Backup Documents 03/23/2010 Item #16F 6
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO '6 F 6
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATU~
Print on pink paper. Attach to original document. Original documents should he hand delivered to the Board Office, The completed routing slip and original
documents are to he jorwarded to the Board ()flice on]v after the HI'anl has t,Jkcn action on the item. i
ROUTING SLIP
Complete routing lines # I through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
ex tion of the Chairman's si ature, draw a line thrall cautio lines # 1 thrall #4, lete the checklist, and forward to Sue Filson (line #5).
Route to Addressee(s) Office Initials Date
List in roudo order
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2,
3.
4, Scott R. Teach, Deputy
Office of the County
Attorne
Board of County Commissioners
ctM
5. Ian Mitchell, Supervisor
6, Minutes and Records
Clerk of Court's Office
PRIMARY CONT ACT INFORMATION
(The primary contact is the holder afthe original document pending BCe approval. Normally the primary contact is the person who created/prepared the executive
summary. Primary contact infonnation is needed in the event one of the addressees above, including Sue Filson, need to contact statffor additional or missing
infonnation. AU original documents needing the Bee Chainnan's signature aJ'(~ to be delivered to the Bee office only after the BCC has acted to approve the
item.
Name of Primary Staff Artie Bay Phone Number 252-3740
Contact
Agenda Date Item was 3/23/10 Agenda Item Number 16F6
A roved b the BCC
Type of Document Resolution Number of Original I-M &R-Need
Attached Documents Attached Ori 'nal Document
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INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/ A" in the Not Applicable column, whichever is
ro riate,
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, This includes signature pages from ordinances,
resolutions, etc, signed by the County Attorney's Office and signature pages from
contracts, agreements, etc, that have been fully executed by all parties except the BCC
Chainnan and Clerk to the Board and ossibl State Officials,
All handwritten strike-through and revisions have been in itialed by the County Attorney's
Office and all other arties exc t the BCC Chairman and the Clerk to the Board
The Chainnan's signature line date has been entered as the date ofBCC approval of the
document or the final ne otiated contract date whichever is a licable,
"Sign here" tabs are placed on the appropriate pages indicating where the Chainnan's
si ature and initials are re uired,
In most cases (some contracts are an exception), the original document and this routing slip
should be provided to Sue Filson in the BCC office within 24 hours ofBCC approval.
Some documents are time sensitive and require forwarding to Tallabassee within a certain
time frame or the BCC's actions are nullified, Be aware of our deadlines!
Tbe document was approved by tbe BCC on_3/23 , (enter date) and all cbanges
made during tbe meeting bave been incorporated in tbe attacbed document. Tbe
Coon Attorne 's Office bas reviewed tbe cban es, if a Iicable.
I~.'
1: Forms! County Forms! Bee Fonnsl Original Documents Routing Slip WWS Original 9.03.04. Revised 1.26.05. Revised 2.24.05
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3,
4,
5,
6,
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1 6 F 6 ",
MEMORANDUM
Date:
March 24, 20 I 0
To:
Artie Bay
EMS Operations Analyst
From:
Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re:
Attesting the Board of County Commissioners is authorized
to administer County affairs and will be legally and financially
responsible for outstanding debt owed to the Centers for
Medicare & Medicaid Services for any ambulance related claims
Attached, for your records is a certified copy of the document referenced above,
(Item #16F6) adopted by the Board of County Commissioners on March 23, 2010.
If you have any questions, please call me at 252-8406,
Thank you,
Attachment (1)
16F6
RESOLUTION NO. 201O-~
A RESOLUTION BY THE COLLIER COUNTY BOARD OF COUNTY
COMMISSIONERS: (1) ATTESTING AS TO THE AUTHORITY OF THE
BOARD TO ADMINISTER THE COUNTY'S AFFAms, INCLUDING THE
RESPONSffiILlTY FOR OVERSIGHT OF MEDICARE AS REQUIRED IN
SECTION 5 OF THE CMS MEDICARE 855B APPLICATION, (2)
ATTESTING TO THE COUNTY'S LEGAL AND FINANCIAL
RESPONSffiILlTY FOR OUTSTANDING DEBT OWED TO CMS AS A
RESULT OF THE FILING AND RECEIVING OF PAYMENTS
ASSOCIATED WITH COLLIER EMSfFIRE GROUND AND Am
RESPONSE UNIT RELATED CLAIMS, (3) DESIGNATING THE BOARD'S
CHAm TO PROVIDE ANY CMS REQUIRED CERTIFICATIONS AND
ASSURANCES; AND (4) PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the Board of County Commissioners of Collier County is the
governing body in and for Collier County, Florida, a political subdivision of the State
of Florida; and
WHEREAS, Florida Statutes 9 125,01(1) grants broad legislative and governing
powers to county governments including performing any acts not inconsistent with
law that are in the common interest of the county that includes the provision of
ambulance, health and welfare programs; and
WHEREAS, the County's ,billing provider for its EMS program, ADPI-
Intermedix (Intermedix Corporation), is requesting an attestation of the County's
authorization to participate in the Medicare program as required by the Centers for
Medicare and Medicaid Services ("eMS"); and
WHEREAS, in order to insure the timely processing and reimbursement of
payment for Medicare related claims filed in connection with the provision of
emergency medical services by Collier EMS, the County hereby attests as to its
authorization to participate in the Medicare program,
NOW THEREFORE, BE IT RESOLVED by the Board of County
Commissioners, Collier County, Florida, that:
L Attestation as to the Authoritv to Administer the Countv's Affairs: The
Collier County Board of Commissioners is lawfully authorized to administer the
16F6
County's affairs, including the responsibility for oversight of Medicare as required
in Section 5 of the CMS Medicare 855B application,
2, Attestation as to the Countv's Lel!:al and Financial Responsibilitv as a
Medicare Prol!:ram Participant: The Collier County Board of
Commissioners attests that the County is legally and financially responsible
for any outstanding debt owed to CMS as a result of the filing and receiving
of payments associated with Collier EMSIFire ground and air response unit
related claims,
3, Certifications and Assurances. The Chair or the Board's designee is
authorized to execute and file on the Board's behalf any CMS required
attestations, certifications and/or assurances to maintain compliance with its
participation in the Medicare program,
4, Effective Date of Resolution. This Resolution adopted after motion, second
and majority vote favoring same, this 23rd day of March, 20 I 0,
ATTEST:
DWIGH.r;.$\;:a1(~~."Clerk
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By: . ~ ,;'. "'., Q(
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::.. .... . . .' '. ~ Clerk
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BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
By: A~W, ~
FRED W, COYLE, Chai .
:!:v* as lI7~ffiCienCy:
Scott Teach
Deputy County Attorney
ltem# J~(P
Agenda '2. -;}2'10
Date ../ ;;.;>
2
Dale 3-~3-l 0
Rec'd I
A-T
Deputy Clerk