HomeMy WebLinkAboutWA DOC Offender Health Care and AmendmentsSTATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS
CONTRACTS AND LEGAL AFFAIRS
P. O. Box 41114 Olympia. Washington 06504.1114 Tel (360) 725.6367
June 8, 2011
City of Pasco Ambulance
PO Box 293
Pasco, WA 99301
Dear Provider:
We are writing to you because you have provided health care services to Washington State Department of Corrections
(Department) offenders in the past. We wish to continue to use your services and to ensure prompt payment for them in the
future. Please be advised, however, that the Washington State Office of Financial Management (OFM) and the
Washington State Auditor require that a written .document specifying the agreement between the Department and any
provider delivering direct services to offenders be in place before services are provided. This is regardless of the dollar
amount involved
In an effort to meet this requirement without burdening providers, we are using this letter of agreement. Once signed by
you and mailed back to the Department as indicated, it will constitute the entire agreement between us. In consideration of
your agreement to provide services to DOC offenders:
1. The Department agrees to pay for BLS and ALS services billed at the usual and. customary billed charge.
2. You agree to bill within 180 days of providing services, utilizing the appropriately completed CMS standardized
form, including but not limited to, dates of service, diagnosis, services provided and service data to include
CPT/HCPCS codes. Bills must be sent to: Department of Corrections, Medical Disbursements Unit, PO Box
41107, Olympia, WA 98504-1107. A completed W-9 is required prior to payment. You will generally receive
payment in 60 days from receipt of completed invoice. Fastest response is through direct deposit.
3. This agreement shall be effective for two years from the date of your signature unless terminated by either the
Department or the Provider upon 30 days written notification to the other.
OFM maintains a central vendor file for Washington State agencies to use for processing vendor payments. Make sure you
have registered as a state-wide vendor at bM://www.ofnlwa.govlisd/vendors.a . You may at your option, register to
receive payment for services to the Department, and any other participating state agency, by direct deposit, the state's
preferred payment method.
It is understood you are not an employee or agent of the Department of Corrections, that those providing services are
licensed, certified, or registered as required by State and/or Federal law, and that you maintain insurance for all liability
resulting from the acts or omissions of the Provider. If this agreement is acceptable please so indicate by your signature
below and return this original letter and a current certificate of insurance in the self-addressed stamped envelope provided.
Please reference the agreement number K9167 on all future billings or correspondence.
Sincerely,
/
GaryBanning
Contracts Administrator
Assigned Agreement Number K9167
Tax Identification Number
IJ
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Sttatte of Watshkin �Fttola o ssrerF o�
ID��epanrltmeia t of tCoinrrercttioinis
s cCo�ifnttiratctt No. Kgi[67
'� tAn§ �JY A�HYlltendhn einitt No. ii
This Unilateral Amendment is made by the state of Washington, Department of
Corrections, hereinafter referred to as Department, for the purpose of unilaterally
amending the above -referenced Contract, heretofore entered into between the
Department and City of Pasco.
The Department will begin utilizing Washington State Health Care Authority's
ProviderOne payment system for billing and reimbursement for dates of service
September 1, 2012 and thereafter. Claims must be submitted electronically
through ProviderOne, but will be paid using your current contracted rate.
The effective date of this amendment is September 1, 2012. All other terms and
conditions contained in the Contract and any amendments thereto shall remain in full
force and effect.
This Contract Amendment, consisting of one (1) page is executed by the person signing
below who warrants that they have the authority to execute this Contract Amendment.
DEPARTMENT OF CORRECTIONS
(Signature)
Gary Banning
(Printed Name)
Contracts Administrator
A41V
Approved as to Form:
This contract amendment format vias approved
as to form by the Office of
t he Attorney General.
Approval on Me.
State of Washington K9167(1) Page 1 of 1
Department of Corrections
State of Wa shimytton
STATg 0
4 )Depatrtttrmuetrntt of c orlrecltilo tus
Cointiracc No. ]K9167
'L 188r1 �Oy� Aurnemtd metrntt -No. .2
This A\mnue)nAmrnrenit is made by the state of Washington, Department of Corrections,
hereinafter referred to as Department, and City of Pasco Ambulance, hereinafter referred to as
the Provider for the purpose of amending the above -referenced Contract, heretofore entered
into between the Department and the Provider.
WHEREAS the purpose of this contract amendment is to extend the period of contract
performance
NOW THEREFORE, in consideration of the terms and conditions contained herein, or attached
and incorporated and made a part hereof, the Department and Provider agree as follows:
Paragraph 2, sub -paragraph #3, is amended, in part, as follows:
This agreement shall be effective for two years from the date of your signature,
August 16. 2011 unless terminated by either the Department or the Provider upon 30
days written notification to the other. This agreement is extended through December
31, 2013.
Additions to this text are shown by underline and deletions by ((st*eeut)). All other terms and
conditions remain in full force and effect. The effective date of this amendment is August 16,
2013.
THIS CONTRACT AMENDMENT, consisting of one (1) page, is executed by the persons
signing below who warrant that they have the authority to execute the contract.
PROVIDER
R
_�W�.fv.0 r'r'�tDdN
(Pnme'+d Name)
( me)
4 /e'%
(Date)
Approved as to Form:
Thisamentlment format was approved
by the office of the Attorney General.
Approval on file.
State of Washington
Department of Corrections
DEPARTMENT OF CORRECTIONS
(Signature)
Gary Banning
(Printed Name)
Contracts Administrator
(Title)
�1i� 1t.3
(Date)
K9167(2) Page 1 of 1
138361
State of Washington Contract No. K9167
Department of Corrections Amendment No. 3
�� ieea a°e
This AmexiLdl Clleimt is made by the state of Washington, Department of Corrections, hereinafter
referred to as Department, and City of Pasco Ambulance, hereinafter referred to as the Contractor, for the
purpose of amending the above -referenced Contract, heretofore entered into between the Department
and the Contractor.
WHEREAS the purpose of this contract amendment is to extend the term;
NOW THEREFORE, in consideration of the terms and conditions contained herein, or attached and
incorporated and made a part hereof, the Department and Contractor agree as follows:
Initial Term Lommentxrnent Date- Initial Term ExpirationNte
08/16/2011 08/15/2041
I*tzxteniietlTonxiconu I*pcedlcntiDate -': Hist.ExtehdedTe*Rxpmfip;T aWO
08/16/2013 12)31/2013
.:. Second, Extended Term Commenrement.Date F-/.„ "Second Vtended•Tei*x irnbonrJate':
01/01/201 12/31/2015
All other terms and conditions remain in full force and effect. The effective date of this amendment is
January 1, 2014.
THIS CONTRACT AMENDMENT, consisting of one (1) page, is executed by the persons signing below
who warrant that they have the authority to execute the contract.
CONTRACTOR DEPARTMENT OF
(Date)
Approved as to Form:
This amendment format was approved
by the office of the Attorney General.
Approval on file.
(Signature
Gary Banning
(Printed Name)
Contracts Administrator
(rifle) 'r^ \k�k
(Date)
State of Washington K9167(3) Page 1 of 1
Department of Corrections 138362
�Q6 STATE. y
f State of Washington Contract No. K9167
Department of Corrections Amendment No. 4
dy `v
+exe
This Amendment is made by the state of Washington, Department of Corrections, hereinafter
referred to as Department, and City of Pasco Ambulance, hereinafter referred to as the Contractor, for the
purpose of amending the above -referenced Contract, heretofore entered into between the Department and
the Contractor.
WHEREAS the purpose of this contract amendment is to extend the term of the agreement;
NOW THEREFORE, in consideration of the terms and conditions contained herein, or attached and
incorporated and made a part hereof, the Department and Contractor agree as follows:
The term of this agreement is extended from January 1, 2016 through December 31, 2017.
Additions to this text are shown by underline and deletions by ((gin)). All other terms and conditions
remain in full force and effect. The effective date of this amendment is January 1, 2016.
THIS CONTRACT AMENDMENT, consisting of one (1) page, is executed by the persons signing below
who warrant that they have the authority to execute the contract.
CONTRACTOR
01KIC*X
(Title)
q— / S
(Date)
Approved as to Form:
This amendment format was approved
by the office of the Attorney General.
Approval on file.
DEPARTMENT OF CORRECTIONS
jo�'e—�'6A_
(Signatu
Gary Banning
(Printed Name)
Contracts Administrator
(Title) 1 n r ( (( /
(Date)
State of Washington K9167(4) Page 1 of 1
Department of Corrections 158364
F _SAIY
> State of Washington
s, or Department of Corrections
Contract No. K9167
Amendment No. 5
This Amendment is made by the Washington State Department of Corrections, hereinafter
referred to as "Department," and City of Pasco Ambulance, hereinafter referred to as the "Contractor," for
the purpose of amending the above -referenced Contract, heretofore entered into between the Department
and the Contractor.
WHEREAS the purpose of this contract amendment is to extend the term of the agreement.
NOW THEREFORE, in consideration of the terms and conditions contained herein, or attached and
incorporated and made a part hereof, the Department and Contractor agree as follows:
Term Commencement Date
Initial Term Expiration Date
08/16/2011
08/15/2012
nded Term Commencement Date
First Extended Term Expiration Date
08/16/2013
RSewnd
12/31/2013
ended Term Commencement Date
Second Extended Term Exp ration Date
01/01/2014
12/31/2015
nded Term Commencement Date
Third Extended Term Expiration Date
1/1/2016
12/31/2017
Fourth Extended Term Commencement Date
1 1 018
Fourth Extended Term Expiration Date
12 31 201
Additions to this text are shown by underline and deletions by ((�'-'; -tet)). All other terms and conditions
remain in full force and effect. The effective date of this amendment is January 1, 2018.
THIS CONTRACT AMENDMENT, consisting of one (1) page, is executed by the persons signing below
who warrant that they have the authority to execute the contract.
CONTRACTOR
dile)
iakg/r7
(Date)
Approved as to Form:
This amendment format was approved
by the office of the Attorney General.
Approval on file.
DEPARTMENT OF CORRECTIONS
— S�0�:f
(Signa re)
John R. Nispel
(Printed Name)
Contracts Administrator
(Tine)
(Date)
State of Washington K9167(5) Page 1 of 1
Department of Corrections 178297