HomeMy WebLinkAboutContract 47721 � 8
CITY SECRETARY
/a N CONTRACT NO.
PROFESSIONAL SERVICES AGREEMENT
.a
This PR SSIONAL SERVICES AGREEMENT ("Agreement") is made and entered into by and
etween the TY OF FORT WORTH (the "City"), a home rule municipal corporation, acting by and
c' y authorized Assistant City Manager, and TEXAS HEALTH HARRIS METHODIST
H L FORT WORTH (the "Consultant" or "Contractor"), a Texas non-profit organization, each
individually referred to as a"party"and collectively referred to as the"parties."
AGREEMENT DOCUMENTS:
The Contract documents shall include the following:
1. This Agreement for Professional Services
2. Schedule A—Sexual Assault Exam—Reimbursement Guidelines of the Attorney General's Office
3. Schedule B—Charge Sheet for Sexual Assault Examination(Attorney General of Texas)
4. Schedule C—Reimbursement for Costs of Sexual Assault Medical Examinations for Law
Enforcement Agencies (Attorney General of Texas)
Exhibits A and B, attached hereto are incorporated herein and made a part of this Agreement for all purposes. In
the event of any conflict between the terms and conditions of Exhibits A and B and the terms and conditions set
forth in the body of this Agreement, the terms and conditions set forth in the body of this Agreement shall
control.
The term "Consultant" or "Contractor" shall include the Consultant or Contractor, and its officers, agents,
employees,representatives, servants,contractors or subcontractors.
The term"City"shall include its officers, employees, agents, and representatives.
1. SCOPE OF SERVICES.
Consultant hereby agrees to provide, in accordance with the appropriate professional standard,the City
with sexual assault examination services for medical forensics purposes, as outlined in Schedule "A," Sexual
Assault Exam—Reimbursement Guidelines of the Attorney GeneraI's Office,which is hereby made part of
this Agreement for all purposes.
2. TERM.
This Agreement shall commence upon the latest signature date herein below("Effective Date") and shall
continue in full force and effect for an initial term of one(1)year("Initial Term").
Following the Initial Term, there shall be one (1) option to renew this Agreement for an additional one
(1)year term("Renewal Term")at the City's option, unless this Agreement is terminated as provided herein.
3. COMPENSATION.
The City shall pay Consultant an amount not to exceed Fifty Thousand Dollars ($50,000.00)per year in
accordance with the provisions of this Agreement and the Payment Schedule attached as Exhibit `B"..
Consultant shall not perform any additional services for the City not specified by this Agreement unless the City
requests and approves in writing the additional costs for such services. The City shall not be liable for any
Professional Services Agreement
OFFICIAL RECORD
Texas Health Harris Methodist Hospital Fort Worth CITY SECRETARY
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FT. WORTH, TX
additional expenses of Consultant not specified by this Agreement unless the City first approves such expenses
in writing.
There is no guarantee expressed or implied as to the minimum quantity of work that the City is obligated
to provide or the minimum compensation to be paid under this Agreement.
Acceptance by Consultant of payment shall operate as and shall release the City from all claims or
liabilities under this Agreement for anything related to, done, or furnished in connection with the services for
which payment is made, including any act or omission of the City in connection with such services.
Consultant shall provide monthly invoices to the City. Invoices shall contain a detailed breakdown to
include: date of service,patient name, and type of service performed including employee name and title.
Payment for services rendered shall be due within thirty(30) days of the uncontested performance of the
particular services so ordered and receipt by City of Consultant's invoice for payment of same. In the event of a
disputed or contested billing, only that portion so contested may be withheld from payment, and the undisputed
portion will be paid. No interest will accrue on any contested portion of the billing until mutually resolved. City
will exercise reasonableness in contesting any billing or portion thereof.
4. TERMINATION.
4.1. Convenience. The City or Consultant may terminate this Agreement at any time and for any
reason by providing the other party with 30 days' written notice of termination.
4.2 Non-appropriation of Funds. In the event no funds or insufficient funds are appropriated by the
City in any fiscal period for any payments due hereunder, City will notify Consultant of such occurrence and this
Agreement shall terminate on the last day of the fiscal period for which appropriations were received without
penalty or expense to the City of any kind whatsoever, except as to the portions of the payments herein agreed
upon for which funds have been appropriated.
4.3 Breach. Either party may terminate this Agreement for breach of duty, obligation or warranty.
4.4 Duties and Obligations of the Parties. In the event that this Agreement is terminated prior to the
Expiration Date, the City shall pay Consultant for services actually rendered up to the effective date of
termination and Consultant shall continue to provide the City with services requested by the City and in
accordance with this Agreement up to the effective date of termination. Upon termination of this Agreement for
any reason, Consultant shall provide the City with copies of all completed or partially completed documents
prepared under this Agreement. In the event Consultant has received access to City information or data as a
requirement to perform services hereunder, Consultant shall return all City provided data to the City in a machine
readable format or other format deemed acceptable to the City.
5. OWNERSHIP AND INTELLECTUAL PROPERTY RIGHTS
5.1 Except for the medical records obtained by and through the sexual assault examinations
performed under this Agreement, the City shall own all right, title, and interest in the work produced by
Consultant under this Agreement(collectively, "Work Product") at all times throughout the world. Further, City
shall be the sole and exclusive owner of all copyright,patent,trademark,trade secret and other proprietary rights
in and to the Work Product. Ownership of the Work Product shall inure to the benefit of the City from the date of
conception, creation or fixation of the Work Product in a tangible medium of expression(whichever occurs first).
Each copyrightable aspect of the Work Product shall be considered a"work-made-for-hire"within the meaning of
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the Copyright Act of 1976, as amended, and City will be considered the author of the Work Product, with all
rights appurtenant thereto. If, and to the extent such Work Product, or any part thereof, is not considered a
"work-made-for-hire" within the meaning of the Copyright Act of 1976, as amended, Consultant hereby expressly
assigns, sells, and transfers, and to the extent any such assignment, sale, or transfer cannot be made at the present
time to City, agrees to assign, sale, and transfer, all exclusive right, title and interest in and to the Work Product,
and all copies thereof, and in and to the copyright,patent,trademark,trade secret, and all other proprietary rights
therein,that the City may have or obtain,without further consideration, free from any claim, lien for balance due,
or rights of retention thereto on the part of the City. Consultant shall have no copyright or other intellectual
property interest in the Work Product.
5.2 The City shall have access to and be entitled to review and copy any portion of the Work Product
at any time.
6. DISCLOSURE OF CONFLICTS AND CONFIDENTIAL INFORMATION.
6.1 Disclosure of Conflicts. Consultant hereby warrants to the City that Consultant has made full
disclosure in writing of any existing or potential conflicts of interest related to Consultant's services under this
Agreement. In the event that any conflicts of interest arise after the Effective Date of this Agreement,
Consultant hereby agrees immediately to make full disclosure to the City in writing.
6.2 Confidential Information. Consultant, for itself and its officers, agents and employees, agrees
that it shall treat all information provided to it by the City as confidential and shall not disclose any such
information to a third party without the prior written approval of the City.
6.3 Protected Health Information. The Parties acknowledge that any medical information obtained
by Consultant during the course of this Agreement is Protected Health Information as defined by the Health
Insurance Portability & Accountability Act of 1996, Public Law 104-191 ("HIPAA") and is protected by the
HIPAA Regulations and state law including the Texas Medical Records Privacy Act ("MRPA"). The Parties
agree to comply with all of the health information privacy and security protections of HIPAA and MRPA.
7. RIGHT TO AUDIT.
7.1 Consultant agrees that the City shall, until the expiration of three (3)years after final payment
under this Agreement, or the final conclusion of any audit commenced during the said three years, have access
to and the right to examine at reasonable times any directly pertinent books, documents, papers and records of
the consultant involving transactions relating to this Agreement at no additional cost to the City. Consultant
agrees that the City shall have access during normal working hours to all necessary Consultant facilities and
shall be provided adequate and appropriate work space in order to conduct audits in compliance with the
provisions of this section. The City shall give Consultant reasonable advance notice of intended audits.
7.2 Consultant further agrees to include in all its subcontractor agreements hereunder a provision to
the effect that the subcontractor agrees that the City shall, until expiration of three (3)years after final payment
of the subcontract, or the final conclusion of any audit commenced during the said three years have access to
and the right to examine at reasonable times any directly pertinent books, documents, papers and records of
such subcontractor involving transactions related to the subcontract, and further that City shall have access
during normal working hours to all subcontractor facilities and shall be provided adequate and appropriate work
space in order to conduct audits in compliance with the provisions of this paragraph. City shall give
subcontractor reasonable notice of intended audits.
Section 7 shall survive the expiration or termination of this Agreement.
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8. INDEPENDENT CONTRACTOR.
It is expressly understood and agreed that Consultant shall operate as an independent contractor as to all
rights and privileges and work performed under this agreement, and not as agent,representative or employee of
the City. Subject to and in accordance with the conditions and provisions of this Agreement, Consultant shall
have the exclusive right to control the details of its operations and activities and be solely responsible for the
acts and omissions of its officers, agents, servants, employees, contractors and subcontractors. Consultant
acknowledges that the doctrine of respondeat superior shall not apply as between the City, its officers, agents,
servants and employees, and Consultant, its officers, agents, employees, servants, contractors and
subcontractors. Consultant further agrees that nothing herein shall be construed as the creation of a partnership
or joint enterprise between City and Consultant. It is further understood that the City shall in no way be
considered a Co-employer or a Joust employer of Consultant or any officers, agents, servants, employees or
subcontractors of Consultant. Neither Consultant, nor any officers, agents, servants, employees or
subcontractors of Consultant shall be entitled to any employment benefits from the City. Consultant shall be
responsible and liable for any and all payment and reporting of taxes on behalf of itself, and any of its officers,
agents, servants, employees or subcontractors.
9. LIABILITY AND INDEMNIFICATION.
9.1 LIABILITY - CONSULTANT SHALL BE LIABLE AND RESPONSIBLE FOR ANY
AND ALL PROPERTY LOSS, PROPERTY DAMAGE AND/OR PERSONAL INJURY, INCLUDING
DEATH, TO ANY AND ALL PERSONS, OF ANY KIND OR CHARACTER, WHETHER REAL OR
ASSERTED, TO THE EXTENT CAUSED BY THE NEGLIGENT ACT(S) OR OMISSION(S),
MALFEASANCE OR INTENTIONAL MISCONDUCT OF CONSULTANT,ITS OFFICERS,AGENTS,
SERVANTS OR EMPLOYEES.
9.2 INDEMNIFICATION - CONSULTANT COVENANTS AND AGREES TO AND DOES
HEREBY INDEMNIFY, HOLD HARMLESS, AND DEFEND, AT ITS OWN EXPENSE, THE CITY
FROM AND AGAINST ANY AND ALL CLAIMS,LAWSUITS,JUDGMENTS,ACTIONS, CAUSES OF
ACTION, LIENS, LOSSES, EXPENSES, COSTS, FEES (INCLUDING, BUT NOT LIMITED TO,
ATTORNEY'S FEES AND COSTS OF DEFENSE), PROCEEDINGS, DEMANDS, DAMAGES,
LIABILITIES, AND/OR SUITS OF ANY KIND OR NATURE, INCLUDING, BUT NOT LIMITED TO,
THOSE FOR PROPERTY LOSS (INCLUDING, BUT NOT LIMITED TO, WORKERS'
COMPENSATION ACT LIABILITY, LOST PROFITS, AND PROPERTY DAMAGE) AND/OR
PERSONAL INJURY (INCLUDING, BUT NOT LIMITED TO,DEATH) TO ANY AND ALL PERSONS,
OR OTHER HARM FOR WHICH RECOVERY OF DAMAGES IS SOUGHT, OF WHATSOEVER KIND
OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR RESULTING FROM
ANY ACTS, ERRORS, OR OMISSIONS OF CONSULTANT AND/OR CONSULTANT'S
CONTRACTORS AND THEIR RESPECTIVE OFFICERS, AGENTS, EMPLOYEES, DIRECTORS,
MEMBERS, PARTNERS, AND REPRESENTATIVES IN CONNECTION WITH THE EXECUTION,
PERFORMANCE, ATTEMPTED PERFORMANCE, OR NONPERFORMANCE OF THIS CONTRACT,
EXCEPT THAT THE INDEMNITY PROVIDED FOR IN THIS PARAGRAPH SHALL NOT APPLY TO
ANY LIABILITY RESULTING FROM THE SOLE GROSS NEGLIGENCE OF THE CITY.
9.3 Consultant agrees to assume full responsibility for complying with all State and Federal
intellectual property laws and any other regulations, including, but not limited to, the assumption of any and all
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responsibilities for paying royalties that are due for the use of other third-party copyrighted works. City
expressly assumes no obligations, implied or otherwise, regarding payment or collection of any such fees or
financial obligations. City specifically does not authorize, permit, or condone the reproduction or use of
copyrighted materials by Consultant without the appropriate licenses or permission being secured by Consultant
in advance. City expressly assumes no obligation to review or obtain appropriate licensing and all such licensing
shall be the exclusive obligation of Artist.
Section 9 shall survive the expiration or termination of this Agreement.
10. ASSIGNMENT AND SUBCONTRACTING.
Consultant shall not assign or subcontract any of its duties, obligations or rights under this Agreement
without the prior written consent of the City. If the City grants consent to an assignment, the assignee shall
execute a written agreement with the City and the Consultant under which the assignee agrees to be bound by
the duties and obligations of Consultant under this Agreement. The Consultant and Assignee shall be jointly
liable for all obligations of the Consultant under this Agreement prior to the effective date of the assignment. If
the City grants consent to a subcontract,the subcontractor shall execute a written agreement with the Consultant
referencing this Agreement under which the subcontractor shall agree to be bound by the duties and obligations
of the Consultant under this Agreement as such duties and obligations may apply. The Consultant shall provide
the City with a fully executed copy of any such subcontract.
11. INSURANCE.
11.1 Coverages and Limits. Consultant shall provide the City with certificate(s) of insurance
documenting policies of the following minimum coverage limits that are to be in effect prior to commencement
of any work pursuant to this Agreement:
(a) Commercial General Liability
$1,000,000 Each Occurrence
$2,000,000 Aggregate
(b) Worker's Compensation- Statutory limits
Employer's liability
$100,000 Each accident/occurrence
$100,000 Disease-per each employee
$500,000 Disease-policy limit
This coverage may be written as follows:
Workers' Compensation and Employers' Liability coverage with limits consistent with
statutory benefits outlined in the Texas workers' Compensation Act(Art. 8308 — 1.01 et
seq. Tex. Rev. Civ. Stat.) and minimum policy limits for Employers' Liability of
$100,000 each accident/occurrence, $500,000 bodily injury disease policy limit and
$100,000 per disease per employee
11.2 General Requirements
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(a) The commercial general liability policy shall name the City as an additional insured
thereon, as its interests may appear. The term City shall include its employees, officers,
officials, agents,and volunteers in respect to the contracted services.
(b) The workers' compensation policy shall include a Waiver of Subrogation (Right of
Recovery) in favor of the City of Fort Worth.
(c) A minimum of Thirty(30) days notice of cancellation or reduction in limits of coverage
shall be provided to the City. Ten (10) days notice shall be acceptable in the event of
non-payment of premium. Notice shall be sent to the Risk Manager, City of Fort Worth,
1000 Throckmorton, Fort Worth, Texas 76102, with copies to the City Attorney at the
same address.
(d) The insurers for all policies must be licensed and/or approved to do business in the State
of Texas. All insurers must have a minimum rating of A- VII in the current A.M. Best
Key Rating Guide, or have reasonably equivalent financial strength and solvency to the
satisfaction of Risk Management. If the rating is below that required,written approval of
Risk Management is required. Evidence of self-insurance will also be accepted in lieu of
an insurance company with the A.M. Best Key Rating Guide requirements listed above.
(e) Any failure on the part of the City to request required insurance documentation shall not
constitute a waiver of the insurance requirement.
(f) Certificates of Insurance evidencing that the Consultant has obtained all required
insurance shall be delivered to the City prior to Consultant proceeding with any work
pursuant to this Agreement.
12. PROFESSIONAL COMPETENCE COMPLIANCE WITH LAWS ORDINANCES RULES
AND REGULATIONS.
Consultant agrees that in the performance of its obligations hereunder, it will comply with all applicable
federal, state and local laws, ordinances, rules and regulations and that any work it produces in connection with
this Agreement will also comply with all applicable federal, state and local laws, ordinances, rules and
regulations. If the City notifies Consultant of any violation of such laws, ordinances, rules or regulations,
Consultant shall immediately desist from and correct the violation.
Consultant and staff shall maintain all required licenses and certifications to perform the services to be
rendered under this Agreement. Consultant certifies that if it uses any employees, subcontractors, or other agents
in the performance of this Agreement, that such persons shall have and maintain all of the current, valid, and
appropriate federal, state, and local licenses and permits necessary for the provision of services under this
Agreement.
All services performed pursuant to this Agreement, shall be performed in accordance with the applicable
professional standard of care. Acceptance of work, payments, or approvals issued by the City or another entity
shall not constitute or be deemed to be a release of the responsibility and liability of Consultant or its officers,
agents, employees, contractors, and subcontractors for the accuracy and competency of its services performed
hereunder.
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13. NON-DISCRIMINATION COVENANT.
Consultant, for itself, its personal representatives, assigns, subcontractors and successors in interest, as
part of the consideration herein, agrees that in the performance of Consultant's duties and obligations hereunder,
it shall not discriminate in the treatment or employment of any individual or group of individuals on any basis
prohibited by law. If any claim arises from an alleged violation of this non-discrimination covenant by
Consultant, its personal representatives, assigns, subcontractors or successors in interest, Consultant agrees to
assume such liability and to indemnify and defend the City and hold the City harmless from such claim.
Section 13 shall survive the expiration or termination of this Agreement.
14. NOTICES.
Notices required pursuant to the provisions of this Agreement shall be conclusively determined to have
been delivered when (1)hand-delivered to the other parry,its agents, employees, servants or representatives, (2)
delivered by facsimile with electronic confirmation of the transmission, or (3) received by the other party by
United States Mail,registered,return receipt requested, addressed as follows:
City of Fort Worth Texas Health Fort Worth
Police Department Attn: Lillie Biggins,RN,FACHE,President
Attn: Sr. Contract Compliance 1301 Pennsylvania Avenue
505 West Felix Street Fort Worth,Texas 76104
Fort Worth Texas 76115
With Copies to: With Copy to:
City of Fort Worth Texas Health Resources
City Manager and City Attorney 612 E.Lamar Blvd., Suite 900
1000 Throckmorton Street Arlington,Texas 76011
Fort Worth, Texas 76102 Attn: General Counsel
15. SOLICITATION OF EMPLOYEES.
Neither the City nor Consultant shall, during the term of this Agreement and additionally for a period of
one year after its termination, solicit for employment or employ,whether as employee or independent contractor,
any person who is or has been employed by the other during the term of this Agreement, without the prior
written consent of the person's employer. Notwithstanding the foregoing, this provision shall not apply to an
employee of either party who responds to a general solicitation of advertisement of employment by either party.
16. GOVERNMENTAL POWERSIIMMMTIES
It is understood and agreed that by execution of this Agreement,the City does not waive or surrender any
of its governmental powers or immunities.
17. NO WAIVER.
The failure of the City or Consultant to insist upon the performance of any term or provision of this
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Agreement or to exercise any right granted herein shall not constitute a waiver of the City's or Consultant's
respective right to insist upon appropriate performance or to assert any such right on any future occasion.
18. GOVERNING LAW/VENUE.
This Agreement shall be construed in accordance with the laws of the State of Texas. If any action,
whether real or asserted, at law or in equity, is brought pursuant to this Agreement,venue for such action shall lie
in state courts located in Tarrant County, Texas or the United States District Court for the Northern District of
Texas,Fort Worth Division.
19. SEVERABILITY.
If any provision of this Agreement is held to be invalid, illegal or unenforceable, the validity, legality
and enforceability of the remaining.provisions shall not in any way be affected or impaired.
20. FORCE MAJEURE.
The City and Consultant shall exercise their best efforts to meet their respective duties and obligations
as set forth in this Agreement, but shall not be held liable for any delay or omission in performance due to force
majeure or other causes beyond their reasonable control, including, but not limited to, compliance with any
government law, ordinance or regulation, acts of God, acts of the public enemy, fires, strikes, lockouts, natural
disasters, wars, riots, material or labor restrictions by any governmental authority, transportation problems
and/or any other similar causes.
21. HEADINGS NOT CONTROLLING.
Headings and titles used in this Agreement are for reference purposes only, shall not be deemed a part of
this Agreement, and are not intended to define or limit the scope of any provision of this Agreement.
22. REVIEW OF COUNSEL.
The parties acknowledge that each parry and its counsel have reviewed and revised this Agreement and
that the normal rules of construction to the effect that any ambiguities are to be resolved against the drafting party
shall not be employed in the interpretation of this Agreement or exhibits hereto.
23. ' AMENDMENTS.
No amendment of this Agreement shall be binding upon a party hereto unless such amendment is set
forth in a written instrument,which is executed by an authorized representative of each party.
24. MODIFICATIONS
No modification of this Agreement shall be binding on Consultant or the City unless set out in writing
and executed by both parties. Any changes to the scope of work or compensation must be in the form of a
written, formal, authorized modification of this Agreement in accordance with all applicable state and city laws,
regulations, and ordinances. In no event shall any verbal authorization changing the scope of work or verbal
agreements for additional compensation be binding upon the City.
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25.NOT AN EXCLUSIVE AGREEMENT
This Agreement is not intended to establish an exclusive provider relationship. City reserves the right to
retain the services of other providers of sexual assault examination services. Such use of alternate providers shall
not be considered a breach of this Agreement.
26. ENTIRETY OF AGREEMENT.
This Agreement, including Exhibits A and B, contains the entire understanding and agreement between
the City and Consultant,their assigns and successors in interest, as to the matters contained herein.Any prior or
contemporaneous oral or written agreement is hereby declared null and void to the extent in conflict with any
provision of this Agreement.
27. COUNTERPARTS.
This Agreement may be executed in one or more counterparts and each counterpart shall, for all
purposes,be deemed an original,but all such counterparts shall together constitute one and the same instrument.
28. MMIGRATION NATIONALITY ACT.
The City of Fort Worth actively supports the Immigration & Nationality Act (INA) which includes
provisions addressing employment eligibility, employment verification, and nondiscrimination. Consultant shall
verify the identity and employment eligibility of all employees who perform work under this Agreement.
Consultant shall complete the Employment Eligibility Verification Form (I-9), maintain photocopies of all
supporting employment eligibility and 'identity documentation for all employees, and upon request, provide City
with copies of all 1-9 forms and supporting eligibility documentation for each employee who performs work
under this Agreement. Consultant shall establish appropriate procedures and controls so that no services will be
performed by any employee who is not legally eligible to perform such services. Consultant shall provide City
with a certification letter that it has complied with the verification requirements required by this Agreement.
Consultant shall indemnify City from any penalties or liabilities due to violations of this provision. City shall
have the right to immediately terminate this Agreement for violations of this provision by Consultant.
29. SIGNATURE AUTHORITY.
The person signing this Agreement hereby warrants that he/she has the legal authority to execute this
Agreement on behalf of the respective party, and that such binding authority has been granted by proper order,
resolution, ordinance or other authorization of the entity. Each party is fully entitled to rely on these warranties
and representations in entering into this Agreement or any amendment hereto.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement in multiples this day of
,20_
CITY OF FORT WORTH: TEXAS HEALTH HARRIS
METHODIST HOSPITAL FORT
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B V �"�C/ �"�-� rllli'e'�Biggins,
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Valerie R. Washington RN,FACBE
Assistant City Manager President
APPROVED RECO NT)ED
By:
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Chief of Police Terri A. DeSio
Assistant General Counsel
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Assistant City Attorney
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OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Professional Services Agreement
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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$700.00.
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):$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 /conveyance of the specimen up to a maximum amount of$20.00
Facility charges:
• 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 U1392, including an itemized statement.
• Revenue code R-450 will 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: $260.00
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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:
Patient's MR Number:
;xaminer's Name: Patient's name:
=acility Name: Date of Birth:
=acility Address: Date of Assault:
=acility City, State:
= Law Enforcement Agency:
acility Phone Number:
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 certified facility. 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-Atfacility otherthan hospital(i.e.,private facility)
57452 SA Exam WITH Colposcope 233.00
Definition-examinerfeeusing colposcope
99283 SA Exam WITHOUT Colposcope 195.00
Definition-examiner fee without colposcope
OTHER CHARGES:
CPT Code Description CHARGE QUANTITY
Laboratory Charges: (Maximum of$150.00 allowed)
81025 0 Pregnancy test(facility charge) 6.00
Definition — Used by facility where the pregnancy test is
performed.
81001 o 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
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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)
87320 187110 0 Chlamydia culture (facility charge) 37.00
Definition—Used by facility where culture is submitted to facility
lab fortreatment&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 Charges: 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 128.00
for suspected_trauma (Women)
99199 0 Anogenital exam utilizing digital photography (high resolution) in 100.00
adult 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 attimes other 20.00
than regularly scheduled hours—i.e.,holidays,Saturday,or
Sunday)
99053 0 Medical services—between 10pmand Sam(Services provided 39.00
between 10::00pm and 8:00am at 24 hour facility-in additional
to basic service)
11015/99070 0 Evidence collection kit 50.00
99070 0 Supplies—details should be provided(maximum of$1o0.Wallowed) 100.00
Submitted by: TOTAL CHARGE
Note:
The maximum aggregate amount for which
the OAG will reimburse is$700.00
Signature
Printed Name
Professional Services Agreement
T7'exas,JQ,Jh Harris Methodist Hospital Fort Worth
SexualASS LL xam Agreement 13 of 14
SCHEDULE C
Reimbursement for Costs of Sexual Assault Medical Examinations
for Law Enforcement Agencies
ATTORNEY GENERAL OF TEXAS (SAMPLE ONLY THIS NOT AN ORIGINAL)
APPLICATION PLEASE 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.
Professional Services Agreement
Sexual Assault Exam Agreement 14 of 14