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Backup Documents 10/11/2016 Item #16E 1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIPI TO ACCOMPANY ALL ORIGINAL DOCUMENTS SE THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR ;`T e 'N 1 V E B Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the Co q Atjofpe l JJWce no later than Monday preceding the Board meeting. 1J 1,I 1 '(r LTJ�b **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document ii,ilk h. gtFAi,th the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the'Munfy"7Atto eynine. Routed by Procurement Services to the Office Initials Date Following Addressee(s) (In routing order) 1. Risk Management Risk `,; t/� ' / �y�` 2. County Attorney Office County Attorney Office /(,J Cm& 10' 20. 1( 3. BCC Office Board of County t7F Commissioners VtAzAkk., 4. Minutes and Records Clerk of Court's Office l0311,1(13 k'zpQt1' 5. Return to Procurement Services Procurement Services Division Contact: Viviana Giarimoustas PRIMARY CONTACT INFORMATION Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees above,may need to contact staff for additional or missing information. Name of Primary Camille Shim-Marinos for Rhonda Burns Phone Number 9-252-9841 Procurement Staff Contact and Date Agenda Date Item was 10/11/2016 N.7 Agenda Item Number C 6.E, ibr Approved by the BCC Type of Document Contract ✓ Number of Original 2 1,/ Attached Documents Attached PO number or account N/A Solicitation/Contract 1." Workers 1/ number if document is Number/Company Compensation Medical to be recorded Name Case/Naples Physician INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature? stioityisp. OK, O3' l— 111 A 2. Does the document need to be sent to another agency for additional signatures? If yes, N/A provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be -� signed by the Chairman,with the exception of most letters,must be reviewed and signed (� by the Office of the County Attorney. P' 4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the N/A document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's CJSM signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip elm- should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved by the BCC on the date above and all changes made CJSM ice ,• during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. , a ` 9. Initials of attorney verifying that the attached document is the version approved by theM101);. BCC,all changes directed by the BCC have been made,and the document is ready for the 4 tO, 741041,41 Chairman's signature. aufr I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12 1E 1 MEMORANDUM Date: October 21, 2016 To: Camille Shim-Marinos Procurement Services From: Teresa Cannon, Deputy Clerk Minutes & Records Department Re: Contract #16-6614 "Workers' Compensation Medical Case Management Program" Contractor: Naples Physician Hospital d/b/a Community Health Partners Attached is an original of the document referenced above, (Item #16E1) approved by the Board of County Commissioners on Tuesday, October 11, 2016. The second original has been held by the Minutes and Records Department as part of the Board's Official Record. If you have any questions, please contact me at 252-8411. Thank you. Attachment AGREEMENT16-6614 1E for .�. "Workers' Compensation Medical Case Management Program" THIS AGREEMENT, made and entered into on this 11' day of W 2016, by and between Naples Physician Hospital Organization d/b/a Community Health Partners, authorized to do business in the State of Florida, whose business address is 851 Fifth Avenue North, Suite 201, Naples FL 34102, (the "Contractor") and Collier County, a political subdivision of the State of Florida, (the "County"): WITNESSETH: 1. AGREEMENT TERM. The Agreement shall be for a three (3) year period, commencing on January 1, 2017, and terminating December 31, 2019, or until all outstanding Purchase Orders issued prior to the expiration of the Agreement period have been completed or terminated. The County may, at its discretion and with the consent of the Contractor, renew the Agreement under all of the terms and conditions contained in this Agreement for two (2) additional one (1) year periods. The County shall give the Contractor written notice of the County's intention to renew the Agreement term prior to the end of the Agreement term then in effect. The County Manager, or his designee, may, at his discretion, extend the Agreement under all of the terms and conditions contained in this Agreement for up to one hundred and eighty (180) days. The County Manager, or his designee, shall give the Contractor written notice of the County's intention to extend the Agreement term prior to the end of the Agreement term then in effect. 2. COMMENCEMENT OF SERVICES. The Contractor shall commence on January 1, 2017. 3. STATEMENT OF WORK. The Contractor shall provide Workers' Compensation Medical Case Management Consulting in accordance with the terms and conditions of Request for Proposal (RFP) #16-6614, Exhibit A — Scope of Services, and the Contractor's proposal referred to herein and made an integral part of this Agreement. This Agreement contains the entire understanding between the parties and any modifications to this Agreement shall be mutually agreed upon in writing by the Parties, in compliance with the County's Procurement Ordinance, as amended, and Procurement Procedures in effect at the time such services are authorized. 4. THE AGREEMENT SUM. The County shall pay the Contractor for the performance of this Agreement based on the unit prices set forth in the Cost of Services, attached hereto as Exhibit B, and pursuant to the price methodology as defined in Section 4.2. Page 1 of 11 #16-6614"Workers'Compensation Medical Case Management Program" IÔEI 4.1 Payment will be made upon receipt of a proper invoice and upon approval by the Director of Risk Management or his designee, and in compliance with Chapter 218, Fla. Stats., otherwise known as the "Local Government Prompt Payment Act." 4.2 Price Methodology: Unit Price: The County agrees to pay a firm total fixed price (inclusive of all costs, including labor, materials, equipment, overhead, etc.) for a repetitive product or service delivered (i.e. installation price per ton, delivery price per package or carton, etc.). The invoice must identify the unit price and the number of units received (no contractor inventory or cost verification. 4.3 Any County agency may utilize services under this Agreement, provided sufficient funds are included in their budget(s). 4.4 Payments will be made for services furnished, delivered, and accepted, upon receipt and approval of invoices submitted on the date of services or within six (6) months after completion of the Agreement. Any untimely submission of invoices beyond the specified deadline period is subject to non-payment under the legal doctrine of "laches" as untimely submitted. Time shall be deemed of the essence with respect to the timely submission of invoices under this Agreement. 5. SALES TAX. Contractor shall pay all sales, consumer, use and other similar taxes associated with the Work or portions thereof, which are applicable during the performance of the Work. Collier County, Florida as a political subdivision of the State of Florida, is exempt from the payment of Florida sales tax to its vendors under Chapter 212, Florida Statutes, Certificate of Exemption # 85-8015966531C-2. 6. NOTICES. All notices from the County to the Contractor shall be deemed duly served if mailed or faxed to the Contractor at the following Address: Naples Physician Hospital Organization d/b/a Community Health Partners 851 Fifth Avenue North, Suite 201 Naples, FL 34102 Phone: (239) 659-7700; Fax: (239) 659-7799 Attn: Kathy Jardone, Chief Operating Officer E-Mail: kiardone(c�chealthpartners.com All Notices from the Contractor to the County shall be deemed duly served if mailed or faxed to the County to: Collier County Government Center Procurement Services Division 3327 Tamiami Trail, East Naples, Florida 34112 Attention: Allison Kearns, Interim Director, Procurement Services Division Telephone: 239-252-8407; Facsimile: 239-252-6480 Page 2 of 11 #16-6614"Workers'Compensation Medical Case Management Program lel 11. NO DISCRIMINATION. The Contractor agrees that there shall be no discrimination as to race, sex, color, creed or national origin. 12. INSURANCE. The Contractor shall provide insurance as follows: A. Commercial General Liability: Coverage shall have minimum limits of $1,000,000 Per Occurrence, $2,000,000 aggregate for Bodily Injury Liability and Property Damage Liability. This shall include Premises and Operations; Independent Contractors; Products and Completed. Operations and Contractual Liability. B. Workers' Compensation: Insurance covering all employees meeting Statutory Limits in compliance with the applicable state and federal laws. The coverage must include Employers' Liability with a minimum limit of $100,000 for each accident. C. Professional Liability: Shall be maintained by the Consultant to ensure its legal liability for claims arising out of the performance of professional services under this Agreement. Consultant waives its right of recovery against County as to any claims under this insurance. Such insurance shall have limits of not less than $500,000 each claim and in the aggregate. Special Requirements: Collier County Government shall be listed as the Certificate Holder and included as an Additional Insured on the Comprehensive General Liability Policy. Current, valid insurance policies meeting the requirement herein identified shall be maintained by Contractor during the duration of this Agreement. The Contractor shall provide County with certificates of insurance meeting the required insurance provisions. Renewal certificates shall be sent to the County ten (10) days prior to any expiration date. Coverage afforded under the policies will not be canceled or allowed to expire until the greater of: ten (10) days prior written notice, or in accordance with policy provisions. Contractor shall also notify County, in a like manner, within twenty-four (24) hours after receipt, of any notices of expiration, cancellation, non-renewal or material change in coverage or limits received by Consultant from its insurer, and nothing contained herein shall relieve Contractor of this requirement to provide notice. Contractor shall ensure that all subcontractors comply with the same insurance requirements that he is required to meet. 13. INDEMNIFICATION. To the maximum extent permitted by Florida law, the Contractor shall indemnify and hold harmless Collier County, its officers and employees from any and all liabilities, damages, losses and costs, including, but not limited to, reasonable attorneys' fees and paralegals' fees, whether resulting from any claimed breach of this Agreement by Contractor, any statutory or regulatory violations, or from personal injury, property damage, direct or consequential damages, or economic loss, to the extent caused by the negligence, recklessness, or intentionally wrongful conduct of the Page 4 of 11 #16-6614"Workers'Compensation Medical Case Management Program" el 16E1 The Contractor and the County may change the above mailing address at any time upon giving the other party written notification. All notices under this Agreement must be in writing. 7. NO PARTNERSHIP. Nothing herein contained shall create or be construed as creating a partnership between the County and the Contractor or to constitute the Contractor as an agent of the County. 8. PERMITS: LICENSES: TAXES. In compliance with Section 218.80, F.S., all permits necessary for the prosecution of the Work shall be obtained by the Contractor. The County will not be obligated to pay for any permits obtained by Subcontractors/Subconsultants. Payment for all such permits issued by the County shall be processed internally by the County. All non-County permits necessary for the prosecution of the Work shall be procured and paid for by the Contractor. The Contractor shall also be solely responsible for payment of any and all taxes levied on the Contractor. In addition, the Contractor shall comply with all rules, regulations and laws of Collier County, the State of Florida, or the U. S. Government now in force or hereafter adopted. The Contractor agrees to comply with all laws governing the responsibility of an employer with respect to persons employed by the Contractor. 9. NO IMPROPER USE. The Contractor will not use, nor suffer or permit any person to use in any manner whatsoever, County facilities for any improper, immoral or offensive purpose, or for any purpose in violation of any federal, state, county or municipal ordinance, rule, order or regulation, or of any governmental rule or regulation now in effect or hereafter enacted or adopted. In the event of such violation by the Contractor or if the County or its authorized representative shall deem any conduct on the part of the Contractor to be objectionable or improper, the County shall have the right to suspend the Agreement of the Contractor. Should the Contractor fail to correct any such violation, conduct, or practice to the satisfaction of the County within twenty-four (24) hours after receiving notice of such violation, conduct, or practice, such suspension to continue until the violation is cured. The Contractor further agrees not to commence operation during the suspension period until the violation has been corrected to the satisfaction of the County. 10. TERMINATION. Should the Contractor be found to have failed to perform his services in a manner satisfactory to the County as per this Agreement, the County may terminate said Agreement for cause; further the County may terminate this Agreement for convenience with a thirty(30) day written notice. The County shall be sole judge of non- performance. In the event that the County terminates this Agreement, Contractor's recovery against the County shall be limited to that portion of the Agreement Amount earned through the date of termination. The Contractor shall not be entitled to any other or further recovery against the County, including, but not limited to, any damages or any anticipated profit on portions of the services not performed. Page 3 of 11 el #16-6614"Workers'Compensation Medical Case Management Program' I6E1 Contractor or anyone employed or utilized by the Contractor in the performance of this Agreement. This indemnification obligation shall not be construed to negate, abridge or reduce any other rights or remedies which otherwise may be available to an indemnified party or person described in this paragraph. This section does not pertain to any incident arising from the sole negligence of Collier County. 13.1 The duty to defend under this Article 13 is independent and separate from the duty to indemnify, and the duty to defend exists regardless of any ultimate liability of the Contractor, County and any indemnified party. The duty to defend arises immediately upon presentation of a claim by any party and written notice of such claim being provided to Contractor. Contractor's obligation to indemnify and defend under this Article 13 will survive the expiration or earlier termination of this Agreement until it is determined by final judgment that an action against the County or an indemnified party for the matter indemnified hereunder is fully and finally barred by the applicable statute of limitations. 14. AGREEMENT ADMINISTRATION. This Agreement shall be administered on behalf of the County by the Risk Management Division. 15. CONFLICT OF INTEREST. Contractor represents that it presently has no interest and shall acquire no interest, either direct or indirect, which would conflict in any manner with the performance of services required hereunder. Contractor further represents that no persons having any such interest shall be employed to perform those services. 16. COMPONENT PARTS OF THIS AGREEMENT. This Agreement consists of the following component parts, all of which are as fully a part of the Agreement as if herein set out verbatim: Contractor's Proposal, Insurance Certificate(s), Exhibit A-Scope of Services, Exhibit B — Cost Schedule, and RFP #16-6614, Scope of Services. 17. SUBJECT TO APPROPRIATION. It is further understood and agreed by and between the parties herein that this Agreement is subject to appropriation by the Board of County Commissioners. 18. PROHIBITION OF GIFTS TO COUNTY EMPLOYEES. No organization or individual shall offer or give, either directly or indirectly, any favor, gift, loan, fee, service or other item of value to any County employee, as set forth in Chapter 112, Part III, Florida Statutes, Collier County Ethics Ordinance No. 2004-05, as amended, and County Administrative Procedure 5311. Violation of this provision may result in one or more of the following consequences: a. Prohibition by the individual, firm, and/or any employee of the firm from contact with County staff for a specified period of time; b. Prohibition by the individual and/or firm from doing business with the County for a specified period of time, including but not limited to: submitting bids, RFP, and/or quotes; and, c. immediate termination of any Agreement held by the individual and/or firm for cause. Page 5 of 11 #16-6614"Workers'Compensation Medical Case Management Program" 090 1 19. COMPLIANCE WITH LAWS. By executing and entering into this Agreement, the Contractor is formally acknowledging without exception or stipulation that it agrees to comply, at its own expense, with all federal, state and local laws, codes, statutes, ordinances, rules, regulations and requirements applicable to this Agreement, including but not limited to those dealing with the Immigration Reform and Control Act of 1986 as located at 8 U.S.C. 1324, et seq. and regulations relating thereto, as either may be amended; taxation, workers' compensation, equal employment and safety (including, but not limited to, the Trench Safety Act, Chapter 553, Florida Statutes, and the Florida Public Records Law Chapter 119, including specifically those contractual requirements at F.S. § 119.0701(2)(a)-(b) as stated as follows: IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS AT: Communication and Customer Relations Division 3299 Tamiami Trail East, Suite 102 Naples, FL 34112-5746 Telephone: (239) 252-8383 The Contractor must specifically comply with the Florida Public Records Law to: 1. Keep and maintain public records required by the public agency to perform the service. 2. Upon request from the public agency's custodian of public records, provide the public agency with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. 3. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the Contractor does not transfer the records to the public agency. 4. Upon completion of the contract, transfer, at no cost, to the public agency all public records in possession of the Contractor or keep and maintain public records required by the public agency to perform the service. If the Contractor transfers all public records to the public agency upon completion of the contract, the Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the Contractor keeps and maintains public records upon completion of the contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the public agency, upon request from the public agency's custodian of public records, in a format that is compatible with the information technology systems of the public agency. Page 6 of 11 #16-6614"Workers'Compensation Medical Case Management Program" e I � > 1 If Contractor observes that the Contract Documents are at variance therewith, it shall promptly notify the County in writing. Failure by the Contractor to comply with the laws referenced herein shall constitute a breach of this Agreement and the County shall have the discretion to unilaterally terminate this Agreement immediately. 20. OFFER EXTENDED TO OTHER GOVERNMENTAL ENTITIES. Collier County encourages and agrees to the successful proposer extending the pricing, terms and conditions of this solicitation or resultant Agreement to other governmental entities at the discretion of the successful proposer. 21. AGREEMENT TERMS. If any portion of this Agreement is held to be void, invalid, or otherwise unenforceable, in whole or in part, the remaining portion of this Agreement shall remain in effect. 22. ADDITIONAL ITEMS/SERVICES. Additional items and/or services may be added to this Agreement in compliance with the Procurement Ordinance, as amended, and Procurement Procedures. 23. DISPUTE RESOLUTION. Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes by negotiation. The negotiation shall be attended by representatives of Contractor with full decision-making authority and by County's staff person who would make the presentation of any settlement reached during negotiations to County for approval. Failing resolution, and prior to the commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through Mediation before an agreed-upon Circuit Court Mediator certified by the State of Florida. The mediation shall be attended by representatives of Contractor with full decision-making authority and by County's staff person who would make the presentation of any settlement reached at mediation to County's board for approval. Should either party fail to submit to mediation as required hereunder, the other party may obtain a court order requiring mediation under section 44.102, Fla. Stat. 24. VENUE. Any suit or action brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in Collier County, Florida, which courts have sole and exclusive jurisdiction on all such matters. 25. AGREEMENT STAFFING. The Contractor's personnel and management to be utilized for this Agreement shall be knowledgeable in their areas of expertise. The County reserves the right to perform investigations as may be deemed necessary to ensure that competent persons will be utilized in the performance of the Agreement. The Contractor's shall assign as many people as necessary to complete the required services on a timely basis, and each person assigned shall be available for an amount of time adequate to meet the required service. Page 7 of 11 #16-6614"Workers'Compensation Medical Case Management Progra lóci 6 E 26. ORDER OF PRECEDENCE. In the event of any conflict between or among the terms of any of the Contract Documents, the terms of the RFP the Contractor's Proposal, and/or the County's Board approved Executive Summary, the Contract Documents shall take precedence. 27. ASSIGNMENT. Contractor shall not assign this Agreement or any part thereof, without the prior consent in writing of the County. Any attempt to assign or otherwise transfer this Agreement, or any part herein, without the County's consent, shall be void. If Contractor does, with approval, assign this Agreement or any part thereof, it shall require that its assignee be bound to it and to assume toward Contractor all of the obligations and responsibilities that Contractor has assumed toward the County. 28. SECURITY. The Contractor is required to comply with County Ordinance 2004-52, as amended. Background checks are valid for five (5) years and the Contractor shall be responsible for all associated costs. If required, Contractor shall be responsible for the costs of providing background checks by the Collier County Facilities Management Division for all employees that shall provide services to the County under this Agreement. This may include, but not be limited to, checking federal, state and local law enforcement records, including a state and FBI fingerprint check, credit reports, education, residence and employment verifications and other related records. Contractor shall be required to maintain records on each employee and make them available to the County for at least four (4) years. All of Contractor's employees and subcontractors must wear Collier County Government Identification badges at all times while performing services on County facilities and properties. Contractor ID badges are valid for one (1) year from the date of issuance and can be renewed each year at no cost to the Contractor during the time period in which their background check is valid, as discussed below. All technicians shall have on their shirts the name of the contractor's business. The Contractor shall immediately notify the Collier County Facilities Management Division via e-mail (DL-FMOPS(c�colliergov.net) whenever an employee assigned to Collier County separates from their employment. This notification is critical to ensure the continued security of Collier County facilities and systems. Failure to notify within four (4) hours of separation may result in a deduction of$500 per incident. Page 8 of 11 #16-6614"Workers'Compensation Medical Case Management Program" 42) I 0 : $. IN WITNESS WHEREOF, the parties hereto, have each, respectively, by an authorized person or agent, have executed this Agreement on the date and year first written above. BOARD OF COUNTY COMMISSIONERS ATTEST: COLLIER COUNTY, FLORIDA Dwight E. Brock, Cle of Courts B : By: 44.14. it;e4, Donna Fiala, Chairman Dated: tC/ ..l, IG (SEAL):J to Chairniail's signature onfp,; Naples Physician Hospital d/b/a Community Health Partners Contractor ¶i . ISCA .. By: Fir Signature Ai • us 141 Lt Co® Co CiA,.. it TTyp- print w', ess nareT TType/print signature and titleT /4J g S- and Witness C�14Sow! E. cadhi-Ecc g TType/print witness nameT 'proved as to Form and Legality: • odr-geA-11/ lr // As- stant County Atto ney Print Name ,tu fiGatijtenda t /Ith: , Gate - I„� �, , Reed �.!_�L�Jrb ;ty Jerk Page 9 of 11 #16-6614"Workers'Compensation Medical Case Management Program' OXY Exhibit A— Scope of Services The Contractor shall provide the following scope of services. • Employ nurse case managers who are dedicated solely to Workers' Compensation medical case management. • The nurse case managers will attempt to contact employees who incur job related injuries or illnesses requiring paid medical care within 24 hours (48 hours for Friday occurrences) of the patient's first medical treatment. • The nurse case managers will participate in monthly telephonic and quarterly on-site file reviews with the County's third party administration company (TPA) and designated County staff. • The nurse case managers shall generate correspondence to authorized treating physicians on topics that include but are not limited to major contributing cause (MCC), County return- to-work policies and patient's prior medical history. • The nurse case managers will review daily, all medical reports received from authorized treating physicians to determine the appropriateness of the treatment and prescribed medications with respect to the job related injury/illness for which they are treating the patient. • The nurse case managers will review all historical treatment records received as a result of medical releases supplied by patients to determine any impact they may have on the . patient's current job related medical condition. • The nurse case managers will maintain daily communications with the County's TPA and designated County staff to impart any pertinent medical findings critical to case management. • The nurse case managers will communicate with providers and facilitate treatment for any patients exposed to communicable diseases. • The nurse case managers will be available to attend doctor appointments, mediations, trials and settlement conferences at the request of the client/adjuster at no additional cost. • The nurse case managers will provide in-service training to providers and their staff as needed. • The nurse case managers will have the capability to forward in a secured manner, medical notes and correspondence to the client, the TPA and the client's legal counsel. • The nurse case managers will maintain a claims database that is well documented and includes a diary program for follow up review of all open and closed claims. • The nurse case managers will be on call 24 hours per day seven days per week, and will return all phone calls in a timely fashion. • The proposer will maintain a network of all medical and therapeutic disciplines that are familiar with treating patients under workers' compensation statutes. • The proposer shall maintain a toll free telephone number throughout the life of the agreement. Conditions: The Contractor shall maintain case management services at a location in Naples, Florida. The Contractor must be able to demonstrate an ability to perform the Scope of Services as described but shall also be able to demonstrate ongoing working relationship with local medical providers in the Naples area; an ability to develop contractual relationships with local medical providers in the Naples, FL area; and demonstrate an ability to support and execute the County's return to work program. Finally, the Contractor shall possess the required credentials and licensure for medical case management firms. Page 10 of 11 #16-6614'Workers'Compensation Medical Case Management Program" 1 Exhibit "B" - Cost Schedule The Contractor shall be paid on a Per Employee Per Month (PEPM) basis. PEPM shall be defined as total full time, part time and job bank employees minus retirees for each participating constitutional agency as of the first day of each month. The amount due each month shall be calculated as PEPM multiplied by the applicable term rate. Term Rate January 1, 2017 through December 31, 2017 $3.03 January 1, 2018 through December 31, 2018 2% increase of current rate to $3.09 January 1, 2019 through December 31, 2019 2% increase of current rate to $3.15 Renewal Period $3.15 Page 11 of 11 #16-6614"Workers'Compensation Medical Case Management Program" k. Detail by Entity Name Page 1 of 4 1 6 E FLORIDA DEPARTmENT OF STATE DIVISION OF P RATIO Detail by Entity Name Florida Not For Profit Corporation NAPLES PHYSICIAN HOSPITAL ORGANIZATION, INC. Filing Information Document Number N93000005824 FEI/EIN Number 65-0531134 Date Filed 12/30/1993 State FL Status ACTIVE Last Event CANCEL ADM DISS/REV Event Date Filed 10/31/2008 Event Effective Date NONE Principal Address 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Changed: 03/19/2004 Mailing Address 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Changed: 04/12/2012 Registered Agent Name &Address COMMUNITY HEALTH PARTNERS 851 FIFTH AVE N 201 NAPLES, FL 34102 Name Changed: 04/12/2012 Address Changed: 04/12/2012 Officer/Director Detail Name &Address Title Director http://search.sunbiz.org/Inquiry/CorporationSearch/SearchRe sultDetail?inquirytype=Entity... 9/15/2016 Detail by Entity Name Page 2 of 4 Cooper, Kevin, Esq. 851 FIFTH AVE. N 16 E STE. 201 NAPLES, FL 34102 Title D Talano, James MD 851 Fifth Ave North STE 201 NAPLES, FL 34102 Title D Lewis, John MD 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title D PARSONS, GARY MD 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title D Kamerman, Max MD 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title D WOLFF, BRIAN MD 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title Director Statfeld, Robert, Dr. 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title Director Perez-Trepichio, Alejandro MD 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 http://search.sunbiz.org/Inquiry/CorporationSearch/SearchRe sultDetail?inquirytype=Entity... 9/15/2016 Detail by Entity Name Page 3 of 4 Title Director 1 Alessi, Albert MD 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title Director Riley, Michael 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Title Director Dutcher, Phil 851 FIFTH AVE. N STE. 201 NAPLES, FL 34102 Annual Reports Report Year Filed Date 2015 04/23/2015 2015 11/24/2015 2016 02/05/2016 Document Images 02/05/2016 --ANNUAL REPORT View image in PDF format 11/24/2015--AMENDED ANNUAL REPORT View image in PDF format 04/23/2015 --ANNUAL REPORT View image in PDF format 02/27/2014 --AMENDED ANNUAL REPORT View image in PDF format 01/10/2014--ANNUAL REPORT View image in PDF format 01/25/2013 --ANNUAL REPORT View image in PDF format 04/12/2012 --ANNUAL REPORT View image in PDF format 01/06/2011 --ANNUAL REPORT View image in PDF format 02/17/2010--ANNUAL REPORT View image in PDF format 04/28/2009 --ANNUAL REPORT View image in PDF format 10/31/2008 -- REINSTATEMENT View image in PDF format 04/23/2007 --ANNUAL REPORT View image in PDF format 03/13/2006--ANNUAL REPORT View image in PDF format 02/03/2005 --ANNUAL REPORT View image in PDF format 03/19/2004--ANNUAL REPORT View image in PDF format 04/17/2003--ANNUAL REPORT View image in PDF format 03/13/2002 --ANNUAL REPORT View image in PDF format http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 9/15/2016 Detail by Entity Name Page 4 of 4 6 03/01/2001 --ANNUAL REPORT View image in PDF format 03/27/2000 --ANNUAL REPORT View image in PDF format 03/29/1999--ANNUAL REPORT View image in PDF format 02/06/1998 --ANNUAL REPORT View image in PDF format 03/10/1997 --ANNUAL REPORT View image in PDF format 04/22/1996--ANNUAL REPORT View image in PDF format 06/23/1995 --ANNUAL REPORT View image in PDF format Copyright©and Privacy Policies State of Florida,Department of State A http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 9/15/2016 PHYSI-6 1 oP EMI, Ac�- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/2016Y) 10/12/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: William H. Kuhlman,CPCU,ARM Insurance and Risk Management PHONE239-649-1444 jA/c,No): 239-649-7933 AX Services,Inc. (A/c.No.Ext): 8950 Fontana Del Sol Way#200 ADDRESS: Naples,FL 34109-4374 William H.Kuhlman,CPCU,ARM RINSURES)AFFORDING COVERAGE NAIC# INSURER A:Hartford Casualty Insurance INSURED Naples Physician Hospital INSURERB:FCCI Insurance Company 10178 Organization,Inc. INSURER C:Darwin Select Insurance Co. 24319 851 5th Avenue North,#201 Naples,FL 34102 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP TYPE OF INSURANCE IVSD WVD LTR NSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X 21SBABV9041 01/01/2016 01/01/2017 DAMAGEO 300,000 CLAIMS-MADE OCCUR X PREMISES(Ea occurrence) $ � MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY I I PRO- LOC PRODUCTS-COMP/OP AGG $ 4,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBaBINEDtSINGLE LIMIT $ 2,000,000 (EaA ANY AUTO 21SBABV9041 01/01/2016 01/01/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS DAMAGE X X NON-OWNED PROPERTY(Peaccident) $ HIRED AUTOS _ AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE 21SBABV9041 01/01/2016 01/01/2017 AGGREGATE $ DED X RETENTION$ 10000 $ WORKERS COMPENSATIONPER OTH- X STATUTE X ER AND EMPLOYERS'LIABILITY YIN1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE 001WC16A73097 01/01/2016 01/01/2017 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Professional Liab 03043578 01/01/2016 01/01/2017 Gen Agg 4,000,000 Claims Made Occur 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Collier County Government is listed as Additional Insured with 30 Days Notice of Cancellation as respects to General Liability. CERTIFICATE HOLDER CANCELLATION COLLCI8 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Collier County Government ACCORDANCE WITH THE POLICY PROVISIONS. 3327 Tamiami Trail East Naples,FL 34112 AUTHORIZED REPRESENTATIVE I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD