HomeMy WebLinkAboutC-8305-2 - Reimbursement Agreement for the Community Paramedicine Pilot ProgramNEWPORT BEACH FIRE DEPARTMENT
P.O. BOX 1768, 100 CIVICCENTFR DRIVE, NEWPORT BEACH,CA 92658-8915
PHONE: 949-644-3355 FAX: 949-644-3120 WWW.NEWPORTBEACH CA. GOV
COMMUNITY PARAMEDICINE PILOT PROJECT
TO: Tony Coppolino, Fire Chief
Fountain Valley Fire Department
10200 Slater Avenue
Fountain Valley, CA 92708
David Segura, Fire Chief
Huntington Beach Fire Department
2000 Main Street
Huntington Beach, CA 92648
FROM: Chip Duncan, Fire Chief
City of Newport Beach Fire Department
100 Civic Center Drive
Newport Beach, CA 92660
DATE: October 19, 2018
This letter is sent to acknowledge the Community Paramedicine Pilot Project ("Project') has
officially concluded. The Project took place from October 2015 to June 30, 2018.
On November 14, 2014, the Office of Statewide Health Planning and Development ("OSHPD')
approved the California Emergency Medical Service Authority's (" EMSA') statewide Community
Paramedicine pilot program. One of the approved pilot projects was Orange County Alternate
Destinations Pilot project C'OCADPP'). Under the OCADPP, the Orange County Fire Chiefs'
Association ("OCFCA') led the instant Project, which included the fellow OCADPP member cities
of Fountain Valley, Huntington Beach, and the City of Newport Beach ("City').
Pursuant to the correspondence dated October 9, 2015, the City was designated as the fiscal
agent to the OCADPP, and agreed to receive the donated funds, pay associated pilot study costs,
and maintain a journal outlining Project costs and expenses.
Among other grant funds received for the Program, the City accepted grant funds from the Hoag
Hospital Community Benefit Program ("Hoag Hospital") at the City Council meetings on June 9,
2015 ($50,685.00) and October 13, 2015 ($125,000.00).
As the Project is now complete, the City shall fully return the remaining grant funds in the amount
of $101,624.85 to Hoag Hospital. Enclosed herewith is the City's financial report of the Program
with the associated expenses and revenue.
4
Sincerely,
D(
Chip Duncan, Fire Chief
Newport Beach Fire Department
ACKNOWLEDGED AND AGREED:
Tony Coppolino, Fire Chief
Fountain Valley Fire Department
David Segura, Fire Chie
Huntington Beach Fire Department
Enclosures: As noted
ORANGE COUNTY ALTERNATE DESTINATION PILOT PROJECT
GRANT FUND FY15
FY16
TOTAL
HOAG HOSPITAL $50,685.00
CA HEALTHCARE $8,600.00
$125,000.00
$8,000.00
$175,685.00
$16,600.00
$59,285.00
$133,000.00
$192,285.00
FY 2015
ACTUAL
Training- Core Education
S
Training - Local ADPT
5
Travel
5
Reseaitbor Services
$ 13,500
S
$
S
FY 2015 TOTAL $ 13,500
FY 2016 (July 2015 -June 2016)
07/18/2017
ACTUAL
Training - Local ADPT
5
15,598.13
Emergency Ambulance Services
S
2,500.00
UCC Charges
it
JiIRI RJ
S
$
S
1,625.00
70.56
Travel/Meetings
$
628.74
Researcher Services
$
16,200.00
Travel/Meetings _
FY 2016 TOTAL $
36,622.43
FY 2017 (July 2016 - June2017)
07/18/2017
ACTUAL
Training - Local ADPT
Emergency Ambulance Services (Transport)
S 828.00
Emergency Ambulance Services (Transport)
$ 60.00
S 10,500.00
UCCCharges
Wke Supplies
$ 1,525.85
Travel/Meetings
$ 13,500.00
$ 390.00
IN Supplies
FY 2018 TOTAL
$ 1,007.12
Travel/Meetings _
S 1,317.26
Researcher Services
$ 15,570.00
FY 2017 TOTAL
$ 31,138.23
FY 2018 (July 2017 - June 2018) 08/09/2018
ACTUAL
Training - Local ADPT
FY2017
Emergency Ambulance Services (Transport)
S 2,700.00
UCC Charges
$ 60.00
1't
ACTUAL EXPENSE
Wke Supplies
5 1,779.49
Travel/Meetings
$ 13,500.00
Researcher Services
5 4,860.00
FY 2018 TOTAL
$ 9,399.49
08/09/2018
TOTAL FUNDING
FY2015
FY2016
FY2017
FY2018
FUND
ACTUAL EXPENSE
ACTUAL EXPENSE
ACTUAL EXPENSE
ACTUAL EXPENSE
AVAILABLE
$192,285.00
$ 13,500.00
$ 36,622.43
$ 31,138.23
$9,399.49
1 $101,624.85
O
c� REIMBURSEMENT AGREEMENT
WITH HOAG MEMORIAL HOSPITAL PRESBYTERIAN
1 FOR THE COMMUNITY PARAMEDICINE PILOT PROGRAM
V
THIS REIMBURSEMENT AGREEMENT ("Agreement") is made and entered into
as of this 1st day of May, 2017 ("Effective Date"), by and between the CITY OF
NEWPORT BEACH, a California municipal corporation and charter city ("NEWPORT
BEACH"), and HOAG MEMORIAL HOSPITAL PRESBYTERIAN, a California nonprofit
public benefit corporation ("HOAG") whose address is One Hoag Drive, Newport Beach,
CA 92663, and is made with reference to the following:
RECITALS
A. NEWPORT BEACH is a municipal corporation duly organized and validly existing
under the laws of the State of California with the power to carry on its business
as it is now being conducted under the statutes of the State of California and the
Charter of NEWPORT BEACH.
B. On November 14, 2014, the California Emergency Medical Services Authority
("EMSK) was approved by the Office of Statewide Health Planning and
Development ("OSHPD") Health Workforce Pilot Projects ("HWPP") program to
pilot Community Paramedicine in twelve (12) sites across the state. One of the
approved pilot projects is the Orange County Alternate Destinations Pilot Project
("OCADPP") led by the Orange County Fire Chiefs' Association ("OCFCA") and
includes the cities of Fountain Valley, Huntington Beach and Newport Beach.
C. Under the leadership of OCFCA, the OCADPP explores a regional approach to
Community Paramedicine and will study if paramedics with advanced training
can safely determine if 9-1-1 patients with non-critical conditions can be
transported to urgent care centers instead of to emergency departments ("EDs")
utilizing approved medical protocols. The overarching goal of this project is to
transport 9-1-1 patients to the right level of healthcare services from the onset to
free up the EDs to care for more critical patients.
D. The objectives of the pilot study are to determine whether applying this new
intervention is safe, effective at reducing costs, and maintains patient
satisfaction. Success of the pilot project will be measured through data collection
regarding patient outcome, patient satisfaction, and cost of services indicators.
Local and State evaluators from University of California Irvine ("UCI"), Orange
County EMS, and the State EMS Authority will be conducting the research and
validating the data.
E. Each fire department has selected a cadre of Alternate Destination Paramedics
("ADPs"). The ADPs have attended advanced training and successfully passed
written and practical evaluations that ensure the competency of ADPs in making
the determination that 9-1-1 patients with non-critical conditions can be
transported to an urgent care center. Ultimately, the patient must consent to
enrollment in the study and agree to be transported to a designated urgent care
center.
F. HOAG has been identified as an OCADPP member and designated as an Urgent
Care Center ("UCC').
G. NEWPORT BEACH has been identified as an OCADPP member and designated
as the fiscal agent. As the fiscal agent, NEWPORT BEACH is responsible for
dispersing grant funds it receives on behalf of the OCADPP to other OCADPP
members to specifically cover the cost of operations related to the OCADPP.
H. As of the Effective Date, NEWPORT BEACH has received grant funds from the
Hoag Hospital Community Benefit Program and California Healthcare Foundation
to cover the cost of operations for the OCADPP. The terms of the grant from the
Hoag Hospital Community Benefit Program and California Healthcare Foundation
are attached hereto as Exhibits A (Grant Award Letter from HOAG Hospital) and
B (Grant Award Letter from California Healthcare Foundation) respectively and
incorporated herein by reference.
NOW, THEREFORE, it is mutually agreed by and between the undersigned
parties as follows:
1. TERM
The term of this Agreement shall commence on the Effective Date and shall
terminate on November 30, 2018 unless extended or terminated earlier as set forth
herein.
2. SERVICES TO BE PERFORMED
2.1 NEWPORT BEACH and HOAG acknowledge that the above Recitals are
true and correct and are hereby incorporated by reference. HOAG shall diligently
perform all the services described in the Scope of Services attached hereto as Exhibit C
and incorporated herein by reference ("Services").
2.2 Specific Obligations and Rights of Newport Beach
2.2.1 NEWPORT BEACH shall act as the fiscal agent by receiving
invoices and reimbursing HOAG pursuant to the Reimbursement Amounts attached
hereto as Exhibit D and incorporated herein by reference.
2.3 Specific Obligations and Rights of HOAG
2.3.1 HOAG shall act as a UCC. HOAG shall perform all the services
described in the Scope of Services attached hereto as Exhibit C and incorporated
herein by reference. HOAG shall also comply with and be fully bound by all applicable
provisions of Exhibits C and D hereto. HOAG shall notify NEWPORT BEACH
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 2
immediately upon discovery that it has not abided or no longer will abide by any
applicable provision of Attachments C and D hereto.
3. REIMBURSEMENT
3.1 NEWPORT BEACH shall reimburse HOAG for the Services on a time and
expense not -to -exceed basis in accordance with the provisions of this Section, the
Reimbursement Amounts and the Billing Process attached hereto as Exhibits D and E,
respectively and incorporated herein by reference. NEWPORT BEACH shall not utilize
or provide any funding other than the grant fundsit receives on behalf of OCADPP to
cover the costs of operations related to the OCADPP.
3.2 HOAG shall submit monthly invoices to NEWPORT BEACH describing the
Services performed the preceding month. HOAG'S invoices shall include a brief
itemized description or statement of the Services performed, (including the specific task,
procedure, any medication(s) prescribed and/or administered) and the date the Services
were performed. Supporting documentation, such as insurance payments received,
insurance denial letters and/or any attempts for collection prior to submitting monthly
invoices must be attached to monthly invoices. To the extent sufficient grant funds
exist, NEWPORT BEACH shall pay HOAG no later than thirty calendar (30) days after
approval of the monthly invoice by NEWPORT BEACH staff.
3.3 NEWPORT BEACH shall reimburse HOAG only for those costs or
expenses specifically approved in this Agreement, or specifically approved in writing in
advance by NEWPORT BEACH.
3.4 NEWPORT BEACH may terminate this Agreement and be relieved of the
payment to HOAG if a) HOAG fails to perform any of the covenants contained in this
Agreement, including but not limited to Attachments C and D hereto, at the time and in
the manner herein provided, or b) NEWPORT BEACH loses funding under the grant.
4. PROJECT MANAGER
4.1 HOAG shall designate a Project Manager, who shall coordinate all phases
of the Project. This Project Manager shall be available to NEWPORT BEACH at all
reasonable times during the Agreement term. HOAG has designated Kelly Reynolds to
be its Project Manager. HOAG shall not remove or reassign the Project Manager or any
personnel listed in Exhibit C or assign any new or replacement personnel to the Project
without the prior written consent of NEWPORT BEACH. NEWPORT BEACH'S
approval shall not be unreasonably withheld with respect to the removal or assignment
of non -key personnel.
4.2 HOAG, at the sole discretion of NEWPORT BEACH, shall remove from
the Project any of its personnel assigned to the performance of Services upon written
request of NEWPORT BEACH. HOAG warrants that it will continuously furnish the
necessary personnel to complete the Project on a timely basis as contemplated by this
Agreement.
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 3
5. ADMINISTRATION
This Agreement will be administered by the Fire Department. NEWPORT
BEACH's EMS Division Chief or designee shall be the Project Administrator and shall
have the authority to act for NEWPORT BEACH under this Agreement. The Project
Administrator shall represent NEWPORT BEACH in all matters pertaining to the
Services to be rendered pursuant to this Agreement.
6. RELATIONSHIP BETWEEN THE PARTIES
It is understood that HOAG shall act in an independent capacity in the
performance of this Agreement and shall not be considered an officer, agent or
employee of NEWPORT BEACH or of the entity from which NEWPORT BEACH
received grant funds. The manner and means of conducting the Services are under the
control of HOAG, except to the extent limited by statute, rule or regulation and the
expressed terms of this Agreement. Nothing in this Agreement shall be deemed to
constitute approval for HOAG or any of HOAG'S employees or agents, to be the agents
or employees of NEWPORT BEACH. Nothing in this Agreement shall create any
contractual relationship between NEWPORT BEACH and any subconsultant nor shall it
create any obligation on the part of NEWPORT BEACH to pay or to see to the payment
of any monies due to any such subconsultant other than as otherwise required by law.
HOAG shall have the responsibility for and control over the means of performing the
Services, provided that HOAG is in compliance with the terms of this Agreement.
7. PROHIBITION AGAINST ASSIGNMENTS AND TRANSFERS
Except as specifically authorized under this Agreement, the Services to be
provided under this Agreement shall not be assigned, transferred contracted or
subcontracted out without the prior written approval of NEWPORT BEACH.
8. SUBCONTRACTING
The subcontractors authorized by NEWPORT BEACH, if any, to perform Work
on this Project are identified in Exhibit C. HOAG shall be fully responsible to
NEWPORT BEACH for all acts and omissions of any subcontractor. Nothing in this
Agreement shall create any contractual relationship between NEWPORT BEACH and
any subcontractor nor shall it create any obligation on the part of NEWPORT BEACH to
pay or to see to the payment of any monies due to any such subcontractor other than as
otherwise required by law. NEWPORT BEACH is an intended beneficiary of any Work
performed by the subcontractor for purposes of establishing a duty of care between the
subcontractor and NEWPORT BEACH. Except as specifically authorized herein, the
Services to be provided under this Agreement shall not be otherwise assigned,
transferred, contracted or subcontracted out without the prior written approval of
NEWPORT BEACH.
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 4
9. RECORDS
HOAG shall keep complete and accurate records and invoices in connection with
the OCADPP and Services provided and any costs charged to NEWPORT BEACH for a
minimum period of three (3) years, or for any longer period required by law, from the
date of final payment to HOAG under this Agreement. All such records and invoices
shall be clearly identifiable. HOAG shall allow a representative of NEWPORT BEACH
to examine, audit and make transcripts or copies of such records and invoices during
regular business hours. HOAG shall allow inspection of all work, data, documents,
proceedings and activities related to the Agreement for a period of three (3) years from
the date of final payment to HOAG under this Agreement.
10. INDEMNIFICATION AND HOLD HARMLESS
10.1 To the fullest extent permitted by law, HOAG shall indemnify, defend and
hold harmless NEWPORT BEACH, its City Council, boards and commissions, officers,
agents, volunteers, employees and any person or entity owning or otherwise in legal
control of the property upon which HOAG performs the Services contemplated by this
Agreement (collectively, the "Indemnified Parties") from and against any and all claims
(including, without limitation, claims for bodily injury, death or damage to property),
demands, obligations, damages, actions, causes of action, suits, losses, judgments,
fines, penalties, liabilities, costs and expenses (including, without limitation, attorneys'
fees for counsel acceptable to NEWPORT BEACH, disbursements and court costs) of
every kind and nature whatsoever (individually, a Claim; collectively, "Claims"), and
which may arise from or in any manner relate (directly or indirectly) to any breach of the
terms and conditions of this Agreement, any work performed or Services provided under
this Agreement including, without limitation, defects in workmanship or materials or
HOAG'S presence or activities conducted in connection with the OCADPP and Services
provided under this Agreement (including the negligent, reckless, and/or willful acts,
errors and/or omissions of HOAG, its principals, officers, agents, employees, vendors,
suppliers, consultants, subconsultants, anyone employed directly or indirectly by any of
them or for whose acts they may be liable, or any or all of them.)
10.2 Notwithstanding the foregoing, nothing herein shall be construed to
require HOAG to indemnify the Indemnified Parties from any Claim arising from the sole
negligence or willful misconduct of the Indemnified Parties. Nothing in this indemnity
shall be construed as authorizing any award of attorney's fees in any action on or to
enforce the terms of this Agreement. This indemnity shall apply to all claims and liability
regardless of whether any insurance policies are applicable. The policy limits do not act
as a limitation upon the amount of indemnification to be provided by HOAG.
11. NOTICES
11.1 All notices, demands, requests or approvals, including any change in
mailing address, to be given under the terms of this Agreement shall be given in writing,
and conclusively shall be deemed served when delivered personally, or on the third
business day after the deposit thereof in the United States mail, postage prepaid, first-
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 5
class mail, addressed as hereinafter provided.
11.2 All notices, demands, requests or approvals from HOAG to NEWPORT
BEACH shall be addressed to NEWPORT BEACH at:
To NEWPORT BEACH: City of Newport Beach
Attention: EMS Division Chief
100 Civic Center Drive
P.O. Box 1768
Newport Beach, CA 92658
11.3 All notices, demands, requests or approvals from NEWPORT BEACH to
HOAG shall be addressed to HOAG at:
To HOAG: Hoag Memorial Hospital Presbyterian
Attn: Kelly Reynolds
510 Superior Avenue, Suite 290
Newport Beach, CA 92663
12. CLAIMS
Unless a shorter time is specified elsewhere in this Agreement, before making its
final request for payment under this Agreement, HOAG shall submit to NEWPORT
BEACH, in writing, all claims for compensation under or arising out of this Agreement.
HOAG'S acceptance of the final payment shall constitute a waiver of all claims for
compensation under or arising out of this Agreement except those previously made in
writing and identified by HOAG in writing as unsettled at the time of its final request for
payment. HOAG and NEWPORT BEACH expressly agree that in addition to any claims
filing requirements set forth in the Agreement, HOAG shall be required to file any claim
HOAG may have against NEWPORT BEACH in strict conformance with the
Government Claims Act (Government Code sections 900 et seq.).
13. TERMINATION
13.1 In the event that either party fails or refuses to perform any of the
provisions of this Agreement at the time and in the manner required, that party shall be
deemed in default in the performance of this Agreement. If such default is not cured
within a period of two (2) calendar days, or if more than two (2) calendar days are
reasonably required to cure the default and the defaulting party fails to give adequate
assurance of due performance within two (2) calendar days after receipt of written
notice of default, specifying the nature of such default and the steps necessary to cure
such default, and thereafter diligently take steps to cure the default, the non -defaulting
party may terminate the Agreement forthwith by giving to the defaulting party written
notice thereof.
13.2 Notwithstanding the above provisions, NEWPORT BEACH shall have the
right, at its sole and absolute discretion and without cause, of terminating this
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 6
Agreement at any time by giving no less than seven (7) calendar days' prior written
notice to HOAG. In the event of termination under this Section, NEWPORT BEACH
shall pay HOAG for Services satisfactorily performed and costs incurred up to the
effective date of termination for which HOAG has not been previously paid. On the
effective date of termination, HOAG shall deliver to NEWPORT BEACH all reports,
Documents and other information developed or accumulated in the performance of this
Agreement, whether in draft or final form.
14. STANDARD PROVISIONS
14.1 Recitals. NEWPORT BEACH and HOAG acknowledge that the above
Recitals are true and correct and are hereby incorporated by reference into this
Agreement.
14.2 Compliance with all Laws. HOAG shall, at its own cost and expense,
comply with all applicable statutes, ordinances, regulations and requirements of all
governmental entities, including federal, state, county or municipal, whether now in
force or hereinafter enacted. In addition, all work prepared by HOAG shall conform to
applicable NEWPORT BEACH, county, state and federal laws, rules, regulations and
permit requirements and be subject to approval of the NEWPORT BEACH.
14.3 Waiver. A waiver by either party of any breach, of any term, covenant or
condition contained herein shall not be deemed to be a waiver of any subsequent
breach of the same or any other term, covenant or condition contained herein, whether
of the same or a different character.
14.4 Integrated Contract. This Agreement represents the full and complete
understanding of every kind or nature whatsoever between the parties hereto, and all
preliminary negotiations and agreements of whatsoever kind or nature are merged
herein. No verbal agreement or implied covenant shall be held to vary the provisions
herein. In the event there are any conflicts or inconsistencies between this Agreement
and any other communication between the parties, the terms of this Agreement shall
govern.
14.5 Interpretation. The terms of this Agreement shall be construed in
accordance with the meaning of the language used and shall not be construed for or
against either party by reason of the authorship of the Agreement or any other rule of
construction which might otherwise apply.
14.6 Severability. If any term or portion of this Agreement is held to be invalid,
illegal, or otherwise unenforceable by a court of competent jurisdiction, the remaining
provisions of this Agreement shall continue in full force and effect.
14.7 Controllinq Law and Venue. The laws of the State of California shall
govern this Agreement and all matters relating to it and any action brought relating to
this Agreement shall be adjudicated in a court of competent jurisdiction in the County of
Orange, State of California.
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 7
14.8 Equal Opportunity Employment. HOAG represents that it is an equal
opportunity employer and it shall not discriminate against any subconsultant, employee
or applicant for employment because of race, religious creed, color, national origin,
ancestry, physical handicap, medical condition, marital status, sex, sexual orientation,
age or any other impermissible basis under law.
14.9 No Attorney's Fees. In the event of any dispute or legal action arising
under this Agreement, the prevailing party shall not be entitled to attorney's fees.
14.10 Counterparts. This Agreement may be executed in two (2) or more
counterparts, each of which shall be deemed an original and all of which together shall
constitute one and the same instrument.
14.11 No Third Party Beneficiaries. This Agreement is entered into by and for
HOAG and the NEWPORT BEACH, and nothing herein is intended to establish rights or
interests in individuals or entities not a party hereto.
14.12 Force Majeure. Except for the payment of money, neither party will be
liable for any delays or other non-performance resulting from circumstances or causes
beyond its reasonable control, including without limitation, fire or other casualty, Act of
God, strike or labor dispute, war or other violence, acts of third parties, or any law,
order, or requirement of any governmental agency or authority other than that of the
parties.
14.13 Amendments. This Agreement may be modified or amended only by a
written document executed by both parties and approved as to form by the City
Attorney.
[SIGNATURES ON NEXT PAGE]
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page 8
IN WITNESS WHEREOF, the parties are signing this Agreement as of the
Effective Date.
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
Date:
CITY OF NEWPORT BEACH,
a California municipal corporation
Date:-)h4ltzi
By: By;
A n C. Harp 6 Dave Ciff
City orney City Manager
ATTEST -
Date:
Date: . q-
r"Wd
By;
Leilani I. Brown
City Clerk
Attachments
REQUESTED AND REVIEWED:
Fire Department/
Date: 01S0'7
By:
Chip Duncan
Fire Chief
HOAG MEMORIAL HOSPITAL
PRESBYTERIAN, a California nonprofit
public
M
ration
Andr'&W R. Guarni
Secretary/Chief Financial Officer
[END OF SIGNATURES]
Exhibit A — Grant Award Letter from HOAG
Exhibit B — Grant Award Letter from California Healthcare Foundation
Exhibit C — Scope of Services
Exhibit D — Reimbursement Amounts
Exhibit E — Billing Process
Exhibit F — Election and Consent Form
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page—9
EXHIBIT A
GRANT AWARD LETTER FROM HOAG
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page A-1
ATTACHMENT
HOA.G MEMORIAL. HOSPnA4:' P.ESWERiAM
Ohoagne lung Drwo, PO a. f.100}Op
#
Nigvffwn b"ch. CA 07658-6104
May 14, 2015
Chief Randy Bruegman
Orange County Fire Chiefs' Association
2400 E. Orangewood Ave
Anaheim, CA 92806
Dear Chief Randy Bruegman,
Congratulations! We are pleased to inform you that a grant in the amount of $50,685 has
been approved by Hoag Memorial Hospital Presbyterian Community Benefit Program for the
project titled Orange County Alternate Destinations Pilot Project.
Our mission as a nonprofit, faith -based hospital is to provide the highest quality health care
services to the communities we serve. We are excited to partner with your organization in
fulfilling our mission and the unmet needs of our community. Acceptance of this grant .,
acknowledges agreement to the following:
• The grant term: July 1, 2014 -June 30, 2015
• The funds must be used specifically for the designated project listed above as outlined
in your FY15 grant application
• Maintain your records to show and account for the uses of grant funds
• Your organization must notify us immediately if there is any change in your public
charity status
• We will be sending a request for a progress report and a final report in the months to
come. More details to follow.
Please submit an invoice with the specified project title and approved amount to:
CommunilyBenefitGrantsPhoag o o, After we receive your invoice, please allow 2-4 weeks
for the delivery of the grant check.
Once again, congratulations on this recognition of the great workyou do to serve the
community. We look forward to working with you during the coming year.
Sinc
erely,
Gwyn Parry, MD
Director Community Benefit
A"/w
Im", e*
Michaell Rose, MSW, LCSW
Director of Community Programs
Minzah Malik, MPH, MBA
Manger Community Benefit
TV 18-3
�wN
CITY OF
r iii -b.-w
...m ^.
q' NEWPORT BEACH
City Council Staff Deport
June 09, 2015
Agenda Item No. 18,
TO: HONORABLE MAYOR AND MEMBERS OF THE CITY COUNCIL
FROM: Scott L. Poster, Fire Chief — (949) 644-3101, sposter@nbfd.net
PREPARED BY: Angela Crespi, Administrative Manager
PHONE: (949) 644-3352
TITLE: Acceptance of Grant Funding for the Community Paramedicine Pilot Project
ABSTRACT:
The Hoag Hospital Community Benefit Program provides grant funding in support of efforts to achieve high
quality health care services for the communities they serve. The City of Newport Beach, under the
sponsorship of the Orange County Fire Chiefs Association, is a participant in the State's Community
Paramedicine pilot study on Alternate Destinations. Acceptance of the grant funding will support the
necessary core and local staff training for the Orange County Alternative Destinations Pilot Project
participants.
RECOMMENDATION:
a) Accept the grant funding in the amount of $50,685 to be utilized for staff training; and
b) Approve Budget Amendment No. 15BA-048 to accept grant funds from the Hoag Memorial Hospital
Presbyterian Community Benefit Program, increase revenue estimates by $50,685 in account 2340-5066,
and increase expenditure appropriations by $50,685 in account 2340-82007.
FUNDING REQUIREMENTS:
This budget amendment records and appropriates $50,665 in additional revenue from the Hoag Memorial
Hospital Presbyterian Community Benefit Program and $50,685 in increased expenditure appropriations.
There are no matching fund requirements to accept this grant.
DISCUSSION:
On November 14, 2014, the California Emergency Medical Services Authority (EMSA) was approved by the
Office of Statewide Health Planning and Development (OSHPD) Health Workforce Pilot Projects (HWPP)
program to pilot Community Paramedicine in 12 sites across California, One of the approved pilot projects
is the Orange County Alternative Destinations Pilot Project (OCADPP) led by the Orange County Fire
Chiefs Association (OCFCA).
Under the leadership of the OCFCA, the Orange County Emergency Medical Services (EMS) system
partners, which includes fire departments in Newport Beach, Huntington Beach, and Fountain Valley, will
explore a regional approach to the Community Paramedic project through the development of an approved
triage process and protocols for transporting patients with non-critical conditions to alternative destinations
other than emergency departments. Patients meeting the approved criteria, and agreeing to participate in
the pilot, will be transported to urgent care centers instead of the emergency department (ED). The
overarching goal of this project is to assist in transporting patients to the right level of heath care services
when they call 911 and freeing up the ED to care for more critical patients.
The objectives of the pilot study are to determine whether applying this new intervention is safe, effective at
reducing costs, and maintains patient satisfaction. Success of the pilot study will be measured through
data collection regarding patient outcomes, patient satisfaction, and cost of service indicators. To validate
the data, both local and State evaluators will be utilized including University of California Irvine (UCI),
Orange County EMS Agency, and the State EMS Authority.
To ensure the safety of the study participants, each participating agency has selected a cadre of Alternate
Destination Paramedics (ADPs). These Paramedics are required to attend educational sessions and
successfully pass the written and practical evaluations prior to study implementation. This training will
ensure that the ADPs are prepared to make the correct determination regarding the appropriateness of
transporting a patient to an urgent care center.
If approved, the grant provided by the Hoag Hospital Community Benefit Program will provide the financial
support needed to cover the necessary staff training. As the designated fiscal agent for the Orange County
study, the City of Newport Beach will be responsible for acceptance and distribution of the grant funds.
The OCFCA and the Orange County EMS system partners are in the process of seeking additional grant
funding required for operation of the OCADPP through Hoag Hospital's Community Benefit Program and
other potential funding sources. If awarded, acceptance of additional grant funding will be brought forth to
the City Council for review and approval.
The baseline data collection phase began in April 2014 and Will continue until the start of the
implementation phase of the study which commences in June 2015 and is expected to run for a period of
up to 2 years.
ENVIRONMENTAL REVIEW:
Staff recommends the City Council find this action is not subject to the California Environmental Quality Act
("CEQK) pursuant to Sections 15060(c)(2) (the activity will not result in a direct or reasonably foreseeable
indirect physical change in the environment) and 15060(c)(3) (the activity is not a project as defined in
Section 15378) of the CEQA Guidelines, California Code of Regulations, Title 14, Chapter 3, because it has
no potential for resulting in physical change to the environment, directly or indirectly.
NOTICING:
The agenda item has been noticed according to the Brown Act (72 hours in advance of the meeting at
which the City Council considers the item).
ATTACHMENTS:
Description
Attachment A - Grant Award Letter
Attachment B - Budget Amendment
EXHIBIT B
GRANT AWARD LETTER FROM CALIFORNIA HEALTHCARE FOUNDATION
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page B-1
ALCALIFORNIA
H EALTHCARR
FOUNDATION
March 5, 2015
Mr. David Kiff
City Manager
City of Newport Beach
100 Civic Center Drive
Newport Beach, CA 92660
Dear Mr. Kiff:
Reference Number: 18762
This letter officially approves your request for a no -cost extension to the project, Community
Paramedicine Data Project Fountain Valley Fire Department. The project is now scheduled to
end on September 30, 2015.
The revised schedule for the remaining deliverables due for this grant is as follows:
Current Due Date Revised Due Date T e of Re rt Re ort Descri do
February 15, 2015
April 15, 2015
Signed Agreement
91 n
May be submitted early.
Febnuuy 27, 2015
April 30, 2015
Interim
Verification from UCSF that
Deliverable
initial data submission of
baseline data has been
received. (may be submitted
early — as soon as deliverable
February _27,2015
April _30,2015
Invoice
is met).
Invoice for Interim
Deliverable. (may be
submitted early — as soon as
deliverable is met).
July 31, 2015
September 30, 2015
Final Deliverable
Pilot site achieving
operational status as
designated by EMSA. Pilot
site to submit invoice for this
payment along with
verification letter from EMSA
of "operational status" of site.
(may be submitted early — as
duly 31, 2015
September 30, 2015
Invoice
soon as deliverable is met).
Invoice of Final Deliverable
(may be submitted early — as
soon as deliverable is met).
163E Webster 51,eel, Sude 400
Oakland, Cablonva %612
T 510 2381040 F 510 2381368
WWW.CfICFORG
City of Newport n 18762, page 2
Payments will he made within 30 days of receipt and acceptance of the contingency ti>r that
payment as detailed below:
Amount
Contingency
Contingency Due Date
$8,600
Interim Deliverable & Invoice
April 30, 2015
$8,000
Final Deliverable &invoice
September 30, 2015
Please call me if you have any questions,
Yours truly,
Sandra Shewry
Director, State Flealth Policy Program
cc: Lisa Kang, Director, Grants Administration
Other Terms
The California HealthCare Foundation may periodically issue a general press release announcing
funded projects, or include this grant in a published list of grants awarded by CHCR If the
Grantee wishes to issue a press release regarding this grant, CHCF requires review and final
sign -off of the text by its Publishing and Communications Department. Any publication
produced by the Grantee that refers or results from this agreement should include an
acknowledgment of CHCF that reads: Supported by the California HeallhCare Foundation,
based in Oakland, California.
Funds paid under this agreement may not be used to: 1) carry out propaganda or otherwise
attempt to influence legislation; 2) influence the outcome of any specific public election; or
3) carry on directly or indirectly any voter registration drive.
If the work performed under this agreement result in access to information that is confidential to,
or a trade secret of the California HealthCare Foundation, you hereby agree not to disclose any
such information without written authorization from the Foundation.
Your signature below acknowledges your acceptance of the agreement as described in this letter.
Please sign this letter, and mail or fax (510-587-0149) one signed copy to Danny Sandoval
Program Associate.
Yours truly,
Craig C. Ziegler
VP of Finance, Administration & Investments
cc: Sandra Shewry, Director, State Health Policy
Lisa Kang, Director, Grants Administration
Name/Signature:
Organization: City of Newport Beach
Tax ID: 95-6000751
Date: •3 1 114 (,S
Citi, Aktomey CAM m-1L311r
ATT/EIS�T�S��y,
W�YQ'�t/ iY'il�DlUY-- 3.13.1
Mani rown, ry owk
Mr'.of New= Beach Reference #18762, Page 3
e�EW�RT
0� 6
u }'
FIFO RNA
L% CALIFORNIA
tt rA Lint'.A R4.
FovNDATRI\
February 12, 2015
Mr. David Kiff
City Manager
City of Newport Beach
100 Civic Center Drive
Newport Beach, CA 92660
Dear Mr. Kiff:
Reference Number: 18762
The California HealthCare Foundation is pleased to award a grant to City of Newport Beach
as a stipend to provide data in support of the Community Paranledicine Data Project. The
amount of this grant is a fixed amount of $16,600.
This agreement is effective February 15, 2015 and terminates on July 31, 2015, unless extended
by written agreement initiated by the Foundation. Sandra Shewry, Director, State Health Policy,
will be your Foundation contact during the course of this project. All correspondence and
invoices related to this project should be addressed to her.
Scope of Work
In support of OSHPD's Health Workforce Pilot Project #173, the grantee will provide the
Community Paramedicine's Independent Evaluator (the Philip R. Lee Institute or Health Policy
Studies at the University of California, San Francisco) with all required data elements.
These data include:
• Baseline data on care provided by pilot sites prior to implementation of the pilot
interventions
• Data on site specific training provided to prospective community paramedics within 30 days
of completion of each of these training components
• Data on implementation of the pilot interventions
The grantee's Local Pilot Program Managers have had opportunities to review and comment on
the data elements for the evaluation and have agreed to provide them. They will have an
opportunity to comment on any proposed changes to the required data elements.
Each Local Pilot Program Managers will have the responsibility for collecting all required data
and forwarding them to the Independent Evaluator. Local Pilot Program Managers may
designate other staff to assist with data collecting and reporting but will be responsible for the
accuracy of data and the timeliness with which data are submitted to the independent evaluator.
Pilot sites will provide the Independent Evaluator with up to date names and contact information
for Local Pilot Program Managers and any other staff assisting with data collection and
reporting.
The grantee understands and agrees that there is a need for all pilot sites to collect similar data
elements. In light of this, the grantee agrees that grantee's pilot site will:
• collect standardized data pertinent to the community paramedicine concept being tested;
• report data elements on each concept being tested (if site is testing more than one concept).
• use the web -based data reporting tools that the Independent Evaluator has developed to
transmit data to the Independent Evaluator;
• report baseline and implementation data on a monthly basis. Baseline data will be reported
for five months, from August 2014 through December 2014. Implementation data will be
reported for the duration of the pilot project — estimated to be from June 2015 through May
2016.
The University of California, Los Angeles Center for Prehospital Care will be responsible for
submitting all data on the core training. Individual pilot sites' Local Pilot Program Managers will
be responsible for submitting data on site specific training.
Deliverables/Payments:
The following deliverables will be due on this grant:
Date Due Tvne of Re ort Re ort Descri tion
February 15, 2015
Signed Agreement
February 27, 2015
Interim Deliverable
Verification from UCSF that initial data
submission of baseline data has been received.
February 27, 2015
Invoice
Invoice for $8,600
July 31, 2015
Final Deliverable
Pilot site achieving operational status as
designated by EMSA. Pilot site to submit
invoice for this payment along with verification
letter from EMSA of "operational status" of site,
July 31, 2015
Invoice I
Invoice for $8,000 (may be submitted early — as
soon as deliverable is met).
Payments will be made within 30 days of receipt and approval of the contingency for that
payment detailed as follows:
Amount
Contingency Contingency Due Date
$8,600 Interim Deliverable and Invoice February 27, 2015
$8,000 Final Deliverable and Invoice I July 31, 2015
Invoices should include Reference #18762.
City of Newport Beach, Reference #18762, Page 2
inf
osend
?ill Print. C-BNS Delivered.
PROCESS SUMMARY REPORT
File Name
Paste # of Total Non Bar.
February 24, 2015
.ion Cade Company Name No Accounts Pages Coded Dupl. Total Amount
NPB0224A NPB.0224.MISC.001.TXT 1 1 1 0 0 $8,600.00
CITY OF NEWPORT BEACH
t ozals: 1 1 0 0 $8,600.00
�EW�Rr CITY OF NEWPORT BEACH
a� e
u i REVENUE DIVISION
A P.O. BOX 3080
^q<lpp PNS'
NEWPORT BEACH, CA 92658-3080
Email: revenuehelp@newportbeachca.gov
CALIFORNIA HEALTHCARE FOUNDATION
ATTN: SANTRA SHEWRY, DIRECTOR
1415 L STREET #820
SACRAMENTO CA 95814-5009
MISCELLANEOUS BILLING - INVOICE
NBID #
ACCT #
INVOICE #
574123
0000022085
GN01002882
INV DATE
DUE DATE
AMOUNT DUE
02/24/15
03/26/15
6,600.00
I ` "'P" I Qty I Unit Price Tax: I Extention:
COMMUNITY PARAMEDICINE
DATA PROJECT
REFERENCE NUMBER: 18762
DATES: 02/15/2015 - 07/31/2015
1.00 8,600.00
0.00 8,600.00
Payments received after the original due date Maybe transferred to other City or Newport Beach accounts or sent to a Collection Agency for recovery. Cost recovery fees or
late payment penalties may be applied after the original due date.
Payments can be made online at www.newportbeachca.govipayments TOTAL INVOICE: $ 8,600.00
and referencing the "NBID #" on the billing statement. PAYMENTS /ADJUSTMENTS: $ 0.00
PAST DUE: $ 0.00
PENALTIES / INTEREST: $ 0.00
Please see the reverse side for details on non-payment penalties. TOTAL AMOUNT DUE: $ 8,600.00
MISCELLANEOUS BILLING - INVOICE
?EW�Rr CITY OF NEWPORT BEACH
o REVENUE DIVISION
G \ P.O. BOX 3080
c c,MpeN`'
NEWPORT VVBEAIICH, CTIA 92I6I58-u3080
III9 u�l� IGnI�IIW�I�I� A I��lu �I IB I�
Please review the back of this document for important information.
NBID #
574123
ACCT #
0000022085
INVOICE #
GN01002882
INV DATE
02/24/15
DUE DATE
03/26/15
Amount Due:
8,600.00
NPB0224A
4000000001 1/1
10rlhigr�rdrll°ItIrIPI l `I diilttlrntptpgrlhlridPln
CALIFORNIA HEALTHCARE FOUNDATION hIIt9lrl�rllUrrr1411�rrIU4rllUrhllll411gtrglrlllltirlu
r ATTN: SSHEWRY, DIRECTOR CITY OF NEWPORT BEACH
11�v 1415 L STREETTREET #820
SACRAMENTO CA 95814-5009 PO BOX 3080
Newport Beach, CA 92658-3080
AROOOOOOOOOD22085000008600003
11,11
IMPORTANT NOTICE
LOcauon of City Hall
B, oig Location - r rter
Office Hours
"r;nri-:�;• - Thursday ? J%am - , azpm
r"las
Maw 4 Ynw
-...:.;,I, no1.,11v
Payment L.occanon - ',1,i, 0014-,'31
NOTICE OF INTENT TO NOTIFY FRANCHISE TAX BOARD OF UNPAID LIABILITIES
The Cay of Newport Beach ;s required by law to provide thja nrluce reiatung that failure W,, pay the liability owed wiR rests
in thus debt being reported to the State Franchise Tax Board frx I," Offset in the evert that you are owed a tax refund
wo1 a Catifornia Lottery prize or have wit -tamed property •r..12;rn s rhe Franchlsa Tax Board will intercept from that mon,,.
the amqunt you owe this agency. California Government Code 5e:;tions 12419.8 and 12419.10 authorize the office of
State Controller to collect money owed to a county or a cit,, ac;ency by intercepting any money that the state owed the
cieotor If you have any questions, or do not believe that Vcu o'roe this debt, please contact ns in writing within 30 days
from the date of this notice- A representative will review qOw objections once they are raceived. If you do riot submit an•,
nblecnons- or d your oblactrons are insufficient the City wrr. proceed with this action
Online Services www.newportboachca.gov
Fstabiish or Cancel Water service
-•onte.v! a Parking Gtatlon
a Parkr,o Penmi
Ap,"ly for Cancet or Update Bu6rtes_s License
`03i1v rote online services available
C' ;= Malting Ad ,
P2,; C,I, Bills
ea F i , Stare ewe, fo+
-e t Alar•
M- S and Bu :mess 1 1;
r'.•yrnent ran be made ;icing your credit card at w_ ww.newportbeachea.govlpayments v,a pr:,...
l 4.1j 71a- 94113. oy ma'- us,rlg the return envei opalm un , nn
I ' C ers_ or (,ity }{a rbn: q
sn,-. Fayn eats mast ce re;;e'v'd by hu d datz an r S per t e .rn
il2;sa:._
isv e t`+g r;IiY 1 tip; res R rl5iol'1 fn' -e'3y ri _ der
rrh-, „!t} or NebVOR Be3Cfn j0,. ytn,_�I':Ze it , t 'ty of . ,, f3 p t:
+H �rinnir: f id r :nzj , ef t yin yo,,,r Lark :, ar , r ,i q ,.. ennuur ,y t:`•e re.F: V the elocro'
Payrnentr Pot rec.eiveq by I;—, Cr, LIJt. ata s , 10,;7 to hi,.y, yinr:;d •ea,
END OF JOB
REPORT
TOTAL NO. OF RECORDS
SUMMARY PAGE NO:
FIRST RECORD:
COMPANY: CITY OF NEWPORT BEACH
CONTROL N0: 4000000001
SUBSCRIBER: CALIFORNIA HEALTHCARE FOUNDATION
LAST RECORD:
COMPANY: CITY OF NEWPORT BEACH
CONTROL NO: 4000000001
SUBSCRIBER: CALIFORNIA HEALTHCARE FOUNDATION
IMPORTANT NOTICE
Location of City Hall
i- .,:-'tar F)'! V� tie.Ao )i' Brach. 1p2Ct i0
&lu ng Location P-,enr:rr i,c,.; ;41 ..1 ,, ,.:{, PaynrentLo-atSon- rastn E, J44Y) 6.14-3'2,
Office Hours-
ay - Thr;rsda�d 7 30am - 5 30pm
f erlay 7 .irj3n- 4'il.)p:n
'exChrrLnu hphd.dya
NOTICE OF INTENT TO NOTIFY FRANCHISE TAX BOARD OF UNPAID LIABILITIES
The City of Newport Beach is required by taw o provide this notw,- eiatlnt; trial failure to pay the liab,lay owed mill result
in this debt being reported to the State Franchise Tax Board for tax offset in the event that you are Owed a tax refund.
WW a California Lottery pnze. or have unclaimed property c;arres. the Franchise Tax Board wdi intercept from that money
the amount you owe this agency Caiiforrna Government Code Sections Q-119.8 and 12419 10 authorize the Office of the
State Controller to collect money owed to a county or a city agency by intercepting any money that the state owed the
debtor If you have any questionsor do not believe that you owe this debt, please contact us in writing within 30 days
from the date of this notice A representative will review your objections once they are received. If you do not submit any
objections, or if your objections are insufficient, the City will procee=d with this action,.
Online Services www.newportbeacbea.gov
Establish or Cancel Water Sery ce
Contest a Parking Citation
Buy a Parking Permit
Apply for. Cancel, or Update Business License
\1Hvl; :TCP..r!m,
ishan ge Ni Address `oi all ancount types
Par silty BIIs
Fast Statements for KASS and Business License
Sig, ap for Select Alert
Payments ran be made using yourcreert card at www.newportbeachca.gov/pay iin s ,iia phone by calling
;9-1 718-199u, by rr•a i using the return ri veto -e en u , d 4+.4 t!- tn, rra;1irn . r� person ar i;iT Hail, bran n
p , y ' t o Your payment
s=,jo, Payments, must lie received by the due deto :r r r r .:void a .dtlo. ai ocriaWes ipostmark dates are r,nt
accept,u ie' Tr .e Oty ` not reap ns Ui- for rna;t delay c - k r.l sei .ice B esartn -.r g
By p^` , jour 1 signed check
t,� the City r r Newo t Beach yv auRur�zr trie City o N .vp-1 B ,; to us, he ore, lune r ronl,atcvi fr-,-ni the check'11!n
eke -o elzrrt nnic fun -.1 transfer from your banning ar ilii for ! earn= am,u.. J as e'1e cnec� if the slecvorr;c fund
EXHIBIT C
SCOPE OF SERVICES
HOAG agrees to:
• Participate in the OCADPP.
• Provide contact person for the OCADPP.
• Follow all established pilot medical protocols i.e. Local EMS Agency — Orange County
EMS (OCEMS) approved Policies and UCC Guidelines.
• Receive and offer services to all eligible patients, including ADP patients requiring off-
site x-rays and laboratory studies.
• Be approved by OCEMS and undergo site inspections.
• Participate in the study data collection required fields, including utilization of OC -MEDS
patient registry.
• Follow established Fee Schedule and Billing Processes for all Services provided to
study patients. Services include but are not limited to all care provided, procedures, x-
rays, labs, UCC initial visit, and follow up visit. UCC further agrees to assume financial
liability for any and all charges incurred for any off-site services, including but not limited
to x-rays and lab work.
• Training and training updates of UCC Staff on OC -MEDS, pilot procedures, data
collection points and billing procedures.
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page C-1
EXHIBIT D
REIMBURSEMENT AMOUNTS
HOAG MEMORIAL HOSPITAL PRESBYTERIAN
FY 2017
Participating urgent care Centers
TOTAL COSTS
RATE OF PAY
Services to designated
Ur ent Care Center
*Up to $35,000
$225 Initial visit,
$125 follow up visit
FY 2017 TOTAL
$35,000
FY 2018
Participating Urgent Care Centers
TOTAL COSTS
RATE OF PAY
Services to designated
Urgent Care Center
*Up to $40000
,
$225 Initial visit,
$125 follow up visit
FY 2018 TOTAL
$40,000
FY 2019
Participating Urgent Care Centers
TOTAL COSTS
RATE OF PAY
Services to designated
Ur ent Care Center
"Up to $40,000
$225 Initial visit,
$125 follow u visit
FY 2019 TOTAL
$40,000
'Note: The total costs for these line items are spread over 4 fiscal years;
however, it is possible that all expenses may occur in 1, 2, or 3 fiscal years.
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page D-1
EXHIBIT E
BILLING PROCESS
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page E-1
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EXHIBIT F
ELECTION AND CONSENT FORM
ELECTION AND CONSENT TO BE TRANSPORTED TO AN
ORANGE COUNTY EMERGENCY MEDICAL SERVICES
(OCEMS) ALTERNATIVE DESTINATION SITE (ADS)
acknowledge that that I have consented to enrollment in the Community Paramedicine Pilot Program;
voluntarily signed the "University of California, Irvine Consent to Act as a Human Research Subject' and
the "University of California, Irvine Health Permission to Use Personal Health Information for Research"
and I hereby consent and agree to be transported to the Alternate Destination Site (ADS) approved by the
Orange County Emergency Medical Services (OCEMS) to receive Pilot patients who elect to be
transported to the ADS rather than an acute care hospital emergency department. I hereby release the
EMS personnel and their employing agencies from any and all legal liability for medical claims resulting
from my election to be transported to the ADS site.
❑ 1 agree 111 Disagree ❑ Not Applicable
X
Patient
PLEASE SIGN HERE
Patient Name: Date:
Address:
Patient Phone: I —-�
WITNESS
I acknowledge that I have witnessed the patienUguardian sign this Patient Care Report.
❑ 1 agree ❑ I Disagree ❑ Not Applicable
PLEASE SIGN HERE
X
Witness Printed Name: IDate:
HOAG MEMORIAL HOSPITAL PRESBYTERIAN Page F-1