HomeMy WebLinkAboutAgreement A-15-523 with Unilab Corporation dba Quest Diagnostics.pdf1
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AGREEMENT
THIS AGREEMENT is made and entered into this ___ day of ______ , 2015, by and
3 between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
4 referred to as ''COUNTY'', and UNILAB CORPORATION dba QUEST DIAGNOSTICS, a California
5 Corporation, whose address is 3714 Northgate Boulevard, Sacramento, California 95834, hereinafter
6 referred to as "CONTRACTOR".
7 WITNESSETH
8 WHEREAS, COUNTY, through its Department of Public Health (DPH) and Department of
9 Behavioral Health (DBH), has a need for clinical laboratory and toxicology testing services including,
10 but not limited to, supplies for specimen collections, phlebotomy services, specimen pick-up and
11 delivery, laboratory testing, critical value reporting, and routing laboratory orders for health programs
12 for COUNTY's consumers and clients ; and
13 WHEREAS, CONTRACTOR is qualified and willing to provide such services pursuant to the
14 terms and conditions of this Agreement.
15 NOW, TIIEREFORE, in consideration of their mutual promises, covenants and conditions,
16 hereinafter set forth, the sufficiency of which is acknowledged, the parties agree as follows:
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1. SERVICES
A. CONTRACTOR shall perform all services and fulfill all responsibil ities for both
COUNTY's DPH and DBH, as identified in Exhibit A, attached hereto and by this reference
incorporated herein.
B. In addition, CONTRACTOR shall perform all services and fulfill all
responsibilities in a manner consistent with COUNTY's Request for Quotation (RFQ) No. 992-5336
dated March 2, 2015, Addendum No. One (1) to COUNTY's RFQ No. 992-5336, dated March 12,
2015, and Addendum No. Two (2) to COUNTY's RFQ No. 992-5336, dated March 27,2015,
hereinafter collectively referred to as COUNTY's Revised RFQ No. 992-5336, and CONTRACTOR's
Response to said Revised RFQ No. 992-5336, dated April 15,2015, all incorporated herein by reference
and made part of this Agreement. In the event of any inconsistency among these documents, the
inconsistency shall be resolved by giving precedence in the following order of priority: 1) to this
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Agreement, includ ing all Exhibits, 2) to the Revised RFQ, 3) to the Response to the Revised RFQ. A
copy of COUNTY's Revised RFQ No. 992-5336 and CONTRACTOR's Response shall be retained and
made available during the term of this Agreement by COUNTY's General Services Department,
Purchas ing Divis io n.
C. CONTRACTOR shall be Clinical Laboratory Improvement Amendments (CLlA)
certified as identified in Paragraph Fourteen (J 4) of this Agreement.
D . CONTRACTOR shall perform blood draws and pick up specimens as deemed
necessary by appropriate COUNTY staff requesting services.
E. CONTRACTOR shall complete all routine blood draws and other specimen
collections as specified by each COUNTY Department's collection requirements .
F . Routine results shall be returned to the requesting COUNTY fucility within
twenty-four (24) hours of collection of specimen or specimen pick up.
G. Location and hours of operation of CONTRACTOR's Patient Service Centers
(PSCs) are identifIed in Exlubit B, attached hereto and incorporated herein by reference.
CONTRACTOR shall notify COUNTY in advance when any of the PSCs are to be closed and alternate
arrangements for specimen collection shall be mutually agreed to.
H. CONTRACTOR may subcontract with local laboratories within Fresno COlmty in
the event that CONTRACTOR is not able to perform all tests and provide all services required
hereunder, but only if such laboratories are able to provide the same or better level and quality of
service as CONTRACTOR. CONTRACTOR may subcontract when esoteric testing is not performed
or to ensure continuity of services during hours other than CONTRACTOR's regularly scheduled
business hours , inc Iud ing weekends and holidays.
CONTRACTOR shall bear sole and primary responsibility for all services,
includ ing results. COUNTY shall not deal with any subcontractor for any services or test results, m
accordance with Paragraph Fifteen (15) of this Agreement. CONTRACTOR shall be responsible for
collecting all results and sending them to the requesting COUNTY Department and clinic within the
timeframes listed in this Agreement. CONTRACTOR shall be solely responsible for all supplies , fees
and payments when they have another clinical laboratory nm any tests.
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1 I. CONTRACTO R shall provide "STAT Testing" as follows:
2 1) "STAT Testing" is defined herein as immediate testing requested by an
3 appropriate COUNTY staff physician.
4 2) CONTRACTOR shall respond to COUNTY's request for STAT Testing
5 within two (2) hours, which shall be measured from the time COUNTY's request was made until the
6 time when CONTRACTOR picks up the specimen or when CONTRACTOR's phlebotomist arrives to
7 draw the specimen, whichever is applicable.
8 3) STAT testing results will be provided to requesting physician or designated
9 staff within two to four (2-4) hours from receipt of specimen in the perfonning laboratory.
10 2. TERM
11 This Agreement shall become effective on the 1 st day of July, 2015 and shall terminate on
12 the 30th day of June, 2018.
13 This Agreement shall automatically be extended for two (2) additional twelve (12) month
14 periods upon the same terms and conditio ns herein set forth, unless written notice of non-renewal is
15 given by CONTRACTOR or COUNTY or COUNTY's DPH Director, or designee, not later than ninety
16 (90) days prior to the close of the then current Agreement tenn.
17 3. TERMINATION
18 A. N on-Allocation of Funds -The terms of this Agreement, and the services to be
19 provided thereunder, are contingent on the approval offimds by the appropriating government agency.
20 Should sufficient fimds not be allocated, the services provided may be modified, or this Agreement
21 terminated, at any time by giving the CONTRACTOR sixty (60) days advance written notice.
22 B. Breach of Contract -Either party may suspend or terminate this Agreement in whole
23 or in part, where in the determination of the terminating party the other party has failed to comply with any
24 term of this Agreement or has otherwise breached its obligations under this Agreement. The terminating
25 party must provide the other party with fifteen (15) days prior written notice of the cause for the
26 termination, giving the breaching party 15 calendar days to cure the breach. If not cured within the 15
27 calendar day time period, then the Agreement will immediately terminate upon the breaching party's
28 receipt of subsequent written notice that the breach has not been cured and the Agreement is terminated.
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1 Where in the determination of the COUNTY there is:
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An illegal or improper use offimds;
A failure to comply with any term of this Agreement;
A substantially incorrect or incomplete report submitted to COUNTY;
Improperly performed service.
C. Without Cause -Under circumstances other than those set forth above, this Agreement
may be terminated by COUNTY or CONTRACTOR upon the giving of sixty (60) days advance written
notice of an intention to terminate to the other party.
In no event shall any payment by COUNTY constitute a waiver by the COUNTY of any
breach of this Agreement or any defuult which may then exist on the partofthe CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or
defuult. COUNTY shall have the right to demand of CONTRACTOR the repayment to COUNTY of any
fimds disbursed to CONTRACTORl.ll1der this Agreement, which in the judgment of COUNTY were not
expended in accordance with the terms of this Agreement. CONTRACTOR shall promptly refimd any
such fimds upon demand or, at COUNTY's option, such repayment shall be deducted from future
payments owing to CONTRACTOR under this Agreement.
4. COMPENSATION
A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation for services provided to each COUNTY Department as stated herein, as fullows:
1) DPH
Compensation paid by COUNTY's DPH to CONTRACTOR shall be
based on a fee for service per test at the rate identified in the DPH Schedule of Fees, attached hereto as
Exlubit C, and by this reference incorporated herein. In no event shall the maximum amount of
compensation paid to CONTRACTOR by COUNTY's DPH exceed Three Hundred Twenty-five
Thousand and nol100 Dollars ($325,000.00) during each twelve-month period of this Agreement.
III
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2) DBH
Compensation paid by COUNTY's DBH to CONTRACTOR shall be
3 based on a fee for service per test at the rate identified in the DBH Schedule of Fees, attached hereto as
4 Exhibit D, and by this reference incorporated herein. In addition, CONTRACTOR shall provide one (1)
5 phlebotomist, two (2) days a week each for three and one half (3.5) hours at DBH's Metro Outpatient
6 Services located at 4441 E. Kings Canyon Road, Fresno, CA 93702. COUNTY's DBH shall pay
7 CONTRACTOR Twenty Five and 00/100 Dollars ($25.00) for each hour or proration thereof worked by
8 the phlebotomist. The maximum compensation for phlebotomist services under this Agreement shall not
9 be in excess of Four Thousand Five Hundred Fifty and 00/100 Dollars ($4,550.00). In no event shall the
10 total maximum amount of compensation paid to CONTRACTOR by COUNTY's DBH exceed Forty
11 Thousand and 00/1 00 Dollars ($40,000.00) during each twelve-month period of this Agreement.
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3) CONTRACTOR shall invoice COUNTY and COUNTY shall only pay for
services provided to clients with Medically Indigent AdultlMedical Services Program (MIAlMSP)
Certification and/or clients with Uniform Method to Detennine Ability to Pay (UMDAP) Certification,
(hereinafter, "Certified Individuals") in accordance with Paragraph Five (5) of this Agreement.
4) Except for Celtified Individuals, CONTRACTOR shall seek compensation
directly from the individuals for whom the services were rendered, or from third-party payers (i.e.
Medicare, Medi-Cal or private heahh insurance) as applicable, and CONTRACTOR agrees COUNTY
shall have no financial liability for services provided to such non-certified individuals. CONTRACTOR
further agrees that in the event any Certified Individual subsequently becomes eligIble for Medi-Cal or
other third party insurance, then CONTRACTOR shall have no right to receive or retain compensation
from COUNTY for services provided for such individuals.
5) CO UNTY shaU, to the best of its knowledge, attempt to identify every
DPH or DBH client at the time of referral for a clinical or toxicology test if they have Medi-Cal,
Medicare or any other third-party insurance. CONTRACTOR shall adjust their billing to switch
payment to Medi-Cal, Medicare or other third-party insurance if at a later time, or when invoiced, that
said client had any health insurance coverage. In the event COUNTY fails to provide any information
that is necessary for CONTRACTOR to bill and collect from a third party payor, whether public or
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1 private, and CONTRACTOR is lll1able to collect for any Services as a result of such failure,
2 CONTRACTOR shall bill COUNTY, and COUNTY shall pay CONTRACTOR for such Services at the
3 fees set forth in Exhibits C and D. Notwithstanding the foregoing, in the event COUNTY subsequently
4 provides CONTRACTOR with accurate billing information within 75 days from the date of service
5 CONTRACTOR shall transfer the charges billed to COUNTY to the applicable third party payor and
6 adjust the charges from the COUNTY aCCOlll1t accordingly. If an invoice for such a client has been paid
7 by the COUNTY, then CONTRACTOR shall credit the COUNTY for that amolll1t already paid within
8 two (2) months after the pertaining information for Medi-Ca~ Medicare or other heahh insurance
9 coverage is provided to the CONTRACTOR.
10 6) With regard to individuals for whom CONTRACTOR provides services at
11 the request of DPH or DBH, but for which services COUNTY is not required to pay, CONTRACTOR
12 agrees to charge the same prices as specified in Exhibits C and D. CONTRACTOR acknowledges that
13 COUNTY shall not be responsible for compensation for these consumers for performed services.
14 7) In the event a DPH or DBH client inadvertently receives clinical or
15 toxicology testing from a party other than CONTRACTOR, CONTRACTOR agrees to work with the
16 providing party to have charges for services applied through this Agreement.
17 B. In no event shall the total maximum compensation amolll1t for this Agreement paid
18 to CONTRACTOR by COUNTY for actual services rendered exceed Three Hlll1dred Sixty-five
19 Thousand and nollOO Dollars ($ 365,000.00) during each twelve-month period of this Agreement.
20 C. It is lll1derstood that all customary expenses incidental to CONTRACTOR's
21 performance of services lll1der this Agreement shall be borne by CONTRACTOR. Payments by COUNTY
22 shall be in arrears, for services provided during the preceding month, within forty-five (45) days after
23 receipt and verification of CONTRACTOR's invoices by COUNTY's DPH and DBH, as applicable. If
24 CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY shall be relieved
25 of its obligation for further compensation.
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5. INVOICING
CONTRACTOR shaU invoice COUNTY in arrears, roonthly by each Department as
follows :
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4 A. Invoices shaU be submitted to the responsible COUNTY Department, as
5 applicable , detailing the Department; appropriate cost center(s); patient's full name, date ofbitth, and
6 Fresno County Medical Record number; date of service; and name of laboratory test performed along
7 with the CPT code to the following addresses:
8 DPH: County of Fresno, Department of Public Health, P.O. Box 11867, Fresno,
9 CA 93775, Attention: Supervising Account Clerk, Business Office.
10 DBH: County of Fresno, Department of Behavioral Health, Accounts Payable,
11 P.O. Box 45003, Fresno, CA 93718, Attention: Business Office.
12 B. Invoices reflecting documented services provided at DBH's Metro Outpatient
13 Services shaH be accompanied by time sheets of CONTRACTOR's phlebotomist. Invoices shaU be in a
14 form and in such detail as acceptable to COUNTY's DBH.
15 C. If invoices are incorrect, COUNTY shall have the right to withhold payment of the
16 invoice that is incorrect. COUNTY shaU provide five (5) days prior notice to CONTRACTOR of any
17 intent to withhold fimds due to incorrect invoices . CONTRACTOR shaU present a corrected invoice to
18 enable COUNTY to make said payment. CONTRACTOR agrees to continue to provide service for a
19 period of ninety (90) days after notifica tio n of an incorrect invoice. If after said ninety (90) day period
20 said invoice(s) is still not corrected to COUNTY's satismction, COUNTY shall have the right to deny
21 payment on such invoices .
22 D. For services performed by CONTRACTOR prior to the termination date of this
23 Agreement but that remain unpaid by County as of the same date, CONTRACTOR shall submit all
24 invoices to COUNTY for services provided within ninety (90) days after Agreement is terminated. If
25 invoices are not submitted within ninety (90) days foUowing termination date of the Agreement,
26 COUNTY shall have the right to deny payment on such invoices.
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1 6. INDEPENDENT CONTRACTOR
2 In performance of the work, duties and obligations assumed by CONTRACTOR lIDder this
3 Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of the
4 CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
5 independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
6 employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no
7 right to control or supervise or direct the manner or method by which CONTRACTOR shall perform its
8 work and function. However, COUNTY shall retain the right to administer this Agreement so as to verifY
9 that CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof
10 CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules and
11 regulations, if any, of governmental authorities having jurisdiction over matters which are directly or
12 indirectly the subject ofthis Agreement.
13 Because of its status as an independent contractor, CONTRACTOR shall have absolutely no
14 right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be solely
15 liable and responsible for providing to, or on behalf o~ its employees all legally-required employee
16 benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
17 matters relating to payment of CONTRACTOR's employees, including compliance with Social Security,
18 withhold ing, and all other regulations governing such matters. It is acknowledged that during the term of
19 this Agreement, CONTRACTOR may be providing services to others unrelated to the COUNTY or to this
20 Agreement.
21 7. MODIFICATION
22 Any matters of this Agreement may be modified from time to time by the written consent
23 of all the parties without, in any way, affecting the remainder.
24 Notwithstanding the above, minor changes, as mutually agreed upon in writing between
25 CONTRACTOR and COUNTY's DPH or DBH Director, or designees, as applicable, may be made to
26 ExhIbit C and/or Exlubit D. Minor changes may include, but are not limited to, the addition of clinical
27 laboratory tests, the addition or deletion of a urinelblood collection/draw or pick up site, and changes in
28 addresses to which notices or invoices are to be sent. Such minor changes shall not significantly aher
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1 the responsibilities outlined in Exhibit A or result in an increase to the maximum compensation under
2 this Agreement.
3 8. NON-ASSIGNMENT
4 Neither party shall assign or transfer this Agreement nor their rights or duties under this
5 Agreement without the prior written consent of the other party.
6 9. HOLD HARMLESS
7 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
8 defend the COUNTY, its officers, agents, and employees from any and aU costs and expenses, including
9 attorney fees and court costs, damages, liabilities, claims, and losses occurring or resulting to COUNTY in
10 connection with third party claims made against COUNTY related to the performance, or failure to
11 perfonn, by CONTRACTOR, its officers, agents, or employees under this Agreement, and from any and all
12 costs and expenses, including attorney fees and court costs, damages, liabilities, claims, and losses
13 occurring or resulting to any person, finn, or corporation who may be injured or damaged by the
14 performance, or failure to perfonn, of CONTRACTO R, its officers, agents, or employees under this
1 5 Agreement.
16 COUNTY agrees to indemnify, save, hold harmless, and at CONTRACTOR'S request,
17 defend the CONTRACTO R, its officers, agents, and employees from any and aU costs and expenses,
18 including attorney fees and court costs, damages, liabilities, claims, and losses occurring or resulting to
19 CONTRACTOR in connection with third party claims made against CONTRACTOR related to the
20 perfonnance, or failure to perfonn, by COUNTY, its officers, agents, or employees under this Agreement,
21 and from any and all costs and expenses, including attorney fees and court costs, damages, liabilities,
22 claims, and losses occurring or resulting to any person, finn, or corporation who may be injured or
23 damaged by the performance, or failure to perfonn, of COUNTY, its officers, agents, or employees under
24 this Agreement.
25 10. INSURANCE
26 Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or
27 any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the following
28 insurance policies throughout the term ofthis Agreement. Notwithstanding anything to the contrary
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1 contained herein, CONTRACTORmay utilize self-insurance for aU or any portion ofthe minimum limits
2 of instrrance required to be carried .
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A.
B.
Commercial General Liability
Cormnercial General Liability Insurance with limits of not less than One Million
DoUars ($1,000,000) per occurrence and an annual aggregate of Two Million
DoUars ($2,000,000). This policy shaU be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations , product
liability, contractual liability, fire legal liability or any other liability mstrrance
deemed necessary because ofthe nature of the Agreement.
Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of not
less than Two Hundred Fifty Thousand DoUars ($250 ,000) per person, Five
Hundred Thousand DoUars ($500,000) per accident and for property damages of
not less than Fifty Thousand DoUars ($50 ,000), or such coverage with a combined
single limit of Five Hundred Thousand DoUars ($500 ,000). Coverage should
include owned and non-owned vehicles used in connection with this Agreement.
C. Professional Liabil ity
D.
If CONTRACTOR 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 DoUars ($1,000 ,000) per occurrence, Three
Million DoUars ($3,000,000) annual aggregate. If the Professional Liability
Insurance policy is written on a claims made basis, the CONTRACTOR shall
maintain the policy of Professional Liability Insurance in full force and affuct for a
period of not less than three (3) years from the termination date ofthis Agreement.
Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
CONTRACTOR shall provide a blanket endorsement to the General Liability
insurance adding the County of Fresno, its officers, agents, and employees, individ ua lly 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 shaU be excess only and not contributing with
insurance provided under CONTRACTOR's policies herein . This insurance shall not be canceUed or
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1 changed without the insurer endeavoring to provide a minimum of thirty (30) days advance written notice
2 given to COUNTY.
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Within thirty (30) days from the date CONTRACTOR executes this Agreement,
CONTRACTO R shall provide certificates of insurance and endorsement as stated above for all of the
foregoing policies, as required herein, to the COW1ty of Fresno, Department of Public Health, P.O . Box
11867, Fresno, CA 93775, Attn: Contracts Section - 6
th Floor, stating that such insurance coverage have
been obtained and are in full force; that the CoW1ty of Fresno, its officers, agents and employees will not be
responsible for any premiums on the policies; that such Commercial General Liability insurance includes
the COW1ty of Fresno, its officers, agents and employees, individually and collectively, as additional
insured, but only insofur as the operations under this Agreement are concerned; that such coverage for
add itional 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 W1der CONTRACTO R's policies herein; and that this insurance shall not be cancelled or changed
without the insurer providing coverage endeavoring to provide a minimum ofthirty (30) days advance,
written notice given to COUNTY. Should any of the described policies be cancelled before the expiration
date thereo£ notice will be delivered in accordance with the policy provisions.
In the event CONTRACTORfuils 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 with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be purchased from companies possessing a current AM. Best, Inc.
rating of A-FSC VII or better.
11. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter
into a contractual relationship with the COUNTY for the purpose of providing services W1der this
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1 Agreement must employ adequate data security measures to protect the confidential information
2 provided to CONTRACTOR by the COUNTY, including but not limited to the foUowing:
3 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
4 CONTRACTOR may not connect to COUNTY networks via personally-owned
5 mobile, wireless or handheld devices, unless the foUowing conditions are met:
6 1) CONTRACTOR has received authorization by COUNTY for
7 telecommuting purposes;
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Current virus protection software is in place;
Mobile device has the remote wipe feature enabled; and
A secure connection is used.
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B. CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
13 peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief
14 Information Officer, and/or designee(s), includ ing but not limited to mobile storage devices. lf data is
15 approved to be transferred, data must be stored on a secure server approved by the COUNTY and
16 transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
17 connection. Said data must be encrypted in transit.
18 C. COUNTY-Owned Computer Equipment
19 CONTRACTOR or anyone having an employment relationship with the
20 COUNTY, may not use COUNTY computers or computer peripherals on non-COUNTY premises
21 without prior authorization from the COUNTY's Chief Information Officer, and/or designee(s).
22 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive data,
23 on any hard-disc drive, on portable storage device, or remote storage installation unless encrypted.
24 E. CONTRACTOR shaU be responsible to employ strict controls to ensure the
25 integrity and security of COUNTY's confidential information and to prevent unauthorized access,
26 viewing, use or disclosure of data maintained in computer files, program docwnentation, data
27 processing systems, data files and data processing equipment which stores or processes COUNTY data
28 internally and externally.
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F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
BIT or higher. Additionally, password, or pass phrase, encryption key or shared keys must be utilized
where applicable.
G. CON1RACTOR is responsible to immediately notifY COUNTY of any violations,
or breaches or potential breaches ofseclU"ity related to COUNTY 's confidential information, data
maintained in computer files, program documentation, data processing systems , data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CON1RACTOR's response to all incidents
arising from a possible breach ofseclU"ity related to COUNTY's confidential client infurmation
provided to CON1RACTOR. CONTRACTOR will be responsible to issue any notification to affected
individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
CONTRACTOR will be responsible for aU costs inclU"fed as a result of providing the required
notificat io n.
12. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A. The parties to this Agreement shall be in strict conformance with all applicable
Federal and State of California and/or local laws and regulations , includ ing 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 InslU"ance Portability and Accountability Act (HlP AA), includ ing but not limited to Section 1320
o 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 , and The Health Information Technology for
Economic and Clinical Health Act (HITECH) regarding the confidentiality and seclU"ity of patient
infurmation, and the Genetic Information Nondiscrimination Act (GINA) of 2008 regarding the
confidentiality of genetic information.
CON1RACTORcovenants and represents to COUNTY, and COUNTY so relies
thereon, that plU"suant to 45 CFR460 .1 03 CON1RACTOR is not required to enter into a HIPAA business
associate contract with COUNTY and that CON1RACTORis excepted from all business associated
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1 requirements under the HIP AA Privacy Rule. CONTRACTOR therefore covenants and agrees to defend,
2 indemnify and hold COUNTY harmless from any and all actions, audits, proceedings, claims, damages,
3 liabilities, penalties or fines brought against the COUNTY under HIP AA law and regulations relative to a
4 finding, decision or claim by the u.s. Department of Health and Human Services, the Office for Civil
5 Rights or other HIP AA enforcement agency of CONTRACTOR's business associate status and fuilure to
6 enter into a HIP AA business associate contract with the COUNTY. All services performed by
7 CONTRACTOR under this Agreement shall be in strict confonnance with all applicable Federa~ State of
8 California and/or local laws and regulations relating to confidentiality.
9 B. CONTRACTOR, including its subcontractors and employees, shall protect, from
10 unauthorized access, use, or disclosure of names and other identifying information, including genetic
11 information, concerning persons receiving services pursuant to this Agreement, except where permitted
12 in order to carry out data aggregation purposes for health care operations [45 CFR Sections 164.504
13 (e)(2)(D, 164.504 (3)(2)(iJ)(A), and 164.504 (e)(4)(Dl. This pertains to any and all persons receiving
14 services pursuant to a COUNTY fimded program This requirement applies to electronic PHI.
15 CONTRACTOR shall not use such identifying information or genetic information for any purpose other
16 than carrying out CONTRACTOR's obligations under this Agreement.
17 C. CONTRACTOR, including its subcontractors and employees, shall not disclose
18 any such identifying infonnation or genetic infonnation to any person or entity, except as otherwise
19 specifically pennitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 or other law,
20 required by the Secretary, or authorized by the client/patient in writing. In using or disclosing PHI that
21 is pennitted by this Agreement or authorized by law, CONTRACTOR shall make reasonable efforts to
22 limit PHI to the minimum necessary to accomplish intended purpose of use, disclosure or request.
23 D. For purposes of the above sections, identifying information shall include, but not
24 be limited to name, identifying number, symbo~ or other identifying particular assigned to the
25 individual, such as finger or voice print, or photograph.
26 E. For purposes of the above sections, genetic information shall include genetic tests
27 offurnily members of an individual or individua~ manifestation of disease or disorder offurnily
28 members of an individua~ or any request for or receipt of, genetic services by individual or fumily
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1 members. Family member means a dependent or any person who is first , second, third, or fourth degree
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F. CONTRACTOR shall provide access, atthe 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 orto 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 CONTRACTOR 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.
CONTRACTOR shall make any amendment(s) to PHl in a designated record set at
the request of COUNTY or individua~ and in the time and manner designated by COUNTY in
accordance with 45 CFR Section 164.526.
CONTRACTOR 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. CONTRACTOR 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 PHl 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 HIP AA 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.
CONTRACTOR 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 .
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CONTRACTOR 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 HIP AA Representative. This written investigation and description of any reporting necessary
shaU be postmarked within the thirty (30) working days of the discovery of the breach to the addresses
below:
County of Fresno
Dept. of Public Health
HIP AA Representative
(559)600-6439
P.O. Box 11867
Fresno, CA 93775
County of Fresno
Dept. of Behavioral Health
HIP AA Representative
(559) 600-3092
4441 E. Kings Canyon Road
Fresno, CA 93702
Cmmty of Fresno
Dept. of Public Health
Privacy Officer
(559)600-6405
P.O. Box 11867
Fresno, CA 93775
County of Fresno
Information Technology Services
Information Security Officer
(559) 600-5800
2048 N. Fine Street
Fresno , CA 93727
H. CONTRACTOR shall make its internal practices, books, and records relating to
18 the use and disclosure of PHI received from COUNTY, or created or received by the CONTRACTOR
19 on behalf of COUNTY, in compliance with HIP AA's Privacy Rule, including, but not limited to the
20 requirements set forth in Title 45, CFR, Sections 160 and 164. CONTRACTOR shall make its internal
21 practices, books, and records relating to the use and disclosure of PHI received from COUNTY, or
22 created or received by the CONTRACTOR on behalf of COUNTY, available to the United States
23 Department of Health and Human Services (Secretary) upon demand.
24 CONTRACTOR shall cooperate with the compliance and investigation reviews
25 conducted by the Secretary. PHI access to the Secretary must be provided during the CONTRACTOR's
26 normal business hours, however, upon exigent circumstances access at any time must be granted. Upon
27 the Secretary's compliance or investigation review, if PHl is unavailable to CONTRACTOR and in
28 possession of a Subcontractor, it must certifY efforts to obtain the information to the Secretary.
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1 1. Safeguards
2 CONTRACTOR shall implement administrative, physica~ and technical
3 safeguards as required by the HIP AA Security Rule, Subpart C of 4S CFR 164, that reasonably and
4 appropriately protect the confidentiality, integrity, and availability of PHI, including electronic PHI, that
5 it creates, receives, maintains or transmits on behalf of COUNTY and to prevent unauthorized access,
6 viewing, use, disclosure, or breach of PHI other than as provided for by this Agreement.
7 CONTRACTOR shall conduct an accurate and thorough assessment of the potential risks and
8 vulnerabilities to the confidential, integrity and availability of electronic PHI. CONTRACTOR shall
9 develop and maintain a written information privacy and security program that includes administrative,
10 technical and physical safeguards appropriate to the size and complexity of CONTRACTOR's
11 operations and the nature and scope of its activities. Upon COUNTY's request, CONTRACTOR shall
12 provide COUNTY with information concerning such safeguards.
13 CONTRACTOR shall implement strong access controls and other security
14 safeguards and precautions in order to restrict logical and physical access to confidentia~ personal (e.g.,
15 PHI) or sensitive data to authorized users only. Said safeguards and precautions shall include the
16 following administrative and technical password controls for all systems used to process or store
17 confidentia~ persona~ or sensitive data:
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l) Passwords must not be:
a. Shared or written down where they are accessible or recognjzable
20 by anyone else; such as taped to computer screens, stored under keyboards, or visible in a work area;
21 b. A dictionary word; or
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c. Stored in clear text
Passwords must be:
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Eight (8) characters or more in length;
Changed every ninety (90) days;
Changed immediately if revealed or compromised; and
27 d . Composed of characters from at least three (3) of the following four
28 (4) groups from the standard keyboard:
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Upper case letters (A-Z);
Lowercase letters (a-z);
Arabic numerals (0 through 9); and
4 4 . Non-alphanumeric characters (punctuation symbols).
5 CONTRACTOR shall implement the following security controls on each
6 workstation or portable computing device (e.g., laptop computer) containing confidential,
7 persona~ or sensitive data:
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Network -based firewall and/or personal firewall;
Continuously updated anti-virus software; and
Patch management process including installation of all operating
11 system/software vendor security patches.
12 CONTRACTOR shall utilize a commercial encryption solution that has received
13 FIPS 140-2 validation to encrypt all confidential, persona~ or sensitive data stored on portable
14 electronic media (includ ing, but not limited to, compact disks and thumb drives) and on portable
15 computing devices (includ ing, but not limited to, laptop and notebook computers).
16 CONTRACTOR shall not transmit confidentia~ persona~ or sensitive data via e-
17 mail or other internet transport protocol unless the data is encrypted by a solution that has been
18 validated by the National Institute of Standards and Techno 10 gy (N 1ST) as conforming to the Advanced
19 Encryption Standard (AES) Algorithm. CONTRACTOR must apply appropriate sanctions against its
20 employees who fail to comply with these safeguards. CONTRACTOR must adopt procedures for
21 terminating access to PHI when employment of employee ends.
22 J. Mitigatio n of Harmful Effects
23 CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that is
24 suspected or known to CONTRACTOR of an unauthorized access, viewing, use, disclosure, or breach
25 of PHI by CONTRACTOR or its subcontractors in violatio n ofthe requirements of these provisions.
26 CONTRACTOR must document suspected or known harmful effects and the outcome .
27 III
28 III
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K. CONTRACTOR's Subcontractors
CONTRACTOR shall ensure that any of its contractors, inc Iud ing subcontractors,
if applicable, to whom CONTRACTOR provides PHI received from or created or received by
CONTRACTOR on behalf of COUNTY, agree to the same restrictions and conditions that apply to
CONTRACTOR 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
CONTRACTOR shall train and use reasonable measures to ensure compliance
with the requirements of these provisions by employees who assist in the performance of fimctions or
activities on behalf of COUNTY under this Agreement and use or disclose PHI and discipline such
employees who intentiona lly violate any provisions of these provisions, includ ing termination of
employment.
M . Termination for Cause
Upon COUNTY 's knowledge of a material breach of these provisions by
CONTRACTOR, COUNTY shall either:
1) Provide an opportunity for CONTRACTOR to cure the breach or end the
violation and terminate this Agreement if CONTRACTOR does not cure the breach or end the violation
within the time specified by COUNTY; or
2) Immediately terminate this Agreement if CONTRACTOR 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 Heahh and Human Services.
N. Judicial or Administrative Proceedings
CO UNTY may terminate this Agreement in accordance with the terms and
conditions of this Agreement as written hereinabove, if: (1) C ONTRACTO R is found guilty in a
criminal proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act;
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or (2) a finding or stipulation that the CONTRACTOR has violated a privacy or security standard or
requirement of the HITECH Act, HIP AA or other security or privacy laws in an administrative or civil
proceeding in which the CONTRACTOR is a party.
O. Effect ofTerrnination
Upon termination or expiration ofthis Agreement for any reason, CONTRACTOR
shall return or destroy all PHI received from COUN1Y (or created or received by CONTRACTOR on
behalf of COUN1Y) that CONTRACTOR still maintains in any form, and shall retain no copies of such
PHI. If return or destruction of PHI is not reasible, 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 CONTRACTOR. If CONTRACTOR destroys the PHI data, a
certification of date and time of destruction shall be provided to the COUN1Y by CONTRACTOR
P. Disclaimer
COUN1Y makes no warranty or representation that compliance by
CONTRACTOR with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will be
adequate or satisfactory for CONTRACTOR's own purposes or that any information in
CONTRACTOR's possession or contro~ or transmitted or received by CONTRACTOR, is or will be
secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR is solely
responsible for all decisions made by CONTRACTOR 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 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 ofHIPAA, the HIPAA regulations, the HITECH Act and other applicable laws relating to
the security or privacy of PHI. COUN1Y may terminate this Agreement upon thirty (30) days written
III
III
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1 notice in the event that CONTRACTOR does not enter into an amendment providing assurances
2 regarding the safeguarding of PHI that COUNTY in its sole discretion, deems sufficient to satisfy the
3 standards and requirements ofHIPAA, the HIPAA regulations and the HITECH Act.
4 R. No Third-Party Beneficiaries
5 Nothing express or implied in the terms and conditions of these provisions IS
6 intended to confer, nor shall anything herein confer, upon any person other than COUNTY or
7 CONTRACTOR and their respective successors or assignees, any rights, remedies, obligations or
8 liabilities whatsoever.
9 S. Interpretation
10 The terms and conditions in these provisions shall be interpreted as broadly as
11 necessary to implement and comply with HIPAA, the HIPAA regulations and applicable State laws. The
12 parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved m
13 favor of a meaning that complies and is consistent with HlP AA and the HIP AA regulations.
14 T. Regulatory References
15 A rererence in the terms and conditions of these provisions to a section in the
16 HIP AA regulations means the section as in effect or as amended.
17 U. Survival
18 The respective rights and obtigations of CONTRACTOR as stated in this Section
19 shall survive the termination orexpiration of this Agreement.
20 V. No Waiver of Obligations
21 No change, waiver or discharge of any liability or obligation hereunder on anyone
22 or more occasions shall be deemed a waiver of performance of any continuing or other obligatio n, or
23 shall prohibit enforcement of any obligation on any other occasion.
24 13. NON-DISCRIMINATION
25 During the perfurmance of this Agreement CONTRACTORshall not unlawfully
26 discriminate agairISt any employee or applicant for employment, or recipient of services, because ofrace,
27 religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition,
28 genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation,
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1 or military and veteran status, pursuant to aU applicable State of California and Federal staMes and
2 regulations.
3 14. LICENSES
4 CONTRACTOR warrants that it possesses and shall maintain the Clinical Laboratory
5 Improvement Amendments (CLIA) Certification and all other licenses and/or certificates required by
6 local, State of California and/or Federal laws and regulations for the conduct of its business and shall
7 operate its business in accordance with all applicable laws and regulations. CONTRACTOR further
8 warrants that all of its personnel performing services under this Agreement shall be licensed and/or
9 certified where required to lawfully perform their duties and shall maintain such licensure and/or
10 certifications throughout the term of this Agreement. CONTRACTOR shall maintain copies of all
11 licenses and/or certifications noted above and shall allow COUNTY to review these documents upon
12 request.
13 15. SUBCONTRACTS
14 CONTRACTOR will be required to assume full responsibility for all services and activities
15 covered by this Agreement, whether or not CONTRACTOR is providing those services directly. Further,
16 COUNTY will consider CONTRACTOR to be the sole point of contact with regard to contractual matters,
17 including payment of any and all charges resulting from this Agreement. CONTRACTOR shall be
18 responsible to CO UNTY for the proper perfonnance of any subcontract.
19 CONTRACTOR shall have commercially reasonable and appropriate written agreements
20 with any third parties performing services for CONTRACTOR where the services will include performing
21 services on work referred to CONTRACTOR by COUNTY.
22 Any subcontractor shall be subject to the same terms and conditions that CONTRACTO R is
23 subject to under this Agreement. CONTRACTOR shall be responsible for informing any subcontractors
24 utilized by CONTRACTOR of all the terms and conditions of this Agreement and of aU the Federal and
25 State of California law requirements incorporated herein.
26 16. REPORTS
27 CONTRACTOR shall provide DPH and DBH with a respective quarterly usage report that
28 shall include but is not limited to, statistical data on the types of tests conducted and the amount invoiced by
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cost center. In addition, CONTRACTOR shall include in said quarterly reports the munber oftests
conducted at each fucility (including pick up location) and the amoW1t invoiced per location.
17. STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY's DBH operates its mental health system
W1der an agreement with the State of California Department of Mental Health, and that W1der said
agreement the State imposes certain requirements on COUNTY and its subcontractors.
CONTRACTOR shall adhere to all State requirements, including those identified in Exlubit E, attached
hereto and by this reference incorporated herein.
18. DISCLOSURE OF SELF-DEALING TRANSACTIONS
10 This provision is only applicable if the CONTRACTOR is operating as a corporation (a
11 for-profit on non-profit corporation) or if during the term of this agreement, the CONTRACTOR
12 changes its status to operate as a corporation.
13 Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing
14 transactions that they are a party to while CONTRACTOR is providing goods or performing services
15 W1der this agreement. A self-dealing transactio n shall mean a transaction to which the CONTRACTOR
16 is a party and in which one or more of its directors has a material financial interest. Members of the
17 Board of Directors shall disclose any self-dealing transactions that they are a party to by completing and
18 signing a Self-Dealing Transactio n Disclosure F onn, attached hereto as Exlub it F and incorporated
19 herein by reference, and submitting it to the COUNTY prior to commencing with the self-dealing
20 transaction or immediately thereafter.
21 19. DISCLOSURE OF OWNERSlllP AND/OR (DNTROL INTEREST
22 INFORMATION
23 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
24 managed care entity as defined in Title 42 of the Code of Federal Regulations sections 455.101,
25 455.104, and 455. 1 06(a)(1),(2).
26 In accordance with Title 42 of the Code of Federal Regulations sections 455.101,455.104 ,
27 455.105 and 455.106(a)(1),(2), information must be disclosed by CONTRACTOR by completing
28 Exlubit G , "Disclosure of Ownership and Control Interest Statement", attached hereto and by reference
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1 incorporated herein. CONTRACTOR shall submit this form to the Department of Behavioral Health
2 within thirty (30) days of the effective date of this Agreement.
3 Submissions shall be scanned pdf copies and are to be sent via e-mail to
4 DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
5 20. AUDITS AND INSPECTIONS
6 Upon reasonable prior written notice, as agreed to by both CONTRACTOR and COUNTY,
7 CONTRACTOR shall at any time during normal business hours, and as often as the COUNTY may deem
8 necessary, make available to the CO UNTY for examination all of its records and data with respect to the
9 matters covered by this Agreement. CONTRACTOR shall, upon request by the COUNTY, permit the
10 COUNTY to audit and inspect all of such records and data necessary to ensure CONTRACTOR's
11 compliance with the terms of this Agreement.
12 If this Agreement exceeds Ten Thousand and Noll 00 Dollars ($10,000.00), CONTRACTOR
13 shall be subject to the examination and audit of the State Auditor for a period of three (3) years after final
14 payment under contract (Government Code Section 8546.7).
15 21. NOTICES
16 The persons and their addresses having authority to give and receive notices under this
17 Agreement include the following:
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COUNTY
Director, County of Fresno
Department of Public Health
P.O. Box 11867
Fresno, CA 93775
Director, County of Fresno
Department of Behavioral Health
4441 E. Kings Canyon Road
Fresno , CA 93702
CONTRACTOR
UniJab Corporation, dba Quest Diagnostics
Contracts Specialist
3714 Northgate Boulevard
Sacramento, CA 95834
Any and all notices between the COUNTY and the CONTRACTOR provided for or
permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
United States Mail, postage prepaid, addressed to such party.
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1 22. GOVERNING LAW
2 The parties agree, that for the purposes of venue, performance under this Agreement is to
3 be in Fresno County, California.
4 The rights and obligatio ns of the parties and aU interpretatio n and performance of this
5 Agreement shall be governed in all respects by the laws of the State of California.
6 23. SEVERABILITY
7 The provisions of this Agreement are severable. The invalid ity or unenforceability of any
8 one provisio n in the Agreement shall not affect the other provisio ns.
9 24. REGULATORY MATTERS.
10 CONTRACTOR may terminate this Agreement on 45 days prior written notice, if any
11 Authority creates, enforces, interprets and/or implements a law, rule, regulation that CONTRACTOR is
12 required to extend the pricing under this Agreement to any third party includ ing but not limited to
13 Medicare, Medi-Cal or any other governmental program. For purposes of this section, "Authority" shall
14 include, but is not limited to, any court, legislative or administrative body, and/or any branch of state,
15 federal or local government (e.g., the Office of Inspector General, Department of Justice, Department of
16 Health and Human Services, Centers fur Medicare and Medicaid Services, and/or California's
17 Department of Health Care Services and/or Department of Managed Health Care).
18 25. LIMITATIONS OF LIABILITY
19 In no event shall either party or its respective officers, directors, employees, agents or
20 affiliates be liable for any special, exemplary, incidental, consequential or punitive damages, whether in
21 contract, warranty, tort, strict liability or otherwise. These limitations shall apply notwithstanding any
22 failure of essential purpose of any limited remedy and shall survive termina tio n of this Agreement.
23 26. ENTIRE AGREEMENT
24 This Agreement, including all Exhibits, COUNTY's Revised RFQ No. 992-5336, and
25 CONTRACTOR's responses thereto, constitutes the entire agreement between the CONTRACTOR and
26 COUNTY with respect to the subject matter hereof and supersedes all previous Agreement negotiations,
27 proposals, commitments, writings, advertisements, publications, and understand ing of any nature
28 whatsoever unless expressly included in this Agreement.
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1 IN \\Tt~i:SS \\'H'EJU:ol:. the patti:!\ ~t(t ha"e t:Y.e'cut:ed th~ r\grc~ot a:'>t~f'h: da~ and year
2 fnt hc:n:hlbove written,
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'""'"'"''""' "·~··-~~· -~··
Secretary (of Corpor!itl:,n), m
aft) ,;0\ssf;biml SccrettU"). nr
C~f Flrllu-.:ial Otlker, or
.m). A!h~is:tmt T rea:surer
t>.dt:: ·-------
M.umna ,~\ddrc!h'i:
7060 N. Recreatl.lt1. Su:le 106
Fn:-.no, CA Ql720
Pho~ No~ (S59) 225-1611.cJ~~t. -*iS
Coruct: Lois Phelps. Ob1rict Sub Mana~tr
f)ltt: l D I t3 !JS
-I I
BERNICE t:. SEIOt;l_ ('~
Board of S~n·isors
Pt.F.ASf'~ SD: ADDm0~.>\1.
SIGNAnrtu: PAGE ATI'ACJU:.D
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APPROVED AS TO LEGAL FORM:
DANIEL C.CEOERBORG, COUNTY COUNSEL
APPR! VEO AS TO ACCOUNTING (~OI!(M
VICKI CROW, C.P.A., AUDITOR-CONTROLLER!
TREASURER-TAX COLLECTOR
REVlEWFD AN /?,//MENDEO FOR APPROV AI.<
By d)/(~
Davi:f Pomaville
Director
Department of Publi: Health
By ~62 tthlea Dawan tee t,:=
Department of Behavioral Health
Fund/Subclass:
AccolUlt:
Organi2ation:
0001/10000
7295
5620 ($325,000)
1620 ($42,000)
1639 ($25,000)
1645 ($20,000)
1648 ($8 ,000)
1650 ($230,000)
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5630 ($40,000)
2093 ($15,000)
2999 ($20,000)
4610 ($5,000)
SCOPE OF WORK
GROUPS I AND II
DEPARTMENTS OF PUBLIC HEALTH
AND BEHAVIORAL HEALTH SERVICE REQUIREMENTS
Exhibit A
Page 1 ofS
The Contractor will be responsible for providing all needed supplies for specimen
collection, collecting and picking up from the various sites.
Services include, but are not limited to, supplies for specimen collections, phlebotomy
services, specimen pick-up and delivery, laboratory testing, critical value reporting and
timely response for STAT and routine laboratory orders. These services will be required
for the operation of County of Fresno and metropolitan Fresno-Clovis sites as outlined
below.
Contractor will provide all laboratory services and necessary supplies. Contractor must
be CLiA (Clinical Laboratory Improvement Amendments) certified . Laboratory services
will be provided in response to telephone or fax requests from authorized nursing or
clerical staff acting as agents of assigned licensed physicians or from requests ordered
through the computer system.
1. All Services will be provided in accordance with Fresno County, State and
Federal clienUconsumer confidentiality requirements.
2. Blood draws/specimen collection will be performed by the Contractor.
Occasionally, County staff will do the collection, as deemed necessary, by
County staff ordering the testing. Contractor will provide a lab book to DBH
outlining specific procedures for specimen collection that are necessary for
processing/testing, such as collection reqUirements, storage requirements,
minimum volumes, etc.
3. The Contractor will provide blood draw services 2 days each week from 8:00 AM
-11 :30 AM at the DBH Metro Outpatient site locate.d at 4441 E. Kings Canyon
Road, Fresno, CA 93702. The specific days will be determined by the DBH
Medical Director, or designee.
4. A list of available testing/collection sites and hours of operation within Fresno
County shall be submitted by Contractor .
5. All STAT services will be provided 7 days per week, 24 hours per day at
designated DBH facilities. All specimen pick-ups, where necessary, will be
performed by the Contractor. STAT response time will be within one hour of
receipt of request. DBH has approximately 10 STAT requests per year.
El>bibit A
Page 2 ofS
6. Reporting of Critical Test Values shall be completed within 30 minutes after
verification and ordering physician will be called with name, date and time of
specimen collection , along with test results, as well as patien!'s /client 's DOB
(Date of Birth) when necessary. Reporting of Critical Test Values ordered during
regular business hours (Monday through Friday 8 :00 am -5 :00 pm) for DBH
shall be provided to the Metro Outpatient nurses with name, date and time of
specimen collection, and test results, as well as patient's/client's DOB (Date of
Birth) when necessary. Reporting for Critical Test Values ordered outside
regular business hours for DBH shall be provided directly to the DBH Medical
Director with name, date and time of specimen collection , and test results , as
well as patient's/client's DOB (Date of Birth) when necessary. Critical Test Value
reporting is rare for DBH and DPH . Critical Test Values also known as "critical
values" and "critical results " are test results that fall significantly outside the
normal range and may represent life-threatening values even if from routine
tests.
7. Billings for services will be submitted on a monthly invoice statement and are to
be listed by Department and cost center, listing the full name of the patient/ciient,
date of birth, Fresno County Medical Record Number, date of service and name
of laboratory test. Payments may be delayed If invoices are incomplete or
incorrect.
Invoices are to be sent to:
Department of Public Health (DPH) PO Box 11867
Fresno , CA 93775
Department of Behavioral Health (DBH) P.O. Box 45003,
Fresno CA 93718
8. Billing Discrepancies: The County prefers the Contractor provide one contact
person to address. billing questions and dis c repancies for DPH and DBH . The
Contractor is to respond to inquiries in a timely manner -within 7 business days.
9. The Contractor will be required to assume full responsibility for all services and
activities offered In the quotation and Agreement , with the exception of services
and acti vities provided by the County of Fresno whether or not they are provided
directly. The County of Fresno will consider the Contractor to be the sole point of
contact with regard to contractual matters , including payment of any and all
charges resulting from the contract. The contractor may not subcontract or
transfer the contract , or any right or obligation arising out of the contract, without
first having obtained the express written consent of the County.
10. Public Health requires a daily 4:30 pm specimen pick-up. All DPH specimens
are to be picked up inthe TB Clinic. Located at 1221 Fulton Mall, F'irst Floor,
Fresno, CA 93775 .
11. Specimen pick-up for DBH facilities shall be no later than 4:00 pm
Exhibit A
Page 3 of8
12. The Contractor shall be responsible for billing Medi-Cal f or Medi-Cal eligible
clients as well as other applicable third party insu rances . The Contractor shall
collect necessary information pertinent to billing Medi-Cal and third party
insurances from clients. DBH reports that currently approximately 45% of their
outpatient billings are Medi-Cal. These Medi-Cal percentages could chan(Je if
the department sees only Medi-Cal recipients. Approximately 46% of the clients
DPH treats are Medi-Cal or Medi-Cal eligible, or have other third party insurance.
13. The Contractor shall provide online access to printable test results, requests and
lab results twenty four hours (24) per day 365 days per year.
14. The Contractor shall provide online access of lab results to medical staff and
these results must be printable. Common tests, such as CBCs, will be available
online within 24 hours of collection . Specialty tests such as Medication level and
Hep-C tests will be available online with in 5 days.
15. The County requires at least 60 days ' prior notice, or reasonable notice, of any
and all system c hanges that impact portal access, invoicing and requisition
forms . The notice should include what chang e is taking place, when it is
happening , what is ca using the change, what will be impacted (I.e., internet
access, account numbers , te st co des, etc.) and how it will be implemented. If the
c hanges will imp act existing account numbers, ihe Contractor will provide
detaited step s t hat w ill be taken to avoid dupli ca te billing .
SCOPE OF WORK
GROUP I
DEPARTMENT OF PUBLIC HEALTH
Exhibit A
Page 4 of8
TYPES OF REQUIRED CLINICAL LABORATORY TESTS
The average volume of clinical laboratory tests that the Public Health Department
conducted in the past year is provided in the Quotation Schedule. While every effort
was made to get the most current information on the types of tests needed by each
program, the types of tests listed below are best estimates only. The County does not
guarantee any minimums for any of the tests listed below .
Program
County Laboratory
Chest Clinic
HI V Prevention Testing
Types of Tests
Maj ori ty of tests are T-Lymphocyte Helper CD
Panels and miscellaneous other tests
T ests include Coccidiodal Serology Panels, liver
funct ion pa nels, TSH and miscellan.eous other tests
HI V Screening, HI V -1 /2 Antigens and Antibodies
(CPT Code 91431), HIV-1/2 Antibody' HI V-
Differentiation (C PT Co de 91432), and HI V-1 RNA
comprise the bulk of testing in this area.
Court Ordered HI V Te s ting Approximately 30 individuals undergo HI V
Screening tests annually
SCOPE OF WORK
GROUP I
DEPARTMENT OF PUBLIC HEALTH
Exhibit A
Pa ge 5 of8
LABORATORY SERVICES FOR FACILITIES THAT OPERATE
MONDAY THROUGH FRIDAY, 8:00 A.M. TO 5:00 P.M.
1. Chest Clinic, 1221 Fulton Mall, Fresno, CA 93775, phone : (559) 600·3413 .
(BILLING/COST CENTER #56201650)
The Chest Clinic provides services for the detection, prevention and treatment of
TB, specifically, skin testing, chest X-rays, prevention treatment, and diagnosis of
an active disease. The clinic also operates a Directly Observed Therapy
outreach unit which monitors and ensures patient compliance with the prescribed
trealment plan.
The state and federal government have established priori lies and objectives
which are designed to address the hl .ghes t priorities in TB control: (1) The first
priority Is to identify persons who have active TB cases "nd ensure that they
complete appropriate therapy, including using confinement measures in
exceptional cases; (2) The second priority is to find and screen persons who
have been in contact with TB clients to determine whether they have TB infection
or disease. and provide them with appropriate treatment. (3) The th ird is to
screen high-risk populations to detect persons who are identified with Multiple
Drug Res istan t TB ,
2. Drug Alcohol Testing, 1221 Fulton Mall, Fresno , CA 93775, phone: (559) 600-
3434. [BILLING/COST CENTER # 56201639)J
HI V counseling and screening services are provided to individuals who are
currently participating in drug/alcohol treatment programs, both residential as well
as outpatient programs . The program is suppo rted through an interagency
agreement with the Substance Abuse Division . In addition to counseling and
testing services, group education is pro vided to clients as well as regular
program up dates with the staff of participating programs.
3. HIV Preventi on Test ing, 1221 Fulton Mall, Fresno , CA 93775, phone: (559) 600-
3434 (B ILLING/COST CENTER #56201645)
Exhibit A
Page 6 of8
HIV counseling and screening services are provided to individuals who
demonstrate an increased risk for HIV transmission. This program is supported
through a grant from the California Department of Public Health.
4. Court Ordered HIV Testing, 1221 Fulton Mall, Fresno, CA 93775, phone: (559)
600-3434, (BILLING/COST #56201648)
Court ordered HIV counseling and screening is provided to individuals who have
been ordered by the court to complete HIV education and testing, under Penal
Code 1202.1.
Exhibit A
Page 7 of'S
SCOPE OF WORK
GROUP II
DEPARTMENT OF BEHAVIORAL HEALTH
TYPES OF REQUIRED CLINICAL LABORATORY TESTS
The average volume of clinical laboratory tests the Behavioral Health Department
conducted in the past year are provided for the programs with the highest utilization.
While every effort was made to get the most current information on the types of tests
needed by each program. the types of tests listed below are best estimates only. The
County does not guarantee any minimums for any of the tests listed below.
Program
Metro Outpatient Services
Pathways to Recovery
Older Adult Mental Health Clinic
Types of Tests
Majority of tests are CBC differential, mostly for
Clozaril monitoring (30%) and Blood Drawing
(15%). Other tests include TSH, Comprehensive
Metabolic Panel, Valproic Acid, Lipid Profile ,
lithium, Hepatic Function Panel, Glucose Plasma,
Triglycerides, AST, Glucose Random, Prolactin,
Urine Toxicology, Hemoglobin A1 C Immunoassay,
EtOH serum, Drug Abuse Panel 9 Serum, and
miscellaneous other tests
Tests include, but are not limited to, Urine
Toxi cology and Pregnancy tests and miscellaneous
other tests
Tests include , but are not limited to,
Comprehensive Metabolic .Panel, CBC differential,
lipid Panel: Hemoglobin A 1 C Immunoassay, TSH,
Urinal ysis Reflex, Valporic Acid, etc .
SCOPE OF WORK
GROUP II
DEPARTMENT OF BEHAVIORAL HEALTH
Exhibit A
Page 8 of8
LABORATORY SERVICES FOR FACILITIES THAT OPERATE
MONDAY THROUGH FRlDAY, 8:00 A.M. TO 5:00 P.M.
Please note that Billing/Cost Center numbers listed at the end of each program below
are for internal use only. DBH facilities and programs that require Contractor's services
include, but are not limited, to the following:
1. Metro Outpatient Services, 4441 E. Kings Canyon Road, Fresno, CA 93702,
phone (559) 600-4099, fax (559) 600~9135. (BILLING/COST CENTER #
56302999)
Metro Services provides culturally appropriate therapeutic outpatient and
rehabilitative group services to seriously and persistently mentally III and
homeless mentally ill consumers. Staff provides medication administration and
education, monitor medication levels for consumers and perform physical and
mental health assessments.
2. Older Adult Mental Health Clinic, 2025 E. Dakota Ave ., Fresno, CA 93726, phone
(559) 600-5755. fax (559) 229-2982 . (BILLING /COST CENTER # 56304610)
3 . Pathways to Recovery, Building 320 , 515 S. Cedar Avenue , Fresno, CA 93702 ,
phone (559) 600-6068, fax (559) 600-6090 . (BILLING/COST CENTER #
56302093)
Pathways to Recovery offers a three track program that provides outpatient
substance abuse treatment services for pregnant and parenting women, mental
health services for CalWORKs clients and co-occurring services for clients with
co-existing mental health and substance abuse challenges.
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
TEST
CODE
14742
4846
11328
15860
6251
N/A
799
285
287
5463
4550
484
480
497
7600
10256
622
10165
4503
4554
718
17304
17303
809
10108
859
867
653
899
905
8563
6448
395
4128
6399
90858
10231
SCHEDULE OF FEES
DEPARTMENT OF PUBLIC HEALTH
TEST
NAME
Amphetamine conf (GC/MS)
Cannabinoid conF (GC/MS)
Cocaine conf (GC/MS)
Opiates conf (GC/MS)
Phencyclidine (PCP) conf (GC/MS)
Ethanol conf (GC/MS)
RPR (screening)
Direct Bilirubin (CPT Code = 82248)
Total Bilirubin (CPT Code = 82247)
Complete Urinalysis (CPT Code = 81000)
General Bacterial Culture
Glucose
Gonorrhea Culture
Gram Stain
Lipid Panel
Liver Function Panel (CPT Code = 80061)
Magnesium
Metabolic Panel (CPT Code= 80048)
Mycobacterial Acid Fast Smear
Mycobacterial Culture
Phosphorus
SDA for Gonorrhea
SDA for Chlamydia
Sed Rate (ESR) Westergren
Stool Culture
T-3, Total (CPT Code = 84480)
T-4 (Thyroxine), Total
TPPA (confirmation)
TSH
Uric Acid
Urinalysis (Micro only)(CPT Code = 81002)
Urinalysis (w/o Mlcro)(CPT Code = 81015)
Urine Culture
VDRL (CSF only)
CBC with Differential
Cocciodlolal Serology Panel
Comprehensive Metabolic Panel' {CPT
Code = 80053;*different from Metabolic Panel
$
UNIT
PRICE
26.00
$ 127.55
$ 17.75
$ 24.50
$ 38.10
N/A
$ 4.56
$ 3.25
$ 3.25
$ 4.00
$ 10.00
$ 5.00
$ 21 .. 15
$ 16.00
$ 9.00
$ 4.27
$ 10.00
$ 4.46
$ 21.55
$ 97.40
$ 3.25
$ 25.00
$ 25.00
$ 11.15
.$ 169.46
$ 28.40
$ 16.30
$ 86.00
$ 8.00
$ 14.35
$ 2.16
$ 1.84
$ 1 1.20
$ 26.35
$ 5.00
$ 153.92
$ 5.57
Exhibit C
Page 1 of 2
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52 ..
53.
54.
55.
56.
57.
58.
59.
60.
61.
TEST
CODE
496
1759
512
501
8475
498
8472
SCHEDULE OF FEES
DEPARTMENT OF PUBLIC HEALTH
TEST
NAME
Hemoglobin A1C Immunoassay
Hemogram (BC w/platelet cOllht)
Hepatitis A Antibody, IgM
Hepatitis B Core Antibody
Hepatitis B Surface Antibody
Hepatitis B Surface Antigen
Hepatitis C (Antl-HCV)
6447/90349 Herpes Simplex Virus, Type I and II, IgG &
IgM
10110 HIV 1 and HIV 2 Antibody (HIV Serology)
5233 HIV 1 Western Blot
40085 HIV.l RNA, QUAL, Real Time peR (Viral load Tests)
91431 HIV Screen Only
7195 Lymphocyte Subset Panel
FPNRl PAP, SurePath Focal Point
CYTPl PAP, Thin Layer Prep
5363 Prostate-specific Antigen
8847 Prothrombin Time
10314 Renal Functional Panel (CPT Code = 80069)
799 STS (Rapid Plasma Reagin) Qual
899 Thyroid Stimulating Hormone
(3rd Generation)
7195 T-Lymphocyte Helper/CO
3679 Toxoplasma Gondll Antibody IgG
91431 HIV-l/2 Antigens and Antibodies,
Fourth Generation, with Reflexes, CPT 91431
91432 HIV-l/2 Antibody Differentiation, CPT 91432
$
$
$
$
$
$
$
UNIT
PRICE
47.00
4.95
11.00
11.00
11.00
11.00
11.00
$ 178.40
$ 25.00
$ 25.00
$ 291.00
$ 22.50
$ 50.00
$ 23.75
$ 22.50
$ 109.00
$ 13.70
$ 4.83
$ 4.56
$ 8.00
$ 50.00
$ 59.50
$ 22.50
$ 25.00
Exhibit C
Page 2 of 2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
TEST
CODE
10306
2128
443
423
14742
10165
8416
8417
3259
329
6399
1759
334
1769
10231
395
19733
2180
136140
136140
29424
701089
701033
701011
457
482
483
484
396
8396
496
498
10306
10256
499
8472
91431
7573
SCHEDULE OF FEES
DEPARTMENT OF BEHAVIORAL HEALTH
TEST
NAME
Acute Hepatitis Panel
Alcohol (Ethanol) Urine
Alcohol, Ethyl (8)
Amitriptyline
Amphetamine Conf by GC/MS, Urine
Basic Metabolic Panel
Barbiturates by GC/MS Urine
Benzodiazepines Conf (GC/MS) Urine
Blood drawing
Carbamazinepine (Tegretol)
CBC (Includes Diff/Plt)
CBC (RBC, H/H, Indices, WBC, Pit)
Cholesterol Direct LDL
Clozapine
Comprehensive Metabolic Panel
Culture, Urine, Routine
Drug Abuse Panel 9, Serum
Drug Screen with Alcohol
Drug Test, General ToXicology, (B)
Drug Test, General Toxicology, (SP)
EIA 10
EIA 10 + Alcohol
EIA 7 + Alcohol w/ GC/MS
EIA 7 + Alcohol w/o Rflx
Ferritin
GGT
Glucose
Glucose, plasma
HCG, Total QL
HCG, Total QN
Hemoglobin AlC Immunoassay
Hep B Surface Ag w/Reflex Confirm
Hepatic Panel Acute w/ Ref
Hepatic Function Panel
Hepatitis B Surface AB, Qual
Hepatitis C
HIV AB, HIV 1/2, EIA, with Reflex
Iron and IBC w/o Reflex
SCHEDULE OF FEES
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
UNIT
PRICE
44.00
75.00
50.00
45.00
26.00
4.46
75.00
25.00
8.00
8.00
5.00
4.95
2.00
18.75
5.57
11.20
$ 366.55
$ 25.00
$ 64.75
$ 64.75
$ 50.00
$ 50.00
$ 50.00
$ 50.00
$ 25.00
$ 15.00
$ 3.50
$ 5.00
$ 4.50
$ 14.00
$ 10.00
$ 11.00
$ 63.00
$ 4.27
$ 25.00
$ 11.00
$ 22.50
$ 30.00
Exhibit D
Page 1 of 2
Exhibit D
Page 2 of 2
DEPARTMENT OF B EHAVIORAL HEALTH
TEST TEST UNIT
CODE NAME PRICE
39 . 14852 Lipid Panel with Refle x to Direct LDL $ 35.00
40 . 7600 l.ipid Profile $ 9 .00
41 . 613 Lllthlum $ 6 .00
42. 622 Magnesium, Serum S 10.00
43. 4846 Marijuana Metabolite, Quant, Urine $ 127 .55
44 . 272 Nortriptyline $ 20.00
45 . 70073 Olanzapine $ 160.00
46. 15860 Opiates, Confirmation by GC/MS, UR $ 24.50
47 , 713 Phenytoin (Oilantin) $ 10.00
48 . 733 Potassium, Serum $ 3.64
49 . 396 Pregnancy Test, Urine $ 4 .50
SO . 746 Prolactin $ 30 .00
51. 5363 Prostate Specific Antigen (PSA) $ 109.00
52 . 10314 Renal Funct ion Panel $ 4.83
53 . 2339 Risperidone $ 92.00
54 . 701030 RPR/Reflex TPPA $ 70.00
55 . 3820 STAT Charge $ 3.0.00
56. 701030 5T$ Titer + T. Paliidum-PA Reflex $ 70.00
57 . 859 T3 Tot,,1 (Triiodothyronine) $ 28 .40
58 861 13 Uptake $ 10.00
59 . 34429 13, Free $ 50.00
60 . 867 T4 (Thyro xi ne) $ 16 .30
61 . 866 T4 , Free $ 10 .00
62 . 896 Trig lycer ides $ 4 .50
63 . 899 TSH $ 8 .00
64 . 36127 TSH Refle x to Free T4 $ 10.00
65 . 3020 Urinalysis C+S , If INO $ /1 ,00
66 . 6448 Urinalysis Macroscopic $ 1.84
67 . 8563 Urinalysis Microscopic $ 2 ,16
68 . 5463 Urinalysis, Complete $ 4 .00
69 . 7909 Urina lysis, Macro W/Refie x to Micro $ 2 .00
70 . 916 Valprolc Acid $ 15 .00
71 . 7065 Vitamin B-12 and Folate $ 50 .00
72 . 17306 Vitamin 0 , 25-hydro xy , LC/MS/MS $ 75.00
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REOUIREMENTS
Exhibit E
Page 1 of 2
The COUNTY and its subcontractors shall provide services in accordance with all
applicable FederaJ and State statutcs and regulations,
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welbreand Institutions Cocies,
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of Califomia and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10,5 and 10,6 of the California Health and Safety Code; Title 22, California Codc
of Regulations, section 51009; and Division I, Part 2,6, Chapters 1-7 of the
California Civil Code,
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make avai lable to COUNTY and to the
public all eligibility requirements to participate in the program plan sel
forth in the Agreement. No person shal I, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded 'Ihlm participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance,
B. Employment Opportunitv
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices, Such practices include retirement, recruitment
advertising, hiring, layoff, tenninatioIl, upgrading, demotion, transfer,
Exhibit E
Page 2 of 2
rates of payor other forms of compensation, use of tilei lities, and other
tenns and conditions of employment.
C. Suspension of Compensation
Ifal) allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY's Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATlENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, ilicluding but
not limited to, laws, regulations ,and State policies relat.in g to patients' rights
Exhibit F
SELF-DEAUNG TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "C ounty"),
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 b.elow:
"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.
INSTRU CTIONS
(1) Enter board member's name, job title (if applicable), and date thi s disclosure is being made .
(2) Enter the board member's company/agency name. and address .
(3) Describe in detail the nature afthe self-dealing·transactlon 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.
(S) Form must be sig ned by the board member that is involved in the sel f -dea ling transaction
described in Sec tions (3) and (4).
Page I 0.1'2
EX}dbit F
(1) Comp any Board Mem b er Inf o rmation:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self~dealing transaction YOLI are a party to):
(4) I:xplain why this sclf-deiJling tl'Clnsaction is consistent with the requirements of Corporations Code 5233 (a);
(5) Authorized Signature
Signature: I Date:
I
Page 2 of2
Exhibit G
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identif in Information
OiSlA
Ad(ho~~ «(I umbe r,@ !r.,el) cny ZIP CO(fo
ellA numbE.'r T:I )(p'~"( 10 (IUl l ll>e.l (EIN ) T~p/1ono nl,lmj:xlI
II. Answer the following question s by checking "Yes" or "No." Ifany of the questions are answered "Yes," list nam es and
addresses of individuals or corporations under "Remarks" on page 2 . Id entify each Item number to be continued.
A. Are there any individual s or o,rgani zat ions having a direct o r Indirect ownership or control Interest
o f five percent or m ore in the Institution , organ izatio ns , or agen cy Ulat have been convic ted of a criminal
.o ffense related ta th e in val vement o f such persons Or organization's in any of the prog rams established
by Titles XVIII, XIX, or XX? ........................................................................................................................ .
B . Are there a ny dire'ctors , o ffi ce rs. agents, .or managing employees of the institution, agency, or
org anizat ia n wha have ever bee n ca nvicted .o f a criminal o ffense· relate d ta thei r inval vement in s uc h
pr og rams established by Title s XV II I, XIX, or XX? ...... .. ............. .0 ................................................ ..
C. Are there any Indi vidu als c urrently employed by the institution, agency, or org aniz·at la n in a manageri al,
accounting, auditing, or similar capacity who were em played by the Institution's, organization 's, o r
agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ......... ..
YES NO
o 0
o C1
o 0
III. A. List names, address es for individuals, or the EINfor organizations having direct .or Indirect ownership or a controlling
interest in th e entity. (See instructions for definition of ownership and cantroiling Interest.) List any additiona l names
and addresses under "Remarks" on page 2 . If mOre than o ne individ ual is reported and any of these persons are
related to each ather, this must be reparted under "R emarks."
NAME ADDRESS EIN
B. Type .of entity : o Sole proprielarship o Partnership o Carparation
o Unincorporated Assoclatlan s o Other (specify) ________ _
C. If the disclos ing entity is a corporation, list name s, addres ses .of the directors, and EIN s far co rpuratian s
under "Remarks,"
D. A re any ow n e rs o f the disclasing entity also owners o f ather Medicare/Medicaid facilities?
(Exa mp le: sole praprietor, pa rtnersh ip , or members of Baard .of Dire ctors) If yes , list names , addres ses
of indi vid uals, a'nd provider numbers .... " ........ '"'''''''''' ...... .0 ....................................................................... , o 0
NAME ADDRESS PROVIDER NUMBER
Exhibit G
YES NO
IV. A. Has there been a change in ownership or control within the last year? ......................................... ,............. 0 0
If yes, give date.
B. Do you anticipate any change of ownership or control within the year? .................................................... ..
Ifyes,when? ____________________________________ ------
C. Do you anticipate filing for bankruptcy within the year? ......................................................................... ..
If yes. when? __________________________________ _
V. Is the facility operated by a management company or leased in whole or part by another organization? ..........
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?
VII. A. Is this facility chain affiliated? .................. ..
ilf es, list name, address of cor oration, and EIN.
EIN
Ad(:Iro~~ (numbm, n;)mo) City Sla t,
B. If the answer to question VilA Is NO, was the facility ever afnliated with a chain?
(If yes, list name. address of corporation, and EIN.)
NamE! .tN
Cily State
ZIP cede
liP COd8
o o
o o
o 0
o 0
o 0
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result In denial of a request to pariielpate or where the enlily already pariiclpates, a termination of
its agreement or contract will) the agency. as appropriate.
Name of cllllhorimd riprt~t,.en(a(iv'!j (typ~d) TIUe
Date
Remarks