HomeMy WebLinkAboutIL219 Interlocal Agreement INTERLOCAL COOPERATIVE AGREEMENT
BETWEEN SKAGIT COUNTY FIRE DISTRICT 13 AND CITY OF ANACORTES
THIS AGREEMENT is made and entered into by and between Skagit County Fire Protection
District 13 ("District'), a fire protection district organized under Chapter 52 RCW, and City of
Anacortes("City"), a Washington municipal corporation, pursuant to the authority granted by
Chapter 39.34 RCW, INTERLOCAL COOPERATION ACT. District and City may be individually
referred to herein as a "Party", and may be collectively referred to herein as the "Parties." In
consideration of the following, the Parties agree as follows:
AGREEMENT
PURPOSE: The Parties desire to enter into a contract for the provision of pre-billing services for
Basic Life Support(BLS)ambulance services provided by District under its agreement
#C20150436 with Skagit County which is attached hereto and incorporated into this agreement
as Exhibit A.
1. RESPONSIBILITIES OF DISTRICT: During the term of this Agreement, the District will
perform the following tasks:
a. The District will obtain, maintain and operate at all times during this Agreement:
i. An Ambulance License
ii. A Business License
iii. Any necessary bank account(s)
iv. A Medicare billing number and other service provider identifiers required
by payers;
v. All necessary Professional Services Agreements for billing services with
third party Billing Service designated by Skagit County for all EMS
agencies ("Billing Service");
vi. A Subscription Agreement with Skagit County-designated electronic
Patient Care Report ("ePCR") system;
vii. Current HIPAA policies and procedures;
viii. A HIPAA compliance officer;
ix. Any necessary patient signature forms;
x. Any necessary patient refusal forms;
xi. Billing and Collection Policy and Procedures (specifying policies for write
offs, financial assistance, and sending accounts to collections);
xii. A Contract and Business Associate Agreement to safeguard Protected
Health Information (PHI)with District's designated Collection Agency and
any other third parties with access to PHI as required by HIPAA
regulations.
b. Obtain training on required and optimal information required for most effective
billing services.
c. Configure District's ePCR system with field validation rules consistent with those
in place at City and QM Billing Module settings that allow flagging of completed
calls for upload to Billing Service.
d. Provide an account login for City billing staff into District's ePCR system.
e. Provide an account login for City billing staff into on line reporting website of
Billing Service.
INTERLOCAL AGREEMENT
PAGE 1
f. Designate a Point of Contact(POC) including email address for any City
questions or requests regarding documentation of EMS transports for billing.
g. Require District EMS providers to enter, sign, complete documentation for, and
lock every transport record in ESO by end of shift including:
i. patient's Medical Record Number at the destination hospital
ii. patient's city and county of residence
iii. patient signature
iv. EMS provider signature
h. Obtain a hospital face sheet for each patient transported and fax that sheet by
end of shift to City secure fax machine at 360-299-1965 or such other secure fax
as shall be designated by City representative in writing.
i. Upon receiving email from City requesting additional information required to
submit a transport to Billing Service for billing, District Point of Contact will follow
up until transport is complete for billing.
j. Respond to requests for Protected Health Information (PHI) for EMS transports
provided by District.
2. RESPONSIBILITIES OF CITY: During the term of this Agreement, the City will perform
the following tasks:
a. No less often than twice each calendar month, log in to District's County-
designated electronic Patient Care Report("ePCR") system and perform Billing
quality management(QM)for each new locked transport record including:
i. Ensuring that each patient address (residency status), level of service,
patient number, patient signature and crew signature are complete;
ii. Attaching each scanned face sheet;
iii. Flagging completed transports for upload to Billing Service for billing;
iv. Emailing District POC to request any missing information required for
billing;
v. Advising via email District POC of any unlocked potential transports.
b. Verify that all transports are uploaded to Billing Service with the correct Level of
Service (LOS), mileage, and residency status.
c. Notify POC within two business days following the end of each month of any
outstanding information from prior month transports required to submit transports
to Billing Service for billing.
3. BILLING, PAYMENT, AND BILLING INFORMATION:
a. Prior to the 15`h day of each calendar month, the City will submit an invoice to the
District for the number of BLS transports performed during the prior calendar
month and transmitted to Billing Service. The rate for each such transport shall
be $5.00.
b. The District will remit payment to City within 30 days of receipt of any City
invoice. Receipt is deemed to be the sooner of the actual date of receipt or
three business days after mailing.
c. The District will remit payment directly to Billing Service for any monthly invoices
the District receives directly from Billing Service.
d. Upon notification from Billing Service of patient accounts past due and subject to
collection agency action per District's Billing and Collection Policy and
Procedures, the City will forward patient accounts to the District's designated
Collection Agency.
INTERLOCAL AGREEMENT
PAGE 2
e. The District will obtain and process its own month-end reports from Billing
Service and will provide copies of or access to such reports to Skagit County.
f. The District will maintain its own Accounts Receivable based on month end
reports from Billing Service.
4. TERM OF AGREEMENT: The term of this Agreement will commence January 1, 2016
and will continue through December 31, 2016. This agreement shall automatically renew
for an unlimited number of additional one-year renewal terms unless either Party
provides written notice of its intent to terminate the agreement at least 60(sixty) days
prior to the end of the current term. Either party may terminate this Contract by giving 90
days' notice in writing either personally delivered or mailed postage-prepaid by certified
mail, return receipt requested, to the party's last known address for the purposes of
giving notice under this paragraph.
5. ADMINISTRATION: The following individuals are designated as representatives of the
respective parties. The representatives shall be responsible for administration of this
Agreement and for coordinating and monitoring performance under this Agreement. In
the event such representatives are changed, the party making the change shall notify
the other party in writing within five (5)days of the change.
a. District's representative shall be the Fire Chief, or his designee.
P.O. Box 1007
La Conner, WA 98257
360-466-1224 voice
360-466-0526 fax
b. City's representative shall be the Fire Chief, or his designee.
904 6th Street
P.O. Box 547
Anacortes, WA 98221
360-293-1925 voice
260-299-1965 fax
6. TREATMENT OF ASSETS AND PROPERTY: No fixed assets or personal or real
property will be jointly or cooperatively, acquired, held, used, or disposed of pursuant to
this Agreement.
7. DEFENSE AND INDEMNITY AGREEMENT. District agrees to defend, indemnify and hold
harmless the City, its appointed and elected agents,employees and officers,from any and all
loss or expense, including but not limited to judgments, settlements,attorney's fees and costs
by reason of any and all claims and demands upon the City, its elected or appointed officials or
employees for damages because of personal or bodily injury, including death at any time
resulting therefrom,sustained by any person or persons and on account of damage to property
including loss of use thereof,whether such injury to persons or damage to property is due to the
negligence of District, its subcontractors, its elected officers, employees or their agents,except
only such injury or damage as shall have been occasioned by the sole negligence of the City, its
appointed or elected officials or employees. It is further provided that no liability shall attach to
either the City or District by reason of entering into this contract,except as expressly provided
herein. District's insurance shall be primary. Any insurance or self-insurance maintained by the
City, its officers, officials,employees or volunteers shall be excess of District's insurance and
shall not contribute to it.
INTERLOCAL AGREEMENT
PAGE 3
8. TERMINATION FOR PUBLIC CONVENIENCE: Either party may terminate the contract
in whole or in part after written notice of not less than thirty(60) business days whenever
either party determines, in its sole discretion, that such termination is in the best
interests of either City or District, respectively. Whenever the contract is terminated in
accordance with this paragraph, City shall be entitled to payment for actual work
performed at unit contract prices for completed items of work. If either party elects to
terminate for public convenience, termination shall be effective no earlier than thirty(30)
days following the other parry's receipt of notice of termination or as otherwise stated in
the termination notice. Termination of this contract by either party at any time during the
term, whether for default or convenience, shall not constitute a breach of contract by that
party.
9. CHANGES, MODIFICATIONS, AMENDMENTS AND WAIVERS: The Agreement may
be changed, modified, amended or waived only by written agreement executed by the
parties hereto. Waiver or breach of any term or condition of this Agreement shall not be
considered a waiver of any prior or subsequent breach.
10. SEVERABILITY: In the event any term or condition of this Agreement or application
thereof to any person or circumstances is held invalid, such invalidity shall not affect
other terms, conditions or applications of this Agreement which can be given effect
without the invalid term, condition, or application. To this end the terms and conditions of
this Agreement are declared severable.
11. ENTIRE AGREEMENT: This Agreement contains all the terms and conditions agreed
upon by the parties. All items incorporated herein by reference are attached. No other
understandings, oral or otherwise, regarding the subject matter of this Agreement shall
be deemed to exist or to bind any of the parties hereto.
12. NO PARTNERSHIP OR JOINT VENTURE: No partnership and/or joint venture exists
between District and City, and no partnership and/or joint venture is created by and
between District and City by virtue of this Agreement. No agent, employee, contractor,
subcontractor, consultant, volunteer, or other representative of the parties shall be
deemed an agent, employee, contractor, subcontractor, consultant, volunteer, or other
representative of the other party.
13. NO THIRD PARTY BENEFICIARIES: This Agreement is not intended to nor does it
create any third party beneficiary or other rights in any third person or party, including,
but not limited to, property owners and/or residents, or any agent, contractor,
subcontractor, consultant, volunteer, or other representative of either party.
14.ASSIGNMENT AND SUBCONTRACTING: Unless otherwise expressly provided herein,
no portion of this Agreement may be assigned, contracted, and/or subcontracted to any
other individual firm, company, and/or entity without the express and prior written
approval of District.
15. VENUE AND CHOICE OF LAW: In the event that any litigation should arise concerning
the construction or interpretation of any of the terms of this Agreement, the venue of
such action of litigation shall be in the Superior Court of the State of Washington in and
for the County of Skagit. This Agreement shall be governed by the law of the State of
Washington.
16. NEUTRAL AUTHORSHIP: Each of the terms of and provisions of this Agreement have
been reviewed and negotiated, and represents the combined work product of the Parties
hereto. No presumption or other rules of construction which would interpret the
provisions of the Agreement in favor of or against the Party preparing the same shall be
INTERLOCAL AGREEMENT
PAGE 4
applicable in connection with the construction of interpretation of any of the provisions of
this agreement. The Parties represent that they have had a full and fair opportunity to
seek legal advice with respect to the terms of this Agreement and have either done so,
or have voluntarily chosen not to do so. The Parties represent and warrant that they
have fully read this Agreement, that they understand its meaning and effect, and that
they enter into this Agreement with full knowledge of its terms. The Parties have entered
into this Agreement without duress or undue influence.
17. SCHEDULE OF ATTACHMENT EXHIBITS. The following attachments are
acknowledged by the parties and made part of this Agreement.
a. Interlocal Agreement C20150436 between Skagit County and District
b. District EMS Policies to be administered
c. Business Associate Agreement between District and City
DATED this day o€' J4nggQ, , 2015
Skagit County Fire District 13:
/1- -ciL 77_a_,0---
Commissioner
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mmissri 'ner
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Commissioner /
INTERLOCAL AGREEMENT
PAGE 5
DATED this 1 day of Pa - , 2015.
City of Anacortes:
ef/
(-Laurie Gere, Mayor
ATTEST:
Steve Hoglund, ity Clerk/Treasurer
ATTEST:
L1At__\ ---
DarcISWetn n, Assistant City Attorney
INTERLOCAL AGREEMENT
PAGE 6
Business Associate Agreement
Between the City of Anacortes and Skagit County Fire District 13
This Business Associate Agreement("Agreement") between the City of Anacortes(City)and Skagit
County Fire District 13 (District) is executed to ensure that City will appropriately safeguard protected health
information ("PHI")that is created, received, maintained, or transmitted on behalf of District in compliance
with the applicable provisions of Public Law 104-191 of August 21, 1996, known as the Health Insurance
Portability and Accountability Act of 1996,Subtitle F—Administrative Simplification,Sections 261,et seq., as
amended ("HIPAA"), and with the Public Law 111-5 of February 17, 2009, known as the American Recovery and
Reinvestment Act of 2009,Title XII, Subtitle D—Privacy,Sections 13400, et seq., the Health Information
Technology and Clinical Health Act, as amended (the "HITECH Act").
A. General Provisions
1. Meaning of Terms.The terms used in this Agreement shall have the same meaning as those terms
defined in HIPAA.
2. Regulatory References.Any reference in this Agreement to a regulatory section means the section
currently in effect or as amended.
3. Interpretation.Any ambiguity in this Agreement shall be interpreted to permit compliance with
HIPAA.
B. Obligations of Business Associate
City agrees that it will:
1. Not use or further disclose PHI other than as permitted or required by this Agreement or as
required by law;
2. Use appropriate safeguards and comply,where applicable, with the HIPAA Security Rule with
respect to electronic protected health information ("e-PHI") and implement appropriate physical,
technical and administrative safeguards to prevent use or disclosure of PHI other than as provided
for by this Agreement;
3. Report to the District any use or disclosure of PHI not provided for by this Agreement of which it
becomes aware, including any security incident(as defined in the HIPAA Security Rule) and any
breaches of unsecured PHI as required by 45 CFR§164.410. Breaches of unsecured PHI shall be
reported to the District without unreasonable delay but in no case later than 60 days after
discovery of the breach;
4. In accordance with 45 CFR 164.502(e)(1)(ii)and 164.308(b)(2),ensure that any subcontractors that
create, receive, maintain, or transmit PHI on behalf of City agree to the same restrictions,
conditions,and requirements that apply to City with respect to such information;
5. Make PHI in a designated record set available to the District and to an individual who has a right of
access in a manner that satisfies the District's obligations to provide access to PHI in accordance
with 45 CFR§164.524 within 30 days of a request;
6. Make any amendment(s)to PHI in a designated record set as directed by the District,or take other
measures necessary to satisfy the District's obligations under 45 CFR§164.526;
7. Maintain and make available information required to provide an accounting of disclosures to the
District or an individual who has a right to an accounting within 60 days and as necessary to satisfy
the District's obligations under 45 CFR§164.528.
8. To the extent that City is to carry out any of the District's obligations under the HIPAA Privacy Rule,
City shall comply with the requirements of the Privacy Rule that apply to the District when it
carries out that obligation;
9. Make its internal practices, books, and records relating to the use and disclosure of PHI received
from,or created or received by City on behalf of the District,available to the Secretary of the
Department of Health and Human Services for purposes of determining City and the District's
compliance with HIPAA and the HITECH Act;
10. Restrict the use or disclosure of PHI if the District notifies City of any restriction on the use or
disclosure of PHI that the District has agreed to or is required to abide by under 45 CFR§164.522;
and
11. If the District is subject to the Red Flags Rule (found at 16 CFR§681.1 et seq.),City agrees to assist
the District in complying with its Red Flags Rule obligations by: (a) implementing policies and
procedures to detect relevant Red Flags(as defined under 16 CFR§681.2); (b)taking all steps
necessary to comply with the policies and procedures of the District's Identity Theft Prevention
Program; (c) ensuring that any agent or third party who performs services on its behalf in
connection with covered accounts of the District agrees to implement reasonable policies and
procedures designed to detect, prevent, and mitigate the risk of identity theft;and (d) alerting the
District of any Red Flag incident(as defined by the Red Flag Rules)of which it becomes aware,the
steps it has taken to mitigate any potential harm that may have occurred,and provide a report to
the District of any threat of identity theft as a result of the incident.
12. Comply with all current rules and regulations pertaining to the OIG Compliance Program for
ambulance suppliers and special bulletin regarding LEIE recommended screening of employees and
any subcontractors.
C. Permitted Uses and Disclosures by Business Associate
The specific uses and disclosures of PHI that may be made by City on behalf of the District include:
1. The preparation of invoices to patients,carriers, insurers and others responsible for payment or
reimbursement of the services provided by the District to its patients;
2. Preparation of reminder notices and documents pertaining to collections of overdue accounts;
3. The submission of supporting documentation to carriers, insurers and other payers to substantiate
the healthcare services provided by the District to its patients or to appeal denials of payment for
the same; and
4. Other uses or disclosures of PHI as permitted by HIPAA necessary to perform the services that City
has been engaged to perform on behalf of the District.
D. Termination
1. The District may terminate this Agreement if the District determines that City has violated a
material term of this Agreement.
2. If either party knows of a pattern of activity or practice of the other party that constitutes a
material breach or violation of the other party's obligations under this Agreement,that party shall
take reasonable steps to cure the breach or end the violation, as applicable, and, if such steps are
unsuccessful, terminate the Agreement if feasible.
3. Upon termination of this Agreement for any reason, City shall return to the District or destroy all
PHI received from the District, or created, maintained, or received by City on behalf of the District
that City still maintains in any form. City shall retain no copies of the PHI. If return or destruction is
infeasible,the protections of this Agreement will extend to such PHI.
Agreed to this day of , 2015.
Skagit County Fire
District 13 City of Anacortes
Signature: Signat e•
Title: aberiryier4 , . Title: na/A---'
Date: / �67/VI-3/110 Date: /Z/zZ/5
Skagit County
Fire Protection District #13
"Professionally Staffed by Volunteers"
cbtrwti
P.O Box 1007
17433 Snee Cosh Road
La Conner,Washington 98257
May 31, 2016
Marcia Hunt
Accountant, Assistant to the City Clerk
City of Anacortes
904 6th Street
P.O. Box 547
Anacortes, WA 98221
Re: SDW PSA
Dear Marcia,
Please find enclosed an executed copy of the Professional Services Agreement
between Fire District 13 and Systems Design West per your request.
If there is anything further, you need from us, please advise
Yours in Safety and Service,
Lt. ary G. Ladd
Community Relations Officer
Skagit County Fire District 13
Cc: Roy Horn, Chief Fire District 13
PROFESSIONAL SERVICES AGREEMENT
This Professional Services Agreement ("AGREEMENT") is made and entered into this 20th day of January,
2016 by and between, Skagit County Fire District 13 ("Fire District") 17433 Snee-Oosh Rd, La Conner, WA
98257-9338 and Systems Design West,LLC a Washington limited liability company having their principal place
of business located at 19265 Powder Hill Place NE Poulsbo, Washington 98370 hereinafter referred to as the
("Consultant") Collectively the Fire District and the Consultant shall be known as the "PARTIES".
RECITALS:
(a) WHEREAS,the Fire District and the Consultant desire to enter into a "Professional Services
Agreement",
(b) NOW, THEREFORE, in consideration for the mutual obligations contained herein the Fire
District and the Consultant, each intending to be legally bound by this agreement, hereby mutually covenant
and agree as follows:
1. SCOPE OF SERVICES.The Consultant shall provide to the Fire District specific services related to the billing
and payment processing of EMS patient transport services that are provided to the general public by the Fire
District.The following Scope of Services shall be incorporated into this contract as general services performed
by the Fire District and the Consultant under this agreement.
1.1 The Fire District, with assistance from Consultant, shall apply for Provider Status or updated Status
with Medicare, Medicaid, and all public and private insurances which will be billed as a part of this Scope of
Services. The Fire District shall assist the Consultant to obtain the necessary certifications, numbers and
documentation needed for Consultant to provide the services identified in sections 1.2 and 1.3 below. The
Fire District agrees to furnish and assist the Consultant with the following:
(a) The Fire District agrees to provide a complete and legible "PCR" (Patient Care Report) to the
Consultant including patient name, address and pertinent billing and insurance information from the field,
including a copy of the patient signature for authorization of benefits and responsibility for payment,
authorizing billing of Medicare, Medicaid and any insurance the patient is a subscriber to.The original patient
signature must be maintained by the Fire District and made available to the Consultant and/or insurance
payers upon request. The amounts to be billed will be determined by the Fire District in the form of a
resolution or ordinance to be incorporated into this agreement as an attachment exhibit.
(b) The Fire District agrees to furnish the Consultant with hospital ER forms (face/admit sheets) with
demographic and insurance information attached to the PCR if requested by Consultant. Copies of any
payments made directly to the Fire District will be forwarded to the Consultant for accounting purposes in a
timely manner. The Fire District agrees to generate any refund checks due to overpayments identified by the
Consultant directly to the payer to which the refund is due, based on detailed information provided by the
Consultant. The Fire District shall provide additional information as may be required by insurance companies
or other agencies in order to facilitate the Consultant's obligations to the Fire District.
(c) The Fire District agrees to furnish to the Consultant to be made part of this agreement as an
attachment: resolutions pertaining to this Scope of Services; specific write off policies; collections
procedures; rates and fees to be charged by the Fire District and administered by Consultant as part of the
Scope of Services performed under this agreement.
1.2 Upon receipt of the PCRs and Batch Log from the Fire District,the Consultant shall:set up a patient
account in Consultant's proprietary software application and create a patient record; perform all billing
operations including follow up statements and any necessary rebilling of EMS patient transport services
provided by the Fire District to the subscriber's medical insurances, Medicare, Medicaid and any and all
known secondary insurance providers; produce and forward CMS 1500 forms and/or electronic medical
claims per payer's rules and regulations within the legal boundaries of all federal and state laws;produce and
mail an initial invoice and subsequent statements to all private patient accounts on behalf of the Fire District;
file any applicable appeals to insurance payers and/or Medicare and Medicaid on behalf of the patient if
necessary to pursue the claim.
1.3 The Consultant shall: receive at its facilities all payments (except those directly deposited into the
Fire District's account by insurances and Medicare/Medicaid via EFT) Explanations of Benefits and Electronic
Remittance Advices;account for all payments; deposit all funds directly into the Fire District's"deposit only"
account;forward deposit information to the Fire District within 24 hours of such deposit; initiate and forward
refund information and adjustments made on behalf of the patient's account to the Fire District. The
Consultant shall provide to the Fire District a minimum of four(4) standard reports each month including: a)
Aged Accounts Receivable b) Month End Summary c) Annual Collection Statistics d) Transaction Journal.
These reports will include information related to amounts billed, amounts collected and uncollected,
insurance and Medicare/Medicaid allowable and disallowable.
1.4 The Consultant shall provide live customer service to Fire District's patients via toll free phone
numbers to answer patient billing questions Monday through Friday from 8:00am through 6:00 pm, Pacific
Standard Time (except Federal holidays).
1.5 The Consultant shall provide all labor, materials and equipment necessary to perform the work
specified in the above scope of services.
2. FEES, EXPENSES, & PAYMENT. For and in consideration of the services provided by the Consultant
identified above, the Fire District shall pay to the Consultant an amount not to exceed $35.00 per transport
for total volume of 1-10 transports per month OR$30.00 per transport for total volume of 11-20 transports
per month, OR $25.00 per transport for total transport volume greater than 21 transports per month. In
addition,the Fire District will pay actual postage for patient invoices and statements per the Scope of Services
performed under this agreement. The Fire District shall remit payment for services rendered under this
agreement to the Consultant within 30 days from receipt of Consultant's monthly invoice to the Fire District.
3. PAYMENT OF TAXES. The Consultant shall be liable for any and all federal, state, and local sales,excise
taxes and assessments as a result of the payment for services rendered under this agreement.
4. TERM OF AGREEMENT. The Consultant shall commence the work called for in this agreement on the date
of the agreement and perform such work uninterrupted and automatically renew upon the anniversary date
unless the agreement is terminated by either party.This agreement may be amended upon the anniversary
date by the parties upon mutual agreement of terms and conditions with the acknowledgement of an
amendment to the Professional Services Agreement to be signed by both parties of the agreement.
5. SCHEDULE OF ATTACHMENT EXHIBITS. The following attachments are acknowledged by the parties and
made part of this Agreement.
# 1: Rates to be charged per transport [to be provided by the Fire District]
#2: EMS Policies to be administered [to be provided by the Fire District]
#3: State of Washington Records Storage Policy
#4: Systems Design Liability Insurance policies
#5: Business Associate Agreement
6. INDEPENDENT CONSULTANT STATUS. The Consultant performs this Agreement as an independent
Consultant, not as an employee of Fire District. Nothing herein contained shall be deemed or construed by
the parties hereto, nor by any third party, as creating the relationship of principal and agent or of partnership
or of joint venture between the parties hereto, it being understood and agreed that neither method of
computation of payment nor any other provision contained herein nor any acts of the parties hereto, shall
be deemed to create any relationship between the parties hereto other than the relationship of Fire District
and an independent Consultant.
7. TERMINATION. Either party may terminate this agreement with a minimum of 30 days notice to the other
party. The Consultant shall upon termination by either party provide 60 days of follow up service to the
outstanding patient accounts including posting payments, making deposits, and two (2) months of follow up
reports to the Fire District. Consultant shall deliver and document the return of all documentation in
Consultants possession per the attached "Records Storage Agreement". In the event this agreement is
terminated by either party and the terms for payment for services include a percent of collections method,
Fire District shall pay to Consultant the agreed upon percentage of collected revenues until all accounts
created by Consultant are settled.
8. INSURANCE. The Consultant shall maintain statutory minimum Worker's Compensation or Labor and
Industry insurance as required by the laws of any state or country in which Services are performed. The
Consultant will provide and make as part of this agreement as an attachment, a certificate of liability
insurance with a minimum amount of commercial general liability of $ 1,000,000 per occurrence and an
aggregate of$ 2,000,000 and maintain such insurance for the duration of this agreement. The Consultant
shall provide an annual updated Certificate of Insurance to the Fire District upon the policy expiration date.
The Consultant shall provide notice to the Fire District in the event the policy is cancelled or terminated for
any reason prior to the policy expiration date.
9. END USER SOFTWARE LICENSE&CONFIDENTIAL INFORMATION. The term "CONFIDENTIAL INFORMATION
AND SOFTWARE" shall mean: (i) any and all Information and proprietary software which is disclosed or
provided by either party ("OWNER OF THE INFORMATION") to the other ("RECIPIENT') verbally,
electronically,visually,or in a written or other tangible form which is either identified or should be reasonably
understood to be confidential or proprietary;and(ii)Confidential Information may include, but not be limited
to, trade secrets, computer programs, software, documentation, formulas, data, inventions, techniques,
marketing plans, strategies, forecasts, client lists, employee information, and financial information,
confidential information concerning Fire District and Consultant's business or organization, as the parties
have conducted it or as they may conduct it in the future. In addition, Confidential Information may include
information concerning any of past, current, or possible future products or methods, including information
about research, development, engineering, purchasing, manufacturing, accounting, marketing, selling,
leasing, and/or software (including third party software).
9.1 TREATMENT OF CONFIDENTIAL INFORMATION. Fire District's Confidential Information shall be treated
as strictly confidential by Recipient and shall not be disclosed by Recipient to any third party except to those
third parties operating under non-disclosure provisions no less restrictive than in this Section and who have
a justified business "need to know". Fire District shall protect the deliverables resulting from Services with
the same degree of care.This agreement imposes no obligation upon the Parties with respect to Confidential
Information which either party can establish by legally sufficient evidence: (a) was in the possession of, or
was rightfully known by the Recipient without an obligation to maintain its confidentiality prior to receipt
from Fire District; (b) is or becomes generally known to the public without violation of this Agreement; (c) is
obtained by Recipient in good faith from a third party having the right to disclose it without an obligation of
confidentiality; (d) is independently developed by Recipient without the participation of individuals who have
had access to the Confidential Information;or(e)is required to be disclosed by court order or applicable law,
provided notice is promptly given to the Fire District and provided further that diligent efforts are undertaken
to limit disclosure.
9.2 CONFIDENTIALITY AND DISCLOSURE OF PATIENT INFORMATION. Use and Disclosure of Protected Health
Information. The parties hereto agree that in order for the Consultant to perform its duties as expected by
the Fire District, it will be necessary for the Consultant to use and disclose Protected Health Information
("PHI"),as such term is defined at 45 CFR §164.501.The parties of this agreement further acknowledge and
make part of this agreement as an attachment to this agreement a "Business Associate Agreement" to be
maintained and updated whenever applicable by either party of this agreement.
9.3 PERMITTED AND REQUIRED USES AND DISCLOSURE OF PHI.The Parties hereto agree that the Consultant
may use and disclose PHI in order to carry out any Payment function covered under the definition of
"Payment" contained in 45 CFR §164.501. The Parties hereto further agree that the Consultant may use or
disclose PHI for any use or disclosure that is required by law.
10. INDEMNITY. Each Party ("INDEMNIFYING PARTY") shall indemnify and hold the other Party
("INDEMNIFIED PARTY") harmless against any third party claim, including costs and reasonable attorney's
fees, in which the Indemnified Party is named as a result of the negligent or intentional acts or failure to act
by the Indemnifying Party, its employees or agents,while performing its obligations hereunder,which result
in death, personal injury, or tangible property damage. This indemnification obligation is contingent upon
the Indemnified Party providing the Indemnifying Party with prompt written notice of such claim,
information, all reasonable assistance in the defense of such action, and sole authority to defend or settle
such claim.
11. SURVIVABILITY. The terms of Section 8 and 9 shall survive termination of this Agreement. If the Parties
have executed a separate agreement that contains confidentiality terms prior to or contemporaneously with
this Agreement, those separate confidentiality terms shall remain in full force to the extent they do not
conflict. The "Business Associate Agreement" has terms incorporated to establish the continuance of
covenants for the parties to disclose PHI for the continued operations of"Payment".
12. WARRANTIES AND REPRESENTATIONS. Each party warrants that it has the right and power to enter into
this Agreement and an authorized representative has executed this Agreement.Consultant warrants that the
Services will be performed in a professional and workmanlike manner in accordance with recognized industry
standards. To the extent Services provided by Consultant are advisory; no specific result is assured or
guaranteed. Consultant EXPRESSLY DISCLAIMS ALL OTHER REPRESENTATIONS OR WARRANTIES, WHETHER
EXPRESSED OR IMPLIED.
13. NOTICE. Any notice, demand, request, consent, approval, or other communication that either party
desires or is required to give to the other party related to any of the content of this agreement shall be
presented in writing and served personally or sent by prepaid,first class mail to the addresses set forth below.
Either party may change its address by notifying the other party of its change of address in writing.
Fire District: Skagit County Fire District 13
17433 Snee-Oosh Rd
La Conner,WA 98257-9338
Consultant: Systems Design West, LLC
19265 Powder Hill PI NE
Poulsbo, WA 98370
14. NONWAIVER. No modification to this Agreement nor any failure or delay in enforcing any term,
exercising any option, or requiring performance shall be binding or construed as a waiver unless agreed to in
writing by both parties. No delay or omission of the right to exercise any power by either party shall impair
any such right or power, or be construed as a waiver of any default or as acquiescence therein. One or more
waivers of any covenant, term or condition of this Agreement by either party shall not be construed by the
other party as a waiver of a subsequent breach of the same covenant, term or condition.
15. APPLICABLE LAW. The laws of the State of Washington shall govern the construction, validity,
performance and enforcement of this Agreement. Venue as to any action, claim, or proceeding arising out
of, or based upon this Agreement, including, but not limited to,any action for declaratory or injunctive relief,
shall be the appropriate court in the State of Washington.
16. CONFLICT OF INTEREST. The Consultant covenants, warrants and represents that the Consultant or any
employees of Consultant has no interest and shall not acquire any interest, direct or indirect, which would
conflict in any manner with the subject matter or the performance of this Agreement.The Consultant further
covenants, warrants and represents that in the performance of this Agreement, no person having any such
interest shall be employed by the Consultant in the future.
17. ENTIRE AGREEMENT. This Agreement and any schedules,appendices,attachments and exhibits attached
hereto sets forth all of the covenants, promises, agreements, conditions and understandings between the
parties hereto, and there are no covenants, promises, agreements, conditions or understandings, either oral
or written, between them other than as herein set forth. Except as herein otherwise expressly provided, no
contemporaneous or subsequent agreement, understanding, alteration, amendment, change or addition to
this Agreement, or any schedule, appendix, exhibit or attachment thereto shall be binding upon the parties
of this Agreement hereto unless reduced to writing and signed by both parties. This Agreement constitutes
a final, complete and exclusive statement of the agreement between the parties.
The Parties hereby agree to all of the above terms,conditions, covenants and have executed this Agreement
by a duly authorized representative.
0 2c,Ib
Dated this 4/fro day of A ' ` ( ,�015
Skagit Cou y Fir District 13
By: v
Print: Ni - CI SS
Title: <S"1 , CI)
Dated this 20th day of January, 2015
Systems Design West, LLC
"Consultant"
By:
Print:Jennifer Braus
Title: CEO
Skagit County
Fire District 13
"Professionally Staffed by Volunteers"
` 6. GPA,
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•.
P.O.Box 1007
17433 Snee-Oosh Road
LaConner,Washington 98257
Ph:(360)-466-1224 Fax:(360)-466-0526
e-mail:ravhorn@cnw.com
Systems Design West July 23, 2015
Attention: Shelly L. Brewington
P.O. Box 3510
Silverdale, Washington 98383-3510
Skagit County Fire District 13
Policy and Procedures for Emergency Medical Services
Patient Accounts: Billing Rates
Effective July 23, 2015
CMS Of Service Level Resident Rate Non-Resident Rate
A0428 BLS—Non-Emergency Transport $425 $638
A0429 BLS—Emergency Transport $590 $885
A0425 Mileage $15.00 $18.00
Resident Rate applies to all residents of Skagit County.
Sincerely,
Charles Hedlund Arne Fohn Larry Kibbee Roy Horn
Commissioner Commissioner Commissioner Fire Chief
Skagit County Fire District 13
Policy and Procedures for Emergency Medical Services
Patient Accounts: Billing and Collection
Effective Date: July 27, 2015
I, Purpose
To establish procedures regarding the billing and collection of fees from patients transported by
Skagit County Fire District 13 ambulances. The intent of this policy is to ensure accountability
and control over revenue for which the Skagit County Fire District 13 has stewardship
responsibility.
II. Coordinated Billing Policy
A. Purpose: The citizens of and visitors to Skagit County and their insurance providers expect to
be charged a common rate for ambulance service in Skagit County regardless of the location
for a request for service.
B. Policy: Skagit County EMS will establish an annual meeting to meet with the EMS agencies
billing for services to discuss the various factors affecting the billing system.
a. Each EMS agency billing for services agrees to utilize a common billing rate. i.
The providers agree to review the current average billing rates for each
level of service and adjust their rates to match for the next annual period.
b. Each EMS agency billing for services agrees to utilize a common bad debt
write-off and private pay policy.
c. Each EMS agency billing for services agrees to consistently apply all applicable
HCPCS procedure and modifier codes.
d. Following the establishment of the common billing rate each year, the Skagit
County Fire District 13 will advise the Billing Company of the rate for each
level of service and will post such rates on the City website.
III. Payment for Services Rendered
a. Policy: It is the policy of Skagit County Fire District 13 to pursue payment for
ambulance transport services according to the fee schedule established by the mayor pursuant
to AMC 13.54.114. The patient is ultimately responsible for the total balance due. Billing and
collection practices will be in compliance with State and Federal laws, including Medicare,
Medicaid and HIPAA guidelines.
b. Procedure: Skagit County Fire District 13 contracts with a third party Billing
Company to invoice patients and their insurance companies for payment of ambulance
transport services according to these policies and procedures and the District's contract with
the Billing Company.
Skagit County Fire District 13 EMS Policy &Procedures—7/27/15 1
i. Skagit County Fire District 13 will advise the Billing Company of any
electronic funds debits and checks dishonored by banks upon which said
checks and electronic payments are drawn. In such cases the Billing Company
shall reverse the payment and shall add a$25.00 fee to the responsible party's
account in accordance with City of Anacortes Ordinance 2832.
IV. Private Payment
a. Policy: All private pay balances are due and payable in full at the time the balance is
billed to the patient. If payment in full is not made within 120 days of the billing date, an
approved payment plan must be in place or the account will be sent to collections. The patient
is ultimately responsible for the total balance due.
b. Procedure:
A. If payment in full cannot be made upon receipt of billing, the responsible party must
contact the Billing Company to arrange for extended payments. Balances must be paid
in full within ten (10)months from date of billing.
B. If the responsible party indicates a hardship to pay within ten (10) months from date of
billing and requests payments be extended further, the following is required:
a. Completed financial assistance application to include a proposed monthly
payment amount.
b. Federal income tax returns for the prior two years.
c. Proof of current income or lack thereof(paycheck stub or unemployment check
stub).
d. The hospital charity determination letter if assistance was granted.
Responsible parties claiming hardship who wish to request extended payment terms
beyond ten (10) months from initial billing, must request a financial assistance
application from the Billing Company within 60 days from the date of the initial
billing. The Billing Company will provide the application to the responsible party
within one (1) week from the date of request. The completed financial assistance
application and supporting documentation must be received by the Billing Company
within two(2)weeks of mailing to the responsible party.
C. If the financial assistance application and supporting documentation are received by the
Billing Company within the required time, the Billing Company will forward that
information to Skagit County Fire District 13 within one (1) week of receiving it from
the responsible party. Skagit County Fire District 13 will review the application in
conjunction with Federal HITS poverty guidelines in place as of the date of service,
determine if additional extension of time is warranted, and if so, establish a monthly
payment plan. Skagit County Fire District 13 will notify the Billing Company of the
result of the application review within one (1) week of receiving the application. The
Billing Company will then communicate the result to the responsible party within one
(1) week. The responsible party must agree by signature to the terms of the payment
plan and must make each scheduled payment on time or the account will be considered
past due and will be sent to collections.
Skagit County Fire District 14 EMS Policy&Procedures—7/27/15 2
D. No financial hardship extension will be granted after an account has been assigned to a
collection agency, and the account will be subject to collection fees in accordance with
RCW 19.16.500.
V. Credit Adjustments
a. Policy: Skagit County Fire District 13 shall approve all credit adjustments and
establish guidelines of accountability for third party billing companies.
b. Procedure: There are several reasons to place a credit adjustment on a patient's
account. Each requires a different level of approval. Outlined below are the adjustments
categories and the level of approval required prior to adjustment.
B. CON I RACTUAL ADJUSTMENTS: These are adjustments made after a payment by a
federal or state agency which requires, by law, that the remaining balance be adjusted.
This does not include contractual obligation adjustments for the full balance of a claim.
Those claims require additional follow up and appeals as they are being denied for other
reasons related to how the claim was submitted.
APPROVAL: Contractual adjustments after payments from Governmental payers
(Medicare, Medicaid, VA, L&I, Tricare and Crime Victims) are made to reflect the
allowed amount approved by contract and must be adjusted. The Billing Company shall
be approved to make these adjustments in the presence of the Explanation of Benefits
(BOB).
C. BAD DEBT WRI1'E-OFF: Accounts are credited upon transfer of unpaid balance to an
outside agency according to Section III below.
APPROVAL: Adjustments must be approved by Skagit County Fire District 13
administrative staff in accordance with the guidelines in the Bad Debt Write-Off Policy
below,
D. BANKRUPTCY WRITE-OFF: Accounts are credited for a patient (or his/her guarantor)
who has filed for bankruptcy and been granted a discharge by the Bankruptcy Court.
APPROVAL: These accounts will be placed on hold without further billing upon notice
of bankruptcy filing form B9 from the bankruptcy court. Once the debtor is entitled to a
discharge the account balance will be credited with the approval of Skagit County Fire
District 13 administrative staff and only with the bankruptcy court discharge notice form
B18.
E. SMALL BALANCE WRI FE-OFF: Accounts are credited if after billing and one or more
payments being received the patient balance falls below twenty-five dollars ($25.00) and
remains unchanged for 90 days.
Skagit County Fire District 13 EMS Policy &Procedures—7/27/15 3
APPROVAL: Adjustments may be made by the Billing Company without prior approval
by Skagit County Fire District 13, upon implementation of the credit adjustment policy.
F. MISC ADJUSTMENTS: Credit Adjustment to a patient account for any reason, not
outlined above.
APPROVAL: Any adjustment over the amount of twenty-five dollars ($25.00) requires
approval by Skagit County Fire District 13. Any adjustment over the amount of
fifty dollars ($50.00)requires approval by Skagit County Fire District 13 Board of Fire
Commissioners.
VI. Small Credit Balance Adjustments
a. Policy: It is the policy of Skagit County Fire District 13 to approve all non-
contractual adjustments and establish guidelines of accountability for third party billing
companies.
b. Procedure: In the event, after all payments and contractual adjustments have been
received and applied to a patient's account, there remains a credit balance of less than$1.00,the
third party billing company shall be authorized to debit the account to a zero balance. Any
credit balance above $1.00 will be refunded to the appropriate payer.
VII. Bad Debt Write-Off
a. Policy: Private pay balances that are one hundred and twenty(120)days from date of
private billing which are not paid in full, and do not have an approved payment plan, will be
referred to an outside vendor for collection. All write offs will be approved by Skagit County
Fire District 13.
b. Procedure: Accounts that meet the bad debt criteria will be transferred to an outside
vendor for collection on a monthly basis.
A. The Billing Company will compile a list of accounts that meet the timelines established
in this policy.
B. Skagit County Fire District 13 staff will edit and approve bad debt selection files.
C. Skagit County Fire District 13 staff will transfer approved bad debt selection files to an
outside collection agency.
D. Skagit County Fire District 13 staff will return unapproved bad debt accounts to the
Billing Company for continued collection efforts.
E. The Billing Company will write off bad debt account balances on approved accounts.
Skagit County Fire District 13 EMS Policy& Procedures—7/27/15 4
Records Storage Policy
Per the following Washington RCW (Revised Code of Washington) 40.14.010 definition of public
records applies to payment information obtained by Systems Design "Contractor" under the Scope of
Services of the Professional Services Agreement of which the parties have hereby entered into per:
RCW 40.14.010
Definition and classification of public records.
As used in this chapter, the term "public records"shall include any paper, correspondence, completed
form, bound record book, photograph,film, sound recording, map drawing, machine-readable
material, compact disc meeting current industry ISO specifications, or other document, regardless of
physical form or characteristics, and including such copies thereof, that have been made by or
received by any agency of the state of Washington in connection with the transaction of public
business, and legislative records as described in RCW 40.14.100.
For the purposes of this chapter, public records shall be classified as follows:
(1) Official public records shall include all original vouchers, receipts, and other documents
necessary to isolate and prove the validity of every transaction relating to the receipt, use, and
disposition of all public property and public income from all sources whatsoever;all agreements and
contracts to which the state of Washington or any agency thereof may be a party; all fidelity, surety,
and performance bonds;all claims filed against the state of Washington or any agency thereof;all
records or documents required by law to be filed with or kept by any agency of the state of
Washington; all legislative records as defined in RCW 40.14.100; and all other documents or records
determined by the records committee, created in RCW 40.14.050, to be official public records.
Per RCW 40.14.060 these documents will be stored per the referenced code:
RCW 40.14.060
Destruction, disposition of official public records or office files and memoranda —Record retention
schedules.
(1)Any destruction of official public records shall be pursuant to a schedule approved under RCW
40.14.050. Official public records shall not be destroyed unless:
(a) Except as provided under RCW 40.14.070(2)(b), the records are six or more years old;
(b) The department of origin of the records has made a satisfactory showing to the state records
committee that the retention of the records for a minimum of six years is both unnecessary and
uneconomical, particularly if lesser federal retention periods for records generated by the state under
federal programs have been established;or
(c) The originals of official public records less than six years old have been copied or reproduced by
any photographic or other process approved by the state archivist which accurately reproduces or
forms a durable medium for so reproducing the original.
(2)Any lesser term of retention than six years must have the additional approval of the director of
financial management, the state auditor and the attorney general, except when records have federal
retention guidelines the state records committee may adjust the retention period accordingly. An
automatic reduction of retention periods from seven to six years for official public records on record
retention schedules existing on June 10, 1982, shall not be made, but the same shall be reviewed
individually by the state records committee for approval or disapproval of the change to a retention
period of six years.
Recommendations for the destruction or disposition of office files and memoranda shall be submitted
to the records committee upon approved forms prepared by the records officer of the agency
concerned and the archivist. The committee shall determine the period of time that any office files or
memorandum shall be preserved and may authorize the division of archives and records management
to arrange for its destruction or disposition.
Systems Design West, LLC "Contractor" a Party of the Professional Services Agreement of which this
attachment is made part of agrees to administer and adhere to RCW 40.14.060 regarding all
qualifying "Provider" documents including but not limited to payer records, EOBs, EFT information,
ERA information related to all payment transactions.
Original patient signatures received will be scanned and stored electronically and/or the original
document will be stored by the Contractor for the entire duration of the Professional Services
Agreement entered into by the parties, including any future term extensions. Upon termination of
the Professional Services Agreement by either party, the Patient Signature documents will be turned
over to the Provider and signed for by an authorized agent of the Provider.
All other documents related to the requirements of the scope of work of the referenced Professional
Services Agreement related to Patient Information that are not required to be retained by any
federal, state or local laws will be stored for use either electronically or as paper documents by the
contractor for a minimum of 3 years from the date of receipt and then returned to the owner party of
this agreement or destroyed upon written direction of the owner.
'Ac CERTIFICATE OF LIABILITY INSURANCE DATE
(MM` )
1 01/03/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must he endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
PHONE 1 FAX
Willis of NY,Inc. . ALc No.extI: ,......- tA/C Not•
200 liberty Street ADDRESS:
New York,NY 10281 INSURERS)AFFORDING COVERAGE NAIL#
INSURER A: Continental Insurance Co.
INSURED INSURER B: Continental Casualty
SYSTEMS DESIGN WEST LLC INSURER C:
19265 POWDER HILL PL NE INSURERD:
POULSBO,WA 98370 INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
'INSR ADDL SUBR POLICY EFF POLICY EXP S LIMIT
LTR TYPE OF INSURANCE INSD WVD_ POLICY NUMBER (MMIDDIYYYY)./MMIOD1YYYY)
•
✓ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
B € 6023971937 01/11/2016 01/11/2017 ECHOCCU DAMAGE-TO-RENTED
CLAIMS-MADE ✓ OCCUR PREMISES(Ea occurrences $ 1,000,000
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
✓ POLICY[ I j 0. LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY (COMBINED c e SINGLE LIMIT E$ 1,400.400
' A - 6023971968 01/11/2016 01/11/2017 BODILY INJURY(Per person) i`S
_ ANY AUTO
ALL OWNED SCHEDULED
— AUTOS AUTOS I BODILY INJURY(Per accident) $
✓ HIRED AUTOS ✓ NON-OWNED PROPERTY DAMAGE
AUTOS Per accident)
$
UMBRELLA LIAB ✓ OCCUR EACH OCCURRENCE S 1,000,000
• EXCESS LAB CLAIMS-MADE 6023971954 01/11/2016 01/11/2017 AGGREGATE $ 1.000,400
DED I RETENTIONS I S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y!N STATUTE I ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N 1 A
(Mandatory in NH) I I E.L.DISEASE-EA EMPLOYEE$
yes,If TON under D -
CJESCSC RIF'IPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $
B Property-Special 6023971937 01/11/2016 01/11/2017 Limits: SITOk BPP
5500k BI
DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WELL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ekte4 9aitelicen
)1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
A 'Professional Collection Ae i
/601 William Way Suite D
Mount Vernon, WA 98273
Ph,360.4 8.8159 Fax: 350.41 .04 7
debtrs@debtrs.com
DEBT RECOVERY SPECIALISTS CONTRACT
This agreement is made this 13th day of August 2015 between; Skagit County Fire District 13,
hereinafter referred to as"Client", and Debt Recovery Specialists, 1601 William Way Suite D, Mount
Vernon, Washington 98273, hereinafter referred to as"Agency".
Whereas,Agency is engaged in the business of soliciting and collecting the payment of claims
from individual persons, businesses and corporations;
Whereas, Client desires, during the term of this agreement, to submit to Agency accounts
that are valid and legally enforceable debts and
Whereas, Agency is qualified to perform such services, and is willing to undertake and perform
such work under the terms and conditions and for the commission hereinafter mentioned.
Wiitnesseth:
That for and in consideration of the mutual covenants hereinafter set forth, it is mutually agreed by and
between the parties as follows:
1. The Agency shall perform all work and furnish all equipment, labor and materials necessary
to collect unpaid accounts referred to them by Client.
2. Agency will exert active and professional collection efforts on those claims held by Agency
for collection. Agency agrees to comply with all applicable federal, state and local laws.
3. Client may from time to time refer various accounts, claims, contracts, checks, drafts and
money orders, here after referred to as instruments or accounts for collection. Such referrals
shall be accomplished by manual, physical or electronic transmission (FTP), internet transfer or
such other means as suitable to meet the needs of Client and Agency. Said transmissions need
not be accompanied by a separate formal document of Assignment, Such referrals shall in any
event operate as an assignment to Agency.
4. Client does hereby assign to Agency any account listed with Agency's office with all rights
or claims relating thereto, including, but not limited to interest, and all costs authorized under
Washington RCW's, authority to demand, sue for in its own name, settle, compromise, reassign,
and warrants that the claim is due and owing.
5. This agreement will be for a term of one year, and the Client agrees to use Agency as its
primary source of outside collection services; provided, however, that this agreement may be
canceled by either party upon 30 days written notice, and provided further that this agreement
shall be automatically renewed from year to year unless canceled, in writing by either party.
6. Upon assignment of an account, by the Client to the Agency, the Agency will add on 33.33%
of the balance due, as allowed by RCW 19.16.500 for non-Medicare accounts. Client will
receive 100% recovery fee on the balance listed. A separate account will be created for
Medicare accounts and the Agency will be entitled to a commission fee equal to 30% of any
monies collected on the assigned account. Client will receive 70% recovery fee. If the
Agency initiates legal action, the Agency will advance any legal fees necessary unless
negotiated differently on an individual account basis, to obtain judgment and will be entitled
to recover those costs from monies collected from the responsible party (ies) before any
funds are applied to the principal balance owing.
7. This agreement gives appropriate authority for Agency to receive payment in cash, check, or
other negotiable instruments and to take possession of collateral, including real and personal
property where applicable, on behalf of Client; and additionally constitutes further authority and
power of attorney to execute, authorize or endorse on behalf of Client.
8. Payments will be remitted to Client by the 15th of the following month with a Statement
Totals Report showing consumer name, account number, payment amount, payment date and
balance owing. The Client agrees to promptly report to Agency all payments received directly
by the Client on any accounts assigned to the Agency.
9. The Client may withdraw, at its sole election, any accounts in the process of collection,
provided that accounts are withdrawn under the terms of this paragraph:
a. have not had payments, payment plans or collection activity within 90 days and/or,
b. Client has no knowledge the account would be paid to them within the next 90 days.
c. Client agrees that if an account is cancelled and Agency has expended any legal fees on
said account, the Client shalt reimburse Agency for any and all legal fees expended by
Agency on said account.
10. Client and Agency agree to indemnify and hold each other harmless from any error
` or omissions of, or arising out of this agreement or its subject matter. The aforesaid duty of
indemnification shall include duty to defend and pay all costs of defense of any and all such
claims.
11. Agency shall obtain and keep in force continually during the term of the agreement
general liability insurance coverage and client blanket bond.
12. Any information provided by Client on the debtor will be used solely for skip tracing and/or
collecting consumer's account. This information will be held by agency in the strictest of
confidence with the exception that in the event of legal action the documentation provided by
the Client may be presented to the court as evidence. Agency retains the right to submit
consumer information for the purpose of credit reporting, and check verification unless
otherwise directed by the Client.
13. Agency is and shall at all times be an independent contractor in the performance of this
Agreement.
14. This agreement should be construed and enforced in accordance with the laws of the
State of Washington. Jurisdiction for any legal action for enforcing the provisions of this
Agreement shall be Skagit County, Washington.
In Witness Whereof, this agreement is signed by the parties this 4 day of 2015.
Debt Recovery Specialists Skagit County Fire District 13
by: — b . 1'"Iy"
Denise L. Decker, Owner Authorize Signature