied Health Practitioner(NP/PA), MA
[efin:itions. Affiliated Office Staff:Affiliated through a health-care provider, hospital or referring partner
Payer or Billing Representative: Needs access to systems for Insurance, billing and payaplated information.
.-
Provider ❑ Affiliated Office Staff❑ Payer or Billing Representative FJConsultant/Other❑
Company Name Dep.
LTitle Phone •-
Supervisors Name Supervisor Contact Number Supervisor's Title
Describe Purpose of Remote Access Who is your Valley Children's Sponsor? (Print Sponsor's Name)
E I -
Requesting Remote User Signature
■. -
Valley Children's -Internal Use(I have read the above and agree to all terms and conditions contained therein.)
Valley Children's Hospital Sponsor Name Employee Number(LSID) Date Access Expires: (Please enter the
(Workforce member authorizing non-employee access.) HR/MedStaff Use Only date this access should be removed)
Valley Children's Hospital Sponsor Signature
(I authorize remote access for the above non-employee.) Date
Note: This form is only an acknowledgment for the authorization of'remote access' and does not grant the user access to any
information system within the Valley Children's Hospital network infrastructure.All requests for access to information systems
must be completed and submitted by a Valley Children's Hospital employee (Sponsor)as an access request on the George page.
MAIL COMPLETED FORMS BACK TO:Valley Children's Hospital 9300 Valley Children's Place, Mailstop PCXG-01,
Madera CA 93638-8762 or fax to 559 353-7169 or email: ITS Serviced esk valIe chiIdrens.or
Page 3 of 3
EXHIBIT B
LIST OF COUNTY OF FRESNO EMPLOYEES TO ACCESS
Authorized to access EMRs from Valley Children's Healthcare(Hospital)Corporate Information System
CMS Division
Employee Name Title Program
Acosta,Tiffany Nicole Sandy Admitting Interviewer CCS Administration
Almaguer,Noel Public Health Nurse CCS Administration
Arce,Sandy Sue Public Health Nurse CCS Administration
Bomgardner,Marla Lynn Supvsng Public Health Nurse CCS Administration
Bong,Vanessa Admitting Interviewer CCS Administration
Burgess Jr.,Joseph E. Staff Nurse CCS Administration
Conde,Marilyn J. Physical Therapist CCS Administration
Constantino,Rudy C Admitting Interviewer CCS Administration
Escobedo,Maria Alicia Admitting Interviewer CCS Administration
Garza-Wayne,Yuidico Admitting Interviewer CCS Administration
Gip,Quy Anh Staff Nurse CCS Administration
Jensen,Maribeth B Staff Nurse CCS Administration
Lawson,Sherilee J. Head Nurse CCS Administration
Lee,Pa Admitting Interviewer CCS Administration
Lopez,Rebecca Admitting Interviewer CCS Administration
Martin,Darawadee M Staff Nurse CCS Administration
Mayugba,Benilda B. Staff Nurse CCS Administration
Mehta,Khusal Public Health Physician CCS Administration
Mendoza,Sonia L Sr Admitting Interviewer CCS Administration
Milburn,Megan Public Health Nurse CCS Administration
Nava,Marcy Melanie Admitting Interviewer CCS Administration
Orejel,Martha Medical Social Worker CCS Administration
Ozaeta,Amada Public Health Nurse CCS Administration
Ramiro,Marjelyn V Staff Nurse CCS Administration
Reyes,Luz M Admitting Interviewer CCS Administration
Reyna,Veronica Staff Nurse CCS Administration
Roberts,Laurie Kay Admitting Interviewer CCS Administration
Robles-Solis,Ariana Medical Social Worker CCS Administration
Rodriquez,Angel Admitting Interviewer CCS Administration
Romans,Robert Admitting Interviewer CCS Administration
Smith,Shavonne Staff Nurse CCS Administration
Staub,Sarrina Admitting Interviewer CCS Administration
Stevens,Kelly D Staff Nurse CCS Administration
Tagoe,Vivien Staff Nurse CCS Administration
Taylor,Bobbi Lynn Sr Admitting Interviewer CCS Administration
Thao,Bernard Admitting Interviewer CCS Administration
Tristan,Anita A. Admitting Interviewer CCS Administration
Tueno,Joele Public Health Nurse CCS Administration
Van helsdingen,Khamsay Staff Nurse CCS Administration
Verma,Rajeev Public Health Physician CCS Administration
Vue,Michael P Admitting Interviewer CCS Administration
Woo,Heather Gin Public Health Nurse CCS Administration
Yang,Jing Staff Nurse CCS Administration
Yang,Timothy Kou Staff Nurse CCS Administration
Bains,Kayli Occupational Therapist CCS Medical Therapy Program
Burckert,Eleana M Physical Therapist CCS Medical Therapy Program
Butler,Denise Dale Occupational Therapist CCS Medical Therapy Program
Dhillon,Harsharn K. Rehabilitative Therapy Manager CCS Medical Therapy Program
Dillard,Destanie Therapy Aide CCS Medical Therapy Program
Elenes,Aida Therapy Aide CCS Medical Therapy Program
Holmes,Danielle M Physical Therapist CCS Medical Therapy Program
Machado,Megan Physical Therapist CCS Medical Therapy Program
Piche,Ross Physical Therapist CCS Medical Therapy Program
Sotelo,Susana Therapy Aide CCS Medical Therapy Program
Sticklin,Amy M. Physical Therapist CCS Medical Therapy Program
Yamashita,Sara Occupational Therapist CCS Medical Therapy Program
LIST OF COUNTY OF FRESNO EMPLOYEES TO ACCESS
Authorized to access EMRs from Valley Children's Healthcare(Hospital)Corporate Information System
COMMUNITY HEALTH
DIVISION
Employee Name Title Program
Amesquita,Amanda Program Technician Epidemiology
Lucas,Anthony Program Technician Epidemiology
Mendoza,Gregory Program Technician Epidemiology
Polfer,Kathrynn Program Technician Epidemiology
Vue,Ge Supervising Public Health Nurse TB Control/Immunization
Al Saghbini,Samer Public Health Physician TB Control/Immunization
Blanks,Scotti Public Health Nurse TB Control/Immunization
Cox,Rogenia Communicable Disease Specialist TB Control/Immunization
Herrera,Rebecca Public Health Nurse TB Control/Immunization
Lee,Vang Public Health Nurse TB Control/Immunization
Lor,Koua Public Health Chemist TB Control/Immunization
Lung,Calvin Public Health Microbiologist TB Control/Immunization
Ramos,Patricia Staff Nurse TB Control/Immunization
Zendejas,Juana Communicable Disease Specialist TB Control/Immunization
Padgett,Lissett Communicable Disease Specialist Communicable Disease Investigation(CDI)
Marron,Martha Communicable Disease Specialist Communicable Disease Investigation(CDI)
Mendoza,Paula Communicable Disease Specialist Communicable Disease Investigation(CDI)
Perez,Angela Communicable Disease Specialist Communicable Disease Investigation(CDI)
Sanchez,Norma Communicable Disease Specialist Communicable Disease Investigation(CDI)
Tran,Thi Public Health Nurse Childhood Lead Poisoning Prevention/CDI
Dang,Michael Public Health Nurse Childhood Lead Poisoning Prevention/CDI
Peterson,Shelby Public Health Nurse Childhood Lead Poisoning Prevention/CDI
Day,Jennifer Public Health Nurse Congenital Syphilis
Carney,Mark Social Worker Congenital Syphilis
Thomas,Kim Communicable Disease Specialist HIV Surveillance
Kitaoka,Kevin Communicable Disease Specialist STD Program
Morales,Agustin Communicable Disease Specialist STD Program
Morales,Jay Communicable Disease Specialist STD Program
Montes,Iris Communicable Disease Specialist STD Program
Vang,Hou Communicable Disease Specialist STD Program
PUBLIC HEALTH NURSING
Employee Name Title Program
Adolf,Natalie Public Health Nurse Coordinator FIMR/SID*Coordinator
Carrasco,Monica Public Health Nurse Foster Care
Chavez,Nadia Public Health Nurse Foster Care
Cunningham,Stacey Public Health Nurse Foster Care
Lopez,Sally Public Health Nurse Foster Care
Petersen,Janelle Public Health Nurse Foster Care
Schmidt,Kathy Public Health Nurse Foster Care
Wade,Lupe Public Health Nurse Foster Care
*Fetal Infant Morbidity Report/Sudden Infant Death