1 MEDICAL DIRECTOR AGREEMENT
first day of October, 2023 the City of Chula Vista
amunicipal corporation, andThe Regentsof the University of California, a California Constitutional corporation, on behalf of the University of California, San Diego, School of Medicine, Department of Emergency Medicine (" UCSD") .
WHEREAS, City operates an emergency medical practice providing services to several hospitals and has the need for a physician to provide medical direction and oversight of nursing, EMT, and paramedics along with supervising programs of quality improvement, chart reviews, monitoring pharmacy and drug usage;
WHEREAS, UCSD employs physicians with training in medicine andemergencymedicine, in particular Jennifer Farah, M.D. (" Physician ), and is willing to provide servicesof Physician to perform such medical direction;
WHEREAS, City desires to secure, and UCSD desires to provide, on a nonexclusive independentcontractor basis, servicesof Physician;
NOW, THEREFORE, it is agreed:
1. Contractor Services. Contractor shall work closely with and report to City Division General Manager or its designee. The scopeof the work to be performed under this Agreement includes, but is not limited to, the activities specified on Exhibit A , which is attachedand incorporated hereto, and such other work as may be reasonably requested from time to time.
Contractor acknowledges that City is
that it canfully perform the Servicessetforth in this Agreement on a timely basis. Accordingly, Contractor acknowledges andagreesthat time is of the essencein the performance of its Services officers, directors, agentsand representatives, successorsand assigns.
1.1 If Physician shall become permanently unavailable, for any reason, Contractor may, in its sole discretion, appoint another physician or terminate this Agreement. If Contractor elects to appoint another physician, such an appointment shall be made with the prior written consent of City and such services shall be provided pursuant to the terms of this Agreement.
2. Changes. At any time, City may request Contractor to make changesto the Services within the general scope of this Agreement such as, but not limited to, alterations in, additions to or deletions from the work, or changesin the sequenceof the performanceof the work. Contractor shall thereafter modify the Services to be performed hereunder. Any changes involving compensation must be agreedupon by both parties in writing at the time the change is made. 2 3. Certifications and Licenses. Physician is and shall continue to be properly licensed to practice medicine in the State of California at all times during the term of this Agreement. In addition, Physician will be a board-certified Emergency Medical Services Physician in the State of California. In addition, Physician agreesto be bound by the principles of ethics of the American Medical Association, and all applicable professional societiesand regulatory bodies, as well as the requirements of Applicable Law during the term of this Agreement.
4. Qualifications to Participate in Federal and State Healthcare Programs. Both parties represent andwarrant that (a) neither it nor any employee, agent, or independentcontractor provided under this Agreement is excluded from participation under any Federal Health Care Program for the provision of items or services for which payment may be made under a Federal Health Care Program; (b) neither it nor any employee, agent or independent contractor provided under this Agreement has been convicted of a felony relating to health care fraud as defined under 42 U.S.C. §1320a-7(a)(3); and (c) no final adverseaction, assuch term is defined under 42 U.S.C. 1320(a)-7(c) has occurred or is pending or threatenedagainst either party or to its knowledge against any employee, agent or independent contractor engaged to provide items or services Agreement, each party agreesto notify the other party in writing of any Exclusions/Adverse Actions within ten (10) days of learning of any such Exclusions/Adverse Actions and provide the basisof the Exclusions/ Adverse Actions. Each party acknowledges that the exclusion of any employee, agent or independent contractor from participation in the Federal Health Care Programs shall result in his or her immediate removal from the performance of duties and responsibilities for the other party under the terms of this Agreement. Each party acknowledges and agreesthat any Exclusions/Adverse Actions of or against it or any employee, agent or independentcontractor utilized, directly or indirectly, in the performanceof this Agreement may serveasthe basisof animmediate termination of this Agreement by the other party. For purposes of this Agreement, a "Federal Health Care Program" shall mean any plan or program providing health care benefits, whether directly through insuranceor otherwise, that is funded directly, in whole or part, by the United States Government ( other than the Federal Employees Health Benefits Program), or any Statehealth care program and shall include, by way of example, the Medicare and Medicaid programs.
5. Obligations. City shall pay Contractor for Services, as more specifically described on Exhibit A, within thirty ( 30) days from date of receipt of invoice.
6. Term and Termination. The term of this Agreement shall commenceon the Effective Date and shall be for a period of three (3) years (October 1, 2023 September30, 2026), with the option of two ( 2) one year extension terms upon mutual written agreement executed by the parties.
Either party may terminate this Agreement without causeat any time by giving the other party thirty ( 30) days advancewritten notice of termination. In addition, either party may terminate this Agreement for causefor a breach of any term of this Agreement upon providing five ( 5) daysadvancewritten notice to the breaching party, setting forth the nature of the breach, and if, within five ( 5) days from receipt of such notice, breaching party doesnot cure the breach within the five ( 5) day period.
7. Audit. At reasonabletimes and upon reasonableprior notice, City recordsand operationsthat pertain to the Services to verify performancehereunder. 3 8. Useof Resources. Any equipment, materials or other items provided or paid for by City (i) shall remain the property of City, ( ii) shall be usedby Contractor only in performance of the Services, and (iii) returned to City upon requestor at the completion of Services. If given authorization to utilize City sameexclusively in performing Services.
Any other or unauthorized use will subject Contractor to immediate termination. In the event of such termination, City shall retain and hereby does not waive any possible legal action or remedies available arising from, or out of this and/or any breach of this Agreement by Contractor.
9. Notification. Each party shall keep the other party informed of its policies, procedures including revised copies of its standardoperating proceduresand standardsof conduct utilized in connection with the Services) and activities relevant to its obligations under this Agreement, andshall meet with representativesof the other party, at mutually acceptabletimes, on a regular basis to review procedures, policies and quality of services. Each party shall update the other party with any material amendmentsto its policies and proceduresthat it makes from time to time.
10. Warranties & Representations.
a. Contractor warrants and represents (i) that it shall perform its/his/her services in accordance with medical industry standards; (ii) that to the best of its knowledge all goods and Services reflected in its billing have beenfurnished asso represented; (iii) all information supplied to and all representationsmade to City shall be true, accurate and complete and in the event such information or representation(s) madeherein becomeinaccurateor incomplete, Contractor will promptly notify City in writing of such occurrence; (iv) it shall perform all its obligations and maintain all records and patient information used for the performance of services under this Health InsurancePortability and Accountability Act of 1996, 42 U.S.C. §§ 1320d through d-8, as amended and the Health Information Technology for Economic and Clinical 45 CFR Parts160, 162 and 164 in the BusinessAssociate
Agreement; (v) it has not been and/or is not currently suspendedand/or found in violation of any Applicable Law and/or stateor professional licensing group standards; and (vi) there is no pending, threatened, and/or anticipated proceeding or litigation against, relating to, or arising out of its medical license and/or medical practice.
b. Each party representsand warrants to the other that ( i) it has the right to enter into this Agreement, to grant the rights granted in this Agreement and to perform fully all of the services and obligations contemplated by this Agreement; (ii) the consent of no other person, political body, board of directors or entity is necessary for it to enter into and fully perform this Agreement; (iii) the person entering into this Agreement is authorized to sign this Agreement on behalf of the party; and, (iv) the parties have reviewed this Agreement with their respective le
11. No Patient Care & Ambulance Ride Alongs.
Services do not include actual patient treatment and/or care. In the event Physician desiresto ride along in an ambulance, Physician shall executethe Non-Employee Voluntary Participation in Medical & Fire Response - Assumption of Risk, Waiver Release & Indemnification Agreement, andspecifically agreesand understandsthat patient careand/or treatmentis outside 4 the scope of this Agreement and any patient treatment or care that Physician provides is
12. Contractor is Independent Contractor. In the performance of this Agreement, Contractor is acting as an independent contractor, and Contractor and its Physician employee will not be treated as an employee with respect to the Services provided pursuant to this Agreement for federal tax or any other purpose. Nothing in this Agreement shall be construed as creating an employment relationship, agency, partnership, or joint venture betweenthe parties. Contractor hereby acknowledgesand agreesthat it shall be responsible for procuring and maintaining any its employees,
including Physician, and to protect its assets. In addition, Contractor payment for Services rendered shall be made in the gross amount, without withholding for federal, state or local income taxes unless City is required by Applicable Law to withhold. City shall not be responsible for the payment of any F.I.C.A., F.U.T.A. or other similar chargeswith respectto Contractor and Contractor agreesto pay all self-employment and other taxes, including income taxes and estimates thereof, as shall be required by the Internal Revenue Code of 1986, as amended, and the Applicable Law of any other government entity having jurisdiction over Contractor. Except as expressly provided in this Agreement, City shall have no direction, supervision or control over Contractor or its employees. Each party shall control and direct the methods by which it performs its responsibilities hereunder. Except asprovided herein, neither party is authorized to act on behalf of the other in any other matter whatsoever.
13. Indemnification
indemnify and hold harmless the other,
for, from and against all costs, claims, losses, liabilities, penalties, fines, citations, expenses, forfeitures or other damages, including but not limited to settlements, defensecosts, judgments, court costs, expert(s) fees and reasonablefees of attorneys, incident to, and which it may incur, becomeresponsiblefor, or pay out asa result of deathor bodily injury to any person, destruction or damage to any property, contamination of or adverse effects on the environment, or any violation of any Applicable Law, to the extent that such damagewas causedby, in whole or in Agreement; or (ii) negligent or willful act(s) or omission(s); or (iii) violation of Applicable Law; iv) any employment, workers
agentsor subcontractors. Nothing in this section shall limit any right to contribution or other allocation of fault between the parties as determined by a court of competent jurisdiction and as permitted by all Applicable Law. Contractor shall havefull and exclusive liability for, andshall indemnify and defend City and its affiliates, shareholders, directors, officers, employees and agents against any loss, cost, liability or claim related to any taxes and contributions for unemployment insurance, workers compensation, retirement benefits, life insurance, and any other employment-related claim, charge and/or litigation, benefits, costs, obligations, safety but only
in proportion to andto the extent suchliability, loss, expense, attorneys' fees, or claims for injury or damages are caused by or result from the negligent or intentional acts or omissions of Contractor, its officers and employees. Contractor shall maintain appropriate insurance to protect City accordingly.
14. EXCLUSION OF CERTAIN DAMAGES. IN NO EVENT SHALL EITHER PARTY, ITS
AFFILIATES OR ANY OF THEIR RESPECTIVE DIRECTORS, OFFICERS, MEMBERS,
SHAREHOLDERS, EMPLOYEES, AGENTS OR SUBCONTRACTORS BE LIABLE TO 5 THE OTHER PARTY FOR LOST PROFITS, SPECIAL, CONSEQUENTIAL, INCIDENTAL,
OR PUNITIVE DAMAGES, REGARDLESS OF THE BASIS OF THE CLAIM, WHETHER
IN CONTRACT, TORT, STRICT LIABILITY, NEGLIGENCE OR OTHER LEGAL OR
EQUITABLE THEORY, WHETHER OR NOT THE PARTY HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
15. Compliance with Applicable Law. Both parties agree to be in full compliance with all Applicable Law relatedto this Agreement and shall immediately notify the non-breachingparty in the event it hasfailed to comply with this Section. In such an event, the non-breaching party may immediately terminate this Agr
and local laws, statutes, regulations, codes, ordinances, professional rules, licensing requirements or standards, and/or Executive Orders, as amended, applicable to the services and/or obligations of the parties hereunder.
16. Compliance Program and Training. Contractor acknowledges that it has received copies of City' s Corporate Compliance Program (" Program"), including its Code of Ethics and Business Conduct andits Anti- Kickback Statute. Contractor shall comply with all aspectsof the Program, Code of Ethics and Business Conduct, and the Anti- Kickback Statute, including any required City compliance training related to each.
17. Compliance with Anti- Kickback Statute. Eachparty shall comply with the FederalHealth Care Kickback Statute ( 42 U.S.C. § 1320a-7b) and any applicable regulations promulgated thereunder. The parties further recognize that this Agreement shall be subject to the amendmentsof the Anti- Kickback Statuteor any of its applicable regulations. In the event any applicable provisions of the Anti- Kickback Statute or its regulations invalidate, or are otherwise inconsistent with the terms of this Agreement, or would cause one or both of the parties to be in violation of the law, the parties shall exercise their best efforts to accommodate the terms and intent of this Agreement to the greatest extent possible consistent with the requirements of the Statute and its applicable regulations.
18. Fair Market Value. This Agreement hasbeennegotiatedat arms length and in good faith by the parties. Nothing contained in this Agreement, including any compensationpaid or payable, is intended or shall be construed: (i) to require, influence or otherwise induce or solicit either party regarding referrals of businessor patients, or the recommending the ordering of any items or services of any kind whatsoever to the other party or any of its affiliates, or to any other person, or otherwise generatebusinessbetweenthe parties to be reimbursed in whole or in part by any health care provider.
19. Regulatory Changes. City reservesthe right to modify this Agreement, upon thirty ( 30) days notice to Contractor in the event any Applicable Law or government policy or program change is passedor adoptedaffecting City
20. Confidential Information. In addition to ProtectedHealth Information asdefined by the Health Insurance Portability and Accountability Act of 1996, as amended, during the course of performing this Agreement, eachparty may from time to time receive confidential information about the other including but not limited to information about the part practices, procedures, strategies, organization, financial and other related information. Neither party shall use or disclose any such confidential information for any purpose other than the 6 limited purpose of performing its obligations under this Agreement, without the prior express written permission of the supplying party. City
and remain the sole property of City. If a party is servedwith a subpoenaor other legal process concerning confidential information of the other party, that party shall immediately ( not more than 48 hours after the receipt) notify the supplying party and shall cooperate with it in any lawful effort to contest the legal validity of such processthe supplying party may wish to pursue.
Upon the termination of the Agreement for any reason, or at any time City may so request, Contractor shall promptly deliver to City all confidential information delivered to Contractor by City, including any copies in its possession, it being agreedthat such confidential information is the property of City.
21. Intentionally Omitted.
22. Ownership of Work, Materials, and Documents. All documents including, but not limited to, deliverables, manuals, programs, designs, reports, protocols, computer programs, code, software, development, systemsdesign, specifications, and any other pertinent data, in whatever form of media, specifica
exclusive property of City. To the extent that title to any such Work may not, by operation of law, vest in City or such Work may not be considered works for hire, Consultant irrevocably assignsall rights, title and interest in Work to City. All such Work shall belong exclusively to City, except asset forth herein, with City having the right to obtain and to hold in its own name, copyrights, registrations, or such other protection as may be appropriate to the subject matter, and any extensions and renewals thereof. Except as provided herein, each party reservesall their respectiverights, title, andownership in their respectiveintellectual property including, but not limited to, rights in any materials, business processes, computer code, software, or documentation, owned or developed by or for each party respectively and independently of this Agreement, and such intellectual property shall remain the sole property of Contractor or City respectively.
23. Force Majeure. Either party shall be excused for failures and delays in performance of its respective obligations under this Agreement due to any causebeyond its control and without fault, including without limitation, any act of God, war, riot or insurrection, law or regulation, strike, flood, fire, terrorism, explosion or inability due to any of the aforementioned causesto obtain labor, materials, roadways or facilities. Nevertheless, each party shall useits best efforts to avoid or remove suchcausesandto continue performancewheneversuchcausesareremoved, and shall notify the other party of the problem.
24. Publicity Provision. Neither party shall use any trademarks, service marks, visual product representations, trade names, logos or other commercial or product designations of the other party shall identify or make referenceto the other party in any advertising or other promotional modality regardlessof its form without explicit prior written consent from said party.
25. IP Provision. Nothing in this Agreement is intendedto grant a licenseor any rights of any nature whatsoeverto City
patents, mask work rights, trademarks, trade names, service marks, logos, copyrights, derivatives, software or any other intellectual property rights of City. 7 26. Dispute Resolution. In the event of a dispute, the parties will consider the use of mediation and/or arbitration to resolve the dispute insteadof litigation except for actions involving equity City any amountsdue.
27. Legal Fees. In the event either party brings any action for any relief, declaratory or otherwise, arising out of this Agreement, or on accountof any breachor default hereof, the prevailing party related to such action.
28. Notices. Any notice required or permitted to be given pursuant to any provisions of this Agreement shall be given in writing, and deposited in the United Statesmail, postagepre-paid, registered or certified mail, return receipt requested, or by a nationally recognized overnight courier service, properly addressedto the following addresses:
To City: To Contractor:
City of Chula Vista UCSD Health Sciences
276 Fourth Avenue Assistant Vice Chancellor
Chula Vista, CA 91910 9500 Gilman Dr. MC0602
Attn: Chris Scott La Jolla, CA 92093-0602
The notification addresseslisted above may be changedby either party with proper notice as listed above.
30. Assignment. Neither party may assign this Agreement to a third party ( except to an affiliate, subsidiary or by way of mergerby thesaleof substantially all theassets) without theprior written consent of the other party, which shall not be unreasonably withheld. City may subcontract its binding upon and for the sole benefit of the parties hereto and their respective successorsand permitted assigns.
31. Wavier. The failure by either party to insist on strict performance by the other party of any provision of this Agreement shall not be a waiver of any subsequentbreach or default of any provision of this Agreement.
32. Severability. If any portion or portions of this Agreement shall be for any reason invalid or unenforceable, the remaining portion( s) shall be valid and enforceable and carried into effect unlessto do so would clearly violate the presentlegal and valid intention of the parties hereto.
33. Survival. Any provisions of this Agreement creating obligations extending beyond the term of this Agreement shall survive the expiration or termination of this Agreement, regardlessof the reasonfor such termination.
34. Headings. The headingsusedin this Agreement are for convenienceonly and do not limit the contentsof this Agreement.
8 35. Variations of Pronouns. All pronouns and variations thereof will be deemed to refer to the masculine, feminine, or neuter, singular or plural, as the identity of a person, persons, or entity may require.
36. Amendments. Any amendmentsto this Agreement shall be effective only if in writing and signed by authorized representativesof both parties.
37. Governing Law and Entire Agreement. This Agreement shall be subject to and governed according to the laws of the State of California, regardlessof whether either party is or may become a resident of another state. The parties agree that the venue and jurisdiction shall be exclusively in the state and federal courts located in the County of San Diego in the State of California. This Agreement constitutes the entire agreement and understanding between the parties with respect to the subject matter hereof and supersedesany previous agreementsor understandings, whether oral or written.
38. Authorization for Agreement. All necessarylaws, resolutions, and corporate actions have duly authorized the execution and performance of this Agreement, and this Agreement constitutes the valid and enforceableobligations of the parties in accordancewith its terms.
39. No Third Party Beneficiary. Neither party intends in any manner whatsoever to createan interest or beneficiary in a third party.
40. Exhibits. All Exhibits referencedherein are incorporated into this Agreement in their entirety.
Agreement when usedthroughout this Agreement shall include all referencedExhibits.
41. Agreement Controls. If there exists or is alleged any ambiguity, difference or inconsistency between the terms of this Agreement and the Exhibit( s), then notwithstanding anything to the contrary in the Exhibit( s), the terms of this Agreement shall prevail over, govern, supersedeand pre-empt the terms of the Exhibit( s).
42. Counterparts. This Agreement may be executedin severalcounterparts, eachof which shall be an original, but all of which shall constitute one and the sameinstrument.
Signature page immediately follows
9 IN WITNESS WHEREOF, the parties hereto havecausedthis Agreement to be executed by their authorized representativeson the day and year first abovewritten.
CITY CONTRACTOR
The City of Chula Vista The Regents of the University of California By: By:
John McCann Rina Davison
Mayor Assistant Vice Chancellor
Health SciencesAdministration
UCSD Health Sciences
Date: _________________________ Date: ________________________ Approved as to Form
Jill D.S. Maland
Lounsbery Ferguson Altona & Peak
Acting City Attorney
10 EXHIBIT A
Contractor Services
1) Medical Director oversight and consultation for patient careservicesprovided by the Fire Department.
2) Medical Director oversight and consultation for patient careservicesprovided by Fire Department outside of their operating areadue to mutual and automatic aid responses. 3) Medical Director oversight and consultation for patient care during public events. 4) Medical Director oversight and consultation for Telehealth, Mobile Integrated Health Programs, and City- basedinitiatives associatedwith servicesfor the unsheltered population intended to reduce impacts to the 911 system. 5) Medical Director oversight and consultation for other City servicessuch aslaw enforcementactivities which overlap with EMS.
6) Supervision of Advanced PracticeProviders (APPs), such asNurse Practitioners (NPs) or Physician Assistants (PAs) for expanding EMS programs.
7) Prior to any ride-alongs, Physician shall executea Non-Employee Voluntary Participation in Medical & Fire Response & Assumption of Risk, Waiver, Release & Indemnification Agreement, a form of which is attachedhereto as Exhibit A- 1. 8) City shall pay to Contractor the sum of Nine
Thousanddollars ($9,000.00) per month. Contractor shall deliver an itemized invoice on a monthly basis no later than the tenth day of the month following Services rendered to City detailing (i) the date Serviceswere provided, (ii) a brief description of the Services provided, (iii) the number of hours of Servicesprovided, (iv) the Nine Thousanddollars 9,000.00) monthly fee due to Contractor, and (v) any pre-approved out-of-pocket costs incurred that are directly related to performing the Services. Contractor shall be reimbursed for all agreedto and pre-approved out-of-pocket costs incurred that are directly related to performing the Servicesunder this Agreement, in a total amount not to exceed Three Thousand dollars ($3,000.00) per year (October 1 September30). Contractor shall coordinate all travel and accommodationsin connection with the Serviceswith the City travel office.
Invoices shall be sent to: Raymond Smith
Email: [email protected]
Paymentsshall be made payable: The Regents of UC
and sentto: UCSD Emergency Medicine
Attn: Maegan Carey
9500 Gilman Drive, MC 8676
La Jolla, CA 92093-8676
9) City and Contractor acknowledge that the amount of time required of Contractor each month likely will fluctuate and there is no minimum or maximum amount of hours per month for which Contractor is engaged. However, it is estimatedthat Contractor's services will be required for up to forty ( 40) hours per month. 10) Such other duties asmay be mutually agreedupon from time to time and addedto this Exhibit A.
11 Exhibit A- 1
NON- EMPLOYEE VOLUNTARY PARTICIPATION IN
MEDICAL & FIRE RESPONSE
ASSUMPTION OF RISK,
WAIVER, RELEASE & INDEMNIFICATION
AGREEMENT
Insert Correct City Legal Entity] ( hereinafter referred to as City emergency response services and activities related Print
Name of Participant] living at _________________________________________________ [Insert Full Address] desire to participate in, observe and/or otherwise take part in Response Services. I
ACKNOWLEDGE THAT MY PARTICIPATION IN THE RESPONSE SERVICES IS STRICTLY
AS AN OBSERVER AND I FURTHER ACKNOWLEDGE THAT I WILL NEITHER BE PERMITTED TO NOR WILL I RENDER ANY PATIENT CARE.
In consideration of City
of ResponseServices, I hereby knowingly, freely and voluntarily agree as follows:
Representations. I representto City that I am legally compete license number is _________________, for the State of ______________ which statesmy birth date as I acknowledge that I am not an employee or agent of City. I representthat I do not have a medical or physical condition or infectious disease which could be triggered by participating in ResponseServices or that could endanger the public and/or myself by participating in ResponseServices.
I understandthat if I receiveda small pox vaccination that I maybe contagiousfor up to four (4) weeksafter my inoculation and I specifically representthat I have not had the small pox vaccination or it has beenat least four (4) weeks from my inoculation. ______ INITIALS Medical Doctor ( Applicable to Medical Doctors Only). If the non- employee ride along is a Medical Doctor, I specifically agree and understand that patient care and/or treatment is outside the scopeof this Agreement and any patient treatment or care that I provide is treatment or care delivered in the course of my medical practice. ______ INITIALS
Disclaimer of Warranty. I understand that each situation that City responds to is based on incomplete and limited information provided often under extreme and emergency conditions and which may or may not be ultimately accurate. Moreover, I understand that each situation will contain unforeseen and unknown hazards, dangers and risks to me and to City. City Services are based upon whatever current information is available, at the time of the Response Services are provided so I expressly understand and agree that City makes no representation or warranty expressed or implied, written or oral regarding ResponseServices to me and to what I may or may not be exposed. _____ INITIALS
Assumption of Risk. I voluntarily and freely, with full understanding that I may be exposing myself to extreme danger, emotional trauma and other risks. I assume all risks in connection with the Response Services. I acknowledge that participating in Response Services may result in, but is not limited to bodily injury, death, emotional trauma, burns, extreme noise, extreme lights and/or 12 exposure to hazards and/ or diseases like airborne or bloodborne pathogens, bacteria or other harmful transmissions to me. Exposure to an airborne or bloodborne pathogen may result in the transmission of AIDS, hepatitis, TB or other infectious diseases. _______ INITIALS Endangerment. I AGREE TO FOLLOW ALL INSTRUCTIONS, PROCEDURES, MEASURES
AND DIRECTIONS GIVEN BY CITY AND UNDERSTAND MY FAILURE TO DO SO MAY RESULT IN PROPERTY DAMAGE OR INJURY OR DEATH TO ME OR TO A THIRD PARTY.
I UNDERSTAND THAT MY PARTICIPATION IN RESPONSE SERVICES MAY BE TERMINATED AT ANY TIME FOR ANY REASON BY CITY. ______ INITIALS Insurance. I understand that I am completely responsible for all insurance coverage which I may wish to purchase to cover my participation in the Response Services.
Confidentiality of Protected Health Information. During my participation in Response Services, I acknowledge that I may be exposedto confidential information and/or Protected Health Information ( for example, patient identity, care and/or treatment information) as defined under HIPAA ( referenced below).
I acknowledgethat City andthe activities involved in ResponseServicesaresubjectto broad, extensiveand comprehensive privacy and confidentiality laws and regulations protecting patient care information. I understandthat I am legally obligated andpersonally responsiblefor holding this information confidentially and not disclosing it to anyone unless such disclosure is permitted under the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. § 1320d through d- the Health Information Technology for Economic and Clinical Health Act of 2009, and any current and future rules and regulations promulgated thereunder, including without limitation, the federal privacy regulations as contained in 45 CFR Parts 160 and 164, the federal security regulations as contained in 45 CFR Parts 160, 162 and 164, and other federal or stateprivacy laws. ______ INITIALS Information regarding a patient is strictly confidential, its disclosure to anyone not specifically permitted is strictly prohibited by law. I specifically agreeto: review City Policies prior to my participation in the ResponseServices; not to take, copy or disclose to the media or anyoneany information I receive, observe, view and/or otherwise have accessto arising out of, in any manner whatsoever, my participation in ResponseServices, unless required by law and you have provided notice to City of the requestprior to disclosure; adhereto HIPAA and other federal and state privacy laws and regulations; keep all Protected Health Information as defined by HIPAA confidential; and not to disclose any ProtectedHealth Information and/or other confidential information unlessso permitted under applicable law. ______ INITIALS Compliance with Applicable Law. I agreeto comply with all Applicable Law during my participation. rules and/or Executive Orders, as amended.
WAIVER, INDEMNITY & RELEASE
I waive, release and discharge City, its parent, subsidiaries and affiliates, and its and their respective officers, directors, stockholders, employees, agents, representatives, insurers, successorsand assigns, of and from any cost, expense, claim, demand, right or cause of action, of any kind or nature whatsoever, whether based on tort, contract, warranty, or other theory of recovery, at law or in equity, vested or contingent, that I or my spouse, family, parents, children, estate, heirs, agents, insurers, successorsor assigns may at any time have as a result of the Response Services for City. In 13 addition, I hereby agree to save, hold, defend and indemnify City, its parent, subsidiaries and affiliates, and its and their respective officers, directors, stockholders, employees, agents, representatives, insurers, successorsand assigns, of and from any cost, expense, claim, demand, right or cause of action, of any kind or nature whatsoever, whether based on tort, contract, warranty, or other theory of recovery, at law or in equity, vested or contingent, that may result, directly or indirectly, from my action or inaction, including my participation in City Response Services. _____
INITIALS
I UNDERSTAND THAT THIS WAIVER, RELEASE AND INDEMNITY IS INTENDED TO
WAIVE, RELEASE, DISCHARGE AND INDEMNIFY IN ADVANCE CITY, ITS PARENT,
SUBSIDIARIES AND AFFILIATES, AND ITS AND THEIR RESPECTIVE OFFICERS,
DIRECTORS, STOCKHOLDERS, EMPLOYEES, INSURERS, AGENTS, REPRESENTATIVES,
SUCCESSORS AND ASSIGNS, FOR, FROM AND AGAINST ANY AND ALL LIABILITY TO ME ARISING FROM THE RESPONSE SERVICES CITY IS INVOLVED IN. THIS INCLUDES,
WITHOUT LIMITATION, ANY LIABILITY ( INCLUDING CONSEQUENTIAL, INDIRECT,
SPECIAL OR INCIDENTAL DAMAGES) ARISING FROM INJURY OR DAMAGE THAT I
SUFFER OR CAUSE DURING THE RESPONSE SERVICES, INCLUDING, WITHOUT
LIMITATION, DEATH, INJURY, EMOTIONAL TRAUMA, BURNS, ILLNESS, DISABILITY,
EXTREME LIGHTS, EXTREME NOISE OR OTHER DAMAGE TO MY PERSON AND/ OR
PROPERTY OR THIRD PARTY, AND ALL RISKS CONNECTED THERETO, WHETHER FORESEEN OR UNFORESEEN, RESULTING FROM NEGLIGENCE OR OTHERWISE. _____
INITIALS
I agreethat this Waiver and Releaseis intended to be asbroad and inclusive aspermitted by the laws of the Stateof ______________. If any provision of this Waiver and Releaseshall be ineffective or invalid, such provision shall be ineffective or invalid only to the extent of such prohibition or invalidity, without invalidating the remainder of suchprovision or the remaining provisions of this Waiver andRelease, which shall remain in full force and effect. _______INITIALS Duty to Inform. So long as I participate in ResponseServices, in the event any representationor obligation of mine in this Agreement is no longer accurate, or true, I agreeto inform City immediately in writing of suchoccurrence. I realize that City is relying upon my representations and agreementsmade in this Agreement and that my failure to adhereto this Agreement could seriously injure someone, causetheir deathor damageproperty. ______ INITIALS 14 I HAVE READ THIS AGREEMENT AND THE WAIVER, RELEASE AND INDEMNITY BEFORE SIGNING IT, AND FULLY UNDERSTAND AND AGREE TO ITS TERMS.
By: _____________________________
Name: ___________________________
Date: ____________________________
AGREED AND ACCEPTED
insert R/M entity]
By:
Name:
Its:
Date: