HomeMy WebLinkAbout2009-129 Agrmt - PSR Physician Services
, ' -
Agreement for Provision of Services
of EMT Supervising Physician
This Amendment to the 2008-2009 Agreement for Provision of Services of EMT
Supervising Physician is maqe 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 ofthis Agreement shall be one (1) year, commencing July 1, 2009 and ending
June 30, 2010. 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 $6,627 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
~M f{O~
() h'lt:.. C~I~r
Date I I I I 0 7
Title
By
PSR Physician Services, an Oregon Limited liability Company
~ D'~P
Paul S. stykus, MD - Member
ISO I cJ?
2009-2010 Agreemeht for Provision of Services of EMT Si,Jpervisi~g Physicia~
PSR Physician Services, LLC
436 Grcindview Drive
Ashland. OR 97520
541601-9709 drrostykus@jcems.net
June 29, 2009
Ashland Fire & Rescue
455 Siskiyou Blvd.
Ashland, OR 97520
John Kams,
Enclosed are two copies of the Agreement for Provision of Services of EMT Supervising Physician
for Ashland Fire & Rescue for the 2009-2010 year. This agreement is an addendum to the '
agreement for 2008-2009, with changes to two sections: Term and Compensation. Please review
this addendum, sign and retum one copy to me,
The total fee for Supervising Physician services by Paul S. Rostykus, MD, MPH for Ashland Fire &
Rescue for the year Juiy 1, 2009 through June 30, 2010 is $6,627 due now.
Please contact me if you have any questions,
Thank you.
Sincerely,
.
Paul S. Rostykus, MD, MPH
Supervising Physician Jackson County EMS
~..
._~
CITY RECORDER
CITY OF
ASHLAND
20 E MAIN ST,
ASHLAND, OR 97520
(541) 488-5300
Page 1 /1
t::';:?""',:.'";]lJA;rE': ;'. ;';"~'7;~
;::';.~,:i'R0'~Nl!JMBER~L', ",'1
7/2/2009
09025
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:
Terms: Net 30 days
Req, Del. Date:
Speciallnst:
Req, No,:
Dept.: FIRE & RESCUE
Contact: Greg Case
Confirming? No
::~jQuantiR?t2'l LIlfn'iF2: ~E::;j.~}~~~:f~.b72~:~~.:.~~=:~I~~~:;~?k:~~besc'rTDti5ii: ': "~ ,~,]~LZ ~,~S:~~~.;~~::'-~~~,~t', ~-:~':l] 2i4lUnitrF.!ricet _Ai ~-\~'BtEiC't';ifirice~t1J
EMT Supervising Physican Contract, Paul
Rostykus, FY 2010
6,627,00
Bill TO: Account Payable
20 EAST MAIN ST
541-552-2028
ASHLAND, OR 97520
SUBTOTAL
TAX
FREIGHT
TOTAL
6627,00
0,00
0,00
6,627,00
~'7ACcof;ntfNlrmj)ef:~i,:;:"~~21 ~:~~)~roje"'rtTNTmlberlif~K;_- 1, r :",:';~~Amourlf~~~X~':J [1' ~~)ACcourWNumtier~~;:;~ ~1S:~;.:1~h)je'cijJ~umb~~ f5~h~~~:Amo:u'ntlf~~~~
E 1 1 0,07, 1 3,00,6041 5 6 627,00
-
AM $.
e~ 7i{?
Aut rized SigrurturV
VENDOR COPY
A request for a Purchase Order
REQUISITION FORM
CITY OF
ASHLAND
Date at Request:
1\~1:/~b91
I,",.,",.,', ',.., I
:" ".' -. .
'. . ',. '.' ':',
THIS REQUEST IS A:
o Change Order(existing PO #
Required Date of Delivery/Service:
Vendor Name
Address
City, State, Zip
Telephone Number
Fax Number
Contact Name
PAtH_ RO.57VR'tL <;' 10 D P5/2 PJ-IVSIC//l/v SEt(VleB L!. C
Ll..J0 GI?AJJ/)//fG'iAJ Dfi. ,
/-lS/./IAND cO~, 97Sz.0
SOLICITATION PROCESS
Small Procurement D Sole Source D Invitation to Bid
D Less than $5,000 D Written findings attached (Copies on file)
D Quotes (Not required)
Coooerative Procurement D Reauest for Prooosal
D State ofOR/WA contract (Copies on file)
Intermediate Procurement D Other government agency contract D Soeciall Exemot
D (3) Written Quotes D Copy of contract attached D Written findings attached
(Copies attached) D Emerqencv
D Contract # D Written findings attached
Description of SERVICES
Cl'1r ..5i1f'c;<' VISlA/G ,p I-IySICI/-lN CCYVT,Pv9Cr
JtlLVI/200Q ;0 dV/l/$30; 2010
o Per attached PROPOSAL
Item # Quantity
Unit
Description of MATERIALS
Unit Price
Total Cost
~
Project Number ______ - ___
o Per attached QUOTE
Account Number L[(2. Pl.. 1:)' pp pJ)_<{I.So
. Items and services must be charged to the appropriate account numbers for the financiats to reflect ihe aciual expenditures accuratety.
By signing this requisition form, I certify that the information provided above meets the City of Ashland public contracting requirements,
and the documentation can be provided upon request, , /J /)
Employee Signature: SupervisorlDept. Head Signature~ 9(~
G: Finance\Procedure\AP\Forms\8_Requisllion form revised
Updated on: 218/2007