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CONTRACT NO.,
AMENDMENT NO. 1 TO CITY SECRETARY CONTRACT 42902
AGREEMENT BETWEEN
TARRANTCOUNTY HOSPITAL DISTRICT
AND
CITY OF FORT WORTH
This Amendment is entered into by and between the Tarrant County Hospital District d/b/a JPS
Health Network ("District) and the City of Fort Worth (City), a home rule municipal
corporation organized under the laws of the State of Texas.
WHEREAS, the parties previously entered into City of Fort Worth City Secretary Contract No.
42902(the "Agreement")which was executed on November 18, 2011;
WHEREAS, the City Council for the City authorized execution of the Agreement along with
four successive two-year renewals in Mayor and Council Communication C-25082;
WHEREAS,the original term of the Agreement expired on September 30, 2013;
WHEREAS, the parties administratively authorized the execution of the first renewal option
upon the expiration of the original term;
WHEREAS, the Agreement involves the performance of sexual assault examinations in
connection with investigations and prosecutions of alleged sexual assaults;
WHEREAS, the District and the City now wish to renew the term of the Agreement by
exercising the Agreement's second renewal option;
WHEREAS,the DISTRICT provides certain health care services in Tarrant County Texas ; and
WHEREAS, the CITY ON BEHALF OF ITS POLICE DEPARTIV,ENT desires to obtain sexual
assault examinations in connection with the investigation or prosecution of alleged sexual assaults;
NOW, THEREFORE, the District and the City, acting through their duly authorized representatives,
enter into the following agreement to amend the Agreement:
SECTION I: DISTRICT OBLIGATIONS ARE TO:
1.Provide Sexual Assault examinations and forensics collection OFFICIAL RECORD
TARY
2.Obtain consents for examination and treatment. C1T� SECRE
F,T,WORTH+YX
SECTION II: CITY OBLIGATIONS ARE TO:
1. Authorize the examination.
2. Pay the fees for services rendered by the DISTRICT within thirty (30) days of billing
date.
Amendment 1 of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 1
SECTION III: FEES FOR SERVICE
1. The fee for sexual assault examination and forensics collection shall be assessed to the CITY
according to the chart attached to this agreement as Schedule "A".
2. Make checks payable to: JPS Health Network
P.O. Box 916046
Fort Worth, Texas 76191-6046
Attention: Cashier
SECTION IV: NOTIFICATION
When this Agreement requires or permits any consent, approval, notice, request, proposal or
demand from one party to another, the consent, approval, notice, request, proposal or demand
must be in writing to be effective and shall be delivered to the party intended to receive it at the
address shown below:
If copies to CITY, to: Program Support Division
505 W. Felix St.
Fort Worth, TX 76115
If copies to CITY, to: City Attorney's Office
Police Legal Advisor
1000 Throckmorton Street
Fort Worth, Texas 76102
If intended for the DISTRICT,to: Robert Earley
President& CEO
1500 South Main Street
Fort Worth, Texas 76104
(817) 927-1290
With copies to DISTRICT, to: VP of Finance
1350 South Main_,
Suite 4000
Fort Worth, Texas 76104
(817) 920-6835
SECTION V: GENERAL TERMS OF AGREEMENT
1. The term of this Agreement shall be from October 1, 2015 to September 30, 2017 ("Initial Term"').
2. This Agreement can be renewed for up to four successive two-year periods.
3. Either Party can terminate this Agreement without Cause after the Initial Term upon 90 days
advance written notice.
4. At the expiration of said term, all obligations of the parties shall continue as required by
federal and state law. Upon expiration, CITY shall reimburse DISTRICT for all billed charges
through the end of the contract term, payable within thirty days.
Amendment 1 of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 2
5. Reimbursement by the CITY shall be made in accordance with Schedule A of this Agreement.
The maximum aggregate amount for which the OAG will reimburse for all costs associated with a
forensic sexual assault examination of a victim is $700 .00. CITY will only reimburse DISTRICT up
to that amount. The CITY will only make payment to the DISTRICT in accordance with the guidelines
in Schedule A and only when accompanied by a charge sheet for each individual (attached as Schedule
B) and with an individual application sheet(attached as Schedule C). Payment shall be made within 30
days from receipt of invoice. Failure to reimburse a properly submitted invoice will result in the
assessment of penalties and interest in the amount of 18% per annum on the amount due beginning on
the 31" day after receipt of the claim.
6. Nothing herein shall prevent the parties at any time from entering into further written
agreements or written amendments hereto as may be mutually acceptable to both parties. This
agreement represents the entire agreement between the parties and supersedes any prior written or oral
agreement and may only be amended in writing signed by both DISTRICT and CITY.
7. This Agreement is not be assignable without the written consent of both parties.
8. This Agreement may be amended only by mutual written agreement. Reimbursement rates
may be amended without written consent to be effective on the date the Attorney General of Texas has
designated.
SECTION VI: MISCELLANEOUS PROVISIONS
1. This Agreement shall be interpreted under the laws of the State of Texas. The venue for any
lawsuit or other judicial or administrative proceeding arising out of this Agreement will be the Fort
Worth Division of the Northern District of Texas if the lawsuit or other proceeding arises in federal court
or Tarrant County, Texas, if the matter arises in state court.
2. Relationship of the Parties - Nothing contained in this agreement, or any document
executed in connection with it, shall be construed by the parties hereto, nor by any third party, to
create the relationship of principal and agent, partnership, joint enterprise, common enterprise,
joint venture,joint owners, or joint tenants between the Parties. The Parties hereby declare and
acknowledge that the relationship existing is one of independent contractors.
3. DISTRICT will not accept a partial payment as payment in full under the terms of this
Agreement. If CITY fails to pay a properly submitted claim/invoice at the total
reimbursement allowable , DISTRICT will consider the claim/invoice as underpaid and will
access penalty and interest on the balance due pursuant to Section V(5) of this Agreement.
4. The following schedules are attached to this agreement:
a. Schedule A: Sexual Assault Exam - Reimbursement Guidelines of the
Attorney General's Office
b. Schedule B: Charge Sheet for Sexual Assault Examination (Attorney General of
Texas)
c. Schedule C: Reimbursement for Costs of Sexual Assault Medical Examinations for
Law Enforcement Agencies (Attorney General of Texas)
Amendment I of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 3
IN WITNESS WHEREOF, the parties hereto have executed this agreement in Fort Worth, Tarrant
County, Texas, to govern the responsibilities of the parties as set forth herein as of October 1, 2015 ,
regardless of the actual date of execution.
City of Fort Worth, Teras Tarrant C01111ty Howital District
d/b/a JP rk
By: By: _
Name: Valerie R. Washington Name:
Title: Assistant City Manager Title:
Date: `5kU�I�j Date: �a U-2 0��
APPROVAL RECOMMENDED BY:
By:\"/
Joel F. Fitzgerald
Chief of Police
Date:
—T
APPROVED AS TO FORM AND LEGALITY:
By: 6
Victoria D. Honey
Assistant City Attorney
Contract Authorization: �ORr.�
M&C: C-25082
Date: 08/02/2011 ® ®�
ATTEST: � o�
FFT. L RECORD
CRETARY
May 7. K � RTH,TX
City Secret
FORM 1295 Certification No: NOT REQUIRED
The agreement is with a governmental entity: (Tarrant County Hospital District).
Amendment 1 of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 4
SCHEDULE A
Sexual Assault Exam
Reimbursement Guidelines of the Attorney General's Office
For maximum reimbursement,submit itemized bills with individual charges listed for each service rendered.The maximum aggregate amount
for which the OAG will reimburse a law enforcement agency for all costs associated with a forensic sexual assault examination of a
victim will be 5700.00.
Sexual Assault Examiner's Fees
Forensic Sexual Assault Exam: $195.00*
Exam and Colposcopy procedure: $233.00*
Associated office visit for colposcopy(non-medical facility):S 26.00
Additional evaluation and management services: $106.00/hour **
*Please note these procedures may not be billed together.
**Requires Documentation of Procedure.
Additional fees:
• Anoscopy procedure up to a maximum amount of$71.00
• Venipuncture procedure up to a maximum amount of$20 00
• Laboratory procedures up to a maximum amount of$150.00 including but not limited to:
• Pregnancy test$6.00
• Urine analysis$9.00
• Drug or alcohol screen$44.00
• Chlamydia culture$37.00
• Gonorrhea testing$16.00
• Syphilis test$11.00
• Sexual Assault kit up to a maximum amount of$50.00
• Supplies and material up to a maximum amount of$100.00
(Requires Documentation of Procedure)
• Handling 1 conveyance of the specimen up to a maximum amount of$20.00
Facility Chames:
• Healthcare facility must be certified by Medicare or by the Joint Commission Accreditation of Health Organizations or licensed by
the Texas Department of Health as a certified facility.
• Charges for healthcare facilities must be on a UB92. including an itemized statement.
• Revenue code R-450 vyill be used for a medical treatment room
• Revenue code R-760 may be used for an emergency room
The maximum amount of the reimbursement for healthcare facility charges'. 5250,00
Amendment I of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 5
i
SCHEDULE B
Charge Sheet for Sexual Assault Examination
Attorney General of Texas
Charge Sheet for Sexual Assault Examination
Provider of Services: Patient Identification:
Patient's Acct Number:
Examiner's Name: Patients MR Number:
Facility Name: Patients name:
Facility Address: Date of Birth:
Facility City,State: Date of Assault:
Facility Phone Number: Law Enforcement Agency:
Law Enforcement Case Number:
Exam Date: Start Time: _ End Time:
FACILITY CHARGE:
Healthcare facility must be certified by Medicare or by the Joint Commission Accreditation of Health
Organizations or licensed by the Texas Department of Health as a certifiedfacility. Charges for healthcare facilities must be
on a UB92, including an itemized statement.
Revenue Description CHARGE QUANTITY
Code*
450 or 760 Treatment Room 250.00
Definition-Revenue code 450 will be used for a medical
treatment room or Revenue code-760 will be used for an
emergency room.
SEXUAL ASSAULT EXAMINER'S FEES:
CPT Code Description CHARGE QUANTITY
99211 Associated office visit 26.00
Definition-At facility other than hospital(i.e.,private facility)
57452 SA Exam WITH Colposcope 233 .00
Definition-examiner fee using colposcope
99283 SA Exam WITHOUT Colposcope 195.00
Definition-examiner fee without colposcope
OTHER CHARGES:
CPT Code Description CHARGE QUANTITY
Laboratory Charges: (Maximum of8150.00 allowed)
81025 0 Pregnancy test(facility charge) 6.00
Definition— Used by facility where the pregnancy test is
performed.
81001 0 Urinalysis(facility charge) 9.00
Definition-Used by facility where urinalysis is
performed.
80101 0 Drug or alcohol screen(facility charge) 44.00
Definition— Used by facility where UDS is performed for
purposes of medical treatment&diagnosis
Amendment I of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 6
SCHEDULE B continued
Charge Sheet for Sexual Assault Examination
Attorney General of Texas
CPT Code Description CHARGE QUANTITY
Laboratory Charges: (Maximum of$150.00 allowed)
87320187110 0 Chlamydia culture(facility charge) 37.00
Definition— Used by facility where culture is submitted to facility
lab for treatment&diagnosis.
87590 0 Gonorrhea testing(facility charge) 16.00
Definition— Used by facility where culture is submitted to facility lab
for treatment&diagnosis.
86592 0 Syphilis test(facility charge) 11.00
Definition— Used by facility where culture is submitted to facility lab
for treatment&diagnosis.
99000 0 Lab Specimen handling(examiner or facility charge) 20.00
Definition— Used by examiner or facility for lab specimen
handling,packaging,&transporting
36415 0 Venipuncture 20.00
Definition-Used by examiner or facility for
Venipuncture
Additional CharQes: QUANTITY
46600 0 Anoscopy with colposcope magnification in males for suspected 71.00
trauma(Males)
99170 0 Anogenital exam with colposcope magnification in childhood for 128.00
suspected trauma(Children)
56820 0 Anogenital exam with colposcope magnification in adult females for 128.00
suspected_trauma (Women)
99199 0 Anogenital exam utilizing digital photography(high resolution) in adult 100.00
females,adult males,or children suspected of trauma
99499 0 Evaluation Fee(requires additional documentation- 106.00
documentation should include detailed explanation)
99050 0 Medical services after hours(Services provided at times other 20.00
than regularly scheduled hours— i.e.,holidays,Saturday,or
Sunday)
99053 0 Medical services — between l0pm and Sam (Services provided 39.00
between 10::00pm and 8:00am at 24 hour facility -in additional to
basic service)
11015199070 0 Evidence collection kit 50.00
99070 0 Supplies— details should be provided(maximum of$100.00 allowed) 100.00
Submitted by: TOTAL CHARGE
Note:
The maximum aggregate amount for which
the OAG will reimburse is$700.00
Signature
Printed Name
Failure of City of Fort Worth Police Department to supply the Law Enforcement Case Number prior of submission of this form to the Texas Attorney
General will result in a denial of the Reimbursements set forth in Schedule A. The City of Fort Worth Police Department will be responsible for
reimbursement at 60%of billed charges for the entire Facility claim and the invoice.
Failure of City of Fort Worth Police Department to submit documents to the Office of the Attorney General timely or fail to receive reimbursement from
the Attorney General does not waive City of Fort Worth Police Department responsibility to reimburse Facility for services.
Amendment 1 of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 7
SCHEDULE C
Reimbursement for Costs of Sexual Assault Medical Examinations
for Law Enforcement Agencies
ATTORNEY GENERAL OF TEXAS (S.4.1fPLE ONL}' 7-111SNOTAN OR1GLV4L)
APPLICATIONPLEASE PRINT CLEARLY IN BLACK INK OR TYPE.
Reimbursement for Costs of Sexual Assault Medical Examinations
Victim
Information
Victim's Last Name First Name Middle Name
The victim is the person
who was
allegedly
sexually Social Security Number Date of Birth Sex: Male
assaulted. Female
Law Enforcement
Agency
Information
Law Enforcement Agency Name
Payment will
not be Mailing Address
processed
without City State Zip
complete
information.
Tax Payer Identification Number(required) Contact Person's Name
Telephone Number(including Area Code) Fax Number
E-Mail Address(if available)
Date of Crime Law Enforcement Case Number
Suspect's Name(if known) Prosecutor's Case Number(if known)
Please check the box below that best describes the type of crime that occurred:
Adult Sexual Assault Child Sexual Assault
( 18 years of age or older) (17 years of age and under)
Date of the Primary Sexual Assault Exam
Signature of Law Enforcement Representative required on reverse side.
Amendment 1 of the CSCO 42902 between the City of Fort Worth and Tarrant County Hospital District 8
M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
CITY COUNCIL AGENDA FoH
COUNCIL ACTION: Approved on 8/2/2011 -Ordinance No. 19815-08-2011
DATE: 8/2/2011 REFERENCE NO.: **C-25082 LOG NAME: 35JPSSANE12
CODE: C TYPE: CONSENT PUBLIC NO
HEARING:
SUBJECT: Authorize Agreement for Sexual Assault Medical Examination Services with the Tarrant
County Hospital District at John Peter Smith Hospital Reimbursed by the Texas Crime
Victim's Compensation Fund in an Amount Not to Exceed $392,000.00 for Two Years and
Adopt Appropriation Ordinance (ALL COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council:
1. Authorize an Agreement for sexual assault medical examination services with the Tarrant County
Hospital District at John Peter Smith Hospital;
2. Authorize the Agreement to begin October 1, 2011 and expire September 30, 2013;
3. Authorize this Agreement to be renewed for up to four successive two-year periods. This action
does not require specific City Council approval provided that the City Council has appropriated
sufficient funds to satisfy the City's obligation during any renewal terms; and
4. Adopt the attached appropriation ordinance increasing estimated receipts and appropriations in
the Grants Fund by$1,960,000.00 ($392,000.00 per two-year period for ten years) upon execution of
the Agreement, contingent upon receipt of funds.
DISCUSSION:
Sexual assault medical examinations have been conducted at John Peter Smith Hospital (JPS), a
division of the Tarrant County Hospital District, for more than 30 years. In 1978, a cooperative effort
between JPS, the Tarrant County District Attorney's Office and the Fort Worth Police Department was
established in an attempt to provide a more complete and uniform collection of evidence, thus
benefiting the criminal investigation procedure. The Attorney General's office of the state of Texas
establishes victim eligibility and allowable reimbursable expenses and will reimburse the City up to
$700.00 per case.
The Police Department will use the Agreement to provide professional examinations for an estimated
280 sexual assault cases each year for Fiscal Year 2012 through Fiscal Year 2013. The charges for
emergency room, tests performed and a hospital fee will be billed to the Police Department at a cost
not to exceed $700.00 per case as allowable and reimbursable expenses by the State of Texas
Crime Victim's Compensation Program.
The attached ordinance appropriates $1,960,000.00 in funding for this program, which is the total
estimated funding that the City will receive if all renewal options under the Agreement are exercised
($392,000.00 for five, two-year periods).
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that upon approval of the above
http://apps.cfwnet.org/council_packet/mc review.asp?ID=15509&councildate=8/2/2011 3/31/2016
M&C Review Page 2 of 2
recommendations and execution of the Agreement, funds will be available in the current operating
budget, as appropriated, of the Grants Fund. The Police Department is responsible for the collection
and deposit of funds due to the City.
TO Fund/Account/Centers FROM Fund/Account/Centers
4) $392,000.00
GR76 488990 035496537010
4) $392,000.00
GR76 539120 035496537010
4) $392,000.00
GR76 488990 035496537020
4) $392,000.00
GR76 539120 035496537020
4) $392,000.00
GR76 488990 035496537030
4) $392,000.00
GR76 539120 035496537030
4) $392,000.00
GR76 488990 035496537040
4) $392,000.00
GR76 539120 035496537040
4) $392,000.00
GR76 488990 035496537050
4) $392,000.00
GR76 539120 035496537050
Submitted for Cit ry Manager's Office by: Charles W. Daniels (6199)
Originating Department Head: Jeffrey W. Halstead (4210)
Additional Information Contact: Gerald L. Chandler(4219)
ATTACHMENTS
35JPSSANE12 AON.doc
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=15509&councildate=8/2/2011 3/31/2016