HomeMy WebLinkAbout2009-056 Health - Department of Family Medicine UNC - Agreement for Medical Director Services~ ease return is copy o ~
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STATE OF NORTH CAROLINA
COUNTY OF ORANGE HEALTH DEPARTMENT AND
THE DEPARTMENT OF FAMILY MEDICINE, UNIVERSITY OF NORTH CAROLINA AT
CHAPEL HILL
AGREEMENT FOR MEDICAL DIRECTOR SERVICES
THIS AGREEMENT, made and entered into this first day of July 2009, by and between The
University of North Carolina at Chapel Hill, hereinafter referred to as the "University," for its
Department of Family Medicine in the School of Medicine, hereinafter referred to as the
"Department" and the Orange County Health Department, hereinafter referred to as the
"OCHD."
WITNESSETH:
WHEREAS, the Department desires to provide Medical Director Services, including general
consultation and clinical services, and to participate in the provision of medical care for
the citizens of the community, and;
WHEREAS, OCHD operates a number of "Outpatient Clinics" located at the site of the
Orange County Health Department in Chapel Hill and Hillsborough, North Carolina, or
other sites that may, from time to time, be provided;
NOW, THEREFORE, in consideration of the premises and the following mutual covenants
and conditions and any sums to be paid, OCHD and the University agree as follows:
1, The Department will provide "Medical Director Services", including the
professional "General Consultation" and "Clinical" services identified below.
2, The Medical Director Services provided by the Department shall include the
following General Consultation Services:
a. act as the principal advisor to OCHD Health Director and OCHD Personal
Health Services Director in matters of medical policy;
b. advise OCHD Health Director and OCHD Personal Health Services Director
on the medical implications of alternatives in clinical program functioning
and management;
c. at the request of OCHD Health Director represent OCHD, and negotiate on
behalf of OCHD, with respect to interagency relationships that involve
medical expertise;
d. advise and interpret the regulatory requirements related to medical aspects of
OCH D'S functions;
e. provide coordination for medical components of the Outpatient Clinics of
OCHD;
f. advise and assist OCHD staff in epidemiological investigations;
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 2 of 10
g. be responsive to community public health concerns directly and in
consultation with OCHD Health Director and OCHD Division Directors;
h. assist OCHD Health. Director and OCHD Personal Health Services Director
in establishment of medical procedures and quality/quantity control
mechanisms;
assist OCHD staff in data analysis towards identification of public health
concerns; .
work with OCHD Health Director and OCHD Division Directors on
formulation of responses to public health concerns;
k. assist with evaluation of medical programs and services provided by OCHD,
including recommendations for constructive change;
maintain close contact and availability through on-site visits at OCHD and
phone consultation to assist OCHD in the discharge of OCHD .
responsibilities;
m. participate in OCHD Division Head management meetings and OCHD
Division level meetings when requested and appropriate;
n. attend Orange County Board of Health meetings when requested;
o. provide medical direction to school health programs in both school systems
in Orange County and medical consultation to both school and OCHD staff
working in or with school health programs;
p. other miscellaneous duties as provided for in the agreement;
q. discharge the above described responsibilities through and with knowledge
aforehand of OCHD Health Director.
3. The Medical Director Services provided by the Department shall include Clinical
Services in compliance with State and Federal guidelines and program rules for all
Outpatient Clinics conducted by OCHD, including without limitation the following
OCHD Outpatient Clinics: Family Planning (FP), Prenatal. Care (PNC), Child Health
(CH), Adolescent Health (ADOL), Tuberculosis (TB), Sexually Transmitted Disease
(STD), General Communicable Disease Control (GEN), Adult Health Preventive
Services (AFi/HP), Primary Care (PC), and Refugee Health (RH). The Clinical
Services provided by the Department shall include the following:
a. Collaboration with OCHD to develop and approve protocols for Outpatient
Clinics. For the mutual benefit of the Department, OCHD, and its prenatal
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 3 of 10
patients, prenatal patients will be managed according to OCHD established
protocols. These protocols will be reviewed annually and be consistent with
protocols used at UNC Department of OB/GYN and Family Medicine outlying
clinics.
b. Primary medical supervision of the nurse practitioners who are employees of
OCHD to include ongoing monitoring and evaluation of the medical acts
performed by the nurse practitioners; Regular individual meetings with the nurse
practitioners will occur according to an agreed upon schedule to review records
of high-risk or problematic patients; Documentation will be recorded in the
patient record indicating that a review occurred and noting any recommended
changes in the plan of care.
c. Co-signing charts of patients seen by new nurse practitioners of OCHD within
five (5) working days for at least the first six months of their nurse practitioner
practice, and face-to-face consultation on a weekly basis for the first month of
their nurse practitioner practice and at least monthly thereafter for the
succeeding five months;
d. A review of all OCHD prenatal records at 16, 28 and 36 weeks to assure that
appropriate medical care is being provided, with a Maternity Chart Review form
completed at each interval.
e. Weekly group meetings with clinical staff in each site according to an agreed
upon schedule to discuss patient care and clinical operation issues.
f. Overall responsibility for medical Residents and medical students working in
clinics including orientation, supervision of practice and assurance of
compliance with OCHD program and documentation requirements.
g. Provision of routine medical services during scheduled on-site times at OCHD
Outpatient Clinics, including documentation of Clinical Services provided per
established OCHD protocols;
h. Medical consultation visits to OCHD patients during on-site scheduled times at
Outpatient Clinics; medical consultation to OCHD nurse practitioners by
telephone when the Medical Director is not on-site at OCHD outpatient clinics.
Continuing education consultation for OCHD nurse practitioners and other
OCHD staff to include regular informal consultation and periodic formal
sessions as appropriate;
j. After-hours medical consultation for primary care patients of OCHD: UNC
Health Care's HealthLink program provides initial triage of after-hours calls as
per the agreement attached hereto and incorporated as exhibit A ("after-hours
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 4 of 10
program"). The Department will provide Medical Director consultation and
supervision to OCHD clinicians (3.5 FNPs) that provide after-hours medical
consultation (on a rotating basis) for OCHD clients referred by HealthLink. The
Medical Director shall-also provide after-hours medical consultation for
HealthLink referred OCHD clients (on a rotating basis) such that each of the 5
clinicians shall provide such after-hours medical consultation 1 week every 4-5
weeks.
k. Discharge the above described responsibilities through and with knowledge
aforehand of OCHD Health Director.
4. OCHD Outpatient Clinics are operational during the normal business hours of 8:00
A.M. to 5:00 P.M., Monday through Friday. On Wednesday, the clinics operate
from 10 AM - 5 PM. In addition, one weekday per site the Outpatient Clinics
(Tuesday -Hillsborough; Thursday -Chapel Hill) operate on a flexible evening
schedule (i.e. 9:30 AM - 6:30 PM) to provide greater access to care. Outpatient
Clinics may run beyond their scheduled time. In addition to the above-described
activities during the after-hours program, the Department is responsible for medical
activities conducted in the Outpatient Clinics in accordance with this agreement
during the entirety of the hours specified in this paragraph.
5. The Department shall provide, at a minimum, the equivalent of .70 Full Time
Equivalent (FTE) personnel to carry out the Medical Director Services described in
this agreement, including the General Consultation and Clinical Services identified
above. Said services will be provided primarily by the "Medical Director", or
"back-up Department physician". The Medical Director shall be board certified in
Family Medicine or an equivalent certification. The Medical Director will report
activities and services performed for OCHD as requested by OCHD Health
Director.
6. The Chair of the Department shall, concurrent with the execution of this agreement,
designate the name of the Medical Director, and the names of five Department
physicians who will rotate as back-up Department physicians, to be "available" to
provide the General Consultation and Clinical Services identified in this agreement.
a. The Department and OCHD shall indicate their mutual 'agreement to the
designation of the Medical Director and designated back-up Department
physicians available to be scheduled in the absence of the Medical Director by
signing the "Designation of Medical Director" attachment to this contract. Any
changes in these designations will be mutually agreed to by the Chair of the
Department and OCHD Health Director. In the event that the Medical Director
or any designated back-up Department physician becomes unwilling or unable
to perform the duties required by this agreement, the Department and OCHD
shall attempt to mutually agree upon replacement(s). If such mutual agreement
is not achieved, then this agreement shall terminate and any payment due as of
the date of termination shall be paid as provided for in paragraph J-8'of this
agreement. ~ ~~ d
~~ ~~
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 5 of 10
b. Substitutions in the scheduling of the Medical Director or designated back-up
Department physician will be the responsibility of the Department in
consultation with OCHD Health Director. Vacation leave, continuing
education, and other assignments requiring temporary back-up coverage will be
mutually agreed upon by the Chair of the Department and OCHD Health
Director.
7. The Medical Director or designated back-up Department physician shall provide a total
of twenty-two (22) hours per week of the foregoing Clinical Services on-site at OCHD
Outpatient Clinics or other sites as provided therefor. Days and times and the identity of
the person or persons scheduled to be on-site to provide this coverage on behalf of the
Department will be mutually agreed to by the Department and OCHD. Although the
Department is not required to provide the attendance of a Medical Director or back-up
Department physician on the premises of OCHD outpatient facilities or other sites
provided therefor at other times, access should be made available during other days and
times as stipulated in this agreement. Substitute coverage by a back-up Department
physician is expected during vacations and other anticipated absences of the Medical
Director or back-up Department physician originally scheduled to be available. The
Medical Director or designated back-up Department physician shall be responsible for
notifying OCHD of schedule changes. If attendance as scheduled of the Medical
Director or designated back-up Department physician is impossible due to unremediable
circumstances, phone coverage of a designated back-up Department physician must be
provided and nurse practitioner charts will be signed by the appropriate designated
Department physician or back up Department physician on call within five (5) working
days. In addition to the foregoing described days and hours, at the request of OCHD
Health Director, the Medical Director or designated back-up Department physician will
provide on-site medical supervision at OCHD Outpatient Clinics or other sites provided
therefor, as necessary, during communicable disease incidents or other public health-
related emergencies.
8. The Medical Director or designated back-up Department physician shall be available six
(6) hours per week for the following: phone consultation during business hours and after-
hours program coverage for clinical/patient issues, phone coverage for consultation and
direction for communicable disease/epidemic control, emergency phone consultation as
needed during non-business hours through a pager system, and direct administrative
and/or consultative services as outlined in General Consultation Services (Paragraph 2).
9. The Department will maintain current registration and licensure of the Medical
Director and designated back-up Department physicians and shall provide copies to
OCHD as appendices to the Designation of Medical Director attachment to this
contract.
10. The Department will assure that the Medical Director and designated back-up
Department physicians are in, and maintain, compliance with OSHA guidelines
regarding bloodborne pathogens including Hepatitis B and TB status as well as
documentation of immunization against measles, mumps, rubella and varicella. In
the event of a bloodborne pathogen exposure, the Department will be responsible
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 6 of t 0
for providing follow-up according to its policies and procedures governing exposure
incidents.
11. The University will be responsible for the negligence of its employees and agents to
the extent of the North Carolina Tort Claims Act. Further, the University will
provide adequate professional liability insurance for the University and its personnel
who provide the services described in the agreement. The insurance limits will be
stated in a Confirmation of Insurance submitted at the time the contract is
commenced.
12. The Department will offer medical consultation in accordance with the appropriate
medical standards and accepted methods and procedures.
13. OCHD agrees to pay the Department in return for the above services equal monthly
installments of TWELVE THOUSAND ONE HUNDRED AND EIGHTEEN DOLLARS
($12,118) for a total of $145,416.
14. The University shall bill OCHD on a monthly basis with the first bill being dated
July 1, 2009 and OCHD shall pay the University within thirty (30) days of receipt of
the University's bill. Any adjustments to the billing shall be taken. into account in
the next succeeding bill or as soon thereafter as reasonably practicable.
15. OCHD agrees to furnish all supplies, equipment, office space and a computer as
needed by the Medical Director; to include the Medical Director in all appropriate
conferences, meetings, correspondence and publications necessary to appropriately
discharge the Medical Director's duties within budgetary constraints.
16. This agreement shall run fora period of TWELVE (12) months, from the 1st day of
July, 2009, to the 30th day of June, 2010, and shall be renewable annually
thereafter upon written notice executed by both parties.
17. This agreement or its renewals may be terminated at any time without penalty by
either party provided that the agreement is terminated either:
a. upon failure of the parties to agree on a replacement Medical Director or
replacement designated back-up Department physician pursuant to
paragraph 6 of this agreement; or
b. upon delivery of written notice of termination furnished to the other party
at least ninety (90) days prior to termination.
In the event of such termination, any payment due shall be prorated to the date of
termination.
18. OCHD hereby agrees with the University that, in their educational and/or
employment practices, OCHD and the University will comply with such non-
discrimination laws as may be applicable to it in the performance of this agreement.
The Department shall abide by pertinent rules and regulations of OCHD, Orange
County, and the North Carolina Department of Health and Human Services in the
conduct of service. The University, the Department and OCHD shall comply with
such confidentiality laws as may be applicable in the performance of this agreement
and acknowledge that in receiving, storing, processing or otherwise dealing with
any confidential information, they will safeguard and not further disclose the
information except as permitted by the Health Insurance Portability and
Accountability Act of 1996, Public Law 104-191, as amended, and the provisions of
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 7 of 10
the Business Associate Agreement which is attached hereto and incorporated herein
by reference.
19. No.provision of this agreement shall be construed or interpreted as creating a
pledge of the faith and credit of the County of Orange or OCHD within the
meaning of any constitutional debt limitation. No provision of this agreement shall
be construed or interpreted as creating a delegation of governmental powers nor as
a donation by or a lending of the credit of the County of Orange or OCHD within
the meaning of the Constitution of the State of North Carolina. This agreement shall
and does not directly or indirectly or contingently obligate the County of Orange or
OCHD to make any payments beyond those appropriated in the sole discretion of
the County of Orange or OCHD for any fiscal year in which this agreement shall be
in effect. No deficiency judgment may be rendered against the County of Orange
or OCHD in any action for breach of a contractual obligation under this agreement
and the taxing power of the County of Orange is not and may not be pledged
directly or indirectly or contingently to secure any moneys due under this
agreement.
20. This agreement supercedes any previous agreements between the parties
concerning the matters agreed to herein. This agreement contains the entire
understanding of the parties and shall not be altered, amended or modified, except
by an agreement in writing executed by the duly authorized officials of both parties.
21. The laws of North Carolina shall govern the validity and interpretation of the
provisions, terms, and conditions of this agreement.
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 8 of 10
IN WITNESS WHEREOF, the parties have hereunto signed this agreement in their official
capacities of the day and year listed below.
FOR AND ON BEHALF OF
FOR AND ON BEHALF OF
ORANGE COUNTY HEALTH DEPARTMENT THE UNIVERSITY OF NORTH CAROLINA
osemary L. mmers, MPH, DrPH
Health Direc or
AT CHAPEL HILL
i
Richard Man ' ~--
Vice-Chancellor fo
Finance and Administration
DATE:
FOR AND N BEHALF THE COUNTY OF
G~-,-~
Valerie Foushee, Chair
Orange County Board of Commissioners
DATE:
~ ~.
~ _ .~
ufr t r
Warren P. Newton, MD
Chair, Family Medicine
DATE: S ~y" riJ
--~ ~ -
William L o e , , M
Dean, S of o Medicin
DATE: /~ ~~Q~
ORANGE
DATE: ~ ~
ORANGE COUNTY FINANCE DIRECTOR:
"This instrument has been pre-audited in the manner required by the Local Government
Budget and Fiscal Control Act."
~ryp
Finance Did
DATE: ~ ~
09-10 AGREEMENT Between UNC School of Medicine
And Orange County Health Department
Page 9 of 10
Designation of Medical Director
Attachment to Contract between the Department of Family Medicine, University of North
Carolina, School of Medicine and the Orange County Health Department for July 1, 2009
through June 30, 2010.
The following physicians are designated by the Department of Family Medicine to fulfill
the terms of the attached contract:
Michael Fisher, MD Medical Director
Bonzo Reddick, MD _ Physician
Martha Carlough MD Physician
_ Cristen Page, MD _ Physician
Dana Iglesias, MD Physician
Kelly Bossenbroek-Fedoriw, MD Physician
Sam Weir, MD Physician
Adam Zolotor, MD Physician
Copies of current registration and licensure for these physicians are attached.
Signed:
~ ~® o~
Warren Newton, Chair
Department of Family Medicine Date
Agreed:
Rosemary Su ers, Health Director
Orange County Health Department Date
Licensee Details
North Carolina Medical Board
Information as of May 8, 2009
Michael John Fisher, MD
Public File: NO
Current License Status: Active
License Number: 9501239
Issue Date: 09/16/1995
Limitations:
Address
123 High Hickory Rd
Chapel Hili, NC 27516-5545
i ~~:~~~15c.?~.' ' ... ...
Practice Phone;
Individual information
Year of Birth: 1947 Annual Renewal Date: 10/15/20`09
PrimaNj+!'~Specialty°~Family Practice Board Certified: Yes ABMS or AOA Approved: Yes
Secofidary $pecialty~~`
Ared.~;$.~•.:of~P:racfic,e'.%.:_~'
.,
Hospital Privileges: University of North Carolina Hospitals
Out Of State Licenses: Illinois,New York
Out Of Country Licenses:
T;Fte abQWe=StatQ:and Country Licenses may be currently Active or Inactive
Sbhool.Name
Univ of Cincinnati
Montefiore Hospital
.,
Hide Licensure History
R~a~Qh GPdQ., 1 License
-. 'Number
°~ ~ 9501239
Supervises Type
~INh.itten; Robin • PA
Xla, Hongling NP
Tvpe Grad Year
Medical School 1973
PGY2 1976
Active License
Subcategory Issue Date Expire Date
09/16/1.995
Supervisor
Status Approval Date Inactive Date
Inactive
Active 10/17/2007
Page 1 of 2
ht>;p:~/www.ncmedboard.org/Clients/NCBOM/Public/Licensee Details.aspx?&EntityID=65214&PublicFile... 5/8/2C
Licensee Details
Address
UNC Hospitals
590 Manning Drive
CB 7595
Chapel Hill, NC 27599-7595
Practice Phone: (919) 843-4708
North Carolina Medical Board
Information as of July 1, 2009
Bonzo Kwesi Reddick, MD
Public File: NO
Current License Status: Active
License Number: 200401669
Issue Date: 12/16/2004
Limitations:
Individual Information
Year of Birth: 1977 Annual Renewal Date: 02/02/2010
Primary Specialty: Family Practice Board Certified: Yes ABMS or AOA Approved: No
Secondary Specialty:
Area(s) of Practice:
Hospital Privileges: Chatham Hospital, Inc.,University of North Carolina Hospitals
Out Of State Licenses:
Out Of Country Licenses:
The above State and Country Licenses may be currently Active or Inactive
School Name Tvpe Grad Year
UNC Hospitals PGY2
Morehouse School of Medicine Medical School 2002
Hide Licensure History
Reason Code License
Number
200401669
Reason Code License
Number
Active License
Subcategory Issue Date Expire Date
12/16/2004
Inactive License
Subcategory Issue Date Expire Date
RTL 04/15/2002
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Licensee Details
North Carolina Medical Board
Information as of May 8, 2009
Martha Christine Carlough, MD
Public File: NO
Current License Status: Active
License Number: 9300433
Issue Date: 09/18/1993
Limitations:
Address
University of North Carolina
Dept of Family Medicine
Manning Dr, CB 7595
~h~pel, Hili, ;NG, 27599-7595
Practice Phone: (919) 966-6055
individual Information
Year of Birth: 1963 Annual Renewal Date: 11/1912009
Prim~ij~~~~8~pecialty: Family Practice Board Certified: Yes ABMS or AOA Approved: Yes
Secbtidary,Specialty:~Obstetrics and Gynecology Board Certifled: Yes ABMS or AOA Approved: No
.-~ . .
AreaY's ~.,of :practise:,, ; .:
(.. ), .
Hospital Privileges: University of North Carolina Hospitals
Out Of State Llcenses: New York,Rhode Island,South Carolina
Out Of Country Licenses: Nepal
Tha.ab.ove.State:and Country Llcenses may be currently Active or Inactive
$~ch`ool Name Tvoe Grad Year
JetFersnn Medical College Medical School 1989
Nllglilarid Hospital PGY1 1992
,Hide Licensure History
Reason Code1. License
Number
9300433
Supervises : Type
Garrett,. David PA
Bernart, D. PA
VAN$REE,RACHEL NP
Goldstein, Ami NP
Active License
Subcategory Issue Date Expire Date
09/18/1993
Supervisor
Status Approval Date Inactive-Date
Inactive
Inactive
Active 09/15/2008
Active 04/28/2006
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Licensee Details
North Carolina Medical Board
Information as of May 8, 2009
Cristen Parker Page, MD
Public File: NO
Current License Status: Active
License Number: 2005-01187
Issue Date: 07/22/2005
Limitations:
Address
UNC Family Practice Center
CB 7595
Chapel Hill, NC 27599-7595
Rractice Phone: (919) 843-2284
Individual Information
Year of Birth: 1974 Annual Renewal Date: 06/17/2010
Primary Specialty; Family Practice Board Certified: Yes ABMS or AOA Approved: Yes
Secondary Specialty:
Area(s) of Practice: Family Medicine
Family Medicine -Adolescent Medicine
Obstetrics
Pediatrics
Hospital Privileges: University of North Carolina Hospitals
Out Of State Licenses:
Out Of Country Licenses:
The above State and Country Licenses may be currently Active or Inactive
School Name
UNC Hospitals
University of North Carolina at
Chapel H111 School of Medicine
Tvpe Grad Year
PGY2
Medical School 2002
Hide Licensure History.:., ,.
Active License
Reason Code License Subcategory Issue Date Expire Date
Number
2005-01187 07/22/2005
Inactive License
Reason Code License Subcategory Issue Date Expire Date
Number
RTL 05131!2002 07/22/2005
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Licensee Details
North Carolina Medical Board
Information as of May 8, 2009
Dana Michelle Iglesias, MD
Public File: NO
Current License Status: Active
License Number: 2009-00657
Issue Date: 04/27/2009
Limitations:
Address
UNC Hospitals
UNC Family practice center
CB # 7595
Chapel Hill, NC 27599
Practice Phone: (919) 966-0210
Individual Information
Year of Birth: 1974 Annual Renewal Date: 10!06/2009
Primary Specialty: Family Practice Board Certified: Yes ABMS or AOA Approved: Yes
Secondary Specialty:
Area(s) of Practice: Family Medicine
Hospital Privileges:
Out Of State Licenses: California
Out Of Country Licenses:
The above State and Country Licenses may be currently Active or Inactive
School Name Tvoe Grad Year
Morehouse School of Mediciene Medical School 2002
Hide Licensure History
Active License
Reason Code License Subcategory Issue Date Expire Date
Number
2009-00657 04!27/2009
Inactive License
Reason Code License Subcategory Issue Date Expire Date
Number
Completed RTL 06/14/2002 06/23/2005
Residency
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Licensee Details
North Carolina Medical Board
Information as of May 8, 2009
Kelly Bossenbroek Fedoriw, MD
Public File: NO
Current License Status: Active
License Number: 2008-01856
Issue Date: 10/28/2008
Limitations
Address
305 Chatham Dr
Chapel Hill, NC 27516
Practice Phone:
Individual Information
Year of Birth: 1976 Annual Renewal Date: 01/04/2010
Primary Specialty: Family Medicine Board Certified: Yes ABMS or AOA Approved: Yes
Secondary Specialty:
Area(s) of Practice: Family Practice
Hospital Privileges:
Out Of State Licenses: Connecticut
Out Of Country Licenses:
The above State and Country Licenses may be currently Active or Inactive
School Name Tvoe Grad Year
Medical University of Toledo Ohio Medical School 2003
Hide L~censure History ,_ y,
Reason Code License
Number
2008-01856
Active License
Subcategory Issue Date
10/28/2008
Expire Date
Page 1 of 1
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Licensee Details
North Carolina Medical Board
Information as of July 1, 2009
Samuel Stucker Weir, MD
Public File: NO
Current License Status: Active
License Number: 28711
Issue Date: 12/04/1984
Limitations:
Address
UNC School of Medicine
Dept of Family Medicine, Aycock Bldg
Manning Drive, CB 7595
Chapel Hill, NC 27599
Practice Phone: (919) 843-4684
individual Information
Year of Birth: 1956 Annual Renewal Date: 06/16/2009
Primary Specialty: Family Practice Board Certified: Yes ABMS or AOA Approved: Yes
Secondary Specialty: Family Practice/Sports Medicine Board Certified: Yes ABMS or AOA Approved: No
Area(s) of Practice:
Hospital Privileges: University of North Carolina Hospitals
Out Of State Licenses:
Out Of Country Licenses:
The above State and Country Licenses may be currently Active or Inactive
School Name Type Grad Year
Duke Medical School 1982
UNC Hospitals PGY1 1983
UNC Hospitals PGY2 1984
Hide Licensure History
Active License
Reason Code License Subcategory Issue Date Expire Date
Number
28711 12/04/1984
Supervisor
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Licensee Details
North Carolina Medical Board
Information as of July 1, 2009
Adam Jason Zolotor, MD
Public File: NO
Current License Status: Active
License Number: 200100497
Issue Date: 04/26/2001
Limitations:
Address
UNC Chapel Hill
UNC Family Practice Center
Manning Dr, CB 7595
Chapel Hill, NC 27599-7595
Practice Phone: 919-966-0210
individual Information
Year of Birth: 1971 Annual Renewal Date: 06/08/2010
Primary Specialty: Family Practice Board Certified: Yes ABMS or AOA Approved: Yes
Secondary Specialty:
Area(s) of Practice:
Hospital Privileges: University of North Carolina Hospitals
Out Of State Licenses:
Out Of Country Licenses:
The above State and Country Licenses may be currently Active or Inactive
School Name
Univ of NC
Univ of Michigan
Hide Licensure History_
Reason Code
Supervisee
License
Number
200100497
Tvpe Grad Year
Medical School 1998
PGY2 2001
Active License
Subcategory Issue Date
04/26/2001
Expire Date
Supervisor
Type Status Approval Date Inactive Date
Page 1 of 2
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February 27, 2009
Addendum A to
Agreement between UNC and OCHD
For Medical Director Services
Whereas, the Chapel Hill-Carrboro City Schools (CHCCS) employs one (1)
School Nurse who is a licensed and qualified Nurse Practitioner (Head Start
Program), and;
Whereas, CHCCS seeks to have the School Nurse provide limited nurse
practitioner services to students at her site, and;
Whereas, the School Nurse Practitioner requires medical supervision, and;
Whereas, the Orange County Health Department (OCHD) maintains a
Memorandum of Agreement with CHCCS to provide medical direction to
school nurses by the OCHD Medical Director, and;
Whereas, The University of North .Carolina at Chapel Hill ('The University') through
its Department of Family Medicine of the UNC School of Medicine (Department)
provides medical supervision to OCHD Nurse Practitioners through its Medical
Director contract and is agreeable to expanding the contract to provide
medical supervision to the CHCCS School Nurse Practitioner.
Therefore,. the above parties agree to the following:
1. OCHD Medical Director (or other mutually agreed upon UNC Family
Practice physician) will provide medical supervision to the CHCCS School
Nurse Practitioner from August 15, 2009 to June 15, 2010 (10 months) in
accordance with the term of the Agreement between The University and
OCHD.
2. CHCCS will maintain medical malpractice insurance equal to or
exceeding $1 million per incident and $3 million upper limit coverage for
its School Nurse Practitioner and will furnish proof of insurance to the
OCHD and the Department.
3. CHCCS will adhere to OCHD nurse practitioner protocols.
4: CHCCS will assure the School Nurse Practitioner has an approved
Registration and Approval to Practice by the NC Board of Nursing and the
NC Medical Board. CHCCS will have on hand a copy of the Nurse
Practitioner's current license to provide to OCHD upon request.
H:\faculty\h\hoover\data\50FiLES\Contracts\Orange County HD\09-10 OCHD\Addendum A to UNC
Agreement 2009-10.doc
February 27, 2009
5. CHCCS will assure the School Nurse Practitioner has a Collaborative
Practice Agreement completed with the University's assigned OCHD
Supervising Physician.
6. CHCCS will assure that the School Nurse Practitioner abides by all laws
and regulations governing the confidentiality of patient information,
including HIPAA privacy rules.
7. OCHD will amend its agreement with CHCCS to include the medical
supervision of its School Nurse Practitioner by the University's assigned
OCHD Medical Director or designee with its corresponding period of
coverage and costs.
8. CHCCS will pay OCHD for medical supervision of its School Nurse
Practitioner the amount of $1000/year (1 hour/month @$100/hour) in one
lump payment by September 30, 2009.
9. OCHD will pay The University for the above services in one lump payment
of $1000 by December 30, 2009.
lO.This agreement is in effect from July 1, 2009 through June 30, 2010.
H:\faculty\h\hoover\data\50FILES\Contracts\Orange County HD\09-10 OCHD\Addendum A to UNC
Agreement 2009-10.doc
February 27, 2009
Signatures:
Rosemary Sum rs, MPH, DrPH
Orange County Health Director
/.1 /~~c.---
Neil Pedersen, PhD
/~~~~
Date
7"~'° f
Date
CHCCS Superintendent d~ -T
_ ~
\, C
_..
yT ~ .~.~ ,~„ t; ~..~ l ~ ~ . a ~
Warren Newton, iiii~ per ~ ~`-' Date
Dean, o0 of edici
Chair, Family Medicine Vice C I for Medical Affairs.
lo~~-G j
~`
.~._ ~ b o /
Valerie Foushee, C it Date
Orange County Board of Commissioners
Orange County Finance Director:
"This instrument has been pre-audited in the manner required by the Local
Government Budget and Fiscal Control Act."
Gary Hu . -
Finance Direc r
Date
H:\faculty\h\hoover\data\50FILES\Contracts\Orange County HD\09-10 OCHD\Addendum A to UNC
Agreement 2009-10.doc
BUSINESS ASSOCIATE AGREEMENT
This Agreement is made effective the 15' Day of July, 2009, by and between Orange
County Government, Health Department, hereinafter referred to as "Covered Entity", and UNC
Department of Family Medicine, hereinafter referred to as "Business Associate," (individually, a
"Party" and collectively, the "Parties").
WITN ESSETH:
WHEREAS, Sections 261 through 264 of the federal Health Insurance Portability and
Accountability Act of 1996, Public Law 104-191, known as "the Administrative Simplification
provisions," direct the Department of Health and Human Services to develop standards to
protect the security, confidentiality and integrity of health information; and
WHEREAS, pursuant to the Administrative Simplification provisions, the Secretary of Health
and Human Services has issued regulations modifying 45 CFR Parts 160 and 164 (the "HIPAA
Privacy Rule"); and
WHEREAS, the Parties wish to enter into or have entered into an arrangement whereby
Business Associate will provide certain services to Covered Entity, and, pursuant to such
arrangement, Business Associate may be considered a "business associate" of Covered Entity as
defined in the HIPAA Privacy Rule (the agreement evidencing such arrangement is entitled
"Agreement for Medical Director Services Between the County of Orange Health Department
and the Department of Family Medicine, University of Norfh Carolina at Chapel Hill," dated July
1, 2009-June 30, 2010, and is hereby referred to as the "Arrangement Agreement"); and
WHEREAS, Business Associate may have access to Protected Health Information (as
defined below) in fulfilling its responsibilities under such arrangement;
THEREFORE, in consideration of the Parties' continuing obligations under the
Arrangement Agreement, the Parties agree to the provisions of this Agreement in order to
address the requirements of the HIPAA Privacy Rule and to protect the interests of both Parties.
DEFINITIONS
Except as otherwise defined herein, terms used in this Agreement shall have the same meaning
as those terms set forth in the HIPAA Privacy Rule.
CONFIDENTIALITY REQUIREMENTS
(a) Business Associate shall:
(i) use or disclose any protected health information solely as
permitted or required by this Agreement, the Arrangement Agreement (if
consistent with this Agreement and the HIPAA Privacy Rule), or as required by law.
(ii) ensure. that its agents, including a subcontractor, to whom it
provides protected health information received from or created by Business
Associate on behalf of Covered Entity, agrees to the same restrictions and
conditions that apply to Business Associate with respect to such information. In
addition, Business Associate agrees to take reasonable steps to ensure that its
employees' actions or omissions do not cause Business Associate to breach the
terms of this Agreement;
09-10 OCBAA with UNC FM Page 1 of 4
(iii) implement appropriate safeguards to prevent use or disclosure of
protected health information other than as permitted or required by this
Agreement;
(iv) permit the Secretary of Health and Human Services to audit
Business Associate's records and practices related to use and disclosure of
protected health information to ensure Covered Entity's compliance with the
terms of the HIPAA Privacy Rule;
(v) report to Covered Entity any use or disclosure of protected health
information which is not in compliance with the terms of this Agreement of which
it becomes aware; and
(vi) mitigate, to the extent practicable, any harmful effect that is
known to Business Associate of a use or disclosure of protected health information
by Business Associate in violation of the requirements of this Agreement.
(b) Notwithstanding the prohibitions set forth in this Agreement or the Arrangement
Agreement, Business Associate may use and disclose protected health
information as follows:
(i) if necessary, for the proper management and administration of
Business Associate or to carry out the legal responsibilities of Business Associate,
provided that as to any such disclosure, the following requirements are met:
(A) the disclosure is required by law; or
(B) Business Associate obtains reasonable assurances from the
person to whom the information is disclosed that it will be held
confidentially and used or further disclosed only as required by law or for
the purpose for which it was disclosed to the person, and the person
notifies Business Associate of any instances of which it is aware in which
the confidentiality of the information has been breached;
(ii) for data aggregation services, if such services are to be provided
by Business Associate for the health care operations of Covered Entity pursuant to
any agreements between the Parties evidencing their business relationship.
III. AVAILABILITY OF PROTECTED HEALTH INFORMATION
Business Associate shall:
(a) at the request of Covered Entity, provide access to protected health information
in a designated record set to Covered Entity or, as directed by Covered Entity, to
an individual, in a time and manner sufficient to permit Covered Entity to comply
with the requirements of 45 CFR 164.524.
(b) at the request of Covered Entity or an individual, make any amendment(s) to
protected health information in a designated record set that are directed by or
agreed to by Covered Entity, in a time and manner sufficient to permit Covered
Entity to comply with the requirements of 45 CFR 164.526.
(c) document disclosures of protected health information and information related to
such disclosures in a manner sufficient to permit Covered Entity to respond to a
request by an individual for an accounting of disclosures of protected health
information in accordance with 45 CFR 164.528 and provide such documentation
to Covered Entity or an individual as directed by Covered Entity.
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IV. TERMINATION
(a) Term: This Agreement terminates when the Arrangement Agreement terminates
or as provided in Paragraph IV.b. below (termination for cause).
(b) Termination for cause: Upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity shall either:
(i) provide an opportunity for Business Associate to cure the breach
or end the violation or, if Business Associate does not cure the breach or end the
violation. within the time specified by Covered Entity, terminate this Agreement
and the Arrangement Agreement; or
(ii) immediately terminate this Agreement and the Arrangement
Agreement if Business Associate has breached a material term of this Agreement
and cure is not possible.
(c) Return or destruction of protected health information: At termination of this
Agreement, the Arrangement Agreement (or any similar documentation of the
business relationship of the Parties), or upon request of Covered Entity, whichever
occurs first, Business Associate shall:
(i) if feasible, return or destroy all protected health information
received from or created or received by Business Associate on behalf of Covered
Entity that Business Associate still maintains in any form. Business Associate shall
only destroy protected health information with the written approval of Covered
Entity. After return or destruction, Business Associate shall retain no copies of such
information.
(ii) if return or destruction is not feasible, Business Associate will provide
Covered Entity with documentation explaining the reason that it is not feasible. If
the protected health information is not returned or destroyed, Business Associate
will extend the protections of this Agreement to the information and limit further
uses and disclosures to those purposes that make the return or destruction of the
information not feasible.
(d) Survival: The obligations of Business Associate under this Agreement shall survive
the expiration, termination, or cancellation of this Agreement, the Arrangement
Agreement and/or the business relationship of the parties, and shall continue to
bind Business Associate, its agents, employees, contractors, successors, and
assigns as set forth herein.
V. MISCELLANEOUS
(a) All protected health information that is created or received by Covered Entity
and disclosed or made available in any form, including paper record, oral
communication, audio recording, and electronic display by Covered Entity or its
operating units to Business Associate or is created or received by Business
Associate on Covered Entity's behalf shall be subject to this Agreement.
(b) A reference in this Agreement to a section in the HIPAA Privacy Rule means the
section as in effect or as amended.
(c) In the event of an inconsistency between the provisions of this Agreement
(including definitions) and mandatory provisions of the HIPAA Privacy Rule, as
09-10 OCBAA with UNC FM Page 3 of 4
amended, the HIPAA Privacy Rule shall control. Where provisions of this
Agreement are different than those mandated in the HIPAA Privacy Rule, but are
nonetheless permitted by the HIPAA Privacy Rule, the provisions of this Agreement
shall control
(dJ Except as expressly stated herein or the HIPAA Privacy Rule, the parties to this
Agreement do not intend to create any rights in any third parties.
(e) This Agreement may be amended or modified only in a writing signed by the
Parties. No Party may assign its respective rights and obligations under this
Agreement without the prior written consent of the other Party. None of the
provisions of this Agreement are intended to create, nor will they be deemed to
create any relationship between the Parties other than that of independent
parties contracting with each other solely for the purposes of effecting the
provisions of this Agreement and any other agreements between the Parties
evidencing their business relationship.
(f) This Agreement will be governed by the laws of the State of North Carolina.
(g) No change, waiver or discharge of any liability or obligation hereunder on .any
one or more occasions shall be deemed a waiver of performance of any
continuing or other obligation, or shall prohibit enforcement of any obligation, on
any other occasion.
(h) The parties agree that, in the event that any documentation of the arrangement
pursuant to which Business Associate provides services to Covered Entity contains
provisions relating to the use or disclosure of protected health information that
are more restrictive than the provisions of this Agreement, the provisions of the
more restrictive documentation will control.
(i) In the event that any provision of this Agreement is held by a court of competent
jurisdiction to be invalid or unenforceable, the remainder of the provisions of this
Agreement will remain in full force and effect.
(j) The headings in this Agreement are for convenience of reference only and shall
not define or limit any of the terms or provisions hereof.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year
written above.
COVERED ENTITY:
BUSINESS ASSOCIATE:
am L. oiler, M MP 1
- ~ _ n, Sch I of Medicine
Title: ~ =~`'~ ~' ~ ~' ' '•~ ~~~~~ , .~~~~~~ ~ ~ , Title: Vice Chancellor for Medical Affairs
~~
~:
_, ~"~ ~.
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