Backup Documents 09/23/2025 Item #16F12 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 F'2
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
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.
** ROUTING SLIP**
Complete routing lines#1 through#2 as appropriate foradditional 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
2.
3. County Attorney Office County Attorney Office •
9/Z(4/26—
4. BCC Office Board of County Commissioners
(//21)
5. Minutes and Records Clerk of Court's Office
4//R 2-S
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Exe tive Summary. Primary contact information is needed in the event one of the
addressees above may need to contact staff for additional or miss g information.
Name of Primary Staff ,(,Q� Phone Number
Contact/Department h v1 m c. tdJ { -wrap A Sa--
Agenda Date Item was Agenda Ttem Number r
Approved by the BCC 6'/c 5 A `(Q,'T=I i'
Type of Document(s) !Ult. ItJ j SYN., 4- L_O.4 Number of Original
Attached Documents Attached 1
PO number or account A0.16-1,09
number if document is
to be recorded 5o OH 10 10
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(instead of stamp)?
2. Does the document need to be sent to another agency for additional signatures? If yes,
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legality. (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.)
4. All handwritten strike-through and revisions have been initialed by the County Attorney 11/4) kik
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
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
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip
should be provided to the County Attorney Office at the time the item is uploaded to the
agenda. Some documents are time sensitive and require forwarding to Tallahassee within a CO
certain time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 9 J31AC nd all changes made during
the meeting have been incorporated in the attached document. The County Attorney Ct
Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the CLt
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04;Revised 1.26.05;2.24.05; 11/30/12;4/22/16;9/10/21
16F12
RESOLUTION NO. 2025- 189
RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS OF
COLLIER COUNTY, FLORIDA,To AUTHORIZE COLLIER COUNTY
EMS TO PARTICIPATE IN INTERGOVERNMENTAL TRANSFERS
WITH THE STATE OF FLORIDA AGENCY FOR HEALTH CARE
ADMINISTRATION AND THE SUPPLEMENTAL PAYMENT
PROGRAM FOR MEDICAID MANAGED CARE PATIENTS;
AUTHORIZING THE CHAIRMAN TO EXECUTE ALL REQUIRED
AGREEMENTS OR DOCUMENTS TO PARTICIPATE IN
INTERGOVERNMENTAL TRANSFERS AND THE SUPPLEMNTAL
PAYMENT PROGRAM FOR MEDICAID MANAGED CARE
PATIENTS SUBJECT TO BOARD RATIFICATION.
WHEREAS, Collier County provides emergency ambulance transportation services
throughout Collier County; and
WHEREAS, the State of Honda has created a supplemental payment program for
Medicaid managed care patients who arc transported to the hospital by public emergency
medical transportation providers and has appropriated an additional $54 million for this
program; and
WHEREAS, Collier County EMS transports more than 1,500 Medicaid managed care
patients annually to hospitals and receives approximately$163 per patient for this service; and
WHEREAS, by participating in the supplemental payment program for Medicaid
managed care patients, Collier County EMS can substantially increase its Medicaid managed
care patient transport revenue and provide better services to the community,
NOW THEREFORE, IT IS RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA, that:
1. Authorizes Collier County EMS to participate in intergovernmental transfers
with the State of Florida Agency Health Care Administration and the supplemental payment
program for Medicaid managed care patients.
2.. Authorizes the Collier County Chairman to execute any and all agreements or
documents necessary for Collier County EMS to participate in intergovernmental transfers or
the Medicaid managed care supplemental payment program subject to ratification by this Board.
'Fills Resolution adopted on this 23"I day of'September 2025 alter motion, second and
majority vote favoring adopt ion.
1 6 F 1 2
ATTEST: • ^ )12 BOARD OF COUNTY COMMISSIONERS
• 0
CRYSTN:K. KINZEIgtCLERK COLLIER COUNTY, FLORIDA
-11), •
. •
Ar,t,r44,004--
cony Clerk
Burt Saunders,Chairman
Attu as•to.etfitlAn's
gimisitUriet nly
Approved as to form and
legal sufficiency:
•
rey A, Klatzkow,County Attorney al)
16F12
Letter of Agreement Amendment
This Amendment is made to the 2024-2025 Public Emergency Medical Transportation Letter
of Agreement previously executed by and between the Collier County (the"IGT Provider") on
behalf of Collier County EMS and the Agency for Health Care Administration, with an effective
date of 9124/2024.
It is mutually understood and agreed upon by and between the undersigned contracting parties
to amend the previously executed Agreement dated December 2, 2024, as follows:
General Provisions
Deleted: 7. This LOA covers the period of July 1, 2024, through June 30, 2025, and shall be
terminated September 30, 2025, which includes the states certified forward period.
Inserted: 7. This LOA covers the period of July 1, 2024, through June 30, 2026, and shall be
terminated September 30, 2026, which includes the states certified forward period.
All provisions not in conflict with this amendment remain in effect. This amendment is hereby
made a part of the Letter of Agreement.
COLLIER COUNTY STATE OF FLORIDA,AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED SIGNED
BY: . BY:
NAME: Stephanie Scanlon
Burt Saunders, Chairman
TITLE: Chief of Medicaid Program
Finance
DATE: IP3P-5 DATE:
ATTEST:
CRYSTAL ;'. L ERK
reputy Cler
Attest as to Chairman's
g,. Signature only
CM)
16F12
Public Emergency Medical Transportation Letter of Agreement
THIS LETTER OF AGREEMENT (LOA) is made and entered into in duplicate on the
day of 5ep-)-, 2025, by and between Collier County (the"IGT Provider") on behalf of Collier
County EMS, and the State of Florida, Agency for Health Care Administration (the
"Agency"), for good and valuable consideration, the receipt and sufficiency of which is
acknowledged.
DEFINITIONS
"Intergovernmental Transfers (IGTs)" means transfers of funds from a non-Medicaid
governmental entity (e.g., counties, hospital taxing districts, providers operated by state or local
government) to the Medicaid agency. IGTs must be compliant with 42 CFR Part 433 Subpart B.
"Medicaid" means the medical assistance program authorized by Title XIX of the Social Security
Act, 42 US.C. §§ 1396 et seq., and regulations thereunder, as administered in Florida by the
Agency.
"Public Emergency Medical Transportation (PEMT)," pursuant to the General Appropriation Act,
Laws of Florida 2025-198 is the program that provides supplemental payments for eligible Public
Emergency Medical Transportation (PEMT)entities that meet specified requirements and provide
emergency medical transportation services to Medicaid beneficiaries.
A. GENERAL PROVISIONS
1. Per Senate Bill 2500, the General Appropriations Act of State Fiscal Year 2025-2026,
passed by the 2025 Florida Legislature, the IGT Provider and the Agency agree that the
IGT Provider will remit IGT funds to the Agency in an amount not to exceed the total of
$708,054.21.The IGT Provider and the Agency have agreed that these IGT funds will only
be used for the PEMT program.
2. The IGT Provider will return the signed LOA to the Agency.
3. The IGT Provider will pay IGT funds to the Agency in an amount not to exceed the total
of$708,054.21. The IGT Provider will transfer payments to the Agency in the following
manner:
a. Per Florida Statute 409.908, annual payments for the months of July 2025
through June 2025 are due to the Agency no later than October 31, 2025, unless
an alternative plan is specifically approved by the agency.
b. The Agency will bill the IGT Provider when payment is due.
4. The IGT Provider and the Agency agree that the Agency will maintain necessary records
and supporting documentation applicable to health services covered by this LOA in
accordance with public records laws and established retention schedules.
a. AUDITS AND RECORDS
Collier County_Collier County EMS_PEM LOA_SFY 2025-26
CAO
16F12
i, The IGT Provider agrees to maintain books, records, and documents (including
electronic storage media) pertinent to performance under this LOA in accordance
with generally accepted accounting procedures and practices, which sufficiently
and properly reflect all revenues and expenditures of funds provided.
ii. The IGT Provider agrees to assure that these records shall be subject at all
reasonable times to inspection, review, or audit by state personnel and other
personnel duly authorized by the Agency, as well as by federal personnel.
iii. The IGT Provider agrees to comply with public record laws as outlined in section
119.0701, Florida Statutes.
b. RETENTION OF RECORDS
i, The IGT Provider agrees to retain all financial records, supporting documents,
statistical records, and any other documents (including electronic storage media)
pertinent to performance under this LOA for a period of six (6) years after
termination of this LOA, or if an audit has been initiated and audit findings have not
been resolved at the end of six (6) years, the records shall be retained until
resolution of the audit findings.
ii. Persons duly authorized by the Agency and federal auditors shall have full access
to and the right to examine any of said records and documents.
iii. The rights of access in this section must not be limited to the required retention
period but shall last as long as the records are retained.
c. MONITORING
i. The IGT Provider agrees to permit persons duly authorized by the Agency to inspect
any records, papers, and documents of the IGT Provider which are relevant to this
LOA.
d. ASSIGNMENT AND SUBCONTRACTS
i. The IGT Provider agrees to neither assign the responsibility of this LOA to another
party nor subcontract for any of the work contemplated under this LOA without prior
written approval of the Agency. No such approval by the Agency of any assignment
or subcontract shall be deemed in any event or in any manner to provide for the
incurrence of any obligation of the Agency in addition to the total dollar amount
agreed upon in this LOA. All such assignments or subcontracts shall be subject to
the conditions of this LOA and to any conditions of approval that the Agency shall
deem necessary.
5. This LOA may only be amended upon written agreement signed by both parties.
The IGT Provider and the Agency agree that any modifications to this LOA shall be in the
same form, namely the exchange of signed copies of a revised LOA.
6. The IGT Provider confirms that there are no pre-arranged agreements (contractual or
otherwise) between the respective counties, taxing districts, and/or the providers to re-
Collier County_Collier County EMS_PEM LOA_SFY 2025-26
CAO
16F12
direct any portion of these aforementioned supplemental payments in order to satisfy non-
Medicaid, non-uninsured, and non-underinsured activities.
7. The IGT Provider agrees the following provision shall be included in any agreements
between IGT Provider and local providers where IGT funding is provided pursuant to this
LOA. Funding provided in this agreement shall be prioritized so that designated IGT
funding shall first be used to fund the Medicaid program and used secondarily for other
purposes.
8. This LOA covers the period of July 1, 2025, through June 30, 2025, and shall be
terminated September 30, 2026, which includes the state's certified forward period.
9. This LOA may be executed in multiple counterparts, each of which shall constitute an
original, and each of which shall be fully binding on any party signing at least one
counterpart.
PEMT Local Intergovernmental Transfers
Program I Amount State Fiscal Year 2025-2026
Estimated 1GTs $708,054.21
Total Funding Not to Exceed $708,054.21
IN WITNESS WHEREOF, the parties have caused this page Letter of Agreement to be
executed by their undersigned officials as duly authorized.
COLLIER COUNTY STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED SIGNED
BY: ,4 . BY:
Burt Saunders, Chairman NAME: Stephanie Scanlon
TITLE: Chief of Medicaid Program
Finance
DATE: l /Z3 /zS DATE:
•
'Mr
•
YSTAL l{' ' l_, ERK
eputy Clerk
Attest as1to Chairman's
'., "virtu 'tte�only
Collier County_Collier County EMS_PEM LOA_SFY 2025-26
CAO
SFY 2025-26 PEMT MCO Allotments 2
MNeudmLrentr t New Federal
Provider Region Total Allotment Total tGTs Needed N Ffl
ndinll
000683100 Marion Carly Fre Rescue B 5 8.755.918.21 S. 3,745,781.81 5 5,010,136.40
125443300 City of Femarcina Beach Fire Dept B 5 52.392.55 S 22,413.53 S 29,979.02
003458200 Winter Park Fire-Rescue E $ 274,811.41 5 117,564.32 $ 157,247.09
003655700 Orlando Fire Department E 5 4,447,628.73 $ 1,902,695.57 3 2,544,933.16
003997800 County of Vdusia B 5 7.138.485.27 5 3,053,844.00 $ 4084,641.27
008855600 City of Ocoee Fire Department E S 934.458.60 5 399,761.39 S 534,697.21
124356900 Bay County EMS Division A S 2.360.783.46 S 1,009,943.17 S 1,350,840.29
014564900 City of Key West Fre Department I 5 238261.37 S 101,928.21 S 136,333.16
017422000 Okaloosa County EMS A 5 3.793.969.26 5 1,623,060.05 5 2,170,909.21
018248400 Palm Beach Gardens Fee Rescue G $ 541,514.45 5 231,659.88 $ 309,854.57
020395700 Delray Beach Fre Rescue G S 658.399.74 $ 281,663.41 S 376,736.33
022548000 _City of Tampa Fire Department 0„, „$ 4.656.824.70 5 1,992,189.81 5 2,664,635.09
023813300 Walton County fire Rescue A S 1,703,631.16 S 728,813.41 3 974,817.75
083899301 Miami Dade County Fire Rescue I S 13.819.371.49 5 5,911,927.13 $ 7,907,444.36
083903500 Martin County Fire Rescue —G S 1,040,366.40 5 445,068.75 $ 595,297.65
084438100 Kissimmee Fire Department E S 1.595.727.45 5 682,652.21 5 913,075.24
084662700 Sarasota County Fire Department F $ 2.957.933.82 5 1,265,404.09 $ 1,692,529.73
084839500 Hendry County F 5 611.620.68 5 261,651.33 S 349,969.35
085063200 Pembroke Pines Fre Rescue H 5 1.634772.38 S 699,355.62 5 935,416.76
087475200 City of Miami Fire Rescue Department , I 5 8,047,995.03 $ 3,442,932.27 3 4,605,062.76
087678000 Paellas County EMS AuUwrity dba Su C S 22,869,473.89 S 9,783,560.93 S 13,085,912.96
087736100 Monroe County Fre Rescue(MCFR) I S 205.827.88 5 88,053.17 $ 117,774.71
087867700 West Palm Beach Fre Rescue G 5 597.524.59 S 255,621.02 S 341,903.57
088015900 PoOr County Board of County Commissi D S 11.664.079.10 S 4,989,893.04 5 6,674,186.06
110095100 Baker County Fire Rescue B 5 234.519.04 5 100,327.25 5 134,191.79
088022100 Lee County EMS F S 6.350.601.08 5 2.716.787.14 5 3.633.813.94
088024800 Jackson County Fre Rescue A 5 1.308.940.60 5 559,964.79 S 748,975.81
088030200 Manatee County Department of Public D S 3,320,689.87 5 1,420,591.13 S 1,900,098.74
088031100 Hollywood Fire Rescue&Beach Safety H 5 1,062,820.35 5 454.674.55 5 608,145.80
088042600 Madison County A S 679.731.00 5 290,788.92 $ 388,942.08
088046900 Okeechobee County Fire Rescue G S 725.387.36 S 310,320.71 S - 415,066.65
088048500 North Pad Fire Rescue , F 5 684,346.53 5 292.763.45 S 391,583.08
088051500 Levy County Department of Pubic Saf B $ 1,137,417.36 $ 486,587.15 $ 650,830.21
088053100 Hamilton County Ambulance Service B S 397.559.68 5 170,076.03 S 227,483.65
088061200 Jefferson County Ambulance Service A $ 389.326.56 5 166,553.90 $ 222,772.66
088065500 SL Lucie County Fire District G 5 6,396,631.68 $ 2,736,479.03 S 3,660,152.65
088070100 City of Miramar Fire Rescue H $ 434.109.72 S 185,712.14 S 248,397.58
088084100 HOtsbarou_h County FireRescue
D S 8,095,647.31 3 3,463,317.92 TS 4,632,329.39
088085000 Srwannee County Fre Rescue B $ 502.354.52 S 343,247.26 S 459,107.26
088086800 Nassau County Fre Rescue B S 1281,746.37 $ 548.331.10 5 733,415.27
088087600 Fla.,ler County Fire Rescue Deparhen B $ 927,472.92 $ 396,772.92 5 530,700.00
088100700 County of Desoto BCC-Desoto County F $ 336,809.27 S 144,087.00 S 192,722.27
088103100 Clay CBOCC-Clay Coady Fre Rescue B S 1.721.344.84 S 736,391.32 S 984,953.52
068104000 City of Jackswwilte Fre and Rescue B $ 12,975,015.61 S 5,550,711.68 $ 7,424,303.93
088105800 Wakulla County Fire Rescue A 5 675.739.18 S 289.081.22 5 386,657.96
088120100 Pasco County Board of County Comm"rss C 5 9.869.384.70 S 4,212,122.77 5 5,647,261.93
111363700 Highlands County EMS D $ 1,587,120.11 S 678,969.98 $ 908,150.13
088137600 Brevard County Fire Rescue E 5 3269,794.25 $ 1,398,817.98 S 1,870,97627
088173200 .,tachua County Fre Rescue B S 5.924.973.96 5 2,534,703.86 $ 3,390,270.10
088175900 Dixie County BOCC-Di ie County ES B $ 459.058.55 S 196.385.25 S 262,673.30
086714100 Indian River County Department of Em G S 1.335.635.85 S S71.385.02 $ 764,250.83
088499500 SI.Claud Fire Rescue E $ 760.315.73 $ 325,263.07, S 435,052.66
088723400 union County Fre Rescue B $ 472.530.93 S 202,148.73 S 270,382.20
089085500 Osceola County Fre Dept E $ 3,426,597.67 S 1,465,898.49 5 1,960,699.18
089269600 Temple Terrace Fre Department D $ 556.483.75 S 238,063.75 S 318,420.00
089282300 City of Mar.,ale H 5 527.168,87 S 225,522.84 $ 301,646.03
089707800 Collier County EMS Department F S 1,655,105.68 S 708.054.21 $ 947,051.47
089871600 Gilchrist Coady B $ 549-872.31 S 235.235.38 5 314,636.93
089925900 Charlotte County Fre&EMS Deparhne F 5 1,863,428.45 S 797,174.69 $ 1,066,253.76
099404900 Brad(od County EMS B 5 1,042,112.82 S 445,815.86 $ 596,296.96
103181100 Lake Emer_ency Medical Services B 5 4,057,304.21 5 1,735,714.74 $ 2,321,589.47
109865100 Gadsden County EMS A 5 1.916.694.21 $ 819.961.78 S 1,096,73143
110344600 Miami Beach Fre Rescue Department I 5 533,780.31 5 228,351.22 Si 305,429.09
111179500 South Walton Fire District A LS 483,258.92 S 206,738.17 S 276,520.75
111779200 Writer Garden Fire Rescue Department E S 546.878.45 S 233,954.60 S 312,923.85
112349200 Hernando County and Fire Rescue Dist B S 5.383.085.28 $ 2.302.883.88 $ 3,080,201.40
112679700 City of Coconut Creek-Fire Rescue H 5 216.056.91 5 92,429.14 S 123,627.7.
113723400 City of Sunrise Fre Rescue H $ 1,304,948.79 $ 558,257.09 $ 746,691.70
113731200 Plant City Fre Rescue D $ 778,403.64 $ 333,001.08 $ 445,402.5.i
113842700 Citrus County Fire Rescue B S 3,131,328.22 5 1,339,582.21 3 1,791,746.01
114515300 Holmes County A S 628.710.63 S 268,962.41 S 359,748.22
116069400 Sumter County Fire&EMS B $ 1.369.815.76 $ 586,007.18 5 783,808.58
117949700 Li.,tnttnouse Point H $ 72,351.62 S 30,952.02 Si 41,399.60
400001300 Boynton Beach Fre Rescue G $ 1.145.775.22 $ 490,162.64 5 655,612.58
400002100 Pompano Beach Fire Rescue _ H S 2,113,790.00 i 5 904,279.36 5 1,209510.64
400006400 Oakland Park Fire Rescue H 5 266.453.55 S 113,988.83 S 152,464.72
400007200 City of Hialeah Fre Department I 5 957.661.01 S 409,687.38 5 547,973.63
400009900 City of Greenacres G 5 434.858.19 S 186,032.33 S 248.825.86
400021800 Riviera Beach Fre Department G $ 1.084.650,58 S 464,013.52 5 620,637.06
400024200 Lehigh Acres Fire Control and Rescue F 5 1,695,398.05 $ 725,291.29 S 970,106.76
400028500 Palm Beach County Fre Rescue G S 9.086.116.04 S 3,1187.040.44 S 5,199,075.60
400032300 Oviedo Fre Department E 5 179.132.63 $ 76,632.94 5 102,499.69
400035800 Laywood Fre Department E $ 300.009.73 $ 128,344.16 5 171,665.57
400037400 City of Laudertrtl Fre Rescue Depar H $ 1.817.896.8.3 S 777,696.26 $ 1,040,200.57
400038200 Orange Courtly Fire Rescue EMS Bureau E $ 12,301,896.06 $ 5,262,751.13 5 7,039,144.93
400039100 City of Coral Springs Fre Departnen H S 999.325.57 $ 427,511.48 $ 571,814.09
400040400 City of Plantation H S 668,005.04 $ 285,772.56 S 382.232,48
400041200 City of Tamarac Fre Department H $ 679,980.48 $ 290,895.65 5 389,084.83
400042100 Bro.,ard Sheriffs Fire Rescue H S 4.443.013.19 $ 1,900,721.04 5 2,542,292.15
400045500 Fort Myers Beach Fire Department F 5 9.979.53 S 4,269.24 $ 5,710.29
400046300 Seminole County EMS/Fre Rescue Divi E S 2,956,312.14 5 1,264,710.34 S 1,691,601.80
400047100 Sanford Fre Department E S 1.042.861.28 $ 446,136.06 5 596,725.22
400050100 North Lauderdale Fre Rescue H S 609.624.77 S 260,797.48 S 348,827.29
400051000 The Town of Davie Fire Rescue H 5 815.078.42 S 348.690.55 5 466,387.87
400057900 City of Stuart Fre Rescue G 5 225,537.46 S 96,484.93 5 129,052.53
400063300 Fort Lauderdale Fire Department Resc H $ 3.128.958.08 S 1,338,568.27 $ 1,790,389.81
400064100 Maitland Fre Rescue Department , E 5 203,083.51 5 86,879.13 S 116,204.38
400101000 Leon County EMS A ,$ 8,082,424.42 $ 3,457,661.17 S 4,624,763.25
400105200 Lake Mary Fire Department E $ 265,455.60 S 113.561.91 $ 151,893.69
400115000 Hardee County Board of County Commis D 5 224.539.51 $ 96,058.00 S 128,481.51
Totals $ 260,000,000.00 $ 111,21,8,000.02_s_ 14877!999.98
Agency for Health care Administration
Bureau of Medicaid Program Finance
1 of I 9/8/2025
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so—
nri9.
a .
Intergovernmental Transfers Questionnaire
IGT Provider Name: Collier County Emergency Medical Services
Health Care Provider Name:
IGT Amount: $ 708,054.21
State Fiscal Year Ending: 6/30/2026
1. What type of governmental entity is your organization considered? (county, city, hospital taxing
district, or other)
County
If other,please explain
2. Does your organization have a relationship with the provider for which you contribute IGTs as named
in the preamble of the enclosed Letter of Agreement(LOA)?
Yes
If yes, please describe your relationship, including services provided to/by the provider to/by the
organization and any other financial transactions between the provider and the organization.
Yes,we are the provider
3. Please describe the source of the IGT funding for your organization, including whether the source is
from a tax, a provider donation, or other funds. Provide the amount of funding from each source.
Source Amount
Ad Valorem $ 708,054
If other,please explain
a. Verify whether the funds are public funds as defined by 42 CFR§433.51, and exclude any federal
funds.
No
If no, please explain
4. Does your organization have taxing authority?
Yes
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5. If the source of IGT funding is from taxes, please answer the following questions:
a. Is the tax a state, county, city, or hospital district tax?
County
If other, please explain
b. What entities are taxed?
Property Owners in Collier County
c. What is the tax structure (i.e. property tax, percentage of revenue, assessment, etc.)?
Ad Valorem/Property Tax
d. What is the amount or percent of the tax?
3.0107 per$1000 value
e. Does at least 85% of the burden of the tax revenue fall on health care providers as defined in 42
CFR§433.55? (Provide the total tax revenue and the health care provider tax burden) If so,
please answer the following questions:
Amount
Total Tax Burden $ -
Healthcare Provider Tax Burden $ -
0.00%
i) Is the tax broad based?A broad based tax can be defined as a tax that is imposed on at least
all health care items or services in the class or providers of such items or services furnished by
all non-Federal, non-public providers in the State, and is imposed uniformly, pursuant to 42
CFR §433.68.
If no, please explain
CA.0
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ii) Is the tax uniform across all entities being taxed? Based on 42 CFR§ 433.68, a health care-
related tax will be considered to be imposed uniformly even if it excludes Medicaid or Medicare
payments(in whole or in part), or both; or in the case of health care-related tax based on
revenue or receipts with respect to a class of items or services, if it excludes either Medicaid or
Medicare revenue with respect to a class of items or services, or both. The exclusion of
Medicaid revenue must be applied uniformly to all providers being taxed.
If no, please explain
iii) Is the tax generally redistributive and a waiver of the broad-based or uniform tax requirement
was granted in accordance with 42 CFR §433.68(e)?
If no, please explain
iv) Does the tax program comply with the hold harmless provisions included in 42 CFR §
433.68(f)?
If no, please explain
v) Does every tax paying entity receive a supplemental payment equal to or exceeding its tax cost?
If yes, please explain
6. Please answer the following regarding provider funds received from the healthcare entity and/or other
health care entities.
a. Are provider voluntary payments or in-kind services received by the organization as defined in 42
CFR§433.52?
No
b. How much of the organization's revenue is received from provider-related donations(Provide the
total revenue and the provider-related donation amounts)?
Total Revenue $
Amount
Provider Related Donations $ -
c. Do individual provider donations exceed $5,000 per year or$50,000 per year for a health care
organizational entity?
No
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16F12
If yes, please list the provider and payment amount.
Provider Name Funding Source Amount
d. Does any portion of the provider donation constitute as a"bona fide donation" pursuant to 42 CFR
§433.54?42 CFR§433.54 requires donations will not be returned to the individual provider,the
provider class, or related entity under a hold harmless provision.
No
e. Is there an agreement between the IGT provider and the health care entity? If so, please specify
whether the agreement is written and provide the details.
7. Were funds utilized for the IGT specifically appropriated by the organization's board?
Yes
If yes, provide the board minutes and date of the appropriation.
certify that the statements and information contained
in this submittal are true, accurate, and complete.
Signature of Officer or Administrator
Title
Date