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Backup Documents 10/12/2021 Item #16K 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE i K 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 County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office CAK 9/24/21 4. BCC Office Board of County �j Commissioners �-4p L I 5. Minutes and Records Clerk of Court's Office 012 21 :tI' pi 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 Staff Colleen A. Kerins/ I / Phone Number 252-8400 Contact/ Department Agenda Date Item was 10/12/21 Agenda Item Number 16K3 Approved by the BCC Type of Document Settlement Agreement Number of Original 1 Attached Documents Attached PO number or account number if document is to be recorded 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? 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 CAK signed by the Chairman,with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 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 CAK 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 CAK signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip N/A 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 10/12/21 and all changes made during X =i .laot the meeting have been incorporated in the attached document. The County IP~Or Attorney's Office has reviewed the changes,if applicable. 9. Initials of attorney verifying that the attached document is the version approved by the Pl BCC,all changes directed by the BCC have been made,and the document is ready for the `/ +z .a• Chairman's signature. „ I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 1 •evised 11/30/12 I K 3 Ann P. Jennejohn From: Ann P.Jennejohn Sent: Wednesday, October 13, 2021 9:44 AM To: 'Colleen.Kerins@colliercountyfl.gov'; VillarrealRosa Subject: Item #16K3 (10/12/21 BCC Meeting) Attachments: Backup Documents 10_12_2021 Item #16K 3.pdf Good Morvtivtg, The attached is for your records. Thank you! Ann Jennejotin 13MR Senior Deputy Clerk II 01,7i�H,, Clerk to the Value Adjustment I3oard 4`. �!y Office: 239-252-8406 Fax: 239-252-8408 (if applicable) Anti..Jevmejohm.@CollierClerk.com x.,r � Office of the Clerk of the Circuit Court & Comptroller of Collier Couvtty 3299 Tawtiawti Trail, Suite #401 Naples, FL 34112-5324 www.CollierClerk.com 16K3 SETTLEMENT AGREEMENT THIS SETTLEMENT AGREEMENT (hereinafter referred to as the "Agreement") is entered into and made on this I" day of Odt-tixt, , 2021, by and between PAULA YOANYS ALPIZAR GOMEZ, hereinafter referred to as "Plaintiff," and COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS, hereinafter referred to as "County." WITNESSETH: WHEREAS, Plaintiff filed a lawsuit against the County in the Circuit Court for the Twentieth Judicial Circuit in and for Collier County, Florida, in the case styled Paula Yoanys Alpizar Gomez v. Collier County Board of Commissioners, Case No. 19-CA-3709 (hereinafter referred to as the"Lawsuit");and WHEREAS, Plaintiff and the County, without either party admitting any liability or fault, desires to settle the Lawsuit and any and all disputes that arise from, relate or refer in any way, whether directly or indirectly, known or unknown, accrued or unaccrued, to the incidents described or allegations made in the complaint filed in the Lawsuit;and, WHEREAS, Plaintiff and the County desire to reduce the settlement to a writing so that it shall be binding upon both parties' respective owners, principals, elected officials, officers, employees, ex-employees, agents, attorneys, representatives, insurers, successors, assigns, heirs, departments, agencies and affiliates. NOW, THEREFORE, in consideration of the mutual covenants, promises and consideration set forth in this Agreement, and with the intent to be legally bound, Plaintiff and County agree as follo s: 1. Plainti and the County �dopt and incorporate the foregoing re itals, sometimes referred to as "Where9s Clauses," by reference into this Agreement. 2. In consideration of the resolution of all disputes or claims arising from or referring or relating in any way, whether directly or indirectly, to the Lawsuit, and for and in consideration of the sum of sixty-five thousand dollars and 0/100 ($65,000.00) and other valuable consideration, the receipt and adequacy of which is hereby acknowledged by Plaintiff, Plaintiff agrees to dismiss the Lawsuit with Prejudice. 3. In consideration of the resolution of the Lawsuit, and for other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, Plaintiff, on behalf of herself, her attorneys, agents, representatives, insurers, heirs, successors and assigns, hereby [19-CA-3709/1665886/1] 1 16 K 3 is: expressly releases and forever discharges the County, as well as its owners, principals, elected officials, officers, employees, ex-employees, agents, attorneys, contractors, representatives, successors, assigns, insurers, heirs, departments, agencies and affiliates, from any and all claims, demands, causes of actions, damages, costs, liens, attorney's fees, expenses, medical bills and obligations of any kind or nature whatsoever, that she has asserted or could have asserted in the Lawsuit or that arise from or relate or refer in any way, whether directly or indirectly, accrued or unaccrued, known or unknown, to the Lawsuit or any incident, event or allegation referred to in the complaint in the Lawsuit. 4. Notwithstanding anything that may be to the contrary in Paragraph 3 of this Agreement, Plaintiff and the County agree that either of them (as well as any other persons or entities intended to be bound) shall, in the event of any breach, retain the right to enforce the terms and conditions of this Agreement. 5. Plaintiff and the County acknowledge and agree that this Agreement is intended to and shall be binding upon their respective owners, principals, elected officials, officers, employees, ex-employees, agents, attorneys, representatives, insurers, successors, assigns, heirs, and affiliates. 6. Plaintiff and the County recognize and acknowledge that this Agreement memorializes and states a settlement of disputed claims and nothing in this Agreement shall be construed to be an admission of any kind, whether of fault, liability, or of a particular policy or procedure,on the part of either Plaintiff or the County. 7. Plaintiff and the County acknowledge and agrcc that this Agreem it is the product of mutual negotiation and no doubtful or ambiguous language or provisi in this Agreement, is to be construed against any party based upon a claim that the party drafted the ambiguous provision or language or that the party was intended to be benefited by the ambiguous provision or language. 8. This Agreement may be amended only by a written instrument specifically referring to this Agreement and executed with the same formalities as this Agreement. 9. In the event of an alleged breach of this Agreement, Plaintiff and the County agree that all underlying causes of action or claims of Plaintiff have been extinguished by this Agreement and that the sole remedy for breach of this Agreement shall be for specific performance of the terms and conditions of this Agreement. In this regard, Plaintiff and the [19-CA-3 709/1 6 65 8 8 6/t] 2 l6K County further agree that the sole venue for any such action shall be in the Twentieth Judicial Circuit in and for Collier County, Florida in Naples, Florida. 10. Plaintiff agrees to use the proceeds of the settlement funds for the payment and satisfaction of all liens, medical bills, attorney fees, and all other expenses, costs, debts,or losses whatsoever, arising out of or in any way connected to the incident described in the Lawsuit, which Plaintiff brought or could have brought in the subject Lawsuit. Plaintiff agrees to be solely responsible for complete payment of these obligations out of the settlement proceeds. 11. The Plaintiff hereby agrees to indemnify and hold harmless the County from any and all claims and/or liens and/or subrogated interests, including but not limited to worker's compensation liens, health insurance liens, Medicaid / Medicare liens, Social Security and any and all attorney's liens and charging liens herein. It is further expressed and understood and agreed, to the extent applicable, the Plaintiff, in concert and consultation with her counsel, aver and covenant that they do not presently anticipate the Plaintiff will require future medical and/or health care treatment for the injuries and/or conditions related to and/or arising from the accident in question. As a condition of and to induce settlement, the Defendant(s)and (their/its) insurer(s) have requested and Plaintiff and their counsel have agreed to determine if Medicare (hereinafter CMS and includes Part C Medicare Advantage Organizations (a/k/a MAO) and/or Medicaid [all collectively referred to as CMS] has any past or future lien interest, and if so, to take all necessary steps to satisfy such liens, past and future. The settlement is based upon a good faith determination of tie parties in order to resolve a question ble claim. The p�.rties have attempted o resolve this matter in compliance with both state and federal law and it is believed that the settlement terms adequately consider Medicare's interests.and do not reflect any attempt to shift the responsibility of treatment to Medicare. The purpose of this settlement is to resolve a disputed claim. If Medicare has a lien or has made payments of Medicare benefits, Plaintiff will do the following: 1. Reporting: Plaintiff agrees the settlement will be reported to the Center for Medicare Services (CMS) and determine whether the Plaintiff is a Medicare beneficiary or Medicare eligible as defined by 42 U.S.C. Section 1395(y)and 42 C.F.R. Section 411.25 (hereinafter the Medicare Secondary Payer Statute). Plaintiff will notify Defendants in writing if CMS has a lien, reporting or set aside requirement and provide the releasor's full address, Social Security Number, date of birth, gender and if available, their [19-CA-3709/1665886/11 3 16K3 Medicare Health Insurance Claim Number (HICN). Provision of this information is a condition of settlement and spaces are provided at the end of the release for compliance. Plaintiffs agree that defendant or its insurer may also report the settlement to Medicare and consent to such reporting and agree to cooperate fully with the defendant and its insurer with respect to such reporting. The parties agree that any present or future action or decision by Medicare on this settlement or Plaintiffs eligibility or entitlement to Medicare benefits in the future, will not render this release void or ineffective, or in any way affect the finality of this settlement. Plaintiff agrees the following information may be reported to Medicare: FULL NAME ON SOCIAL SECURITY CARD: Paula Yoanys Alpizar Gomez SOCIAL SECURITY NUMBER: 752 41 7270 DATE OF BIRTH: 08/13/1972 GENDER: F MEDICARE HEALTH INSURANCE CLAIM NUMBER(HICN): I have not 2. Conditional Payment Liens: Plaintiff further covenants and agrees that if CMS or a Medicare Advantage Organization (hereinafter MAO) has made conditional payments and/or has a lien and/or is expected to make future payments prior to closing, Plaintiff agrees not to disburse the settlement funds until (he/she/they) (has/have) (i) reported the settlement to CMS;(ii) obtained a Conditional Payment Notice and Demand Letter; (iii) fully paid and satisfied the Medicare lien; and (iv) obtained proof of iii by faxing Defendant(s) the Final Payment, Reimbursement and Recovery Demand Letter. Plaintiff agrees that the released parties may elect to pay CMS or MAO lien directly from the settlement funds. Plaintiff acknowledges CMS may charge interest on any additional payments not made within 60 days and Plaintiffs agree to be responsible for such interest should it accrue. 3. Medicare Set Asides: It is further expressly understood and agreed, to the extent applicable, Plaintiff agrees to set aside unds necessary to pay for any anticipated future medical and/or health care needs of Pla ntiff,for any injury and/or condition that requires treatment that arises from the injuries lated and/or caused by the accident in question. Plaintiff has conferred with their medi al experts to determine the amount necessary to set aside and self administer for anticip ted future medical expenses or healthcare needs. Plaintiff agrees to set aside $ of the settlement for these purposes and notify Medicare that these funds have been set aside. If an LMSA or Medical Cost Projection was done,the amount stated therein shall be set aside. Any LMSA or Medical Cost Projection is hereby incorporated by reference into this agreement. Alternatively, if nothing has been set aside for future costs it is because Plaintiff has covenanted that he does not reasonably anticipate that he will require medical and/or health care treatment for the injuries and/or conditions related and/or arising from the accident in question and to the extent he does, he will use the net settlement proceeds for related costs if they are incurred. 4. Cooperation and Indemnity: Plaintiff and her counsel agree to fully cooperate with the Defendant(s) and CMS at Plaintiff's own expense with respect to these provisions, [19-CA-3709/1665886/1] 4 l6Kr, including production of documents or information or preparation of a Medicare set aside. Plaintiff agrees to execute any authorizations required by Defendant, his insurer(s) or CMS for purposes of complying with these paragraphs. Plaintiff and her counsel understand that these conditions are a basis of the settlement and Plaintiff's counsel agrees to the above terms. Plaintiff acknowledges that additional reimbursement may be due to Medicare and as such remain obligated to Medicare for any such additional payments. Plaintiff agrees to hold harmless and indemnify the Defendant(s) and (his/her/their)insurers, including their own negligence, from and against any and all liens, interest, damages, including costs and attorney's fees, for Plaintiff's failure to comply with the terms of this release, for plaintiff's failure to reimburse Medicare or any Medicare Advantage Organization (MAO) and for any action taken by Medicare to determine the validity of this release, the validity of any reimbursement, the validity of any lien or validity of any set aside(self allocated or otherwise). 12, This Agreement shall be governed by the laws of the State of Florida. DI WITNESS WHEREOF, Plaintiff and the County have signed and sealed this Agreement and Release as set forth below. By: 1:0-------- Paula Yoar ys Alpizar Gomez, Plaintiff STATE OF FLORIDA COUNTY OF COLLIER The foregoing instrument was acknowledged before me by means of X physical presence or_ online notarizatio , this 23 day of :I-04 , 2021, by Paula Yoa ys Alpizar Gomez. y?"P' CHRISTINEHIKA -�/ ,bk �L � (Signature of Notary Public-State of Florida • . I MY COMMISSION SI GO 157 ='a Pam= EXPIRES December 11,2021' ' Re�`R"' Bonded TMu Now Public Undo/writers in. (Print,Type, or Stamp Commissioners Name of Notary Public) _Personally Known OR ) Produced Identification Type of Identification Produced: FL nod Au+2.4U c [19-CA-3709/1665886/1] 5 I6K4 AS'T,C GOJ4Ky: Pr,K�1CkMI>,E�slerk BOA LINTY CO ION RS Q.,•• �11..�y- 1 OF CO COUNTY,FLO \r By: ` �tC , By: ' Penny Tayl , Chairperson Date: b-1 -a I Date: t©•I a-a‘ Approv d a to fo and legality en A. erins Assistant County Attorney 1 1 [19-CA-3709/1665886/1] 6