HomeMy WebLinkAbout5.628 Original ContractOctober 19th, 2009
City of Port Angeles Fire Department
Attn: Chief Daniel McKeen
102 East Fifth Street
Port Angeles, WA 98362 -3014
Dear Chief McKeen,
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SYSTEMS 1 DESIGN°
Another year has come and almost gone, we hope that all is well with you and, your staff as
we come to the end of the year. It has been a busy year for Systems Design; we have made
many improvements to our services and we plan to continue to upgrade our operations as
we move forward. Our objective is to provide our first responder clients with world class
patient billing services at the most reasonable price possible.
That brings me to the cost of our services. I am proposing to extend our Professional
Services Agreement for an additional year which would take us through December 31
2010. I am pleased to offer the same 2009 contract price of ($ 22) per transport, plus actual
postage expense, for the 2010 contract period. Even though some costs have increased, we
are able to maintain our prices this year and improve our delivery of services. Our software
and operations investments are yielding results that we are passing on to our. clients.
The Systems Design contract may be extended for additional terms upon mutual agreement
of both parties (See Article 2- Term of the Agreement). This letter, when signed below, can
serve as mutual agreement of both parties. If you agree with this extension, please return
one signed copy of this letter to our office at your earliest convenience. Please don't hesitate
to call me with any questions you may have.
On behalf of all of the staff at Systems Design, we would like to thank you for your
continued support. We look forward to another successful year of service with your
organization.
Approved: Systems Design West, LLC
By:
C. Mark ' pice
CEO, Systems Design West, LLC
Approved: City of Port Angeles Fire Dept
By:
:Date: t 1 1 0 ro
PO Box 3510 • Silverdale, WA 98383 • (360)692.5242 • Fax (360)698.4968
www.SystemsDesignEMS.com
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SYSTEMS DESIGN NORTHWEST, INC.
Medical Blllmg Systems & Services
P.O Box 3510 Sllverdale, WA 98383
(360) 692-5242
(800) 585-5242
Fax (360) 698-4968
September 24, 2008
City of Port Angeles Fire Department
Attn: Chief Dan McKeen
102 E 5th Street
Port Angeles, W A 98362-3014
Dear Chief McKeen,
The fall rains are moving in, so it must be time for reviewing next year's budget. It's been an
exciting year with the start up of our new billing software, and this coming year will see the full
transition into the new system. I hope you're liking what you see! Your current contract runs
through December 31, 2008. The contract may be extended for additional terms upon mutual
agreement of both parties (See Article 2 - Term ofthe Agreement).
I am proposing to extend our Professional Services Agreement for an additional year which
would take us through December 31, 2009. I am happy to report that, even though our expenses
have increased, we will be able to maintain your rate at $22.00 per MIR, plus actual postage
expense. Weare able to do this by adding new clients through your kind referrals and improving
efficiencies.
This letter, when signed below, can serve as the "mutual agreement of both parties". If you have
any questions, or would prefer to execute a new contract, please give me a call. If you agree to
the extension, please return one signed copy of this letter to our office at your earliest
convemence.
On behalf of your Account Manager, Sue, and the rest of the staff at Systems Design Northwest,
I'd like to thank you fer your continued support. 'Ve-have enjoyed working with you these past
years and look forward to many more.
Thanks in advance for your prompt attention to this matter.
::~es::west, me.
Roger A. Zegers, r
President
Approved, City of Port Angeles Fire Dept
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BUSINESS ASSOCIATE AGREEMENT
THIS BUSINESS ASSOCIATE AGREEMENT (this "Agreement ") is made this lst
day of January, 2010, between Systems Design West, LLC, a limited liability company duly
organized under the laws of the State of Washington (the "Company "), and City of Port
Angeles duly organized under the laws of the State of Washington (the "Provider "), This
Agreement supplements and is made a part of that certain contract entitled "Professional.
Services Agreement" entered into by the Company and the Provider.
WITNESSETH:
WHEREAS, the Provider and the Company desire to enter into a "Business
Associate Agreement ",
NOW, THEREFORE, in consideration for the mutual obligations contained herein
the Company and the Provider, each intending to be legally bound, hereby mutually
covenant and agree as follows:
1. Term. This Agreement shall be effective as of the date first above written.
Subject to the provisions of Section 3 of this Agreement, this Agreement shall remain in full
force and effect for as long as the Provider utilizes the services of Company.
2. Use and Disclosure of Protected Health Information. The parties hereto
agree that in order for the Company to perform its duties as expected by the Provider, it will
be necessary for the Company to use and disclose Protected Health Information ( "PHI "), as
such term is defined at 45 CFR §164.501.
2.1 Permitted and Required Uses and Disclosures of PHI The parties
hereto agree that the Company may use and disclose PHI in order to carry out any Payment
function covered under the definition of "Payment " contained in 45 CFR § 164.501. The
parties hereto further agree that the Company may use or disclose PHI for any use or
disclosure that is required by law.
3. Termination.
3.1 Termination by the Provider for Breach. Pursuant to 45 C.F.R.
§ 164.504(e)(2)(iii), the Provider may terminate this Agreement if the Provider determines
that the Company has breached a material term of this Agreement. In the event of a
material breach of the Company's duties and responsibilities contained in Sections 4.1
through and including 4.9 of this Agreement, the Provider may immediately terminate this
Agreement upon written notice to the Company. In the event of a claimed material breach
of any other provision of this Agreement by the Company, the Provider shall give the
Company written notice of the alleged material breach. The Company shall have ten (10)
days from the date of any written notice of breach to cure the alleged breach. In the
event the Company cures the alleged breach within the ten (1 0) day time period, this
5.(V$
Agreement shall remain in full force and effect. In the event that the Company fails to
cure the alleged breach within the ten (10) day time period, this Agreement shall
terminate.
3.2 Termination by the Company for Breach. In the event of a
claimed material breach of any provision of this Agreement by the Provider, the
Company shall give the Provider written notice of the alleged material breach. The
Provider shall have ten (10) days from the date of any written notice of breach to cure the
alleged breach. In the event the Provider cures the alleged breach within the ten (10) day
time period, this Agreement shall remain in full force and effect. In the event that the
Provider fails to cure the alleged breach within the ten (10) day time period, this
Agreement shall terminate.
4. Duties and Responsibilities of the Company.
4.1 Restrictions on Use and Disclosure of PHI. The Company shall .
not use or further disclose any PHI other than as permitted or required by this Agreement,
or as required by law;
4.2 Safeguarding of PHI. The Company shall use appropriate
safeguards to prevent the use or disclosure of PHI other than as provided for in this
Agreement;
4.3 Reporting of Unauthorized Use or Disclosure of PHI. The
Company shall report to the Provider any use or disclosure of PHI not provided for by
this Agreement of which the Company becomes aware;
4.4 Protection of PHI by Agents and Subcontractors. The Company
shall ensure that any agents, including any subcontractors, to whom it provides PHI
received from, or created or received by the Company on behalf of the Provider, the
Provider agrees to the same restrictions and conditions that apply to the Company with
respect to such PHI;
4.5 Access to PHI. The Company shall make available PHI in .
accordance with 45 CFR §164.524. Within ten (1 0) days after receipt of a request from
the Provider for access to PHI in the possession of the Company, the Company shall
make such PHI available to the Provider. Within ten (10) days after receipt of a request
from an individual for access to PHI in the possession of the Company, the Company
shall forward such request to the Provider;
4.6 Amendments to PHI. Within ten (10) days after receipt of a
request from the Provider for an amendment to any PHI, the Company shall make the
requested PI -II available to the Provider for amendment and shall incorporate any such
amendments into the PHI in accordance with 45 CFR § 164.526. Within ten (10) days
after receipt of a request from an individual for an amendment to any PHI, the Company
shall forward such request to the Provider;
4.7 Accountings. Within ten (10) days after receipt of notice from the
Provider that the Provider has received a request from an individual for an accounting of
disclosures of PH1 regarding the individual during the six (6) years prior to the date on
which the accounting was requested, the Company shall make available to the Provider
such information as is in the Company's possession and is required for the Provider to
provide an accounting of disclosures of PHI to the individual in accordance with 45 CFR.
§ 164.528;
4.8 Internal Practices, Books, and Records. The Company shall make
its internal practices, books, and records relating to the use and disclosure of PHI
received from, or created or received by the Company on behalf of the Provider available
to the Secretary of the Department of Health and Human Services for purposes of
determining the Provider's compliance with. Subpart E of Part 164 of Title 45 of the Code
of Federal Regulations; and,
4.9 Duties with Regard to PHI Upon Termination of this Agreement.
At termination of this Agreement, if feasible, the Company shall return or destroy all PHI
received from or created or received by the Company on behalf of the Provider that the
Company still maintains in any form and retain no copies of such PHI. If such return or
destruction is not feasible, the Company shall extend the protections of this Agreement to
the PHI and limit further uses and disclosures of the PHI to those purposes that make the
return or destruction of the PHI not feasible.
5. Duties and Responsibilities of the Provider.
5.1 Preparation and Delivery of Accountings. It shall be the sole
responsibility of the Provider to prepare and deliver any accounting requested pursuant to
45 CFR § 164.528;
5.2 Decisions Concerning Access to PHI. In the event that an
individual has requested access to PHI directly from the Company, and the Company has
forwarded such request to the Provider in accordance with. Section 4.5 of this Agreement,
it shall be the sole responsibility of the Provider to determine whether to grant or deny
such access; and,
5.3 Amendment of PHI. In the event that an individual has requested
an amendment to PHI directly from the Company, and the Company has forwarded such .
request to the Provider in accordance with Section 4.6 of this Agreement, it shall be the
sole responsibility of the Provider to determine whether to allow or disallow such
amendment.
6. Representations and Warranties of the Provider. The Provider hereby
represents and warrants to the Company as follows:
6.1 Accurate Information. All accounts placed with the
Company by the Provider shall contain accurate information;
6.2 Consents and Authorizations. Prior to disclosing any PHI to the
Company, the Provider shall obtain all required consents and authorizations pursuant to
45 CFR §164.506 and 45 CFR § 164.508 respectively, sufficient to permit the disclosure
of PHI from the Provider to the Company, and to permit the Company to perform its
duties pursuant to the terms of this Agreement;
6.3 No Restrictions. The Provider shall not place any account with the
Company if the Provider has agreed to any individual's request to restrict the use or
disclosure of PHI connected with such account pursuant to 45 CFR § 164.522; and,
6.4 Organization and Authority. The Provider is validly organized .
under the laws of the State of Washington and has all requisite power and authority to
enter into this Agreement and to perform its obligations hereunder. This Agreement has
been duly executed and delivered by the Provider and constitutes a legal, valid and
binding obligation of the Provider, enforceable against it in accordance with its terms.
7. Confidentiality. The Company agrees to keep all Protected. Health
Information received from, or created or received by the Company on behalf of the
Provider confidential except as necessary for the Company to perform its duties pursuant
to the terms of this Agreement. The Company's duty to maintain the confidentiality of
Protected. Health Information which shall continue forever, unless disclosure of such
information should be allowed or required by law.
8. No Third Party Beneficiaries. The Provider and the Company
hereby expressly understand and agree that individuals whose PHI is disclosed by the
Provider to the Company are not intended to be third party beneficiaries of this
Addendum or the Contract for Services.
9. Independent Contractor Status. The parties hereto expressly
agree that in performing its duties under this Addendum and the Contract for Services,
the Company is acting as an independent contractor of the Provider. Nothing contained
herein is intended, nor shall it be construed to create, a joint venture relationship, a
partnership, or an employer- employee relationship between the parties.
10. Enforcement. If either party resorts to legal action to enforce or
interpret any provision of this Agreement, the prevailing party shall be entitled to recover
the costs and expenses of the action, including without limitation, reasonable attorneys'
fees.
11. Severability. If any provision of this Agreement shall be adjudged .
by any court of competent jurisdiction to be invalid or unenforceable for any reason, such
judgment shall not affect, impair or invalidate the remainder of this Agreement.
12. Change of Law. The parties hereto shall modify any term of this
Agreement at anytime if it is determined that the inclusion of any term of this Agreement
or the omission of any term from this Agreement violates any federal or state law or
regulation, including, without limitation: the Standards for Privacy of Individually
Identifiable Health Information (45 CFR Parts 160 and 164); the Health Insurance
Reform: Standards for Electronic Transactions; Announcement of Designated Standard
Maintenance Organizations (45 CFR Parts 160 and 162); and, the Security and Electronic
Signature Standards (the "Security Standard ") (45 CFR Part 142) (or the final version of
the Security Standard once such final version is released), all promulgated under the
Health Insurance Portability and Accountability Act of 1996 (Pub.L. 104 -191).
IN WITNESS WHEREOF, the parties hereto have executed and delivered
this Agreement as of the day and year first above written.
By L.
Print Name Oa n oi Cie
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Date
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Address: 1 D Eris,- Ste'
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Systems Design West. LLC
Print Name
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SYSTEMS DESIGN NORTHWEST, INC.
Medical Billing Systems & Services
P.O. Box 35 10 Silverdale. WA 98383
(360) 692-5242
(800) 585-5242
Fax (360) 698-4968
August 28, 2007
City of Port Angeles Fire Department
Attn: Chief Dan McKeen
102 E 5th Street
Port Angeles, W A 98362-3014
Dear Dan,
The fall rains are moving in, so it must be time for reviewing next year's budget. Time flies
when you are having fun! Your current contract runs through December 31, 2007. The contract
may be extended for additional terms upon mutual agreement of both parties (See Article 2 -
Term of the Agreement).
I am proposing to extend our Professional Services Agreement for an additional year which
would take us through December 31, 2008. The new rate would be $ 22.00 per MIR, plus actual
postage expense. Based on your average number of transports for the first half of 2007, this
would amount to a monthly increase of approximately $70.25.
This letter, when signed below, can serve as the "mutual agreement of both parties". If you have
any questions, or would prefer to execute a new contract, please give me a call. If you agree to
the extension, please return one signed copy of this letter to our office at your earliest
convemence.
On behalf of your Account Manager, Sue, and the rest of the staff at Systems Design Northwest,
I'd like to thank you for your continued support. We have enjoyed working with you these past
years and look forward to many more.
Thanks in advance for your prompt attention to this matter.
Approved: Systems Design Northwest, Inc.
Approved, City of Port Angeles Fire Dept.
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Roger A. Zegers,
President
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Systems pesign Northwest, Inc.
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adj~sted .the, ~CltY'scambulance..traD:spqrf~ '; ,
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" At' our last City Council' meeting, 'the Council
charges as follows: ,,:' '
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. Advance ,Life Srippo~ transport,'(base) charge froiD."$4~O~0'$509,:~' ,,~ ':,' ,",: :c':" ,',\;",', ,', " ",
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. The addition of aparamedic)nter,c~t char~~ of $5,QO,: TWs :c~arge will,he 9ill~(rtQ.';';, '" : >' ,
the agency, requesting the "Raramedicintercept. ' " .7,: ',', ," : ':\ ',; ,\ ': /~:, ,C:<'," ',-:, " ,
, ,I , . , .," ",','; ,', " ' ",:,",. ,'" ,:.." ',', "',', ~ ',:, " '.,":~",.',,:,: .',",~r".' ;//':',',';:"
, 'All other City related ambulance charges are, unaffected.' Attached is a copy of ' the Pori:, r' , ,'. ',:,: .
:,' .Angeles City'~rd~~ce adj~s~ing th~ Medic I'tran,sRort c4arge,~.' >""':"/" '"" ",':' ", ;':~;::'" ;,,:> "<'~:} :"Y";d;'~':
, " Tp-e,adjusted'rate~ take effect on J~uary'12,2007." :, ' ",' ',: " ,~,; ",,:' ',~] ,c ;:":," '::~'~, '~: ',,>, " ,":~ >:' j'
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If you have any questions regarding the adjustment C!r the paramedi'6 'intercept-' charg~/yo~:: ", . 'I ,r,' ,; ,
, can contact me at 360 4174651. ! ' , , :' , ,
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Port Angeles Fire Department
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pc: Yvonne Ziomkowski, Finance Director
'Becky Upton, Ci,ty Clerk
Attachment: Ordinance #3268
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102 EAST FIFTH S,TREET · PORT ANGELES, WA 98362-3014
PHONE 360-417-4655. FAX 360-417'4659. E-MAIL parflre@cityofpa us
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ORDINANCE NO. 3268
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AN ORDINANCE of the City of Port Angeles, Washington, adjusting the Medic
I base transport charge for advanced life support services and adding a
paramedic intercept service charge to Gover a gap in the, ,cur;rent
ordinance, and amending Ordinance 3143, as amended, and Chapter 3.70
. of the Port Angeles MUIlicipal ,Code.
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THE CITY COUNCIL OF THE CITY OF PORT ANGELES does hereby ordain as
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follows:
Section 1. Ordinance 3143, as amended, and Chapter 3.70 of the Pi;>rt Angeles
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'Municipal Code are hereby amended by amending 3.70.095 PAMC to read as follows:
3.70.095 Fire Department Fees - Medic 1. The following rates are established for
ambulance services performed by the City's Medic I Utility:
A. Medic I transports that involve advanced life support (ALS) services requiring
,~ither the administration of at least three different medications or the provision of a least one ALS
procedure as identified as ALS-2 in Medicare's current ambulance fee schedule.
1. Base Charge $580.00] . '
2. Disposable equipment charge $ 33.00
3. Mileage : , $ 10.09 per mile
B. Medic I transports that involve advanced life support services not covered by
Section A above:
1. Base Charge $4-8B:OO $500.00
2. Disposable Equipment Charge $ 33.00
3. Mileage ~- $ 10.00 per mile
4. Paramedic intercept service charge $500.00
C. Medic I transports that involve only basic life support services:
1. Base Charge $380.00
2. Disposable Equipment Charge $ 33.00
3. Mileage $ 10.00 per mile
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I person or circumstances, is held invalid, the remainder of the Ordinance, or application of the
II provisions of the Ordinance to 0 th er persons or circum stan ces, is not affected.
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Section 2- Severability. If any provision of this Ordinance, or its application to any
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Section 3 - Corrections. The City Clerk and the codifiers of this ordinance are
authorized to make necessary corrections to this ordinance including, but not limited to,
correction ofthe scrivener's/clerical errors, references, ordinance numbering, section/subsection
numbers and any references thereto.
Section 4 - Effective date. This ordinance, being an exercise of a power specifically
delegated to the City legislative body, is not subject to referendum. This ordinance shall take
effect five (5) days after passage and publication of an approved summary thereof consisting of
the title.
PASSED by the City Council of the City of Port Angeles at a regular meeting of said
Council held on the 2nd day of January , 200L.
ATTEST:
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Becky J. U n, ity Cler
~p' OVED AS TO Fa---
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William E. Bloor, City Attorney
PUBLISHED: Jon:J.
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7 ,2007
By Summary
G ILegal_BackupIORDINANCES&RESOLUTIONS\2006-22 MediC I Rates 083006 wpd
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SYSTEMS DESIGN NORTHWEST, INC.
Medical Billing Systems & Services
PO Box 3510 5i1verdale, WA 98383
(360) 692-5242
(800) 585-5242
Fax (360) 698-4968
August 22, 2006
City of Port Angeles Fire Department
Attn: Chief Dan McKeen
102 E 5th Street
Port Angeles, WA 98362-3014
Dear Chief McKeen,
It must be budgeting time as I am starting to get calls about our billing rates for next year. Time
flies when you are having fun! The current contract runs through December 31, 2006. The
contract may be extended for additional terms upon mutual agreement of both parties (See
Article 2 - Term of the Agreement).
I am proposing to extend our Professional Services Agreement for an additional year which
would take us through December 31, 2007. The new rate would be $ 21.50 per MIR plus actual
postage expense. Based on your average number of transports, this would amount to a monthly
increase of approximately $52.90. This is your first increase in two years.
This letter, when signed below, can serve as the "mutual agreement of both parties". If you have
any questions, or would prefer to execute an entire new contract, please give me a call. If you
agree to the extension, please return a signed copy of this letter to our office at your earliest
convemence.
On behalf of your Account Manager, Sue, and the rest of the staff at Systems Design, 1'd like to
thank you for your continued support. We have enjoyed working with you these past years and
look forward to many more.
Thanks in advance for your attention to this matter.
Approved: Systems Design Northwest, Inc.
Approved, City of Port Angeles Fire Dept
BY:~~
Roger A. Zegers,
President
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.~ORTANGELES
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, "" Roger Zegers, Preside~t
:,: $ystems Design Northwest, Inc.
POBox 3510'
'Silverdale, W A98383
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Dear Mr. Zegers,
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At the November 1 st Port Angeles 'City ~ouncil meeting, the Council' approv,~<;t:anAncr~ase' ,,' ,/~" :
'i~theCity's~bulancetrallsport.charges"asf(mows:', ,~,':' I".', ~:', .',:::,J: ,,<:,"~"~': ',','"
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Basic life supp.ort transport (base)'charge fro~ $3 r'S;to'$3'80"and , :' , ; ~ ~', ~. . ' "", ',: -" ,
A~dAdvanced Life Support-2 transport (b,asefcI1argeset a($$'80.";" ,..', ' ,~" ;',':"
-, - ,,' ! < ; ,~ - I I ~ f _"'I~\ I ''', ,I ~ ~ < I' ,:. ~ : 4: '). ,1 "
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All other City related 'ambulance charges are 'Unaffected:~Attaclied is a 'copy' 6f:the,'Pprt ,,0,", : !
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, ~ Angeles City Ordinance adjusting:the Medic I transport chaig~s:' " ',", ' .
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, Tbe adjusted rates' ta~e effec(op November 11, -20Q5:' ',w " ,':-, '. \" ~_ ,::,,'
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~, ", ' ", ' , If you have any questions regardingthe adjustments to Port Ange.1es ',8 arp.~ul<lnce 'ti:~sP'~rt'; >' ' :'
, charges, you Ca]1 c,ontact: me at 360-417,-4655..' -" - ., ',"- "~ " "
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Coral Whe'eler, Administrative Assistant
Port Angeles Fire Department
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Attachments
pc: Dan McKeen, Fire'Chief
. Yvonne Ziomkowski, Finance'Director
Becky Upton, City Clerk
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102 EAST FIFTH STREET. PORT ANGELES, WA 98362-3014
PHON E '360-417-4655 · FAX 360-417-4659 · E-MAI L PAFl RE@CI PORT-ANG,ELES WA US, ' '
ORDINANCE NO. 3221
AN ORDINANCE of the City of Port Angeles, Washington,
revising the City's Fire Department Fees - Medic I, and Chapter
3.70' of the Port Angeles Municipal Code.
THE CITY COUNCIL OF THE CITY OF PORT ANGELES DOES HEREBY
ORDAIN as follows:
Section 1.
Chapter 3.70 PAMC is hereby amended by amending PAMC 3.70.095
to read as follows:
3.70.095 Fire Department Fees - Medic 1. The following rates are established for
ambulance services performed by,t,he City's Medic I Program:
A. Medic I transports that involve advanced life support (ALS) services requiring
either the administration of at least three different medications or the provision of at least 1 ALS
procedure as identified as ALS-2 ill Medicare's current ambulance fee schedule.
1.
2.
3.
Base Charge
Disposable equinment charge
Mileage
$580.00
$ 33.00
$ 10.00 per mile
B.:k--Medic I transports that involve advanced life support services-:- not covered bv
Section A above.
1. Base Charge
2. Disposable Equipment Charge
3. Mileage
$480.00
$ 33.00
$ 10.00 per mile
-- --_ _~__--~~ C.~Medic I transports.that involve onlvbasic life support services:-
1. Base Charge ' $315.00380.00
2. Disposable Equipment Charge $ 33.00
3. Mileage $ 10.00 per mile
Section 2.
Except as provided above Chapter 3.70 P AMC IS ratified and
confrrmed.
- 1 -
Section 3 - Corrections.
The City Clerk and the codifiers of this ordinance are
authorized to make necessary corrections to this ordinance including, but not limited to, the
correction of the scrivener's/clerical errors, references, ordinance numbering, section/subsection
numbers and any references thereto.
Section 4 - Severability.
If any provisions of this Ordinance or its application to
anyperson or circumstances, is held invalid, the remainder of the Ordinance, or application of the
provisions of the Ordinance to other persons or circumstances, is not affected.
Section 5 - Effective Date.
This Ordinance shall take effect five days following the
date of its publication by summary.
PASSED by the City Council of the City of Port Angeles at a regular meeting of said
Council held on the ~ day of November, 2005.
~[){MoJl
Richard A. Headrick, Mayor
bo~~ .11ptD"-
Becky J. Up ,. Clerk
APPfVED AS TO FO
1/5-& ~--~
William E. Bloor, City Attorney
ATTEST:
- PUBLISHED: November 6- ~--:-- 2005-
By Summary
G:\Legal_Backup\ORDINANCES&RESOLUTIONS\2005- 37 .MedicIRates 1 0-6-05 wpd:
October 26, 2005
- 2 -
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WAS H I N G TON, U. S. A.
FIRE DEPARTMENT
October 5, 2005
Roger Zegers, President
Systems Design Northwest, Inc.
POBox 3510
Silverdale, W A 98383
Dear Roger,
Enclosed is a letter extending the term of our ambulance transport billing- agreement through
December 31, 2006. Also enclosed is the new provision outlining o,ur agency's responsibility
to secure (l signature for each patient authorizing the billing of their insurance.' >
Both items are signed. The City retained your original and sent a copy to you with an original
signature from our City Manager.
, "
If you have any questions regarding the ,signed copies, you_can contact m~ ~t 360 417 4651. .
Sincerely,
0.
~~
Dan McKeen, Fire Chief
Port Angeles. Fire Department
DM/cw
Attachments
pc: Becky Upton, City Clerk
,.
102 EAST FI FTH STREE;T · PORT ANGELES, WA 98362-3014
PHON E 360-417-4655 · FAX 360-417-4659. E-M~IL: PAFIRE@CI PORT-ANGELES WA US
~,
SYSTEMS DESIGN NORTHWEST, INC.
~edical Billing Systems & Services
P.O Box 35 I 0 Sllverdale, WA 98383
August 29,2005
(360) 692-5242
(800) 585-5242
Fax (360) 698-4968
Chief Daniel McKeen
City of Port Angeles Fire Department
102 E 5th Street
Port Angeles, W A 98362-3014
Dear Chief McKeen
2005 has been another eventful year for everyone involved in ambulance transport services and billing.
MedIcare has required that all claims to them must now be submitted electronIcally, regardless of the size of the
provIder. Due to tIghtening Federal budgets, claIms are becomIng subject to even tighter prepayment reVIews.
However, it IS the final year of the phase-in period for the National Fee Schedule for ambulance, so 2006
MedIcare reimbursement levels will be calculated from a blend of only two Fee Schedules, rather than three!
It has also been a very good year! We continue to grow, due to so many kInd referrals from our clIents.
We have added to our staff and reorganized our managerial structure to accommodate this phenomenal growth.
But most Importantly, we have been able to achieve growth and stIll maIntaIn the quality of service you have
come to expect. On behalf of the entire staff, I would lIke to thank you for your continUIng support.
As we approach fall, I'm sure next year's budget is a priority in your workload. As we do every year at this
tIme, we have reVIewed our own budget to determine what fees we WIll need to charge next year. I am happy
to report that for 2006, even though our expenses have Increased, we will be able to maIntaIn your rate at
$21.00 per transport for another year. We are able to do thIS by adding new clIents and imprOVIng effiCIenCIes.
ThIS letter, when SIgned below, can serve as the 'mutual agreement of both parties' referenced In our current
contract. If you have any questions, or would prefer to sign an entIrely new contract, please gIVe my assistan~
Shelley BreWIngton, or me a call. If you agree to the extension, please return one SIgned copy of thIS letter at
your earlIest convenience. In addition, you wIll find attached an Addendum to the Professional Services
Agreement regardIng the ResponsibilitIes of the Ambulance ProvIder. It is a requirement of all insurance
companies that the SIgnature of the patient or other authorized indIVIdual be on file prior to claim submISSIOn.
Many clIents are already gettIng patIent SIgnatures In conjUnctIOn with HIP AA, but you should be aware that
thIS is an absolutely mandatory Medicare documentation requirement, with serious consequences for
noncomplIance. Please return a SIgned copy of the Addendum along WIth the extenSIOn letter for our files.
On behalf of Kim and the rest of the staff at Systems Design Northwest, I want to again say , Thank You'. We
have enjoyed working with you all these years and look forward to many more.
Thanks in advance for your attention to thIS matter.
. ,/ Approved: Systems Design Northwest, Inc.
Approved:
By: fC~
Roger A. Zegers,
PreSIdent / CEO
By~:f2-v=-
Date: /O/-S-/a..r-
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t:
Addendum to Professional Services Agreement dated
Systems Design NW, Inc. and
between
Add to ARTICLE I - DESCRIPTION OF SERVICES:
Responsibilities ofthe Ambulance Provider:
Secure from the patient or other authorized individual the authorization to bill Medicare,
Medicaid and any other governmental agencies or insurance companies. Signature must be
maintained in Ambulance Provider's office and made available to Systems Design NW, Inc.
upon request. No transport services will be forwarded to Systems Design NW, Inc. for billing
purposes if such authorization has not been received.
By ~ :f2"":,~
Title: 0 ~;f.-re""'"
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Date: /o/s- h..r-
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By: fl~
Title: President / CEO
Date: August 29.2005
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~~YSTEMS DESIGN NORTHWEST, INC.
Medical Billing Systems & Services
PO Box 35 I 0 Sllverdale. WA 98383
(360) 692-5242
(800) 585-5242
Fax (360) 698-4968
January 5, 2005
Coral Wheeler, Administrative Assistant
City of Port Angeles Fire Department
102 East Fifth Street
Port Angeles, W A 98362-3014
Dear Coral,
Please find enclosed your signed copy of the updated professional service agreement for 2005. I
have also included a copy of our Declarations Page as proof of our liability coverage as
referenced in Article VI-Insurance. If you require additional documentation, please let me know.
It's always a pleasure to work with you!
Sincerely,
, :L1~^ J
~~p~
Shelley Brewington, Administrative Assistant
Systems Design Northwest
sb
Attachment: Professional Service Agreement
Insurance Declarations Page
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PROFESSIONAL SERVICES AGREEMENT
'v
This AGREEMENT made this 2151 day of December, 2004, by and between the City of Port Angeles
("City") and Systems Design Northwest, Inc., a sole proprietorship ("Systems Design").
ARTICLE I - DESCRIPTION OF SERVICES
Systems Design agrees to provide billing services to the City for its ambulance transportation
services, which services shall be in accordance with recognized standards for ambulance transport
billing services and shall be in accordance with applicable government rules and regulations.
Responsibilities of the City:
1. Apply for "Provider Status" with Medicare, DSHS, Labor & Industries, and any private
insurance company which will be billed.
2. Complete the Medical Incident Report ("MIR"), including patient name, address, and
pertinent billing information.
3. Forward MIRs, hospital face sheets, and copies of payments made to the City to Systems
Design on a weekly basis.
4. Provide additional information as may be required by insurance companies or agencies in
order to complete the processing of billing ambulance charges.
Responsibilities of Systems Design:
1. Entry of AccountlPatient records.
2. Entry of all charges, payments, and adjustments.
3. Production and mailing ofHCFA 1500 forms for all insurance charges entered. Optionally,
the claims may be transmitted electronically to participating insurance companies and
agencIes.
4. Print, stuff, and mail private statements (monthly).
5. Production of monthly reports and delivery to the City. Selection of reports to be mutually
agreed upon based on the current reports available in the Systems Design MMS software.
6. Collection procedures as approved by the City.
7. Review all accounts and rebill/follow-up as necessary.
Page 1 of 4
8. Deposit all payments mailed to Systems Design in an account specified by the City no less
than weekly or when the total of the checks on hand reaches $2,500.00. The City shall have
sole control over this account with Systems Design having deposIt only access. Copies of all
deposit slips will be forwarded directly to the City.
9. Systems Design shall investigate the feasibility of electronic remittance. If it is mutually
determined to be in its best interest of the City, Systems Design shall implement electronic
remittance from major insurance carriers.
10. Provide customer service via toll free phone lines for all patient billing questions, Monday
through Friday, 8:00 a.m. to 5:00 p.m. (Federal holidays excepted).
11. Provide all necessary supplies including insurance forms, private statements, envelopes and
backup diskettes.
ARTICLE II - TERM AND TERMINATION OF THE AGREEMENT
This Agreement shall be for ambulance transports occurring between July 25, 200J January 1, 2005
through December 31,-2-004 2005. This Agreement may be renewed for additional terms upon the
mutual agreement of both parties. This Agreement may be terminated by either party upon 30 days
written notice to the other party at the address below.
Upon termination of this Agreement, Systems Design shall provide follow-up private billings and
payment posting as necessary for a period of one additional month. Within 30 days ofthis additional
month of service, Systems Design shall return all materials, medical incident reports, and other
documentation provided to it by the City under this Agreement. Systems Design shall also provide
a detailed report of the current status of all outstanding accounts.
ARTICLE III - PAYMENT FOR SERVICES
Systems Design shall submit a bill to the City on a monthly basis for services provided. The amount
of the bill shall be calculated as the total of:
A. $21.00 $20.00 for each MIR entered during the current billing period.
D. 50% OfIcccipt5 Icedvcd TIn alllc5ident t1ansports and ambulance sGlviees provided pliO!
to July 25, 200J (disposable equipment fee only) .
B. €: Actual postage expenses.
Payment by the City to Systems Design shall be made within 30 days of receipt of such billing. Upon
renewal of this Agreement for additional terms, the rate used in the above calculation may be
adjusted to a new rate as mutually agreed.
Page 2 of 4
ARTICLE N - CONFIDENTIALITY
Systems Design shall not release any information provided to it under this Agreement to any source,
provided however, that it may release mformation (includmg copies of MIRs) as required by
insurance companies or agencies to facilitate payment for claims submitted.
ARTICLE V - INDEMNIFICATION / HOLD HARMLESS
Systems Design shall defend, indemnify and hold the City, its officers, officials, employees and
volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney
fees, arising out of or in connection with the performance ofthis Agreement, except for injuries and
damages caused by the sole negligence of the City.
The City shall defend, indemnify and hold Systems Design its officers, officials, employees and
volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney
fees, arising out of or in connection with the performance ofthis Agreement, except for injuries and
damages caused by the sole negligence of Systems Design.
ARTICLE VI - INSURANCE
Systems Design shall obtain and maintain professional liability insurance with limits no less than
$1,000,000 per claim and shall forward the City a certificate of insurance so verifying.
ARTICLE VII - MISCELLANEOUS
This Agreement may be modified or amended only in writing and signed by each of the parties.
This Agreement is to be governed and construed under the laws of the State of Washington.
This Agreement contains the entire agreement between the City and Systems Design with respect
to the subject matter of this Agreement. All prior arrangements or undertakings are superseded by
this Agreement.
In the case anyone or more provisions contained in this Agreement shall be determined to be invalid,
illegal or unenforceable in any respect, the remaining provisions contained herein shall not in any
way be affected or impaired thereby.
The tolerance of a breach or default under this Agreement shall not be construed to be a waiver of
such breach or default.
All notices hereunder by either party to the other shall be in writing. All notices, demands and
requests shall be deemed given when mailed, postage prepaid, registered or certified mail, return
receipt requested to the address below.
Page 3 of 4
City of Port Angeles
POBox 1150
P'Q:Q WA98362
By: ~cfO~
Richard Headrick, Mayor
Attest:
By:.60~~^-
Becky n, ity Cler
Approved as to form:
1l~--- ~
William Bloor, City Attorney
. ,
,
Systems Design Northwest, Inc.
POBox 3510
Silverdale, W A 98383-3510
(-- '1- 'Z-Ot:JS
Date
Page 4 of 4
Policy t-4umber
98-C2-4050-6
DECLARATIONS PAGE
AMENDED OCT 20 2004
STATE FARM FIRE AND CASUALTY COMPANY
PO BOX 5000, DUPONT WA 98327-5000
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
Named Insured and Mailing Address
2114-F480 K
SYSTEMS DESIGN NW INC
PO BOX 3510
SILVERDALE WA 98383-3510
Cov A -Inflation Coverage Index: N/A
BUSINESS POLICY - SPECIAL FORM 3 Cov B - Consumer Pricelndex: 185.2
AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automatically
subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will
give you and the Mortgagee/Lienholder written notice in compliance witli the policy provisions or as required by law.
Policy Period: 12 Months The ~oIICY period begins and ends at 12:01 am standard time at the
Effective Date: APR 20 2004 premises location.
Expiration Date: APR 20 2005
Named Insured: Corporation
Your policy is amended OCT 202004
NUMBER OF ADDL INTERESTS CHANGED
Location of Covered Premises:
9975 MICKELBERRY RD STE 101
SILVERDALE WA 98383-9195
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Limits of Insurance Occupancy: Off 1 ce
Excluded
$ 46,000
$ Actual loss
Section II
L Business Liability
M Medical Payments
Products-Completed Operations
(PCO) Aggregate
General Aggregate (Other
Than PCO)
I
1,000,000
5,000
2,000,000
2,000,000
Deductibles - Section I
$ 500 BasIc
$
In case of loss under this policy, the deductible will be
applied to each occurrence and will be deducted from the
am.ount of the loss. Other deductibles may apply - refer to
polley.
Endorsement Premium None
Forms, Options, and Endorsements
SpeCial Form 3
WA Amendatory Endorsement
Tree Debris Removal
Business Policy Endorsement
SpeCial Form 3 Endorsement
Policy Endorsement
Glass Deductible Deletion
FP-6103
FE-6247.1
FE-6451
FE-6464
FE-6500.1
FE -6503
FE-6538.1
Discounts Applied'
Renewal Year
Years In Business
Claim Record
Prepared
NOV 23 2004
FP-8030.2C
06/1993
Your policy consists of this page, any endorsements
and the policy form. PLEASE KEEP THESE TOGETHER.
Continued on Reverse Side of Page
OTHER LIMITS AND EXCLUSIONS MAY APPLY - REFER TO YOUR POLICY
Countersigned
By
KEN HALL
(360) 692.2900
AI63
Agent
(o1f2172b
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~ORTANGELES
WAS H I N G TON, U. S. A.
FIRE DEPARTMENT
September 28, 2004
Roger Zegers, President
Systems Design Northwest, Inc.
POBox 3510
Sllverdale, W A 98383
Dear Mr. Zegers,
At our last CIty Council meeting, the Council adjusted the City's ambulance transport
charges as follows:
BasIc lIfe support transport (base) charge from $280 to $315, and
Advanced life support transport (base) charge from $450 to $480.
All other CIty related ambulance charges are unaffected. Attached IS a copy of the Port
Angeles CIty Ordinance adjusting the Medic I transport charges.
The adjusted rates take effect on October 1,2004.
If you have any questions regarding the adjustments to Port Angeles's ambulance transport
charges, you can contact me at 360-417-4651.
Smcerely,
o
Dan McKeen, Fire Chief
Port Angeles Fire Department
Attachment
pc: Yvonne Ziomkowski, Fmance Director
Becky Upton, CIty Clerk
102 EAST FIFTH STREET · PORT ANGELES, WA 98362-3014
PHON E 360-417-4655 · FAX 360-417-4659 · E-MAI L PAFI RE@CI I?ORT-ANGELES WA US
ORDINANCE NO. :1170
AN ORDINANCE of the City of Port Angeles, Washington, adjusting the
Medic I base transport charge for advanced life support serVIces and
basic life support services, and amending Ordinance 3143, as
amended, and Chapter 3.70 of the Port Angeles Municipal Code.
THE CITY COUNCIL OF THE CITY OF PORT ANGELES does hereby ordain
as follows:
Section 1.
Ordinance 3143, as amended, and Chapter 3.70 of the Port Angeles
MunicIpal Code are hereby amended to read as follows:
3.70.095 Fire Department Fees - MedIc 1. The followmg rates are establIshed for
ambulance servIces performed by the CIty'S MedIC I Program:
A MedIC I transports that mvolve advanced lIfe support services'
1. Base Charge $450.00480.00
2. DIsposable Eqmpment Charge $ 33.00
3. Mileage $ 10.00 per mile
B. Medic I transports that involve baSIC lIfe support services'
1. Base Charge $280.00315.00
2. Disposable Eqmpment Charge $ 33.00
3. MIleage $ 10.00 per mile
Section 2- Severability. If any provision of this Ordinance, or ItS application to any
person or cIrcumstances, is held invalId, the remamder of the Ordinance, or applicatIOn of the
proVISIOns of the Ordmance to other persons or CIrcumstances, IS not affected
Section 3 - Effective Date. ThIS Ordinance shall take effect fIve (5) days after its
publicatIOn by summary.
PASSED by the City Council of the City of Port Angeles at a regular meeting of
- 1 -
said Council held on the 21 st
day of September, 2004.
lli4 ~ (jflJLl
MAYOR
ATTEST:
.on ~;,(~L~pI:bA
Becky J. U , Cit Clerk
APP~OVED A~O F~
V~ -- to ~
William E. Bloor, City Attorney
PUBLISHED: September 26, 2004
By Summary
G:\Legal_Backup\ORDINANCES&RESOLUTIONS\2004-17.Medlc 1 Rate Ad]
- 2 -
~
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PROFESSIONAL SERVICES AGREEMENT
~
~
This AGREEMENT made this 3rd day of September, 2003 by and between the City of Port Angeles
("City") and Systems Design Northwest, Inc., a Washington corporation.
ARTICLE I - DESCRIPTION OF SERVICES
Systems Design Northwest, Inc. agrees to provide billing services to the City for its ambulance
transportation services, which services shall be in accordance with recognized standards for
ambulance transport billing services and shall be in accordance with applicable government rules
and regulations.
Responsibilities of the City:
1. Apply for "Provider Status" with Medicare, DSHS, Labor & Industries, and any private
insurance company which will be billed.
2. Complete the Medical Incident Report ("MIR"), including patient name, address, and
pertinent billing information.
3. Forward MIRs, hospital face sheets, and copies of payments made to the City to Systems
Design Northwest, Inc. on a weekly basis.
4. Provide additional information as may be required by insurance companies or agencies in
order to complete the processing of billing ambulance charges.
Responsibilities of Systems Design Northwest, Inc.:
1. Entry of Account/Patient records.
2. Entry of all charges, payments, and adjustments.
3. Production and mailing ofHCFA 1500 forms for all insurance charges entered. Optionally,
the claims may be transmitted electronically to participating insurance companies and
agencIes.
4. Print, stuff, and mail private statements (monthly).
5. Production of monthly reports and delivery to the City. Selection of reports to be mutually
agreed upon based on the current reports available in the Systems Design Northwest, Inc.
MMS software.
6. Collection procedures as approved by the City.
Page 1 of 4
7. Review all accounts and rebill/follow-up as necessary.
8. Deposit all payments mailed to Systems Design Northwest, Inc. in an account specified by
the City no less than weekly or when the total ofthe checks on hand reaches $2,500.00. The
City shall have sole control over this account with Systems Design Northwest, Inc. having
deposit only access. Copies of all deposit slips will be forwarded directly to the City.
9. Systems Design Northwest, Inc. shall investigate the feasibility of electronic remittance. If
it is mutually determined to be in its best interest ofthe City, Systems Design Northwest, Inc.
shall implement electronic remittance from major insurance carriers.
10. Provide customer service via toll free phone lines for all patient billing questions, Monday
through Friday, 8:00 a.m. to 5:00 p.m. (Federal holidays excepted).
11. Provide all necessary supplies including insurance forms, private statements, envelopes and
backup diskettes.
ARTICLE II - TERM AND TERMINATION OF THE AGREEMENT
This Agreement shall be for ambulance transports occurring between July 25, 2003 through
December 31, 2004. This Agreement may be renewed for additional terms upon the mutual
agreement of both parties. This Agreement may be terminated by either party upon 30 days written
notice to the other party at the address below.
Upon termination ofthis Agreement, Systems Design Northwest, Inc. shall provide follow-up private
billings and payment posting as necessary for a period of one additional month. Within 30 days of
this additional month of service, Systems Design Northwest, Inc. shall return all materials, medical
incident reports, and other documentation provided to it by the City under this Agreement. Systems
Design Northwest, Inc. shall also provide a detail report of the current status of all outstanding
accounts.
ARTICLE III - PAYMENT FOR SERVICES
Systems Design Northwest, Inc. shall submit a bill to the City on a monthly basis for services
provided. The amount of the bill shall be calculated as the total of:
A. $20.00 for each MIR entered during the current billing period.
B. 50% of receipts received for all resident transports and ambulance services provided prior
to July 25,2003 (disposable equipment fee only) .
C. Actual postage expenses.
Page 2 of 4
. .
Payment by the City to Systems Design Northwest, Inc. shall be made within 30 days of receipt of
such billing. Upon renewal of this Agreement for additional terms, the rate used in the above
calculation may be adjusted to a new rate as mutually agreed.
ARTICLE IV - CONFIDENTIALITY
Systems Design Northwest, Inc. shall not release any information provided to it under this
Agreement to any source, provided however, that it may release information (including copies of
MIRs) as required by insurance companies or agencies to facilitate payment for claims submitted.
ARTICLE V - INDEMNIFICATION / HOLD HARMLESS
Systems Design Northwest, Inc. shall defend, indemnify and hold the City, its officers, officials,
employees and volunteers harmless from any and all claims, injuries, damages, losses or suits
including attorney fees, arising out of or in connection with the performance of this Agreement,
except for injuries and damages caused by the sole negligence of the City.
The City shall defend, indemnify and hold Systems Design Northwest, Inc., its officers, officials,
employees and volunteers harmless from any and all claims, injuries, damages, losses or suits
including attorney fees, arising out of or in connection with the performance of this Agreement,
except for injuries and damages caused by the sole negligence of Systems Design Northwest, Inc.
ARTICLE VI - INSURANCE
Systems Design Northwest, Inc. shall obtain and maintain professional liability insurance with limits
no less than $1,000,000 per claim and shall forward the City a certificate of insurance so verifying.
ARTICLE VII - MISCELLANEOUS
This Agreement may be modified or amended only in writing and signed by each of the parties.
This Agreement is to be governed and construed under the laws of the State of Washington.
This Agreement contains the entire agreement between the City and Systems Design Northwest, Inc.
with respect to the subject matter of this Agreement. All prior arrangements or undertakings are
superseded by this Agreement.
In the case anyone or more provisions contained in this Agreement shall be determined to be invalid,
illegal or unenforceable in any respect, the remaining provisions contained herein shall not in any
way be affected or impaired thereby.
The tolerance of a breach or default under this Agreement shall not be construed to be a waiver of
such breach or default.
Page 3 of 4
All notices hereunder by either party to the other shall be in writing. All notices, demands and
requests shall be deemed given when mailed, postage prepaid, registered or certified mail, return
receipt requested to the address below.
City of Port Angeles
POBox 1150
Port Angeles, W A98362
~ )f2:._-
City Manager
OW~
Fire Chief
Systems Design Northwest, Inc.
POBox 3510
Silverdale, W A 98383-3510
fIG
s esign Northwest, Inc.
/0-3- Zo03
Date
APPZ;:t~~ ~
City Attorney'\
Q/3u/CJ3
I /
Date
Page 4 of 4
~
.1Jd:D
Business Associate Contract \J-...i..!2.tL- ~. 5. {oe:J 8
1. SYSTEMS DESIGN NORTHWEST, Inc. ("SYSTEMS DESIGN") and
Port Angeles Fire Department ("AMBULANCE PROVIDER") shall
carry out their obligations under this Agreement in compliance with the
privaqr regu.,lations.pursuant.to Public Law 104-191 of August 21, 1996,
known as the Health Insurance Portability and Accountability Act of 1996,
Subtitle F - Administrative Simplification, Sections 261, et seq., as amended
("HIPAA "), to protect the privacy of any personally identiilable protected
health information ("PHI") that is collected, processed or learned as a result
of the Billing Services provided hereunder. In conformity therewith,
SYSTEMS DESIGN agrees that it will:
a. Not use or further disclose PHI except as permitted under this
Agreement or required by law;
b. Use appropriate safeguards to prevent use or disclosure of PHI except
as permitted by this Agreement;
c. To mitigate, to the extent practicable, any harmful effect that is
known to SYSTEMS DESIGN of a use or disclosure of PHI by SYSTEMS
DESIGN in violation of this Agreement.
d. Report to AMBULANCE PROVIDER any use or disclosure of PHI not
provided for by this Agreement of which SYSTEMS DESIGN becomes
aware;
e. Ensure that any agents or subcontractors to whom SYSTEMS DESIGN
provides PHI, or who have access to PHI, agree to the same
restrictions and conditions that apply to SYSTEMS DESIGN with
respect to such PHI;
f. Make PHI available to AMBULANCE PROVIDER and to the individual
who has a right of access as required under HIPAA within 30 days of
the request by AMBULANCE PROVIDER on the individual;
g. Incorporate any amendments to PHI when notified to do so by
AMBULANCE PROVIDER;
h. Provide an accounting of all uses or disclosures of PHI made by
SYSTEMS DESIGN as required under the HIPAA privacy rule within
60 days;
i. Make its internal practices, books ~d records relating to the use and
disclosure of PHI available to the Secretary of the Department of
Health and Human Services for purposes of determining SYSTEMS
DESIGN'S and AMBULANCE PROVIDER'S compliance with HIPAA;
and
/
/
.j. At the termiD;ation of this Agreement, return or destroy all PHI
received from, or created or received by SYSTEMS DESIGN on behalf
of AMBULANCE PROVIDER, and if return is infeasible, the
protections of this agreement will extend to such PHI.
2. The specific uses and disclosures of PHI that may be made by
SYSTEMS DESIGN on behalf of AMBULANCE PROVIDER include:
a. The preparation of invoices to patients, carriers, insurers and others
responsible for payment or reimbursement of the services provided
by AMBULANCE PROVIDER to its patients;
b. Preparation of reminder notices and documents pertaining to
collections of overdue accounts;
c. The sublllission of supporting documentation to carriers, insurers and
other payers to substantiate the health care services provided by
AMBULANCE PROVIDER to its patients or to appeal denials of
payment for same.
d. Uses required for the proper management of SYSTEMS DESIGN as a
business associate.
e. Other uses or disclosures of PHI as pennitted by HIPAA privacy rule.
3. Notwithstanding any other provisions of this Agreement, this
Agreement may be tenninated by AMBULANCE PROVIDER, in its sole
discretion, if AMBULANCE PROVIDER determines that SYSTEMS DESIGN
has violated a tenn or provision of this Agreement pertaining to
AMBULANCE PROVIDER'S obligations under the HIPAA privacy rule, or if
SYSTEMS DESIGN engages in conduct which would, if committed by
AMBULANCE PROVIDER, would result in a violation of the HIPAA privacy
rule by AMBULANCE PROVIDER.
Port Angeles Fire Department
ulance Provider - Print Name
SYSTEMS DESIGN NORTHWEST. Inc.
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Roger A. Zegers
President
~ -/2- --03
Date
Signature
Dan McKeen
By: Print Name
Fire Chief
5. f.p~8
PROFESSIONAL SERVICES AGREEMENT
This AGREEMENT made this 2 ~71i day of ,{j"vtJu-l>tYL ,2002 by and between the
City of Port Angeles ("City") and Roger A. Zegers, dba Systems Design, a sole proprietorship
("Systems Design").
ARTICLE I - DESCRIPTION OF SERVICES
Systems Design agrees to provide billing services to the City for its ambulance transportation
services, which services shall be in accordance with recognized standards for ambulanc~ transport
billing services and shall be in accordance with applicable government rules and regulations.
Responsibilities of the City:
1. Apply for "Provider Status" with Medicare, DSHS, Labor & Industries, and any private
insurance company which will be billed.
2. Complete the Medical Incident Report ("MIR"), including patient name, address, and
pertinent billing information.
3. Forward MIRs, hospital face sheets, and copies of payments made to the City to Systems
Design on a weekly basis.
4. Provide additional information as may be required by insurance companies or agencies in
order to complete the processing of billing ambulance charges.
Responsibilities of Systems Design:
1. Entry of Account/Patient records.
2. Entry of all charges, payments, and adjustments.
3. Production and mailing ofHCF A 1500 forms for all insurance charges entered. Optionally,
the claims may be transmitted electronically to participating insurance companies and
agencIes.
4. Print, stuff, and mail private statements (monthly).
~
5. Protluction of monthly reports and delivery to the City. Selection of reports to be mutually
agreed upon based on the current reports available in the Systems Design MMS software.
6. Collection procedures as approved by the City.
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7. Review all accounts and rebill/follow-up as necessary.
8. Deposit all payments mailed to Systems Design in an account specified by the City no less
than weekly or when the total ofthe checks on hand reaches $2,500.00. The City shall have
sole control over this account with Systems Design having deposit only access. Copies of all
deposit slips will be forwarded directly to the City.
9. Systems Design shall investigate the feasibility of electronic remittance. If it is mutually
determined to be in its best interest ofthe City, Systems Design shall implement electronic
remittance from major insurance carriers.
10. Provide customer service via toll free phone lines for all patient billing questions, Monday
through Friday, 8:00 a.m. to 5:00 p.m. (Federal holidays excepted).
11. Provide all necessary supplies including insurance forms, private statements, envelopes and
backup diskettes.
ARTICLE II - TERM AND TERMINATION OF THE AGREEMENT
This Agreement shall be for ambulance transports occurring between April 1 ,2002 through June 30,
2003. This Agreement may be renewed for additional terms upon the mutual agreement of both
parties. This Agreement may be terminated by either party upon 30 days written notice to the other
party at the address below.
Upon termination of this Agreement, Systems Design shall provide follow-up private billings and
payment posting as necessary for a period of one additional month. Within 30 days of this additional
month of service, Systems Design shall return all materials, medical incident reports, and other
documentation provided to it by the City under this Agreement. Systems Design shall also provide
a detail report of the current status of all outstanding accounts.
ARTICLE III - PAYMENT FOR SERVICES
Systems Design shall submit a bill to the City on a monthly basis for services provided. The amount
of the bill shall be calculated as the total of:
A. $20.00 for each non-resident MIR entered during the current billing period (full transport
billing).
B. 50% of receipts received for all resident transports (disposable equipment fee only) .
C. Actual postage expenses.
Page 2 of 4
Payment by the City to Systems Design shall be made within 30 days of receipt of such billing. Upon
renewal of this Agreement for additional terms, the rate used in the above calculation may be
adjusted to a new rate as mutually agreed. In addition to the foregoing, Systems Design shall be paid
a one-time setup fee of $400.00 upon execution of this Agreement.
ARTICLE IV - CONFIDENTIALITY
Systems Design shall not release any information provided to it under this Agreement to any source,
provided however, that it may release information (including copies to MIRs) as required by
insurance companies or agencies to facilitate payment for claims submitted.
ARTICLE V - INDEMNIFICATION / HOLD HARMLESS
Systems Design shall defend, indemnify and hold the City, its officers, officials, employees and
volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney
fees, arising out of or in connection with the performance ofthis Agreement, except for injuries and
damages caused by the sole negligence of the City.
The City shall defend, indemnify and hold Systems Design, its officers, officials, employees and
volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney
fees, arising out of or in connection with the performance ofthis Agreement, except for injuries and
damages caused by the sole negligence of Systems Design.
ARTICLE VI - INSURANCE
Systems Design shall obtain and maintain professional liability insurance with limits no less than
$1,000,000 per claim and shall forward the City a certificate of insurance so verifying.
ARTICLE VII - MISCELLANEOUS
This Agreement may be modified or amended only in writing and signed by each of the parties.
This Agreement is to be governed and construed under the laws of the State of Washington.
This Agreement contains the entire agreement between the City and Systems Design with respect
to the subject matter of this Agreement. All prior arrangements or undertakings are superseded by
this Agreement.
In the case anyone or more provisions contained in this Agreement shall be determined to be invalid,
illegal or unenforceable in any respect, the remaining provisions contained herein shall not in any
way be affected or impaired thereby.
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.
The tolerance of a breach or default under this Agreement shall not be construed to be a waiver of
such breach or default.
All notices hereunder by either party to the other shall be in writing. All notices, demands and
requests shall be deemed given when mailed, postage prepaid, registered or certified mail, return
receipt requested to the address below.
City of Port Angeles
POBox 1150
Port Angeles, W A 98362
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Fire Chief
Systems Design
POBox 3510
Silverdale, WA 98383-3510
Ol~
OWrkr, Design
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Date
as to form:
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Date
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