Ambulance Service Agreement
AMBULANCE SERVICE CONTRACT
.5;
This Contract, dated this ~ day of , 2004, is entered into by and
between: City of Salina, E.M.S., hereinafter r en- to as " Ambulance Transport Provider"
and Presbyterian Manor of Salina, hereinafter referred to as "Nursing Facility".
RECITALS
1.
The Nursing Facility is engaged in the business of providing skilled nursing services and
is duly licensed to do so. The Ambulance Transport Provider is engaged in the business
of medical transportation and other emergency medical services. The Ambulance
Transport Provider is a licensed Type I Ambulance Service and all its technicians are
certified by the Kansas Board of Emergency Medical Services.
2.
The Nursing Facility desires to obtain certain services of the Ambulance Transportation
Provider on the terms and conditions stated in the Contract and the Ambulance Provider
desires to provide services to these terms and conditions.
3.
In consideration of the mutual promises contained in the Contract, the parties agree as
following.
TERM
4.
This Contract is effective the from the first day of July, 2004, through the thirtieth day of
June, 2005.
5.
This Contract will automatically renew for additional periods on the same terms and
conditions unless either party sends to the other party a written notice of termination by
certified mail, return receipt requested, thirty (30) days before the expiration date.
SERVICES
6.
The Ambulance Transportation Provider shall be responsible for furnishing the necessary
personnel and equipment necessary in its opinion to provide the services within the scope
of this Contract. At the request of the Nursing Facility, the Ambulance Transportation
Provider agrees to provide to patients of the Nursing Facility the services described in
the attached Schedule 1, which is incorporated herein by reference.
CALL ARRANGEMENT
7. The Nursing Facility may enter into contracts with other transport providers, at their option.
8.
FEES AND BILLING
The fees for services provided under the Contract are stated in the attached Schedule 2,
and may be modified by the Ambulance Provider during the term of the Contract which
is incorporated herein by reference.
9.
The Ambulance Transportation Provider shall bill the patient and/or any available
reimbursement source for services, except that in the case of specific services provided
by the Ambulance Transportation Provider that are covered by applicable laws or
regulations - including without limitation, and as an example only, provisions of Section
4432 of the Balanced Budget Act of 1997 and relevant sections of the Code of Federal
Regulation and other authoritative documents implementing, Section 4432, that require
that reimbursement be made to the Nursing Facility, the Ambulance Transportation
Provider shall bill the Nursing Facility for such services.
10.
The Nursing Facility agrees to provide the Ambulance Transportation Provider with
information regarding the patient's care plan, status, and history to facilitate proper
determination by the Ambulance Transportation Provider whether the Nursing Facility
should be billed for specific services. To the extent patient consent is required for
provision of information to the Ambulance Transportation Provider, the Nursing Facility
will use its best efforts to obtain that consent.
11.
The parties agree to develop a process whereby they will use their best efforts to work
together and consult in good faith to expeditiously address patient information and billing
issues relating to this Contract.
12.
The Nursing Facility agrees to advise the Ambulance Transportation Provider whether it is
. a Medicare's Prospective Payment System Provider.
13.
The Nursing Facility agrees to pay the fees stated on Schedule 2 for services properly
billed to it within thirty (30) days of the mailing of an invoice to it for services, subject to
the Ambulance Transportation Provider's standard billing and collection procedures.
14.
In the event the Nursing Facility is billed for services, it may collect any available co-
insurance or deductible.
MEDICAL NECESSITY
15.
With the respect to any services for which the Ambulance Transportation Provider bill
the Nursing Facility, the Nursing Facility shall be responsible for determining medical
necessity of the services and shall pay the Ambulance Transportation Provider without
regard for whether reimbursement sources challenge the medical the medical necessity of
the services, audit claims relating to the services, or make claims against the Nursing
Facility relating to the services. With respect to any services which the Ambulance
Transportation Provider does not submit a bill to the Nursing Facility, the Ambulance
Transportation Provider releases the Nursing Facility of any responsibility for payment.
19.
PHYSICIAN CERTIFICATION
16.
The Nursing Facility agrees to comply with any rules or regulation with respect to
physician certification for ambulance transportation. In the event required physician
certification is not obtained, the Ambulance Transportation Provider reserves the right
not to provide transportation.
INSURANCE AND INDEMNIFICATION
17.
Each party shall maintain liability insurance in the minimum amounts required by law.
ENTIRE AGREEMENT
18.
This Contract, including any schedules attached hereto, constitutes the sole and only
agreement of the parties regarding its subject matter and supersedes any prior
understandings or written or oral agreements between the parties respecting this subject
matter. Neither party has received or relied upon any written or oral representations to
induce it to enter into this Contract except that each party has relied only on any written
representations contained herein.
AMENDMENT
No agreement or understandings varying or extending this Contract shall be binding upon
the parties unless it is memorialized in a written amendment signed by an authorized
officer or representative of both parties. The parties agree that they will not seek any oral
amendment of this Contract.
ASSIGNMENT
20.
This Contract shall inure to the benefit of and shall be binding upon the successors and
assigns of each party. Neither party shall assign their rights or obligations under this
Contract without the prior written approval of the other party, except that a party may
assign this Contract to any person or entity that acquires substantially all of that party's
. business.
LEGAL CONSTRUCTION
21.
In the event that anyone or more of the provisions contained in this Contract shall for any
reason be held to be invalid, illegal, or unenforceable in any respect, such invalidity,
illegality, or unenforceability shall not affect any other provisions and the Contract shall
be construed as if such invalid, illegal, or unenforceable provision had never been
contained in it.
COMPLAINTS
22. The Nursing Facility agrees that all complaints or unusual incidents involving personnel or
service of the Ambulance Transportation Provider will be promptly reported to management
of the Ambulance Transportation Provider and will be described in an incident report
detailing the circumstances surrounding the complaint or detailing the circumstances
surrounding the complaint or incident, including the persons or entities involved, date and
time of the event at issue, and description of events at issue.
City of Salina, E.M.S.
By:
Date:
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Presbyterian Manor of Salina
By: -tdh'l iv:k.V, ¿];7Lhutd4a~
- l -
Fran Paxton, Admmistrator
Date:
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1 .bOO Y
,
FINANCE DEPARTMENT
TELEPHONE. (785) 309-5735
FAX. (785) 309-5738
TDD . (785) 309-5747
E-MAIL. rod.franz@salina.org
WEBSITE . w\vw.salina-ks.gov
Rod Franz
Director of Finance
300 West Ash. PO. Box 736
Salina, Kansas 67402-0736
Salina
CITY OF SALINA
EMERGENCY MEDICAL SERVICE
SCHEDULE 1
City of Salina, Emergency Medical Service is licensed as a Type I Ambulance Service; a Type
I service is a ground-based service which provides emergency response and Advanced Life
Support to include all authorized activities of Mobile Intensive Care Technician (Paramedic).
FINANCE DEPARTMENT
Rod Franz
Director of Finance
300 West Ash. PO. Box 736
Salina, Kansas 67402-0736
Salina
TELEPHONE. (785) 309-5735
FAX. (785) 309-5738
TDD . (785) 309-5747
E-MAIL. rod.franz@salina.org
WEBSITE . www.salina-ks.gov
SCHEDULE II
2004 CITY OF SALINA E.M.S. RATES *
SERVICE LEVERL
DESCREPTION
BILLING FEE/COST
A426 - ALS 1 - Non Emergency
A427 - ALS 1 - Emergency
A433 - ALS 2 - Emergency
A428 - BLS - Non-Emergency
A429 - BLS - Emergency
A425 - Mileage
TNT - Treatment no Transport
Non-Emergency Response
ALS assessment or provision
of at least one ALS intervention
Emergency Response
ALS assessment or provision
of at least one ALS intervention
Emergency Response
Adm. of 3 meds, IV push
Manual Defibrillation, ET,
Cardiac Pacing, 10, Chest
Decompression
N on Emergency Response
Basic Life Support Care
Emergency Response
Basic Life Support Care
Loaded Miles
Number of miles Patient
is transported
$ 330.00
$ 390.00
$ 390.00
$ 250.00
$ 360.00
$ 7.25/
per mile
$ 120.00
Emergency!N on-emergency Response
On-scene treatment, but no
Transport
* Subject to change annually, or as determined by the Salina City Commission.
FD1O6 / 23/5/2004