REQUEST FOR BIDS 2017 AMBULANCE BILLING SERVICE FOR THE CITY OF HAZELWOOD FIRE DEPARTMENT HAZELWOOD, MISSOURI

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1 REQUEST FOR BIDS 2017 AMBULANCE BILLING SERVICE FOR THE CITY OF HAZELWOOD FIRE DEPARTMENT HAZELWOOD, MISSOURI Bid Opening: Friday, December 1, 2017 at 11:00 a.m.

2 TABLE OF CONTENTS Request for Bids 1 Background 2 Scope of Services 3 Specifications 5 Bid Form Ambulance Billing Services Contract 17 Affidavit of Compliance 21 n-collusion Affidavit 23

3 REQUEST FOR BIDS The City of Hazelwood Fire Department (the Department ) is requesting bids from qualified firms ( Firms ) to provide ambulance billing, financial reporting and analytical services. This includes complete management of the billing process from patient to account closure. This request for bids defines the scope of services and outlines the requirements that must be met by Firms interested in providing such services. Firms shall carefully examine the entire bid package and any addenda thereto, and all related materials and data referenced in performing the service. Firms are advised to read all sections of the bid package before submitting a bid. The bid must be honored for a minimum of 120 days and may not be withdrawn once opened. The Department will receive sealed response up to 11:00 a.m., on Friday, December 1, 2017 addressed to Dave Herman, Fire Chief, Hazelwood Fire Department, 6800 Howdershell Road, Hazelwood, MO at which time they will be opened publicly. Responses received after this time will not be accepted. Bid packages are available at the Hazelwood Fire Department Station Howdershell Road, Hazelwood, MO or under the City Government tab and Bid Opportunities tab. If you retrieve this document off the internet, please submit your business information to Lisa Schwan, Admin Secretary (lmschwan@hazelwoodmo.org), so you can be contacted of any changes. The Department reserves the right to accept or reject any and all bids or portions thereof and to accept any presented which meet or exceed the specifications and which we deem to be in the best interest of the City. The Department is not required to accept the lowest bid and the decision of the City shall be conclusive and final. Information concerning this bid package is available from Dave Herman, Fire Chief, 6800 Howdershell Road, Hazelwood, MO 63042, or via at drherman@hazelwoodmo.org. A copy of this bid package must be submitted with each bid and shall become part of the final contact. The bid will not be considered if a copy of this package is not made part thereof. On the copy returned, each bidder shall indicate in the appropriate blank whether the proposed billing agency meets the specifications of that particular section. If any exception is noted, a written explanation of what is proposed in lieu of the specified requirements shall be indicated. A responsible representative of the company submitting the bid sign on the place provided on the last page and same must notarized. Total price on bid must include all items listed in the specifications. Listing any items contained in our specifications as an extra cost will automatically be cause for rejections. Any bid submitted without listing exceptions shall be required to meet every detail of the specifications regardless of cost to the bidder. The bidder agrees to indemnify, defend and hold harmless the City of Hazelwood and every employee from any liability or financial loss including, with limitation, attorney s fees and cost arising in any manner whatsoever from any intentional, reckless, negligent, or otherwise wrongful asks, errors or omissions of bidder or any person employed by bidder, including agents and independent contractors, in the performance of the ambulance billing for the City. 1

4 BACKGROUND The City of Hazelwood Fire Department is located in St. Louis County MO, We operate one (1) Advance Life Support (ALS) ambulance that responded to over 1,800 calls in For our residents we accept insurance payments only; we do not bill our residents for co-pays. nresidents are expected to pay 100%. Patient care reports are generated on Code Red Software. All data, including signatures are acquired in the field by the attending paramedics. Currently, the Department charges are $800 for ALS 1, $1,000 for ALS 2, $700 for BLS and $12 per miles for each transport. 2

5 SCOPE OF SERVICES The City of Hazelwood Fire Department is interested in retaining an experienced billing agency to process ambulance transport claims with any and all private payers, private health insurance companies, Medicare, Medicaid, Tri-Care, HMO and PPO organizations, motor vehicle insurance companies, personal injury claims, worker compensation claims and United States Public Health Service to assure compliance with HIPAA/Medicare/Medicaid regulations and proper filing of all claims and conduct extensive follow-up regarding the status of those claims. 1. Bill patients or their insurance providers (including Medicare and/or Medicaide), up to three (3) times for emergency medical services rendered by the Client. In the event of partial payment from an insurance company, the Service providers shall bill the patient monthly, for up to three (3) months, for the balance due. 2. Prepare and submit accurate and complete insurance claims according to the rates established by the Department, guidelines and procedures established by the Department and Firm and all applicable laws and regulations including those of Medicare, Medicaid and any other applicable carriers including both commercial and private insurances. 3. Perform all diagnosis and procedure coding as may be required for such medical claims and to make necessary inquires of various health care providers as may be required for coding. 4. Cross reference patient files by various methods, i.e. last name, social security number, address (either pickup or residence) and date of service. Along with utilize available resources and databases, to obtain billing insurance information on private pay patients. 5. Verification and Missing Information Follow-up: The Vendor will provide labor, materials and equipment for verification of the downloaded transport information and patient information. The Firm will promptly notify the Department regarding missing information required to complete the billing process. 6. Prepare and mail invoices to patients/parties responsible for co-pays and/or deductibles, private pay and uninsured patients or as directed by the Department. Upon receipt of the ambulance report data, review, prepare and mail invoices to the patient within three (3) business days or submit claim to payor if insurance information is readily available. This mailing shall include all necessary forms for payment processing, along with a return envelope. 7. Post payments within 72 hours of receipt to the appropriate accounts and provide payment posting and revenue reports to the Department on a monthly basis. The Department will ensure that all checks are copied and copies of checks and EOS are given to the Firm to be posted and reconciled to the patient accounts. 8. Provide the Department with an itemized report of all invoices and claims billed, monies collected and outstanding balances on a monthly basis to and in a form required by the Department. 9. The Firm will be expected to provide analysis and expertise in all issues related to ambulance billing. This includes analysis of trends and other pertinent issues that may develop. 3

6 10. At a minimum, a written monthly report reviewing the performance of the accounts receivable should be prepared, identifying among other issues, the strengths, weaknesses and opportunities of the performance. Also key issues that might arise in the future should be identified, along with strategies to address the issues. This report should be prepared quarterly. 11. The Firm shall provide the Department with additional reports regarding write-offs and payment plan status on a monthly basis and in a format required by the Department. 12. The Firm will invoice the Department monthly for services rendered on a percentage of monies collected. 13. The Firm will provide EMS personnel with appropriate training concerning documentation. The Firm will act as a consultant regarding EMS billing and collection services. 14. The Firm will provide staff representatives who will provide the patient account information Monday through Friday, during normal business hours, excluding holidays recognized by the Department. A toll free customer service number must be provided and must be listed on all correspondence. 15. The Firm is responsible for providing all materials and resources required for the performance of the contract including, but not limited to, facilities, equipment, statements postage and personnel. 16. Request for refunds must include the patients payment information along with detailed explanation of why the refund is requested and all information necessary to submit refund. 17. The Firm acting on behalf of the Department will remain respectful and mindful of the needs of the Department s Citizen and patients. Weekly and monthly installment payments can be made available. 18. The Firm will provide collections services up and including: representing the Department when claims are denied or under paid. 19. The Firm shall hold all records and information received from the Department in strict confidence. Access must be limited only to those personnel directly involved in processing data. The Firm shall be responsible for all records and information required under local, state and federal laws. In all circumstances, complained with Health Insurance Portability Protection Act (HIPPA) requirements shall be strictly observed by both parties. 20. The Firm will work directly with representative from the Department to make available any additional reports, reasonably requested, for accounting or management purposes. 4

7 SPECIFICATIONS 1. The Firm must provide a history of the Company, qualifications and years of experience in Ambulance billing. 2. The Firm must describe their capability to provide automated claims submission to applicable insurance carriers. 3. The Firm must also provide references from five (5) current EMS Service providers who submit their runs to the Vendor via electronic interface. 4. The Firm must provide a time line of events that must take place from start-up to full operation. 5. The Firm must provide explanation of positive techniques used to work with and assist private pay patients in satisfying their bill and assurance that agency will refrain from using threats or intimidation as a collection technique. 6. The Firm should provide information on the availability and descriptions of reports that can be generated. 5

8 7. The Firm should confirm they have developed and implemented a compliance plan to insure billing procedures comply with all local, state and federal laws, rules and regulations. Further, the Firm shall provide the name and title of their compliance officer. 8. The Firm shall confirm that, to the best of their knowledge, they are not presently the subject of any federal or state investigation involving fraudulent or abusive billing practices, and if such investigations are ongoing or have occurred within the past (5) five years, the Vendor shall provide the nature and outcome of such investigations with the response to this RFP. 9. Indicate whether or not you as the Firm has had a contract terminated in the last (5) years, and describe the nature and circumstances. Termination for default is defined as notice to stop performance due to the Firm s non-performance or poor performance and the issue of performance was either (a) not litigated due to inaction on the part of the Firm, or (b) litigated, and such litigation determined that the Firm was in default. 10. Please list the software used, how often it is updated and method of training staff. 11. The Department or its agent reserves the right to audit the records of the Firm during normal business hours upon giving reasonable notice of intent to do so. 12. The Firm, by virtue of the proposal, agree to hold The Department harmless from liability incurred in the performance of the contract, additionally, the Firm agrees to comply with all laws as applicable for work with a government. 6

9 13. The Firm shall describe their internal audit program. 14. The Firm shall describe their staff along with their credentials and training. 15. A n-collusion Affidavit, by which the signed of the proposal declares that all persons, companies or parties interested in the contact as principals are named therein; that the proposal is made without collusion with any other person, persons, company or parties submitting a proposal; that it is in all respects fair and in good faith without collusion or fraud; and that the signer of the proposal has authority to contractually bind the Firm. 16. The contract shall be for a period of one (1) year from the initial date of signing with the option to renew at the discretion of the Department for a two (2) additional year term. 17. Describe any value added services provided by the Firm that are not covered by the RFP, but would assist the Department in enhancing collections. Include examples of these services. 18. The Firm must provide a detailed pricing structure and services provided in this RFP. 7

10 19. ALIEN REGISTRATION, COMPLIANCE AND ENFORCEMENT A. DEFINITIONS. As used in this section, the following terms shall have the following meanings: (1) "Business entity", any person or group of persons performing or engaging in any activity, enterprise, profession, or occupation for gain, benefit, advantage, or livelihood. The term "business entity" shall include but not be limited to self-employed individuals, partnerships, corporations, contractors, and subcontractors. The term "business entity" shall include any business entity that possesses a business permit, license, or tax certificate issued by the state, any business entity that is exempt by law from obtaining such a business permit, and any business entity that is operating unlawfully without such a business permit. The term "business entity" shall not include a self-employed individual with no employees or entities utilizing the services of direct sellers as defined in subdivision (17) of subsection 12 of section , RSMo; (2) "Contractor", a person, employer, or business entity that enters into an agreement to perform any service or work or to provide a certain product in exchange for valuable consideration. This definition shall include but not be limited to a general contractor, subcontractor, independent contractor, contract employee, project manager, or a recruiting or staffing entity; (3) "Employee", any person performing work or service of any kind or character for hire within the state of Missouri; (4) "Employer", any person or entity employing any person for hire within the state of Missouri, including a public employer. Where there are two or more putative employers, any person or entity taking a business tax deduction for the employee in question shall be considered an employer of that person for purposes of sections to ; (5) "Employment", the act of employing or state of being employed, engaged, or hired to perform work or service of any kind or character within the state of Missouri; (6) "Federal work authorization program", any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or an equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, under the Immigration Reform and Control Act of 1986 (IRCA), P.L ; (7) "Knowingly", a person acts knowingly or with knowledge, (a) With respect to the person's conduct or to attendant circumstances when the person is aware of the nature of the person's conduct or that those circumstances exist; or 8

11 (b) With respect to a result of the person's conduct when the person is aware that the person's conduct is practically certain to cause that result; (8) "Municipality", the City of Hazelwood. (9) "Public employer", every department, agency, or instrumentality of the state or political subdivision of the state; (10) "Unauthorized alien", an alien who does not have the legal right or authorization under federal law to work in the United States, as defined in 8 U.S.C. 1324a(h)(3); (11) "Work", any job, task, employment, labor, personal services, or any other activity for which compensation is provided, expected, or due, including but not limited to all activities conducted by business entities. B. ILLEGAL ACTS. 1. business entity or employer shall knowingly employ, hire for employment, or continue to employ an unauthorized alien to perform work within the municipality. 2. As a condition for the award of any contract or grant in excess of five thousand dollars by the municipality the business entity shall, by sworn affidavit and provision of documentation, affirm its enrollment and participation in a federal work authorization program with respect to the employees working in connection with the contracted services. Every such business entity shall also sign an affidavit affirming that it does not knowingly employ any person who is an unauthorized alien in connection with the contracted services. 3. The affidavit shall be approved as to form by the municipal attorney. 4. An employer may enroll and participate in a federal work authorization program and shall verify the employment eligibility of every employee in the employer's hire whose employment commences after the employer enrolls in a federal work authorization program. The employer shall retain a copy of the dated verification report received from the federal government. Any business entity that participates in such program shall have an affirmative defense that such business entity has not violated subsection 1 of this section. 5. A general contractor or subcontractor of any tier shall not be liable under this section when such general contractor or subcontractor contracts with its direct subcontractor who violates subsection 1 of this section, if the contract binding the contractor and subcontractor affirmatively states that the direct subcontractor is not knowingly in violation of subsection 1 of this section and shall not henceforth be in such violation and the contractor or subcontractor receives a sworn affidavit under the penalty of perjury attesting to the fact that the direct subcontractor's employees are lawfully present in the United States. C. ENFORCEMENT. The attorney general shall enforce the requirements of sections to

12 2. An enforcement action shall be initiated by means of a written, signed complaint under penalty of perjury as defined in section , RSMo, to the attorney general submitted by any state official, business entity, or state resident. A valid complaint shall include an allegation which describes the alleged violator as well as the actions constituting the violation, and the date and location where such actions occurred. A complaint which alleges a violation solely or primarily on the basis of national origin, ethnicity, or race shall be deemed invalid and shall not be enforced. 3. Upon receipt of a valid complaint, the attorney general shall, within fifteen business days, request identity information from the business entity regarding any persons alleged to be unauthorized aliens. Such request shall be made by certified mail. The attorney general shall direct the municipality to suspend any applicable license, permit, or exemptions of any business entity which fails, within fifteen business days after receipt of the request, to provide such information. 4. The attorney general, after receiving the requested identity information from the business entity, shall submit identity data required by the federal government to verify, under 8 U.S.C. 1373, the immigration status of such persons, and shall provide the business entity with written notice of the results of the verification request: (1) If the federal government notifies the attorney general that an employee is authorized to work in the United States, the attorney general shall take no further action on the complaint; (2) If the federal government notifies the attorney general that an employee is not authorized to work in the United States, the attorney general shall proceed on the complaint as provided in subsection 5 of this section; (3) If the federal government notifies the attorney general that it is unable to verify whether an employee is authorized to work in the United States, the attorney general shall take no further action on the complaint until a verification from the federal government concerning the status of the individual is received. 5. (1) If the federal government notifies the attorney general that an employee is not authorized to work in the United States, and the employer of the unauthorized alien participates in a federal work authorization program, there shall be a rebuttable presumption that the employer has met the requirements for an affirmative defense under subsection 4 of section B, and the employer shall comply with subsection 6 of this section. (2) If the federal government notifies the attorney general that an employee is not authorized to work in the United States, the attorney general shall bring a civil action in Cole County if the attorney general reasonably believes the business entity knowingly violated subsection 1 of section

13 (a) If the court finds that a business entity did not knowingly violate subsection 1 of this section, the employer shall have fifteen business days to comply with subdivision (1) and paragraph (a) of subdivision (2) of subsection 6 of this section. If the entity fails to do so, the court shall direct the municipality to suspend the business permit, if such exists, and any applicable licenses or exemptions of the entity until the entity complies with subsection 6 of this section; (b) If the court finds that a business entity knowingly violated this section, the court shall direct the municipality to suspend the business permit, if such exists, and any applicable licenses or exemptions of such business entity for fourteen days. Permits, licenses, and exemptions shall be reinstated for entities who comply with subsection 6 of this section at the end of the fourteen day period. 6. The correction of a violation with respect to the employment of an unauthorized alien shall include the following actions: (1) (a) The business entity terminates the unauthorized alien's employment. If the business entity attempts to terminate the unauthorized alien's employment and such termination is challenged in a court of the state of Missouri, the fifteen-business-day period for providing information to the attorney general referenced in subsection 3 of this section shall be tolled while the business entity pursues the termination of the unauthorized alien's employment in such forum; or (b) The business entity, after acquiring additional information from the employee, requests a secondary or additional verification by the federal government of the employee's authorization, under the procedures of a federal work authorization program. While this verification is pending, the fifteen-business-day period for providing information to the attorney general referenced in subsection 3 of this section shall be tolled; and (2) A legal representative of the business entity submits, at an office designated by the attorney general, the following: (a) A sworn affidavit stating that the violation has ended that shall include a description of the specific measures and actions taken by the business entity to end the violation, and the name, address, and other adequate identifying information for any unauthorized aliens related to the complaint; and (b) Documentation acceptable to the attorney general which confirms that the business entity has enrolled in and is participating in a federal work authorization program. 7. The suspension of a business license or licenses under subsection 5 of this section shall terminate one business day after a legal representative of the business entity submits the 11

14 affidavit and other documentation required under subsection 6 of this section following any period of restriction required under subsection 5 of this section. 8. For an entity that violates subsection 1 of this section for a second time, the court shall direct the municipality to suspend, for one year, the business permit, if such exists, and any applicable license or exemptions of the business entity. For a subsequent violation, the court shall direct the municipality to forever suspend the business permit, if such exists, and any applicable license or exemptions of the business entity. 10. This section shall not be construed to deny any procedural mechanisms or legal defenses included in a federal work authorization program. 11. Any business entity subject to a complaint and subsequent enforcement under this section or any employee of such a business entity, may challenge the enforcement of this section with respect to such entity or employee in the courts of the state of Missouri. 12. If the court finds that any complaint is frivolous in nature or finds no probable cause to believe that there has been a violation, the court shall dismiss the case. For purposes of this subsection, "frivolous" shall mean a complaint not shown by clear and convincing evidence to be valid. Any person who submits a frivolous complaint shall be liable for actual, compensatory, and punitive damages to the alleged violator for holding the alleged violator before the public in a false light. If the court finds that a complaint is frivolous or that there is not probable cause to believe there has been a violation, the attorney general shall issue a public report to the complainant and the alleged violator stating with particularity its reasons for dismissal of the complaint. Upon such issuance, the complaint and all materials relating to the complaint shall be a public record as defined in chapter 610, RSMo. 13. The determination of whether a worker is an unauthorized alien shall be made by the federal government. A determination of such status of an individual by the federal government shall create a rebuttable presumption as to that individual's status in any judicial proceedings brought under this section or section The court may take judicial notice of any verification of an individual's status previously provided by the federal government and may request the federal government to provide automated or testimonial verification. 14. Should the federal government discontinue or fail to authorize or implement any federal work authorization program, the municipality shall review this section for the purpose of determining whether the sections are no longer applicable and should be repealed. 12

15 20. CONTRACT SUM AND PAYMENTS Based upon Applications for Payment submitted by the Contractor on or before the twentieth day of the month for work performed, in accordance with the General Conditions, the City shall pay the Contractor for the performance of the work, the sum of the Request for Proposal form price as follows: a. Preferably E-Payables (Commercial Credit Card) Acceptable? Yes (circle one) b. Final payment within 30 days after the work is fully completed and accepted by the City and the Contract is fully performed. 13

16 ADDITIONAL ITEMS All records and documentation associated with the billing and collection will remain the sole property of the City of Hazelwood Fire Department and shall be available at any time to the City of Hazelwood s internal and external auditors for compliance with all appropriate accounting standards and practices. All records, documentation and data associated with billing and collections will be confidential records and will not be sold, distributed or made accessible to any other parties. All records are to be acquired and stored in a secure and confidential manner. data provided by the City of Hazelwood Fire Department can be used for any other reason than the purpose of collecting fees in connection with ambulance services. The successful bidder will furnish the most recent company annual report with the bid. The successful bidder shall fully comply with HIPAA regulations and agree to execute a business associate agreement. The successful bidder shall not assign the contract or subcontract the whole or any part of the contract. The successful bidder will agree that notwithstanding the existence of any dispute between the parties, insofar as possible under the terms of the contract to be entered into each party will continue to perform the obligations required of it during the continuation of any such dispute unless enjoined or prohibited by a court. If the City of Hazelwood Fire Department cancels the contract for the provision of the billing services, bidder must, within three (3) days of the notice of service termination, provide the Department will all data, data files, data tables and data backup files of all data related to the Hazelwood Fire Department accounts in a format prescribed by the Hazelwood Fire Department. Bidder must certify that all Hazelwood Fire Department related data has been removed and purged from their systems and no copies of data or data backup files are in billing service s possession or available to the billing service in any form whatsoever. If the bidder chooses to cancel said agreement, bidder will give the City such notice in writing 120 days prior to the date they wish to terminate service and supply any records requested by the City within 21 days of such written request. Prices quoted herein must be firm for a period of not less than 120 days after date of bid openings plus one (1) year should the contract be awarded. 14

17 BID FORM Chief Dave Herman City of Hazelwood Fire Department 6800 Howdershell Road Hazelwood, MO Chief Herman: The undersigned, having read, understood and being familiar with the enclosed documents agrees to provide ambulance billing services to the City of Hazelwood Fire Department at the following percentage: Name of Bidder: Mailing Address: Telephone Number: Fax Number: Address: % of Monthly Revenue Collected Authorized Signature: Title: Date: Subscribes and sworn to before me this day of, Corporate Seal Attest to Seal tary of Public 15

18 Checklist of items to be includes with bid: n-collusion affidavit Affidavit of compliance Specifications Bid Form completed Annual Report 16

19 THE CITY OF HAZELWOOD FIRE DEPARTMENT 2017 AMBULANCE BILLING SERVICE The agreement is made this day of, 2017 between the City of Hazelwood Fire Department, Hazelwood, Missouri (hereinafter CITY ) and (hereinafter ). WITNESSETH THAT: In consideration of the premises and of the mutual promises, covenants and agreements herein contained, the adequacy and sufficiency of which are hereby acknowledge and confesses, the parties hereto do mutually promise, covenant and agree as follows: 1. To offer professional consultation at no additional cost which will included, but is not limited to, regarding cost analysis, appropriate fees, procedures that need to be adopted or changed by the City in order to properly compliant with Medicare/Medicaid, necessary forms needed for certain procedures as well as possible contracts for the other needed information, i.e,. HIPAA regulations, Insurance Carriers Contracts/negotiations, and relations between community and EMS. 2. To file insurance claims on behalf of insured patients for ambulance service with any and all Private Health Insurance Companies, Medicare, Medicaid, VA, HMO and PPO organizations, Motor Vehicle Insurance Companies, Personal Injury Claims, Workers Compensation Claims and United States Public Health Services. will conduct extensive follow-up regarding the status of those claims, without request from the City. 3. To perform all diagnosis and procedure coding as may be required for such medical claims and to make necessary inquires of various health care providers as may be required for such coding. 4. To prepare and send all statements for amounts due to the City for ambulance service provided to its customers. The statements are aged and generate special messages for second, third and final notices. 5. To place toll-free number and address on all correspondence to patients and insurance carriers. 6. To use positive techniques to work with and assist private pay patients in satisfying their bill and to refrain from using threats or intimidation as a collection technique. must be compliant with all laws and regulations with debt collection practices. 7. To work with attorneys on personal injury and worker s compensation cases for such time, as believes it is prudent to pursue such sources of payment, recognizing that such claims are normally dependent upon the settlement of the case for payment. 17

20 8. To provide informational on site seminars, as needed to the Paramedics to train them in the proper preparation and documentation for all run sheets and reports used for billing. 9. To prepare daily and monthly reports for use by the City detailing collection activities, quantity of runs, breakdown of types of runs, source of revenue, etc. 10. To provide all long distance calls associated with electronic claims submissions and billing for the City. 11. All records and documentation associated with the billing and collection will remain sole property of the City, and shall be available at any time, to the City s internal and external auditors for compliance with all appropriate accounting standards and practices. 12. To work directly with representatives from the City to make available any additional reports, request for accounting or management purpose. 13. To provide all statements, claim forms and paper associated with billing for the City. 14. The parties of this agreement agree that venue shall lie exclusively in the Circuit Court of St. Louis County, State of Missouri, in the event of any litigation between them with regards to the matter encompassed by the agreement. THE CITY AGREES: 1. To pay a monthly fee of %. 2. To collect at the time of transport any and all medical information, including patient s signatures on all waivers of liability forms, and the assignment of benefits/release of information form. 3. To receive all monies upon billing by and to provide a daily log sheet showling all payments received and the source of payments, by patient. 4. To secure such approvals and furnish such forms, purchase orders and procedures as required for the execution of this agreement and the payments herein contemplated in accordance with applicable statues and ordinances. 18

21 GENERAL PROVISIONS 1. Either party upon thirty (30) days written notice to the other party may terminate this agreement. 2. This agreement may be amended or modified upon mutual agreement at any time, but all modifications must be in writing to be effective. 3. This agreement will remain in effect for a period of two (2) years from the date of the original signatures below, and may be renewed from year to year thereafter upon annual approval by the City. 19

22 In witness whereof, the parties hereto have executed this agreement the day and year first written. EXECUTED BY AUTHORIZED REPRESENTATIVES OWNER: City of Hazelwood (NAME OF BIDDER) Matthew Zimmerman City Manager By: (Name) (Title) Date ATTEST: Date WITNESS: Christine Thomas, CMC City Clerk By: Print Name Date Date APPROVED AS TO FORM: Kevin O Keefe City Attorney CONTRACT AUTHORIZED BY CITY OF HAZELWOOD ORDINANCE: City of Hazelwood Contract: 2017 Ambulance Billing Service 20

23 AFFIDAVIT OF COMPLIANCE STATE OF COUNTY OF w this day of, 2017, the undersigned, being first duly sworn, deposes and says: 1. I am more than 18 years of age. 2. I make this affidavit from my personal knowledge of the facts stated herein or upon information and facts available to me as a duly authorized owner, partner, corporate, or LLC officer or Human Relations Director of (name of corporation, LLC, sole proprietorship or partnership) 3. I am authorized to make this affidavit on behalf of (name of business entity, same as above) 4. I state and affirm that is enrolled and is (name of business entity, same as above) currently participating in E-Verify, a federal work authorization program or another equivalent electronic verification of work authorization program operated by the United States Department of Homeland Security under the Immigration Reform and Control Act of Further, does not knowingly employ any person (name of business entity, same as above) who is an unauthorized alien. 6. Further, has performed an electronic (name of business entity, same as above) verification check as described above on all workers hired since January 1, 2009 or obtained documents required for completion of a federal I-9 form before it began participating in e-verify. I certify under penalty of perjury that the statements above are complete, true and accurate to the best of my knowledge and belief. (Authorized Agent, Partner, Owner or Officer) Printed Name If business has a Human Relations Director or equivalent that person must sign as an affiant as well. I certify under penalty of perjury that the statements above are complete, true and accurate to the best of my knowledge and belief. (Human Relations Director) Printed Name This form is promulgated to 15CSR The Attorney General has deemed this affidavit sufficient in form to satisfy the requirements of section , RSMo., Supp

24 FURTHER THE AFFIANT SAYETH NOT (Signature) On this day of, in the year 20, before me, a tary Public in and for said state, personally appeared, known to me to be the person who executed the within affidavit, and acknowledged to me that he/she executed the same for the purposes therein stated. IN WITNESS WHEREOF, I have herunto set my hand and affixed my official seal in the county and state aforesaid, the day and year first above written. My Commission Expires: tary Public SEAL 22

25 CITY OF HAZELWOOD NON-COLLUSION AFFIDAVIT STATE OF MISSOURI ) ) SS County of St. Louis ) being first duly sworn on oath deposes and states: I. That in connection with this procurement: a. the prices in this bid have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; b. the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to opening, directly or indirectly, to any bidder or to any competitor; and c. no attempt has been made or will be made by the bidder to induce any other person or firm to submit or not submit a bid for the purpose of restricting competition. II. The undersigned further states: a. he is the person in the bidder s organization responsible within that organization for the decision as to the prices being bid herein and that he has not participated, and will not participate, in any action contrary to (I)(a) through (I)(c) above; or b. he is not the person on the bidder s organization responsible within that organization for the decision as to the prices being bid herein but that he has been authorized in writing to act as agent for the person responsible for such decision in certifying that such persons have not participated, and will not participate, in any action contrary to (I)(a) through (I)(c) above. III. It is expressly understood that the foregoing statements, representations, and promises are made as a condition to the right of the bidder to receive payment under any award made hereunder. FOR CORPORATIONS: (Corporate Seals) Name of Firm Please check: ( ) Corporation ( ) Partnership or ( ) Sole Proprietor ( ) Limited Liability Company ATTEST TO SEAL: Signature and Title of Bidder SUBSCRIBED AND SWORN TO before me this day of, 20 tary Public t City of Hazelwood Contract: 2017 Ambulance Billing Service 23