HomeMy WebLinkAbout2014-193 Agrmt - EMT Supervising Physcian - Rosthykus MD
Agreement for Provision of Services
of EMT Supervising Physician
This Agreement is made on the date last written below by and between PSR Physician
Services, an Oregon limited liability company ("Physician") and Ashland Fire & Rescue
("Agency").
Recitals
A. Physician employs Paul S. Rostykus, MD who is licensed to practice medicine in the
State of Oregon, and is qualified and approved as a Supervising Physician by the Board
of Medical Examiners ("Board") pursuant to OAR 847-035-0020. Physician represents
that Paul S. Rostykus, MD is (i) currently licensed to practice medicine under ORS
Chapter 677 and is actively registered and in good standing with the Board; (ii) is
currently engaged in the practice of medicine; (iii) is a resident of and is actively
practicing in the area in which the emergency service is located; (iv) possesses the
knowledge of skills assigned by standing order to Emergency Medical Technicians and
First Responders as defined at Oregon law; and (v) possesses thorough knowledge of
laws and rules of the State of Oregon pertaining to Emergency Medical Technicians and
First Responders as required by Oregon law.
B. Agency would like to employ Physician to perform services as the Supervising
Physician pursuant to OAR 847-035-0020.
C. All services hereunder shall be performed exclusively by Paul S. Rostykus, MD.
Agreement
1.0 Scope of Services
Physician shall perform the following services:
(i) The duties of Supervising Physician as described in OAR 847-035-0025,
including the ability to delegate responsibilities to the Agency as provided therein.
(ii) Coordinate Agency activities with other EMS agencies in Jackson County.
(iii) Evaluate and make recommendations concerning Agency's EMS training
programs, equipment, and apparatus.
(iv) Coordinate with Agency administration the implementation of disciplinary
measures that would limit or modify a First Responder or EMT's scope of
practice or duties.
Page 1 - 2014-2015 Agreement for Provision of Services of EMT Supervising Physician
2.0 Term
The term of this Agreement shall be one (1) year, commencing July 1, 2014 and ending
June 30, 2015. Either party may terminate this Agreement at any time for any reason upon
sixty (60) days advance written notice to the other.
3.0 Physician Insurance
Physician shall maintain professional malpractice insurance with coverage limits of not
less than one million dollars ($1,000,000.00).
4.0 Agency Duties
Agency shall commit sufficient staff, resources, and other support to enable Physician to
carry out its duties as Supervising Physician pursuant to OAR 847-035-0025 and other
requirements of Oregon law, including, but not limited to:
(1) Provision of a designated Agency liaison to provide single-point communication
with the Agency and to help carry out the provisions of this Agreement.
(ii) Provide means and support for documentation and record keeping to enable
Physician to perform his duties hereunder.
(iii) Provide timely response to the recommendations of Physician.
(iv) Provide in-service training programs to help meet the recertification requirements
of Agency's First Responders and EMTs.
(v) Maintain an effective quality assurance program for Agency operations.
(vi) Maintain professional malpractice insurance for Agency's First Responders and
EMTs with coverage limits of not less than one million dollars ($1,000,000.00).
5.0 Compensation
Agency shall pay Physician $7,508 per year as compensation for the services
performed under this Agreement. Payment shall be made no later than the 30th of September
of the term of this Agreement, unless other arrangements have been mutually agreed to.
Page 2 - 2014-2015 Agreement for Provision of Services of EMT Supervising Physician
6.0 Miscellaneous
6.1 Independent Contractor. Physician is an independent contractor and not an
employee of Agency.
6.2 Assignment. This Agreement may not be assigned by either party.
6.3 Nonwaiver. Waiver by either party of strict performance of any provision of this
Agreement shall not be a waiver of or prejudice the party's right to require strict performance of
any other provision.
6.4 Attorney Fees. If suit or action or arbitration is instituted in connection with any
controversy arising out of this Agreement, the prevailing party shall be entitled to recover in
addition to costs such sums as the arbitrator or court may adjudge reasonable as attorney fees
at trial, on petition for review, and on appeal.
6.5 Applicable Law and Jurisdiction. This Agreement shall be governed by and
construed in accordance with the laws of the state of Oregon. Jurisdiction shall be in state or
federal court in Jackson County, Oregon.
7.0 DEA Registration
If Agency provides EMS care at the level of AEMT, EMT-Intermediate or Paramedic
which involves the use of DEA (Drug Enforcement Administration) controlled substances, the
Agency will obtain a DEA Registration in the name of Paul S. Rostykus, MD and will comply
with all regulations and policies regarding controlled substance use.
Ashland Fire & Rescue
By Date 7 I Lz
Title r r~~ C fl ► mow'
PSR Physician Services, an Oregon Limited Liability Company
/
By ~ Date l/ c~
Paul S. Rostykus, D - Member
A7 E AS TO FORM
.~ww
-Ash a rf4 Attorney
Dat 077 7 Ll- ell Page 3 - 2014-2015 Agreement for Provision of Services of EMT Supervising Physician
Nautilus Insurance Company
c/o Berkley Select, LLC
250 S. Wacker Drive, Suite 700
Chicago, IL 60606
EMS MEDICAL DIRECTORS ERRORS & OMMISSIONS INSURANCE POLICY
DECLARATIONS PAGE
This is a claims made and reported policy. Please read this policy and all endorsements
and attachments carefully.
Policy Number: EMD_1000015_P-7 Renewal of Number: EMD_1000015_P-6
1. NAMED INSURED: Paul S. Rostykus, M.D. dba PSR Physician Services
MAILING ADDRESS: 436 Grandview Drive
Ashland
OR
97520
DESCRIPTION OF INSURED'S BUSINESS: EMS Medical Director
2. POLICY PERIOD: Effective Date: 8/1/2013 Expiration Date: 8/1/2014
Effective 12:01 a.m. Standard Time at the mailing address of the named insured.
3. LIMIT OF LIABILITY:
a. Each Claim: $1,000,000
b. Aggregate: $3,000,000
4. RETROACTIVE DATE: 8/1/2007
If a date is indicated, this insurance will not apply to any act, error, omission or
medical professional injury which occurred before such date.
5. DEDUCTIBLE:
a. Each Claim: $0
b. Aggregate: N/A
6. PREMIUM: $3,717.00
7. ENDORSEMENTS:
Refer to Schedule of Endorsements SSM-0139(11/07)
PRODUCER: Avreco
550 W. Van Buren Street, Suite 1200
Chicago, IL 60607
COUNTERSIGNED BY: DATE: 08/06/13
Where required by law
SSM-0148(6/09) Page 1 of 1
Page 1 / 1
CITY OF
. ASHLAND DATE PO NUMBER
20 E MAIN ST. 7/24/2014 12397
ASHLAND, OR 97520
(541) 488-5300
VENDOR: 006381 SHIP TO: Ashland Fire Department
PSR PHYSICIAN SERVICES, LLC, DR. PAUL ROSI (541) 482-2770
ATTN: PAUL ROSTHYKUS MD 455 SISKIYOU BLVD
436 GRANDVIEW DR ASHLAND, OR 97520
ASHLAND, OR 97520
FOB Point: Req. No.:
Terms: Net 30 days Dept.:
Req. Del. Date: Contact: Greq Case
Special Inst: Confirming? NO
Quantity Unit Description Unit Price' Ext. Price
EMT Supervisinq Physician - FY 2015 7,508.00
SUBTOTAL 7,508.00
BILL TO: Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2010 TOTAL 7,508.00
ASHLAND, OR 97520
Account Number Project Number Amount Account Number Project Number ` Amount
E 110.07.13.00.60415 7,508.00
VENDOR
Authori Signature/% COPY
FORM #3
CITY OF
~~'~iii t)u -dr ASHLAND
IZ~Ql1ISITId~I Lis 4feot ectuest:
6z- Required date for delivery:
Vendor Name PSR Physician Services LLC
Address, City, State, Zip 3 Grandview Drive, Ashland OR. 97520
don(act Mama A Telephone Number Paul Rusty us MID 541- 601 9709
Pax 1Vumber
E] Emergency
PSR Physician Services, LLC
436 Grandview Drive ❑ Invitation to Bid (Copies on file) ❑ Form #13, Written findings and Authorization
Date approved by Council: ❑ Written quote or proposal attached
Ashland, OR 97520-1620
Cooperative Procurement
Less man ao,uuu ❑ Request for Proposal Co ies on file) ❑ State of Oregon
❑ Direct Award -DO M apprflvedou c Contract #
❑ Verbal/Written quote(s) or proposal(s) / State of Washington
Intermediate Procurement Sole Source Contract #
GOODS & SERVICES Applicable Form (#5,6, 7 or 8)r~y~1!Y`~ ❑~Other government agency contract
$5.000 to $100.000 a- Written quote or proposal attac edp / Agency
❑ (3) Written quotes and solicitation attac ed` it Form #4, Personal Services $5K to_$75K% Contract #
PERSONAL SERVICES O-_Sn!c al-Procurement'-- Intergovernmental Agreement
$5.000 to $75.000 ❑ Form #9, Request for Approval ❑ Agency
❑ Less than $35,000, by direct appointment ❑ Written quote or proposal attached Date original contract approved by Council:
❑ (3) Written proposals/written solicitation Date approved by Council: (Date)
❑ Form #4, Personal Services $5K to $75K Valid until: Date
Description of SERVICES Total Cost
y rSilf,~G~~Si~/G~y~
/ C 7-
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost
TOTAL COST
❑ Per attached quotelproposal
$
Project Number _ _ _ _ _ _ - _ _ _ f 0- 7- -00. .SGT Account Number_ i~_ ~ _s 6_~ /
Account Number Account Number
*Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures.
IT Director in collaboration with department to approve all hardware and software purchases:
ITDirector Date Support-Yes/No
By si . 'rag t isition form,) certify that the City's public contracting requirements have been satisfied.
Employee Signature: ~ Department Head Signature: L el"
((Equal to or greater than $5,000)
City Administrator:
(Equal to or greater than 25,000)
Funds appropriated for current fiscal year. E / NO 'o V,
Finance Director- (Equal to orgrea than $5,000) D to
Comments:
Form #3 - Requisition