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HomeMy WebLinkAboutContract 50875 CITY SECRETARY CONTRACT N0. Slula B �Vy a 24`�R�i PROFESSIONAL SERVICES AGREEMENT G\ C S C This PROFESSIONAL SERVICES AGREEMENT ("Agreement") is made and entered into by and between the CITY OF FORT WORTH (the "City"), a home rule municipal corporation, acting by and through, its duly authorized Assistant City Manager, and TEXAS HEALTH RESOURCES (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—Forensic Sexual Assault Examination Reimbursement Guidelines from 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) 5. Schedule D- Verification of Signature Authority 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 General'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 Seventy-five Thousand Dollars ($75,000.00) per year in accordance with the provisions of this Agreement and the Payment Schedule attache hibit "B".. Professional Services Agreement OFFICIAL RECORD Texas Health Resources I of 10 CITY SECRETARY FT.WORTH,T 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 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 bunds. In the event no funds or insufficient fiends 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 finds 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 Professional Services Agreement Texas Health Resources 2of10 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 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, sel Is, 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. Professional Services Agreement Texas Health Resources 3of10 Section 7 shall survive the expiration or termination of this Agreement. S. 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 Joint 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 responsibilities for paying royalties that are due for the use of other third-party copyrighted works. City Professional Services Agreement Texas Health Resources 4 of 10 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 (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. Professional Services Agreement Texas Health Resources 5of10 (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. Professional Services Agreement Texas Health Resources 6of10 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 party, 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 Resources Police Department Attn:Joan Shinkus Clark Attn: Sr. Contract Compliance 612 E. Lamar Blvd, Suite 900 505 West Felix Street Fort Worth, Texas 76011 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 900 200 Texas 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 gcneral solicitation of advertisement of employment by either party. 16. GOVERNMENTAL POWERS/IMMUNITIES 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 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. Professional Services Agreement Texas Health Resources 7of10 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 party 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. 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 Professional Services Agreement Texas Health Resources 8of10 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. IMMIGRATION NATIONALITY ACT. Contractor shall verify the identity and employment eligibility of its employees who perform work under this Agreement, including completing the Employment Eligibility Verification Form (I-9). Upon request by City, Contractor shall provide City with copies of all I-9 forms and supporting eligibility documentation for each employee who performs work under this Agreement. Contractor shall adhere to all Federal and State laws as well as establish appropriate procedures and controls so that no services will be performed by any Contractor employee who is not legally eligible to perform such services. CONTRACTOR SHALL INDEMNIFY CITY AND HOLD CITY HARMLESS FROM ANY PENALTIES, LIABILITIES, OR LOSSES DUE TO VIOLATIONS OF THIS PARAGRAPH BY CONTRACTOR, CONTRACTOR'S EMPLOYEES, SUBCONTRACTORS, AGENTS, OR LICENSEES. City, upon written notice to Contractor, shall have the right to immediately terminate this Agreement for violations of this provision by Contractor. 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. 30. PROHIBITION ON CONTRACTING WITH COMPANIES THAT BOYCOTT ISRAEL Contractor acknowledges that in accordance with Chapter 2270 of the Texas Government Code, the City is prohibited from entering into a contract with a company for goods or services unless the contract contains a written verification from the company that it: (1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract. The terms "boycott Israel" and "company" shall have the meanings ascribed to those terms in Section 808.001 of the Texas Government Code. By signing this contract, Contractor certifies that Contractor's signature provides written verification to the City that Contractor: (1) does not boycott Israel; and (2)will not boycott Israel during the term of the contract. Professional Services Agreement Texas Health Resources 9of10 IN WITNESS WHER OF, the parties hereto have executed this Agreement in multiples thisMyd of 21 CITY OF F^vR T WORTH: TE7P, RNj,NEA-BC, LTH ICES RC ES By:. By: Jesus J. Chapa rk Assistant City Manager CENP, FACHE, FAAN, EVP, Texas Health Chief Nursing Executive APPROV REC MENDED e ti Chief1 F. Fitz r Chief of Police APPROVED AS TO FORM AND LEGALITY: By: Matthew A. Murr Assistant City Attorney FORT ATTES By: a J. K City Secret " �XAS NO M&C REQUIRED Contract Compliance Manager: By signing I acknowledge that I am the person responsible for the monitoring and administration of this contract, including ensuri4Rodrigue rmance and reporting requirements. ;arnes •' EFR ECON® Senior Contract Compliance Specialist ETARY 4 ?P? Professional Services Agreement Texas Health Resources 10 of 10 Schedule A Forensic Sexual Assault Examination Reimbursement Guidelines Forensic Sexual Assault Examination Reimbursement Guidelines Law enforcement agencies can apply for reimbursement for the forensic costs associated with forensic sexual assault examinations pursuant to articles 56.06 and 56.065,Texas Code of Criminal Procedure. What is covered? The Crime Victims'Compensation Program will reimburse law enforcement"reasonable costs"associated with forensic sexual assault examinations of victims of alleged sexual assaults in an amount not to exceed $1,000.00 for dates of crime on or after July 15,2016. For dates of crime prior to July 15,2016,the amount shall not exceed$700.00. Law enforcement is not required to pay any costs for treatment of injuries. Expenses other than the actual costs for the forensic sexual assault examination,such as treatment or diagnosis of a victim,are not allowable expenses and will not be reimbursed as a forensic sexual assault examination reimbursement to law enforcement. However,victims may seek reimbursement for the costs under a CVC claim or an Emergency Medical Care claim. (Visit the Texas Attorney General website for more information.) What constitutes a forensic sexual assault examination? A forensic sexual assault examination consists of four parts: • History for the purpose of diagnosis and treatment • Detailed head-to-toe assessment for trauma • Detailed anogenital assessment for trauma;and • Forensic evidence collection as indicated by history and findings CVC will not reimburse law enforcement for: • Forensic sexual assault examination of a suspected perpetrator • Laboratory analysis of victim's clothing,crime scene materials,or objects including weapons • Pharmacy,including take home drugs and self-administered drugs • Paternity tests • Multiple examinations of the same victim for the same crime • Follow up care or treatment for medical treatment • Travel time How to Apply The law enforcement agency may seek reimbursement using the OAG Application for Reimbursement. The following are guidelines to provide further assistance in completing the application: Complete all sections of the one-page application for reimbursement. • Include date of crime. • The verification section of the application must be signed by an appropriate representative of the law enforcement agency who has knowledge of the facts stated in the verification. • Incomplete applications will not be processed and will be returned to the law enforcement agency noting the reason the application is incomplete. Attach all bills associated with the requested forensic sexual assault examination to the application. The bills should include the appropriate billing codes or itemization for individual charges. Include proof of payment,such as a copy of the check that shows the cost of the forensic sexual assault examination has been paid by the law enforcement agency. Revised July 21,2016 Billing 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 for dates of crime before July 15,2016 • $1,000.00 for dates of crime on or after July 15,2016 For maximum reimbursement,submit itemized bills from the provider with individual charges listed for each service rendered. See the Standard Costs Associated with Examination for maximum reimbursement rates. Reimbursement of reasonable costs is based on the Medical Fee Guidelines established by the Texas Department of Insurance, Division of Workers'Compensation. Sexual assault examiner and sexual assault nurse examiners(SANE)billing • A sexual assault examiner or a sexual assault nurse examiners(SANE)should bill the law enforcement agency his or her usual and customary charge for the examination on his or her standard billing form. • The bill must include a descriptive itemized statement of the services provided and be signed by a physician or licensed nurse practitioner.The OAG will determine the appropriate CPT/Revenue codes. It is not necessary for all four parts of the forensic sexual assault examination to be completed to be eligible for reimbursement. To be eligible for reimbursement of examiner fees,the medical provider who conducts the examination must at a minimum interact with the patient while initiating at least one part of the examination. For example: • This would include a medical provider or SANE who was called out to perform the examination and began the consent process and patient history,but was unable to begin any other assessments because the patient did not consent to further examination. • This would not include a patient no show. Itemized medical services • Each cost associated with the medical services or procedures in a forensic sexual assault examination must be itemized and,for services provided by a physician,should be identified with a five-digit Current Procedural Terminology(CPT)code. • The CPT code is a nationally accepted systematic listing which is published by the American Medical Association.CPT coding provides an accurate identification of services and procedures. • If there are no specific CPT codes for the medical services or procedures provided in the forensic sexual assault examination,CVC will accept a Revenue Code,or the CPT code for services or procedures that are comparable to those used in the forensic sexual assault examination. Resubmission • If you feel payment was incorrect or are requesting a supplemental payment,bills may be submitted to CVC for further review. • Copies of the original bill with the original OAG claim number,original explanations of benefits,and a new itemized bill and reason or explanation of resubmission must be attached to the request. • If after further review additional payments are needed,a supplemental payment will be issued. Revised July 21, 2016 Schedule 6 Charge Sheet for Sexual Assault Examination Standard Costs Associated with Examination (Dates of crime on or after 7/15/16) Maximum aggregate amount of reimbursement:$1000 Examiner Fees Possible Code/s Description Limit Notes 99283- Sexual Assault $233.00 • Examiner fee for an exam performed by a physician, 99285, Exam licensed nurse practitioner,sexual assault examiner, 57452- or sexual assault nurse examiner. • This fee covers the basic patient evaluation,however 57420 additional examinations may be required based on the findings and history,such as an anogenital assessment or anoscopy, may be submitted for reimbursement. • Sexual assault examiners and sexual assault nurse examiners(SANE)may submit a standard billing form with a descriptive itemized statement. Place of Service Possible Code/s Description Limit Notes 99211 Place of service $125.00 This includes exams conducted in any healthcare setting fee for exam in other than a hospital(non-facility setting). non-facility setting FAC Place of service $350.00 • This includes exams conducted at a hospital(facility fee for exam in a setting). R-450 or R- facility setting • A hospital includes a general or special hospital 760 licensed under the Texas Health and Safety Code, Chapter 241. • Charges for hospitals must be on a UB-04, including an itemized statement. Revenue code R-450 or R-760 might be used in conjunction with this fee. Exam Fees Possible Code/s Description Limit Notes 99170 Anogenital Exam $150.00 Anogenital exam using magnification(magnification *99199— includes colposcope,SDFI,or other medically accepted requires magnification for anogenital assessment. itemization or a description of services billed 56820 Exam of Vulva $150.00 Exam of the vulva using magnification (magnification with includes colposcope,SDFI,or other medically accepted Magnification magnification for assessment). 46600 Anoscopy $71.00 Examination by physician,sexual assault nurse examiner, or sexual assault examiner where an anoscopy is performed. Revised July 21,2016 Standard Costs Associated with Examination (Dates of crime on or after 7/15/16) Maximum aggregate amount of reimbursement:$1000 Sexual Assault Kit Possible Code/s Description Limit Notes 99070/Kit Sexual Assault kit $50.00 This may be used in addition to supplies-digital photography charged under 99070 or other supplies charged under 99070. Laboratory (Maximum reimbursement for all lab fees:$250.00) Possible Code/s Description Limit Notes CPT code Pathology and $250.00 Requires a detailed or itemized description with a range Laboratory breakdown of charges. 80047- Procedures . Maximum reimbursement for all lab fees:$250.00. 89398 Laboratory procedures including, but not limited to: ■ Pregnancy test ■ Urine analysis ■ Drug or alcohol screen ■ STD Testing ■ Venipuncture ■ Handling/conveyance of the specimen Additional Charges Possible Code/s Description Limit Notes 99499 Additional $106.00/ • Requires Documentation of Procedure. Evaluation Hour • This includes additional time needed after the start of Management the exam. • Examples:language barrier,extensive exam,trauma, waiting for law enforcement arrival to pick up evidence. 99070 Supplies: Digital $100.00 • Requires a detailed or itemized description. Photography 0Use of digital photography during examination. • This includes setup and take down of equipment, burning of CDs,and other activities. • This may be used in addition to the kit under 99070/Kit or other supplies charged under 99070. 99070 Supplies $100.00 • Requires a detailed or itemized description. • Extensive laboratory procedures that require excess supplies and materials require Documentation of Procedure and will be reimbursed up to a maximum amount of$100.00 for the supplies and materials. • This may be used in addition to the kit under 99070/Kit or supplies-digital photography charged under 99070. 99050 After Hours $39.00 This includes weekends,holidays,or exams conducted between 10pm-8am. Revised July 21,2016 Schedule C Reimbursement for Costs of Sexual Assault Medical Examinations for law Enforcement Agencies ATTORNEY GENERAL OF TEXAS CRIME VICTIMS' COMPENSATION INSTRUCTIONS FOR APPLYING FOR REIMBURSEMENT FOR COSTS OF SEXUAL ASSAULT MEDICAL EXAMINATIONS (For Law Enforcement Agencies Only) For questions regarding this program please e-mail: sexualassaultexams@texasattornevgeneral.gov COMPLETING THIS APPLICATION • Read the instructions before you begin in order to complete each section correctly. • Include information supporting the sexual assault exam request, the case or offense report number, or a letter outlining the circumstances of the exam request. Proof of payment must accompany this application. Failure to provide this information will cause the application to be returned. • On application to the attorney general, law enforcement agencies are entitled to be reimbursed for the reasonable costs of a sexual assault medical examination requested by the law enforcement agency on behalf of a victim of an alleged sexual assault for use in the investigation or prosecution of the offense. • Article 56.06 (c), Texas Code of Criminal Procedure, as amended by the 77th Legislature, does not require a law enforcement agency to pay any costs of treatment of injuries, therefore, those costs are not covered by this program. • Mail your completed application to: Attorney General of Texas Crime Victims' Compensation (009) Law Enforcement Reimbursement for Sexual Assault Exams P.O. Box 12880 Austin, Texas 78711-2880 INSTRUCTIONS • All bills associated with the requested sexual assault medical exam must have been received and paid for by the law enforcement agency requesting reimbursement prior to sending in this application. • All bills considered for reimbursement must be itemized and submitted on standardized health insurance claim forms (i.e. UB 04 or CMS 1500). Non-physicians can bill using usual and customary format billings. • All law enforcement agency information must be completed prior to payment. Payment cannot be made without the law enforcement agency's Tax Payer Identification Number. ,r CC Sexual Assault., imbursement Victim Information The victim is the who was iii# etdlyF +E assaulted. Victim's Last Name: Victim's First Name: Victim's Middle Name: Date of Birth: Gender: Date of Crime: ©Male ®Female Law Enforcement Agency Information Payment will not be processed without complete information. Date of Sexual Assault Exam: Date Law Enforcement Paid: Law Enforcement Paid Amount: Law Enforcement Agency Name: Tax Payer Identification Number(Required): Mailing Address: City: State: Zip: Law Enforcement Agency Contact Person: Telephone Number(Including Area Code): Fax Number(Including Area Code): E-Mail Address (If Available): Law Enforcement Case Number: Suspect Name: Certification I certify that the sexual assault exam, which is the subject of this application, was either requested by a law enforcement agency under Texas Code of Criminal Procedure Article 56.06 or performed in accordance with Article 56.065. The exam was performed by a physician or an individual described under the Texas Government Code, Section 420.003. 1 certify that the bill has been paid and the information in this application is true and correct to the best of my knowledge. Printed Name: Title: Signature of Law Enforcement Representative: Date: I I I I� II I P.O.Box 12880 TEL 1-800-983-9933 HTTP://WWW.TEXASATrORNEYGENERAL.GOVNICTIMS/REIMBURSE.SHTML Schedule D Verification of Signature Authority Schedule D VERIFICATION OF SIGNATURE AUTHORITV Execution of this Signature Verification Form ("Form") hereby certifies that the following individuals and/or positions have the authority to legally bind Vendor and to execute any agreement, amendment or change order on behalf of Vendor. Such binding authority has been granted by proper order, resolution, ordinance or other authorization of Vendor. City is fully entitled to rely on the warranty and representation set forth in this Form in entering into any agreement or amendment with Vendor. Vendor will submit an updated Form within ten (10) business days if there are any changes to the signatory authority. City is entitled to rely on any current executed Form until it receives a revised Form that has been properly executed by Vendor. Name: Position: Signature Name: Position: Signature Name: Position: Signature 16, rTitle P c".e: Date: