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SH21-044 - ELLENSBURG FAMILY MEDICINE PSA 2 SIDED - FULLY EXECUTED
PROFESSIONAL SERVICES AGREEMENT This Agreement is made by and between Kittitas County (hereinafter "the County") and Ellensburg Family Medicine (hereinafter "Contractof).The County and Contractor agree as follows: General Conditions;Exhibit A (Scope of Work);Exhibit B (Compensation); Exhibit C (Proof of Insurance). 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'notice in writing either personally delivered or mailed postage-prepaid by certified mail,return receipt requested, to the party's last known address for the purposes of giving notice under this paragraph. Contractor acknowledges and by signing this Agreement agrees that the Indemnification provisions set forth in Paragraphs 7 (Independent Contractor),9 (Taxes), 15 (Defense and Indemnity Agreement),21 (Patent/Copyright Infringement)and 24 (Confidentiality),are totally and fully part of this Agreement and have been mutually negotiated by the parties. Professional Services Agreement (Form rev.09/24/2018) Page 1 of 21 IN WITNESS WHEREOF,the parties have executed this Agreement this day of ÏLL,2021. EIIensburg Family Medicine COUNTY OF KITTIT S BOARD F COUN C NERS Signature of'$natory (Date /(////2 ) c alrman Print Name of Signatory bóinmissioner COUNTY OF KITTITAS SHERIFF'S OFFICE Co Clay Myfrs,Shedf TTEST: lerk of t Board-Julie Kjorsvik 3 Deputy Clerk of the Board-Mandy Buchholz APPROVED AS TO FORM: Douglas R.Mithhell, Deputy Prosecuting Attorney County's Address:Contractor Address:Kittitas County Ellensburg Family Medicine 205 West 5 6 Avenue,Suite 1082156PayneRd.Ellensburg,WA 98962Ellensburg,WA 98926 Contractor Contact:Project Contact: Zach Deffinbaugh Steve Panattoni,Superintendent 509-962-7527 Professional Services Agreement (Form rev.DB/24/2018) Page 2 of 21 M' GENERAL CONDITIONS 1.Scope 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 the Agreement period.No material,labor,or facilities 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 otherwise by the County,Contractor shall perform the work in accordance with any schedules made a part of this Agreement 4.Definitions: 4.1 "Additional Insureds"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 "Support"means the following:Contractor's directors,officers,employees, agents and representatives;and sub-Contractors of any tier;the respective directors,officers,employees,agents and representatives of these sub- Contractors of any tier;and any other person or entity acting under the direction or control of,or on behalf of,Contractor or any Contractor's sub- Contractors of any tier in connection with or incident to the performance of the Work or this Agreement. 4.3 The "Work"means all of the duties listed in Exhibit A and the performance of all other obligations,under this Agreement by Contractor or its Support. 5.Accountinq and Payment for Contractor Sentiœs: Payment to the Contractor for sentices rendered under this Agreement shall be as set forth in Exhibit "B".Where Exhibit "B"requires payments by the County,payment shall be based upon billings,supported unless othenNise provided in Exhibit "B",by documentation of units of work actually performed and amounts earned,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 "B"or approved in writing in advance by the Kittitas County Board of Commissioners,the County will not reimburse the Contractor for any costs or expenses incurred by the Contractor in performance of this Agreement. Where 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.09/24/2018) Page 3 of 21 r 6.Assignment 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.Independent 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 as an independent Contractor. The Contractor acknowledges that the entire compensation for this Agreement is specified in Exhibit "B"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 Insureds, 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 Employment: 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 Internal Revenue Service at the end of the calendar year in accordanœ with the applicable IRS regulations.It 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.09/24/2018) Page 4 of 21 personal property to which the County does not hold title.The County is exempt from Federal Excise Tax. 10.Requlations and Requirement: 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.Right to Review: This contract is subjectto review by any Federal or State auditor.The County or its designee shall have the right to review and monitor 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 County deems pertinent to the Agreement and its performance,and any and all communications with or evaluation by sentice recipients under this Agreement.The Contractor shall presente 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 available 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 If any change in the Work causes an increase or decrease on Contractor's cost of,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 adjustment,submit to the County a written statement setting forth any adjustment claimed. Professional Services Agreernent (Form rev.09/24/2018) Page 5 of 21 12.5 If any change results in a decrease in the Work pedormed,Contractor shall be entitled to compensation associated with changing the Work,such as revising design already completed,revising calculations already performed, and revising documents. 13.Termination for Default: If 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 the 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.If the Agreement is terminated for default,the Contractor shall not be entitled to receive any fudher 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 the 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. If 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. 14.Termination for Public Convenience: The County may terminate the Agreement in whole or in pad 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 actual work performed at unit contract prices for completed items of work.In 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 &Indemnity Agreement: The Contractor agrees to and shall defend,indemnify and hold harmless the County,its Additional Insureds,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 Insureds,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 09/24/2018) 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 or damage as shall have been occasioned by the sole negligence of the County, its Additional Insureds,appointed or elected officials,agents,or employees.It is further provided that no liability shall attach to the County by reason of entering into this contract, except as expressly provided herein. 16.Industrial Insurance Waiver: With respect to the performance of this Agreement and as to claims against the County,its Additional Insureds,officers,agents and employees,the Contractor e×pressly waives its immunity under Title 51 of the Revised Code of Washington,the Industrial Insuranœ 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: In the event that any litigation should arise concerning the construction or interpretation of any of the terms of this Agreement,the venue of such action of litigation shall be in the Superior Court of the State of Washington in and for the County of Kittitas.This Agreement shall be governed by the law of the State of Washington. 18.Withholdinq Payment: In the event the Contractor has failed to perform any obligation to be performed by the Contractor under this Agreement within the time setforth in this Agreement,then the County may,upon written notice,withhold all monies due and payable to Contractor,without penalty,until such failure to perform is cured or otherwise adjudicated. 19.Future Non-Allocation of Funds: If 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 penalty 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: 20.1 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 20.2 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.09/24/2018) Page 7 of 21 obligations of the Contractor under this Agreement in accordance with its terms. 20.3 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. 20.4 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. 20.5 The Contractor is not in violation of any applicable law,ordinance or regulation the consequence of which will or may materially affect Contractor's ability to perform its 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. 20,6 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.Patent/Copyright Infringement: 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 Contractor 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: 22.1 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 County at the earliest possible time in order that such matters 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 09/24/2018) Page 8 of 21 stated,the records,orders,instructions,and decisions of the Kittitas County Commissioners shall be final and conclusive. 22.2 Notice of Potential Claims The Contractor shall not be entitled to additional compensation which otherwise 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 Potential Claim 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 insofar as possible,the amount of the potential claim,Contractor shall keep full and complete daily records of the work performed,labor and material used,and all costs and additional time 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 thirty (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 suppoding documents evidencing the amount or extension of time claimed to be due. 23.Ownership of Items Produced: All writings,programs,data,public records or other materials prepared by the Contractor and/or its consultants or sub-Contractors,in connection with performance of this Agreement shall be the sole and absolute property of the County. 24.Confidentiality: 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 court after having acquired jurisdiction over the County.Contractor shall immediately give to the County notlœ of any judicial proceedings seeking disclosure of such information.Contractor shall indemnify and hold harmless the County,its Additional insureds,officiais,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.09/24/2018) Page 9 of 21 25.Notice: Exæpt as set forth elsewhere in the Agreement,for all purposes under this Agreement, except service of proæss,notice shall be given by the Contractor to the department head of the department for whom senlices are rendered,and to the Kittitas County Commissioners,205 W5th 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 Severability: If 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 pedormance 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 assed 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 Contractor'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 Index (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.09/24/2018) Page 10 of 21 28.Walver: Walver 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 this Agreement shall be held to be waived,modified or deleted except by an instrument,in writing,signed by the parties hereto, 29.Survival: The provisions of paragraphs 7,9,11,13,14,15,16,17,18,19,20,21,22,23,24,28,30, 31,and 32 shall survive,notwithstanding the termination or invalidity of this Agreement for any reason. 30.Nondiscrimination: 30.1 The County is an equal opportunity employer. 30.2 Nondiscrimination in Employment in 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, marital status,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 the 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 advertising, 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,national origin,sex,sexual orientation,marital status,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.09/24/2018) Page 11 of 21 as may be required to ensure full compliance with the provisions in the immediately preceding paragraphs herein. 31.Prevailinq Wage: 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 Industries.The schedule of prevailing wages rates for the locality or localities of the Work is determined by the Industrial Statistician of the Department of Labor and industries.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 rates shall be referred for arbitration to the Director of the Department of Labor and Industries.The arbitration decision shall be final ând conclusive and binding on al parties involved in the dispute as provided for by RCW 39.12.060. 32.Debarment Certification: The Contractor certifies that it: 32.1 Is not presently debarred,suspended,proposed for debarment,declared ineligible or voluntarily excluded from covered transactions by any Federal department or agency. 32.2 Has not within a three-year period preceding the e×ecution of this contract with Kittitas County,been convicted of or had a civil judgment 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,theft,forgery,bribery,falsification or destruction of records,making false statements,tax evasion,receiving stolen property,making false claims,or obstruction of justice. 32.3 Is 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. Professional Services Agreement (Form rev.09/24/2018) Page 12 of 21 EXH1BlT "A" SCOPE OF WORK In addition to providing all material and labor,the Contractor shall perform the following: 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 under this contract Provide on-call service from a Qualified Healthcare Professional (QHCP)--i.e.the Physician's Assistant i Nurse Practitioner to the facility on a 24 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.g.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 staff,of all existing equipment and supplies immediately upon takeover of contractresponsibilities. Review current and prior medical problems,screen for mental illness,dental issues, 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 correctional facilities and inmate populations. Obtain,at Contractor's own expense,all licenses and/or 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 Senrices Agreernent (Form rev,09/24/2018) Page 13 of 21 Intake screening daily and official medical intake on appropriate inmates after 72 hours, perforrn 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/Intake area by health trained KCJ staff,including Mental Health Questionnaire (including suicidal assessment)and the Health History Screening.Appropriate action will be 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 24/7 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 initial screening will include,but is not limited to: .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,dateltime 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; •Behavior,including state of consciousness,ment a I status,appearance, conduct,tremors,and sweating, •History of suicidal ideation,tendency or attempts; Based on the information gathered,Contractor will make recommendations that may include,but are not limited to: •Referral to an emergency healthcare facility; •Placement in the general inmate population and referrai to the normally scheduled healthcare services at the jail facility; •Placement in isolation; •Placement in observation area (awaiting psychiatric evaluation); Professional Services Agreement (Form rev.09/24/2018) Page 14 of 21 Perform a PPD on each inmate when medically appropriate,unless medicallycontraindicated.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 staff member working in the Kittitas County Jail once ayear. 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: .Review of the screeninglintake forms by medical and mental health staff; •Recording of vital signs,height,weight,etc.; •Complete medical history and physical examination; •Mental Health screening; •Dental screening; •Vision and Hearing screening; •Blood sampling for screening and urine sarnpling as needed; .Initiation of therapeutic measures when appropriate; •Other tests and examinations as indicated; •Proper signatures,co-signatures,dates and times. Health appraisal physical examinations of female inmates will include the followingadditionalassessments: •Inquiry about menstrual cycle and menstrual bleeding including abnormalities,current use of contraceptives,presence of an lUD,breast masses and nipple discharge,and possible pregnancy. 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 the365thdayofdetention. Perform a physical examination on each inmate working in the kitchen before helshe 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.09/24/2018) Page15of21 within KCJ. Provide designated members of the KCJ staff 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 ne×t scheduled QHCP visit, Physician or Mid-level provider (PA/NP)sick call will 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 nearest hospital facility. Coordinate with a local hospital for routine outpatientlinpatient 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.Contractor will work closely with the KCJ staff to keep off-premises inmate healthcare visits at as low a level as possible,In every case possible Contractor will utilize telephone consultations,in-house evaluations,and other available methods to identify and address health issues before they become critical.In critical care situations,the Contractor,when on-site,will triage the patient whenever possible before activating emergency medical transpod.In the event that an inmate must be hospitalized,Contractor will follow the course of the admitted inmate,communicate with the attending physician and nurses and return the inmate to the KCJ as soon as practical. Make referral arrangements with other medical specialists for treatment of those inmates with medical problems that extend beyond the scope of services 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.09/24/2018) Page 16 of 21 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 pedinent 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 with all applicable Federal and State privacy laws with respect to sending and receipt of medical information. Ensure that accurate,comprehensive,legible up-to-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.Capies of medical records or a summary of medical records will be fonNarded 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 revised 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 screenings,physicals,emergency room visits,hospitalizations,inmates released prior to physical,HIV,PPO,RFR,VORL tests administered and positive status of same. Professional Senrices Agreement {Form rev.09/24/2018) Page 17 of 21 Establish a formulary for the pharmaceuticals used to treat the most common conditions. Provide the County with 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 Manual will be reviewed periodically in cooperation with the Jail Superintendent,and any needed changes incorporated into themanual. Contractor will not provide acute &chronic psychiatric care including medication management unless the psychiatric medication is used for a non-psychiatric medical reason. Professional Sentices Agreernent (Form rev.09/24/2018) Page 18 of 21 EXHIBIT "B" COMPENSATION As full compensation for satisfactory performance of the work described in Exhibit "A", including but not limited to onsite medical care up to five (5)days per week,not to e×ceed 20 hours per week,and on-call medical service on a 24 hours per day,seven days per week, 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. •If 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%. •Visits made at Contractor's facilities. Invoices from Contractor for services rendered under this Agreement shall be sent to the following: By Mail:Kittitas County Sheriffs Office Attn:Accounts Payable 307 W.Umptanum Rd. Ellensburg,WA 98926 Or e-mail:_shfiscal@co.kittitas.wa.us Professional Services Agreement (Form rev.09/24/2018) Page 19 of 21 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 Insureds 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 County.If 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: Commercial General Liability Insurance Coverage limits not less than: •$5,000,000 per occurrence •$1,000,000 personal and advertising injury,each offense •Certificate Holder -Kittitas County •The Certificate must name the County as additional insured •Sixty (60)days written notice to the County of cancellation of the insurance policy Commercial Automobile Liability Insurance (if ANY use of vehicle in performance) Automobile Liability for owned,non--owned,hired,and leased vehicles (MCS 90 endorsement and a CA 9946 endorsement must be attached if 'pollutants'are to be transported) •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. Professional Liability (Medical Malpractice) The Contractor providing professional services shall provide evidence of Professional Liability Insurance covering professional errors and omissions.Such policy must provide the following minimum limits: •$1,000,000 per claim ·$2,000,000 annual aggregate Professional Sentices Agreement (Form rev.09/24/2018) Page 20 of 21 If 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. Additional Coverage May Be Required: Workers'Compensation in amounts required by law. Contractor shall furnish the County a Certificate of insurance to include the Policy Endorsements/Exclusions as evidence that 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 shaH 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 Insurance with Endorsements/Exclusions,properly completed and in the amount required,is attached hereto. Failure of the Contractor to fully comply 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.09/24/2018) Page 21 of 21 BUSINESS ASSOCIATE ADDENDUM EXHIBIT "D"TO THE CONTRACT TO WHICH TT IS ATTACHED This Addendum is incorporated into the contract to which this document is attached between Kittitas County Washington on behalf of the Office or Department thereof ("Covered Entity") and the other party or parties thereto ("Business Associate").The singular shall include the plural and the plural the singular as required by the context. The Business Associate acknowledges and agrees that Protected Health information (PIII)in any forrnat,including electronic PHI (ePHI),can be used,shared,created,retained or transferred only within the parameters of this document and the Department of Health and Human Services Privacy Regulations,Code of Federal Regulations,("CFR"),Title 45,Sections 160 and 164,or as required by law. CFR Title 45,Sections 160 and 164 and any applicable Washington statutory law ("RCW")or Administrative Code ("WAC")provision (Federal and State statutory or regulatory standards applicable to this addendum are collectively referred to as "law")are by way of reference,an integral part of this Addendum as if incorporated in full.Business Associate is charged with the knowledge of and agrees to abide by the terms and conditions of law.To the extent that any applicable provision ofRCW or WAC provides for or mandates any standard differing from those of Federal law,the standard more restrictive of disclosure shall control subject to federal preemption;this applies throughout this Addendum without regard to any further explicit reference to RCW or WAC provisions. This Addendum is effective upon signing of this attachment or the contract to which it is attached,whichever is prior in time. L PURPOSE The Covered Entity needs to make available and/or disclose to the Business Associate certain PHI for management,administration,and legal responsibilities during the normal course of business between the parties as referenced in the contract or other agreement 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 with regard to its use and protection of that PHI IL RESPONSIBILITIESOF BUSINESS ASSOCIATE The Business Associate hereby agrees to do the following: A.Use and Disclosure:Use and/or disclose PHI only as permitted or required by this Addendum,Health Insurance Portability and Accountability Act (HIPAA),and the Health Infonnation Technology for Economic and Clinical Health Act (Division A,Title XIII of the American Recovery and Reinvestment Act of 2009,Pub.Law ll 1-5,2009 HR l)("HlTECH").The Business Associate shall use and disclose PHÏ only if such use or disclosure,respectively,is in compliance with each applicable requirement of 45 CFR §l64.504(e)or other law.The Business Associate is directly responsible for full B.A.A.Attachment Page I of 5 compliance with the privacy provisions of law that apply to the Business Associate to the same extent as the Covered Entity. B.Security:Irnplement administrative,physical,and technical safeguards that reasonably and appropriately protect the confidentiality,integrity,and availability of the PHI that it creates,receives,maintains,or transmits on behalf of the Covered Entity as required by law.The Business Associate is directly responsible for compliance with the security provisions of HIPAA and HITECH to the same extent as the Covered Entity. C.Improper Disclosures:Report all unauthorized or otherwise 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 two (2)business days of the discovery of a breach as defined at 45 CFR §\64.402 notify the Covered Entity of any breach of unsecured PHL 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 including a voice rnail or similar message.Written notification shall follow within that two {2)period by fax and be confirmed by direct contact with the intended recipient,and include the identification of each individual whose unsecured PHI has been,or is reasonably believed by the Business Associate to have been,accessed,acquired,or disclosed during such 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 in the breach (such as whether full name,social security number,date of birth, home address,account number,diagnosis,disability code,or other types of infornation 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;the contact procedures of the Business Associate for individuals to ask questions or learn additional information,which shal include a toll free nurnber,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 treated as discovered in accordance with the terms of 45 CFR §164.410.The information shall be updated promptly 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 that any agent,including all of its employees,representatives,and subcontractors,to whom it provides PHI received from,or created or received by Business Associate on behalf of Covered Entity agrees to the same restrictions and B.A.A.Attachment Page 2 of 5 conditions that apply through this Addendum to Business Associate with respect to such information. G.Right of Access: L 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,make 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 Hutnan Services,for the purpose of determining compliance with HIPAA,HITECH,and/or this Addendum. 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 1ndividual for access to PHI in accordance with 45 CFR §164.524. H.Documentation of Disclosures:Docurnent 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 Plll 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.§17935(c)(1)and 45 CFR §l 64.528,of disclosures of PHI that have been made by the Business Associate acting on behalf of the Covered Entity.The accounting shall be provided by the Business Associate to the Covered Entity or to the individual,as directed by the Covered Entity. I.Amendments:Make any amendments to PHI that the Covered Entity directs or agrees to pursnant to 45 CFR §164.526 at the request of Covered Entity,within five (5)business days of written 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 oE45 CFR 164,cornply with the requirements of Subpart E that apply to the covered entity in the performance of such obligations. III.PERMITTEDUSES AND DISCLOSURES BY BUSINESS 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.§17935(b)(l). B.A.A.Attachment Page 3 of 5 B.Except as otherwise limited in this Addendum or by law,Business Associate may use PHl to provide Data Aggregation services to Covered Entity as permitted by 45 CFR § 164.504.(e)(2)(i)(B). IV.TERMAND TERMINATION A.Term:This Addendum shall become effective on the Effective Date and 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 Cause: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 Addendum if Business Associate does not cure the breach or end the violation within five (5)business days of receipt of written notice by the Covered Entity,or immediately terminate this Addendum if Business Associate has breached a material terrn of this Addendum and cure is not possible. C.Other Termination:This Addendum may be terrninated by Covered Entity without cause upon thirty (30)days prior written notice to the other party,which notice shall specify the date of termination. D,Effect of Termination:Except as provided in paragraph B.of this Section,upon termination of this Addendum,for any reason,Business Associate shan return 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 law. In the event that Business Associate determines that returning or destroying the PHI is not feasible,Business Associate shall extend the protections of this Addendum to such PHI and limit further disclosures of such PHI to those purposes that make return or destruction infeasible,for so long as Business Associate maintains such PHI.Business Associate must provide written notice of the conditions that make retum or destruction not feasible;if Covered Entity does not concur in that assessment,Business Associate shall retum or destroy the PHI within five (5)business days. V.MISCELLANEOUS A.Defense and Indernnification: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 liinitation attorneys'fees,expert witness fees,and costs of investigation, litigation,or dispute resolution,relating to or arising out of any breach of this Addendum by Business Associate,its employees,officers,agents,or sub-contractors.This provision B.A.A.Attachtnent Page 4 of 5 is supplernental to and to be interpreted and applied in a manner consistent with,any indemnification provision of the agreement to which this Addendum is attached. B.Reimbursement for Costs Incurred 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 investigation relating to or arising out of a breach of unsecured PHI by the Business Associate,including mittgation. C.Regulatory References:A reference in this Addendum to a Section in the Department of Health and Human Services Privacy Regulations,CFR,Title 45,Sections 160 and 164 means the Section as in effect or as amended,and for which compliance is required. D.Amendment:Changes in the law are automatically incorporated herein without need for explicit amendment.The Parties agree this this Addendum may be amended from 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 other provisions of law. E.Notices:Whenever Covered Entity or Business Associate is required to give notice to the other party,notice shall be in writing,posted in the US Mail,and deemed delivered after three (3)business days except as described in II.D.,above. F.Survival:The obligations of the Business Associate shall survive the termination 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 Regulations,CFR,Title 45,Sections 160 and 164 and other provisions of law.Any provision of the Underlying Agreement that is directly contradictory to one or more terms of this Addendum is superseded by the terms of this Addendum to the extent necessary for the parties'compliance with HIPAA. B.A.A.Attachment Page 5 of 5 ^RD CERTIFICATE OF LIABILITY INSURANCE °^¾ñ2°o THIS CERTIFICATEIS ISSUED AS A MATTER OF [NFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATEHOLDER,THISCERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW.THIS CERTIFICATEOF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZEDREPRESENTATIVEORPRODUCER,AND THE CERTIFICATEHOLDER. iMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAlVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NTACT CM&F Group CM&F Group Inc o.Ext);1-800-2214904 C,No}:110 West 40th Street info@cmfgroup.com10thFloor,Suite 1000/1001 NewYork,NY 10018 IN'jiURER(S)AFFORDINGCOVERAGE NAIC# INSURERA:MEDICAL PROTECTIVE COMPANY-MPC INSURED INSURER B: Ellensburg Family Medicine NSURER c: 2156 PAYNE RO lNSURER DELLENSBURG,WA98926-7898 INSURER E I[NSURER F :i COVERAGES CERTIFICATE NUMBER:REVISIONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITlON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATEMAYBEISSUEDORMAYPERTAIN,THE INSURANGE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONSOF SUCH POLICIES LlMETS SHOWN MAY HAVE BEEN REDUCED BY PA1D CLAIMS. ÏNŠR dADDL|SUBR POLICYEFF |PGLICYEXPLTRTYPEOFIN$URANCE |INSU i M i POLICY NUMBER MMIOD/YYYY)(MMIDDIYYYY)LIMITS A X COMMERCIAL GENERAL LIABILITY US4661 11/29/2021 11/29/2022 EACH OCCURRENGE s 1,0DD,000 ||f5KRFÆGETðld-NII-0CLAIMSMADEXOCCURPREMISES(Ea occurrence)s 1,000,000 MED EXP (Any one person)5 PERSONALAADVlNJURY $1,ÛQÜ,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE S Û.ÛÛÜ,000 POLËCY JERC LOC PRODUCTS-COMPIOPAGG S 6.OOÛ.ÜOÛ OTHER:S AUTOMOBILELIABILITY MS En t)SINGLEUMIT g ANY AUTO 80DJLY INJURY (Per person)5 U OSDONLY TH ULEO BODILY INJURY (Per acciderrt)S HIRED I NON OWNED PROPERTY DAMAGEAUTOSONI.Y ALFTOS ONLY (Per accitient)1 I , UMBRELLALIAB OCCUR EACHOCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE 5 OE RETENTION S 5 WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDEMT $OFFfCERIMEMBEREXCLUDEDT NIA (Mandatory in NN)E.L.OISEASE -EA EMPLOYEE 5 If yes,describe under DESCRIPTION DF OPERATIONS DeϤw E I_DISEASE -POLICY LIMIT 5 A Professional Liability X LI54661 11/29/2021 11/29/2022 Per Incident 1,000,000 Aggregate 6,000,000 DESCRIPTION OFOPERATLONS I LOCAT10NS IVEHICLES (ACDRD 101,Additional Remarks Schedule,may be attachedif more space is required) Occurrence Coverage Professional Liability Additional Insured: Kittitas County Nurse Practitioner Group 205 W 5th Ave Ellensburg,WA98926 CERTIFICATEHOLDER CANCELLATlON Kittilas County 205 W 5th Ave SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTIGE WILL BE DELIVERED INEllensburg,WA98926 ACCORDANCE WITH THE POLICY PROVISIONS. A RE NTAT ©1988-2016 ACORD CORPORATION.All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD ^D CERTIFICATE OF LIABILITY INSURANCE °^1°2°o THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER.THISCERTIFICATEDOESNOTAFFIRMATIVELYORNEGATLVELYAMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW.THIS CERTLFICATE OF INSURANCEDOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATEHOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LO T CT CM&F Group CM&F Group inc.(Tc NEu,En):1-800-221-4904 A C,Nol: 110 West 40th Street geMD Ess:info@cmfgroup.com 10th Floor,Suite 1000/1001 NewYork,NY 10018 INSURER(B)AFFORDINGCOVERAGE NAIC# fNSURERA:MEDICAL PROTECTIVE COMPANY-MPC INSURED (NSURER B Ellensburg Family Medicine INSURERC: 2156 PAYNE RO ELLENSBURG,WA98926-7898 FNSURERE: FNSURER F : COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POLICY PERIODINDICATED.NOTWETHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERT1FICATEMAYBEISSUEDORMAYPERTAIN,THE INSURANCE AFFORDED BY THE POLPCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDíTIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLA1MS. INSR|IADOLSUBR POUCYEFF \POLICYEXPLTRITYPEOFINSURANCEggggPOLICYNUMBER(MMIDDIYYYYll[MM10DIYYYY LIMITS A X COM#IERCIALGENERALUABIUTY X U54661 11/29/2021 11/29/2022 EACHOCCURRENCE s 1,000,000 DÄNIAGE TO RENTEDCLAIMSMADEXoccuRPREMISES(Ea accurrence)s 1,000,000 MEO EXP (Any one person)5 PERSONAL&ADVINJURY S 1,000,000 GEN L AGGREGATE UM IT APPLIES PER:GENERAL AGGREGATE a 6,000,000 X POLICY ERG LOC PRODUCTS-COMPIOPAGO s 6,000,000 i OTHER: AUTOMDBfLE LLABILITY En 80ydE SINGLE LlMIT 5 ANY AUTO BCDILY INJURY (Per pam¡on)5 AO ES ONLY I OULED BODILY INJURY (Per accident)S HIRED NON WNED PROPERTY DAMAGEAUTOSONLY_AUTOSONLY (Peraccident) UMBRELLALIAB OCCUR EACHOCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE s DED RETENTlON S $ WORKER$COMPENSATION |PER (|OTH- ANDEMPLOYERS'LLABILITY YlN i STATUTE I i ER ANYPROPRIETORIPAATNERIEXECUTIVE E.L EACH ACCIDENT 5OFFICER/MEMEIER EXCLUDED9 N i A (Mandatory in NN)E.L DISEASE -EA EMPLDYEE S If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POUCY UMIT 5 A Professional Liability U54681 11/29/2021 11/29/2022 Per Incident 1,000,000 Aggregate 6,000,000 DESCRIPTlON OF OPERATIONS ?LOCATIONS /VERICLES (ACORD 101,Add[tlanal Remarks Schedule,may be attachedir more space is required) Occurrence Coverage General Liability Additional Insured: Kittitas County Nurse Practitioner Group 230 Grant Rd Ste B27 Ellensburg,WA98926 CERTIFICATEHOLDER CANCELLATION Kittitas County 230 Grant Rd Ste B27 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPERATION DATE THEREOF,NOTICE WILL BE DELIVERED IN205W5thAveAccCRDANCEWITHTHEPOLICYPROVISIONS,Ellensburg,WA98926 AUTHORIZEDREP EN ©1988-2016 ACORD CORPORATLON.AII rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD -ga CERTIFICATE OF LIABILITY INSURANCE °^ÌToÎ2°o THIS CERTIFICATEIS [SSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RJGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATEOF INSURANCE DOES NOT CONSTITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATEHOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER T CT CM&F Group CM&F Group inc.ZNE y 1-800-221-4904 No): 110 West 40th Street (MO ESS:i fD®cmfgroup.com 10th Floor,Suite 1000/1001 New York,NY 1DO18 INSURER(S)AFFORDING COVERAGE NAIC # INSURERA:MEDICAL PROTECTIVE COMPANY-MPC INSURED INSURER B : Ellensburg Family Medicine INSURERC: 2156 PAYNE RD INSURERO:ELLENSBURG,WA98926-7898 i INSURER E :I INSURERF: COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: TH[S IS TO CERT1FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHlCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSEONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. [NSR |ADOL]SUBR I POLICY EFF I POUCY EXP LTR I TYPE OF INSURANCE I INSD WVR PoucY NUMBER |(MMID0tYYYY}(MMí0DIYYYY)LIMITS A X 1 COMMERCIALGENERALLIABILITY LIS4661 11/29/2021 11/29/2022 EACHOCCURRENCE 5 1,000,000 CLAIMS-MADE OCCUR r EubcNe rrDence) s 1,000,000 MED EXP (Any one person)$ PERSONALAADVINJURY s 1,000,000 GËN'L AGGREGATE LIM T APPUES PER GENERAL AGGREGATE s 6,000,000 X POUCY ERC LOC PRODUCTS-COMPIOPAGG s 6,000,000 i OTHER S AUTOMOBILELIABILITY EOaMa dE SINGLELlMIT g ANY AUTO BODILY 1NJURY (Per person)5 AU OESDONLY THEDULED BODILY INJURY (Per accident)5 HIRED NON-OWNED PROPERTYDAMAGE gAUTOSONLYAUTOSONLY(Per âncidenn UMBRELLALIAB OCCUR EACHOCCURRENCE S EXCESS LIAS CLAIMS-MADE AGGREGATE 5 OED RETENTIONS 8 WORKERS COMPENGATION PER OTH- AND EMPLOYERS'LIABILITY YlN STATUTE ER ANYPROPRIETORIPARTNERIEXECUT1VE E.L EACH ACCIDENT $OFFICERIMEMBER EXCLUDED7 (Mandatory In NH)EL DISEASE -EA EMPLOYEE S if yes,describe under DESCRIPTION OF OPERATIONS telow EL Ol5EASE -POUCY LLMIT S A Professional Liability U54661 11/29/2021 11/29/2022 Per Incident 1,000,000 Aggregate 6,000,DOD I DESDRIPT10N OFQPERATIONS /LOCATlONSIVEHICLES (ACORD 101,Additional Rettiarks Schedule,muy be attached ir mom space is required) Occurrence Coverage Nurse Practitioner Group CERTIFICATEHOLDER CANCELLATION Kittitas County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELLVERED IN ACCORDANCE WITH THE POLICY PROVISLONS. A N ©1988-2015 ACORD CORPORATION.AII rights reserved. ACORD 25 (2016/03}The ACORD name and logo are registered marks of ACORD Ellensburg Family Medicine 2156 PAYNE RD ELLENSBURG,WA 98926-7898 Re:Policy#U54661 Dear Ellensbura Familv Medicine Thank you for choosing CM&F Group,Inc.for your healthcare professional liability insurance needs. CM&F has been in business since 1919 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 INSURANCE) Please review these documents for accuracy and keep them in a safe place.If you have any questions, please call us at 1-800-221-4904 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 deliveringsuperior 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 >Medical Payments $25,000/$100,000 >License Defense $25,000/$100,000 >HIPAA Defense $25,000 >Deposition Defense $10,000 >First Aid Coverage$15,000 >Loss Of Earnings $2,500 per day/$35,000 >Good Samaritan Coverage included >Biomedical Defense $10,000 >Assault Upon You $25,000 If you would like to review your coverage,please visit the CM&F Client Access Portal (www.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 24/7.But should you need personal assistance,the CM&F Customer Care Team is at your service Monday -Friday: Customer Service Claim Team at 1-800-221-4904 Email:info@cmfgroup.com 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 York,NY 10013-2B15 info@cmferoup.com |www.cmfgroup.com 1800.221.4904 The Medical Protective Company® A STOCK INSURA (CE COMPAriYSEli,I Reed Rand,Fort M.myne,Indiana 4faS35strengtinDefense.50utions,since 1899. MULTI-5PECIALTY HEALTHCARE *ROFESSIONAL-CERTIFICATE PolicV 2021-11-29 TO:2022-11-29 certificate Number:US4661Pedod:at 12:01 a.rn.Standard Time at the address of the First Named Insured, Item 1(a)Named Insured:N/A Student Non-Insured acting in the capacity of an Administrative First Named Insured Ellensbura Familv Medicine Professional Services Specialty,NP Gmup Classification:N/A Iti....1(f.)Addit;ù..¿.I I..su.uds. First Named Insured Address: 2156 PAYNE RD ELLENSBURG.WA 98926-7898 New Busine s X Renewal Business P=ILICY TYi E*RETROACTIVE LIMITS OF LIABILITYCOVERAGES:Standard ConvertibleOccurrenceOaimsMadeClaimsMade DATE Per Gaim /Aqqregate PROFESSIONAL LIABILny $1,000,000 $6,000,000 A.Professional Liabilty (PL)&Included Included B.Good Samaritan Acts $25,000 $25,000 C.Assault Upon You $15,000 $15 000 D.First Aid $25,000 5100,000 E.Medical Payments F.Deposition Fees X $10,000 510 000 -Administrative Hearing Expense $25,000 5100,000 -Sexual Misconduct Expense $25,000 525,000 -Loss of Earnings $2,500 535,000 -HIPAA Proceeding Expense 525,000 $25,000 -Biomedical Waste Hearing Expense $10,000 $10,000 WORKPLACE LIABILTTY A.Healthcare Professional Premises Liability & B.Personal Injury Liability Workplace Lisalility dans narapplyit the deneral Uahifîly insuring A greemenf la sua part of your cou rage. EMPLOYMENT PRACTICES LIABILITY" CYBER LIABILITY BILLING PRACTICES ®ULATORY COMMERCÎAL GENERAL LIABILITY -Each Occurrence Limit $1,000 000 -Damages to Premises Rented $1,000,000 to an Insured Business $1,000,000 -Personal &Advertising Injury X -General Aggregate Limit $6,000,000 -Product Completed Operations Aggregate $6,000,000 -Hired and Non-Owned Auto GenerufLiebiHtrduesrrorappIrifthuWurkplacrUabillryinsuringAyrtementismad=partoryoureuvvage. FORMS &ENDORSEMENTS:Master Policy Number:|MMPOC19190 [N WITNESS WHEREDF,The Medfæl Protective Company has caused this policy to be signed by ils Prestdent afid Corporate Secretary (andSEEPOLICYFORMS&ENDORSEMENTS SCHEDULE countersignedbvilsduivAuthanzedRecresentative.whereneœssary) Premium:$4.932.00 For Service or questions,please call:President Surcharges: CM&F Group,Inc.1-800-221-4904 LG RACACLawl ) FOTAL:$4.932.00 Secretary *THIS POLICY CONTAINS CLAIMS-MADE COVERAGE,C untersgnatureiAultiertzedRepresentative:**CLAIM EXPENSE IS PAID WITHIN THE LIMITS OF LIABILITY,NOTICE LIMITS MAY CHANGE BY COVERAGE PROVISION OR ENDORSEMENT. PLEASE READ YOUR POLICY AND ENDORSEMENTSCAREFULLY. DISCUSS WITH YOUR INSURANCE AGENT IF NEEDED. 18011 01/14 The Medical Protective Company® A STOCK INSURANCE COMPANY 5814 Reed Road,Fort Wayne,Indiana 46835 Strength.Defense.Solutions.Since 1899. MULTI-SPECIALTY HEALTIICARE PROFESSIONAL MASTER POLICY CERTIFICATE OF INSURANCE SClfEDULE OF POLICY FORMS &ENDORSEMENTS Forms and Endorsements of your Certificate are as follows: Form #Description |Form No.iTitle ----+-------------------------------------------------------------------------- |MCL ICover Letter )18011 IMPS Multi-Specialcy Bealtheare Professionals Policy Certificate | |1B507 MPS Multi-Specialcy Mealtheare Professionals Form &Endorsement Schedule |18505 |MFS Multi-specialEy Healthcare Professionals Policy Schedule of Insurede i 118511 IGeneral Definitions |18519 IGeneral Conditions [19522 1General Exclusions |18528 |Professional Liability Insuring Agreement -Occurrence |18560 ICammercial General Liability Insuring Agreement -Occurrence 118617 10isclosure Notice of Terrorism Insurance Coverage ! 118620 ICap on Losses from Certified Acts of Terrorism Endorsement 119565 [Additional Insured -Lessors of Premises &Leased Equipment |19120 IMPS Economic Sanctions Exclusion Endorsement [19121 1Economic Sanctions Exclusions Endorsemenc (GL)| |19098 IMPS Blanker Separate Limit Endorsement -PL Only i |19187 IBiomedical Waste Hearing Expense Endorsement -Occurrence | |19218 IReuse or Multidase Supply Procedure Exclusion Endorsement | |19631 |Procedures Exclusion Endorsement | 18752 |Washington Amendatory Endorsement ÷--------------+---------------------------------------------------- -------------------------------÷ 18507 All other terms and conditions of the Policy remain unchanged.08/13 The Medical Protective Company® ASTOCK INSURANCE COMPANY 5814 Reed Road,Fort Wayne,Indiana 46835 Strength.Defense.Solutions.Since 1899. MULTI-SPECIALTY HEALTHCARE PROFESSION4L MASTER POLICY SCHEDULE OF INSUREDS ENDORSEMENT Item l(a)of the CERTIFICATE is as follows: ITEM 1(a)NAMED INSURED PROFESSIONAL SERVICES SPECIALTY TYPE MODIFIED PREMIUM RETROACTIVE I)Individual COVERAGE SURCHARGEDATE*E)Entity ENDORSEMENT TAXES CLASS (If Applicable)S)Student NUMBER (If Applicable) Ellensburg Family Medicine E Not Applicable included Each employee,shareholder,partner,volunteers or independent contractor Healthcare Professional of EIIensburg Family Medicine but only while providing professional services on behalf or under the direction or control of Ellensburg Family Medicine excluding any physician,podiatrist,chiropractor,optometrist,nurse rnidwife,certified registered nurse anesthetist or dentist I Not Applicable included unless designated as an [nsured under your Certificale or by endorsement listed on your Certificate. Item 1(b)of the CERTIFICATE is as follows: PREMIUM AFFILIATED ITEM 1(a)NAMED SURCHARGEITEM1(b)ADDITIONAL INSURED INSURED TAXES (lf Applicable) Kittitas County All 1(a)Named Insureds Listed Above Included Kittitas County All 1(a)Named Insureds Listed Above Included All other terms and conditions of the Policy remain unchanged. 18505 08/13