HomeMy WebLinkAbout2010-105 Agrmt - PSR Physician Services
PSR Physician Services, LLC
436 Grandview Drive
Ashland, OR 97520
541 601-9709 I drrostykus@jcems.net
June 10, 2009
Ashland Fire & Rescue
455 Siskiyou Blvd.
Ashland, OR 97520
John Karns,
Enclosed are two copies of the Agreement for Provision of Services of EMT Supervising Physician
for Ashland Fire & Rescue for the 2010-2011 year. This agreement is an addendum to the
agreement for 2009-201 0, with changes to two sections: Term and Compensation. Please review
this addendum, sign and return one copy to me.
The total fee for Supervising Physician services by Paul S. Rostykus, MD, MPH for Ashland Fire &
Rescue for the year July 1, 2010 through June 30, 2011 is $6,792 due by September 30, 2010.
Please contact me if you have any questions.
Thank you.
Sincerely,
poJ)
Paul S. Rostykus, MD, MPH
Supervising Physician Jackson County EMS
.
Agreement for Provision of Services
of EMT Supervising Physician
This Amendment to the 2009-2010 Agreement for Provision of Services of EMT
Supervising Physician 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").
The following items are amended to read as follows:
2.0 Term
The term of this Agreement shall be one (1) year, commencing July 1, 2010 and ending
June 30, 2011. Either party may terminate this Agreement at any time for any reason upon
sixty (60) days advance written notice to the other.
5.0 Compensation
Agency shall pay Physician $6,792 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.
Ashland Fire & Rescue
By
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Date
t. I 2 I I /0
Title
PSR Physician Services, an Oregon Limited Liability Company
By ~~!J Date 0 ,1S-dl1
2010-2011 Agreement for Provision of Services of EMT Supervising Physician
Page 1/1
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CITY OF CITy RECORD
ASHLAND .
20 E MAIN ST.
ASHLAND, OR 97520
(541) 488-5300
'::. DATE:-":l,;1
~L'~~,; 80,NUMBER~.A:.
7/13/2010
09629
VENDOR: 006381
PSR PHYSICIAN SERVICES, LLC, DR. PAUL ROSl
436 GRANDVIEW DR
ASHLAND, OR 97520
SHIP TO: Ashland Fire Department
(541) 482-2770
455 SISKIYOU BLVD
ASHLAND, OR 97520
FOB Point:
Tenns: Net 30 days
Req. Del. Date:
Speciallnst:
Req. No.:
Depl.:'
Contact: Greg Case
Confirming? No
:\'QllanlitV ..,: .,\>..,'''-~-, ' "\r:::-:i";~I.:T:.-':':: .;"~:." ,,'>.<:" /,,: ::~:':DescrjDtion~-,:'~::, ," .'. ".' ~ ~ ;;; ~:~. . . ;" :,":: ~.; .!. ~ 'Un'it 'Riice-: '" ...~.~_-:'
'Ex!:: pHce':,~;:~~_,,:
,;Unit... "
EMT Supervising Physician 6,792.00
Contract Renewal
July 1, 2010 to June 30, 2011
.
,
SUBTOTAL 6 792.00
BILL TO: Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2028 TOTAL 6,792.00
ASHLAND, OR 97520
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E 1 1 0.07. 1 3.00.6041 5 6 792.00
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Autho ed Signature ,
VENDOR COPY
A reque~t for a Purchase Order
REQUISITION FORM
CITY OF
ASHLAND
Date of Request: &~t~t~:~~\~~K~f~
THIS REQUEST IS A:
o Change Order(existing PO #
Required Date of Delivery/Service: I~~t::":,';:~';~~;*i;~ I
PlluL f(o.gYK1I5 J'1..D . p.<;f< PlIlI..S/NI7/I! 5El~tI/Ct;"S, aC.
LiSe. &IMA/fJ//Jt:u/DI?' .
/1.5/-1 L/?/1//J O/fC/.ON Cj 7520
'5'11 {f,O 1- 97 ocr
Yendor Name
Address
City, State, Zip
Telephone Number
Fax Number
Contact Name
SOLICITATION PROCESS
Small Procurement o Sole Source 0 Invitation to Bid
0 Less than $5,000 o Written findings attached (Copies on ille)
o Quotes (Not required)
Coooerative Procurement 0 Reauest for ProDosal
0 Slate of ORIWA contract (Copies on file)
Intermediate Procurement o Other government agency contract 0 SDecial1 ExemDt
o (3) Written Quotes 0 Copy of contract attached 0 Written findings attached
(Copies attached) 0 Emeraencv
0 Contract # 0 Written findings attached
Description of SERVICES
ef"Jr StlPol?vLf/#"G f/lys lelAA! &/I!TI(fieJ*"" F?EH6'I(),.9L--
;Juty ISr )010 70 JtlNc30, 201 (
o I'er attached PROPOSAL
Total Cost
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Item # Quantity
Unit
Description of MATERIALS
Unit Price
Total Cost
o Per attached QUOTE
r~cL"3
Project Number ______. ___
4-ppY'.<J~' aY"<-,-~
,tfro-- ' "'1/ 0 0
Account Number 119. QI. a. f)() ~f2Jl~O
. Items and services musl be charged to the appropriale accounl numbers for the financials to reflecl the, actual expenditures accuralely,
By signing this requisition form, / certify that the information provided above meets the City of Ashland public contracting require
and the documentation can be provided upon request.
EmployeB Signature:
Supervisor/Dept. Head Signature:
G: Finance\Procedure\AP\Forms\8_Requisition form revised
Updated on: 218/2007