HomeMy WebLinkAboutAgreement A-20-122 with Sante Health System.pdf-1-
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A G R E E M E N T
THIS AGREEMENT is made and entered into this day of __________, 2020, by and between
the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter referred to as
"COUNTY", and SANTÉ HEALTH SYSTEM, d.b.a. ADVANTEK BENEFIT ADMINISTRATORS, hereinafter
referred to as “ADMINISTRATOR” , a California corporation address is 7370 N. Palm Ave., Fresno, CA
93711. COUNTY and ADMINISTRATOR are referred to herein, collectively, as "Parties", or “Party”
individually.
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Public Health, is in need of a qualified agency to
administer the Non-Resident Specialty Care (NRSC) program; and
WHEREAS, ADMINISTRATOR, has the expertise and qualified personnel to administer NRSC
payments for the provision of specialty medical services for indigent residents (“Beneficiaries” or
Beneficiary”) that do not qualify for other health care options (e.g., full-scope Medi-Cal, MISP); and
WHEREAS, Parties entered into Agreement No. 18-638 effective, April 20, 2018 to administer the
NRSC program; and
WHEREAS, County Agreement No. 18-638, expires on April 19, 2020;
WHEREAS, the Parties mutually desire for ADMINISTRATOR to continue to provide the services it
provided under COUNTY Agreement No. 18-638;
WHEREAS, ADMINISTRATOR desires to continue to administer the NRSC services by selecting
Beneficiaries from referrals it obtains from certain federally funded clinics and/or emergency medical
hospitals that coordinate with federally funded clinics (see referral list attached hereto as Exhibit A and
incorporated by this reference herein) who meet certain eligibility criteria on a first come first serve basis to
certain medical providers (see medical provider list attached hereto as Exhibit B and incorporated by this
reference herein) who perform non-emergency or urgent specialty care services to Beneficiaries.
Now, therefore, COUNTY and ADMINISTRATOR, in consideration of the covenants, agreements,
and conditions herein contained, the parties hereto agree as follows:
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24th March
Agreement No. 20-122
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1. RESPONSIBILITIES OF THE ADMINISTRATOR
In consideration for the compensation as described in Section 2, COMPENSATION, herein,
ADMINISTRATOR shall be responsible to:
A. Select Beneficiaries From Referrals: ADMINISTRATOR shall be responsible to
select Beneficiaries from referrals exclusively provided by certain federally funded clinics and/or
emergency hospitals that coordinate with the federally funded clinics listed in Exhibit A in accordance
with the below provisions.
1) Referral Form: ADMINISTRATOR shall administer the NRSC services by
accepting the Specialty Care Referral Form (“Referral Form”) (attached hereto as Exhibit C and
incorporated by this reference herein) from the federally funded clinics and/or emergency hospitals who
coordinate with the federally funded clinics listed in Exhibit A.
a. ADMINISTRATOR shall not process payment from any other
method or form of referral with respect to NRSC services covered under this agreement.
2) Referral Form Must Be Complete and Accurate: ADMINISTRATOR shall
screen each Referral Form to ensure they are accurate and complete prior to processing for payment.
a. An accurate and complete Referral Form means it contains the
following (note: the numbers below reflect the numbers identified in the boxes of the Referral Form for
ease of reference):
1. Date of request
2. Date last seen by requesting physician
3. Beneficiary’s first and last name, date of birth, age, and gender
4. Beneficiary’s address:
• If the Beneficiary does not have an address because he/she is
homeless, this portion of the Referral Form must be marked “none”
or “homeless”, a blank would be considered an incomplete Referral
Form to be denied by ADMINISTRATOR.
5. Either: (a) “Yes” marked to the Beneficiary having no Share-of Cost
restricted Medi-Cal and there is a DHCS Medi-Cal Eligibility Response
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Transaction that is dated no more than 45 days prior to the date
ADMINISTRATOR received the Specialty Care Referral Form ; or (b)
“No” marked to the Beneficiary having restricted Medi-Cal and a “Yes”
marked to the Beneficiary having a pending Medi-Cal application with the
Medi-Cal application date.
•If “Yes” is marked to having restricted Medi-Cal, but there is no
DHCS Medi-Cal Eligibility Response Transaction that is dated no
more than 45 days prior to the date ADMINISTRATOR received
the completed Specialty Care Referral Form, ADMINISTRATOR
shall deny the Referral Form
•If “Yes” is marked to having restricted Medi-Cal, but the Medi-Cal
Response Transaction that ADMINISTRATOR receives shows that
the Beneficiary has a share-of-cost, ADMINISTRATOR shall deny
the Referral Form
•If “Yes” is marked to having restricted Medi-Cal, but the Medi-Cal
Response Transaction that ADMINISTRATOR receives shows that
the Beneficiary does not have restricted Medi-Cal, but has full
scope or no Medi-Cal, ADMINISTRATOR shall deny the Referral
Form
•If “No” is marked to the Beneficiary having restricted Medi-Cal, but
a “No” (instead of a “Yes”) is marked to the Beneficiary having a
pending Medi-Cal application, ADMINISTRATOR shall deny the
Referral Form
6.Full name of referring physician, which may be either the emergency
care, treating, or the primary care physician, tax identification number of
the federally funded clinic or emergency hospital on the referral list in
Exhibit A; and name of the federally funded clinic/emergency hospital,
which must be listed on Exhibit A
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• If the name of the clinic/hospital and location provided on the
Referral Form is not on the referral list in Exhibit A, the referral
shall be denied by ADMINSTRATOR
7. Contact person at the federally funded clinic/emergency hospital
listed; telephone and facsimile of federally funded clinic/emergency
hospital listed; name of the primary care physician must be filled in if the
referring physician (e.g., the emergency physician) is not the primary care
physician
• ADMINISTRATOR need not deny the Referral Form if there is no
name of the primary care physician
8. The address of the federally funded clinic or emergency hospital
listed
• If the address listed does not match up with a location of a
federally funded clinic or emergency hospital listed in Exhibit A,
ADMINISTRATOR must deny the Referral Form
9. The type of referral requested must be marked and the CPT code/s
shall be filled in
• If a note is written on the Referral Form for a different type of
specialty care service not within the scope of the NRSC funding
attached hereto as Exhibit D (and incorporated by this reference
herein), the ADMINISTRATOR shall seek approval or denial of
service from the COUNTY’S Department of Public Health Director,
or his/her designee, as soon as possible so that the County may
determine whether or not an approved provider is able and willing
to provide the specialty care service requested on the Referral
Form. The COUNTY’S Department of Public Health Director or
his/her designee shall respond in writing to the ADMINISTRATOR
approving or denying the requested specialty care service
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10. Medical Diagnosis, ICD-10 Code, and Date of Onset must be filled in
by the referring physician
11. Referring physician comments and clinical data is optional and
ADMINISTRATOR shall not automatically deny the referral if the
remaining portions of the Referral Form is complete and accurate
12. Beneficiary must mark his/her language that he/she speaks or fill in
his/her language in the “other” box
13. Beneficiary must fill in his/her full name, sign and date the
Applicant’s Attestation in his/her appropriate language of Spanish or
English
• If Beneficiary indicates he/she speaks a different language than
English/Spanish, ADMINISTRATOR shall notify the COUNTY’S
Department of Public Health Director, or his/her designee, as soon
as possible so that the COUNTY may provide the Beneficiary with
an attestation translated to his/her language for signature
• Upon completion of the attestation in the appropriate language, the
ADMINISTRATOR may move forward with processing the Referral
Form
14. The Beneficiary’s referring physician must fill in his/her full name,
sign and date the appropriate Physician’s Attestation under primary or
emergency
3) Denial of Incomplete and Inaccurate Referral Forms: ADMINISTRATOR
shall deny any inaccurate or incomplete Referral Forms in writing, and provide that denial to the
clinic/hospital, referring physician, primary care physician (if different), and applicant. COUNTY shall
have no obligation to compensate ADMINISTRATOR for such referral claim/s if the Referral Form is not
accurate and complete as provided in Section 1, A, 2) above.
4) Preliminary Assurance if Referral Form is marked “Yes” to Pending Medi-
Cal Application: ADMINISTRATOR is required to obtain a preliminary assurance in writing from
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COUNTY’S Director of Department of Public Health, or his/her designee, if a Referral Form is marked
“Yes” to “Medi-Cal application pending”. Request for Preliminary Assurance should include a recent
DHCS Medi-Cal Eligibility Response Transaction printout. Upon ADMINISTRATOR’S receipt of the
written preliminary assurance from the COUNTY’S Director of Department of Public Health, or his/her
designee; it may proceed with processing payment as provided herein.
a.ADMINISTRATOR is not required to obtain the COUNTY’S
preliminary assurance on Referral Forms that are marked “Yes” to Restricted Medi-Cal and are accurate
and complete in accordance to Section b, 1) above, prior to processing payment as set forth in Section
2, COMPENSATION. However, ADMINISTRATOR may consult with COUNTY’S Director of
Department of Public Health, or his/her designee, on an as needed basis should ADMINISTRATOR
have questions pertaining to whether a Referral Form is complete and accurate.
B.Process Referral Claim Only for Claims within the Scope of Services or Other
COUNTY Pre-Approved Specialty Care: ADMINISTRATOR shall only process referral claims that
request reimbursement from the NRSC Scope of Services, which are listed in Exhibit D or which have
been pre-approved by the County as in Section 1., A., 2), a., 9 above. COUNTY shall not be
responsible for providing payment for those referral claims that are not within the Scope of Services
listed in Exhibit D or otherwise have not been pre-approved by COUNTY and reserves the right to deny
payment on such claim/s under Section 2, A herein.
1)Exclusions from the Scope of Services: ADMINISTRATOR shall not
process referral claims and COUNTY shall not be responsible for providing payment for the following
services:
➢Medical services provided outside the Fresno metropolitan area
➢Specialty medical services not referred by a clinic or hospital listed on
Exhibit A
➢Specialty medical services not provided by the medical providers listed on
Exhibit B
➢Any service not covered by Medi-Cal
➢Primary care
➢Emergency care (i.e., a medical condition manifesting itself by acute
symptoms of sufficient severity, including severe pain, such that the
absence of immediate medical treatment could reasonably be expected to
result in placing the patient’s health in serious jeopardy, serious
impairment to bodily functions, and/or serious dysfunction to any bodily
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organ or part)
➢Prenatal/pregnancy related services (prenatal care, labor, deliver, up to 60
days postpartum care, and family planning)
➢Non-emergency dental, vision, and behavioral health care services
➢Organ transplants
➢Chiropractic services and acupuncture services
➢Fertility treatments and reversals, family planning services, and impotency
services
➢Abortion services
➢Breast and cervical cancer treatment
➢Skilled nursing facilities and long-term care facilities
➢Methadone Maintenance and drug and alcohol treatment
➢Allergy testing, injections, or treatment
➢Sexual reassignment surgery
➢Gastric bypass or other weight loss surgery and weight loss/control
services
➢Non-emergency follow-up care provided in an emergency room
➢Non-emergency Hepatitis C treatment
➢Minor consent services (substance abuse treatment 12 or older, mental
health services 12 or older, family planning/pregnancy-related services,
sexually transmitted diseases 12 or older, and sexual assault/rape
treatment)
➢Child Health and Disability Prevention [CHDP] (i.e., regular pediatric
primary care, immunizations, nutrition and lead screening, vision, hearing,
and lab tests, dental, outreach and educational services, referrals for
further diagnosis/treatment, and temporary full scope Medi-Cal benefits)
➢Refugee Medical Assistance or Entrant Medical Assistance
➢Emergency Disaster Relief
➢MISP benefits
➢Any service that a FQHC or RHC is mandated to provide by Federal law
(42 U.S.C. §254b(b)) (e.g. primary care, immunizations, communicable
disease screening, cancer screening, diagnostic, laboratory, radiology
services, eye, ear and dental screenings for children, and pharmaceutical
services)
C.Refer Beneficiaries to Medical Providers: ADMINISTRATOR shall assist the
federally funded clinics and/or emergency hospitals listed in Exhibit A on an as needed basis to find the
appropriate medical providers listed in Exhibit B to provide non-emergency specialty care services within
the Scope of Services listed in Exhibit D to Beneficiaries.
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D.ADMINISTRATOR shall respond to County within 3 business days to requests for
clarification of Beneficiary Referral Forms, questions, noted errors with requests for correction, and/or
for action to be taken on a specific Beneficiary account.
E.ADMINISTRATOR agrees to meet either monthly or quarterly in-person or
electronically to discuss contract administration issues and needs of both ADMINISTRATOR and
COUNTY.
F.ADMINISTRATOR shall have it’s own internal tracking system to track
Beneficiaries eligibility period.
1)When granting a new term for a Beneficiary that has previously been
approved, the same member identification number will be used.
2.COMPENSATION
In exchange for performing the responsibilities listed in Section 1, herein, ADMINISTRATOR
shall obtain reimbursement according to the provisions below.
A.Reimbursement for Third Party Administration Fees and Specialty Professional
Medical Services:
Specialty Medical Services: For the Term of this Agreement set forth in Section 3,
herein, if a federally funded clinic or emergency hospital (in Exhibit A) provides a complete and accurate
Referral Form to ADMINISTRATOR in accordance with Section 1, A, 2) above, and ADMINISTRATOR
has received any necessary written preliminary assurances from COUNTY’S Director of Department of
Public Health , or his/her designee (if required under Section 1, A, 4) above, COUNTY shall reimburse
ADMINISTRATOR for the fees incurred by the medical providers (in Exhibit B) for providing non-
emergency specialty care services within the Scope of Services (in Exhibit D) or which have been
preapproved by the COUNTY to the Beneficiaries according to the fee-for-service Medi-Cal rates
incurred during the date of service and subject to the availability of NRSC funding in Section 2, B below.
Third Party Administration Fees: For the Term of the Agreement set forth in Section 3
herein, COUNTY shall reimburse ADMINISTRATOR for third party administration fees at the monthly
rate of either eight percent (8%) or Five Thousand and No/100 Dollars ($5,000.00), whichever is the
greater amount for the total amount of fees incurred in processing claims from the medical providers (in
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Exhibit B) with respect to the Beneficiaries for non-emergency specialty care services (in Exhibit D),
subject to available funding set forth in Section 2, B below, and the Referral Forms being complete and
accurate in accordance with Sections 1, A, 2), and 1, A, 4). ADMINISTRATOR shall not be entitled to
any reimbursement for non-emergency specialty medical services and third party administration fees
once the contract maximum has been reached.
1)Reimbursement Contingencies for Specialty Medical Services and Third
Party Administration Fees/Valid Claims: ADMINISTRATOR shall only be entitled to reimbursement for
specialty medical services performed by the medical providers listed in Exhibit B and third party
administration fees under this Section 2, A, if ADMINISTRATOR: (a) selects Beneficiaries from referrals
only provided by federally funded clinics and/or emergency hospitals listed in Exhibit A; (b) has received
from a federally funded clinic and/or emergency hospital listed in Exhibit A, a complete and accurate
Referral Form as set forth in Sections 1, A, 2) and 1, A, 4); (c) receive written preliminary assurances
from the COUNTY’S Director of Department of Public Health, or his/her designee, on Referral Forms
marked “Yes” to “Medi-Cal application pending”; (d) medical providers in Exhibit B seek reimbursement
for necessary non-emergency specialty medical services as listed in Exhibit D or which have been pre-
approved by the COUNTY, and not an excluded services listed in Section 1, B, 1); (e) ensures there is
available funding to process payment in accordance with the maximum payment limit in Section 2, B; (f)
processes payment in accordance with Section 2,B; and (g) submits invoice/s to COUNTY as set forth in
Section 2,D.
B.Maximum Payment/Availability of Funds: In no event shall the total available
funds for NRSC reimbursement for non-emergency specialty medical services provided by medical
providers (listed in Exhibit B) and third party administrative fees charged by ADMINISTRATOR be in
excess of Three Million Dollars ($3,000,000.00) (“Available Funding/Contract Maximum”).
ADMINISTRATOR shall not be entitled to receive any further payment from COUNTY upon receipt of
valid claims from medical providers and third party administrative fees that reach the Available Funding
limit. This Agreement shall automatically terminate once the Available Funding has been exhausted, as
set forth in Section 3 herein.
1)Notice of 85% Expenditure of Funds/Winding Down Procedure:
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ADMINISTRATOR agrees that when the total combined amount of valid claims received and third party
administrative fees charged reached eighty-five percent (85%) of the Available Funding (i.e., Two Million
Five Hundred Fifty Thousand Dollars and Zero Cents ($2,550,000), ADMINISTRATOR shall
immediately provide written notice to: (a) the federally funded clinics and emergency hospitals listed in
Exhibit A; (b) the medical providers listed in Exhibit B; and (c) COUNTY.
The written notice shall contain the following points:
➢There remains only fifteen percent (15%) in available funding.
➢The medical providers are required to forward all claims for reimbursement
to ADMINISTRATOR within the next thirty (30) calendar days, and the
medical providers shall only receive a pro-rata portion of their claims on
the remaining available funds if the remaining funds are less than the total
amount of the claims and third party administrative fees combined.
➢Federally funded clinics and/or emergency hospitals listed in Exhibit A
shall have ten (10) calendar days to submit accurate and complete
Referral Forms to ADMINISTRATOR, and there will be no guarantee that
these Referral Forms will be processed and/or accepted by
ADMINISTRATOR.
➢ADMINISTRTOR will provide written notice in the future to the medical
providers, federally funded clinics and emergency hospitals if additional
funding becomes available.
In the event the claims from medical providers in the thirty (30) calendar days after eighty-five percent
(85%) of the Available Funding is expended, does not exhaust the Available Funding limit in Section
2,B, ADMINISTRATOR shall process payment for the full amount for those claims in accordance with
this Section 2. After such reimbursement, ADMINISTRATOR shall provide written notice to the medical
providers and federally funded clinics and emergency hospitals (in Exhibits A and B) with a copy to
COUNTY indicating that there is available funding. The notice shall state that the medical providers
shall have an additional thirty (30) calendar days to submit claims to ADMINISTRATOR and that the
federally funded clinics and emergency hospitals shall have an additional ten (10) calendar days to
submit accurate and complete Referral Forms to ADMINISTRATOR. The ADMINISTRATOR shall add
to the notice that there will be no guarantee that the Referral Forms will be processed and/or accepted
by ADMINISTRATOR. The ADMINISTRATOR shall process payment on the remaining Available
Funding on a pro-rata basis for a portion of their claims if the remaining Available Funding is less than
the total amount of the claims and the third party administrative fees combined.
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The foregoing winding down procedure shall continue and repeat until the Available Funding is
completely exhausted.
C. Waiver: ADMINISTRATOR, including its respective predecessors, successors,
subcontractors, agents, officers, representatives, executors, beneficiaries and assigns, agrees and
acknowledges that it will release and forever discharge the COUNTY from any and all actions, causes of
actin, claims, suits, judgements, demands, liens, promises, agreements, contracts, obligations, rights,
penalties, sanctions, damages, punitive damages, attorneys’ fees, costs, losses, liabilities, demands,
fees or expenses of any kind or nature it may or will have against the COUNTY with respect to
reimbursement for any and all claims relating to services Beneficiaries received under this Agreement
and third party administration fees that would exceed the Available Funding in Section 2, B.
D. Billing/Invoicing: ADMINISTRATOR shall accept claims from the medical
providers listed in Exhibit B who provide non-emergency specialty medical services to Beneficiaries
within the Scope of Services (Exhibit D) or which were pre-approved by COUNTY, in accordance with
the terms of this Agreement and subject to the compensation contingencies set forth in Sections 2. A
and 2, B. After accepting a claim that meets the compensation contingencies in Sections 2. A and 2, B,
ADMINISTRATOR shall submit an invoice to the COUNTY for reimbursement of such claim.
Such invoice for reimbursement shall contain the following information: (a) the
date/s of service; (b) full and complete descriptions of each service provided; (c) the cost of each
specialty medical service provided; (d) cost of the third party administrative fee; (e) the total amount
billed by ADMINISTRATOR to date for specialty medical services and third party administration fees
under this agreement; (f) the Medi-Cal codes utilized to determine cost of service; and (g) the name and
current contact information of the Beneficiary who received such services.
1) Claims shall be submitted to COUNTY electronically or on a HCFA-1500
billing form.
2) ADMINISTRATOR agrees to submit invoices/reimbursement claims to
COUNTY for services referred under this Agreement no later than ninety (90) days after the service was
delivered.
3) COUNTY agrees to reimburse ADMINISTRATOR, subject to
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contingencies set forth in Sections 2, A and 2, B forty-five (45) calendar days after receipt and
verification of the invoices form ADMINISTRATOR.
4)Invoices shall be submitted to County of Fresno, Department of Public
Health, P.O. Box 11867, Fresno, CA 93775, Fresno, CA 93775, Attn: DPH Director.
5)Invoiced to COUNTY for specialty medical services shall be coded and
billed correctly pursuant to the fee-for-service Medi-Cal rate in effect at the time the medical service was
rendered according to the procedure code located at :
http://files.medi-cal.ca.gov/pubsdoco/Rates/RatesHome.asp
6)It is understood that all expenses incidental to ADMINISTRATOR'S
performance of services under this Agreement shall be borne by ADMINISTRATOR.
3.TERM
The term of this Agreement shall be for a period of three (3) years, commencing on the 20th of April
2020 through and including the 19th of April, 2023. This Agreement may be extended for two (2) additional
consecutive twelve (12) month periods upon written approval of both parties no later than thirty (30) days
prior to the first day of the next twelve (12) month extension period. The COUNTY’S Director of Public
Health, or his or her designee, is authorized to execute such written approval on behalf of COUNTY based
on ADMINISTRATOR’S satisfactory performance. The same terms and conditions herein set forth, unless
written notice of nonrenewal or termination as set forth in Section 4 is provided by COUNTY or COUNTY’S
Director of Public Health, or his/her designee.
4.TERMINATION
A.Non-Allocation of Funds: The terms of this Agreement, and the services to be
provided hereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated, at any time by giving the ADMINISTRATOR thirty (30) days advance written notice.
B.Breach of Contract: The COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of the COUNTY there is:
1)An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
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3) A substantially incorrect or incomplete report submitted to the COUNTY;
4) Improperly performed service.
In no event shall any payment by the COUNTY constitute a waiver by the COUNTY of any breach
of this Agreement or any default, which may then exist on the part of the ADMINISTRATOR. Neither shall
such payment impair or prejudice any remedy available to the COUNTY with respect to the breach or
default. The COUNTY shall have the right to demand of the ADMINISTRATOR the repayment to the
COUNTY of any funds disbursed to the ADMINISTRATOR under this Agreement, which in the judgment of
the COUNTY were not expended in accordance with the terms of this Agreement. The ADMINISTRATOR
shall promptly refund any such funds upon demand.
C. Without Cause: Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written notice of
an intention to terminate to ADMINISTRATOR.
Upon termination or expiration of this Agreement under Sections 3 and/or 4
herein, each Party shall continue to remain liable for their own obligations or liabilities, as indicated
herein, originating prior to termination of this Agreement.
5. INDEPENDENT CONTRACTOR
In performance of the work, duties and obligations assumed by ADMINISTRATOR under this
Agreement, it is mutually understood and agreed that ADMINISTRATOR, including any and all of the
ADMINISTRATOR'S officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no right
to control or supervise or direct the manner or method by which ADMINISTRATOR shall perform its work
and function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
ADMINISTRATOR is performing its obligations in accordance with the terms and conditions thereof.
ADMINISTRATOR and COUNTY shall comply with all applicable provisions of law and the rules
and regulations, if any, of governmental authorities having jurisdiction over matters the subject thereof.
Because of its status as an independent contractor, ADMINISTRATOR shall have absolutely no
right to employment rights and benefits available to COUNTY employees. ADMINISTRATOR shall be
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solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
benefits. In addition, ADMINISTRATOR shall be solely responsible and save COUNTY harmless from all
matters relating to payment of ADMINISTRATOR'S employees, including compliance with Social Security
withholding and all other regulations governing such matters. It is acknowledged that during the term of this
Agreement, ADMINISTRATOR may be providing services to others unrelated to the COUNTY or to this
Agreement.
6.MODIFICATION
With the exception of deletions and additions of federally funded clinics and/or emergency hospitals
under Section 6, A, herein, and medical providers under Section 6, B, herein, any matters of this
Agreement may be modified from time to time by the written consent of all the parties without, in any way,
affecting the remainder.
A.COUNTY’S Director of Department of Public Health shall have the sole discretion to
add or delete the federally funded clinics and/or emergency hospitals that coordinate with federally funded
clinics listed in Exhibit A, attached hereto. COUNTY shall place ADMINISTRATOR on notice immediately
upon deleting or adding federally funded clinics and/or emergency hospitals that coordinate with federally
funded clinics listed in Exhibit A.
B.COUNTY’S Director of Department of Public Health shall have the sole discretion to
add or delete the medical providers listed in Exhibit B, attached hereto. COUNTY shall place
ADMINISTRATOR on notice immediately upon deleting or adding medical providers on Exhibit B.
7.NON-ASSIGNMENT
Neither party shall assign, transfer or sub-contract this Agreement nor their rights or duties under
this Agreement without the prior written consent of the other party.
8.HOLD HARMLESS
ADMINISTRATOR agrees to indemnify, save, hold harmless, and at COUNTY'S request, defend
the COUNTY, its officers, agents, and employees from any and all costs and expenses (including attorney’s
fees and costs), damages, liabilities, claims, and losses occurring or resulting to COUNTY in connection
with the performance, or failure to perform, by ADMINISTRATOR, its officers, agents, or employees under
this Agreement, and from any and all costs and expenses (including attorney’s fees and costs), damages,
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liabilities, claims, and losses occurring or resulting to any person, firm, or corporation who may be injured or
damaged by the performance, or failure to perform, of ADMINISTRATOR, its officers, agents, or employees
under this Agreement.
9.INSURANCE
Without limiting the COUNTY's right to obtain indemnification from ADMINISTRATOR or any third
parties, ADMINISTRATOR, at its sole expense, shall maintain in full force and effect, the following
insurance policies or a program of self-insurance, including but not limited to, an insurance pooling
arrangement or Joint Powers Agreement (JPA) throughout the term of the Agreement:
A.Commercial General Liability: Commercial General Liability Insurance with limits of
not less than two million dollars ($2,000,000.00) per occurrence and an annual aggregate of four million
dollars ($4,000,000.00). This policy shall be issued on a per occurrence basis. COUNTY may require
specific coverages including completed operations, products liability, contractual liability, Explosion-
Collapse-Underground, fire legal liability or any other liability insurance deemed necessary because of the
nature of this contract.
B.Automobile Liability: Comprehensive Automobile Liability Insurance with limits of not
less than one million dollars ($1,000,000.00) per accident for bodily injury and for property damages.
Coverage should include any auto used in connection with this Agreement.
C.Professional Liability: If ADMINISTRATOR employs licensed professional staff,
(e.g., Ph.D., R.N., L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of
not less than one million dollars ($1,000,000.00) per occurrence, three million dollars ($3,000,000.00)
annual aggregate.
D.Cyber Liability: Cyber Liability Insurance with limits not less than two million
dollars ($2,000,000) per occurrence or claim, two million dollars ($2,000,000) aggregate. Coverage
shall be sufficiently broad to respond to the duties and obligations as is undertaken by
ADMINISTRATOR in this Agreement and shall include, but not be limited to, claims involving
infringement of intellectual property, including but not limited to infringement of copyright, trademarks,
trade dress, invasion of privacy violations, information theft, damage to or destruction of electronic
information, release of private information, alteration of electronic information, extortion and network
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security. The policy shall provide coverage for breach response costs as well as regulatory fines and
penalties as well as credit monitoring expenses with limits sufficient to respond to these obligations.
E.Worker's Compensation: A policy of Worker's Compensation insurance as may be
required by the California Labor Code.
F.Additional Requirements Relating to Insurance: ADMINISTRATOR shall obtain
endorsements to the Commercial General Liability insurance naming the County of Fresno, its officers,
agents, and employees, individually and collectively, as additional insured, but only insofar as the
operations under this Agreement are concerned. Such coverage for additional insured shall apply as
primary insurance and any other insurance, or self-insurance, maintained by COUNTY, its officers, agents
and employees shall be excess only and not contributing with insurance provided under
ADMINISTRATOR'S policies herein. This insurance shall not be cancelled or changed without a minimum
of thirty (30) days advance written notice given to COUNTY.
Within thirty (30) days from the date ADMINISTRATOR signs and executes this
Agreement, ADMINISTRATOR shall provide certificates of insurance and endorsement as stated above
for all of the foregoing policies, as required herein, to the County of Fresno, Department of Public
Health, P.O. Box 11867, Fresno, California 93775, Attention: Business Manager, stating that such
insurance coverage have been obtained and are in full force; that the County of Fresno, its officers,
agents and employees will not be responsible for any premiums on the policies; that such Commercial
General Liability insurance names the County of Fresno, its officers, agents and employees, individually
and collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned; that such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, shall be
excess only and not contributing with insurance provided under ADMINISTRATOR'S policies herein;
and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days
advance, written notice given to COUNTY.
///
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In the event ADMINISTRATOR fails to keep in effect at all times insurance
coverage as herein provided, the COUNTY may, in addition to other remedies it may have, suspend or
terminate this Agreement upon the occurrence of such event.
All policies shall be issued by admitted insurers licensed to do business in the
State of California, and such insurance shall be purchased from companies possessing a current A.M.
Best, Inc. rating of A FSC VII or better.
10.AUDITS AND INSPECTIONS
The ADMINISTRATOR shall at any time during business hours, and as often as the COUNTY may
deem necessary, make available to the COUNTY for examination all of its records and data with respect to
the matters covered by this Agreement. The ADMINISTRATOR shall, upon request by the COUNTY,
permit the COUNTY to audit and inspect all of such records and data necessary to ensure
ADMINISTRATOR'S compliance with the terms of this Agreement.
If this Agreement exceeds ten thousand dollars ($10,000.00), ADMINISTRATOR shall be subject to
the examination and audit of the Auditor General for a period of three (3) years after final payment under
contract (Government Code Section 8546.7).
11.NOTICES
The persons and their addresses having authority to give and receive notices under this Agreement
include the following:
COUNTY ADMINISTRATOR
Director, County of Fresno Advantek Benefit Administrators
Department of Public Health Chris Cheney
P.O. Box 11867 Attn: Chris Cheney
Fresno, CA 93775 Title: CFO
7370 N. Palm Ave., Suite #101
Fresno, CA 93711
All notices between the COUNTY and ADMINISTRATOR provided for or permitted under this
Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three COUNTY business days after deposit in the United States mail, postage prepaid,
addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
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COUNTY business day after deposit with the overnight commercial courier service, delivery fees prepaid,
with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by
telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission is
completed outside of COUNTY business hours, then such delivery shall be deemed to be effective at the
next beginning of a COUNTY business day), provided that the sender maintains a machine record of the
completed transmission. For all claims arising out of or related to this Agreement, nothing in this section
establishes, waives, or modifies any claims presentation requirements or procedures provided by law,
including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government Code,
beginning with section 810).
12.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A.The parties to this AGREE shall be in strict conformance with all applicable Federal
and State of California laws and regulations, including but not limited to Sections 5328, 10850, and 14100.2
et seq. of the Welfare and Institutions Code, Sections 2.1 and 431.300 et seq. of Title 42, Code of Federal
Regulations (CFR), Section 56 et seq. of the California Civil Code and the Health Insurance Portability and
Accountability Act (HIPAA), including but not limited to Section 1320 D et seq. of Title 42, United States
Code (USC) and its implementing regulations, including, but not limited to Title 45, CFR, Sections 142, 160,
162, and 164, The Health Information Technology for Economic and Clinical Health Act (HITECH)
regarding the confidentiality and security of patient information, and the Genetic Information
Nondiscrimination Act (GINA) of 2008 regarding the confidentiality of genetic information.
Except as otherwise provided in this Agreement, ADMINISTRATOR, as a Business
Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform functions,
activities or services for or on behalf of COUNTY, as specified in this Agreement, provided that such use or
disclosure shall not violate the Health Insurance Portability and Accountability Act (HIPAA), USC 1320d et
seq. The uses and disclosures of PHI may not be more expansive than those applicable to COUNTY, as
the “Covered Entity” under the HIPAA Privacy Rule (45 CFR 164.500 et seq.), except as authorized for
management, administrative or legal responsibilities of the Business Associate.
B.ADMINISTRATOR, including its subcontractors and employees, shall protect, from
unauthorized access, use, or disclosure of names and other identifying information, including genetic
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information, concerning persons receiving services pursuant to this Agreement, except where permitted in
order to carry out data aggregation purposes for health care operations [45 CFR Sections 164.504 (e)(2)(i),
164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)] This pertains to any and all persons receiving services pursuant
to a COUNTY funded program. This requirement applies to electronic PHI. ADMINISTRATOR shall not
use such identifying information or genetic information for any purpose other than carrying out
ADMINISTRATOR’s obligations under this Agreement.
C.ADMINISTRATOR, including its subcontractors and employees, shall not disclose
any such identifying information or genetic information to any person or entity, except as otherwise
specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 or other law, required
by the Secretary, or authorized by the client/patient in writing. In using or disclosing PHI that is permitted by
this Agreement or authorized by law, ADMINISTRATOR shall make reasonable efforts to limit PHI to the
minimum necessary to accomplish intended purpose of use, disclosure or request.
D.For purposes of the above sections, identifying information shall include, but not be
limited to name, identifying number, symbol, or other identifying particular assigned to the individual, such
as finger or voice print, or photograph.
E.For purposes of the above sections, genetic information shall include genetic tests of
family members of an individual or individual, manifestation of disease or disorder of family members of an
individual, or any request for or receipt of, genetic services by individual or family members. Family
member means a dependent or any person who is first, second, third, or fourth degree relative.
F.ADMINISTRATOR shall provide access, at the request of COUNTY, and in the time
and manner designated by COUNTY, to PHI in a designated record set (as defined in 45 CFR Section
164.501), to an individual or to COUNTY in order to meet the requirements of 45 CFR Section 164.524
regarding access by individuals to their PHI. With respect to individual requests, access shall be provided
within thirty (30) days from request. Access may be extended if ADMINISTRATOR cannot provide access
and provides individual with the reasons for the delay and the date when access may be granted. PHI shall
be provided in the form and format requested by the individual or COUNTY.
ADMINISTRATOR shall make any amendment(s) to PHI in a designated record
set at the request of COUNTY or individual, and in the time and manner designated by COUNTY in
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accordance with 45 CFR Section 164.526.
ADMINISTRATOR shall provide to COUNTY or to an individual, in a time and
manner designated by COUNTY, information collected in accordance with 45 CFR Section 164.528, to
permit COUNTY to respond to a request by the individual for an accounting of disclosures of PHI in
accordance with 45 CFR Section 164.528.
G.ADMINISTRATOR shall report to COUNTY, in writing, any knowledge or reasonable
belief that there has been unauthorized access, viewing, use, disclosure, security incident, or breach of
unsecured PHI not permitted by this Agreement of which it becomes aware, immediately and without
reasonable delay and in no case later than two (2) business days of discovery. Immediate notification shall
be made to COUNTY’S Information Security Officer and Privacy Officer and COUNTY’S DPH HIPAA
Representative, within two (2) business days of discovery. The notification shall include, to the extent
possible, the identification of each individual whose unsecured PHI has been, or is reasonably believed to
have been, accessed, acquired, used, disclosed, or breached. ADMINISTRATOR shall take prompt
corrective action to cure any deficiencies and any action pertaining to such unauthorized disclosure
required by applicable Federal and State Laws and regulations. ADMINISTRATOR shall investigate such
breach and is responsible for all notifications required by law and regulation or deemed necessary by
COUNTY and shall provide a written report of the investigation and reporting required to COUNTY’S
Information Security Officer and Privacy Officer and COUNTY’S DPH HIPAA Representative. This written
investigation and description of any reporting necessary shall be postmarked within the thirty (30) working
days of the discovery of the breach to the addresses below:
County of Fresno County of Fresno County of Fresno
Dept. of Public Health Dept. of Public Health Information Technology Services
HIPAA Representative Privacy Officer Information Security Officer
(559) 600-6439 (559) 600-6405 (559) 600-5800
P.O. Box 11867 P.O. Box 11867 333 W. Pontiac Way
Fresno, CA 93775 Fresno, CA 93775 Clovis, CA 93612
H.ADMINISTRATOR shall make its internal practices, books, and records relating to
the use and disclosure of PHI received from COUNTY, or created or received by the ADMINISTRATOR on
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behalf of COUNTY, in compliance with HIPAA’s Privacy Rule, including, but not limited to the requirements
set forth in Title 45, CFR, Sections 160 and 164. ADMINISTRATOR shall make its internal practices,
books, and records relating to the use and disclosure of PHI received from COUNTY, or created or
received by the ADMINISTRATOR on behalf of COUNTY, available to the United States Department of
Health and Human Services (Secretary) upon demand.
ADMINISTRATOR shall cooperate with the compliance and investigation reviews
conducted by the Secretary. PHI access to the Secretary must be provided during the
ADMINISTRATOR’S normal business hours, however, upon exigent circumstances access at any time
must be granted. Upon the Secretary’s compliance or investigation review, if PHI is unavailable to
ADMINISTRATOR and in possession of a Subcontractor, it must certify efforts to obtain the information to
the Secretary.
I.Safeguards:
ADMINISTRATOR shall implement administrative, physical, and technical
safeguards as required by the HIPAA Security Rule, Subpart C of 45 CFR 164, that reasonably and
appropriately protect the confidentiality, integrity, and availability of PHI, including electronic PHI, that it
creates, receives, maintains or transmits on behalf of COUNTY and to prevent unauthorized access,
viewing, use, disclosure, or breach of PHI other than as provided for by this Agreement. ADMINISTRATOR
shall conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the
confidential, integrity and availability of electronic PHI. ADMINISTRATOR shall develop and maintain a
written information privacy and security program that includes administrative, technical and physical
safeguards appropriate to the size and complexity of ADMINISTRATOR’S operations and the nature and
scope of its activities. Upon COUNTY’S request, ADMINISTRATOR shall provide COUNTY with
information concerning such safeguards.
ADMINISTRATOR shall implement strong access controls and other security
safeguards and precautions in order to restrict logical and physical access to confidential, personal (e.g.,
PHI) or sensitive data to authorized users only. Said safeguards and precautions shall include the following
administrative and technical password controls for all systems used to process or store confidential,
personal, or sensitive data:
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1)Passwords must not be:
a.Shared or written down where they are accessible or recognizable
by anyone else; such as taped to computer screens, stored under
keyboards, or visible in a work area;
b.A dictionary word; or
c.Stored in clear text
2)Passwords must be:
a.Eight (8) characters or more in length;
b.Changed every ninety (90) days;
c.Changed immediately if revealed or compromised; and
d.Composed of characters from at least three (3) of the following
four (4) groups from the standard keyboard:
e.Composed of characters from at least three (3) of the following
four (4) groups from the standard keyboard:
(1)Upper case letters (A-Z);
(2)Lowercase letters (a-z);
(3)Arabic numerals (0 through 9); and
ADMINISTRATOR shall implement the following security controls on each workstation
or portable computing device (e.g., laptop computer) containing confidential,
personal, or sensitive data:
i.Network-based firewall and/or personal firewall;
ii.Continuously updated anti-virus software; and
iii.Patch management process including installation of all operating
system/software vendor security patches.
ADMINISTRATOR shall utilize a commercial encryption solution that has received
FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable electronic
media (including, but not limited to, compact disks and thumb drives) and on portable computing devices
(including, but not limited to, laptop and notebook computers).
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ADMINISTRATOR shall not transmit confidential, personal, or sensitive data via e-
mail or other internet transport protocol unless the data is encrypted by a solution that has been validated
by the National Institute of Standards and Technology (NIST) as conforming to the Advanced Encryption
Standard (AES) Algorithm. ADMINISTRATOR must apply appropriate sanctions against its employees
who fail to comply with these safeguards. ADMINISTRATOR must adopt procedures for terminating
access to PHI when employment of employee ends.
J. Mitigation of Harmful Effects: ADMINISTRATOR shall mitigate, to the extent
practicable, any harmful effect that is suspected or known to ADMINISTRATOR of an unauthorized
access, viewing, use, disclosure, or breach of PHI by ADMINISTRATOR or its subcontractors in
violation of the requirements of these provisions. ADMINISTRATOR must document suspected or
known harmful effects and the outcome.
K. ADMINISTRATOR’S Subcontractors: ADMINISTRATOR shall ensure that any of
its contractors, including subcontractors, if applicable, to whom ADMINISTRATOR provides PHI
received from or created or received by ADMINISTRATOR on behalf of COUNTY, agree to the same
restrictions, safeguards, and conditions that apply to ADMINISTRATOR with respect to such PHI and to
incorporate, when applicable, the relevant provisions of these provisions into each subcontract or sub-
award to such agents or subcontractors..
L. Employee Training and Discipline: ADMINISTRATOR shall train and use
reasonable measures to ensure compliance with the requirements of these provisions by employees
who assist in the performance of functions or activities on behalf of COUNTY under this Agreement and
use or disclose PHI and discipline such employees who intentionally violate any provisions of these
provisions, including termination of employment.
M. Termination for Cause: Upon COUNTY’S knowledge of a material breach of
these provisions by ADMINISTRATOR, COUNTY shall either:
1) Provide an opportunity for ADMINISTRATOR to cure the breach or
end the violation and terminate this Agreement if ADMINISTRATOR does
not cure the breach or end the violation within the time specified by
COUNTY; or
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2)Immediately terminate this Agreement if ADMINISTRATOR has
breached a material term of these provisions and cure is not possible.
3)If neither cure nor termination is feasible, the COUNTY’S Privacy
Officer shall report the violation to the Secretary of the U.S. Department of
Health and Human Services.
N.Judicial or Administrative Proceedings: COUNTY may terminate this Agreement
in accordance with the terms and conditions of this Agreement as written hereinabove, if: (1)
ADMINISTRATOR is found guilty in a criminal proceeding for a violation of the HIPAA Privacy or
Security Laws or the HITECH Act; or (2) a finding or stipulation that the ADMINISTRATOR has violated
a privacy or security standard or requirement of the HITECH Act, HIPAA or other security or privacy
laws in an administrative or civil proceeding in which the ADMINISTRATOR is a party.
O.Effect of Termination: Upon termination or expiration of this Agreement for any
reason, ADMINISTRATOR shall return or destroy all PHI received from COUNTY (or created or
received by ADMINISTRATOR on behalf of COUNTY) that ADMINISTRATOR still maintains in any
form, and shall retain no copies of such PHI. If return or destruction of PHI is not feasible, it shall
continue to extend the protections of these provisions to such information, and limit further use of such
PHI to those purposes that make the return or destruction of such PHI infeasible. This provision shall
apply to PHI that is in the possession of subcontractors or agents, if applicable, of ADMINISTRATOR. If
ADMINISTRATOR destroys the PHI data, a certification of date and time of destruction shall be
provided to the COUNTY by ADMINISTRATOR.
P.Disclaimer: COUNTY makes no warranty or representation that compliance by
ADMINISTRATOR with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will be
adequate or satisfactory for ADMINISTRATOR’s own purposes or that any information in
ADMINISTRATOR’s possession or control, or transmitted or received by ADMINISTRATOR, is or will be
secure from unauthorized access, viewing, use, disclosure, or breach. ADMINISTRATOR is solely
responsible for all decisions made by ADMINISTRATOR regarding the safeguarding of PHI.
Q.Amendment: The parties acknowledge that Federal and State laws relating to
electronic data security and privacy are rapidly evolving and that amendment of these provisions may be
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required to provide for procedures to ensure compliance with such developments. The parties
specifically agree to take such action as is necessary to amend this agreement in order to implement the
standards and requirements of HIPAA, the HIPAA regulations, the HITECH Act and other applicable
laws relating to the security or privacy of PHI. COUNTY may terminate this Agreement upon thirty (30)
days written notice in the event that ADMINISTRATOR does not enter into an amendment providing
assurances regarding the safeguarding of PHI that COUNTY in its sole discretion, deems sufficient to
satisfy the standards and requirements of HIPAA, the HIPAA regulations and the HITECH Act.
R.No Third-Party Beneficiaries: Nothing express or implied in the terms and
conditions of these provisions is intended to confer, nor shall anything herein confer, upon any person
other than COUNTY or ADMINISTRATOR and their respective successors or assignees, any rights,
remedies, obligations or liabilities whatsoever.
S.Interpretation: The terms and conditions in these provisions shall be interpreted
as broadly as necessary to implement and comply with HIPAA, the HIPAA regulations and applicable
State laws. The parties agree that any ambiguity in the terms and conditions of these provisions shall be
resolved in favor of a meaning that complies and is consistent with HlPAA and the HIPAA regulations.
T.Regulatory References: A reference in the terms and conditions of these
provisions to a section in the HIPAA regulations means the section as in effect or as amended.
U.Survival: The respective rights and obligations of ADMINISTRATOR as stated in
this Section shall survive the termination or expiration of this Agreement.
V.No Waiver of Obligations: No change, waiver or discharge of any liability or
obligation hereunder on any one or more occasions shall be deemed a waiver of performance of any
continuing or other obligation, or shall prohibit enforcement of any obligation on any other occasion.
13.GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno County,
California.
The rights and obligations of the parties and all interpretation and performance of this Agreement
shall be governed in all respects by the laws of the State of California.
14.NON-DISCRIMINATION
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During the performance of this Agreement, ADMINISTRATOR shall not unlawfully discriminate
against any employee or applicant for employment, or recipient of services, because of race, religious
creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic
information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation,
military status or veteran status pursuant to all applicable State of California and Federal statutes and
regulation.
15.REPORTS
ADMINISTRATOR shall work with the COUNTY to develop monthly reports.
16.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the ADMINISTRATOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of the agreement, the ADMINISTRATOR changes its
status to operate as a corporation.
Members of the ADMINISTRATOR’S Board of Directors shall disclose any self-dealing
transactions that they are a party to while ADMINISTRATOR is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the
ADMINISTRATOR is a party and in which one or more of its directors has a material financial interest.
Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to by
completing and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit E and
incorporated herein by reference, and submitting it to the COUNTY prior to commencing with the self-
dealing transaction or immediately thereafter.
17.SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of any
one provision in the Agreement shall not affect the other provisions.
18.ENTIRE AGREEMENT
This Agreement constitutes the entire agreement between the ADMINISTRATOR and COUNTY
with respect to the subject matter hereof and supersedes all previous Agreement negotiations, proposals,
commitments, writings, advertisements, publications, and understanding of any nature whatsoever unless
expressly included in this Agreement.
1 IN WITNESS WHEREOF, he parties hereto have executed this Agreement as of the day and year first
2 hereinabove written .
3 SANTE HEALTH SYSTEM d.b.a
ADVANTEK BENEFIT ADMINISTRATORS
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(Authorized Signature)
(Chairman of the Board, or President or Vice
President)
(Authorizedg'natu re)
17 ·-· C.AWl,A', ~~n~~J & T~tl~o
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(Corporation, or any Assistant Secretary, or Chief
Financial Officer, or any Assistant Treasurer)
7370 N. Palm Avenue, Suite# 101
Mailing Address
Fresno, California 93711
FOR ACCOUNTING USE ONLY:
Fund : 0001
Org : 5240
Account: 7295
Subciass: 10000
COUNTY OF FRESNO:
E___:.a-~~-
Ernest BuddyMend,hairmanoftheBoardoF-
-27-
Supervisors of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
By :
1
EXHIBIT A
Referrals to ADMINISTRATOR shall derive from the following Federally Funded Clinics and
Emergency Hospitals:
Clinica Sierra Vista – Divisadero
145 N. Clark St.
Fresno, CA 93701
Phone (559) 457-5900/FAX (559) 457-5990
United Health Centers – Huron
16928 11th St.
Huron, CA 93234
Phone (559) 945-2541/FAX (559) 945-1107
Clinica Sierra Vista – Easton
5784 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5600/FAX (559) 457-5690
United Health Centers – Kerman
517 S. Madera Ave.
Kerman, CA 93630
Phone (559) 846-6330/FAX (559) 846-5553
Clinica Sierra Vista – Elm
2760 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5314/FAX (559) 457-5390
United Health Centers – Mendota
121 Barboza St.
Mendota, CA 93640
Phone (559) 655-5000/FAX (559) 655-5000
Clinica Sierra Vista – Elm
2740 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5200/FAX (559) 457-5290
United Health Centers – Orange Cove
445 11th St.
Orange Cove, CA 93646
Phone (559) 626-4031/FAX (559) 626-4963
Clinica Sierra Vista – Elm
2756 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5345/FAX (559) 457-5395
United Health Centers – Parlier
650 S. Zediker Ave.
Parlier, CA 93648
Phone (559) 646-3561/FAX (559) 646-6780
Clinica Sierra Vista – Garland
3727 N. First St., #106
Fresno, CA 93726
Phone (559) 457-6900/FAX (559) 457-6990
United Health Centers – Sanger
2502 Jensen Ave.
Sanger, CA 93657
Phone (559) 875-6000/FAX (559) 875-6016
Clinica Sierra Vista – North Fine
1945 N. Fine Ave., #100
Fresno, CA 93727
Phone (559) 457-5650/FAX (559) 457-5695
United Health Centers – Reedley
1560 E. Manning Ave.
Reedley, CA 93654
Phone (559) 638-2019/FAX (559) 638-2136
Clinica Sierra Vista – Orange & Butler
1350 S. Orange Ave.
Fresno, CA 93702
Phone (559) 457-5400/FAX (559) 457-5491
United Health Centers – Raisin City
6425 W. Bowles Ave.
Raisin City, CA 93652
Phone (559) 233-0111/FAX (559) 233-0112
2
Clinica Sierra Vista – Regional Medical
2505 E. Divisadero St.
Fresno, CA 93721
Phone (559) 457-5500/FAX (559) 457-5599
United Health Centers – Lemoore
1270 N. Lemoore Ave.
Lemoore, CA 93645
Phone (559) 924-2015/FAX (559) 925-0568
Clinica Sierra Vista – West Shaw
4739 W. Shaw Ave., #108
Fresno, CA 93722
Phone (559) 457-6800/FAX (559) 457-6890
Valley Health Team – Kerman
449 S. Madera Ave.
Kerman, CA 93630
Phone (559) 365-2970/FAX (559) 846-9353
Clinica Sierra Vista – West Fresno
302 Fresno St., Suite #101
Fresno, CA 93706
Phone (559) 457-5700/FAX (559) 457-5790
Valley Health Team – Kerman
942 S. Madera Ave.
Kerman, CA 93630
Phone (559) 364-2980/FAX (559) 846-9157
Clinica Sierra Vista – Gaston Middle School
1120 E. Church Ave.
Fresno, CA 93706
Phone (559) 457-6970/FAX (559) 457-6695
Valley Health Team – Kerman Unified
School District
702 S. Eighth St.
Kerman, CA 93630
Phone (559) 364-2975/FAX (559) 846-5001
Valley Health Team – San Joaquin
San Joaquin, CA 93660
Phone (559) 693-2462/Phone (559) 693-2467
FAX (559) 693-2398
Valley Health Team – Sablan
927 O St.
Firebaugh, CA 93600
Phone (559) 659-3037/FAX (559) 659-3434
Valley Health Team – Clovis
180 W. Shaw Ave., Suite B
Clovis, CA 93612
Phone (559) 203-6600/FAX (559) 326-5273
Adventist Health – Kerman Central
275 S. Madera#201
Kerman, CA 93630
Phone (559) 846-5240/FAX (559) 846-3787
Adventist Health – Lemoore East
810 East D St.
Lemoore, CA 93245
Phone (559) 924-7711/FAX (559) 924-1658
Adventist Health – Fowler
119 Sixth St.
Fowler, CA 93625
Phone (559) 834-1614/FAX (559) 834-0015
Adventist Health – Coalinga
155 S. Fifth St.
Coalinga, CA 93210
Phone (559) 935-4282/FAX (559) 935-4285
Adventist Health – Orange Cove
1455 Park Ave.
Orange Cove, CA 93646
Phone (559) 626-0882/FAX (559) 626-7498
Adventist Health – Parlier/Newmark
155 S. Newmark Ave.
Parlier, CA 93648
Phone (559) 646-1200/FAX (559) 646-6622
Adventist Health – Sanger
1939 S. Academy
Sanger, CA 93657
Phone (559) 887-6900/FAX (559) 875-6011
3
Adventist Health – Caruthers East
2357 W. Tahoe
Caruthers, CA 93609
Phone (559) 864-5200/FAX (559) 864-8403
Adventist Health – Caruthers
2440 W. Tahoe
Caruthers, CA 93609
Phone (559) 864-3212/FAX (559) 864-8510
Adventist Health – Reedley Cyprus
372 W. Cyprus
Reedley, CA 93654
Phone (559) 626-0882/FAX (559) 643-8057
Adventist Health – Kingsburg
1251 Draper St.
Kingsburg, CA 93631
Phone (559) 897-6610/FAX (559) 897-6611
Adventist Health – Huron
16916 Fifth St.
Huron, CA 93234
Phone (559) 945-9090/FAX (559) 945-9100
Adventist Health – Reedley
1311 11th St.
Reedley, CA 93654
Phone (559) 638-3227/FAX (559) 638-3799
Adventist Health – Riverdale
3567 Mt. Whitney Ave.
Riverdale, CA 93656
Phone (559) 867-7200/FAX (559) 867-0152
Adventist Health – Selma Central
2141 High St., #E
Selma, CA 93662
Phone (559) 891-2611/FAX (559) 891-2616
Adventist Health – Kerman
1000 S. Madera
Kerman, CA 93630
Phone (559) 846-9370/FAX (559) 846-9352
Adventist Health – Selma Campus
1041 Rose Ave.
Selma, CA 93662
Phone (559) 856-6090/FAX (559) 856-6092
Community Medical Centers – Emergency
Department
2823 Fresno St.
Phone (559) 459-3998/FAX (559) 459-7417
Family HealthCare Network – Specialty
Health Center
290 N. Wayte, 2nd Floor
Fresno, CA 93701
Phone (559) 793-3501 Ext. 1412
FAX (559) 459-5040
Community Medical Centers –Ambulatory
Care Center
290 N. Wayte
Fresno, CA 93701
Phone (559) 459-1877/FAX (559) 459-4877
Family HealthCare Network – Family
Medicine
290 N. Wayte, 2nd Floor
Fresno, CA 93701
Phone (559) 793-3501 Ext. 1420
FAX (559) 459-6109
Family HealthCare Network – Women’s
Health Center
290 N. Wayte, 1st Floor
Fresno, CA 93701
Phone (559) 793-3501 Ext. 1244
FAX (559) 459-4454
Family HealthCare Network – Internal
Medicine
290 N. Wayte, 2nd Floor
Fresno, CA 93701
Phone (559) 793-3501 Ext. 3797
FAX (559) 459-5097
EXHIBIT B
ADMINISTRATOR shall process claims under this Agreement from the following medical providers:
Central California Ear Nose & Throat
1351 E. Spruce Ave.
Fresno, CA 93720
Phone (559) 432-3303/FAX (559) 432-1468
California Eye Institute
1360 E. Herndon
Fresno, CA 93720
Phone (559) 449-5000/FAX (559) 449-5044
Community Medical Centers
2823 Fresno Street
Fresno, CA 93721
Phone (559) 459-6000
Community Medical Centers – Specialty Health
Center
290 N. Wayte, 2nd Floor
Fresno, CA 93701
Phone (559) 459-7300/FAX (559) 459-5040
Central California Faculty Medical Group
2625 E. Divisadero
Fresno, CA 93721
Phone (559) 453-5200/FAX (559) 453-5233
Central California Faculty Medical Group
Diana Johnson, Accounts Receivable Manager
2625 E. Divisadero
Fresno, CA 93721
Phone (559) 453-5200 Ext. 292
Email: diana.johnson@ccfmg.org
Pathology Associates
305 Park Creek Road
Clovis, CA 93611 and/or
PO Box 509015, Dept. WS206
San Diego, CA 92150
California Cancer Center
7257 N. Fresno Street
Fresno, CA 93720
Phone (559) 477-4050
Clovis Community Medical Center
2755 Herndon Ave.
Clovis, CA 93611
Phone (559) 324-4000
Family HealthCare Network
305 E. Center Ave.
Visalia, CA 93291
Phone (559) 791-7050
Community Cancer Institute
785 N. Medical Center Drive West
Clovis, CA 93611
Phone (559) 387-1764/Fax (559) 387-1776
EXHIBIT C
Page 1 of 6
SPECIALTY CARE REFERRAL FORM
Please submit this form to:
1. Date of Referral:____/____/_____ 2. Date Client Last Seen by Referring Physician:____/____/____
PATIENT INFORMATION
3. Patient Name: Last First Middle Date of Birth (Mo/Day/Yr): Age: Gender:
M F
4. Address: Street City State Zip Code Phone Number:
( )
5.
Does patient have no Share-of-Cost Restricted Medi-Cal? Yes No
➢ If “Yes”, is a DHCS Medi-Cal Eligibility Response Transaction printout included with this referral? Yes No
➢ If “No”, is the patient’s Medi-Cal application pending? Yes No Medi-Cal application date:_____________
REFERRING CLINIC/HOSPITAL INFORMATION
6. Referring Physician (please print): Tax ID #: Referring Clinic Name:
7. Contact Person in Referring
Provider’s Office:
Telephone #:
( )
Fax #:
( )
Name of PCP (if different than referring
physician):
8. Referring Clinic/Hospital Address: Street City State Zip Code
REFERRAL REQUESTED
9. ☐ Cardiology ☐ Dermatology ☐ Endocrinology ☐ Gastroenterology
☐ Inpatient
Hospitalization ☐ Laboratory Services ☐ Neurology ☐ Gynecology
☐ Oncology ☐ Ophthalmology ☐ Oral/Maxillofacial ☐ Orthopedics
☐ Otolaryngology
(ENT) ☐ Outpatient Surgery ☐ Pharmacy Services ☐ Pulmonology
☐ Urology ☐ Radiology, including Computerized Tomography (CT) Scans and Magnetic Resonance Imaging (MRI)
CPT Codes:_________________________________________ Other:__________________________________________
CLINICAL INFORMATION
10. Medical Diagnosis ICD-10 Code Date of Onset
month/year
Advantek Benefit Administrators
P.O. Box 1507, Fresno, CA 93716-1507
Attn: Jeanisha Dennie/FAX# (559) 228-4279
EXHIBIT C
Page 2 of 6
11.Referring Physician Comments:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Client clinical data attached: Lab Reports: ☐ X-ray: ☐ Narrative Reports: ☐Medication Report: ☐
☐ Other:
________________________________________________________________________________________________
APPLICANT’S LANGUAGE PREFERENCE
12. I prefer to speak in the language checked below:
Prefiero hablar el idioma indicado a continuación:
English/Ingles ☐
Spanish/Español ☐
Other/Otro ☐What language do you speak/Qué idioma habla:_________________
Please tell us which language or format you would prefer for your written information:
Por favor, indique cual idioma o formato usted prefiere para su información escrita:
English/Ingles ☐
Spanish/Español ☐
Other/Otro ☐What language do you read and write/En qué idioma usted lee y
escribe:___________________
APPLICANT’S ATTESTATION
(Sign one of the attestations below dependent upon language preference)
13.I, _________________________________, attest the following is true and correct under penalty and
perjury under the laws of the State of California: (1) I am currently a resident of the County of Fresno;
(2) I do not have a household income that exceeds 138% of the current Federal Poverty Level; (3) I have
applied for full scope Medi-Cal benefits; and (4) I have exhausted all other health care options available
to me, including but not limited to third party payors such as private insurance, the U.S. Department of
Veterans Affairs, Worker’s Compensation, Medicare, through my own or my spouse’s place of
employment, through my parent(s) or guardian(s), or motor vehicle or homeowner insurance coverage.
I acknowledge and understand that submission of this referral form is only to obtain necessary non-
emergency specialty care services listed herein and is solely dependent upon available funding to
reimburse qualified specialty care medical providers who may perform such services.
I understand and acknowledge that I do not have a legal right to receive non-emergency specialty
care services and that such services are dependent upon my continued eligibility and the
availability of such funding.
(Applicant’s Attestation continues on Page 3)
EXHIBIT C
Page 3 of 6
Further, I do waive, release and forever discharge any and all claims or actions, known or
unknown, that I may have against the County of Fresno and Santé Health System, d.b.a. Advantek
Benefit Administrators, pertaining to the processing of this referral form and receipt of non -
emergency specialty medical services.
Applicant Signature: __________________________________________ Date: _________________
OR
Yo, ________________________________, doy fe de que lo siguiente es verdadero y correcto bajo
pena de perjurio en virtud de las leyes del estado de California: (1) actualmente resido en el condado de
Fresno; (2) no poseo ingresos familiares que superen el 138 % del nivel de pobreza federal; (3) he
solicitado beneficios de Medi-Cal integrales; y (4) he agotado todas las demás opciones de atención
médica que tenía disponibles, lo que incluye a mero título enunciativo pagos por parte de terceros, tales
como seguro privado, el Departamento de Asuntos de los Veteranos de los EE. UU., indemnización por
accidente laboral, Medicare, a través de mi propio lugar de trabajo o el de mi cónyuge, a través de mis
padres o tutores, o cobertura de seguro del propietario de vivienda o vehículo motorizado.
Reconozco y entiendo que la presentación de este formulario de remisión tiene como único fin obtener
los servicios de atención especializada necesarios y que no sean de emergencia enumerados en el
presente y que esto depende únicamente de la disponibilidad de fondos para reembolsar a los
proveedores médicos de atención especializada que pudieran prestar dichos servicios.
Reconozco y comprendo que no tengo derecho legal a recibir servicios de atención especializada y
que no sean de emergencia, y que dichos servicios dependen de mi elegibilidad continua y de la
disponibilidad de dichos fondos.
Asimismo, renuncio, libero y exonero para siempre cualesquiera reclamos o acciones, conocidos o
desconocidos, que pudiera tener en contra del condado de Fresno y Santé Health System, que
opera bajo el nombre de Advantek Benefit Administrators, en lo referido al procesamiento de este
formulario de remisión y a la recepción de servicios médicos especializados que no sean de
emergencia.
Firma del solicitante: ____________________________________________ Fecha: ____________
EXHIBIT C
Page 4 of 6
PHYSICIAN’S ATTESTATION
(Sign one of the attestations below dependent upon patient care setting)
REFERRING PRIMARY CARE/TREATING PHYSICIAN’S ATTESTATION
14.
I, ________________________________, attest it is true and correct under penalty and perjury under
the laws of the State of California that I provided primary care and/or other medical services to the
Applicant and that Applicant has a need for non-emergency specialty medical services necessary to
avoid endangerment to life or health.
Physician Signature: ___________________________________________ Date: ________________
OR
REFERRING EMERGENCY DEPARTMENT PHYSICIAN’S ATTESTATION
I, ________________________________, attest it is true and correct under penalty and perjury under
the laws of the State of California that I provided emergency department services to the Applicant and
that Applicant has a need for non-emergency specialty medical services necessary to avoid
endangerment to life or health.
Physician Signature: ___________________________________________ Date: ________________
EXHIBIT C
Page 5 of 6
INSTRUCTIONS FOR COMPLETING
THE SPECIALTY CARE REFERRAL FORM
1.Date of Referral: Enter the date the form is completed.
2.Date Client Last Seen by Referring Physician: Enter the date the patient was last seen by the referring
physician.
Patient Information
3.Patient Name: Enter the patient’s last, first, and middle names, date of birth, age at the time of request
and gender.
4.Address and Phone Number: Enter the patient’s street address, city, state, and zip code. Do not enter a
P.O. Box number unless that is the patient’s street address. If the patient does not have an address
because he/she is homeless, enter “none” or “homeless” in this area. If left blank, the form is considered
incomplete and will be denied. Enter the patient’s home or cell phone number, including the area code.
5.Does Patient have no share-of-cost Restricted Medi-Cal: Circle “Yes” if the patient has no share-of-cost
Restricted Medi-Cal. A DHCS Medi-Cal Eligibility Response Transaction printout printed within 45
days of the date of Advantek’s receipt of the Referral must be included with the Referral showing the
individual’s Medi-Cal status. The individual must have active no share-of-cost Restricted Medi-Cal in
order to be eligible for NRSC. Circle “No” if the patient does not have Restricted Medi-Cal. If “No” is
circled, answer whether or not the patient’s Medi-Cal application is pending by circling either “Yes” or
“No” and enter the date the patient applied for Medi-Cal, if applicable. If “Yes” Medi-Cal application is
pending, …. Administrator is expected to review MEDS prior to processing an NRSC program payment
claim to assure consumer met the no share-of-cost Restricted Medi-Cal eligibility criteria.
Referring Clinic/Hospital Information
6.Referring Physician, Tax ID # and Clinic Name: Enter the full name of the referring physician, which
may be either the emergency care or primary care/treating physician. Enter the Tax Identification
number of the federally funded clinic, emergency hospital, or other hospital-based specialty clinic.
Enter the name of the clinic, hospital, hospital-based-clinic.
7.Contact Person in Referring Provider’s Office, Telephone #, Fax #, and Name of PCP: Enter the name
of the contact person in the clinic or hospital that can be contacted regarding the referral, his/her
telephone and FAX number, and the name of the patient’s primary care physician if the referring
physician is not the patient’s primary care physician.
8.Referring Clinic/Hospital Address: Enter the complete street address of the referring clinic or hospital.
Do not enter the clinic or hospital’s corporate address unless this is also the address where the referring
physician provided medical care to the patient.
Referral Requested
9.Referral Requested: Check the box next to the type of referral requested and enter the CPT Code of the
requested specialty service where indicated.
EXHIBIT C
Page 6 of 6
Clinical Information
10.Medical Diagnosis, ICD-10 Code, and Date of Onset: The Medical Diagnosis, ICD-10 and Date of
Onset must be filled in by the referring physician.
11.Referring Physician Comments and Client Clinical Data Attached: Referring physician comments and
attaching any clinical data is optional for submittal of the Form to Advantek; however, if request is
approved, the specialist may require specific patient clinical data at his/her discretion.
Applicant’s Language Preference
12.Spoken Language and Written Language: Patient must mark his/her language that he/she speaks and
reads and writes by checking the appropriate box. If “Other” is marked, enter the other language where
indicated. If client does not speak (including sign language), read or write, enter “None” where
appropriate.
Applicant’s Attestation
13.Applicant’s Attestation: The patient must fill in his/her full name, sign, and date the Applicant’s
Attestation in his/her appropriate language. If the applicant indicates he/she speaks, reads, and/or writes
in a different language, the County may provide the applicant with an attestation translated to his/her
language for signature as soon as possible.
Physician’s Attestation
14.Referring Primary Care or Treating Physician’s Attestation or Referring Emergency Department
Physician’s Attestation: Fill in the referring physician’s name and sign and date the appropriate
attestation for either primary care physician, treating physician, or emergency department physician.
1
EXHIBIT D
The scope of services for Non-Resident Specialty Care consist of the following:
A.Endocrinology
B.Neurology
C.Pulmonology
D.Cardiology
E.Orthopedics
F.Gynecology
G.Otolaryngology (ENT)
H.Dermatology
I.Oncology
J.Gastroenterology
K.Oral and Maxillofacial Surgery
L.Ophthalmology
M.Inpatient Hospitalization
N.Outpatient Surgery
O.Radiology, including Computerized Tomography (CT) Scans and Magnetic
Resonance Imaging (MRI)
P.Laboratory Services
Q.Pharmacy Services
R.Urology
Exhibit E
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which
one or more of its directors has a material financial interest.”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member’s name, job title (if applicable), and date this disclosure is being
made.
(2)Enter the board member’s company/agency name and address.
(3)Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a.The name of the agency/company with which the Corporation has the
transaction; and
b.The nature of the material financial interest in the Corporation’s transaction that
the board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5)Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit E (continued)
2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code
5233 (a):
(5) Authorized Signature
Signature: Date: