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HomeMy WebLinkAbout010912_ca03 " ~ ~6N- . . Consent Agenda (~~q,':pi JEFFERSON COUNTY PUBLIC HEALTH ~$';;::':-"O" . 615 Sheridan Street . Port Townsend. Washington. 98368 . .!1'9 _.JeffenloncountypubDchealth.org December 19, 2011 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENbA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Jean Baldwin, Director DATE: Yo...nucu'f CJ I d.D I d, SUBJECT: Agenda Item - Contract Agreement with Public Health of King County for Breast Cervical & Colon Health Program Services; January 1, 2012 - June 3D, 2012; $8,458 STATEMENT OF ISSUE: Jefferson County Public Health, Community Health, Is requesting Board approval of the Contract Agreement with Public Health of King County for Breast Cervical & Colon Health Program Services; January 1, 2012 - June 30, 2012; $8,458 A,NAL YSIS/STRATEGIC GOALS/PRO'S and CON'S: This agreement between Jefferson County and King County Department of Public Health provides Breast and Cervical Health Care; (Screening & Referral Services) to a specific segment of the population. Services are available to women who lack Insurance to pay for preventive services such as health exams, mammograms and pap tests. This Indudes women age 40-64 with Incomes at or below 250% of Federal Poverty Level, women below 300% of FPL, and women aged 30-39 with breast findings. These services will also be available to women who may not be eligible for Medicare. JCPH will serve 33 clients in this contract period. This contract provides for colon health services to certain counties that contract with Public Health of King County, Jefferson County Is not one of those counties. FISCAL IMPACT/COST BEN Em ANALYSIS: The agreement provides $15,385 In State funding. No general fund dollars support this program. The agreement provides: $3,100 In Public Education/Outreach $4,950 for Clinical Services (Fee-for-Service) $300 for Client Support Services $78 for Incidental Expenses COMMUNITY HEALTH DEVELOPMENTAL DISABILmES MAIN: (360) 385-9400 FAX: (360) 385-9401 PUBLIC HEALTH Al.WIlWS W!l1lllJ1l1iI F!lilll WEll lID HEALTHIER COMMUNITY ENVIRONMENTAL HEALTH WATER QUALITY MAIN: (380) 385-9444 FAX: (360) 379-4487 ~ _ o~ Consent Agenda RECOMMENDAnON: JCPH management request approval of the Contract Agreement with Public Health of KIng County for Breast Cervical & Colon Health Program Services; January 1, 2012 - June 30, 2012; $8,458 REVIEWED BY: ~~ / /~~2- Date ~~~!~(:K~!~l!~ ~ King County Contract No. PREV23 6 B Federal Taxpayer ID No. 91-6001322 This form is available in alternate formats for people with disabilities upon request. KING COUNTY CONTRACT FOR SERVICES WITH OTHER GOVERNMENT, INSTITUTION, OR JURISDICTION - 2012 Department Seattle-King County Dept. of Public Health (a.k.a. Public Health - Seattle & King Division County)/PREV Contractor Jefferson Counlv Public Health prolect TItle Breast, Cervical and Colon Health Proaram Contract Amount Eiaht Thousand Four Hundred Fiflv Eioht Dollars and Zero Cents Contract Period Start date: 01/01/2012 End date: 06/30/2012 THIS CONTRACT is entered into by KING COUNTY (the "County"), and Jefferson County Public Health (the "Contractor"), whose address is 615 Sheridan, Port Townsend, WA 98368. WHEREAS, the County has been advised that the following ara the current funding sources, funding levels and effective dates: FUNDING SOURCES FUNDING LEVELS EFFECTIVE DATES FEDERAL Federal Catalogue No.93.283 $5,028.00 1/1/2012 - 6/30/2012 STATE $3,430.00 1/1/2012 - 6/30/2012 TOTAL $8,458.00 1/1/2012.6/30/2012 and WHEREAS, the County desires to have certain services performed by the Contractor as described in this Contract, and as authorized by the 2012 Annual Budget. NOW THEREFORE, in consideration of payments, covenants, and agreements hereinafter mentioned, to be made and performed by the parties hereto, the parties covenant and do mutually agree as follows: Incomoratlon of Exhibits The Contractor shall provide services and comply with the requirements set forth in the follOWing attached exhibits. which are incorporated herein by reference: A Program Exhibits and Requirements . Exhibit A: Scope of Work . Exhibit B: Budget . Exhibit C: Invoice . Exhibit D: Credentials Requirements B King County Required Forms . Exhibit E: Certificate of Insurance and Additional Insured Endorsement Contract # PREV2368 Page # 1 of9 II Term and Termination A This Contract shall commence on 01/01/2012, and shall terminate on 06/30/2012, unless extended or terminated earlier, pursuant to the terms and conditions of the Contract. B This Contract may be terminated by the either party without cause, in whole or in part, prior to the date specified in Subsection IIA above, by providing the other party thirty (30) days advance written notica of the termination. C The County may terminate this Contract. in whole or in part, upon seven (7) days advance written notice in the event: (1) the Contractor materially breaches any duty. obligation, or service required pursuant to this Contract. or (2) the duties, obligations, or services required herein become impossible. illegal, or not feasible. If the Contract is terminated by the County pursuant to this Subsection II.C. (1), the Contractor shall be liable for damages, including any additional costs of procurement of similar services from another source. If the termination results from acts or omissions of the Contractor, including but not limited to misappropriation, nonperformance of required services, or fiscal mismanagement, the Contractor shall retum to the County immediately any funds, misappropriated or unexpended, which have been paid to the Contractor by the County. D If County or other expected or actual funding is withdrawn, reduced, or limited in any way prior to the termination date set forth above in Subsection IIA., the County may, upon written notification to the Contractor, terminate this Contract in whole or in part. If the Contract is terminated as provided in this Subsection: (1) the County will be liable only for payment in accordance with the terms of this Contract for services rendered prior to the effective date oftermination; and (2) the Contractor shall be released from any obligation to provide such further services pursuant to the Contract as are affected by the termination. Funding or obligation under this Contract beyond the current appropriation year is conditional upon appropriation by the County Council of sufficient funds to support the activities described in the Contract. Should such appropriation not be approved. this Contract will terminate at the close of the current appropriation year. E Nothing herein shall limit, waive, or extinguish any right or remedy provided by this Contract or law that either party may have in the event that the obligations, terms, and conditions set forth in this Contract are breached by the other party. 111 Comoonsatlon and Method of PaYment A The County shall reimburse the Contractor for satisfactory completion of the services and requirements specified in this Contract, payable in the following manner: Upon receipt and approval of a signed invoice as set forth in Exhibit C that complies with the budget in Exhibit B. B The Contractor shall submit an invoice and all accompanying reports as specified in the attached exhibits not more than 60 working days after the close of each indicated reporting period. The County will initiate authorization for payment after approval of corrected invoices and reports. The County shall make payment to the Contractor not more than 30 days after a complete and accurate invoice is received. C The Contractor shall submit its final invoice and all outstanding reports within 90 days of the date this Contract terminates. If the Contractor's final invoice and reports are not submitted by the day specified in this subsection, the County will be relieved of all liability for payment to the Contractor of the amounts set forth in said invoice or any subsequent invoice. D When a budget is attached hereto as an exhibit, the Contractor shall apply the funds received from the County under this Contract in accordance with said budget. The contract may contain Contract # PREV2368 Page#20f9 separate budgets for separate program components. The Contractor shall request prior approval from the County for an amendment to this Contract when the cumulative amount of transfers among the budget categories is expected to exceed 10% of the Contract amount in any Contract budget. Supporting documents necessary to explain fully the nature and purpose of the amendment must accompany each request for an amendment. E If travel costs are contained in the attached budget, reimbursement of Contractor travel, lodging, and meal expenses are limited to the eligible costs based on the following rates and criteria. 1 The mileage rate allowed by KIng County shall not exceed the current Intemal Revenue Service (IRS) rates per mile as allowed for business related travel. The IRS mileage rate shall be paid for the operation, maintenance and depreciation of individually owned vehicles for that time which the vehicle is used during work hours. Parking shall be the actual cost. When rental vehicles are authorized, govemment rates shall be requested. If the Contractor does not request govemment ratas, the Contractor shall be personally responsible for the difference. Please reference the federal web site for current rates: http://www.gsa.gov. 2 Reimbursement for meals shall be limited to the per diem rates established by federal travel requisitions for the host city in the Code of Federal Regulations, 41 CFR S 301, App.A. 3 Accommodation rates shall not exceed the federal lodging limit plus host city taxes. The Contractor shall always request govemment rates. 4 Air travel shall be by coach class at the lowest possible price available at the time the County requests a particular trip. In general, a trip is associated with a particular work activity of limited duration and only one round-trip ticket, per person, shall be bllled per trip. IV Internal Control and Accountlna SYStem The Contractor shall establish and maintain a system of accounting and intemal controls which complies with applicable, generally accepted accounting principles. and govemmental accounting and financial reporting standards. V Debarment and Susoenslon Certification Agencies receiving federal funds that are debarred, suspended, or proposed for debarment are excluded from contracting with the County. The Contractor, by signature to this Contract, cerllfies that the Contractor is not presently debarred, suspended, or proposed for debarment by any Federal department or agency. The Contractor also agrees that it will not enter Into a subcontract with a contractor that is debarred, suspended, or proposed for debarment. The Contractor agrees to notify King County In the event it, or a subcontractor, Is debarred, suspended, or proposed for debarment by any Federel department or agency. For more Information on suspension and debarment, see Federal Acquisition Regulation 9.4. VI Maintenance of RecordslEvaluatlons and Insoectlons A The Contractor shall maintain accounts and records, including personnel, property, financial, and programmatic records and other such records as may be deemed necessary by the County to ensure proper accounting for all Contract funds and compliance with this Contract. S In accordance with the nondiscrimination and equal employment opportunity requirements set forth in Section XIV. below, the Contractor shall maintain the following: 1 Records of employment, employment advertisements, application forms, and other pertinent data, records and information related to employment, applications for employment or the administration or delivery of services or any other benefits under this Contract; and 2 Records, including written quotes, bids, estimates or proposels submitted to the Contractor by all businesses seeking to participate on this Contract, and any other information necessary to document the actual use of and payments to subcontractors and suppliers in this Contract, including employment records. Contract # PREV2368 Page # 3 of9 The County may visit, at any mutually agreeable time, the site of the work and the Contractor's office to review the foregoing records. The Contractor shall provide every assistance requested by the County during such visits. In all other respects, the Contractor shall make the foregoing records available to the County for inspection and copying upon request. If this Contract involves federal funds, the Contractor shall comply with all record keeping requirements set forth in any federal rules, regulations or statutes Included or referenced in the contract documents. C Except as provided in Section Vii of this Contract, the records listed in A and B above shall be maintained for a period of six (6) years after termination hereof unless permission to destroy them is granted by the Office of the Archivist in accordance with Revised Code of Washington (RCW) Chapter 40.14. o Medlcel records shall be maintalned and preserved by the Contractor in accordance with state and federal medicel records statutes, including but not limited to RCW 70.41.190, 70.02.160, and standard medlcel records practice. If the Contractor ceases operations under this Contract, the Contractor shall be responsible for the disposition and maintenance of such medicel records. E The Contractor agrees to cooperate with the County or its agent in the evaluation of the Contractor's performance under this Contract and to make available all information reasonably required by any such evaluation process. The results and records of said evaluations shall be maintained and disclosed in accordance with RCW Chapter 42.56. F The Contractor agrees that all information, records, and data collected in connection with this Contract shall be protected from unauthorized disclosure in accordance with appllceble state and federal law. Vii ComDllance with the Health Insurance Portabilitv Accountabilitv Act of 1996 fHIPAAl The Contractor shall not use protected health information created or shared under this Contract in any manner that would constitute a violation of HIPAA and any regulations enacted pursuant to its provisions. Contractor shall read and certify compliance with all HIPAA requirements at htlp:l/www.kingcounty.govlheaithserviceslhealthlpartnershipslcontracts VIII Audits A If the Contractor or subcontractor is a municipal entity or other government institution or jurisdiction, or is a non-profit organization as defined in OMB Circular A-133, and expends a total of $500,000 or more in federal financial assistance and has received federal financial assistance from the County during its fiscal year, then the Contractor or subcontractor shall meat the respective A-133 requirements described In subsections V1II.B. and VIII.C. B If the Contractor is a non-profit organization, it shall have an independent audit conducted of its financial statement and condition, which shall comply with the requirements of GAAS (generally accepted auditing standards); GAO's Standards for Audits of Governmental Organizations, Programs, Activities, and Functions; and OMB Circular A-133, as amended, and as applicable. The Contractor shall provide a copy of the audit report to each County division providing financial assistance to the Contractor no later than six (6) months subsequent to the end of the Contractor's fiscal year. The Contractor shall provide to the County its response and corrective action plan for all findings and reportable conditions contained in its audit. When reference is made in Its audit to a "Management Letter" or other correspondence made by the auditor, the Contractor shall provide copies of those communications and the Contractor's response and corrective action plan. Submittal of these documents shall constitute compliance with subsection VillA. C if the Contractor is a municipal entity or other government institution or jurisdiction, It shall submit to the County a copy of its annual report of examination/audit, conducted by the Washington State Auditor, within thirty (30) days of receipt, which submittal shall constitute compliance with subsection VillA o If the Contractor, for-profit or non-profit, receives in excess of $100,000 in funds during Its fiscal year from the County, It shall provide a fiscal year financial statement prepared by an independent Contract # PREV2368 Page # 4 of 9 Certified Public Accountant or Accounting Firm within six (6) months subsequent to the close of the Contractor's fiscal year. E Additional audit or review requirements which may be imposed on the County will be passed on to the Contractor and the Contractor will be required to comply with any such requirements. IX Corrective Action If the County determines that a breach of contract has occurred, that is, the Contractor has failed to comply with any terms or conditions of this Contract or the Contractor has failed to provide in any manner the work or services agreed to herein, and if the County deems said breach to warrant corrective action, the following sequential procedure will apply: A The County will notify the Contractor in writing of the nature of the breach; The Contractor shall respond in writing within three (3) working days of its receipt of such notification, which response shall indicete the steps being taken to correct the specified deficiencies. The corrective action plan shall specify the proposed completion date for bringing the Contract into compliance, which date shall not be more than ten (10) days from the date of the Contractor's response, unless the County, at its sole discretion, specifies in writing an extension in the number of days to complete the corrective actions; B The County will notify the Contractor in writing of the County's determination as to the sufficiency of the Contractor's corrective action plan. The determination of sufficiency of the Contractor's corrective action plan shall be at the sole discretion of the County; C In the event that the Contractor does not respond within the appropriate time with a corrective action plan, or the Contractor's corrective action plan is determined by the County to be insufficient, the County may commence termination of this Contract in whole or In part pursuant to Section II.C.; D In addition, tha County may withhold any payment owed the Contractor or prohibit the Contractor from incurring additional obligations of funds until the County Is satisfied that corrective action has been taken or completed; and E Nothing herein shall be deemed to affect or waive any rights the parties may have pursuant to Section II. Subsections B, C, D, and E. X Dispute Resolution The parties shall use their best, good-faith efforts to cooperatively resoive disputes and problems that arise in connection with this Contract. Both parties will make a good faith effort to continue without delay to carry out their respective responsibilities under this Contract while attempting to resolve the dispute under this section. XI Hold Harmless and Indemnification A In providing services under this Contract, the Contractor is an independent Contractor, and neither it nor its officers, agents, employees, or subcontractors are employees of the County for any purpose. The Contractor shall be responsible for all federal and/or state tax, industrial insurance, and Social Security iiability that may result from the performance of and compensation for these services and shall make no claim of cereer service or civil service rights which may accrue to a County employee under state or locellaw. The County assumes no responsibility for the payment of any compensation, wages, benefits, or taxes by, or on behalf of the Contractor, its employees, subcontractors and/or others by reason of this Contract. The Contractor shall protect, indemnify, and save harmless the County, its officers, agents, and employees from and against any and all claims, costs, and/or losses whatsoever occurring or resulting from (1) the Contractor's failure to pay any such compensation, wages, benefits, or taxes, and/or (2) the supplying to the Contractor of work, services, materials, or supplies by Contractor employees or other suppliers in connection with or support of the performance of this Contract. Contract # PREV2368 Page # 5 of9 B The Contractor further agrees that it is financially responsible for and will repay the County all indicated amounts following an audit exception which occurs due to the negligence, intentional act, and/or failure, for any reason, to comply with the terms of this Contract by the Contractor, its officers, employees, agents, or subcontractors. This duty to repay the County shall not be diminished or extinguished by the prior termination of the Contract pursuant to the Duration of Contract or the Termination section. C The Contractor shall defend, indemnify, and hold harmless the County, its officers, employees, and agents from any and all costs, claims, judgments, and/or awards of damages, arising out of, or in any way resulting from, the negligent acts or omissions of the Contractor, its officers, employees, subcontractors and/or agents in its performance or non-performance of its obligations under this Contract In the event the County incurs any judgment, award, and/or cost arising therefrom Including attomeys' fees to enforce the provisions of this article, all such fees, expenses, and costs shall be recoverable from the Contractor. . D The County shall defend, Indemnify, and hold harmless the Contractor, its officers, employees, and agents from any and aU costs, claims, judgments, and/or awards of damages, arisa out of, or in any way result from, the negligent acts or omissions of the County, its officers, employees, or agents in its performance or non-performance of its obligations under this Contract. In the event the Contractor incurs any judgment, award, and/or cost arising therefrom including attomeys' fees to enforce the provisions of this article, all such fees, expenses, and costs shall be recoverable from the County. E Claims shall include, but not be limited to, assertions that use or transfer of software, book, document, report, film, tape, or sound reproduction or material of any kind, delivered hereunder, constitutes an infringement of any copyright, patent, trademark, trade name, and/or otherwise results In unfair trade practice. F Nothing contained within this provision shall affect and/or alter the application of any other provision contained within this Contract G The indemnification, protection, defense and save harmless obligations contained herein shall survive the expiration, abendonment or termination of this Agreement. XII Insurance Reauirements By the date of execution of this Contract, the Contractor shall procure and maintain for the duration of this Contract, insurance against claims for injuries to persons or damages to property which may arise from, or in connection with, the performance of work hereunder by the Contractor, its agents, representatives, employees, and/or subcontractors. The costs of such insurance shall be paid by the Contractor or subcontractor. The Contractor may fumish separate certificates of insurance and policy endorsements for each subcontractor as evidence of compliance with the insurance requirements of this Contract. The Contractor is responsible for ensuring compliance with all of the insurance requirements stated herein. Failure by the Contractor, its agents, employees, officers, subcontractors, providers, and/or provider subcontractors to comply with the insurance requirements stated herein shall constitute a material breach of this Contract. Specific coverages and requirements are at http://www.kingcounty.gov/healthserviceslhealthlparlnershipslcontracts; contractors shall read and certify compliance. XIII AsslQnmentlSubcontractina A The Contractor shall not assign or subcontract any portion of this Contract or transfer or assign any claim arising pursuant to this Contract without the written consent of the County. Said consent must be sought in writing by the Contractor not less than fifteen (15) days prior to the date of any proposed assignment. B 'Subcontracf shall mean any agreement between the Contractor and a subcontractor or between subcontractors that is based on this Contract, provided that the term 'subcontract" does not include the purchase of (1) support services not related to the subject matter of this Contract, or (2) supplies. Contract # PREV2368 Page # 6 of9 C The Contractor shall include Sections 111.0., IV, V, VI, VII, VIII, XI, XII, XIV, XV, XXI, and XXV, in every subcontract or purchase agreement for services that relate to the subject matter of this Contract. o The Contractor agrees to Include the following language verbatim in every subcontract, proVider agreement, or purchase agreement for services which relate to the subject matter of this Contract: .Subcontractor shall protect, defend, indemnify, and hold harmless King County, its officers, employees and agents from any and all costs, claims, judgments, and/or awards of damages arising out of, or in any way resulting from the negligent act or omissions of subcontractor, its officers, employees, and/or agents in connection with or in support of this Contract. Subcontractor expressly agrees and understands that King County Is a third party beneficiary to this Contract and shall have the right to bring an action against subcontractor to enforce the provisions of this paragraph." XIV Nondiscrimination and Eaual EmDlovrnent ODDortunitv The Contractor shall comply with all applicable federal, state and local laws regarding discrimination, Including those set forth in this Section. During performenca of the COntract, the Contractor agrees that it will not discriminate against any employee or applicant for employment because of the employee or applicant's sex, race, color, marital status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or age except by minimum ege and retirement provisions, unless based upon a bona fide occupational qualification. The Contractor will make equal employment opportunity efforts to ensure that applicants and employees are treated, without regard to their sex, race, color, marital status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or age. Additional requirements are at http://www.kingcounty.govlhealthserviceslhealthlparlnershipslcontracls; contractors shall read and certify compliance. XV Conflict of Interest A The Contractor agrees to comply with applicable provisions of K.C.C. 3.04. Failure to comply with such requirements shall be a material breach of this contract, and may result in termination of this Contract pursuant to Section II and subject the Contractor to the remedies stated therein. or otherwise available to the County at law or in equity. B The Contractor agrees, pursuant to KCC 3.04.060, that it will not willfully attempt to secure preferential treatment in its dealings with the County by offering any valuable consideration, thing of value or gift, whether In the form of services, loan, thing or promise, in any form to any county official or employee. The Contractor acknowledges that If it is found to have violat~d the prohibition found in this paragraph, its current contracts with the county will be cancelled and it shall not be able to bid on any county contract for a period of two years. C The Contractor acknowledges that for one year after leaving County employment, a former county employee may not have a financial or beneficial interest In a contract or grant that was planned, authorized, or funded by a county action in which the former county employee participated during county employment. Contractor shall identify at the time of offer current or former County employees involved in the preparation of proposalS or the anticipated performance of Work if awarded the Contract. Failure to identify current or former County employees involved in this transaction may result in the County's denying or terminating this Contract. After Contract award, the Contractor is responsible for notifying the County's Project Manager of current or former County employees who may become involved in the Contract any time during the term of the Contract. XVI EauiDment Purchase. Maintenance. and Owners hiD A The Contractor agrees that any equipment purchased, in whole or in part, with Contract funds at a cost of $5,000 per item or more, when the purchase of such equipment is reimbursable as a Contract budget item, is upon lts purchase or receipt the property of the County and/or Contract # PREV2368 Page # 7 of9 federal/state government. The Contractor shall be responsible for all such property, including the proper care and maintenanca of the equipment. 8 The Contractor shall ensure that all such equipment will be returned to the County or federal/state government upon termination of this Contract unless otherwise agreed upon by the parties. XVII Proprletarv Rlahts The parties to this Contract hereby mutually agree that if any patentable or copyrightable material or article should result from the work described herein, all rights accruing from such material or article shall be the sole property of the party that produces such material or article. If any patentable or copyrightable material or article should result from the work described herein and is jointly produced by both parties, all rights accruing from such material or article shall be owned In accordance with US Patent Law. Each party agrees to and does hereby grant to the other party, irrevocable, nonexclusive, and royalty-free license to use, aCCOrding to law, any material or article and use any method that may be develOped as part of the work under this Contract. The foregoing products license shall not apply to existing training materials, consulting aids, checklists, and other materials and documents of the Contractor which are modffied for use in the performance of this Contract. The foregoing provisions of this section shall not apply to existing training materials, consulting aids, checklists, and other materials and documents of the Contractor that are not modffied for use in the performance of this Contract. XVIII Political ActivitY Prohibited None of the funds, materials, property, or services provided directly or indirectly under this Contract shall be used for any partisan political activity or to further the election or defeat of any candidate for public office. XIX Kina County Recvcled Product ProcurementPollcv In accordance with King County Code 10.16, the Contractor shall use recycled paper for the production of all printed and photocopied documents related to the fulfillment of this Contract. In addition, the Contractor shall use both sides of paper sheets for copying and printing and shall use recycled/recyclable products wherever practical in the fulfillment of this Contract. XX Future Support The County makes no commitment to support the services contracted for herein and assumes no obligation for Mure support of the activity contracted herein except as expressly set forth in this Contract. XXI Entire ContractJWaiver of Default The parties agree that this Contract is the complete expression of the terms hereto and any oral or written representations or understandings not incorporated herein are excluded. 80th parties recognize that time is of the essence In the performance of the provisions of this Contract. Waiver of any default shall not be deemed to be a waiver of any subsequent default. Waiver or breach of any provision of the Contract shall not be deemed to be a waiver of any other or subsequent breach and shall not be construed to be a modfficetion of the terms of the Contract unless stated to be such through written approval by the County, which shall be attached to the original Contract. XXII Contract Amendmerrts Either party may request changes to this Contract. Proposed changes which are mutually agreed upon shall be incorporated by written amendments to this Contract. XXIII Notices Whenever this Contract provides for notice to be provided by one party to another, such notice shall be in writing and directed to the chief executive office of the Contractor and the project representative of the Contract # PREV2368 Page # 8 of9 County department specified on page one of this Contract. Any time within which a party must take some action shall be computed from the date that the notice Is received by said party. XXIV Services Provided in Accordance with Law and Rule and Rellulation The Contractor and any subcontractor agree to abide by the laws of the slate of Washington, rules and regulations promulgated thereunder, and regulations of the state and federal govemments, as applicable. which control disposition of funds granted under this Contract, all of which are incorporated herein by reference. In the event that there is a conflict between any of the language contained in any exhibit or attachment to this Contract. the language in the Contract shall have control over the language contained in the exhibit or the attachment. unless the parties affirmatively agree in writing to the contrary. XXV ADDlicable Law This contract shall be construed and interpreted in accordance with the laws of the State of Washington. The venue for any action hereunder shall be in the Superior Court for King County, Washington. XXVI No Third PartY Beneficiaries Except for the parties to whom this contract Is assigned in compliance with the terms of this contract, there are no third party beneficiaries to this contract. and this contract shall not impart any rights enforceable by any person or entity that is not a party hereto. IN WITNESS HEREOF, the parties hereby agree to the terms and conditions of this Contract: KING COUNTY Jefferson County Public Health FOR Signature King County Executive NAME (Please type or print) Date Date Approved as to Form: OFFICE OF THE KING COUNTY PROSECUTING ATTORNEY PHSKC Contract # - Breast, Cervical and Colon Health Program Appr-6\'ea as k) form only: f) ,. J L)Z7/'Zt)I/ Jefferson Co. Prosecut s Office Contract # PREV2368 Page # 9 of9 exhibit A : Scope of Work JEFFERSON COUNTY PUBLIC HEAL TH OUTREACH & RECRUITMENT, CLINICAL SERVICES and CLIENT SUPPORT SERVICES I CASE MANAGEMENT January 1, 2012 through June 30,2012 BACKGROUND This six-month contract is made by Public Health-Seattle & King County's Breast, Cervical and Colon Health Program (BCCHP) with Jefferson County Public Health (Contractor) to provide BCCHP program services to eligible clients according to the procedures, protocols and reimbursement rates of the BCCHP. All grant source funds for this contract are administered by the Washington State Department of Health (DOH) and encumbered into this contract's Budget (Exhibit B) according to the July-June WA State fiscal year. ELIGIBLE POPULATIONS SERVED The BCCHP serves clients who meet the following age, income, insurance and residency criteria: . Women, aged 40-64 for breast & cervical services . Women aged 35-39 with breast findings . Clients over 64 may be enrolled if ineligible for Medicare . Have incomes at or below 250% of the Federal Poverty Level (FPL) . Women at or below 300% FPL for breast services only . Lack insurance or have insurance with a higher than $500 deductible . Are residents of Washington state PROGRAM ADMINISTRATION The contractor will perform the services outlined in this Scope of Work (Exhibit A). . Contracted funds will also be described as "slots", meaning the number of clients that can be enrolled by the Contractor within the budgeted amount Clinical slots shall be monitored monthly by the Contractor and BCCHP. . Note New Procedural Protocol Chanaes for 2012: Jefferson County Public Health will be limited to serving 33 clients In this contracted six month period, to be enrolled at the pace of less than 6 clients per month. Chanaes to this monthlv pace need approval bv the BCCHP. . The Contractor will designate a representative to check in on a monthly basis with the BCCHP Fiscal Manager to ensure numerical enrollments-to-avallable- . budget balance, and assure all clinic managers are aware of enrollment restrictions. . This six-month contract's Budget (Exhibit B) serves solely as a guideline to show an approximate mix of services that could be provided within the allotted Budget . The CDC and WA State DOH have determined that costs for 'Facility Fees' will be included in each applicable CPT code on our current and future Fee Schedules. . BCCHP forms must be submitted within 45 days of services to be eligible for reimbursement, although certain exceptions will be evaluated on a case-by-case basis. . The Contractor is to perform services for breast, cervicai and/or colon cancer screening and diagnostic services as described in the BCCHP Contractor's Procedure Manual, the CDC and DOH Policies and Procedures, including subsequent amendments, and according to applicable local, state and federal laws or regulations. Failure to do so PREV2368 - Jefferson County Public Health Page 1014 may result in the reduction of funds, suspension of services or the termination of this contract. PERFORMANCE REQUIREMENTS A brief description of services provided under this agreement is as fallows: OUTREACH and RECRUITMENT Outreach and Recruitment programs are part of Public Health's Medicaid Administrative Match program far state funded programs. The objectives of these efforts are to: . Increase the number of women receiving annual health screenings, Pap tests, and mammograms through BCCHP and ather programs, . Reduce barriers that prohibit women from receiving screening services, . Raise community awareness about the importance of breast and cervical health screening and haw and where to obtain those services and . Educate women about Medicaid support far treatment of breast and cervical cancer. contracted activities should be planned to focus an reaching women in our priority populations. Successful programs may incorporate any or all of the following: 1. Identify communication networks for women in priority populations in order to identify and refer women in need of mammograms, Pap tests and other women's health services to appropriate providers. 2. Use a combination of small group, one-ta-one education and media to educate, encourage and assist women in obtaining women's health services. 3. Use outreach & recruitment techniques that are developed with community input appropriate for priority populations, (Le., our video presentation, "Mammogram Screening-Taking Care of Ourselves & Each Other") to encourage and assist women to obtain mammograms. 4. Identify women and men eligible far BCCHP and refer far services. Motivate, assist and fallow-up with women who are rarely screened or haven't seen a provider in years to help them obtain screening services. Work with Pubic Health to develop a local media plan. 5. Work with clinic screening coordinators to schedule client appointments and assure they obtain available services such as an exams and mammograms. and to return for their next scheduled exam. 6. provide information and referral about Medicaid programs, services and eligibility requirements. 7. Maintain HI PM-regulated confidentiality of all BCCHP client data and medical records conceming outreach clients. 8. Collect data about outreach activities. Assist Public Health in designing community awareness activities that are appropriate for priority populations that encourage women to seek aut mammography, Pap tests, colon cancer screenings and other health care services. PREV236B - Jefferson County Public Health Page 2 of4 CLINICAL SERVICES The Contractor will: Maintain HIPAA regulated confidentiality of all BCCHP client data and medical records. Comply with CDC and DOH Performance Indicators. . The time from documented abnormal breast finding to complete diagnostic work-up is less than 60 days. . The time from documented diagnosis of breast cancer, breast pre-cancer or colorectal cancer to the start of treatment is less than 60 days. . The time from the date of documented cervical cancer or pre-cancer to the start of treatment is less than 90 days. Make best efforts to submit BCCHP clinical forms (consent, enrollment, exam and reimbursement forms and, if applicable, diagnostic forms) to BCCHP at Public Health within 10 business days (or two weeks) from the date of service. Maintain files of current WA State licensure and/or certification for health care professionals who perform medical procedures under this contract. These files shall be made available to BCCHP staff to view upon site inspection. Attend the annual BCCHP mandatory meeting and a minimum of two other meetings and/or trainings as scheduled by the DOH or Public Health. Assure that administrative and heaith care personnel that work with the BCCHP and BCCHP clients will review the DOH on-line BCCHP training module that corresponds to their work. This training is available at: htto:/Idohmedia.doh.wa.oov/bcchol CLIENT SUPPORT SERVICES Part of Public Health's Medicaid Match Program. The contractor will: 1. For BCCHP clients: Develop patient tracking systems to assure timely and appropriate follow-up of clients with abnormal breast or cervical cancer findings. 2. Assure access to diagnostic follow-up and monitor clients until a diagnosis is reached. 3. Implement a re-screening reminder system for BCCHP clients. 4. Assure and document that appropriate follow-up tests are scheduled and return appointments are made. 5. Assure that test results are reviewed by providers in a timely manner. 6. Provide clients with test results in a timely manner. 7. Document all findings and assure that Public Health has documentation. BILLING PROCEDURES AND PAYMENT BCCHP at Public Health will: . Pay for services provided within the corresponding contract period. . Monitor contracted funds and generate monthly clinical services billing reports for the contractor from complete, timely and accurate BCCHP forms, as submitted by the contractor. The reports will detail client names, dates of service, CPT codes and fees. . Create a monthly invoice from the monthly billing reports and send to the Contractor for review and approval. The original inked-signature from the Contractor's authorized representative as mailed to the BCCHP constitutes approval for payment. . BCCHP will pay the Contractor based on the invoice. PREV2368 - Jefferson County Pub>>c Health Page 30f4 . Reimburse for appropriate and authorized CPT-coded clinical services at the current BCCHP Fee Schedule rates. Any updates or revisions to the Fee Schedules will be sent to the Contractor and take precedence over earlier versions. . Either pay directly on invoice to the Contractor for intemal funds transfer, or via Purchase Order (p.O.) to a subcontracting agency for required date-of-service anesthesia, pathology or laboratory charges for CPT codes on the current Fee Schedule. . Pay for Client Support Services based on the BCCHP rate per woman enrolled and screened per annum. . Be limited to paying only the amount of money in the Contractor's budget (Exhibit B). . Reserve the right to determine the amount of any reduction, based on Contractor performance or fund source grant reduction, and to unilaterally effect any reduction upon written notification. Any reduction shall be based on a review of the Contract's expenditure patterns and actual performance. The Contractor will: . Accept the amount for authorized CPT -coded services on the current BCCHP Fee Schedule and not bill BCCHP clients for any differences between service charges and BCCHP reimbursement . Mail back the signed original invoice to Public health within 10 business days of receipt. . Certify that work to be performed under this contract does not duplicate any work to be charged against any other contract, subcontract, or other funding source. PREV2368 - Jefferson Courrty Pubfic Health Pll\Je4014 exhibit B : Budget Jefferson County Public Health 615 Sheridan Port Townsend, WA 98368 January 1, 2012 thru June 3D, 2012 BUDGET DETAIL 2012 TOTAL FUNDS ALLOCATED ~.. .,;,':;'2__,>..:..~ , ,"-,"",,- ...--= ~. - ~- ~ ~ Breast, Cervical & Colon Health Program BCCHP Outreach & RecruItment $ 3,100.00 ClInical Services $ 4,950.00 ClIent Support Services f Case Management $ 330.00 ~velt~ BCCHP Annual Mee= $ 78.00 ~ "'"' - ~- ., '-~ Total Annual Budget h 8,458.00 The Budget is Based on Averaaed Welahts per CPT Coded Procedures, Specialists, Treatment or Facilities Fees &for Ne otlated Fundln toward Outreach & Recruitment Services as Follows... AntlclDated #s I ;~"'" - ---~ ",.--'''''=--....- -=',= ~--'.~ , WBCHP 33 BCHP Services Averaae a Combined $150foatient 33 Client Suooar! Services Are Set at $10/oatient "X" Outreach & Recruitment Determined bv FTElNEED '-'-=~'-,-<_.._-- - ---';-"~--""-- - -~-, = -. ~- _n_ -~...,'-':'- '_',...,..".~ ""-, ~ -,,- ., PREV2368 - Jefferson County Public Health BiillJ JeffelSon County Public Health 615 Sheridan, PortTownse 00, ";;':'1): ':C:{I,,:."iLB' ': :mu"';':'\'1;:"li':'II,;,J , .' " ,,"", '11'€'1'" ,'". " ,.,.. S " i~~~~I:~..;~j~i~~:~~~ii~ff- '>, ..." IContract #PREV2368 I Please review, sign and MAIL this Invoice WA 95366 within 10 days of receipt: Attention: Scott Feast@Address Above Call wI questions TEL=206-263-6175 Contract Period: 1M12012 to 12/3112012 Exhibit C Year 2012 Contract Status Current Billing Period Jan-June 2012 c.,utacted Una IIems current Contracted Accumulated Available Expenses Budget Expense Balance WBCHP CIlnlcal SeIvi<les $0.00 SS,028.OO $0.00 S5,028.oo WBCHP Client Support Services $0.00 $330.00 $0.00 $330.00 Qutreacl1&- $0.00 $3,100.00 SO.OO $3,100.00 Total $0.00 $8,458.00 $0.00 S8,458.oo I certify the costs UemIzed above were Jm;urred for the period: Jan..June 2012 and thalthe reJrnbunlement amount reflectes.... reasonably as possible, the true value of the costs being claimed. X X Jefferson County Public Health Dale Authorized SJanalure PIelIse Print Name Below Signature For BCCHP Depmtment Use Only aaowTHIS UIlE For BCCHP Department Use Only Pay Contracted Accumulated Available Expense Sunumuy' ORGJPROJ: 8052/358 Current Budget Exponas Balmtce FED-OOHWBCHP 47453 A SO.OO $5,028.00 SO.oo SS,028.oo ST-DOHWBCHP 47454 B $0.00 $3,430.00 $0.00 $3,430.00 Total $0.00 $8,458.00 $0.00 $8,458.00 PIHIC - WIII3' MIDbI' IIatD PREV2368 - Jefferson County Public Health Tuesday, November 29, 2011 Exhibit D Credentials Requirement If your agency assigns licensed health care professionals to provide services under the attached contract, the following becomes material to this contract and non-compliance with this Exhibit will be cause for termination of the contract in accordance with Section li of the contract: . If a licensed health care professional provides health care services at a Public Health - Seattle & King County (PHSKC) clinic or site, each health care professional must initially register within 10 days of beginning to provide health care services by completing a Licensed Independent Practitioner Profile form. This form can be obtained by contacting PHSKC Credentials Office at (206) 263-8360. As additionally required, each practitioner must further complete online the One Health Port enrollment system htto:/lwww.onehealthPOrt.comlaboutlindex.pho (If the practitioner has done so, the data Is retrieved by PHSKC and limited paperwork will be needed.) Many services are billable and agreements between PHSKC and contractors must be complied with. These agreements include practitioner enrollments and are primarily addressed to, but not limited to, independent health care practitioners such as MDs, ARNPs, PAs, Dentists, some mental health care and allied health professionals. . If a licensed health care professionai does not perform services at a PHSKC clinic, but performs health care servicas pursuant to this contract, your agency agrees to Internally require each practitioner to undergo a credentialing process and meet the essential credentialing standards. (No contact needs to be made to the PHSKC Credentials OffIca and no registration is required.) At a minimum, the following for each of seid practitioners must be on file at your agency for annual audits by PHSKC: 1) Evidence of primary source verification of the practitioner's licensure, certification and/or registration. 2) Evidence of review and verification of the professional education degree(s). 3) Evidence of review and verification of professional references. 4) Evidence of review or history of liability claims and adverse actions. 5) Evidence of review of the practitioner's health fitness for work. 6) Evidence of review of any findings from professional review organizations. 7) Evidence of practice reviews by peers. 8) Evidence of protocols and procedures that establish a secure environment to safeguard the confidentiality of each practitioner's professionai credentials. if you have any questions about these requirements, please contact the PHSKC Credentials Office at 401 Fifth Avenue, Suite 1000, Seattle, WA 98104-1818, Phone: 206-263-8360, Fax: 206-205-6236, Email: ioseoh.tridente@kinocountv.oov. Revised November 16,2010 PREV2368 - Jefferson County Public Health Public Health I-ft Seattle & King County ... Exhibit D-l Licensed Indeoendent Practitioner Profile (for the Aaencv contractor) Public Health -Seattle & King County (PHSKC) Revised December 15,2010 To register you with Pub"c Health - Seattle & King Couuty (pHSKC), in agreement with your employer, agency or school, this Exhibit A form must be completed by you. It is for potential billinglenrollmentinto selected PHSKC member health payer plans, quality assurance, insurance verification, audits. Complete this prior to or no later than 10 days after you begin practice at a PHSKC work site. Wtth this info, we can verifY your work at PHSKC to your future employers. This form (& documents you provide below) is in agreement with your agency or school. Data is kept confidential; some is shared with insurers. Fax comvleted to: 206-205-6236 or mail bad< (address lost uaue). For help. call 206-263-8360. Co tete only : ... '.' ...... .... 'j, '.Yon are a License(fInd~pel!~eJitl'~tltillher* (LIPs are "health care providers who, within the scope of their training, llcenslire, aiulexper/<1nce; o/m..lndemndelJtly diagTi(}se. Initfate. alter or terminate health care treatl1telJt....." (-exoetPtfromthe?lfSKC~tia\s Policy) (MD Residents are LIPs.) . '\'110 have no p"rsonal contract bl#eeu yon aud PHSKC . Yon areeinployed by anagtncy(orscbool}wbo1:On1raetswithPHSKC for yourwork . Yon practice at amsKCellnic or work locatlon(but are not an employee ofPHSKC) STOP! Ifymi do not meet allcriteriiJ, you are completing the wrongform. Call the Credentials office at PHKSC at 206-263-8360 or ioseoh.tridenfe@J;lmrcO'tmtv.(lOVfor help or clarification. Thank you. Check off and ENLCOSE COPIES OF THE DOCUMENTS below that von possess: o A copy of your current practitioner Bcense (larger size, not the wallet size). o A Curriculum Vitae showing professional employment, education, and certifications. Today's date: YourNPl # FiTst Middle List other/former names used: All degrees!certs: Your Name: Last (MD. ARNP. PA. MPH. etc.) SSN: Practitioner License # Active License? YES 0 No D Pending License? YES D No D List the Al!encv/SchooIIHosDitallResldencv that emDlovs vou or that vou are affiliated with. This is where vour pavcheck comes from. Thev must have a contract in place with Public Health for the work vou oerform. Agency Name: Your sturt date with this group: Address: Are you a PCP at this site? City: State: Zip: Fax: Agency Office Manager! Phone: Manager Email Tax lD Are you the sole proprietor of this agency? Yes 0 No 0 (Jfyes, stop here. Call 206.263.8360 for next step.) Is the address above your primary practice location? Yes 0 No 0 (if uno," list thallocation): Primary Practice .location: PREV2368 - Jefferson County Public Health Your Home Address OPTIONAL Required: Home phone: Other phone: I 0'cle: <;en pager I VOlceJnBll Yonr Emnil: Fax: With re1!ard to vour assi1!nment at soecificallv at PHSKC: IMPORTANT comolete aU information: Your PHSKC work site(s): Program Name: (peds, OB, etc.) Your Specialty/ies: Foreign Languages conversational in: PHSKC Clinic I Site Supervisor: Precentor or Snnervisor that oversees vour clinical work at PHSKC: Name/titIe: Phone: (Years down the road, this supervisor may get asked to complete clinical evaluation forms on you for your work at this assignment. Preceptors and supervisors are then easy to locate.) ANWER EACH: What are your expected ID!!!. and end dates? Start Date: Estimate: average number orhours per week AreyouaPCPatthisPHSKCworkslte? Yes D Are you on a Fellowship? Yes D No D Are you an Attending MD? Yes D No D Are you an MD Resident? Yes D No D End Date: MTWTh No D Hours: Are you a Preceptor? Yes D Are you a Volunteer? Yes D What year Resident? F (circle which days) NoD NoD Briefly describe your work or project while at PHSKC: Circle resoonse about Patient Panel: What gender patients do you see? Both Male only Will you deliver babies for PHSKC patients? Yes D No D female only Pl.age range: Do you provide Obstetrics services? Yes D No D Past association with PHSKC: Were you ever a contractor, resident or an emDlovee of the PHSKC before this current assignment? Yes D No D If YES, Continue. If NO, go to Enrollments below. Dates of your previous assignment/employment: Site: Employee? Job Title Job Class No. (At this time, are you also currently a PHSKC employee? Yes D No D Contractor? Contract No. Dates: Contract Name: (Example: UW Soh of Moo) Residency School, City/State: PREV2368 - Jefferson County Public Health ENROLL~: Have you alreadv submitted your online Washlnflfon Practitioner Aoo/tcation with the State's One Health Port? htto://www.onehealthoort.com/aboutlindex.php Yes 0 No D You nury be required to do SQ, Checkfirst withPublic Health Credentillls ()jJke,206-263-8360 Joseph.trldente@kingcounty.gov Your personal DBA # (Drug Enforcement Agency #) Expires: flfvour 11(1_ is on the DEA. it is your versonal DEA Do not list your work site DEA, supervisors DEA, other DBA. List your own. EncWrlte N/A if you do not have one.) You need only complete this/arm once for the duration of your assignment at PHSKC. If there are significant changes e.g., work site, contact the Credentials Ojftce at Public Health, 206-263-8360. Your Signature: Your Charting Signature: o Signature required on the Release form, next page (to collect insurance malpractice, other data) o Copy this for your PHSKC Site SupervisorD Copy this for your records o Fax back to: 206-205-6236 or US mail to Credentials Office HSKC, 401 Fifth Avenue, Suite 1000, Seattle, W A 98104 or lnIeroffice Mall: Credentials Office CNK~PH.1000. Phone contact: 206-263-8360 or (1) AUTHORIZATION FOR COLLECTION AND DISCLOSURE OF INFORMATION The undersigned ("AppUcant") hereby authorIzeS PUBUC HEAlTH - SEATTLE & KING COUNTY ("PHSKC") to collect and varlfy Information and documentation (collectively, "information") relevant to rrrt application for appolntmentfre-appolnlment or enrollment/re- enrollment to any entity (healthcare faclJlty, HMO,PPO,lnsuranoe company, medical bureau/society or other entity), where I currently have, am currentiy applying for, or In the future will be applying for membership andlor privllages, pursuant to an agreement between the entity and PHSKC. The Information collected and verified may Include, but not be limited to, the following: all stsle professional llcense(s); faderal and state controlled substance registrations; medlcaJldentel school education; completion of Internships, residencies, fellowships or preceptorshlpa; spsclalty board certlficatlon(s), If applicable; professional liability Insurance coverage including 10 year claims history; evidence of my competence, sklJl, parformance, and health stetus as evaluated by three professional peer references and by any previous or current healthcare affiliations; Information contelned In the National Practitioner Data Bank; certification by the Educational Commission for Foreign Medical Greduatas, If applicable; and written confirmation from any current healthcare afflIlatlons where I have been credentialed pursuent to Washln9ton Slate law. PHSKC Is authorized to maintain and update any of the above information as tt deems appropriate. I further authorize PHSKC to disclose any and all Information obtained from, or related to, my application for membership and/or privilages at the entity or any other antitias with which I currentiy haVe, am currentiy applying for, or In the future win be applying for membership and/or privileges. (2) AIJTHORIZATlON FOR DISCLOSURE OF INFORMATION TO PHSKC BY 3rd PARTlESlRELEASE FROM UABIL/TY I hereby authorize any IndMdual, entity, organization or agency contacted by PHSKC for purposas of collecllng or verifying any Information Identified In Paragraph (1) to disclose such Information to PHSKC. A photocopy of this signed authorization shall constitute vaIld authorization to disclose such Information. I have reviewed this Information as of the most recent date listed below. I furthar agree to release and hold harmless from any liabiltty, demages, loasas, claims or expenses, any Individual, entity, organization or agency that dlsclosas Information to PHSKC In good felth compliance with a request for Information from PHSKC. (3) DECISIONS REGARDING APPOINTMENT AND PRIVILEGES I understand that the Information provided to an entity by PHSKC is Intended for use in the entity's credentiaIlng or enrollment processes. I further understand and agree that the entity Is solely responsible for evaluating such information and making decisions regarding membership and/or privileges, and that PHSKC has no authority or responsibiltty for such decisions. (4) RELEASE FROM UABIL/TY I hereby expressly release and hold harmless PHSKC, Its employees, agents, representatives, successors, and assigns, from any liability, demages, lossas, claims or expenses, resulting from actions or omissions by PHSKC who in good faith collect, verify and disclose information relating to my appiication. I have read and understand the terms of this Authorization and agree to be bound thereby. Date Signature of Applicant (stamp Is not acceptable) Printed Name of Applicant Form Originated by: Credentials 0/ Public Heolth - Seattle & King County. 401 Fifth Avenue Suite 1000. Seal/Ie. W A 98104-2333 Plume: 206-263-8360 Fax 206-205-6236 Attention: Credentialing Menager Revised November 16, 20 I 0 PREV2368 - Jefferson County Public Health EXHIBIT E ~11~lilfi.II!II!~~~~:j:~:=1~IB~::~~l~l!llillli![:jl[1:!!111!jll!I!:I\lii:~~!I[!lj~I[1~:llj;i::1:l!:I!::li!jji!::~:::j!:!:!:[:!:11:1!:!! 'l'lIlUJllllnPli:A'FilISJSSUBDA$ At.lATTllllOPINI'OSMA1'lONONL.V ANDWNl'llIl8NORIOlITS UI'ONnmCli!R"J1FlCATI! HOLIJJlll. 'IIIIS~PCESNI1I'_llXTJlND1lRA1._1'BB to_AGu_svnmPOLlCYIJBL/JW :~r. :::::.. :.':~;::~::::;~::::;~:::~::'~:~:::~:~::::::;3:;::~:;:~~:::::t:~:i:::::w~""::" ....,....~;.....~:t::::::i:::::;:i:::::::::::::;::::::::::;:{:~::::::t:~~ .Mfemu COIlDty. WashIngton WashingtOn Countles Risk Pool Alln: LeslIe Locke 25SS R. W. Johnson Road SW. Suite 106 1'0 Box 1220 Tumwater, WashhIgton 98512-6103 Fort Townsend. WA 98U8 THIlllll TOCIlRTlI'YnlA1tllBLI/IBILlI'Y I'oLICYLISTilDllllLOWllASllI!BNlSSOllOTO 'nlJiPARl'lCllWtINGMEMllER NAMED AIIOYBI'OR 'l1IB1'OLlOY I'IlIllOO~NOI'WIrlIllTANDINO ANYilEQtJlREMBNr. Tl!RMOR CONDn'lOIIOF ANY (XJN'OlACT OR OlIlBRlXlCUMBNTwrm RJlSPIlCfTO_ TlllSClll<Ul'''-'^TS MAY BE IllSUllD OR MAYPBJttAlN. TIlIlcoVEll.AOllS - BY TBBPOLICYIlllSCRlllBl> HlIllBIN IS 8UllJJlCTTO ALL 'l1IB'lllRMS, BXCLlJSION.'lAND(XlNlJlTlON8 OF SlICHPOLICY. POLICYNlJMBERl POLICY\WFIICI1VEDATE: POLICY EXPIRATION DATE: IJMITS OFUABILlTY EACROCCDllltENCE >>1 Mil! PO coJIfBINED: 'tYPES OF INsuRANCE AFfORDED: 201UOI2- October 1. 2011 October I, 2012 $100000011. Includlng: General LIability BudlIy Jnjmy PemnnaI Injwy Proper\y Damago Bl'rors and OmmlssIonsIProfessional Advortislng Il\Iwy ConltacIual Automobile LIabiUty Owned, llOllllWlle4 and l1irod autos Includlng: ::::~""""h"~""':""':""""'" ..::::;::=::::;:;;::;:;:::;::;::::::::::-.......... ":::::::::::::;:;:::::;:::;:::;:;:;:;::::;:;::::;:::;:::;::::;:;:::::;:::;::::::::::::::::::::::::: saouLD'mE.ABOVEDtiSCRlB'SI>POl.1CYlmCANCRJ!D: 8EPQ1lB't1II!tootJRA't1ON DA'lETHEKBOP. nm1S$UBll WD.l. BNO&t\VOR lO:r.wr..30DAYS WRl1"l'ENNOTICBTOTftB cmatfiCA'IEliOLDER,. ml'rFArwRE TO MAl!. SUCH NO'llCB SEIA1LrMPOSB~OllLlABIL1TY OF ANY lOND UFONTHB~ flRDSAGBNTS em REPRESENTATIVES. Al>'...,....Jt to provide bJeasl8Dli terVicsll1eaIIh ...., prOJllllll'S' KIng County Dllrlng the JMlIlCYjlellod 10101/11-10101112 :I:1~::~:~;~:::~:P~~:~~:::::::~::;~:~:~~::~:i::~~:1!::i~:~~:t:[[::~~~::~U:l~~~~~:j:~Jtt~!lmm:~~:~~i::~::::.~wl~)::~~~~:r~1:~}:J~jJi~ij - ~~~ Seattle-KJng County IJept ofP.bIle Health ska Pnbllo HeaIIIl- SeatIIe & KIng County CIalm. tali""