COMPLETED BOARD ORDER AND AME
=�17
Before the Board of Supervisors in and for the
County of Monterey, State of California
Agreement No. A-11709
Authorize the Purchasing Manager for Natividad Medical
Center NMC) to execute Amendment #1 to the Agreement
A-11709 with Supplemental Health Care Services for
Ancillary and Respiratory Registry Staffing Services at NMC
in an amount not to exceed $250,000 in the aggregate and
$125,000 for the period July 1, 2011 to June 30, 2012...........
Upon motion of Supervisor Salinas, seconded by Supervisor Calcagno, and carried by those
members present, the Board hereby;
Authorized the Purchasing Manager for Natividad Medical Center NMC) to
execute Amendment #1 to the Agreement # A-11709) with Supplemental Health
Care Services for Ancillary and Respiratory Registry Staffing Services at NMC in
an amount not to exceed $250,000 in the aggregate and $125,000 for the period
July 1, 2011 to June 30, 2012.
PASSED AND ADOPTED on this 28`h day of June, 2011, by the following vote, to wit:
AYES: Supervisors Calcagno, Salinas, and Parker
NOES: None
ABSENT: Supervisors Armenta and Potter
I, Gail T. Borkowski, Clerk of the Board of Supervisors of the County of Monterey, State of California, hereby
certify that the foregoing is a true copy of an original order of said Board of Supervisors duly made and entered in the
minutes thereof of Minute Book 75 for the meeting on June 28, 2011.
Dated: June 29, 2011 Gail T. Borkowski, Clerk of the Board of Supervisors
County of Monterey, State of California
By
Deputy
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COMPLETED BOARD ORDER AND AME
=�Original Agreement No or PO#. A-1 1709)
RENEWAL AMENDMENT NO. 1
FOR PROFESSIONAL SERVICE AGREEMENT
BETWEEN Supplemental Health Care Services AND
THE NATIVIDAD MEDICAL CENTER
FOR
Ancillary and Respiratory Registry Staffine Services
The parties to Professional Service Agreement, dated June 1, 2010 between the County of Monterey, on
behalf of Natividad Medical Center NMC"), and Supplemental Health Care Services Contractor),
hereby agree to renew their Agreement No. A-11709) on the following terms and conditions:
1. Contractor will continue to provide NMC with the same scope of service as stated in the original
Agreement No. A-11709).
2. This Amendment shall become effective on July 1, 2011 and shall continue in full force until June
30, 2012.
3. The total amount payable by County to Contractor under Agreement No. A-11709) shall not
exceed the tot 1 sum of $250,000 for the full term of the Agreement and $125,000 for fiscal year
p'-
4. All other terms and conditions of the Agreement shall continue in full force and effect.
5. A copy of this Amendment shall be attached to the original Agreement No. A-11709).
IN WITNESS WHEREOF, the parties hereto are in agreement with this Amendment and
Professional Service Agreement on the basis set forth in this document and have executed this
amendment on the day and year set forth herein.
NATIVIDAD MEDICAL CENTER
Signature
Purchasing Manager
Dated
Signature Dated t t I
NMC CEO
Approved as to Legal Form:
Charles J. McKee, County Counsel
tacy Saetta, Depu
Attorneys for County and NMC
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SIGNED BOARD REPORT AND SUPPO
@�MONTEREY COUNTY BOARD OF SUPERVISORS
MEETING: June 28, 2011 AGENDA NO.:
SUBJECT: Authorize the Purchasing Manager for Natividad Medical Center NMC)
to execute Amendment #I to the Agreement # A- 11709) with
Supplemental Health Care Services for Ancillary and Respiratory
Registry Staffing Services at NMC in an amount not to exceed $250,000
in the aggregate and $125,000 for the period July 1, 2011 to June 30,
2012.
DEPARTMENT: Natividad Medical Center
RECOMMENDATION:
It is recommended that the Board of Supervisors authorize the Purchasing Manager for Natividad
Medical Center NMC) to execute Amendment #I to the Agreement # A- 11709) with Supplemental
Health Care Services for Ancillary and Respiratory Registry Staffing Services at NMC in an amount
not to exceed $250,000 in the aggregate and $125,000 for the period July 1, 2011 to June 30, 2012.
SUMMARY/DISCUSSION:
Natividad Medical Center NMC) contracts with outside staffing agencies that provide the hospital
with Respiratory Therapists, Occupational and Physical Therapists when the hospital is unable to
recruit licensed personnel for these positions, and also to cover short term absences of existing staff.
The affected departments are also currently working on cross training efforts to provide coverage to
support these service lines.
These positions are essential in order for NMC to meet clinical needs, and to comply with
regulations as established by The Joint Commission; a regulatory agency that sets standards of care
for hospitals and ancillary clinical services. This action will allow NMC to continue to provide
appropriate staffing to cover the Cardiopulmonary, and Occupational/Physical Therapy
Departments; until the time where permanent replacements are determined.
Actual dollars spent as of June 8, 2011 are $31,010, out of the $125,000 budgeted for the period of
July 1, 2010 to June 30, 2011. A contingency amount of $125,000 is based on historic actual usage
and needed reserve in order to maintain a method of payment for the period of July 1, 2011 to June
30, 2012.
OTHER AGENCY INVOLVEMENT:
The Amendment has been reviewed and approved by County Counsel, the Auditor/Controller's
office and the Natividad Medical Center Board of Trustees.
FINANCING:
The cost for this Amendment is $125,000 and is included in the 2011/2012 Fiscal Year
Recommended Budget. This action will not require any additional General Fund subsidy.
Prepared by:
John Nevill, Director of Cardiopulmonary 755-4366
April 4, 2011
Harry Weis
Chief Executive Officer
Attachments: Amendments #1, Original Agreement, Board Order
Attachments are on file with the Clerk of the Board
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@�MONTEREY COUNTY BOARD OF SUPERVISORS
MEETING: June 8, 2010
AGENDA NO.:
SUBJECT: Authorize the Purchasing Manager for Natividad Medical Center NMC)
to execute an Agreement with Supplemental Health Care Services for
Temporary Staffing Services at NMC in an amount not to exceed
$125,000 for the period June 1, 2010 to June 30, 2011,
DEPARTMENT: Natividad Medical Center
RECOMMENDATION:
It is recommended the Board of Supervisors authorize the Purchasing Manager for Natividad
Medical Center NMC) to execute an Agreement with Supplemental Health Care Services for
Temporary Staffing Services at NMC in an amount not to exceed $125,000 for the period June 1,
2010 to June 30, 2011.
SUMMARY/DISCUSSION:
Natividad Medical Center NMC) contracts with outside staffing agencies that provide the hospital
with Respiratory Therapists when the hospital is unable to recruit licensed personnel for these
positions, and also to cover short term absences of existing staff. The Cardiopulmonary Department
at NMC provides services 24 hours per day, 7 days per week for inpatients and Monday through
Friday 8:00 A.M. to 4:30 P.M. for outpatients.
Respiratory Therapists work with the hospital's Physician and Nursing staff to provide diagnostic as
well as clinical services to assist Respiratory and Cardiac compromised patients. Services provide
include assessment and treatment of adult, pediatric and neonatal patients. Additional hospital
departments Outpatient and Occupational Therapy and Pharmacy) are also included in the
Agreement in case of emergency need of licensed and qualified temporary services.
OTHER AGENCY INVOLVEMENT:
The Agreement has been reviewed and approved by County Counsel, the Auditor/Controller's
office, and the Natividad Medical Center Board of Trustees' Finance Committee.
FINANCING:
The cost for this Agreement is $125,000; $8,000 is included in the Fiscal Year 20 9-2-01-0-Approved
B-udget-and-$-l 17,000 is approved-in the Fiscal Year 2010/2011 Recommended Budget. This action
will not require any additional General Fund subsidy.
Prepared by:
John Nevill Harry Weis
Cardiopulmonary Manager Chief Executive Officer
May_1-0,204-0
Attaclunents: Agreement, Board Order
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SIGNED BOARD REPORT AND SUPPO
@�7
20
Before the Board of Supervisors in and for the
County of Monterey, State of California
Agreement No: A 11709
Authorize the Purchasing Manager for Natividad
Medical Center NMC) to execute an Agreement with
Supplemental Health Care Services for Temporary
Staffing Services at NMC in an amount not to exceed
$125,000 for the period June 1, 2010 to June 30, 2011.
Upon motion of Supervisor Armenta, seconded by Supervisor Parker, and carried by those
members present, the Board hereby:
Authorized the Purchasing Manager for Natividad Medical Center NMC) to execute an
Agreement with Supplemental Health Care Services for Temporary Staffing Services at NMC in
an amount not to exceed $125,000 for the period June 1, 2010 to June 30, 2011.
PASSED AND ADOPTED this 8`h day of June, 2010, by the following vote, to wit:
AYES: Supervisors Armenta, Calcagno, Salinas, Parker, Potter
NOES: None
ABSENT: None
I, Gail T. Borkowski, Clerk of the Board of Supervisors of the County of Monterey, State of California, hereby
certify that the foregoing is a true copy of an original order of said Board of Supervisors duly made and entered in
the minutes thereof of Minute Book 75 for the meeting on June 8, 2010.
Dated: June 11, 2010 Gail T. Borkowski, Clerk of the Board of Supervisors
County of Monterey, State of California
By l
Deputy
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SIGNED BOARD REPORT AND SUPPO
@�A Notivi ad MEDICALCENTER
COUNTY OF MONTEREY AGREEMENT FOR PROFESSIONAL SERVICES
MORE THAN $100,000)
This Professional Services Agreement hereinafter Agreement") is made by and between Natividad
Medical Center NMC"), a general acute care teaching hospital wholly owned and operated by the County
of Monterey, which is a political subdivision of the State of California and Supplemental Health Care
hereinafter CONTRACTOR").
In consideration of the mutual covenants and conditions set forth in this Agreement, the parties agree as
follows:
I SERVICES TO BE PROVIDED. NMC hereby engages CONTRACTOR to perform, and
CONTRACTOR hereby agrees to perform, the services described in Exhibit A in conformity with the
terms of the Agreement. The services are generally described as follows: Provide Temporary
Staffing including but not limited to Therapy PT, OT, SLP, COTA, PTAs) Radiology, Pharmacy
2. PAYMENTS BY NMC. NMC shall pay the CONTRACTOR in accordance with the payment
provisions set forth in Exhibit A, subject to the limitations set forth in this Agreement. The total amount
payable by NMC to CONTRACTOR under this Agreement shall not exceed the sum of $125,000
3. TERMS OF AGREEMENT The term of this Agreement is from JJun 1, 2010 to Jun 30, 2011
unless sooner terminated pursuant to the terms of this Agreement. This Agreement is of no force or
effect until signed by both CONTRACTOR and NMC and with NMC signing last and CONTRACTOR
may not commence work before NMC signs this Agreement.
4. ADDITIONAL PROVISIONS/EXHIBITS. The following attached exhibits are incorporated herein
by reference and constitute a part of this Agreement:
Exhibit A Scope of Services/Payment Provisions
5. PERFORMANCE STANDARDS.
5.1. CONTRACTOR warrants that CONTRACTOR and Contractor's agents, employees, and
subcontractors performing services under this Agreement are specially trained, experienced,
competent,-and_appropriately licensed to_perform the_work_and delh er_tlie_ser ices required under
this Agreement and are not employees of NMC, or immediate family of an employee of NMC.
5.2. CONTRACTOR, its agents, employees, and subcontractors shall perform all work in a safe and
skillful manner and in compliance with all applicable laws and regulations. All work performed
under this Agreement that is required by law to be performed or supervised by licensed personnel
shall be performed in accordance with such licensing requirements.
5.3. CONTRACTOR shall furnish, at its own expense, all materials, equipment, and personnel
necessary to carry out the terms of this Agreement, except as other wise specified in this
Agreement. CONTRACTOR shall not use NMC premises, property inc uding equipment,
Revised NMC PSA Form over $100,000
Page 1 of 8
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@�instruments, or supplies) or personnel for any purpose other than in the performance of its
obligations under this Agreement.
6. PAYMENT CONDITIONS.
6.1. CONTRACTOR shall submit to the Contract Administrator an invoice on a form acceptable to
NMC. If not otherwise specified, the CONTRACTOR may submit such invoice periodically or at
the completion of services, but in any event, not later than thirty 30) days after completion of
services. The invoice shall set forth the amounts claimed by CONTRACTOR for the previous
period, together with an itemized basis for Administrator or his or her designee shall certify the
invoice, either in the requested amount or in such other amount as NMC approves in conformity
with this Agreement, and shall promptly submit such invoice to the County Auditor-Controller for
payment. The County Auditor-Controller shall pay the amount certified within thirty 30) days of
receiving the certified invoice.
6.2. CONTRACTOR shall not receive reimbursement for travel expenses unless set forth in this
Agreement; and then only in accordance with any applicable County policies.
7. TERMINATION.
7.1. During the term of this Agreement, NMC may terminate the Agreement for any reason by giving
written notice of termination to the CONTRACTOR at least thirty 30) days prior to the effective
date of termination. Such notice shall set forth the effective date of termination. In the event of such
termination, the amount payable under this Agreement shall be reduced in proportion to the services
provided prior to the date of termination.
7.2. NMC may cancel and terminate this Agreement for good cause effective immediately upon written
notice to Contractor. Good cause" includes the failure of CONTRACTOR to perform the required
services at the time and in the manner provided under this Agreement. If NMC terminates this
Agreement for good cause, NMC may be relieved of the payment of any consideration to
Contractor, and NMC may proceed with the work in any manner, which NMC deems proper. The
cost to NMC shall be deducted from any sum due the CONTRACTOR under this Agreement.
8. INDEMNIFICATION: CONTRACTOR shall indemnify, defend and hold harmless, NMC and the
County of Monterey hereinafter County"), it officers, agents and employees from any and all claims,
liability, losses, whatsoever including damages to property and injuries to or death of persons, court
costs, and reasonable attorneys' fees) occurring or resulting to any and all persons, firms or corporations
furnishing or supplying work, services, materials, or supplies in connection with the performance of this
Agreement, and-from any and all claims, liabilities and-losse occurring or resultmg to any person, firm,
or corporation for damage, injury, or death arising out of or connected with the Contractor's
performance of this Agreement, unless such claims, liabilities, or looses arise out of the sole negligence
or willful misconduct of NMC. Contractor's performance" includes Contractor's action or inaction and
the action or inaction of Contractor's officers, employees, agents and subcontractors.
9. INSURANCE.
9.1. Evidence of Coverage:
Prior to commencement of this Agreement, the CONTRACTOR shall provide a Certificate of
Insurance" certifying that coverage as required herein has been obtained. Individual endorsements
Revised NMC PSA Form over $100,000 Page 2 of 8
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@�executed by the insurance carrier shall accompany the certificate. In addition, the CONTRACTOR
upon request shall provide a certified copy of the policy or policies.
This verification of coverage shall be sent to NMC's Contracts/Purchasing Department, unless
otherwise directed. The CONTRACTOR shall not receive a Notice to Proceed" with the work
under this Agreement until it has obtained all insurance required and NMC has approved such
insurance. This approval of insurance shall neither relieve nor decrease the liability of the
Contractor.
9.2. Qualifying Insurers: All coverage's except surety, shall be issued by companies which hold a
current policy holder's alphabetic and financial size category rating of not less that A-VII,
according to the current Best's Key Rating Guide or a company of equal financial stability that is
approved by NMC's Contracts/Purchasing Director.
9.3. Insurance Coverage Requirements: Without limiting Contractor's duty to indemnify,
CONTRACTOR shall maintain in effect throughout the term of this Agreement a policy or policies
of insurance with the following minimum limits of liability:
Commercial general liability insurance, including but not limited to premises and operations,
including coverage for Bodily Injury and Property Damage, Personal Injury, Contractual Liability,
Broad form Property Damage, Independent Contractors, Products and Completed Operations, with a
combined single limit for Bodily Injury and Property Damage of not less than $1,000,000 per
occurrence.
Exemption/Modification Justification attached; subject to approval).
Business automobile liability insurance, covering all motor vehicles, including owned, leased, non-
owned, and hired vehicles, used in providing services under this Agreement, with a combined single
limit for Bodily Injury and Property Damage of not less than $1,000,000 per occurrence.
Exemption/Modification Justification attached; subject to approval).
Workers' Compensation Insurance, If CONTRACTOR employs other in the performance of this
Agreement, in accordance with California Labor Code section 3700 and with Employer's Liability
limits not less than $1,000,000 each person, $1,000,000 each accident and $1,000,000 each disease.
F]' Exemption/Modification Justification attached; subject to approval).
Professional-liability insiTranct-if reFquir-ed-forth- rofas o-n serv ceg-b i provided-; e, those
persons authorized by a license to engage in a business or profession regulated by the California
Business and Professions Code), in the amount of not less than $1,000,000 per claim and $2,000,000
in the aggregate, to cover liability for malpractice or errors or omissions made in the course of
rendering professional services. If professional liability insurance is written on a claims-made"
basis rather than an occurrence basis, the CONTRACTOR shall, upon the expiration or earlier
termination of this Agreement, obtain extended reporting coverage tail coverage") with the same
liability limits. Any such tail coverage shall continue for at least three years following the expiration
or earlier termination of this Agreement.
F Exemption/Modification Justification attached; subject to approval).
Revised NMC PSA Form over $100,000
Page 3 of 8
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
FO96183-U03
FO96184-U03
FO99828-U03
MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
AUTHORIZE-U07
THE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
1-U07
TO-U07
THE-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
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6/17/2011-U011
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A-11709)-U012
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HEALTH-U012
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REGISTRY-U012
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AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$250,000-U012
IN-U012
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AGGREGATE-U012
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THE-U012
PERIOD-U012
JULY-U012
1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@�9.4. Other Insurance Requirements:
All insurance required by this Agreement shall be with a company acceptable to NMC and issued
and executed by an admitted insurer authorized to transact insurance business in the State of
California. Unless otherwise specified by this Agreement, all such insurance shall be written on an
occurrence basis, or, if the policy is not written on an occurrence basis, such policy with the
coverage required herein shall continue in effect for a period of three years following the date
CONTRACTOR completes its performance of services under this Agreement.
Each liability policy shall provide that NMC shall be given notice in writing at least thirty days in
advance of any endorsed reduction in coverage or limit, cancellation, or intended non-renewal
thereof. Each policy shall provide coverage for CONTRACTOR and additional insured with respect
to claims arising from each subcontractor, if any, performing work under this Agreement, or be
accompanied by a certificate of insurance from each subcontractor showing each subcontractor has
identical insurance coverage to the above requirements.
Commercial general liability and automobile liability policies shall provide an endorsement naming
the County of Monterey, its officers, agents, and employees as Additional insureds with respect to
liability arising out of the Contractor's work, including ongoing and completed operations, and shall
further provide that such insurance is primary insurance to any insurance or self-insurance
maintained by the County and that the insurance of the Additional Insureds shall not be called upon to
contribute to a loss covered by the Contractor's insurance. The required endorsement from for
Commercial General Liability Additional Insured is ISO Form CG 20 10 1 1-85 or CG 20 10 10 01
in tandem with CG 20 37 10 01 2000). The required endorsement from for Automobile Additional
Insured Endorsement is ISO Form CA 20 48 02 99.
Prior to the execution of this Agreement by NMC, CONTRACTOR shall file certificates of
insurance with NMC's Contracts/Purchasing Department, showing that the CONTRACTOR has in
effect the insurance required by this Agreement. The CONTRACTOR shall file a new or amended
certificate of insurance within five 5) calendar days after any change is made in any insurance
policy, which would alter the information on the certificate then on file. Acceptance or approval of
insurance shall in no way modify or change the indemnification clause in this Agreement, which
shall continue in full force and effect.
CONTRACTOR shall at all times during the term of this Agreement maintain in force the insurance
coverage required under this Agreement and shall send, without demand by NMC, annual
certificates to NMC's Contracts/Purchasing Department. If the certificate is not received by the
expiration date, NMC sha11 nori CONTRACTOI d-CONTRACTOR shall-have five calends
days to send in the certificate, evidencing no lapse in coverage during the interim. Failure by
CONTRACTOR to maintain such insurance is a default of this Agreement, which entitles NMC, at
its sole discretion, to terminate the Agreement immediately.
10. RECORDS AND CONFIDENTIALITY.
10.1. Confidentiality, CONTRACTOR and its officers, employees, agents and subcontractors shall
comply with any and all federal, state, and local laws, which provide for the confidentiality of
records and other information. CONTRACTOR shall not disclose any confidential records or other
confidential information received from NMC or prepared in connection with the performance of this
Revised NMC PSA Form over $100,000 Page 4 of 8
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
FO96183-U03
FO96184-U03
FO99828-U03
MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
AUTHORIZE-U07
THE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
1-U07
TO-U07
THE-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
6/17/2011-U011
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A-11709)-U012
SUPPLEMENTAL-U012
HEALTH-U012
CARE-U012
SERVICES-U012
ANCILLARY-U012
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TO-U012
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PERIOD-U012
JULY-U012
1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@�Agreement, unless NMC specifically permits CONTRACTOR to disclose such records or
information. CONTRACTOR shall promptly transmit to NMC any and all requests for disclosure of
any such confidential records or information. CONTRACTOR shall not use any confidential
information gained by CONTRACTOR in the performance of this Agreement except for the sole
purpose of carrying out Contractor's obligations under this Agreement.
10.2. NMC Records. When this Agreement expires or terminates, CONTRACTOR shall return to NMC
and NMC records which CONTRACTOR used or received from NMC to perform services under
this Agreement.
10.3. Maintenance of Records. CONTRACTOR shall prepare, maintain, and preserve all reports and
records that may be required by federal state, and County rules and regulations related to services
performed under this Agreement. CONTRACTOR shall maintain such records for a period of at
least three years after receipt of final payment under this Agreement. If any litigation, claim,
negotiation, audit exception, or other action relating to this Agreement is pending at the end of the
three year period, then CONTRACTOR shall retain said records until such action is resolved.
10.4. Access to and Audit of Records. NMC shall have the right to examine, monitor and audit all
records, documents, conditions, and activities of the CONTRACTOR and its subcontractors
related to services provided under this Agreement. Pursuant to Government Code section 8546.7,
if this Agreement involves the expenditure of public funds in excess or $10,000, the parties to this
Agreement may be subject, at the request of NMC or as part of any audit of NMC, to the
examination and audit of the State Auditor pertaining to matters connected with the performance
of this Agreement for a period of three years after final payment under the Agreement.
10.5. Royalties and Inventions. NMC shall have a royalty-free, exclusive and irrevocable license to
reproduce, publish, and use, and authorize other to do so, all original computer programs, writings,
sound recordings, pictorial reproductions, drawings, and other works of similar nature produced in
the course of or under this Agreement. CONTRACTOR shall not publish any such material
without the prior written approval of NMC.
11. NON-DISCRIMINATION. During the performance of this Agreement, Contractor, and its
subcontractors, shall not unlawfully discriminate against any person because of race, religious creed,
color, sex, national origin, ancestry, physical disability, mental disability, medical condition, marital
status, age over 40), or sexual orientation, either in Contractor's employment practices or in the
furnishing of services to recipients. CONTRACTOR shall ensure that the evaluation and treatment of its
employees and applicants for employment and all persons receiving and requesting services are free of
such discrimination. CONTRACTOR and any subcontractor shall, in the performance of this
Agre~merit,~futl~omply^vvith 11-fede al ate; anzl-local-IaZVS~~rdreg it tuns which prohibit
discrimination. The provision of services primarily or exclusively to such target population as may be
designated in this Agreement shall not be deemed to be prohibited discrimination.
12. COMPLIANCE WITH TERMS OF STATE OR FEDERAL GRANT. If this Agreement has been or
will be funded with monies received by NMC pursuant to a contract with the state or federal government
in which NMC is the grantee, CONTRACTOR will comply with all the provisions of said contract, and
said provisions shall be deemed a part of this Agreement, as though fully set forth herein. Upon request,
NMC will deliver a copy of said contract to Contractor, at no cost to Contractor.
Revised NMC PSA Form over $100,000 Page 5 of 8
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
FO96183-U03
FO96184-U03
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MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
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THE-U07
PURCHASING-U07
MANAGER-U07
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NO.-U07
1-U07
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960-NMC-U08
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6/17/2011-U011
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SUPPLEMENTAL-U012
HEALTH-U012
CARE-U012
SERVICES-U012
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THE-U012
PERIOD-U012
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1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@ �13, INDEPENDENT CONTRACTOR. In the performance of work, duties, and obligations under this
Agreement, CONTRACTOR is at all times acting and performing as an independent CONTRACTOR
and not as an employee of NMC. No offer or obligation of permanent employment with NMC or
particular County department or agency is intended in any manner, and CONTRACTOR shall not
become entitled by virtue of this Agreement to receive from NMC any form of employee benefits
including but not limited to sick leave, vacation, retirement benefits, workers' compensation coverage,
insurance or disability benefits. CONTRACTOR shall be solely liable for an obligated to pay directly all
applicable taxes, including federal and state income taxes and social security, arising out of Contractor's
performance of this Agreement. In connection therewith, CONTRACTOR shall defend, indemnify, and
hold NMC and the County of Monterey harmless from any and all liability, which NMC may incur
because of Contractor's failure to pay such taxes.
14. NOTICES. Notices required under this Agreement shall be delivered personally or by first-class,
postage per-paid mail to NMC and Contractor's contract administrators at the addresses listed below.
FOR NATIVIDAD MEDICAL CENTER:
Contracts/Purchasing Manager
Name and Title
FOR CONTRACTOR:
1441 Constitution Blvd. Salinas, CA. 93906
Address
831.755.4111
Phone
15. MISCELLANEOUS PROVISIONS.
Address
15.1. Conflict of Interest. CONTRACTOR represents that it presently has no interest and agrees not to
acquire any interest during the term of this Agreement, which would directly, or indirectly
conflict in any manner or to any degree with the full and complete performance of the professional
services requirec moo be rendered under this Agreemen
15.2. Amendment. This Agreement may be amended or modified only by an instrument in writing
signed by NMC and the Contractor.
15.3. Waiver Any waiver of any terms and conditions of this Agreement must be in writing and signed
by NMC and the Contractor. A waiver of any of the terms and conditions of this Agreement shall
not be construed as a waiver of any other terms or conditions in this Agreement.
15.4. Contractor. The term Contractor" as used in this Agreement includes Contractor's officers,
agents, and employees acting on Contractor's behalf in the performance of this Agreement.
Revised NMC PSA Form over $100,000
Page 6 of 8
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
FO96183-U03
FO96184-U03
FO99828-U03
MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
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30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@
�15.5. Disputes. CONTRACTOR shall continue to perform under this Agreement during any dispute.
15.6. Assignment and Subcontracting. The CONTRACTOR shall not assign, sell, or otherwise transfer
its interest or obligations in this Agreement without the prior written consent of NMC. None of the
services covered by this Agreement shall be subcontracted without the prior written approval of
NMC. Notwithstanding any such subcontract, CONTRACTOR shall continue to be liable for the
performance of all requirements of this Agreement.
15.7. Successors and Assigns. This Agreement and the rights, privileges, duties, and obligations of NMC
and CONTRACTOR under this Agreement, to the extent assignable or delegable, shall be binding
upon and inure to the benefit of the parties and their respective successors, permitted assigns, and
heirs.
15.8. Compliance with Applicable Law. The parties shall comply with all applicable federal, state, and
local laws and regulations in performing this Agreement.
15.9. Headings. The headings are for convenience only and shall not be used to interpret the terms of
this Agreement.
15.10. Time is of the Essence. Time is of the essence in each and all of the provisions of this Agreement
15.11. Governing Law. This Agreement shall be governed by and interpreted under the laws of the State
of California.
15.12. Non-exclusive Agreement. This Agreement is non-exclusive and both NMC and
CONTRACTOR expressly reserve the right to contract with other entities for the same or similar
services.
15.13. Construction of Agreement NMC and CONTRACTOR agree that each party has fully
participated in the review and revision of this Agreement and that any rule of construction to the
effect that ambiguities are to be resolved against the drafting party shall not apply in the
interpretation of this Agreement or any amendment to this Agreement.
15.14. Counterparts This Agreement may be executed in two or more counterparts, each of which shall
be deemed an original, but all of which together shall constitute one and the same Agreement.
15.15. Integration. This Agreement, including the exhibits, represents the entire Agreement between
NMCand-th-e-C-O RAC-TOR with-respect-to the-subject-matter-cfthis Agre-ement-and-shall
supersede all prior negotiations. Representations, or agreements, either written or oral, between
NMC and CONTRACTOR as of the effective date of this Agreement, which is the date that
NMC signs the Agreement.
15.16. Interpretation of Conflicting Provisions In the event of any conflict or inconsistency between the
provisions of this Agreement and the Provisions of any exhibit or other attachment to this
Agreement, the provisions of this Agreement shall prevail and control.
Revised NMC PSA Form over $100,000 Page 7 of 8
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
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FO99828-U03
MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
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REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
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960-NMC-U08
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THE-U012
PERIOD-U012
JULY-U012
1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@
�NATIVIDAD MEDICAL CENTER
By:
NMC Contracts/Purchasing Agent
Date:
Department Head if applicable)
Date:
By: Z~n J G
St y Saetta, D puty County Counsel
Date: 6Wk
By:
Auditor/Contfoiler
Date: 5 11 1t)
CONTRACTOR
Contractor's Business Name***
gnature df Chair, Presidentkor Vice-President
Name and Title
Date: &21 v /l U
By:
CFO, Treasurer or Asst. Treasurer
ignature of Secretary, Asst cret
Name and Title
Date: / V
***INSTRUCTIONS: If CONTRACTOR is a
corporation, including limited liability and
non-profit corporations, the full legal name
of the corporation shall be set forth above
together with the signatures of two
specified officers. If CONTRACTOR is a
partnership, the name of the partnership
shall be set forth above together with the
signature of a partner who has authority to
execute this Agreement on behalf of the
partnership. If CONTRACTOR is
contracting in and individual capacity, the
individual shall set forth the name of the
business. if any and shall personally sign
the Agreement.
Revised NMC PSA Form over $100,000
Page 8 of 8
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
FO96183-U03
FO96184-U03
FO99828-U03
MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
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1-U07
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960-NMC-U08
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6/17/2011-U011
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IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$250,000-U012
IN-U012
THE-U012
AGGREGATE-U012
$125,000-U012
THE-U012
PERIOD-U012
JULY-U012
1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@
�Schedule A
Natividad Hospital
Client 2011 Bill Rates
Regular
Registry/Per
Diem Regular
Weekend
Base Travel*
Specialty Hours Hours Hours
Occupational Therapist & Physical Therapist $68.00 $68.00 $70/hour*
Speech Language Pathologist $73.00 $70.00 $72/hour*
Occupational Therapist Assistant & Physical
Therapist Assistant $56.00 $57.00 $59/hour*
$62,00- $67/hour*
Respiratory Therapist $67.00/hour
*Travel Rates: Negotiated on a case by case basis pending request/geographic location. Rate is agreed and
confirmed in writing prior to assignment.
Billable Mileage or Transportation Costs: In the event that Client requires Company Health Care Personnel to
travel between facilities during any work day, mileage between facilities will be billed to Client at a rate of
$ per mile.
Billable Housing Costs: No Billable Housing Costs; rates are inclusive.
Billable Employment Conversion Permanent Placement) Costs: Any Company Health Care Personnel, whose
profile has been submitted to Client by Company, may not be employed at Client either directly or through another
Agency for one year following the termination of the assignment for any reason. However, any Company health Care
Personnel may become an employee of the client with the payment of a placement fee and a 30 day notice of perm
hire at the Client facility. If the employee has worked less than 520 hours, Client agrees to pay a Ten Thousand
$10,000) fee for said hire. If the employee has worked 520 1040 hours and Client desires to make Company health
Care Personnel a direct employee, Client agrees to pay an Eight Thousand Dollar $8,000) fee. In the event that after
employee has worked 1040 hours of service client wishes to hire employee directly a Four Thousand $4,000) fee will
be due.
Billable Shift or Assignment Cancellation Terms: A Thirty 30) day notice is required for cancellation of all travel
assignments. Two 2) week notice for cancellation of 30 day or ongoing assignments and a Forty eight 48) hour
cancellation of PRN shifts is required; otherwise a four 4, 6, or 8) hour minimum billing for Shifts will be assessed
depending on confirmation of 6, 8, or 10 hour confirmed assignment.
Other Billable Costs or Terms:
Overtime rate equal to time and one half on hours worked as required by the highest of federal or state law.
Holiday rate equal to time and one half on hours worked as required by the highest of federal or state law.
*All rates include payroll costs, employee benefits, malpracticelliability insurance, and travel expenses if
required and not agreed upon with confirmation of assignment.
Signature Date
BIB]
40740-U01
SIGNED-U02
BOARD-U02
REPORT-U02
SUPPORTING-U02
DOCS-U02
LI21329-U03
FO96183-U03
FO96184-U03
FO99828-U03
MG99940-U03
AS99966-U03
AS99967-U03
AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
REPORTS-U03
7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
AUTHORIZE-U07
THE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
1-U07
TO-U07
THE-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
6/17/2011-U011
AGREEMENT-U012
A-11709)-U012
SUPPLEMENTAL-U012
HEALTH-U012
CARE-U012
SERVICES-U012
ANCILLARY-U012
RESPIRATORY-U012
REGISTRY-U012
STAFFING-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$250,000-U012
IN-U012
THE-U012
AGGREGATE-U012
$125,000-U012
THE-U012
PERIOD-U012
JULY-U012
1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
2012.-U012
SIGNED BOARD REPORT AND SUPPO
@
�Schedule A
Natividad Hospital
Client 2010 Bill Rates
Regular
Registry/P
er Diem Regular
Weekend Base
Travel*
Call Back/Holiday
Specialty Hours Hours Hours Hours
Occupational Therapist & Physical Therapist $67.00 $68.00 $70/hour* Time and %2 Base Rate
Speech Language Pathologist $73.00 $70.00 $72/hour* Time and %2 Base Rate
Occupational Therapist Assistant & Physical
Therapist Assistant $56.00 $57.00 $59/hour* Time and %2 Base Rate
$62,00- $66/hour* Time and % Base Rate
Respiratory Therapist 66.00/hour
*Travel Rates: Negotiated on a case by case basis pending request/geographic location. Rate is agreed and
confirmed in writing prior to assignment.
Billable Mileage or Transportation Costs: In the event that Client requires Company Health Care Personnel to
travel between facilities during any work day, mileage between facilities will be billed to Client at a rate of
$ per mile.
Billable Housing Costs: No Billable Housing Costs; rates are inclusive.
Billable Employment Conversion Permanent Placement) Costs: Any Company Health Care Personnel, whose
profile has been submitted to Client by Company, may not be employed at Client either directly or through another
Agency for one year following the termination of the assignment for any reason, However, any Company health Care
Personnel may become an employee of the client with the payment of a placement fee and a 30 day notice of perm
hire at the Client facility. If the employee has worked less than 520 hours, Client agrees to pay a Ten Thousand
$10,000) fee for said hire. If the employee has worked 520- 1040 hours and Client desires to make Company health
Care Personnel a direct employee, Client agrees to pay an Eight Thousand Dollar $8,000) fee, In the event that after
employee has worked 1040 hours of service client wishes to hire employee directly a Four Thousand $4,000) fee will
be due.
Billable Shift or Assignment Cancellation Terms: A Thirty 30) day notice is required for cancellation of all travel
assignments.-Two-(2) week notice-for-cancell ation-of-30-day-or-ongoing-assignments-and-a-Forty=eight(48)-hour
cancellation of PRN shifts is required; otherwise a four 4, 6, or 8) hour minimum billing for Shifts will be assessed
depending on confirmation of 6, 8, or 10 hour confirmed assignment.
Other Billable Costs or Terms:
Overtime rate equal to time and one half on hours worked as required by the highest of federal or state law.
Holiday rate equal to time and one half on hours worked as required by the highest of federal or state law.
*All rates include payroll costs, employee benefits, malpractice/llability insurance, and travel expenses if
required and not agreed upon with confirmation of assignment
BIB]
40740-U01
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TO-U012
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30,-U012
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SIGNED BOARD REPORT AND SUPPO
@�A~ & CERTIFICATE OF LIABILITY INSURANCE DATE MM/DDNYYY)
10/1/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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
Commercial Lines 206) 892-9200 CONTACT
NAME:
PHONE IFAX
I
A Li
#
D0
408 o E t A/C No:
nc. C
O
Wells Fargo Insurance Services USA,
c
8 MA L
ADDRESS:
601 Union Street, Suite 1300 PRODUCER SHCSERVIC
CUSTOMER ID #:
Seattle, WA 98101-1371
INSURERS AFFORDING COVERAGE NAIL #
INSURED INSURER A Homeland Insurance Company of NY 34452
SHC Services, Inc.
INSURER B National Union Fire Ins. Co. of Pittsburgh, PA
19445
1640 West Redstone Center Dr., Ste 200 INSURER C
Park City UT 84098 INSURER D
INSURER E
INSURER F
COVERAGES
CERTIFICATE NUMBER: 1862753
REVISION NUMBER: See below
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF AN Y CONTRACT OR OTHER DOCUMENT WITH RESPE CT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
ILTR I TYPE OF INSURANCE ADDL SUBRI
INSR WV POLICY NUMBER POLICY EFF POLICY EXP
MM/DD/YYYY MM/DDIYYYY LIMITS
1 GENERAL LIABILITY I
A MFL-0465-10
10/01/2010 10/01/2011 ILEACH OCCURRENCE $ 1,000,000
X I DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY I I PREMISES Ea occurrence $ 100,000
CLAIMS-MADE J OCCUR MED EXP Any one person) $ 5,000
PERSONAL & ADV INJURY $ Included
GENERAL AGGREGATE $ 3,000,000
EN'L AGGREGATE LIMIT APPLIES PER:
G PRODUCTS COMP/OP AGG $
PRO-
X $
POLICY
LOC
POLICY
B AUTOMOBILE LIABILITY 0934688 10/01/2010 10/01/2011 COMBINED SINGLE LIMIT
$ 1,000,000
Ea accident)
ANY AUTO BODILY INJURY Per person) $
ALL OWNED AUTOS BODILY INJURY Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE
$
X HIRED AUTOS Per accident)
NON-OWNED AUTOS 1 $
$
A L UMBRELLA LIABI OCCUR MFX-0138-10 10/01/2010 10/01/2011 EACH OCCURRENCE i s 7,000,000
I EXCESS LIAB CLAIMS-MADE AGGREGATE $ 7,000,000
DEDUCTIBLE $
H H RETENTION $ I s
WORKERS COMPENSATION I y I WC STATU- OTH-1
Unr
i
JTS
R
B AND EMPLOYERS' LIABILITY Y/N I 069862301 10/01/2010 10/01/2011 L
M
E
1
000
000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? N / A California EL. EACH ACCIDENT
$
Mandatory in NH) EL DISEASE EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT $ 1,000,000
A Medical Professional Liability MFL-0465-10 10/01/2010 10/01/2011 $1,000,000 OCC
$3,000,000 AGG
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES Attach ACORD 101, Additional Remarks Schedule if more space is required)
Evidence of Insurance
CERTIFICATE HOLDER
Natividad Medical Center
Attn: Sarah More, Staffing Coordinator
P.O. Box 81611
Salinas CA 93912-1611
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 2009/09) The ACORD name and logo are registered marks of ACORD
BIB]
40740-U01
SIGNED-U02
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SUPPORTING-U02
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FO96183-U03
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AS99966-U03
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AI103232-U03
DO104188-U03
C10-U03
BOARD-U03
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7/15/2011-U04
MARCELLAC-U04
16745-U05
1-U06
AUTHORIZE-U07
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SIGNED BOARD REPORT AND SUPPO
@�EXHIBIT B
INSURANCE JUSTIFICATION
Vendor/Contractor Name: Supplemental Healthcare Services SHC)
General Liability Auto Additional Insured Endorsements
Business Justification:
The vendor has provided proof of General Liability Insurance at the required amounts. Due
to the type of service provided by the vendor NMC request the Agreement be approved and
the requirement for General Liability Additional Insured Endorsement be waived.
Automobile Liability Additional Insured Endorsements
Business Justification:
The vendor has provided proof of Automobile Liability Insurance. NMC requests the
Agreement be approved and the requirement for the Additional Insured Endorsement for
Auto Insurance be waived.
Harry Weis
Chief Executive Officer
Date: 1(3JIta
BIB]
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IN-U012
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THE-U012
PERIOD-U012
JULY-U012
1,-U012
2011-U012
TO-U012
JUNE-U012
30,-U012
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SIGNED BOARD REPORT AND SUPPO
@�YEAR Withholding Exemption Certificate
2011
This fore can only be used to certify exemption from nonresident withholding under California Revenue
and Taxation Code R&TC) Section 18662. Do not use this form for exemption from wage withholding.)
File this form with your withholding agent. Please type or print)
Withholding agent's name
Natividad Medical Center
Payee's name
SHC Services, Inc.
Address number and street, PO Box, or PMB no.)
1640 W. Redstone Center Drive
City
Park City
CALIFORNIA FORM
590
Payee's Li SSN or ITIN
1 SOS tile no. F J CA corp. no. f FEIN
1 6 1 2 1 6 7 9 6
State
U T
ZIP Code
Apt. no] Ste. no
2 0 0
8-4 0 9 8
Read the following carefully and check the box that applies to the payee.
I certify that for the reasons checked below, the payee named on this form is exempt from the California income tax withholding
requirement on payment(s) made to the entity or individual.
Individuals Certification of Residency:
I am a resident of California and I reside at the address shown above. If I become a nonresident at any time, I will promptly
notify the withholding agent. See instructions for General Information D, Who is a Resident, for the definition of a resident.
1Z Corporations:
The above-named corporation has a permanent place of business in California at the address shown above or is qualified
through the California Secretary of State SOS) to do business in California. The corporation will file a California tax return
and withhold on payments of California source income to nonresidents when required. If this corporation ceases to have
a permanent place of business in California or ceases to do any of the above, I will promptly notify the withholding agent.
See instructions for General Information F, What is a Permanent Place of Business, for the definition of permanent place of
business.
Partnerships or limited liability companies LLC):
The above-named partnership or LLC has a permanent place of business in California at the address shown above or is
registered with the California SOS, and is subject to the laws of California. The partnership or LLC will file a California tax
return and will withhold on foreign and domestic nonresident partners or members when required. If the partnership or
LLC ceases to do any of the above, I will promptly inform the withholding agent. For withholding purposes, a limited liability
partnership LLP) is treated like any other partnership.
Tax-Exempt Entities:
The above-named entity is exempt from tax under California Revenue and Taxation Code R&TC) Section 23701
insert letter) or Internal Revenue Code Section 501(c) insert number). The tax-exempt entity will withhold on payments
of California source income to nonresidents when required. If this entity ceases to be exempt from tax, I will promptly notify the
withholding agent. Individuals cannot be tax-exempt entities.
Insurance Companies, Individual Retirement Arrangements IRAs), or Qualified Pension/Profit Sharing Plans:
The above-named entity is an insurance company, IRA, or a federally qualified pension or profit-sharing plan.
California Trusts:
At least one trustee and one noncontingent beneficiary of the above-named trust is a California resident. The trust will file a
California fiduciary tax return and will withhold on foreign and domestic nonresident beneficiaries when required. If the trustee
becomes a nonresident at any time, I will promptly notify the withholding agent.
Estates Certification of Residency of Deceased Person:
I am the executor of the above-named person's estate. The decedent was a California resident at the time of death. The estate
will file a California fiduciary tax return and will withhold on foreign and domestic nonresident beneficiaries when required.
Nonmilitary Spouse of a Military Servicemember:
I am a nonmilitary spouse of a military servicemember and I meet the Military Spouse Residency Relief Act MSRRA)
requirements. See instructions for General Information E, MSRRA.
CERTIFICATE: Please complete and sign below.
Under penalties of perjury, I hereby certify that the information provided in this document is, to the best of my knowledge, true and
correct. If conditions change, I will promptly notify the withholding agent.
Payee's name and title type or print) Steen Ure, CFO
Payee's signature
Daytime telephone no._435-776-7213
Date 03/10/2011
For Privacy Notice, get form FTB 1131 7061113 Form 590 C2 2010
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SIGNED BOARD REPORT AND SUPPO
@�Supplemental rl' Health Care SM
WORKFORCE SOLUTIONS
March 20, 2011
Sid Cato
Management Analyst/Contracts
Natividad Medical Center
1441 Constitution Blvd.
Salinas, CA 93906
Dear Sid,
Attached is our renewal amendment. Please let me know if you need any additional information.
Thank you for your continuing support. We look forward to working with you more this year!
Thanks again!
Best,
Cindi S. Levin
Market Manager
333 Gellert Blvd., #150, Daly City, CA 94015
Ph: 650) 758-4700 Fax: 650) 758-4711
BIB]
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