HomeMy WebLinkAbout2016-219 Agrmt - PSR Physician Services - Rostykus
Agreement for Provision of Services
of EMS 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 Oregon Medical Board ("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 EMS Providers as defined at Oregon law and rule; and (v) possesses thorough
knowledge of laws and rules of the State of Oregon pertaining to EMS Providers 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) The duties of Medical Director as described in OAR 333-250, including the ability to delegate
responsibilities to the Agency as provided therein.
(iii) Coordinate Agency activities with other EMS agencies in Jackson County.
(iv) Evaluate and make recommendations concerning Agency's EMS training programs, equipment, and
apparatus.
(v) Coordinate with Agency administration the implementation of disciplinary measures that would limit or
modify an EMS Provider's scope of practice or duties.
2.0 Term
The term of this Agreement shall be one (1) year, commencing July 1, 2016 and ending June 30, 2017.
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).
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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:
(i) 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
EMS Providers.
(v) Maintain an effective quality assurance program for Agency operations.
(vi) Maintain professional malpractice insurance for Agency's EMS Providers with coverage limits of
not less than one million dollars ($1,000,000.00).
5.0 Compensation
Agency shall pay Physician $7,850 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.
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 & Re cue, By
By Al_" Gam..- Date 7 / G e
APP D S TO FORM
Title
Ashland Apt. Ity Attorney
PSR Physician Services, an Oregon Limited Liability Company ~9
Date-
l
By Date
Paul S. ostykus, M P- Member
Page 2 - 2016-2017 Agreement for Provision of Services of EMS Supervising Physician
PSR Physician Services,, LLC
436 Grandview Drive
Ashland, OR 97520
541-601-9709 rostykusmd@mind.net
July 5, 2016
Fire Chief
Ashland Fire & Rescue
455 Siskiyou Blvd.
Ashland, OR 97520
John Karns,
Enclosed are two copies of the Agreement for Provision of EMS Supervising Physician Services
for Ashland Fire & Rescue for the 2016-2017 year. Please review this agreement, sign and return
one copy to me. Changes for this year include addition of Ambulance Medical Director (OAR
333-250), minor editing, Term and Compensation.
The total fee for Supervising Physician services by Paul S. Rostykus, MD, MPH for Ashland Fire
& Rescue for the year July 1, 2016 through June 30, 2017 is $7,850 due by September 30, 2016.
Please contact me if you have any questions.
Thank you.
Sincerely,
l^
Paul S. Rostykus, MD, MPH
EMS Supervising Physician/Medical Director
Jackson County Ambulance and Fire Agencies
P Purchase Order
A& . Fiscal Year 2017 Page: 1 of: 1
tv
THIS NUMBER MUST APPEAR ON ALL
INVOICES, PACKAGES AND SHIPPING PAPERS.
B City of Ashland
I ATTN: Accounts Payable
L 20 E. Main Purchase 45
L Ashland, OR 97520 Order #
T
O
V PSR PHYSICIAN SERVICES, LLC S
H
E DR. PAUL ROSTYKUS
N 436 GRANDVIEW DR P See Shipping Information Below
DO ASHLAND, OR 97520
R T
Vendor Phone Number Vendor Fax Number Requisition Number Delivery Reference
541 482-2824 DAVID SHEPERD
Date Ordered Vendor Number Date Required Freight Method/Terms Department/Location
07/28/2016 528 FOB ASHLAND OR City Accounts Payable
Item# Descri tion/PartNo QTY UOM Unit Price ` Extended Priee_
AMBULANCE PHYSICIAN SERVS
The Above Purchase Order Number Must Appear On All
Correspondence - Packing Sheets And Bills Of Lading
1 FY 2017 Supervising Physician Services for Ambulance 1.0 $7,850.00 $7,850.00
Personal Services $5,000 to $75,000
Approved by Council on August 4, 2015
Beginning: 07/01/2016
Completion: 06/30/2017
GL Account: $7,850.00
Ship To: C/O Fire and Rescue Department
455 Siskiyou Blvd
Ashland, OR 97520
GL SUMMARY
071300 - 604150 $7,850.00
2e Z
By; e. Date.
Authorized Siqnature PO Total It7 Ran nn
FORM #3 CITY OF
ASHLAND
REQUISITION Date of request: 07-20-16
Required date for delivery:
Vendor Name PSR Physician Services, LLC
Address, City, State, Zip 463 Grandview Dr Ashland, OR 97520
Contact Name & Telephone Number Paul Rostykus 541-601-9709
Fax Number
SOURCING METHOD
❑ Exempt from Competitive Bidding ❑ Emergency
❑ Reason for exemption: ❑ Invitation to Bid (Copies on file) ❑ Form #13, Written findings and Authorization
❑ AMC 2.50 Date approved by Council: ❑ Written quote or proposal attached
❑ Written quote or proposal attached Attach co of council communication -(If council approval required, attach co of CC
❑ Small Procurement Cooperative Procurement
Less than $5,000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon
Date approved by Council:
❑ Direct Award -(Attach copy of council communication) 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) ❑ Other government agency contract
$5,000 to $100,000 Written quote or proposal attached Agency
❑ (3) Written quotes and solicitation attached Q Form #4, Personal Services $5K to $75K Contract #
PERSONAL SERVICES ❑ Special 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 - (Attach copy of council communication)
Description of SERVICES Total Cost
FY 2017 Supervising Physician Services for Ambulance $ 7,850
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost
TOTAL COST
Per attached quote/proposal $
Project Number _ _ _ _ _ Account Number _ _ _ -
Account Number i 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:
IT Director Date Support -Yes/ No
By signing this requisition form, I certify that the City's public contracting requirements have been satisfied.
Employee: Department Head: f f
(Equal to or greater than $5,000)
Department Manager/Supervisor: City Administrator:
(Equal to or greaater than $25,000)
Funds appropriated for current fiscal year YES / NO Finance Director- (Equal to or gr4ierr than $5,000) Date
Comments:
Form #3 - Requisition