AGREEMENT BETWEEN THE COUNTY OF SAN MATEO AND
HEALTH ADVOCATES, LLC

THIS AGREEMENT, entered into this _____ day of _______________ , 2009, by and between the COUNTY OF SAN MATEO, hereinafter called "County," and HEALTH ADVOCATES, LLC, hereinafter called "Contractor";

W I T N E S S E T H:

WHEREAS, pursuant to Government Code, Section 31000, County may contract with independent contractors for the furnishing of such services to or for County or any Department thereof;

WHEREAS, it is necessary and desirable that Contractor be retained for the purpose of cost recovery and legal services.

NOW, THEREFORE, IT IS HEREBY AGREED BY THE PARTIES HERETO AS FOLLOWS:

1.

Exhibits and Attachments

The following exhibits and attachments are included hereto and incorporated by reference herein:

Exhibit A—Services
Exhibit B—Payments and rates
Exhibit E—Corporate Compliance SMMC Code of Conduct (Third Parties)
Attachment H—HIPAA Business Associate requirements

Attachment I—§ 504 Compliance

2.

Services to be performed by Contractor

In consideration of the payments set forth herein and in Exhibit “B,” Contractor shall perform services for County in accordance with the terms, conditions and specifications set forth herein and in Exhibit “A.”

3.

Payments

In consideration of the services provided by Contractor in accordance with all terms, conditions and specifications set forth herein and in Exhibit "A," County shall make payment to Contractor based on the rates and in the manner specified in Exhibit "B." The County reserves the right to withhold payment if the County determines that the quantity or quality of the work performed is unacceptable. In no event shall the

County’s total fiscal obligation under this Agreement exceed NINE HUNDRED EIGHTY FOUR THOUSAND DOLLARS ($984,000). Notwithstanding the foregoing, all payments to the Contractor are made on a contingency fee basis, as set forth in Exhibit B to this agreement.

4.

Term and Termination

Subject to compliance with all terms and conditions, the term of this Agreement shall be from May 1, 2009 through April 30, 2010.

This Agreement may be terminated by Contractor, the Chief of the Health System or her designee at any time without a requirement of good cause upon thirty (30) days’ written notice to the other party.

In the event of termination, all finished or unfinished documents, data, studies, maps, photographs, reports, and materials (hereafter referred to as materials) prepared by Contractor under this Agreement shall become the property of the County and shall be promptly delivered to the County. Upon termination, the Contractor may make and retain a copy of such materials. Subject to availability of funding, Contractor shall be entitled to receive payment for work/services provided prior to termination of the Agreement. Such payment shall be that portion of the full payment which is determined by comparing the work/services completed to the work/services required by the Agreement.

5.

Availability of Funds

The County may terminate this Agreement or a portion of the services referenced in the Attachments and Exhibits based upon unavailability of Federal, State, or County funds, by providing written notice to Contractor as soon as is reasonably possible after the County learns of said unavailability of outside funding.

6.

Relationship of Parties

Contractor agrees and understands that the work/services performed under this Agreement are performed as an independent Contractor and not as an employee of the County and that Contractor acquires none of the rights, privileges, powers, or advantages of County employees.

7.

Hold Harmless

Contractor shall indemnify and save harmless County, its officers, agents, employees, and servants from all claims, suits, or actions of every name, kind, and description, brought for, or on account of: (A) injuries to or death of any person, including Contractor, or (B) damage to any property of any kind whatsoever and to whomsoever belonging, (C) any sanctions, penalties, or claims of damages resulting from Contractor’s failure to comply with the requirements set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all Federal regulations promulgated thereunder, as amended, or (D) any other loss or cost, including but not limited to that caused by the concurrent active or passive negligence of County, its

officers, agents, employees, or servants, resulting from the performance of any work required of Contractor or payments made pursuant to this Agreement, provided that this shall not apply to injuries or damage for which County has been found in a court of competent jurisdiction to be solely liable by reason of its own negligence or willful misconduct.

The duty of Contractor to indemnify and save harmless as set forth herein, shall include the duty to defend as set forth in Section 2778 of the California Civil Code.

8.

Assignability and Subcontracting

Contractor shall not assign this Agreement or any portion thereof to a third party or subcontract with a third party to provide services required by contractor under this Agreement without the prior written consent of County. Any such assignment or subcontract without the County’s prior written consent shall give County the right to automatically and immediately terminate this Agreement. County authorizes contractor to retain Leibovic Law Group, LLP to undertake the activities as set forth in Exhibit A to this Agreement.

9.

Insurance

The Contractor shall not commence work or be required to commence work under this Agreement unless and until all insurance required under this paragraph has been obtained and such insurance has been approved by Risk Management, and Contractor shall use diligence to obtain such insurance and to obtain such approval. The Contractor shall furnish the County with certificates of insurance evidencing the required coverage, and there shall be a specific contractual liability endorsement extending the Contractor's coverage to include the contractual liability assumed by the Contractor pursuant to this Agreement. These certificates shall specify or be endorsed to provide that thirty (30) days' notice must be given, in writing, to the County of any pending change in the limits of liability or of any cancellation or modification of the policy.

(1)

Worker's Compensation and Employer's Liability Insurance The Contractor shall have in effect during the entire life of this Agreement Workers' Compensation and Employer's Liability Insurance providing full statutory coverage. In signing this Agreement, the Contractor certifies, as required by Section 1861 of the California Labor Code, that it is aware of the provisions of Section 3700 of the California Labor Code which requires every employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the provisions of the Code, and will comply with such provisions before commencing the performance of the work of this Agreement.

(2)

Liability Insurance The Contractor shall take out and maintain during the life of this Agreement such Bodily Injury Liability and Property Damage Liability Insurance as shall protect him/her while performing work covered by this Agreement from any and all claims for damages for bodily injury, including accidental death, as well as any and all claims for property damage which may arise from contractors operations under this Agreement, whether such operations be by himself/herself or by any sub-contractor or by anyone directly or indirectly employed by either of them. Such insurance shall be combined single limit bodily injury and property damage for each occurrence and shall be not less than the amount specified below.

Such insurance shall include:

(a)

Comprehensive General Liability . . . . . . . . . . . . . . .

$1,000,000

(b)

Motor Vehicle Liability Insurance . . . . . . . . . . . . . . .

$1,000,000

(c)

Professional Liability . . . . . . . . . . . . . . . . . . . . . . . . .

$1,000,000

County and its officers, agents, employees and servants shall be named as additional insured on any such policies of insurance, which shall also contain a provision that the insurance afforded thereby to the County, its officers, agents, employees and servants shall be primary insurance to the full limits of liability of the policy, and that if the County or its officers and employees have other insurance against the loss covered by such a policy, such other insurance shall be excess insurance only.

In the event of the breach of any provision of this section, or in the event any notice is received which indicates any required insurance coverage will be diminished or canceled, the County of San Mateo at its option, may, notwithstanding any other provision of this Agreement to the contrary, immediately declare a material breach of this Agreement and suspend all further work pursuant to this Agreement.

10.

Compliance with laws; payment of Permits/Licenses

All services to be performed by Contractor pursuant to this Agreement shall be performed in accordance with all applicable Federal, State, County, and municipal laws, ordinances and regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Federal Regulations promulgated thereunder, as amended, and will comply with the Business Associate requirements set forth in Attachment “H,” and the Americans with Disabilities Act of 1990, as amended, and Section 504 of the Rehabilitation Act of 1973, as amended and attached hereto and incorporated by reference herein as Attachment “I,” which prohibits discrimination on the basis of handicap in programs and activities receiving any Federal or County financial assistance. Such services shall also be performed in accordance with all applicable ordinances and regulations, including, but not limited to, appropriate licensure, certification regulations, provisions pertaining to confidentiality of records, and applicable quality assurance regulations. In the event of a Contractor and all of its subcontractors will adhere to all applicable provisions of

Chapter 4.106 of the San Mateo County Ordinance Code, which regulates the use of disposable food service ware.

Contractor will timely and accurately complete, sign, and submit all necessary documentation of compliance.

11.

Non-Discrimination and Other Requirements

A.

Section 504 applies only to Contractors who are providing services to members of the public. Contractor shall comply with § 504 of the Rehabilitation Act of 1973, which provides that no otherwise qualified handicapped individual shall, solely by reason of a disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination in the performance of this Agreement.

B.

General non-discrimination. No person shall, on the grounds of race, color, religion, ancestry, gender, age (over 40), national origin, medical condition (cancer), physical or mental disability, sexual orientation, pregnancy, childbirth or related medical condition, marital status, or political affiliation be denied any benefits or subject to discrimination under this Agreement.

C.

Equal employment opportunity. Contractor shall ensure equal employment opportunity based on objective standards of recruitment, classification, selection, promotion, compensation, performance evaluation, and management relations for all employees under this Agreement. Contractor’s equal employment policies shall be made available to County of San Mateo upon request.

D.

Violation of Non-discrimination provisions. Violation of the non-discrimination provisions of this Agreement shall be considered a breach of this Agreement and subject the Contractor to penalties, to be determined by the County Manager, including but not limited to:

i)

termination of this Agreement;

ii)

disqualification of the Contractor from bidding on or being awarded a County contract for a period of up to 3 years;

iii)

liquidated damages of $2,500 per violation;

iv)

imposition of other appropriate contractual and civil remedies and sanctions, as determined by the County Manager.

To effectuate the provisions of this section, the County Manager shall have the authority to examine Contractor’s employment records with respect to compliance with this paragraph and/or to set off all or any portion of the amount described in this paragraph against amounts due to Contractor under the Contract or any other Contract between Contractor and County.

Contractor shall report to the County Manager the filing by any person in any court of any complaint of discrimination or the filing by any person of any and all charges with the Equal Employment Opportunity Commission, the Fair Employment and Housing Commission or any other entity charged with the investigation of allegations within 30 days of such filing, provided that within such 30 days such entity has not notified Contractor that such charges are dismissed or otherwise unfounded. Such notification shall include the name of the complainant, a copy of such complaint, and a description of the circumstance. Contractor shall provide County with a copy of their response to the Complaint when filed.

E.

Compliance with Equal Benefits Ordinance. With respect to the provision of employee benefits, Contractor shall comply with the County Ordinance which prohibits contractors from discriminating in the provision of employee benefits between an employee with a domestic partner and an employee with a spouse.

F. E.

The Contractor shall comply fully with the non-discrimination requirements required by 41 CFR 60-741.5 (a), which is incorporated herein as if fully, set forth.

12.

Compliance with Contractor Employee Jury Service Ordinance

Contractor shall comply with the County Ordinance with respect to provision of jury duty pay to employees and have and adhere to a written policy that provides that its employees shall receive from the Contractor, on an annual basis, no less than five days of regular pay for actual jury service in San Mateo County. The policy may provide that employees deposit any fees received for such jury service with the Contractor or that the Contractor deduct from the employees’ regular pay the fees received for jury service.

13.

Retention of Records, Right to Monitor and Audit

(a) CONTRACTOR shall maintain all required records for three (3) years after the COUNTY makes final payment and all other pending matters are closed, and shall be subject to the examination and/or audit of the County, a Federal grantor agency, and the State of California.

(b) Reporting and Record Keeping: CONTRACTOR shall comply with all program and fiscal reporting requirements set forth by appropriate Federal, State and local agencies, and as required by the COUNTY.

(c) CONTRACTOR agrees to provide to COUNTY, to any Federal or State department having monitoring or review authority, to COUNTY's authorized representatives, and/or their appropriate audit agencies upon reasonable notice, access to and the right to examine all records and documents necessary to determine compliance with relevant Federal, State, and local statutes, rules and regulations, and this Agreement, and to evaluate the quality, appropriateness and timeliness of services performed.

14.

Merger Clause

This Agreement, including the Exhibits attached hereto and incorporated herein by reference, constitutes the sole Agreement of the parties hereto and correctly states the rights, duties, and obligations of each party as of this document's date. In the event that any term, condition, provision, requirement or specification set forth in this body of the agreement conflicts with or is inconsistent with any term, condition, provision, requirement or specification in any exhibit and/or attachment to this agreement, the provisions of this body of the agreement shall prevail. Any prior agreement, promises, negotiations, or representations between the parties not expressly stated in this document are not binding. All subsequent modifications shall be in writing and signed by the parties.

15.

Controlling Law and Venue

The validity of this Agreement and of its terms or provisions, as well as the rights and duties of the parties hereunder, the interpretation, and performance of this Agreement shall be governed by the laws of the State of California. Any dispute arising out of this Agreement shall be venued either in the San Mateo County Superior Court or in the United States District Court for the Northern District of California.

16.

Notices

Any notice, request, demand, or other communication required or permitted hereunder shall be deemed to be properly given when both (1) transmitted via facsimile to the telephone number listed below and (2) either deposited in the United State mail, postage prepaid, or when deposited for overnight delivery with an established overnight courier that provides a tracking number showing confirmation of receipt, for transmittal, charges prepaid, addressed to:

In the case of County, to:

San Mateo Medical Center

222 West 39^th Avenue

San Mateo, CA 94403

Attn: Isela Montenegro

Facsimile: (650) 372-9396

In the case of Contractor, to:

Health Advocates, LLC
14721 Califa Street
Van Nuys, CA 91411
Attn: Al Leibovic, President
Facsimile: (818) 995-9599

In the event that the facsimile transmission is not possible, notice shall be given both by United States mail and an overnight courier as outlined above.

IN WITNESS WHEREOF, the parties hereto, by their duly authorized representatives, have affixed their hands.

COUNTY OF SAN MATEO

By:

Mark Church, President
Board of Supervisors
County of San Mateo

Date:

ATTEST:

By:

Clerk of Said Board

HEALTH ADVOCATES, LLC

Contractor’s Signature

Date:

EXHIBIT A

In consideration of the payments set forth in Exhibit “B”, Contractor shall provide the following services:

A.

ELIGIBILITY SERVICES (Acute and Psych accounts)

1.

Eligibility Fee: Medi-Cal, California Children Services (CCS), Medicare and Victims of Crime (VOC), Workers’ Compensation, Eligibility Services (Pre-Legal), Third Party Liability.

2.

The following services are included:

a.

Comprehensive Services, including hospital based and field eligibility support for the Medi-Cal, Social Security (SSI/SSD (SSA)), California Children Services (CCS), CMSP, Genetically Handicapped Persons Program (GHPP), and Victims of Crime (VOC) programs, as well as Fair Hearings, SSA appeals and TAR/billing appeals.

b.

Cost Recovery Services provided by ethnically diverse and experienced bilingual staff to screen and/or process applications for all eligible patients, including incompetent, deceased and homeless patients, and staff attorneys for Fair Hearings, SSI/SSD appeals, and other appeals.

c.

Established Relationships with County Human Services Agency (HSA) and other County and State DSS offices for application, Medi-Cal and SSA disability evaluations and Fair Hearings.

d.

Client Satisfaction and Communication. In addition to regularly scheduled meetings, Contractor will also provide customized management reports, graphs and charts which will be presented weekly, monthly, annually or on demand. Contractor will also maintain in-house software systems support staff to provide any additional report and/or systems for proper delivery of the contract requirements.

e.

Client training as well as telephone consultation on all issues ranging from Medi-Cal to Third Party Liability will be conducted by Contractor’s attorneys and experienced managers.

f.

Contractor will be proactive with SSA and HSA in representing patients in the application and/or appeal of their SSI/SSD cases and in obtaining Medi-Cal and Medicare eligibility.

g.

Medi-Cal TAR and Billing and Appeals, if requested by County. Contractor’s process includes administrative appeals and legal action, with the approval of County.

h.

Skiptracing Department. Contractor will utilizes search engines, public record databases and field investigators to locate patients once discharged from the hospital.

i.

SMMC continued control of the referral process will include a review of all proposed procedures with SMMC staff who will retain the final approval on all procedures. Contractor will adjust its procedures to comply with SMMC guidelines/processes.

B.

MEDI-CAL BILLING

Medi-Cal Billing (Pre-Legal). Once Medi-Cal eligibility is established, Contractor will assume responsibility for billing the appropriate fiscal intermediary for all services. This will include obtaining treatment authorization and billing both hospital (UB92) and professional (1500) charges.

C.

LEGAL SERVICES

Administrative Appeals, Legal Action, and/or Attorney Intervention. For TAR appeals, County agrees to provide Contractor with copies of all medical records.

D.

THIRD PARTY RECOVERY (TPR) SERVICES (WORKERS COMPENSATION, TPL, ETC

1.

Third Party Liability and Worker’s Compensation (Pre-Legal)

2.

The following services are included:

a.

Correspondence Unit. At SMMC’s option and at no additional cost, Contractor will provide Full Time Employees (FTE’s) to process all attorney requests for business records received by SMMC. These FTE’s will be stationed on-site at SMMC.

b.

Full Scope Identification of Patients with Potential TPC Cases. This includes all patient types including self-pay, Medi-Cal, managed care, etc., as well as all inpatient, outpatient, physician and clinic services. Contractor will also perform comprehensive investigation and review of all police and ambulance reports. Contractor will file lien for all cases authorized by law or court decisions, including contractual adjustments.

c.

Comprehensive Lien Process. Contractor will file liens via certified mail with all parties, when required by California Statute. Contractor’s TPL process will also include a review of relevant provider contracts to ensure contract compliance as well as regular follow-up on all liened accounts supported and managed by the most sophisticated TPL collection system available.

d.

Provide experienced settlement support.

e.

In-House Attorney Support. Attorneys and experienced support staff will be exclusively dedicated to TPL issues, case processing, negotiations and legal intervention including SMMC authorized legal action(s) against attorneys and patients that ignore SMMC’s liens.

f.

Full Statutory Compliance on Medi-Cal Liens includes the immediate processing of refunds to the Medi-Cal Program on behalf of SMMC and full compliance with Medi-Cal’s TPL requirements.

E.

HMO AND PPO INSURANCE COLLECTION

HMO/PPO: Insurance/Managed Care Claims (Pre-Legal)/COBRA. Contractor will aggressively follow-up, appeal, arbitrate and/or litigate insurance denial appeals and underpayment recovery.

F.

CORRESPONDENCE UNIT

Contractor will provide employees to process and respond to all civil attorney correspondence and subpoena requests for Business Records. SMMC will provide Contractor with access to workspace, supplies, computers, printers, hospital stationary, and postage in order to complete this process. Contractor will provide all labor, supervision, wages, benefits, workers compensation, payroll taxes, etc for this task.

G.

RELATIONSHIP

Contractor agrees to meet with Patient Access Manager or designee on an as needed basis.

H.

TERM AND TERMINATION

Notwithstanding the language in paragraph 4. Term and Termination. Page 2 of this Agreement, upon termination of this Agreement Contractor shall be authorized and required to retain and continue to perform all services contracted herein on all open Eligibility and other Third Party Recovery accounts until final disposition. If any accounts retained by Contractor are

approved, Contractor shall be entitled to its fee in accordance with Exhibit “B” of this Agreement.

EXHIBIT B

In consideration of the services provided by Contractor in Exhibit “A”, County shall pay Contractor based on the following fee schedule:

All cost recovery services, including all legal services, are provided by Contractor on a contingency fee basis.

SERVICES

FEES

A.

ELIGIBILITY SERVICES (Acute and Psych accounts)

1.

Eligibility Fee: Medi-Cal, California Children Services (CCS), Medicare and Victims of Crime (VOC), Third Party Liability, Workers’ Compensation, Eligibility Services (Pre-Legal).

a.

Prior to Attorney intervention

18% of all facility per diem amount recovered

b.

Medi-Cal or SSA (Fair Hearing/Appeal) or after Attorney intervention

25% of all facility per diem amount recovered

B.

ELIGIBILITY SERVICES (Outpatient & Emergency Room)

1.

Eligibility fee prior to attorney intervention – Minimum fee of $350 per approved patient or 25% of reimbursement, whichever is greater.

2.

These fees include the following services as described in Exhibit A.

a.

Comprehensive Services

b.

Cost Recovery Services

c.

Established Relationships

d.

Client Satisfaction and Communication

e.

Client Training

f.

Innovative Solutions

g.

Medi-Cal TAR and Billing and Appeals

h.

Skiptracing Department

i.

SMMC continued control

C.

LEGAL SERVICES

1.

Administrative Appeals, Legal Action, and/or Attorney Intervention. For TAR appeals, County agrees to provide Contractor with copies of all medical records.

a.

All sums recovered

25% of all facility per diem amount recovered

D.

THIRD PARTY RECOVERY (TPR) SERVICES (WORKERS COMPENSATION, TPL, ETC

1.

Third Party Liability and Worker’s Compensation (Pre-Legal)

a.

Prior to Attorney Intervention

18% of all sums recovered

b.

After Attorney intervention

25% of all sums recovered plus out of pocket costs

2.

These fees include the following services as described in Exhibit A:

a.

Correspondence Unit

No additional cost

b.

Full Scope Identification of Patients with Potential TPC Cases

c.

Comprehensive Lien Process

d.

Settlement Support Unit

e.

In-House Attorney Support

f.

Full Statutory Compliance on Medi-Cal Liens

E.

HMO AND PPO INSURANCE COLLECTION

1.

Insurance/Managed Care Claims (Pre-Legal)/COBRA

a.

Prior to Attorney Intervention

10% of all facility per diem

amount recovered

b.

After Attorney Intervention

25% of all facility per diem amount recovered plus out of pocket costs

F.

CORRESPONDENCE UNIT

No Cost to County

1.

Contractor shall only retain all payments received from outside parties (attorneys, liability carriers, etc.) for providing the documents requested.

G.

The term of this Agreement is May 1, 2009, to April 30, 2010 Total payments for services provided under this agreement will not exceed NINE HUNDRED EIGHTY FOUR THOUSAND DOLLARS ($984,000). Invoices will be approved by the Patient Access Manager and paid within 30 days of receipt of invoice.

H.

Invoice Dispute Resolution – County agrees to review all invoices submitted by Contractor and submit all disputes via email within 30 days to Contractor at al@healthadvocates.com. Contractor is required to review and respond to all emails within 30 days of receipt. If Contractor response is not satisfactory to County, County shall notify Contractor via email and the parties shall meet in person or via conference call within 30 days to resolve all disputed invoices.

EXHIBIT E

CORPORATE COMPLIANCE SMMC CODE OF CONDUCT (THIRD PARTIES)

The person/entity listed below (the “Undersigned”) recognizes and is fully dedicated to advancing SMMC’s commitment to full compliance with all Federal, State, and other governmental health care program requirements, including its commitment to prepare and submit accurate claims consistent with such requirements.

The Undersigned will comply with all Federal, State or other governmental health care program requirements and with SMMC’s policies and procedures relating to SMMC’s Corporate Compliance Program, including the requirements set forth in the Corporate Integrity Agreement (CIA) to which SMMC is a party (available online at http://www.oig.hhs.gov/fraud/cia/agreements/ the_county_of_san_mateo_03062009.pdf).

The Undersigned, to the extent its contractual duties require it to submit the reports covered in this paragraph, will promptly submit accurate information for Federal health care cost reports including, but not limited to, the requirement to submit accurate information regarding acute available bed count for Disproportionate Share Hospital (DSH) payment.

The Undersigned will report to the SMMC Compliance Officer any suspected violation of any Federal health care program requirements or of SMMC’s Compliance Program policies and procedures.

The Undersigned has the right to use the SMMC Disclosure Program by calling the Compliance Hotline or reporting incidents to the Compliance Officer. SMMC is committed to non-retaliation and will maintain, as appropriate, confidentiality and anonymity with respect to such disclosures.

The Undersigned understands that non-compliance with Federal health care program requirements and SMMC’s Compliance Program policies and procedures, and failing to report such violations, could result in termination of the Agreement and/or any other penalties permitted by law.

The Undersigned is responsible for acquiring sufficient knowledge to recognize potential compliance issues applicable to the duties outlined in the Agreement and for appropriately seeking advice regarding such issues.

The Undersigned will not offer, give or accept any bribe, payment, gift, or thing of value to any person or entity with whom SMMC has or is seeking any business or regulatory relationship in relation to said business or regulatory relationship (other than payments authorized by law under such relationships). The Undersigned will promptly report the offering or receipt of such gifts to the SMMC Compliance Officer.

The Undersigned will not engage in any financial, business, or other activity which competes with SMMC/County business which may interfere or appear to interfere with the performance of the duties under the Agreement or that involve the use of SMMC/County property, facilities, or resources, except to the extent consistent with the SMMC/County Incompatible Activities and Outside Employment policy and the Agreement.

The Undersigned will cooperate fully and honestly with internal audits and monitoring programs to help assure that SMMC’s compliance is maintained with all applicable federal/state regulations, the Joint Commission standards, and hospital system-wide policies.

TO REPORT VIOLATIONS, CALL THE COMPLIANCE HOT LINE: (800) 965-9775

The Undersigned hereby certifies by signing below that an authorized representative has received this Code of Conduct, understands it, has authority to commit the Undersigned to this Code of Conduct, and hereby commits the Undersigned to comply with this Code of Conduct.

Name of Person/Entity (the “Undersigned”)



Signature and Printed Name Date

Name of Person/Entity (the “Undersigned”)



Signature and Printed Name Date