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HomeMy WebLinkAboutContract 42902• r C" 9MMARY D� Na CONTRACY AGREEMENT BETWEEN TARRANT COUNTY HOSPITAL DISTRICT AND CITY OF FORT WORTH WHEREAS, the Tarrant County Hospital District d /b /a JPS Health Network ( "DISTRICT') provides certain health care services in Tarrant County Texas; and WHEREAS the CITY OF FORT WORTH ON BEHALF OF ITS POLICE DEPARTMENT ( "CITY ") desires to obtain sexual assault examinations in connection with the investigation or prosecution of an alleged sexual assault: SECTION I: DISTRICT OBLIGATIONS ARE TO: 1. Provide Sexual Assault examination and forensics collection 2. Obtain consents for examination and treatment. 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. 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 Whenever 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 intended for the CITY, to: Fort Worth Police Department ��_- ---- -� Program Support Division OFFICIAL. RECORD! 350 West Belknap Fort Worth, Texas 76102 CITY SECRETARY Phone (817) 392 -4239 FT. WORTH, TX Sexual Assault Exam Agreement Page 1 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: Doris Hunt, VP of Finance 1350 South Main, Suite 4000 Fort Worth, Texas 76104 (817) 920 -6835 SECTION V: TERMS OF AGREEMENT: The term of this Agreement shall be from October 1, 2011 to September 30, 2013. 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 pursuant to federal and state law. Upon expiration, reimbursement will be fully billed charges payable within thirty days. 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 90 days. 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 91St 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 supercedes any prior written or oral agreement and may only be amended in writing signed by both DISTRICT and CITY. 7. This Agreement, or any portion thereof shall not be assignable without the express, 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. Sexual Assault Exam Agreement Page 2 Section VI: Other Provisions 1. Venue - 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 herein or any document executed in connection herewith shall be deemed or construed by the Parties hereto, nor by any third party, as creating 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. SCHEDULES Schedule A Sexual Assault Exam — Reimbursement Guidelines of the Attorney General's Office Schedule B Charge Sheet for Sexual Assault Examination (Attorney General of Texas) Schedule C Reimbursement for Costs of Sexual Assault Medical Examinations for Law Enforcement Agencies (Attorney General of Texas) Sexual Assault Exam Agreement Page 3 IN WITNESS WHEREOF, the parties hereto have executed this agreement in multiples in Fort Worth, Tarrant County, Texas, to govern the responsibilities of the parties as set forth herein as of October 1, 2011, regardless of the actual date of execution. CITY OF FORT WORTH TARRANT COUNTY HOSPITAL DISTRICT on behalf of Fort Worth Police Department d /b /a JPS Health Network BY: W. Jeffrey als ead ��•��T,�� Chief of Police 00 BY: CharleVz,ff Daniels Assistant City Manager X7_1 Vs APPROVED AS TO FORM AND LEGALITY: Jessie Assis ATTEST: Ity angsvang City Attorney N Authorization: M &C: e LA BY: ;�nrp_ __�_ Robert Earley President & CEO DATE: _ 1 L 1 X77 j 1 I oRr2a� 0 0 0 0 0 OFFICIAL RECORDS iT Y SECRETARY f T. ViORTH< TX Sexual Assault Exam Agreement Page 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 $700.00. Sexual Assault Examiner's Fees Forensic Sexual Assault Exam: $195.0 0 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: $250.00 Sexual Assault Exam Agreement Page 5 SCHEDULE B Charge Sheet for Sexual Assault Examination Attorney General of Texas Charge Sheet for Sexual Assault Examination Provider of Services: Patient Identification: CHARGE Patient's Acct Number: Examiner's Name: Patient's MR Number: 26.00 Patient's name: Facility Name: Date of Birth: Facility Address: Date of Assault: Facility City, State: Definition - Revenue code 450 will be used for a medical 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 certified facility. Charges for healthcare facilities must be on a 0892. includina an itemized statement Revenue Description CHARGE QUANTITY Code* Associated office visit 26.00 450 or 760 Treatment Room 250.00 57452 Definition - Revenue code 450 will be used for a medical 233.00 treatment room or Revenue code -760 will be used for an 99283 emergency room. 195.00 SEXUAL ASSAULT EXAMINER'S FEES: CPT Code Description CHARGE QUANTITY 99211 Associated office visit 26.00 81025 Definition — At facility other than hospital (ie., private facility) 6.00 57452 SA Exam WITH Colposcope 233.00 Definition — examiner fee using col osco e 99283 SA Exam WITHOUT Colposcope 195.00 Definition — examiner fee without col osco e 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 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 Sexual Assault Exam Agreement Page 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) 87320 / 87110 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, & transporting 36415 0 Venipuncture 20.00 Definition — Used by examiner or facility for Veni uncture 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 at times other 20.00 than regularly scheduled hours — i.e., holidays, Saturday, or Sunda 99053 0 Medical services — between 10pm and 8am (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 $100.00 allowed) 100.00 Submitted by: Note: The maximum aggregate amount for which the OAG will reimburse is $700.00 Signature Printed Name TOTALCHARGE Failure of City of Fort Worth Police Department to supply the Law Enforcement Case Number prior of submission of this form to City of Fort Worth_ Police Department 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 Sexual Assault Exam Agreement Page 7 SCHEDULE C Reimbursement for Costs of Sexual Assault Medical Examinations for Law Enforcement Agencies ATTORNEY GENERAL OF TEXAS (SAMPLE ONLY THIS NOT AN ORIGINAL) APPLICATIONPLEASE PRINT CLEARLY IN BLACK INK OR TYPE. Reimbursement for Costs of Sexual Assault Medical Examinations Victim Information Victim's Last Name The victim is the person who was allegedly sexually Social Security Number assaulted. Law Enforcement Agency Information Law Enforcement Agency Name Payment will not be Mailing Address processed without City complete information. First Name Date of Birth Tax Payer Identification Number (required) Telephone Number (including Area Code) E -Mail Address (if available) Date of Crime Suspect's Name(if known) Middle Name Sex: _ Male Female State Zip Contact Person's Name Fax Number Law Enforcement Case Number 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. Sexual Assault Exam Agreement Page 8 Official site of the City of Fart Worth, Texas FORT WORT11 Aft 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 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 41 $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 41 $392,000.00 GR76 488990 035496537050 4 $392,000.00 GR76 539120 035496537050 Submitted for City Manager's Office by- Originating Department Head: Additional Information Contact: ATTACHMENTS 35JPSSAN_E12 AON.doc FROM Fund /Account /Centers Charles W. Daniels (6199) Jeffrey W. Halstead (4210) Gerald L. Chandler (4219)