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From page 72... ... 72 APPENDIX C -- BUSINESS ASSOCIATE AGREEMENTS, GUIDES, NOTICES, POLICIES, PRACTICES, AND PROCEDURES PROVIDED BY TRANSIT AGENCIES File Source Document 1: Page 73 Department of Health and Human Services, Washington, DC Business Associate Agreement (sample with provisions highlighted) 2: Page 81 Dallas Area Rapid Transit ADA Paratransit Eligibility Certification Applications 3: Page 88 Greater Attleboro-Taunton Regional Transit Authority 3.a - GATRA Internal Operating Procedure 3.b. Read the entire page →
From page 73... ... 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES SAMPLE BUSINESS ASSOCIATE AGREEMENT PROVISIONS (Published January 25, 2013) Introduction A "business associate" is a person or entity, other than a member of the workforce of a covered entity, who performs functions or activities on behalf of, or provides certain services to, a covered entity that involve access by the business associate to protected health information. Read the entire page →
From page 74... ... 2 received from, or created or received by the business associate on behalf of, the covered entity; (9) require the business associate to ensure that any subcontractors it may engage on its behalf that will have access to protected health information agree to the same restrictions and conditions that apply to the business associate with respect to such information; and (10) Read the entire page →
From page 75... ... 3 (a) Business Associate. Read the entire page →
From page 76... ... 4 the requested access or whether the business associate will forward the individual's request to the covered entity to fulfill) and the timeframe for the business associate to provide the information to the covered entity.] Read the entire page →
From page 77... ... 5 which the business associate will de-identify the information and the permitted uses and disclosures by the business associate of the de-identified information.] Read the entire page →
From page 78... ... 6 (b) [Optional] Read the entire page →
From page 79... ... 7 responsibilities and the business associate needs to retain protected health information for such purposes after termination of the agreement] Upon termination of this Agreement for any reason, business associate, with respect to protected health information received from covered entity, or created, maintained, or received by business associate on behalf of covered entity, shall: 1. Read the entire page →
From page 80... ... 8 (c) [Optional] Read the entire page →
From page 138... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 1 CONTRACT NO. ______________________ BLANKET PURCHASE AGREEMENT PART I General Program Description This Blanket Purchase Agreement (BPA) Read the entire page →
From page 139... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 2 provides for the amount of the additional fee. After-hours rates can only be paid for transportation occurring from 6:01 PM to 5:59 AM daily, all day Saturday and Sunday and on New Year's Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day and Christmas Day. Read the entire page →
From page 140... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 3 certified mechanic annually. Inspection must include checking fluid levels, belts/hoses, cooling system, battery, emission, filters, air conditioning, steering, suspension, brakes, exhaust system, fluid leakage, and visual inspection of vehicle exterior. Read the entire page →
From page 141... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 4 needed the Contractor must receive prior approval for such change from the brokerage. Trips not provided as authorized will not be reimbursed. Read the entire page →
From page 142... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 5 past five (5) years. Read the entire page →
From page 143... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 6 18.7. Organization and Authority. Read the entire page →
From page 144... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 7 PART II General Provisions 1. Description of Agreement This Blanket Purchase Agreement (BPA) Read the entire page →
From page 145... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 8 6.1. No payment will be made for duplicate mileage. Read the entire page →
From page 146... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 9 8.6. Payment by SAMTD is considered to be payment in full of all services provided by Contractor under this BPA through the date of Contractor's invoice. Read the entire page →
From page 147... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 10 providing coverage in the event a worker is determined to be a subject worker of Contractor ("if any" coverage) Read the entire page →
From page 148... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 11 the earliest possible time (and in no event later than the next day) in writing with a full description of the defect, problems, or nonconformance. Read the entire page →
From page 149... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 12 BROKER. Any such termination of this BPA shall be without prejudice to any obligations or liabilities of either party already accrued prior to such termination. Read the entire page →
From page 150... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 13 Contractor, whether in paper, electronic or other form, that are pertinent to this Agreement in such a manner as to clearly document Contractor's performance. All financial records, other records, books, documents, papers, plans, records of shipments and payments and writings of Contractor whether in paper, electronic or other form, that are pertinent to this Agreement, are collectively referred to as "Records." Contractor acknowledges and agrees that BROKER, OHA and the Oregon Secretary of State's Office and the federal government and their duly authorized representatives shall have access to all Records to perform examinations and audits and make excerpts and transcripts. Read the entire page →
From page 151... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 14 28. Confidentiality Contractor shall treat all information and, in particular, information relating to recipients (Clients) Read the entire page →
From page 152... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 15 31. Special Federal Requirements 31.1 Contractor agrees to comply with the relevant parts of 45 CFR Part 74, Part 80, Part 84, Part 86, Part 90, Part 91, Part 92 and Office of Management and Budget (OMB) Read the entire page →
From page 153... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 16 (d) The penalties that may be imposed upon employees for drug abuse violations. Read the entire page →
From page 154... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 17 33. Mediation Should any dispute arise between the State of Oregon and BROKER which relates to this BPA and is the subject of non-binding mediation process, the Contractor agrees to participate in good faith in the non-binding mediation process. Read the entire page →
From page 155... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 18 38. Third Party Beneficiaries BROKER and Contractor are the only parties to this BPA and are the only parties entitled to enforce its terms. Read the entire page →
From page 156... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 19 Attachment A CRIMINAL RECORDS AND BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION PACKET All persons who apply for positions that involve transporting customers of Salem Area Mass Transit District (SAMTD) and TripLink must undergo a criminal records and background check. Read the entire page →
From page 157... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 20 Instructions for Completing Form Disclose All History. You must disclose your complete criminal history. Read the entire page →
From page 158... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 21 Criminal History Records Check and Fair Credit Reporting Act Disclosure and Authorization Form Form A Oregon Revised Statutes (ORS) 181.537 and 267.237 provide SAMTD access to Oregon State Police and Federal Bureau of Investigation (FBI) Read the entire page →
From page 159... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 22 • I have received a copy of the document entitled "Summary of Your Rights under the Fair Credit Reporting Act." By signing this authorization form, I am consenting to SAMTD obtaining information from CRAs in accordance with the FCRA. • If SAMTD determines that I am disqualified from providing transportation for SAMTD customers, the disqualification notice and Appeals Procedure will be sent to me. Read the entire page →
From page 160... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 23 BLANKET PURCHASE AGREEEMENT PART III CONTRACTOR INFORMATION AND PRICING 160 Read the entire page →
From page 161... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 24 BUSINESS PROFILE 1. Read the entire page →
From page 162... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 25 RATE SHEET (See new rate sheet next page) Date: _____________________________ Provider Code:_________ Contract #: ______________ # of Vehicles:______ Business Name:__________________________________________________________ Mailing Address:__________________________________________________________ NUMBER & STREET _____________________________________________ CITY STATE ZIP Phone Number: (____) Read the entire page →
From page 163... ... TRIPLINK Blanket Purchase Agreement CONTRACT BPA 7/01/2013 26 RATE SHEET Date: _____________________________ Mailing Address:__________________________________________________________ NUMBER & STREET _____________________________________________ CITY STATE ZIP Phone Number: (____) ______ - _______ Fax Number: (____) Read the entire page →
From page 164... ... TRIPLINK Blanket Purchase Agreement CONTRACT 27 WORK SITE SCHEDULE 1. List business hours and days during which you are available to operate TRIPLINK Services. Read the entire page →
From page 165... ... TRIPLINK Blanket Purchase Agreement CONTRACT 28 Name: Telephone: Title: Location: 5. What is the date you will begin BROKER Service under this BPA. Read the entire page →
From page 166... ... TRIPLINK Blanket Purchase Agreement CONTRACT 29 6. COMPUTER INFORMATION Computer Hardware and Software Requirements Scheduled Carriers A Scheduled Carrier is defined as any provider who pre-schedules trips or will have trips pre-scheduled for them to specific vehicles or runs. Read the entire page →
From page 167... ... TRIPLINK Blanket Purchase Agreement CONTRACT 30 (b) PROVIDER agrees to observe complete confidentiality with regard to all aspects of the software and agrees: (1) Read the entire page →
From page 168... ... TRIPLINK Blanket Purchase Agreement CONTRACT 31 7. Driver and Vehicle Information Yes No ___ ___ Drivers for my organization are skilled in passenger assistive techniques and are trained to use any specialized equipment such as wheelchair lifts to assist in loading and unloading riders. Read the entire page →
From page 169... ... Provider Enrollment Agreement OHA 3975 (Rev. Read the entire page →
From page 170... ... Provider Enrollment Agreement OHA 3975 (Rev. Read the entire page →
From page 171... ... Provider Enrollment Agreement OHA 3975 (Rev. Read the entire page →
From page 172... ... Provider Enrollment Agreement OHA 3975 (Rev. Read the entire page →
From page 173... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 1 of 42 SUBCONTRACTOR AGREEMENT This Agreement ("Agreement") Read the entire page →
From page 174... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 2 of 42 applicable to Providers' ability to perform Subcontracted Work at a minimum. Read the entire page →
From page 175... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 3 of 42 7. Read the entire page →
From page 176... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 4 of 42 Information which: (i) Read the entire page →
From page 177... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 5 of 42 13. Read the entire page →
From page 178... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 6 of 42 which shall be deemed an original but all of which together will constitute one and the same instrument. Read the entire page →
From page 179... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 7 of 42 IN WITNESS WHEREOF, the parties have signed this Agreement on the date written above. Read the entire page →
From page 180... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 8 of 42 EXHIBIT A SCOPE OF WORK Contractor and Subcontractor understand and agree as follows: 1. Read the entire page →
From page 181... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 9 of 42 410-136-3020 New Rule General Requirements for NEMT (1) Read the entire page →
From page 182... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 10 of 42 (7) Read the entire page →
From page 183... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 11 of 42 (e) Read the entire page →
From page 184... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 12 of 42 (13) Read the entire page →
From page 185... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 13 of 42 410-136-3040 New Rule Vehicle Equipment and Subcontractor Standards (1) Read the entire page →
From page 186... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 14 of 42 (a) Read the entire page →
From page 187... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 15 of 42 410-136-3060 New Rule Ownership of Equipment and Property (1) Read the entire page →
From page 188... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 16 of 42 410-136-3080 New Rule Out-of-State Transportation (1) Read the entire page →
From page 189... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 17 of 42 410-136-3120 New Rule Attendants for Child Transports (1) Read the entire page →
From page 190... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 18 of 42 Stats. Read the entire page →
From page 191... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 19 of 42 410-136-3140 New Rule Secured Transports (1) Read the entire page →
From page 192... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 20 of 42 410-136-3180 New Rule Transportation of Clients Changing Hospitals or Other Facilities (1) Read the entire page →
From page 193... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 21 of 42 410-136-3260 New Rule Brokerage Reimbursements to Subcontractors (1) Read the entire page →
From page 194... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 22 of 42 (a) Read the entire page →
From page 195... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 23 of 42 410-136-3280 New Rule Client Reimbursed Mileage, Meals and Lodging (1) Read the entire page →
From page 196... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 24 of 42 (10) Read the entire page →
From page 197... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 25 of 42 410-136-3300 New Rule Modifications Based on Client Circumstances (1) Read the entire page →
From page 198... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 26 of 42 410-136-3320 New Rule Member Rights and Confidentiality (1) Read the entire page →
From page 199... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 27 of 42 410-136-3340 New Rule Reports and Documentation (1) Read the entire page →
From page 200... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 28 of 42 (F) Read the entire page →
From page 201... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 29 of 42 410-136-3360 New Rule Audits (1) Read the entire page →
From page 202... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 30 of 42 202 Read the entire page →
From page 203... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 31 of 42 EXHIBIT B COMPENSATION Compensation will be paid as capitation rates on a per Member per month basis to cover all NonEmergent Medical Transportation as outlined using the following schedule: Counties Total NEMT CCO Plus (1) Read the entire page →
From page 204... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 32 of 42 (6) Read the entire page →
From page 205... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 33 of 42 EXHIBIT C BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ("Agreement") Read the entire page →
From page 206... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 34 of 42 involving the disclosure of PHI by the Affiliated Covered Entity to Business Associate, or the creation, receipt, maintenance, or transmission of PHI by Business Associate on behalf of the Affiliated Covered Entity. Read the entire page →
From page 207... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 35 of 42 the course of its fulfillment of its obligations pursuant to this Agreement and the activities set forth in the Other Agreement(s) Read the entire page →
From page 208... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 36 of 42 Agreements by Third Parties. Read the entire page →
From page 209... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 37 of 42 disclosures of PHI and/or access report in accordance with 45 C.F.R. Read the entire page →
From page 210... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 38 of 42 Mitigation. Read the entire page →
From page 211... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 39 of 42 Term and Termination. Read the entire page →
From page 212... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 40 of 42 such breach and Business Associate shall cooperate fully in the efforts by the Affiliated Covered Entity to cure Business Associate's breach. Read the entire page →
From page 213... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 41 of 42 same force and effect as though such void or unenforceable provision had been deleted. Read the entire page →
From page 214... ... Sample contract between XXX Health Plans and YYY Council of Governments. 8.c - Salem-Keizer - Subcontractor Agreement Page 42 of 42 AFFILIATED COVERED ENTITY: BUSINESS ASSOCIATE: By: By: Title: VP-COO Title: Date: Date: 214 Read the entire page →

From page 72...

... 72 APPENDIX C -- BUSINESS ASSOCIATE AGREEMENTS, GUIDES, NOTICES, POLICIES, PRACTICES, AND PROCEDURES PROVIDED BY TRANSIT AGENCIES File Source Document 1: Page 73 Department of Health and Human Services, Washington, DC Business Associate Agreement (sample with provisions highlighted) 2: Page 81 Dallas Area Rapid Transit ADA Paratransit Eligibility Certification Applications 3: Page 88 Greater Attleboro-Taunton Regional Transit Authority 3.a - GATRA Internal Operating Procedure 3.b.