HomeMy WebLinkAboutPSA Ellensburg Family MedicineThis Agreement is made by and between Kittitas County (hereinafter "the County")
and Ellensburg Family Medicine (hereinafter "Contractof'). The County and Contracior
agree as follows:
General Conditions; Exhibit A (Scope of Work); Exhibit B (Compensation);
Exhibit C (Proof of lnsurance).
copies of which are attached hereto and incorporated herein by this reference as fully as if
set forth herein.
The term of this Agreement shall commence on the date this agreement is signed.
Any party may terminate this Agreement by giving thirty (30) days' noiice in writing eitner
personally delivered or mailed postage-prepaid by certified mail, return receipt requested,
to the party's last known address for the purposes of giving noiice under this paragiaph.
Contractor acknowledges and by signing this Agreement agrees that the
lndemnification provisions set forth in Paragraphs 7 (lndependent Contraitor), g (Taxes),
15 (Defense and lndemnity Agreement), 21 (Patent/Copyright lnfringement) and 24
(Confidentiality), are totally and fully part of this Agreement and havl been mutually
negotiated by the parties.
Professional Services Agreemenl (Form rev. $9n4ftAfi)
Page 1 ot21
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WTNESS WHEREOF, the parties have executed this Agreement this
2021.
Ellensburg Family Medicine COUNTY OF
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Print Name of
COUNTY OF KITTITAS
SHERIFF'S OFFICE
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Clay Mydrs, SherF
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the Julie Kjorsvik
r:tU Clerk of the Board- Mandy
APPROVEDAS TO FORM
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Contractor Address:
Ellensburg Family Medicine
2156 Payne Rd.
Ellensburg, WA 98926
Contractor Contact:
Zach Deffinbaugh
Professional Services Agreement (Form rev. 0912412018)
Page 2 of 21
Douglas R. Mithhell,
Deputy Prosecutin g Attorney
County's Address:
Kittitas County
205 West Sih Avenue, Suite 108
Ellensburg, WA 98962
ProJect Contact:
Steve Panattoni, Superintendent
509-962-7527
GENERAL CONDITIONS
1. Scooe of Contractor's Services:
Contractor agrees to provide to the County services and any materials setforth in the project
narrative identified in Exhibit''A" during theAgreement period. No material, labor, orfacilities
will be furnished by the County, unless otherwise provided for in the Agreement.
2. Performance of Work:
Contractor shall perform work in accordance with, and shall comply with, all of the provisions
of this Agreement. All work shall comply with applicable codes and ordinances.
3. Schedule,of Performance:
Unless directed othenruise by the County, Contractor shall perform the work in accordance
with any schedules made a part of this Agreement.
4. Definitions:4.1 "Additional lnsureds" means the County, its successors and assigns, and
the respective directors, officers, employees, agents and representatives of
the County and its successors and assigns.4.2 "$upport" means the following: Contractor"s directors, officers, employees,
agents and representatives; and sub-Contractors of any tier; the respective
directors, officer$, employees, agents and representatives of these sub-
Coniractors of any tier; and any other person or entity acting under the
direction or control ol or on behalf ol Contractor or any Contractor's sub-
Contractors of any tier in connection with or incident to the performance of the
Work orthis Agreement.4.3 The "Work" means all of the duties listed in Exhibit A and the performance of
all other obligations, Llnder this Agreement by Contractor or its Support.
5. Accountinq and Payment for Contractor Services:
Payment to the Contracior for services rendered under this Agreement shall be as set forth
in Exhibit "8". Where Exhibit "8" requires payments by the County, payment shall be based
upon billings, supported unless othenrrrise provided in Exhibit "8", by documentation of units
of work actually performed and amounts eamed, including where appropriate, the actual
number of days worked each month, total number of hours for the month, and the total dollar
payment requested. Unless specifically stated in Exhibit "8" or approved in writing in
advance by the Kittitas County Board of Commissioners, the Coung will not reimburse the
Contractor for any costs or expenses incurred by the Contractor in performance of this
Agreement.
\y'y'here required, the County shall, upon receipt of appropriate documentation, compensate
the Contractor, no more often than monthly, through the County voucher system, for the
Contractor's service pursuant to the fee schedule set forth in Exhibit "B".
Professional Services Agreement (Form rev. 0912412018)
Page 3 of 21
6. Assiqnment and Subcontractinq:
No portion of this Agreement may be assigned or subcontracted to any other individual, firm
or entity without the express and prior written approval of the County.
7. lndependent Contractor:
The Contractor's services shall be furnished by the Contractor as an independent Contractor
and nothing herein contained shall be construed to create a relationship of employer-
employee or master-servant, but all payments made hereunder and all services performed
shall be made and performed pursuant to this Agreement by the Contractor" a$ an
independent Contractor.
The Contractor acknowledges that the entire compensation for this Agreement is speclfied
in Exhibit "8" and the Contractor is not entitled to any County benefits including, but not
limited to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance
benefits, or any other rights or privileges afforded to Kittitas County employees.
Contractor will defend, indemnify and hold harmless the County, its Additional lnsureds,
officers, agents or employees from any loss or expense, including but not limited to
settlements, judgments, setoffs, attorneys' fees or costs incurred by reason of claims or
demands because of breach of the provisions of this paragraph.
8. No Guarantee of Emplovment:
The performance of all or part of this Agreement by the Contractor shall not operate to vest
any employment rights whatsoever and shall not be deemed to guarantee any employment
of the Contractor or any employee of the Contractor or any sub-Contractor or any employee
of any sub-Contractor by the County at the present time or in the future.
9. Taxes:
The Contractor understands and acknowledges that the County will not withhold Federal or
State income taxes. Where required by State or Federal law, the Contractor authorizes the
County to make withholding for any taxes other than income taxes (i.e. Medicare). All
compensation received by the Contractor will be reported to the lnternal Revenue Service
at the end of the calendar year in acmrdance with the applicable IRS regulations. lt is the
responsibility of the Contractor to make the necessary estimated tax payments throughout
the year, if any, and the Contractor is solely liable for any tax obligation arising from the
Contractor's performance of this Agreement. The Contractor hereby agrees to indemnify
the County against any demand to pay taxes arising from the Contractor's failure to pay
taxes on compensation earned pursuant to this Agreement.
The County will pay sales and use taxes imposed on goods or services acquired hereunder
as required by law. The Contractor must pay all other taxes including, but not limited to:
Business and Occupation Tax, taxes based on the Contractor's gross or net income, or
Professional Services Agreement (Form rev. 09124nA18\
Page 4 of 21
personal property to which the County does not hold title. The County is exempt from
Federal Excise Tax.
10. Requlalipns and Requiremenl:
This Agreement shall be subject to all laws, rules and regulations of the United States of
America, and State of Washington, and political subdivisions of the State of Washington,
and to any other provisions set forth herein or in the attached exhibits.
'11. Riqht to Review:
This contract is subjectto review by any FederalorState auditor. The County or its designee
shall have the righi to review and moniior the financial and service components of this
program by whatever means are deemed expedient by the County. Such review may occur
with or without notice, and may include, but is not limited to, on-site inspection by County
agents or employees, inspection of all records or other materials which the Coung deems
pertinent to the Agreement and its performance, and any and all communications with or
evaluation by service recipients under this Agreement. The Contractor shall preserve and
maintain all financial records and records relating to the performance of work under this
Agreement for 6 years after contract termination, and shall make them avaitable for such
review, within Kittitas County, State of Washington, upon request.
12. Modifications:
12.1 Either party may request changes in the Agreement. Any and all agreed
modifications shall be in writing, signed by each of the parties.
12.2 The County may, at any time, by written notice thereof to Contractor ("Change
Notice") makes changes in the work within the general scope of this
Agreement, including, but not limited to: (a) changes in, revisions to,
substitutions for, additions to or deletions of any Work; (b) changes in
schedule; and (c) acceleration, deceleration or suspension of performance of
any Work.
12.3 lf any change in the Work causes an increase or decrease on Contractor's
cost ol or the time required for, performance of the Work, an equitable
adjustment in the compensation to Contractor and in the schedule for the
performance of the Work shall be made to reflect such an increase or
decrease.
12.4 Notwithstanding any dispute or delay in arriving at a mutually acceptable
equitable adjustment, Contractor shall proceed in accordance with all Change
Notices. Contractor must, within thirty (30) days after receipt of any Change
Notice that does not set forth any acceptable adjustmeni, submit to the county
a written statement setting forth any adjustment claimed.
Professional Services Agreement (Form rev. Agl24n}18)
Page 5 of 21
12.5 lf any change results in a decrease in the Work performed, Contractor shall
be eniitled to compensation associated with changing the Work, such as
revising design already completed, revising calculations already performed,
and revising documents.
1 3. Termin?tjon.fo[ Defa.ult:
lf the Contractor defaults by failing to perform any of the obligations of the Agreement or
becomes insolvent or is declared bankrupt or commits any act of bankruptcy or insolvency
or makes an assignment for ihe benefit of creditors, the County may, by depositing written
notice to the Contractor in the U.S. mail, postage prepaid, terminate the Agreement, and at
the County's option, obtain performance of the work elsewhere. lf the Agreement is
terminated for default, the Contractor shall not be entitled to receive any further payments
under the Agreement until all work called for has been fully performed. Any extra cost or
damage to the County resulting from such default(s) shall be deducted from any money due
or coming due to lhe Contractor. The Contractor shall bear any extra expenses incurred by
the County in completing the work, and all damage sustained, or which may be sustained
by the County by reason of such default.
lf a notice of termination for default has been issued and it is later determined for any reason
that the Contractor was not in default, the rights and obligations of the parties shall be the
same as if the notice of termination had been issued pursuant to the Termination for Public
Convenience paragraph hereof.
1 4. Terminat!-oJl fgr Public Convenience.
The County may terminate the Agreement in whole or in part whenever the County
determines, in its sole discretion that such termination is in the best interests of the County.
Whenever the Agreement is terminated in accordance with this paragraph, the Contractor
shall be entitled to payment for actualwork performed at unit contract prices for completed
items of work. ln the event of such termination, an equitable adjustment shall be made in
the compensation payable to Contractor.
An equitable adjustment in the contract price for partially completed items of work will be
made, but such adjustment shall not include provision for loss of anticipated profit on deleted
or uncompleted work. Termination of this Agreement by the County at any time during the
term, whether for default or convenience, shall not constitute a breach of contract by the
County.
15. Defense & lndemnity Aof,gement:
The Contractor agrees to and shall defend, indemniff and hold harmless the County, its
Additional lnsureds, appointed and elective officers, agents and employees, from and
against 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 County, its Additional
lnsureds, its elected or appointed officials, agents, or employees for damages because of
personal or bodily injury, including death at any time resulting therefrom, sustained by any
Professional Services Agreement (Form rev. 09124nA18,
Page 6 of 21
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 the
Contractor, its sub-Contractors, its elected officers, employees or their agents, except only
such injury ordamage as shall have been occasioned by the sole negligence of the County,
its Additional lnsureds, appointed or elected officials, agents, or employees. lt is further
provided that no liability shall attach to the County by reason of entering into this contract,
except a$ expressly provlded herein.
16, lndustrial lnsurance Waiver:
Wth respect to the performance of this Agreement and as to claims against the County, its
Additional lnsureds, officers, agents and employees, the Contractor expressly waives its
immunity under Title 51 of the Revised Code of Washington, the lndustrial lnsurance Act,
for injuries to its employees and agrees that the obligations to indemnify, defend and hold
harmless provided in this agreement extend to any claim brought by or on behalf of any
employee of the Contractor. This waiver is mutually negotiated by the parties to this
Agreement.
17. Venue and Choice of Law:
ln 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 Kittitas. This Agreement
shall be governed by the law of the State of Washington.
18. Wthholding Pavment:
ln the event the Contractor has failed to perform any obligation to be performed by the
Contractor under this Agreement within the time set forth in this Agreement, then the County
may, upon written notice, withhold all monies due and payable to Contracior, without
penalty, until such failure to perform is cured or otherwise adjudicated.
19. Future Non-Allocation of Funds.
lf sufficient funds are not appropriated or allocated for payment under this Agreement for
any future fiscal period, the County will not be obligated to make payments for services or
amounts incurred after the end of the current fiscal period. No penalg or expense shall
accrue to the County in the event this provision applies.
20. Contractor Commitments, Warranties and Representations:
The Contractor represents and warrants to the County as follows:2Ai The Contractor is duly incorporated, validly existing and in good standing
under the laws of the State of Washington and has all requisite corporate
power and authority to enter into and to perform its obligations under this
Agreement.
24.2 The Contractor has the authority to execute this Agreement, to make the
representations and warranties set forth in it and to perform the
Professional Services Agreement (Form rev. 09n4nT8)
PageT ol21
24.3
20.4
20.5
20.6
obligations of the Contractor under this Agreement in accordance with its
terms.
This Agreement has been validly executed by an authorized
representative of the Contractor and constitutes a valid and legally
binding and enforceable obligation of Contractor.
The Contractor has or will obtain prior to the commencement date such
licenses, permits and other authorizations from federal, state and other
governmental authorities, as are necessary for the performance of its
obligations under this Agreement.
The Contractor is not in violation of any applicable law, ordinance or
regulation the consequence of which willor may materially affect
Contractor's abillty to perform lts obligations under this Agreement. The
Contractor is not subject to any order or judgment of any court, tribunal or
governmental agency which materially and adversely affects its
operations or assets in the State of Washington, or its ability to perform
its obligations under this Agreement.
None of the representations or warranties in this Agreement, and none of
the documents, statements, certificates or schedules furnished or to be
furnished by Contractor pursuant hereto or in connection with the
performance of the obligations contemplated under this Agreement,
contains or will contain any untrue statement of a material fact or omits or
will omit to state a material fact necessary to make the statements of fact
contained therein not misleading.
21 . PatentlCopvriqht lnfrinoene-nt:
Contractor will defend and indemnify the County from any claimed action, cause or demand
brought against the County; to the extent such action is based on the claim that information
supplied by the Contractor infringes any patent or copyright. The Contractor will pay those
costs and damages attributable to any such claims that are finally awarded against the
County in any action. Such defense and payments are conditioned upon the following:
21 .1 Contractor shall be notified promptly in writing by County of any notice of such
claim-
21.2 Contracior shall have the right, hereunder, at its option and expense, to obtain
for the County the right to continue using the information, in the event such
claim of infringement is made, provided no reduction in performance or loss
results to the County.
22. Disputes:22j General
Differences between the Contractor and the County, arising under and by
virtue of the Agreement Documents shall be brought to the attention of the
Coun$ at the earliest possible time in order that such matiers may be settled
or other appropriate action promptly taken. Except for such objections as are
made of record in the manner hereinafter specified and within the time limits
Professional Services Agreement (Form rev. Q5124t2018|
Page I of21
stated, the records, orders, instructions, and decisions of the Kittitas County
Commissioners shall be flnaland conclusive.
22.2 Notice of PotentialClaims
The Contractor shall not be entitled to additional compensation which
othenrise may be payable, or to extension of time for (1) any act or failure to
act by the County, or (2) the happening of any event or occurrence, unless
the Contractor has given the County a written Notice of PotentialClaim within
ten (10) days of the commencement of the act, failure, or event giving rise to
the claim, and before final payment by the County. The written Notice of
Potential Claim shall set forth the reasons for which the Contractor believes
additional compensation or extension of time is due, the nature of the cost
involved, and insofaras possible, the amount of the potentialclaim. Contractor
shall keep full and complete daily records of the work performed, labor and
material used, and allcosts and additionaltime claimed to be additional.
22.3. Detailed Claim
The Contractor shall not be entitled to claim any such additional
compensation, or extension of time, unless within thirly (30) days of the
completion of the portion of the work from which the claim arose, and before
final payment by the County, the Contractor has given the County a detailed
written statement of each element of cost or other compensation requested
and of all elements of additional time required, and copies of any supporting
documents evidencing the amount or extension of time claimed to be due.
23. Ownership of ltems Produced:
All writings, programs, data, public records or other materials prepared by the Contractor
andlor its consultants or sub-Contractors, in connection with performance of this Agreement
shall be the sole and absolute property of the County.
24. Confidentialitu:
The Contractor, its employees, sub-Contractors, and their employees shall maintain the
confidentiality of all information provided by the County or acquired by the Contractor in
performance of this Agreement, except upon the prior written consent of the Kittitas County
Prosecuting Attorney or an order entered by a eourt after having acquired jurisdiction over
the County. Contractor shall immediately give to the County notice of any judicial
proceedings seeking disclosure of such information. Contractor shall indemnify and hold
harmless the County, its Additional lnsureds, officials, agents or employees from all loss or
expense, including, but not limited to settlements, judgments, setoffs, attorneys' fees and
costs resulting from Contractor's breach of this provision.
To the extent that any information obtained by the Contractor is required to be shared with
or provided to others by the terms of the Statement of the Work, this provision is not
breached by such acts.
Professional Services Agreement (Form rev. A912412018)
Page 9 of21
25. Notice:
Excepi as set forth elsewhere in the Agreement, for all purposes under this Agreement,
except service of process, notice shall be given by the Contractor to the department head
of the department for whom services are rendered, and to the Kittitas County
Commissioners, 205 WSrh Ave, Suite 108, Ellensburg, WA 98926, Notice to the Contractor
for all purposes under this Agreement shall be given to the address reflected on the
signature page. Notice may be given by delivery or by depositing in the U.S. Mail, first class,
postage prepaid.
26. Severabilitv:
lf any term or condition of this Agreement or the application thereof to any person(s) or
circumstances is held invalid, such invalidity shall not affect other terms, conditions or
applications 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.
27, Miscellaneous:
27 "1 The County's failure or delay to insist upon strict performance of any of the
provisions of this Agreement or to exercise any rights or remedies under this
Agreement shall not be construed as a waiver or relinquishment to any extent
of its right to assert or rely upon any such provisions, rights or remedies in that
or any other instance; rather the same shall be and remain in full force and
effect.
27.2 This Agreement embodies the entire Agreement between the County and
Contractor, and supersedes any and all prior agreements, regarding the
Work. No change, amendment or modification of any provisions of this
Agreement shall be valid unless set forth in a written instrument signed by the
party to be bound thereby.
27.3 The rights and remedies of the County set forth in any provision of this
Agreement are in addition to and do not in any way limit any other rights of
remedies afforded to the County by any other provisions of this Agreement,
by any of Contracto/s Support or by law.
27.4 The headings of sections and paragraphs of this Agreement are for
convenience of reference only and are not intended to restrict, affect or be
of any weight in the interpretation or construction of the provisions of such
sections or paragraphs.
27.5 This Agreement will be automatically renewed yearly for a period of one
additional year unless either party gives 120 calendar days advanced
notice of its indication not to renew. The rate of compensation shall
increase by the same amount as the Consumer Price lndex (CPI) or five
(5) percent annually, which is ever is less. The rate of compensation shall
not be decreased by any decrease in the CPl.
Professional Services Agreement (Form rev. Ogn4n}18)
?age 1A of21
28. Waiver:
Waiver of any breach or condition of this Agreement shall not be deemed a waiver of any
prior or subsequent breach. No terms or conditions of ihis Agreement shall be held to be
waived, modifled or deleted except by an instrument, in writing, signed by the parties hereto.
29. Survival:
The provisions of paragraphs 7 , 9, 11 , 13, 14,1 5, 16, 17 , 18, 19, 20, 21, ZZ, ZS, 24,28, 90,
31, and 32 shall suruive, notwithstanding the termination or invalidity of this Agreement for
any reason.
30. Nondiscrimination:
30.1 The County is an equal opportunity employer
30.2 Nondiscriminati in Emolovment
ln the performance of this Agreement, the Contractor will not
discriminate against any employee or applicant for employment on the
grounds of race, creed, color, national origin, sex, sexual orientation,
maritalstatus, age or the presence of any sensory, mental or
physical handicap; provided that the prohibition against discrimination
in employment because of handicap shall not apply if ihe particular
disability prevents the proper performance of the particular worker
involved. The Contractor shall ensure that applicants are employed, and
that employees are treated during employment without discrimination
because of their race, creed, color, national origin, sex, sexual orientation,
marital status, age or the presence of any sensory, mental or physical
handicap. Such action shall include, but not be limited to employment,
upgrading, demotion or transfers, recruitment or recruitment advertlsing,
layoff or termination, rates of pay or other forms of compensation, and
programs for training including apprenticeships. The Contractor shall take
such action with respect to this Agreement as may be required to ensure
full compliance with local, state and federal laws prohibiting discrimination
in employment.
30.3 Nondiscrimination in Services
The contractor will not discriminate against any recipient of any services
or benefits provided for in this Agreement on the grounds of race,
creed, color, nationalorigin, sexl sexualorientation, maritalstatus, age or
the presence of any sensory, mental or physical handicap.
30.4 If any assignment and/or subcontracting has been authorized by the
County, said assignment or subcontract shall include appropriate
safeguards against discrimination. The Contractor shall take such action
Professional Services Agreement (Form rev. 0912412018)
Page 11 of21
as may be required to ensure full compliance with the provisions in the
immediately preceding paragraphs herein.
31. Prevailinq Waqe.:
Contractor shall pay the prevailing rate of wages to all workers, laborers, or mechanics
employed in the performance of any part of the Work in accordance with RCW 39.12
and the rules and regulations of the Department of Labor and lndustries. The schedule
of prevailing wages rates for the locality or localities of the Work is determined by the
lndustrial Statistician of the Department of Labor and lndustries. lt is the Contractor's
responsibility to verify the applicable prevailing wage rate. lt is understood that the
Contractor is responsible for obtaining and completing all required government forms
and submitting same to the proper authorities.
Disputes regarding prevailing wage raies shall be referred for arbitration to the Director
of the Department of Labor and lndustries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for by RCW
39.12.060.
32. Debarment Certifi cAtionl
The Contractor certifies that it:32J ls not presently debarred, suspended, proposed for debarment, declared
ineligible or voluntarily excluded from covered transactions by any Federal
depailment or agency.
32.2 Has not within a three-year period preceding the execution of this contract
with Kittitas County, been convicted of or had a civiljudgment rendered
against them for commission of fraud or a criminal offense in connection
with obtaining, attempting to obtain, or performing a public or private
agreement or transaction, violation of Federal or State antitrust statutes or
commission of embezzlement, thefi, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, receiving
stolen property, making false claims, or obstruction of justice.
32.3 ls not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State, or local) with commission of any of
the offenses enumerated in paragraph 32.2 of this section.
32.4 Has not within a three-year period preceding the preceding the execution
of this contract with Kittitas County had one or more public transactions
(Federal, State, or local) terminated for cause of default.
P rofess ional Services Agreement (Form rev. 09124 I 2O1 8)
Page 12 of 21
EXHIBIT ''A'
SCOPE OF WORK
ln addition to providing all material and labor, the Contractor shall perform the following:
Provide on-site medicalcare to the inmate population within the Kittitas County Jail (KCJ)
that appropriately approximates the care offered to citizens in the local community up to
five (5) days per week, not to exceed twenty (20) hours.
Provide fully qualified professional healthcare staff to deliver healthcare services under
this contract.
Provide on-call service from a Qualified Healthcare Professional (OHCP) - i.e. the
Physician's Assistant / Nurse Practitioner to the facility on a24 hours per day, seven days
per week, 365 days per year basis.
Set up meetings between the Contractor and the Kittitas County Jail to discuss all inmates
with ongoing serious healthcare issues. Cases of significance will be given special
attention in the transition to avoid interruptions in appropriate care.
Develop a written, individualized treatment plan for inmates requiring close medical care or
supervision (e.9. those inmates with chronic or convalescent care, suicidal tendencies or
a history of seizures, etc.) The treatment plan will include directions to healthcare and other
personnel in care and supervision of the patient, as well as any required pharmacological
support.
Perform an inventory, with the KCJ siaff, of all existing equipment and supplies
immed iately upon takeover of contract responsibil ities.
Review current and prior medical problems; screen for mental illnesa, denial issue$,
sexually transmitted disease, tuberculosis, drug and alcohol use and many other
conditions found in the general public as well as those more prevalent in correctional
healthcare.
Strictly adhere to Nursing and Care protocols appropriate to correctionalfacilities and
inmate populations.
Obtain, at Contractor's own expense, all licenses andlor certifications necessary to render
medical and health services within the Kittitas County Jail. Contractor will ensure that all its
employees rendering services possess all licenses and/or certifications necessary to
render medical services within the jail.
Professional Services Agreement (Form rev. 09f2412A18)
Page 13 of21
lntake screening daily and official medical intake on appropriate inmates after 72 hours,
perform TB testing and urine drug tox screening (KCJ to provide urine cups) in
accordance with intake protocol. Hep A or other laboratory testing can be facilitated as
needed.
Review initial medical and mental health screenings conducted in the Booking/lntake
area by health trained KCJ staff, including Mental Health Questionnaire (including
suicidalassessment) and the Health History Screening. Appropriate action willbe taken
to verify prescription medications, consult with the inmate's private healthcare provider
and address immediate problems of newly admitted inmates to the KCJ. Contractor
staff will be available on a 24ft on call basis for review of screenings in the event that
an inmate presents with a medical problem, to determine if the inmate should be
accepted into KCJ or referred to another appropriate healthcare service provider.
The initialscreening will include, but is not limited to:
r Medical history of current and prior illness and health problems including
mental health, dental, communicable and chronic diseases;. Drug/alcohol use; including types, methods, amounts, frequency, date/time of
last use, and history of problems related to stoppage;. Current medications;. Body deformities including scars, marks and tattoos, and assessment of the
ability to perform activities of daily living and status of ambulation;. Condition of skin including trauma markings, bruises, lesions, jaundice, rashes,
infestations, discharge, needle marks or other indications of drug abuse;r Behavior, including state of consciousness, m e n t a I status, appearance,
conduct, tremors, and sweating,. Hastory of suicidal ideation, tendency or attempts;
Based on the information gathered, Contractor will make recommendations that may
include, but are not limited to:
r Referral to an emergency healthcare facility;. Placement in the general inmate population and referral to the normally scheduled
healthcare services at the jail facitity;. Placement in isolation,. Placement in observation area (awaiting psychiatric evaluation);
Professional Services Agreement (Form rev. 0912412018li
?age 14 ol21
Perform a PPD on each inmate when medically appropriate, unless medically
contraindicated. The TB test will be read by an appropriately trained QHCP and
recorded in the inmate's medical record. Any inmate with positive skin-test reactions
or with a history of positive reactions or who is symptomatic will be given a chest x-
ray within 96-hours of skin test reading or identification of history or ofsymptoms.
Perform TB testing for each stafl member working in the Kittitas County Jail once a
year.
Complete health appraisal physical examinations of all newly arriving inmates within
14 calendar days of arrival at KCJ. Health appraisal physical examinations will include
but are not limited to:
r Review of the screening/intake forms by medical and mental health staff;. Recording of vital signs, height, weight, etc.,. Complete medical history and physical examination;e Mental Health screening;. Dental screening;. Vision and Hearing screening;r Blood sampling for screening and urine sampling as needed;r lnitiation of therapeutic measures when appropriate;r Other tests and examinations as indicated;. Proper signatures, co-signatures, dates and times.
Health appraisal physical examinations of female inmates will include the following
additional assessments:
lnquiry about menstrualcycle and menstrual bleeding including abnormalities,
current use of contraceptives, presence of an lUD, breast masses and nipple
discharge, and possible pregnancy"
o
Any abnormal results of the health appraisal examination will be reviewed by the
physician for appropriate disposition.
Perform an annual examination for all inmates remaining at the Kittitas County Jail
for over a one-year period. This examination will occur as close as possible to the
365th day of detention.
Perform a physicalexamination on each inmate working in the kitchen before he/she
can begin work for food service or in an inmate trustee position"
Provide procedural guidance, initial direction and periodic inspection and evaluation
of the administration of medication activities performed by non-medical personnel
Professional Services Agreement (Form rev. Agl,24l2018)
Page 15 of21
within KCJ.
Provide designated members of the KCJ statf with training for administering
medications, including recognition of response to drug reactions and unanticipated
side effects. Contractor will be on premises at the KCJ on a periodic schedule and
will be available by telephone if circumstances require such response.
Conduct Sick Call Clinic on a regular basis for inmates desiring or needing medical
attention. Clinic will be conducted as directed by the doctor that is hired and in
accordance with State of Washington standards.
All inmates requesting care will receive a response on the next scheduled QHCP visit.
Physician or Mid-level provider (PA/NP) sick callwill be conducted weekly on a regularly
scheduled basis.
Respond immediately to healthcare emergencies that occur in the KCJ when requested
by KCJ staff. A Physician/PAINP will be on-call to the KCJ on a twenty-four (24) hour,
seven (7) day a week basis to aid in the determination of whether or not an inmate
requires transfer to the nearesi hospital facility,
Coordinate with a local hospital for routine outpatient/inpatient services to meet the
healthcare requirements of inmates at the KCJ that cannot be provided within the facility
but will not be financially responsible for the cost of such care. Contractorwillwork closely
with the KCJ staff to keep off-premises inmate healthcare visits at as low a level as
possible. ln every case possible Coniractor will utilize telephone consultations, in-house
evaluations, and other available methods to identify and address health issues before
they become critical. ln critical care situations, the Contractor, when on-site, willtriage the
patient whenever possible before activating emergency medical transport. ln the event
that an inmate must be hospitalized, Contractor will lollow the course of the admitted
inmate, communicate with the attending physician and nurses and return the inmate to
the KCJ as $oon as practical.
Make referral arrangements with other medical specialists for treatment of those inmates
with medical problems that extend beyond the scope of seryices provided onsite,
including special laboratory tests, x-rays and other ancillary services.
Develop and implement a program for the care of chronic-care inmates. The chronic care
provided will entail the development of an individual treatment plan by the responsible
physician specifying instructions on diet, medication, and diagnostic testing. Chronic care
inmates will be provided a review by a physician minimally every three (3) months and at
greater frequency when medically indicated.
Professional Services Agreement (Form rev. 0912412A18j
Page 16 of21
Review all medical records of inmates prior to their scheduled transfer from KCJ for
expiration of sentence and, if necessary, will refer to the appropriate community medical
facility at no cost to the County. A medical record review will also be conducted for
inmates who are released for reasons other than expiration of sentence. Records
reviewed in all instances described above will be stamped with the following information:
Date; Referral Made; By and To Whom; Signature ofReviewer.
All records will be reviewed no later than 96 hours after dateltime released
Develop a procedure for obtaining and sending pertinent medical information to and
from emergency facilities and outside specialty consultants and for inmates that are
transferred to other detention facilities. These procedures will comply wiih all applicable
Federal and State privacy laws with respect to sending and receipt of medical information.
Ensure that accurate, comprehensive, legible upto-date medical information is
maintained on each inmate under its care. All medical records will be considered
confidential. Procedures will be instituted for the receipt and filing of all reports and
documentation from outside consultations, emergency room visits, and inpatient
hospitalizations. The Contractor will maintain current medical records on all KCJ inmates
and necessary medical records will accompany the inmates to all medical consultation,
appointments and sick calls. Copies of medical records or a summary of medical records
will be fonvarded with the inmate when transferred to another facility. Contractor will
release medical records only as required by KCJ procedures and all applicable Federal,
State and Local law(s). Contractor will sign and adhere to the provisions of the Business
Associate Agreement attached hereto and incorporated by reference as a component of
compliance with confidentiality standards.
Comply with the KCJ health services policies, procedures, and medical protocols
approved by the Jail Superintendent. As required, Contractor will facilitate the
development and implementation of new and revlsed policies, procedures, and medical
protocols. As requested, Contractor will also assist in the development and refinement of
current policies. Comply with and complete required CJIS Security Awareness Training.
Meet with Jail Superintendent or his designee to discuss healthcare on a monthly basis.
Submit statistical reports to KCJ by the 15th of each month. This report will include month
and year-to-date figures for the following areas: intake screenlngs, physicals, emergency
room visits, hospitalizations, inmates released prior to physical, HlV, PPO, RFR, VORL
tests administered and positive status of same.
Professional Services Agreement {Form rev. 0912412018}
Page 17 of 21
Establish a formulary for the pharmaceuticals used to treat the most common conditions
Provide the Coun$ wiih Contractor's standard Medical Policies and Procedures Manual.
Any needed changes to this manual will be incorporated at the start of this Agreement.
The Medical Policies and Procedures Manualwill be reviewed periodically in cooperation
with the Jail Superintendent, and any needed changes incorporated into the manual.
Contractor will not provide acute & chronic psychiatric care including medication
management unless the psychiatric medication is used for a non-psychiatric medical
reason.
Professional Services Agreement (Form rev. 4912412018)
Page 18 of21
EX!-JBr "8"
COMPENSATION
As full compensation for satisfactory performance of the work described in Exhibit 'A",
including bui not limited to onsite medical care up to five (5) days per week, not to exceed
20 hours perweek, and on-call medicalservice ana24 hours perday, seven days perweek,
365 days per year basis. The County shall pay Contractor compensation not to exceed
$100,000.00 annually or $8,333.34 per month.
The above described compensation does not include the following costs, to be determined
by agreement of the County and Contractor.
. X-ray services not to exceed Medicaid rates.. lf labs are drawn by Contractor and are not acute in nature, fees will be assessed
by using Contractor's reference Laboratory (LabCorp) current patient fee schedule
not to exceed Medicaid rates.. Other supplies not provided by the County will be provided at cost plus 15%.r Visits made at Contractor's facilities.
lnvoices from Contractor for services rendered under this Agreement shall be sent to the
following:
By Mail
Or e-mail:
Kittitas County Sheriffs Office
Attn: Accounts Payable
307 W Umptanum Rd.
Ellensburg, WA 98926
shfi scal@co. kittitas.wa. us
Professional Services Agreement (Form rev. 0Sn4nA18)
Page 19 ol21
EXHIBIT "C"
PROOF OF INSURANCE
The Contractor shall secure and maintain in effect at all times during performance of the
Work such insurance as will protect Contractor, its Support and the Additional lnsureds
from all claims, losses, harm, costs, liabilities, damages and expenses arising out of
personal injury (including death) or property damage that may result from performance of
the work or this Agreement, whether such performance is by Contractor or any of its
Support.
All insurance shall be issued by companies admitted to do business in the State of
Washington and have a rating of A-, Class Vll or better in the most recently published
edition of Best's Reports unless otherwise approved by the CounhT. lf an insurer is not
admitted, all insurance policies and procedures for issuing the insurance policies must
comply with Chapter 48.15 RCW and 284-15 WAC.
The Contractor shall provide proof of insurance for:
X Comrnercial General Liabilitv hqtlrpnce
Coverage limits not less than:. $5,000,000 per occurrence. $1,000,000 personal and advertising injury, each offense. Certificate Holder - Kittitas Countyr The Certificate must name the County as additional insured. Sixtv (60) days written notice to the County of cancellation of the insurance
PolicY
K CommercialAutomobile Liabilitv lnsurancg (if ANY use of vehicle in performance)
Automobile Liability for owned, non-owned, hired, and leased vehicles (MCS gA
endorsement and a CA 9946 endorsement must be attached if 'pollutants'are to be
tnnsported)
' Coverage limits not less than:. $1,000,000 combined single limit. Thirty (30) days written notice to the County of cancellation of the insurance
policy.
X Professional Liability {Medical Malpractice)
The Contractor providing professional services shall provide evidence of
P rofessional Liabiliiy I nsurance covering professional errors and ornissions. Such
policy must provide the following minimum limits:. $1,000,000 per claim. $2,000,000 annual aggregate
Professional Services Agreement (Form rev. 091241?.018)
Page20 al21
lf insurance is on a claims-made form, its retroactive date, and that of all
subsequent renewals, shall be no later than the effective date of this
Agreement.
fi Workers'Compensation in amounts required by law.
Contractor shall furnish the County a Certificate of lnsurance to include the Policy
Endorsements/Exclusions as evidence thai policies providing insurance required by this
Agreement are in full force and effect. Contractor hereby waives all rights of recourse,
including any right to which another may be subrogated, against Kittitas County for
personal injury, including death, and property damage. Contractor's insurance policies
required above shall be primary insurance and shall be non-contributing with any
other insurance maintained by Kittitas County.
The Contractor shall assume full responsibility for all loss or damage from any cause
whatsoever to any tools, Contractor's employee-owned tools, machinery, equipment, or
motor vehicles owned or rented by the Contractor, or the Contractor's agents, suppliers
or contractors.
The Contractor shall have sole responsibility for ensuring the insurance coverage and
limits required are obtained by subcontractors.
NOTE: No contract shall form until and unless a copy of the Certificate of
lnsurance with Endorsements/Exclusions, properly completed and in the amount
required, is attached hereto.
Failure of the Contractor to fully cornply with the above insurance requirements during
the term of the Agreement shall be considered a material breach of contract and cause
for immediate termination of the Agreement at the County's discretion. Alternatively, the
County may procure and maintain, at the Contractor's sole expense, insurance to the
extent deemed proper up to the amount of the required coverage(s). The County may
offset the cost of such insurance against payment due to the Contractor under this
Agreement.
Professional Services Agreement (Form rev. O9lz4nlfi,
Page?1 of21
I
Additional Ma Be Required:
Buswrss AssocnrE AnosNnuvt
EXHIBIT ,.D', To Tgn CoNTRACT TO WHICH IT IS ATTACHED
This Addendurn is incorporated into the contract to which this docurnent is attached between
Kittitas County Washington on behalf of the Office or Departrnent thereof ("Covered Entity")
and the other party or parties thereto ("Business Associate"). The singnlar shall include the plural
and the plural the singular as required by the context.
The Business Associate acknorvledges and agrees that Protected Health lnfonnation {PHI) in any
format, including electronic PHI (ePHI), can be used, shared, created, retained or transferred
only r,vithin the parameters of this document and the Department of Health and Human Services
Privacy Regulations, Code of FederalRegulations, ("CFR"), Title 45, Sections 160 and 164, or
as required by law.
CFR Title 45, Sections 160 and 164 and any applicable Washington stafutory law ("RCW") or
Admirristrative Code ("WAC") provision (Federal and State statutory or regulatory standards
applicable to this addendurn are collectively referred to as "law") are by way of reflerence, an
integral part of this Addendum as if incorporated in iull. Business Associate is charged with the
knowledge of and agrees to abide by rhe tenns and conditions of law. To the extent that any
applicable provision of RCW or WAC provides for or mandates any standard differing from
those of Federal law, the standard more restrictive of disclosure shall ccntrol subject to federal
preemption; this applies throughout this Addendum wilhout regard to any further explicit
reference to RCW or WAC provisions.
This Addendum is effective upon signitg of this attachment or tlre contract to which it is
attached, whichever is prior in time.
L PURPOSE.
The Covered Entity needs to make available andlor disclose to the Business Associate cerlain
PHI for management, administration, and legal responsibilities during the normal course of
business between the parties as referenced in the contract or other agreenrent to which this
document is attached and incorporated by reference. This document is intended to define and
incorporate but not limit the obligations of the Business Associate lvith regard to its r"rse and
protection of that PHI.
IL RESPONSIBILITIES OF BUSINESS ASSOCIATE
The Business Associate hereby agrees to do the following:
A. Use and Disqlqsure: Use andlor disclose PHI only as permitted or required by this
Addendum, Health lnsurance Ponability and Accountability Act (HIPAA), and the
Health lnfonnation Technology for Economic and Clinical Health Act (Division A, Title
Xlll of the American Recovery and ReinveshnentAct of 2009, Pub. Lar,v l l l-5, 2009
HR 1) ("HITECH"). The Business Associate shall use and disclose PHI only if such use
or disclosure, respectively, is in compliance with each applicable requirement of 45 CFR
g 164.504(e) or other law. The Business Associate is directly responsible for ftill
B. A. A. Attachment Page I of 5
compliance with the privacy provisions of law that apply to the Business Associate to the
sanre extent as the Covered Entity.
B. Security: Implement adrninistrative. physical, and technical safeguards that reasonably
and appropriately protect the confidentiality, integrity, and availability of the PFII that it
creates, receives, maintains, or transmits on behalf of the Covered Entity as required by
law. The Business Associate is clirectly responsible for compliance with the security
provisions of HIPAA and I{ITECH lo the same extent as the Covered Entity.
C. lrnproper Disclosurcs: Report all unaurhorizedor other"wise improper disclosures of PHI,
or security incident, to the Covered Entity within two (2) days of the Business
Associate's knowledge of such event.
D. Notice of Breach: Within ti,vo {2) business days of the discovery oIa breach as defined at
45 CFR 9164.402 notify the Covered Entity of any breach of unsecured PHI. Notification
shall by the most rapid means reasonably possible, such as telephonic notice made
directly to an appropriate person within the covered entity and not inclLrding a voice rnail
or similar message. Written notification shall follow within that fwo (2) period by lax and
be confimed by direct contact with the intended recipient, and include the identification
of each individual whose unsecured PHI has been, or is reasotably believed by the
Business Associate to have been, accessed, acquired, or disclosed during sr.rch breach; a
brief description of what happened, including the date of the breach and the date of the
discovery of the breach, if known; a description of the types of unsecured PHI that were
involved iil the breacli (such as whether full name, social security number, date of birth,
home address, account number, diagnosis, disability code, or other types of information
were involved); any steps individuals should take to protect themselves from potential
harm resulting from the breach; a brief description of what the Business Associate is
doing to investigate the breach, to mitigate harm to individuals, and to protect against any
further breaches; tl-re contact procedures of the Business Associate far individuals to ask
questions or learn additional information, which shall include a toll fiee number, an e-
mail address, Web site, or postal address; and any other information required to be
provided to the individual by the Covered Entity pursuant to 45 CFR $ 164.404, as
amended" A breach shall be tr"eated as discovered in accoldance with the terms of 45 CFR
$ 164.410. The information shall be updated prnmptly and provided to the Covered Entity
as requested by the Covered Entity,
E. Mitigation: Mitigate, to the extent practicable, any harmful effect that is known to
Business Associate of a use or disclosure of PHI by Business Associate in violation of the
requirements of this Addendum or the law.
F. Agents: Ensure fhat any agent, including all of its employees, representatiyes, and
subcontractors, to whsm it provides PHI received from, or created or received by
Business Associate on behalf of Covered Entity agrees to fhe same restrictions and
B. A. A. Attachment Page 2 of 5
conditions that apply tluough this Addendlrm to Business Associate with respect to such
information.
G. tught of Asqgss:
1. From time to tirne upon reasonable advance notice, or upon a reasonable
determination by Covered Entity that Business Associate has potentially or actually
breached this Adclendum, rnake internal practices, books, and records relating to the
use and disclosure of PHI received from, or created or received by Business Associate
on behalf of Covered Entity available to the Covered Entity, or at the request of the
Covered Entity to the Secretary of Department of Health and Fluman Services, for the
purpose of determining compliance with HIPAA, HITECH, and/or this Addendurn.
2. From time to time upon reasonable advance notice, or upon a reasonable
determination by Covered Entity that Business Associate has potentially or actually
breached this Addendum, to permit Covered Entity to respond to a request by an
Individual for an accounting of disclosures of PHI in accordance with 45 CFR
$ 164"528, or to permit Covered Entity to respond to a request by an lndividual for
access to PHI in accordance with 45 CFR fi164.524.
H. Documentation of Disclosures: Document such disclosures of PHI and information
related to such disclosures as would be required for Covered Entity to respond to a
request by an Individual for an accounting of disclosures of PHi in accordance with 45
CFR $ 164.528. Should an individual make a request to Covered Entity for an accounting
of disclosures of his or her PHi pursuant to 45 CFR $ 164.528, Business Associate agrees
to promptly provide an accounting, as specified under 42 U.S.C, {i 17935(c) (l) and 45
CFR $ 164.528, of disclosures of PHI that have been made by the Business Associate
acting on behalf of the Covered Entity. The aecounting shall be provided by the Business
Associate to the Covered Entity or to the individual, as directed by the Ccvered Entity.
L Amendmentsl Make any amendments to PHI that the Covered Entity directs or agrees to
pursuant to 45 CFR *164.526 at the request of Covered Entity, within five (5) br.tsiness
days of i,vritten request by Covered Entity"
J. Other: To the extent the Business Associate is to carry out one or more of the covered
entities obligations under Subpart E of 45 CFR 164, comply with the requirements of
Subpart E that apply to the covered entity in the performance of such obligations.
1fi. PBRMITTED USES AND DISCLOSURES BY BUSTNESS ASSOCIATE
A. Except as otherwise limited in this Addendum or by law, Business Associate may use
Protected Health Information for the proper management and administration of the
Business Associate or to carry out the legal responsibilities of the Business Associate.
The Business Associate shall limit its use and disclosure of, and requests for, PHI to the
minimum necessary as determined in accordance with 42 U.S.C. $ l7935tbxl),
B. A. A. AttachrnentPage 3 of 5
w
v
B. Except as otherwise limited in this Addendum or by lau', Br.rsiness Associate may use
PHI ro provide Data Aggregation services to Covered Entity as permitted by a5 CFR g
164.504.(e)(2XiXB).
TERNI AND TERMINATION
A. ]-enrr: This Addendum shall become effective on the Effective Date ar.rd shall continue in
effect until all obligations of the parties have been met, unless terminated as provided
herein or by mutual agreement of the parties
B. Termination for Ca*se: Upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity may provide an opportunity for Business Associate
to cure the breach or end the violation and terminate this Addendurn if Business
Associale does not cure the breach or end the violation,,vithin five (5) business days of
receipt of written notice by the Covered Entity, or immediately teminate this AddendLrm
if Business Associate has breached a material term of this Addendum and cure is not
possible.
C. Other Termination: This Addendum may be terminated by Covered Entity withar.rt cause
upon thirty (30) days prior wriften notice to the other party, which notice shall specify the
date of termination.
D. Effect o-f Terminalipn: Except as provided in paragraph B. of this Section, upon
termination of this Addendum, for any reason, Business Associate shall retunr or destroy
all PHI received from Covered Entity, or created or received by Business Associate on
behalf of Covered Entity. This provision shall apply to PHI that is in the possession of
subcontractors or agents of Business Associate. Business Associate shall retain no copies
of the PHL Destruction must be by means that meet or exceed the standards of lar.v.
In the event that Business Associate deterrnines that returning or destroying the PHI is
not feasible, Business Associate shall extend the protections of this Addendum to such
PHI and limit fiirther disclosures of such PHi to those purposes that make rehrm or
destruction infeasible, for so long as Business Associate maintains such PHL Business
Associate must provide written notice of the conditions that make return or destnrctiorl
not feasible; if Covered Entity does not concur in that assessment, Business Associate
shall return or destroy the PHI within frve (5) business days.
MISCf,LLANEOU$
A. Defense and Indemnification: Business Associate shall defend, indemnify and hold
harmless Covered Entity from and against all claims, liabilities, judgments, fines,
assessments, penalties, awards or other expenses, of any nature whatsoever, including
without limitation aftorneys' fees, expert witness fees, and costs of investigation,
litigation, or dispute resolution, relating to or arising out of any breach of this Addendurn
by Business Associate, its employees, officers, agents, or sub-contractors. This provision
B. A. A. Attachment Page 4 of 5
is supplemental to and to be interpreted and applied in a manner consistent with, any
indemnification provision of the agreemeilt to which this Addendum is attached.
B. Reimbursernent for Costs.Incumed Due to Breach: Business Associate shall reimburse
Covered Entity, without limitation, for all costs of investigation, dispute resolution,
notification of individuals, the media, and the government, and expenses incurred in
responding to any audits or other investigaiion relating to or arising out of a breach of
unsecured PHI by the Business Associate, including mitigation.
C. Regulatory References: A reference in this Addendum to a Section in the Departnent of
Health and Human Services Pfivacy Regulations, CFR, Title 45, Sections 160 and 164
lxeans the Section as in effect or as amended, and for which compliance is required.
O. Anend!0gt]I: Changes in the law are automatically incorporated herein without need lor
explicit amendment. The Parties agree this this Addendum may be amended liom time to
time if otherwise necessary for Covered Entity to comply with the requirements of the
Department of Health and Human Services Privacy Regulations, CFR, Title 45, Sections
160 and 164 and otherprovisions of law.
E. Notices: Whenever Covered Entity or Business Associate is reqr"rired to give notice to the
other paffy, notice shall be in writing, posted in the US Mail, and deemed delivered after
thrce (3) business days except as described in IL D., above.
F. Survival: The obligations of the Business Associate shallsurvive the tennination of this
Addendum.
G. Interpretation: Any ambiguity in this Addendum shall be resolved in favor of a meaning
that permits Covered Entity to comply with the Department of Health and Human
Services Privacy Regnlations, CFR, Title 45, Sections 160 and 164 and other provisions
of law. Any provision of the Underlying Agreement that is directly contradictary to one
or more terns of this Addendum is superseded by the terms of this Adclendum to the
extent necessary for the parties' compliance with HIPAA.
B. A. A. Attachment Page 5 of 5
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
REVISION NUMBER:
CANCELI-A
@ 1988-2016 ACORD CORPORA
The ACORD name and logo are registered marks of ACORD
HOLDER
DA"IE aMit xx)rYYftl
11t10t2821
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
CERTIFICATE DOES T.IOT AFFIRMANVELY OR NEGATIVELY AMEND,
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOI/V. THIS CERTIFICATE OF INSURANCE DOES NOT COHSTITUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, Al{D THE CERTIFICATE HOLDER.
IMPORTANT:the cerliticate an lilsuRED,the must ItTISURED provisions or
SUEROGANON ls VI'AIVED,subject to the terms and conditlons of the pollcy c9fiain policies may requirE an endorsement.A Etatement onthisdoesnotcontertotheholderlnlieuolsuch
PRODUCER
CM&F Group lnc.
1 10 Vvest 40th Street
1Oth F,oor, Suite 1000/1001
NewYork, NY 10018
CM&F
1"800-2214904
r: MEDICAL
INSUREO
Ellensburg Family Medicine
2,I56 PAYNE RD
ELLENSSURG, WA98S26.7898
INSURER B .
INSURER C
INSURER D:
INSURER E :
INSURFR F:
THIS IS TO CERTIFY THAT THE POLICIES OF BELOW HAVE BEEN ISSUED TO THE IN5URED NAMED ABOVE FOR THE POLICY PERIOOINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERII' OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PSRTA|N, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUSJECT TO ALL
'HE
TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHO\AN MAY HAVE BEEN REDUCED 8Y PA|D CLAIMS.
INSKITR TYPE OF INSURANCE POUCYilUMSFR UMITIi
A X COMIIIERCIAL GENERAL LIABILITY
CLAIMS.MAOE OCCUR
LIMITAPPLIES
PRO-JECI I I
PgR:
LOCXPOLICY
X
u54661 11t29t2021 11129t2022 EACH OCCURRENCE e 1,000,000
UAMAgtr I9FCNIEU
PRFMISFS lF tr r,rFn El s 1,000,000
MED EXP (Any ms peGon)!
PERSONAL & ADV INJURY 5 1,000,000
GENEMLAGGREGAIE o 6,000,000
PRODUCTS. COMP'OF ACG $ 6,000,000
AUTOMOSILE UASILITY
ANY AUTQ
OV\[.IEO
AUIOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
ATJIOS
NON-OI rNEO
AUTOS ONLY
wn
IFA s
BODILY INJURY (P€r p6rson)s
BOOILY INJURY {Per a€cid6nt)5
UMBREIiALIAE
EXCESSUAg
OCCUR
CLAIMS.MAOE
EACH OCCURREIICE I
ACGREGATE t
ntrn RETENTION 5 $
$toRt(ERs COMPENSAITOiT
ANYPROPR IETORJPARTNER/EXECUTIVE
OFFICERfI'EMS€R EXCLUOED?
(Mandatory ln NH!
lf y63, de8cribe und€r
DESCFIPTION OF OPERATIONS bslM
Y'Nn It tA
HEK
STATI ITF
(J I t"t-FP
E-1. EACH AC'IOEN'$
E.L DISEASE . EA EMPLOYET $
E,L DISEASE. POLICY LIMIT $
A Probssional Liability X u54661 11125t2021 11t29t2022 Per lncidenl
Aggregate
1,000,000
6,000,000
DESCRIPIIONOFOPERAnoilSILOCAIONSTVEHICLES iACORDl0l,Add[ionilRem{rt!schedulermrybealtached,fmonEprcetsEqutrudl
Occunence Coverage Professional Liability Additional lnsured:
Kittitas County
Nur$e Praclitioner Group 205 W ith Ave
Ellensburg, WA98926
SHOULD ANV OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION BATE THEREOF, NOTICE WILL gE OELIVERED IN
ACCORDAT{CE W|TH THE pOLlCy pROVtSlOr{S.
Kitlitas Coung
205 W slh Ave
Ellensburg,WA98926
e.-z-ffi1-AUIHOREEO REFRESENTATIVE
ACORD 25 (2016/03)
All rights reserved.
CERTIFICA
CERTIFICATE OF LIABILITY INSURANCE
NUMBER:REVISION NUMBER
@ 1 988-201 6 ACORD CORPORATION. Att rights reseryed.
The ACORD name and logo are reglstered marks of ACORD
DAIE I$M/ODTYYVY)
finano21
THIS CERTIFICATE IS ISSUE8 AS A MATTER OF INFORTI'ATION ONLY AND CONFERS NO RIGHTS UPOI'I THE CERTIFICATE HOLDER. THIS
CERNFrcATE DOES NOT AFFIRI,ATIVELY OR NEGATIVELY ATUIEND, EXTENO OR ALTER THE COVERAGE AFFORDEO BY THE PoLIcIEs
SELOW- THIS CERTIFICATE OF IIISURANCE OOES NOT COa{STffUTE A COT,ITRACT BETWEEN THE ISSUING TNSURER{S), AUTHORTZED
REPRFSENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
lMPoRTANT:lfthece*ificateholderisanADDlTloNALlNsuRED,thepolicy(ies}mui{trivndo]8od.
ll SUBROGATION lS WAlvED, subject to the terms and conditlons of lhe policy, certain poilcls$ may require an endor€oment. A slalement on
this cortiflcate does not confer rights to the certilicate holder in ligu ofsuch endonsement(3).
PRODUCER
CM&F Group lnc.
11014&st 40th Street
1oth Floor, Suite 1000/100'l
Na,rrYork, NY 10018
CM&F
1-800-2214904
INSURERTSI AFFOROING COVERAGE NAIC #
INSURERA; MEDICAL PROTECTIVE COMPANY- MPC
INSURED
Ellensburg Family Medicine
2,I56 PAYNE RD
ELLENSBURG, WA98926.78S8
INSURER B :
INSURER C :
INSURER O :
INSURER E ;
INSURER F :
THIS IS TO CERTIFY THAT THg POLICIES OF INSURANCH LISTED BELOW HAVE BEEN ISSUED TO THE
IHOICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDI1ION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERIAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOVIN MAY HAVE BEEN REDUCED BY PAID CLAIMS-
INSURED NAMED ABOVE FOR THE POLICY PERIOD
INSRIE TYPE OF INSURANCE POUCY NUIIllEEP Ltilrts
EACH OCCURRENCE s 1,000,000
s 1,000,000
MED EXP tAny one torsonl E
PERSONAL & AOV INJURY r 1,000,000
GENERALAGGREGATF s 6,000,000
PRODUCTS. COMP/OF AGG s 6,000.000
A COMMERCIALGENERAL LNAILITY
GEN'LAGGREGATE LIMIT
X
X
nf--l pno-
L,- J JECTxPOUCY
CLAIMS.MADE OCCUR
PFR:
LOC
X u5466 t 11t29t2021 11t29t2022
I
BOOILY INJURY tPer pelsl !
EODILY INJURY {Per a6idsnt}
$
AUTOMOBILE LIABIUTY
SCHEDULED
ALTTOS
NON"OWT.JED
AUTOS ONLY
AUIOS
ITIRED
AUTOS ONLY
ONLY
ANY AUTO
OW\]ED
$
FACH OCCURRENCE DUMSRELLAUAE
EXCESS UAB
OCCUR
CLAIMS.MAOE AGGREGATE I
DED RFTFNTION S
tstsKGTA'I ITF UIH.FR
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE E
ANI' EMPLOYERS' LIAdILITV tlEXCLUOED?N/A
E,L. DISEASE . POUCY IIMIT
A Professional Liability u54661 11t29n921 11t29t2022 Per lncidenl
Aggregate
'1,000,000
6,000,000
DESCHPfiONOFOPFRATIONSILOCAIONSTVEHICLES {ACOR0 lOt,AddldonalRemrksSqhedsls,mybeettscieditmorcrpa@'rtsquindl
Occunence Coverage General Liability Additional lnsured:
Kiltitas County
Nurse Practilioner Grcup 230 Grant Rd-Ste 827
Ellensburg, WA989?6
$HOULD ANY OF THE ABOVE DE$CRIBED POLICIE$ EE CAITICELLED SEFORE
THE EIPIF.ATION DATE THEREOF, NONCE WLL BE DELTVERED II{
ACCORDAHCE IIVITH THE POLICY PROVISIONS.
Kitlitas County
230 Grant Rd Ste 827
205w5th Ave
Ellensburg,WA98926
C.*t--€ffi=:4:-AU1TIORIZED REPRESENTATIVE
ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER:REVISION NUITIBER:
O 1S88-20teACORD CORPORATION. All rights reserued.
The ACORD name and logo are registered marks of ACORD
DA1E {MM/DD/YYYY)
11t1U2421
THIS CERTIFICATE IS ISSUED AS A IIIATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AIIIEND, EXTEND OR ALTER THE GOVERAGE AFFORDED BY THE POLICIES
SELOW. THIS CERTIFICATE OF lltISURAllCE OOES NOT COilSrlTUTE A CONTRACT BETWEEN THE lSSUtNc IilSURER(S|, AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATF HOLDER.
the ceriilicatq holder is an ADDITIONAL INSURED,must have AODITIONAL INSURED provisions o.
lf SUBROGATION lS WAIVED, sublEct to the terms and conditions of the certaln pollcies may require an endorsement. A stai6m6nt on
thls certlficate does to thE certiflcate holder ln lleu of such
PRODUCER
CM&F Grorp lnc.
'110 Vlbst 40th Street
1oth Floor, Suite 100011001
NewYork, NY 10018
1-80a-2214904
MPC
INSURED
Ellensburg Family Medicine
2156 PAYNE RD
ELLENSBURG, WA98926-7898
INSURER 8 :
INSURERC:
INSUNER O :
INSUR€R E :
INSURER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED
INDICATED. NOTWTHSTANDING ANY RHQUIR€MENT, TERM OR
BELOW HAV€ BEEN ISSUEO 10 THg INSURED NAMEO ABOVE FOR lHE POLICY PERIOD
CONDITION OF ANY CONTRACI OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TH€ INSURANCE AFFORDED 8Y IHH POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIFS, LIMITS SHO'TiN MAY HAVE BEEN RFDUCED BY PAID CLAIMS.
INSR TYFE OF INSURANCE poLleY NililEFt POUCY EFF
LIMITS
A X COMMERC'AL 6ENER.AL UABILITY
CLAIMS.MADE OCCUR
GEN'L AGGREGATE LIMIT l PERi
LOCX"o''""l l588f
X
u54661 11t29t2021 11t29t2022 EACH @CURRENCE o 1,000,000
s 1,000,000
MED EXP (Any one D€mnl i
PERSOML & ADV INJURY e 1,000,000
GENFRAL AGGREGATE s 6,000,000
PRODUCTS. COMP/OF AGG r 6,000,000
$
AUTOilOAILE LIAAIL|TY
AI.IY AUIO
owNED
AUTO$ ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON"OW!ED
AUIOS ONLY
g
BODILY INJURY {Per psrson)$
BOO,LY INJURY (P6r accideno s
$
UMBRELI-ALIIE
EXCESS LIAS
occuR
CLAIMS-MADE
EACH OCCURRENCE I
AGGREGATE s
oFn FFTFN?NN T e
WORI(ERS COMPEiI$AION
Y, trl
ANYPROPRIETOR/PARTNER,IEXECU'IVE
OFFICERN/!€MBER EXCLUDED?
(Mandatory ln I'lH)
lfyss, desdib€ undsr
nFSCRIPTION .}F OPFRAtIrrNq kltu
N'A
PTK
STAT! TF UIH-Fd
E.L, EACH ACCIDENI $
E-1. D'SEASE . EA EMPLOYEF $
E.t, DISEASE. POUCY IIMIT I
A Professional Liability us66'1 't1t29t2121 11t29t2fr22 Per lncidenl
Aggregate
1,000,000
6,000,000
DESGRIPIIONOFOPERAIONSTLOCAnONSTVEHICLES {ACORDl0l,AddltiomlR€mfftGSchedute}maybaafiacfiedilmonrlrc6irr.qutrurt}
Occunence Coverage
Nurse Praclitioner Group
SHOULD AIiIY OF THE ABOVE DESCRIBED POLICIES BE CANCELL€D BEFoRE
THE AXPIRATION OATE TTIEREOF, NOTICE WILL B€ DELIVERED II{
ACCORDA''ICE ffiTH THE POLICY PROVISIONS.
Kitlita$ County
e*-z*ffii-AU1HORIZ€O NEPRESEITITATIYE
ACORD 25 (2016/031
Ellensburg Family Medicine
2156 PAYNE RD
ELLENSBURG, WA 98926.7898
Re: Policy# U54661
Dear Ellensburq Familv Medicine
Thank you for choosing CM&F Group, Inc. for your healthcare professional liability insurance needs.
CM&F has been in business since l9l9 and has provided stable, secure and reliable insurance programs to
healthcare practitioners since 1947. When you consider our 65+ years of experience in the malpraclice aren4
coupled with the financial superiority olour carrier partners - you can rest assured that your professional integrity
is very well protecled,
ENCLOSED ARE YOUR POLICY DOCUMENTS:
1. Multi-Specialty Healthcare Professional - CERTIFICATE
2. Mandatory & Optional Endorsements
3. Acord Certificate of Liability (PROOF OF INSURANCE)
Please review these documents for accuracy and keep them in a safe place. lfyou have any questions,
please call us at l-800-221-49A4 or send us an e-mail to: info@cmfgroup.com. Aside from providing access to the
highest quality coverages on the market, we are fully committed to delivering superior customer service, so please
know that we welcome your call should you have any questions or need assistance at any time.
Your healthcare professional liabilify policy offers broad coverage, including the following policy
features and benefits which we call {6The CM &F'Advantage",
> Professional Liability $ 1,000, 000196,000,000
> License Defense $2S,000/$1 00,000
> Deposition Defense $10,000
> Loss Of Earnings $2,500 per day/$35,000
> Biomedical Defense $10,000
> Medical Payments $25,0001$1 00,000
> EIPAA Defense $25,000
> First Aid Coverage$15,000
> Good Samaritan Coverage lncluded
> Assault Upon You$25,000
If you would like to review your coverage, please visit the CM&F Client Access Portal
(www.MYeME4CCOUNT.com): The secure C]l/.&F Client Access Portal is updated in real time wiih payments
and balances so that you can track your costs, coverage and renewal dates - at your convenience 24/7 . Bul should
you need personal assistance, the CM&F Customer Care Team is at your service Monday - Friday:
Customer Service Claim Team at l-800-221-4904
Email:
We wish you continued success and thank you again for choosing CM&F!
Sincerely,
The CM&F Group, Inc.
99 Hudson StreeL 12th Floor, NewYork, NY 10013-2815
info@cmferoup.com I www.cmfgroup.com
L.84A.22L.4904
The Medical Protective Companyo
A sTl'CK II{SURANCE COMPANY
5414 Resd Road, FortW-ync, Indirna <16815
Strenqth. 9ef€nse. Solutlons, Since L899.
MULTI.SPECIALTY HEALTHCARE PROFESSIONAL - CERTIFICATE
POrtGy
Periodr
2021-11-29 rot2A22-11-29
tt 12:01 a.m. Standad Time at the addffi ofthe Rct Nam€d lnsurcd.Certificate Numbdr:u54661
Item 1(a) ilamed Insured:N/A Sfrrdent an
Ellensburq Familv Medicine
Services Specialty: NP Gmup
rvA
2156 PAYNE RD
ELLENSBURG. WA 98926.7898
Item 1(b) Additional Insureds:
New Businss X Renewal Business
COVERAGES:RETROACTNIE
DATE
|JHITS OF LIABILITY
Per Qaim / AsqreqateOcoJn€nc€Sandad
6airc i4ade
Com.Bble
Chims lfdde
LIASIUTY
A. Professional Uability (PL) &
B. Good Samaritan Acts
C. Assault Upon You
D. First Aid
E. Medical Payments
F. Deposition Fees- Adrninistrative Hearing Expense- Sexual Misconduct Expense- l-oss of Earnings- HIPM Proceeding Expense- Biomedical Waste Hearing Expense
X
$1,000,000
lncluded
$25,000
$1 5,000
$25,000
$10,000
$25,000
$25,000
$2,500
$25,000
$10,000
$6,000,000
lncluded
$25,000
$15,000
$100,000
$10.000
$100,000
$25,000
$35,000
$25,000
$10,000
WORI(PIACE LIABIUTY
A. Healthcare Professional Premlses
Uability &
B. Personal Injury Liability lltMotol*. LJ6ifltu dos doa zort, it th.CesC Uzhititul,/dnc AM,ltffidc Mof wotFvfraa-
:MPLOYMENT PRACTICES LIABILITY" "
CYBER LTABILITY
BILTING PRASNCES & REGULATORY
:OMMERCIAL GTNERAL LIABILITY
- Each Occunence Umit- Damages to Premises Rented
to an Insured Business- Pemonal &Advertislng lnjury
- General Aggregate Limit- Product Completed operauons Aggregate- Hired and Non-0wned Auto
X
aqerd U.hilily daB nd ewly tl tht Wo,'pLca Uabltlty tietldg Agnffil l. ffida F& af yow aovaga
$1,000,000
$1,000,000
$1,000.000
$6,000,000
$6,000,000
SEE POLICY FORMS & ENDORSEMENTS SCHEDULE
lilaster Pollcy ilumber:
IN WITNEsS WHiREOF, The iledlcl PrOt€CUw @fipany has @u*d tlis
pdicy b be 3gn€d by its ltegdent nd Co{porate saKtery (i/d
6JnE.sis.Fd bv its dulv Auhorized Rercsslbbve. whm nEessary),
rC'\rg*.,-rruJcf -o-r.',^{)
S€mlarv
Premium: $4.932.00
Surcharges: $0.00laxes: $0.00IoTAL: S4.932.00
For SeMce or questions, please call:
CM&F Group, lnc. 1{00-221-4904
NOTICE
}TI.Ii5 POLICY C{}ruTA:Hs CLAIMS.IVTADE COVf RtG'.** clAti,l rxPEItsE t5?Al* wlTHIlI ?HE Llt4ITS AF LtAAtLr'y.
UMIIS MAY CIIANGE BYCOVERAGE PROVISION OR EI{DORSEMENT.
PLEASE READ YOUR POLICY A]{D ENDoRSEME'{TS CARER'LLY.
DISCUS' WTTH YOUR II{SURANCE AGEIIT IF NEEDED.
Counl€EignafuE / Auhorieed Reprer6ntalive:
1801 I Q1t14
The Medical Protective Company@
A sTOCK IHSURA]ICE COT,IPANY
5814 Reed Road, FortWayne, Indiana 46835
Stren$h. Defense. Solulions. Since 1899.
MULTI-SPECIALTY HEALTHCARE PROFESSIONAL
MASTER POUCY
CE RTI FI CAT E O F I NS A RANCE
SCHEDALE OF POLICY FORMS & ENDORSEMENTS
Forms and Endorsements of your Certificate are as follows:
Farm# Description
+--------------- +-------------
lFom No I Title
lCover Letter
IMPS !',lulL!-Special.ty tlealtheara Ptof,ess:ona.ls policy Certificate
,t1?S l',lu1ti-Specialty Healthcare profesaionals Eoru t Endorsenent Schedute
IMFS l'tu1li-SFecj.aLty HealLhcare Professionals Palicy Schedule of fnsuredg
lGenersl Defin:tions
lceneraf Condiiians
I General Exclusions
lProfessional Ltabillty Insu:ing Agreemeni - Occuftence
lComerc1al General Llabiliiy Insuring Agreesenl - Occurrence
lDisclosure $otj.ce of Terrorism Insulance Coverage
jCap on Lo6ses Frofi CetCified Acts of ?erotj.sm Endorsenent
lAddj.tional lrsured - Lessors of Prenises 6 Leased Equipment
,M95 Econonic Sanclions Exclusion Andorsemesl
lEcononic Sarclions ExcluEions Endorsenent {GL}
lM?S Blankel Separate l,-imic Endorsenent - pL Only
lBj.omedj,cal t{aste ilearing Expense Endorsement - Occurrenee
lReuse or Multidose Supply Procedure exclusion Endorsenent
I Procedures Exclusion EndorEemen!
lWashj,ngton Amendalory EndorseRenl
I
----+
I
I
I
I
I
I
I
i
I
I
i
I
I
t
I
I
I
I
I
i Mct
I 1801r.
| 1 8507
I 1 8s05
| 18511
I 1S51 9
I rB52Z
| 18528
| 18560
I 18517
t78620
t18569
,19720
i 19121
I 1 9098
I 1 9187
119218
| 19631
t18152
+---- -- * - - --- ---+'
18507 All other terms and conditions of the Policy remain unchanged,08/13
The Medical Protective Company@
A gTOCK IIISURAIICE COMPAT{Y
5814 Rsed Road, FortWayne, Indiana 46835
Strength. Defense. Solutions. Since 1899.
MALTI-S PECALTY HEALTH CARE PROF ESSI ONAL
MASTER POUCY
SCIIEDALE OF INSAREDS ENDORSEMENT
Item 1(a) of the CERTIFICATE is as follows:
Ellensburg Family Medicine
Each gmployee, shareholder. partner, voluntoers or
independeni contractor Heallhcaro Profsssional of
Ellensburg Family Medicins but only while providiflg
professlonal seMces on behal{ or under the direction or
conltol of El{ensburg Family Medlcine oxcluding any
physician, pdiakist, chiropraclor, optometrist, nurse
midwlfe, csrtified rogistered nurse anesth€tist or denlist
unless designated as an lnsured undar your Csrlificate
or by endorsement llsted on you. Cerlilicale.
Item l(b) of the CERTIFICATE is as follows:
Kittitas County
Kittitas County
All other terms and conditions of the Policy remain unchanged.
E Not Applicable
Not Applicable
AII 1{a) Named lnsureds Listed Above
All 1(a) Named lnsureds Listed Above
lncluded
lncluded
lncluded
lncluded
ITEM 1(a) NAMED INSURED PROFESSIONAL SERVICES
SPECIALTY
CLASS
RETROACTIvE
DATE*
flf Applicable)
TYPE
I) Individual
E) Entity
S) Student
MODIFIED
COVERAGE
ENDORSEMENT
NI]MBER
PREMIUM
SURCIIARGE
TAXES
flf Apolicable)
rTEM l(b) ADDTTIONAL INSURED AFFILIATED ITEM 1(a) NAMEI)
INSURED
PREMIUM
SURCHARGE
TAXES
(lf Applicable)
18505 08/1 3
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER REVISION NUMBER:
DAIE (MM/DO/YYYY}
11t10t2021
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 COVEMGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or bo endomed.
lf SUBROGATION lS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorcement. A siatomont on
this certificate does not confer rights to the certificate holder in lieu of such endosement(s).
PRODUCER
CM&F Group lnc.
110 \Abst 40th Sheet
1oth Floor, Suite 1000/1001
NewYork, NY 10018
CM&F
1-800-221-4904
INSURERISI AFFORDING COVERAGE NAIC#
TNSURERA: MEDICAL PROTECTIVE COMPANY- MPC
INSURED
Ellensburg Family Medicine
2156 PAYNE RD
ELLENSBURG, WA98926-7898
INSURER B :
INSURER C :
INSURER D :
INSURER E
INSURER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING 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,
INSRlTo TYPE OF INSURANCE tNch POLICY NUMEER LIMITS
A X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
LIMITAPPLIES PER:
3F8; f-l,-o"X
X
u54661 11t29t2021 11t29t2022 EACH OCCURRENCE s 1,000,000
L
F s 1,000,000
MED EXP (Any one person)$
PERSONAL & ADV INJURY e 1,000,000
GENERAL AGGREGATE s 6,000,000
PRODUCTS - COMP/OP AGG s 6,000,000
$
AUTOMOBILE LIABILITY
ANY AUTO
OVVNED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON.OVVI\ED
AUTOS ONLY
I
BODILY INJURY (P€r person)$
BODILY INJURY (Per a6idont)$
$
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE
EACH OCCURRENCE $
AGGREGATE u
DED RETENTION S U
WORKERS COMPENSANON
AND EMPLOYERS' LIABILITY fl
OPERATIONS belM
N/A
PERSTATI ITF
UIH-FR
E,L. EACH ACCIDENI $
E.L, DISEASE - EA EMPTOYEE $
E.L. OISEASE - POLICY LIMIT $
A Professional Liability X u54661 11t29t2021 11t29t2022 Per lncident
Aggregate
1,000,000
6,000,000
DESCRIPTIONOFOPEMTIONSTLOCATIONSTVEHICLES (ACORDl0l,Addltional RemartsSchodul€,maybeatt chedif monspacelsEquircd)
Occurrence Coverage Professional Liability Additional lnsured:
Kittitas County
Nurse Practitioner Group 205 W sth Ave
Ellensburg, WA98926
CERTIFICATE HOLDER ELLATION
@ 1988-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Kittitas County
205 W Sth Ave
Ellensburg,WA98926
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION OATE THEREOF, NOTICE WLL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 25 (2016/03)
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER:REVISION NUMBER:
DATE (MM'DD/YYYY}
11110t2021
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 CONSTTTUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate holder is an ADDlTlOltlAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endoFed.
lf SUBROGATION lS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorcement. A statement on
this csrtificate does not conler rights to the certificate holder in lieu of such endorcement(s).
PRODUCER
CM&F Group lnc.
110 M/est 40th Street
1oth Floor, Suite 1000/1001
NewYork, NY 10018
CM&F
1-800-221-4904
INSURER(SI AFFORDING COVERAGE NAICf
INSURERA: MEDICAL PROTECTIVE COMPANY- MPC
INSURED
Ellensburg Family Medicine
2156 PAYNE RD
ELLENSBURG, WA98926-7898
INSURER B :
INSIIRER C :
INSURER D :
INSURER E
INSURER F
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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.
INSRITR TYPE OF INSURANCE FOLICY NIIMRFR POLIGY EXP LIMITS
A X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LI[IIT APPLIES PER:
X ror'"" f--l 55.oi f l ,o.
X
X u54661 't1t29t2021 '11t29t2022 EACH OCCURRENCE s 1,000,000
E 1,000,000
MED EXP (Anv one person)$
PERSONAL & ADV INJURY E 1,000,000
GENERALAGGREGATE s 6,000,000
PRODUCTS - COMP/OP AGG s 6,000,000
s
AUTOMOBILE LIABILITY
ANY AUTO
o\ n{ED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUIOS
NON.OVTJNED
AUTOS ONLY
$
BODILY INJURY (P€r person)$
BODILY INJURY (Per accident)$
s
s
UMBRELLALIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE
EACH OCCURRENCE s
AGGREGATE s
DFD RFTFNTION S $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY r N/A
PERSTATI ITF
uth-FR
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
A Professional Liability u54661 11t29t2021 11n9t2022 Per lncidenl
Aggregate
1,000,000
6,000,000
OESCRIPTIONOFOPERATIONSTLOCATIONSTVEHICLES (ACORDl0t,Additional Rsmark!Schedule,mybeattrchedlfmoruspaceiBrequir€d)
Occurrence Coverage General Liability Additional lnsured:
Kittitas County
Nurse Practitioner Group 230 Grant Rd Ste 827
Ellensburg, WA98926
CERTIFICATE HOLDER CANCELLATION
Kittitas County
230 Grant Rd Ste 827
205 W 5th Ave
Ellensburg,WAg8926
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WLL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2016 ACORD CORPORATION. All rights reserved.
The AGORD name and logo are registered marks of ACORDACORD 25 (2016/03)
DATE (MM'DD'YYYY}
11nU2021
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 CERTIFTCATE OF INSURANCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: lf the certificate holder is an ADDITIONAL INSUREO, the policy(ies) must have ADDITIONAL INSURED provisions or be endorced.
lf SUBROGATION lS WAIVED, subject to the terms and conditions of the policy, certain policies may requiro an ondo.lsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CM&F Group lnc.
1 10 \A/est 40th Street
1Oth Floor, Suite 1000/1001
NewYork, NY 10018
CM&F
1-800-221-4904
info@cmfgroup.com
INSURERISI AFFORDING COVERAGE NAIC#
INsURERA: MEDICAL PROTECTIVE COMPANY- MPC
INSURED
Ellensburg Family Medicine
2156 PAYNE RD
ELLENSBURG, WA98926-7898
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSIIRER F :
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER:REVISION NUMBER
@ 1 988-201 6 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of AGORD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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.
tNstttTp TYPE OF INSURANCE POLICY NUMBER
POLICY EFFIMM'DDffiI LIMITS
EACH OCCURRENCE s 1,000,000
UAMAGE IUHtNIbU
PRFMISFS /Fe 6.fl rran.Ft s 1,000,000
l\rED EXP (Anv one D€rson)$
PERSONAL & ADV INJURY s 1,000,000
GENERAL AGGREGATE E 6,000,000
PRODUCTS - COIUP/OP AGG s 6,000,000
A COMMERCIAL GENERAL LIABILITY
GEN'L AGGREGATE LIMIT APPLI
X
X f__l pno-
I I JECT
X
POLICY
CLAIMS-MADE OCCUR
PER:
LOC
u54661 11t29t2021 11t29t2022
cI $
BODILY INJURY (P€r p€rson)$
BODILY INJURY (P€r accid6nt)$
$
AUTOMOBILE LIABILITY
ANYAUTO
ovl ED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON.OVVNIED
AUTOS ONLY
$
EACH OCCURRENCE $UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIIUS-IUADE AGGREGATE $
DED RETENTION S $
Ptt{STATI ITF
UIH.
ER
E.L, EACH ACCIDENT $
E L DISEASE - EA EMPLOYEE $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNERYEXECUTIVE
OFFICERYMEMBER EXCLUDED?
(Mandatory in NH)
lf yes, d€scribe under
DESCRIPTION OF OPERATIONS belN
Y'N
N/A
E.L. DISEASE - POLICY LIMIT s
A Professional Liability u54661 11t29t202',1 11t29t2022 Per lncident
Aggregate
1,000,000
6,000,000
DESCRIPTIONOFOPERATIONSTLOCATIONSTVEHICLES (ACORDl0l,AddltlonalRomatlcSchedule,maybeattachedlfmorcspacsirEquir€d)
Occurrence Coverage
Nurse Practitioner Group
SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE wlLL BE DELIVEREO IN
ACCORDANCE WTH THE POLICY PROVISIONS.
Kittitas County
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
Ellensburg Family Medicine
2156 PAYNE RD
ELLENSBU RG, WA 98926.7898
Re: Policy# U54661
Pear Ellensburq Familv Medicine
Thank you for choosing CM&F Group, Inc. for your healthcare professional liability insurance needs.
CM&F has been in business since l9l9 and has provided stable, secure and reliable insurance programs to
healthcare practitioners since 1947. When you consider our 65+ years of experience in the malpractice arena,
coupled with the financial superiority of our carrier partners - you can rest assured that your professional integrity
is very well protected.
ENCLOSED ARE YOUR POLICY DOCUMENTS:
1 Multi-Specialty Healthcare Professional - CERTIFICATE
2. Mandatory & Optional Endorsements
3. Acord Certificate of Liability (PROOF OF INSLIRANCE)
Please review these documents for accuracy and keep them in a safe place. Ifyou have any questions,
please call us atl-800-221-4904 or send us an e-mail to: info@cmfgroup.com. Aside from providing access to the
highest quality coverages on the market, we are fully committed to delivering superior customer service, so please
know that we welcome your call should you have any questions or need assistance at any time.
Your healthcare professional liability policy offers broad coverage, including the following policy
features and benefits which we call "The CM &f,'Advantage".
> Professional Liability $ 1, 000, 000/$6, 000, 000> License Defense $25,000/$1 00,000
> Deposition Defense $10,000
> Loss Of Earnings 92,500 per day/$35,000
> Biomedical Defense $10,000
> Medical Payments $25,000/$1 00,000
> HIPAA Defense $25,000
> First Aid Coverage$15,000
> Good Samaritan Coverage lncluded
> Assault Upon You$25,000
If you would like to review your coverage, please visit the CM&F Client Access Portal
(urury,-MYCMFACCOUNT.com): The secure CM&F Client Access Portal is updated in real time with payments
and balances so that you can track your costs, coverage and renewal dates - at your convenience 2417.But should
you need personal assistance, the CM&F Customer Care Team is at your service Monday - Friday:
Customer Service Claim Team at l-800-221-4904
Email:
We wish you continued success and thank you again for choosing CM&F!
Sincerely,
The CM&F Group,Inc.
99 Hudson Street 12th Floor, New Yorh NY 10013-2815
info@cmfgrouo.com I www.cmfgroup.com
7.800.22L.4904
The Medical Protective Company@
A STOCK INSURAI{CE CO}IPA]IY
5814 Reed Road, Fort Wayne, Indiana 46835
Strength. Defense, Solutions. Since 1899.
M ULTI-SPECIALTY HEALTHCARE PROFESSIONAL
MASTERPOLICY
CERTI FICATE OF INSURANCE
SCHEDULE OF POLICY FORMS & EAIDORSEMENTS
Forms and Endorsements of your Certificate are as follows:
Form # Description
lForm No. lTitle I
+---------------+-------- - ----------+
|MCL lcover Letter I
118011 IMPS Multi-Specialty Healthcare Professionals Policy Certificate I
118507 IMPS Multi-Specialty Healthcare ProfessionaLs Form & Endorsemen! Schedute I
118505 IMPS Multi-Specialty Heafthcare Professionals Policy Schedule of lnsureds I
118511 lceneral Definitions I
| 18519 lceneral Conditions I
178522 lceneral Exclusions I
118528 lProfessionaL Liability Insuring Agreement - Occurrence I
118560 lcomerciaf ceneral tiabili-ty Insuring Agreement - Occurrence I
118617 lDisclosure Notiee of Terrorism Insurance Coverage I
11,8620 lCap on Losses Fron Certified Acts of Terrorism Endorsement I
118565 lAdditional Insured - tessors of Premises & Leased Equipmen! I
1191,20 IMPS Economic Sanctions Exclusion Endorsement I
11,9L27 lEconomic Sanctions Exclusions Endorsement (cL) |
119098 IMPS Blanket Separate Limit Endorsement - pL Only I
119187 lBiomedical Waste Hearing Expense Endorsement - Occurrence I
\I92LB lReuse or Muftidose Supply Procedure Exclusion Endorsement I
119631 lProcedures Excfusion Endorsement I
11,8152 lwashington Amendatory Endorsement I
+- --------------+-- ------- -----------+
18507 All other terms and conditions of the Policy remain unchanged.08/13
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
November 12,2021
Agenda Date
December 7 021
Fund/Department
30 / Sheriff
C ontractlGrant Information
Contract lGrant Agency: Professional Service Agreement with Ellensburg Family Medicine and Kittitas
County
Period Begin Date: I2l7l202I (or signing of
agreement)
Period End Date: TBD
Total Grant/Contract Amount: Not to exceed $100,000 annually
Grant/Contract Number: SH21-044
ContracVGrant Summary: This agreement is between Kittitas County and Ellensburg Family Medicine to
provide on-site medical care to the inmate population within the Kittitas County Jail (KCJ) that
appropriately approximates the care offered to citizens in the local community up to five (5) days per
week, not to exceed twenty (20) hours; provide fully qualified professional healthcare staff to deliver
healthcare services; provide on-call service from a Qualified Healthcare Professional (QHCP); set up
meetings with KCJ to discuss all inmates with ongoing serious healthcare issues; develop a written,
individualized treatment plan for inmates requiring close medical carc or supervision; review current and
prior medical problems: screen for mental illness, dental issueso sexually transmitted disease, tuberculosis,
drug/alcohol use and many other conditions found in the general public as well as those more prevalent in
correctional healthcare; strictly adhere to Nursing and Care protocols appropriate to correctional facilities
and inmate populations; Obtain, at Contractor's own expense, all licenses andlor certifications necessary
to render medical and health services within KCJ; Intake screening daily and official medical intake on
appropriate inmates after 72 hours; Review initial medical and mental health screenings conducted in the
Booking/Intake, including Mental Health Questionnaire (including suicidal assessment) and the Health
History Screening (Based on the information gathered, Contractor will make recommendations); Perform
a PPD on each inmate when medically appropriate; Perform TB testing for each staff member working in
KCJ once ayear; Complete health appraisal physical examinations of all newly arriving inmates within 14
calendar days of arrival; Perform an annual examination for all inmates remaining at KCJ for over a one,
year period; Provide procedural guidance, initial direction and periodic inspection and evaluation of the
administration of medication activities performed by non-medical personnel within KCJ; Provide
designated members of the KCJ staff with training for administering medications; Conduct Sick Catl
Clinic on a regular basis for inmates desiring or needing medical attention; Coordinate with a local
hospital for routine outpatienVinpatient services to meet the healthcare requirements of inmates that
cannot be provided within the facility; Review all medical records of inmates prior to their scheduled
transfer from KCJ for expiration of sentence; Develop a procedure for obtaining and sending pertinent
medical information
Grant/Contract Review Page 1
In-Kind $
Explain
Is Equipment being purchased? No Who owns equipment? na
New Personnel being hired? No Contact HR hirine - reporting requirements - na
Future impacts or liability to Kittitas County:
Bu Information
Pass Throu Information
Prosecutor Review
Budeet Amendment Needed?
New Division Created? No
Yes! attach budget form No E Why not
Already budgeted
Revenue Code N/A
Expense Code:
0013009541 13
Agency to Pass Through NA
Amount to Pass Through $0
Sub-Contract Approved Date:
Has the Prosecutor reviewed this agreement?YesDk No CAMAS# 53022
Coun D artments acted
Submitted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Signature: e/et t *zw+t Date:1lll2l2l
Department: Sheriff
of InformationA
Auditor's Office
Human Resource
Prosecutor's Office
Who the
Reviewer Date
Grant/Contract Review Page 2