HomeMy WebLinkAbout1991-107
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RESOLUTION NO. 91-107
2 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AGREEMENT BY AND BETWEEN THE CITY OF
3 SAN BERNARDINO AND COURTESY SERVICES OF SAN BERNARDINO, INC. TO
PROVIDE BILLING SERVICES FOR THE EMERGENCY MEDICAL SERVICE FEE
4 PROGRAM.
5 BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY
OF SAN BERNARDINO AS FOLLOWS:
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SECTION 1. The Mayor is hereby authorized and directed to
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execute on behalf of said City an agreement by and between the
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City of San Bernardino and Courtesy Services of San Bernardino,
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Inc. to provide billing services for the Emergency Medical
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Service fee program, a copy of said agreement is attached hereto,
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marked Exhibit "A", and incorporated herein by reference as fully
as though set forth at length.
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SECTION 2.
The authorization to execute the above-
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referenced agreement is rescinded if the parties to the agreement
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fail to execute it within sixty (60) days of the passage of this
resolution.
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DCR/dys/courtesy.res 1
March 18, 1991
1 RESOLUTION.. .AUTHORIZING THE EXECUTION OF AN AGREEMENT BY AND
BETWEEN THE CITY OF SAN BERNARDINO AND COURTESY SERVICES OF
2 SAN BERNARDINO, INC.... FOR THE EMERGENCY MEDICAL SERVICE FEE PROGRAM.
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I HEREBY CERTIFY that the foregoing resolution was duly
5 adopted by the Mayor and Common Council of the City of
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San Bernardino at a
regular
meeting thereof, held on the
day of
, 1991, by the following vote, to wit:
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1st
April
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Council Members:
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ESTRADA
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REILLY
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FLORES
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MAUDSLEY
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MINOR
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POPE-LUDLAM
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MILLER
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AYES
NAYS
ABSTAIN
x
x
x
x
x
x
x
~~~d-
Cit Clerk
of
The foregoing resolution is hereby approved thi[';/, 2nd day
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April
, 1991.
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23 Approved as to
form and legal content:
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JAMES F. PENMAN,
City Attorney
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DCR/dys/courtesy.res
March 18, 1991
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fu,o.o.l-\OI
1
AGREEMENT
2
THIS AGREEMENT, made and entered into this 15th
day
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of
1991 by and between the CITY OF
April
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SAN BERNARDINO, a Charter City of the State of California
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("Ci ty") and COURTESY SERVICES OF SAN BERNARDINO, INC., a
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California corporation ("Courtesy"):
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WITNESSETH:
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WHEREAS, City has established a billing program for
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Emergency Medical Services (EMS) provided by City, and
WHEREAS, Courtesy asserts that it is expert and competent
to prepare billing for such services and provide necessary
reports to City, and
WHEREAS, the parties desire to enter into an Agreement for
Courtesy to prepare such billing and to provide City with such
reports,
NOW THEREFORE, the parties hereto agree as follows:
1. City will provide the following services and
information:
a. City, by and through its Fire Department, will
provide necessary billing information from EMS calls to Courtesy
for bill preparation.
City may use a form which substantially
conforms to that form attached hereto as Exhibit "1" and
incorporated herein.
By mutual agreement between the parties,
the form or such necessary information may be altered or adjusted
from time to time.
b. Payments on bills will be received in and
receipted by City, by and through its Finance Department.
DAB/ses/dys/courtes2.agr 1
March 18, 1991
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City, by and through its Finance Department,
c.
2 shall forward a copy of the receipt to Courtesy for data base
3 updating.
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City, by and through its Finance Department, will
d.
5 provide Courtesy by the lOth of each month a list of all members
6 of the Emergency Medical Services fee program as of the last day
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Such report shall not be required if
of the previous month.
8 there is no change in the member list.
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2.
Courtesy shall provide the following services and
10 information:
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a.
Upon receipt from City, Courtesy will input
12 billing information into computer and generate individual bills.
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Within thirty (30) days of receipt of
b.
14 information, Courtesy will forward bills to City's print shop to
15 be metered and mailed.
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c.
Courtesy will provide the City's Finance and Fire
17 Departments with reasonable reports on the program as requested
18 by heads of such departments.
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d.
Courtesy will assist the City's Finance
Department with answering billing questions.
At the option of
21 City, Courtesy may respond directly to consumer or may provide
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22 answers to City.
Courtesy will not alter billing charges once
e.
24 generated unless authorized by the City's Finance Department.
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f.
Courtesy will incorporate the member information
provided by City into the data base before billing.
Such
27 members will not be billed.
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DAB/Ses/dys/courtes2.agr 2
March 18, 1991
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1
3.
This Agreement shall commence on the day and date
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first above shown and shall terminate on June 30, 1993.
Either
3 party may terminate this Agreement at any time upon thirty (30)
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days written notice to the other.
Upon termination all records
5 within the computer data bases, etc. dealing with the City
6 billing shall be returned to the City by Courtesy.
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4.
For services provided pursuant to this Agreement,
8 Courtesy shall be compensated 9.5% of the amount collected from
9 bills with the exception of the membership fee payable monthly,
by the fifteenth of the subsequent month.
All billing costs
11 shall be the sole cost and expense of Courtesy.
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5.
Courtesy shall be responsible only for the preparation
13 of bills and shall have no obligation whatsoever relating to
14 receipt or posting of cash, checks, or other payments.
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6.
For the purposes of this Agreement Courtesy shall be
16 an independent contractor and shall not be considered as an agent
17 or employee of City.
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7.
Any notice to be sent pursuant to this Agreement from
19 one party to the other shall be in writing and deposited with the
20 United states Postal Service, postage prepaid and addressed as
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21 follows:
TO CITY:
City Administrator
City of San Bernardino
300 N. "D" Street
San Bernardino, CA 92418
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TO COURTESY:
Courtesy Services of San Bernardino, Inc.
338 West Seventh Street
San Bernardino, CA 92401
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Nothing in this paragraph shall be construed to prevent the
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giving of notice by personal service.
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DABjsesjdysjcourtes2.agr 3
March 18, 1991
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8.
Courtesy may not assign this Agreement, nor may it be
2 assigned by operation of law, without prior written approval by
3 City.
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9.
Courtesy agrees to defend, indemnify, save and hold
5 City, its officers, agents and employees harmless from any claims
6 or suits that may be brought by third persons on account of
7 personal injury, death, or damage to property, or a property or
8 business or personal interest, arising from any negligent act or
9 omission by Courtesy while performing services under this
10 Agreement.
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10. City shall have the right during the term of this
12 Agreement and for 180 days thereafter to examine Courtesy's books
13 and records as they pertain to this Agreement during business
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hours and upon reasonable notice.
Courtesy agrees to make such
15 books and records available within the City limits of the City of
16 San Bernardino for such examination.
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11. This document contains the entire agreement between
18 the parties and may only be amended in writing.
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DAB/ses/dys/courtes2.agr 4
March 18, 1991
1 AGREEMENT BY AND BETWEEN THE CITY OF SAN BERNARDINO AND
COURTESY SERVICES OF SAN BERNARDINO, INC.
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IN WITNESS WHEREOF, the parties hereto have executed this
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Agreement on the day and date first above shown.
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ATTEST:
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..) . "J1{
BY: ! /1 'v~/u0(. , I /",-'v'h '-t,') ,
City Clerk .
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Approved as to form
and legal content:
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JAMES F. PENMAN,
City Attorney
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OF
J ('
'M2o T f!c.~
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COURTE Y S VIC~
SAN BER RDINO INC. J
/ I /~j
BY: I-
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BY:
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DAB/ses/dys/courtes2.agr 5
March 18, 1991
~
.
SectJnn C ,
C:~M~~e~r~~d ~I~~~~r~i~? 0 ( Do ~~. in u.. spac. )
. SectiOn F . .
FIRE MEO Member No.
ITlID OJ
SllCtionA
TI1IIl~: DVM ~ D PrivateVehide
AmbulanCa: Courtesy Uril II 0 []PM D EMT
Saetion 0
[ Wo
[Oja ]
SllCtionG
IrmTINo'ITlIDJ
Section E
Section B
[ LooMIo.
Sp.l
00_ ]
UNIT 1
DISPATCH
ARRIVAL
FINISHED
TOTAL
RESPONSE
Dasdnatlon:
OSt.B. OSBCMC O~H
o Ll.UMC 0 Klliaar 0""..
I'IIIIaraNlma f>9a _ Sax OM OF O,O.B.
S Space
Adctaoa Ajt.No City Zip
I Parertl
TaIephone Legal Gardan Addrass
L HaaIth IrISU'ane& Carrier Group' Pdiey No. Med.Care No
L
I Sac. Sac. No. IrISU'ane& Poky HoIdar
N EfTllIoyer Adaass City Phone
G D Industrial Injury D ALS Charge $200 D SLS Charge $ 100
BSH Cor1a1 NO BSHCa1ad
NO
Charge
pt. I ned A.MA
Care Refused
Public Service
D.OA
Section J
Situation:
Action:
Section K
SBFO EMS Providers Names B 8 B B
(First In~ial and Last Name)
R"IlOrting 0Iliear
Sig1 Officer in Charge Rarl< Reviewed By
,.rm M. 2
EXHIBIT 11111
l
MEDICAL I BILL RELEASE
I request that payment of authorized Medicare and! or other insurance benefits be made e~her to me or on my behaff TO THE CITY OF
SAN BERNARDINO or ~'s agents for any medically related services fumished to me by the C~ of San Bernardino Fire Department. I
authorize any holder of medical information about me to release to the Heahh Care Financing Administration and ~'s agents or other
authorized interested parties information needed to determine these benef~s or the benefits payable to related services.
I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. ~
other heahh insurance is indicated in ~em 9 of the HCFA 1500 form OR elsewhere on other approved claim forms of eledronically
submitted claims, my signature authorizes release of the information to the insurer or agency shown.
Only in Medicare accepted assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier
as the full charge, and the patient is responsible only for the dedudible, coinsurance and noncovered services. Coinsurance and the
deductible are based upon the charge determination of the Medicare carrier.
I understand that any form of payment other than payment in full at time of service of this bill const~utes the granting of credtt to me by
the C~ of San Bernardino. Further in accordance w~h this granting of cred~ I authorize and dired any agency, company or person
holding information relating to my credit history and background to release such information to The C~ of San Bernardino or it's agents.
I herebv aaree to Dav anv balance due after Insurance Davment If I am not a current FIREMED Member
If I am a current FIREMED Member my Insurance deductible balance owed to the City of
San Bernardino has been pre-paid by the membership and any payment made to the C~y of San Bernardin~
or ~'s agents by my insurance on my beha~ will be accepted as payment in full.
X
Patient Signature
X
Signed for Patient by
PrW
Reason I patient was unable ID sign lor seW
I hereby certffy that the above named patient was accompanied to this facil~y by the San Bernardino C~y Fire Dept.
FACUTY SGtBl Tm.E DATE
NOTICE TO MEDICARE BENEFICIARY
Medicare will only pay for services that ~ determines to be "reasonable and necessary" under Sadion 1862(a)(1) of the Social Security
Ad. We believe that, for the services provided to you OR about to be provided to you by the San Bernardino C~ Fire Dept., Medicare
may deny payment unless certain diagnosis OR cond~ions are present.
~QC~C~~QCCCCCCC~C:
ell
~1CCCCCCCCCCCCCCCCCCCCCCCCCccccccccccccccccccccccccccac:c:cccccccor~cc
SBFD PI MEDIC
AMB..PI MEDIC
INITIATED ALS SERVICES TO PT. YESD NoD
INITIATED ALS SERVICES TO PT. YESD NoD
PROVIDED ALS SERVICES TO PT. )'ES D NO [1
PROVIDED ALS SERVICES TO PT. YES D NO CJ