Backup Documents 12/09/2025 Item #16E 1ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO , ,6E
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.
**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 Addressees (List in routing order)
Office
Initials
Date
1. Risk
Risk Management
2. County Attorney Office
County Attorney Office
4. BCC Office
Board of County
Commissioners
4. Minutes and Records
Clerk of Court's Office
PY 10/
5. Procurement Services
Procurement Services
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, ma 1 need to contact staff for additional or missing information.
Name of Primary Staff
Deidra De La Cruz/ Procurement
Contact Information
239-252-8950
Contact / Department
Agenda Date Item was
December 9, 2025
Agenda Item Number
16.E.1
Approved by the BCC
Type of Document
Amendment
Number of Original
1
Attached
Documents Attached
PO number or account
N/A
14-6293
Millennium Physician
number if document is
Collier County On -Site
Group, LLC
to be recorded
Medical Clinic
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 STAMP OK
N/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
dd
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
dd
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
dd
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 December 9, 2025, and all changes made
N/A is not
during the meeting have been incorporated in the attached document. The County
an option for
Attorne 's Office has reviewed the changes, if applicable.
0this
line.
9.
Initials of attorney verifying that the attached document is the version approved by the
N/A is not
BCC, all changes directed by the BCC have been made, and the document is ready for theJ/r►�
an option for
Chairman's signature.
this line.
Please email an additional copy to
Madison.Bird@Collier.gov
16E1
FOURTH AMENDMENT TO AGREEMENT 414-6293
FOR
"COLLIER COUNTY ON -SITE MEDICAL CLINIC"
Cfy�
THIS FOURTH AMENDMENT, made and entered into on this day of
1
-e(4-' \'A C t , 2025, by and between Millennium Physician Group, LLC (the "Provider" or
"Millennium") and Collier County, a political subdivision of the State of Florida, (the "County" or
"Owner") (collectively, the "Parties"):
WHEREAS, on September 9, 2014 (Agenda Item 16.E.7), the County entered into
Agreement No. 14-6293 (the "Agreement") with the Provider, with a commencement date of November
14, 2014, to provide on -site primary care health services with an initial five-year term with five additional
one-year renewal terms; and
WHEREAS, on October 10, 2017 (Agenda Item 16.E.2), the County approved the First
Amendment to the Agreement expanding all four clinic models to include limited pharmacy services
with reimbursement from the County for the actual cost paid by the Provider with no additional markup
to the County; and
WHEREAS, on October 8, 2019 (Agenda Item 16.E.3), the County approved the Second
Amendment to the Agreement to replace Exhibit A Scope of Services in its entirety, including pricing
for the next five-year period (Exhibit 13-1 Fee Schedule), and renewing the Agreement for an additional
five-year term with a new Agreement end date of November 13, 2024; and
WHEREAS, on June 25, 2024 (Agenda Item 16.E.1), the County approved the Third
Amendment to the Agreement to extend the Agreement through December 31, 2025, and include pricing
for the extended period; and
WHEREAS, the Parties desire to further extend the Agreement through and including June
30, 2026, with no changes to the existing pricing, so that the County can coordinate the new onboarding
of a replacement vendor that has been selected through a competitive procurement process.
NOW, THEREFORE, in consideration of the mutual promises and covenants herein
contained, it is agreed by the Parties as follows:
1. The above recitals are hereby incorporated into this Fourth Amendment as if fully set forth herein.
2. Upon execution of this Fourth Amendment, the Agreement shall be extended through and
including June 30, 2026, with no changes to the existing pricing.
3. All other terms and conditions of the Agreement, as previously amended, shall remain the same.
SIGNATURE PAGE TO FOLLOW
Page 1 of 2
Fourth Amendment to Agreement #14-6293 SAO
16E l
IN WITNESS WHEREOF, the Parties have executed this Fourth Amendment on the date and
year first written above by an authorized person or agent.
ATTEST:
Crystal K. Kinzel, Clerk of the Circuit
Court and Comptroller
By: —
Dated:l �o 125
(SEAL) A test as to Chairman-,
signature only
Contractor's Witnesses:
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First Witness
tTy*print witness nameT
Second Wi ness
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r V �c"••.. ERIKA HO
NotxWEII
• `Fy Public - State of Florida
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BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
By:�-
B rt. . Saunders; hairman
CONTRACTOR:
Millennium Physician Group, LLC
Signature
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TType/print signature and titleT
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Date
Approved as to Form and Legality:
I
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Scott R. Teach
Deputy County Attorney
Page 2 of 2
Fourth Amendment to Agreement # 14-6293
6 CAO
16E 1d 4
AFFIDAVITREGARDING LABOR AND SERVICES
.AND CONTRACTING WITH ENTITIES OF FOREIGN COUNTRIES OF CONCERN PROFIIBITED
Effective July I, 2024, pursuant to § 787.06(I1)• Florida Statutes, when a contract is executed, renewed, or extended between a
nongovernmental entity and a governmental entity, the nongovernmental entity must provide the governmental entity with an
affidavit signed by an officer or a representative of the nongovernmental entity under penalty of perjury attesting that the
nongovernmental entity does not use coercion for labor or services.
Effective January 1, 2024. a governmental entity may not accept a bid on, a proposal for, or a reply to, or enter into, a contract with
an entity which would grant the entity access to an individual's personal identifying information unless the entity provides the
government with an affidavit signed by an officer or representative under penalty of perjury attesting that the entity does not meet
am of the following criteria: (a) the entity is owned by the government of a foreign country of concern; (b) the government of a
foreign country of concern has a controlling interest in the entity; or (c) the entity is organized under the laws of or has its principal
place of business in a foreign country of concern.
Effective Juh 1, 2025, when an entity extends or renews a contract with a governmental entity which would grant the entity access
to an individual's personal identifying information, the entity must provide the governmental entity with an affidavit signed by an
officer or representative of the entity under penalty of perjury attesting that the entity does not meet any of the criteria in paragraphs
(2)(a)-(c), § 287.138. Florida Statutes.
Nongovernmental Entity's Name:
Millennium Physician Group, LLC
Address:
2675 Winkler Ave, Suite 490, Fort Myers, FL 33901
Phone Number:
U ). 3- 3 g 3 -1 13 S
Authorized Representative's Name:
Taylor Hall
Authorized Representative's Title:
CFO
Email Address:
taylor.hall@mpgus.com
(Name of Authorized Representative), as authorized representative attest under
penalty of perjury that - 11 r •, ^ Vti y f . (Name of Nongovernmental Entity) does not: (1) use
coercion for labor or services as defined in § 787.06, Florida Statutes, and (2) the nongovernmental entity is not (a) owned by
a government of a foreign country of concern, (b) that a foreign country of concern does not have a controlling interest in the
entity, and (c) that the entity is not organized under the laws of or has its principal place of business in a foreign country of
concern, all as prohibited under § 287.138, Florida Statutes.
Under penalty of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true.
(Signature of authorized representative) Date
STATE OF ' 1
COUNTY OF
SwRrn to (or affirmed) and subscribed before me, by means \V(ameof
ysical presence or ❑online notarization this
day of ► 0 "a by Tt7 Affiant), who produced his Florida Driver's License as
identification.
Notary Public
ERIKA HOWELL
t_ {tilt l r \j if2 f �• • Notary Public Slat* of Florida
Corn fission Expires — — �. ComTlsston f NH 715651
.. MY Comm. Expkes Sep 6, 2029
lorded through National Notary Assn,
Personally KnownrR Produced identification ❑
Type of Identification Produced:
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