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HomeMy WebLinkAboutA-06-352 DPH Misc. Docs.pdf CONTRACT STATUS FORM ��ti CO RECEIVE .: � fp O 856 O DATE: December 01, 2023 FEB 2 2 ES'� DIVISION(S): Emergency Services DEPA�OMI�ACTSSBL ION L (Lead Division listed first) CONTRACTOR: Community Regional Medical Center SERVICES: EMT-P Clinical Training Experience CONTRACT TERM: 7/1/06 to 6/30/24 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2024 ❑ Extend contract through: , 20 With no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 60 , 20 Cancel contract effective: , 20 1-1 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: ; Program Supervisor/Staff Analyst: Date: �-/ 1 Y/14 Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CONTRACT STATUS FORM DATE: December 01, 2022 DIVISION(S): Emergency Medical Services RECEIVE (Lead Division listed first) 2023 CONTRACTOR: Community Regional Medical Center FEB 7 { SERVICES: EMT-P Clinical Training Experience DEPARCONNR OC V 5tC CONTRACT TERM: 7/1/06 to 6/30/23 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2023 Extend contract through: , 20 With no changes in terms or conditions. ❑ With the following change(s): © Evergreen: Continue contract through: , 20 Z ❑ Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Analyst: Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 _ CO O UP CNTRACT STATUS FORM It DATE: December 01, 2021 RECEIVED FxtiS� DIVISION(S): Emergency Medical Services DEC 0 7 20 1 (Lead Division listed first) CONTRACTOR: CommunityRegional Medical Cen�eAr ONTR CT PUBLIC EALTH 9 CONTRACTS SECTION SERVICES: EMT-P Clinical Training Experience CONTRACT TERM: 7/1/06 to 6/30/22 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2022 Extend contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): �( Evergreen: Continue contract through: to I i a -' 20 7i3 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: 0 -Z�Program Supervisor/Staff An yst Date: lZ/ Division Manager: Date: +Z 17 /Z I Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 COUP CONTRACT STATUS FORM RECEIVE o s o DATE: December 01, 2020 FxES� JAN 14 2021 DIVISION(S): Emergency Medical Services (Lead Division listed first) DEPARTMENT OF PUBLIC HEALT CONTRACTS SECTION CONTRACTOR: Community Regional Medical Center SERVICES: EMT-P Clinical Training Experience CONTRACT TERM: 7/1/06 to 6/30/21 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2021 Extend contract through: , 20 ❑ With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: ! vd , 20 Z ❑ Cancel contract effective: , 20 11 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. Program Supervisor/Staff A lyst: Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 w CO U� CWNTRACT STATUS FOwM �� r M O� s6 O DATE: December 02, 2019 FxES� DIVISION(S): Emergency Medical Services RECEIVEF (Lead Division listed first) JUN 2 3 202 CONTRACTOR: Community Regional Medical Center DEPARTMENT OF PUBLIC SERVICES: EMT-P Clinical Training Experience CONTRASTS SECTION CURRENT PERIOD: 7/1/06 to 6/30/20 E Auto-renewal rough: (If not chgKmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Evergreen Agreement-Please Review Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2020 ❑ Renew contract through: , 2a ❑ With no changes in terms or conditions. 11 With the following change(s): Evergreen: Continue contract through: , 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff An st: Date: Division Manager: Date: �,jlzo ro Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 ti CO U� CONTRACT STATUS FORS O� 36 O DATE: November 29, 2018 ES� DIVISION(S): Emergency Medical Services RECEIVED (Lead Division listed first) DEC 0 6 2018 CONTRACTOR: Community Regional Medical Center DEPARTMENT OF PUBLIC LTH SERVICES: EMT-P Clinical Training Experience CONTRACTS SECTIO CURRENT PERIOD: 7/1/06 to 6/30/2019 E Auto-renewal: ❑ through: (If not checkmarked above, contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2019 ❑ Renew contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 20 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff alyst: Date: Z Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 _ CO, CONTRACT STATUS FORM DATE: December 01, 2017 RECEIVED DIVISION(S): Emergency Medical Services (Lead Division listed first) JAN 2 3 2 CONTRACTOR: Community Regional Medical CenterDEPARTMENT OF PUBVHLTH CONTRACTS SE SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/17 to 6/30/2018 E Auto-renewal: O through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2018 Renew contract through: , 20 ❑ With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. Program Supervisor/Sta nal Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 �• CO� U� CONTRACT STATUS FORM 19 ti DATE: November 28, 2016 FRESH DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Community Regional Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/16 to 6/30/17 E Auto-renewal: 1 - through: (if not the ontract will terminate ENTIRE TERM: 7/1/2006 to Evergreen a t�went period.) ORGANIZATION #(s): 56201694 DEC 0 5 2016 CONTRACT AMOUNT $0.00 DEPARTMENT Of PUBLIC HEAL ADDITIONAL INFO: CONTRACTS SECTION Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2017 Renew contract through: 120 /)6 With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: (kogram Supervisor/S An ly Date: t 1 Division Manager: Date: lZ Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CO, MNTR.ACT STATUS F01 4 O� s6 O DATE: November 20, 2015 FxES� DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Community Regional Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/15 to 6/30/16 E Auto-renewal: through: (if not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2016 2-Renew contract through: CP/ 3067 , 20 . kV ith no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: 20 . ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: \\��P,,rogram Supervisor/Staff nalyst: Date: ` , ,� ivision Manager: Date: !c� a-, Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 W COUP CONTRACT STATUS FORM DATE: December 01f, 2014 FxES� DIVISION(S): Emergency Medical Services RECEIVED (Lead Division listed first) CONTRACTOR: Fresno Community Hospital & Medical Center JAN 14 2015 DEPARTMENT OF PUBLIC HEALTH SERVICES: EMT-P Clinical Training Experience CONTRACTS SECTION CURRENT PERIOD: 7/1/14 to 6/30/15 E Auto-renewal: through: (If not the marked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2015 O'Renew contract through: ! ��5 , 20 IVith no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: 20 ❑ Cancel contract effective: , 20 1-1 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: V�rogram Supervisor/Staff aly Date: � Division Manager: Date: 1 Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 ti coU� CMTRACT STATUS FORM /7 DATE: December P< 2013 DES DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Fresno Community Hospital & Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/13 to 6/30/14 E Auto-renewal: ❑ through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): /7 Complete the information below and return to DPH Contracts by: March 20 P-I'R'�enew contract through: JVAe- 36 , 20_/,J�2. RECEIVED Ith no changes in terms or conditions. ...A4 DEC 19 2013 DEPARTMENT OF PALIC hEALTh ❑ With the following change(s): CONTRACTS SECTION ❑ Evergreen: Continue contract through: 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): approved by: �rogram Supervisor/Staff lyst Date: �ivision Manager: r Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CONTRACT STATUS FORM �w co�,�, O� s6 O DATE: December 03, 2012 DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Fresno Community Hospital & Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/12 to 6/30/13 E Auto-renewal: O through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2013 ❑ Renew contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): _ aEvergreen: Continue contract through: 6 T" 20 Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Superviso taffAnal s — Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CO tj� CONTRACT STATUS FOR U § '� DATE: Decembers 2011 DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Fresno Community Hospital & Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/11 to 6/30/12 E Auto-renewal: [I through: (if not checkmarked above, contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State[Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2012 Renew contract through: , 20-, With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: �;�.� 3- , 20 1-3 , Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervi r/Staff An la s � `-- -� Date: / Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 445-7090 CONTRACT STATUS FORM w co�,� o� o DATE: December 01, 2010 DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Fresno Community Hospital & Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/10 to 6/30/11 E Auto-renewal: through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2011 Renew contract through: , 20 With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: 3 C1 20 Al ❑ Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervise tall Analyst. Date: 4 Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 �� COUP CONTRACT STATUS F09M ', RECEIVED 1a36 ° DATE: November 24, 2009 JAN 2 DIVISION(S): Emergency Medical Services DEPARTh1Eid'i Gi:ruE_iC r,_ i TH (Lead Division listed first) CON T RA S SEC T ION CONTRACTOR: Fresno Community Hospital & Medical Center SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/09 to 6/30/10 E Auto-renewal: through: (If not the marked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2010 Renew contract through: 0 / so 20 A�Vw no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: , Program Supervisor/Staff alyst: Date: Division Manager: Date: I Z7 /O Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 CID Contract Renewal/Termination Form O 1856 O DATE: December 01, 2008 Esn DIVISION(S): Emergency Medical Services RECEIVED (Lead Division listed first) JAN 0 6 2009 CONTRACTOR: Fresno Community Hospital and Medical C?RFIAENT OF PUBLIC HEALTH CONTRACTS SECTION SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/08 to 6/30/09 E Auto-renewal: E through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract #: A-06-352 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2009 Renew contract through: 0 , 20 With no changes in terms or conditions. ❑ With the following change(s): EEvergreen: Continue contract through: 20 ECancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff nalyst, Date: �Qivision Manager: c Date: / ker Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 co r ow Contract Renewal/Termination Form It V O 360 DATE: November 21, 2007 FRE`'5 TO: Emergency Medical Services RECEjVEr, CONTRACTOR: Fresno Community Hospital and Medical Center DEpgRTMAN C�lQ6 ECM r nEA1 Ty SERVICES: EMT-P Clinical Training Experience ON CURRENT TERM: 7/1/07 to 6/30/08 E Auto-renewal: ❑ Through: FULL TERM: 7/1/2006 to Evergreen ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 LEAD DEPT: DCH State/Vendor#: N/A ADDITIONAL INFO: Contract #: A-06-352 Please complete and return this form to DCH Contracts by: March 1, 2008 Renew contract through: , 20 With no changes in terms or conditions. Amend with the following change(s): Evergreen: Continue contract through: cJ01i e 36 , 20 ❑ Cancel contract effective: , 20 Additional Information: Submitted by: 1 Print Name: Le � �� Title: Signature: Date: /Z Phone #: y = � Approved by: Division Manager Initial: St Analyst Initial: Department Head: < Date: /,V.�qx Submit to: DCH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 r ti coU� Contract Renewal/Termination'Form ti� 0 DATE: December 01, 2006 FItEs� TO: Emergency Medical Services RECEIVED CONTRACTOR: Fresno Community Hospital and Medical Center APR 0 5 DEPARTMENT OF CUMMUNITYHEALTH SERVICES: EMT-P Clinical Training Experience CONTRACTS SECTION CURRENT TERM: 7/1/06 to 6/30/07 E Auto-renewal: -, Through: FULL TERM: 7/1/2006 to Evergreen ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 LEAD DEPT: DCH State/Vendor#: N/A ADDITIONAL INFO: Contract#: A-06-352 Please complete and return this form to DCH Contracts by: March 1, 2007 IVRenew contract through: 130 AR , 20 PqWith no changes in terms or conditions. With the following changes: ❑ Cancel contract effective: , 20 ❑ Additional Information: Approved by: Print Name: '�� LyNG� Division Manager Initial: Signature: Staff Analyst Initial: Title: Date: /z /z OG Phone #: 'J? 7 ' c Department Hea �-- �` Date: DCH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 c coU� County of Fresno DEPARTMENT OF PUBLIC HEALTH DAVID POMAVILLE, DIRECTOR July 28, 2015 Tim Joslin, President & CEO Community Regional Medical Center 2823 Fresno Street Fresno, CA 93721 Dear Contractor, The County of Fresno, Department of Public Health has not received current verification of your insurance requirements in accordance with the "Insurance" Section of the Agreement between the County of Fresno and your agency. Please send us an original insurance certificate(s) verifying that your insurance is in compliance for the period of the Agreement at your earliest possible convenience but no later than thirty (30) days from the date of this letter. Please fax a copy of the certificate to (559) 600-7687 Attn: Contracts and mail the original to: Roberta Bynum, Senior Staff Analyst County of Fresno, Department of Public Health Contracts Section — 61h Floor P.O. Box 11867 Fresno, CA 93775 If you have any questions, please contact me at (559) 600-7090. Sincerely, Roberta Bynum Senior Staff Analyst RB:Iw Promotion,preservation and protection of the community's health 1221 Fulton Mall/P. 0. Box 11867, Fresno, CA 93775 (559) 600-3200 - FAX(559) 600-7687 Equal Employment Opportunity - Affirmative Action - Disabled Employer www.co.fresno.ca.us - www.fcdl2h.org