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Home My WebLink About2019-253-E Health - Triangle Urology vasectomy services amendment DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D ORANGE COUNTY AMENDMENT TO SERVICES AGREEMENT NORTH CAROLINA THIS AMENDMENT, made and entered into this the 24' day of April, 2019, by and between the County of Orange, a body politic and corporate of the State of North Carolina, ("County"), and Triangle Urology Associates, P.A. ("Provider"); WITNESSETH: WHEREAS, the County and Provider entered into a Services Agreement dated, July 1, 2018, to provide services to be rendered by Provider to County's Health Department("Original Agreement"); and WHEREAS, the County and Provider desire to amend the Original Agreement, while keeping in effect all terms and conditions of the Original Agreement not inconsistent with the terms and conditions set forth below. NOW THEREFORE, for and in consideration for the mutual covenants and agreements made herein, the parties agree to amend the Original Agreement, effective July 1, 2018 ("Effective Date") as follows: The amount to be paid by the County shall not exceed eight thousand two hundred dollars, ($8,200). Except for the changes made to the payments amount in section 1. Payment herein, the Original Agreement shall remain in full force and effect to the extent it is not inconsistent with this Amendment. In the event that there is a conflict between the Original Agreement and this Amendment,this Amendment shall control. IN WITNESS WHEREOF, Orange County and the Consultant have signed this Amendment,this the 24' day of April,2019. FOR oocusigned by T TT" oocusigneci by j�jbin�ln l�, f YS �avuln. br6wv- By - a6379946755E477.. By: FEC8A8247EA246D.. County Manager Davin Brown, CFO Triangle Urology Associates Revised Dec 2018 DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D [Departmental Use Only] TITLE TriangleUrology-Steriliz. FY 2018-2019 ORANGE COUNTY CONTRACT UNDER$5,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 1st day of July, 2018, ("Effective Date")by and between Orange County, North Carolina, a body politic and corporate organized under the laws of the State of North Carolina, (the "County"), party of the first part; and Triangle Urology Associates, P.A. (the "Provider"),party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement,time being of the essence: The services and/or materials and/or construction (hereinafter referred to collectively as "Services") to be furnished under this Agreement are as follows: Provider will perform vasectomy and post-procedure semen analysis to uninsured males referred by Orange County Health Department. OCHD will pay Provider $850 per procedure performed inclusive of the post-precedure semen analysis. The term of this agreement rendered shall be from July 1, 2018 to June 30,2019. Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities,mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement,without the prior written approval of the County. SPECIFIC TERMS 1. Payment: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed Three thousand four hundred dollars, ($3,400). Payment shall be made within thirty (30) days of an invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. 2. Non—waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non-Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent contractor, and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may Revised 10/17(Mgr appry 5k 6/18) 1 DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D be required by County's Risk Manager as such insurance requirements are described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at http://www.orangecountVnc.gov/departments/purchasing division/contracts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall be designated here N/A (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 5. Indemni : The Provider agrees, without limitation, to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider in carrying out Provider's duties and obligations related to the Services to be provided in this Agreement. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon reasonable notice to Provider. 7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. Modifications may be evidenced by telefacsimile signature. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the parties to comply with Article I IA and Article 40 of North Carolina General Statute Chapter 66. 8. Governing Law and Priority: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina and Orange County. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non- Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.oran ecogAtync. og v/departments/purchasing_division/contracts.php.). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. By executing this Agreement Provider affirms Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms herein shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Dispute Resolution: Neither party may initiate binding arbitration. Any disputes shall be resolved by nonbinding mediation. If such mediation fails either party may initiate litigation to resolve the dispute. Should either party initiate litigation to settle any dispute involving the terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in Orange County, North Carolina. Revised 10/17(Mgr appry 5k 6/18) 2 DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D 10. Non Appropriation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. IN WITNESS WHEREOF, Orange County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER By: By: Department Director Title: 200 S. Cameron St. Triangle Urology Associates, P.A. P.O. Box 8181 205 Frasier Street Hillsborough,NC 27278 Durham,NC 27704 Revised 10/17(Mgr appry 5k 6/18) 3 DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D Hanover Instfrance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 WORKERS COMPENSATION RENEWAL INFORMATION PAGE RENEWAL OF WZ6-AO04288-04 CARRIER CODE NO. 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6-AO04288-05 06/26/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address Agent Telephone: 844-367-7899 TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF NC LLC ATTW DAVIN BROWN CL HANOVER CSCISTE 350 205 FRASIER ST 4605 FALLS OF NEUSE RD DURHAM, NC 27704 RALEIGH, NC 27609 Federal ID No. 561205950 SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER WORKPLACES NOT SHOWN ABOVE. IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. ENTITY OF INSURED - CORPORATION ITEM 2. POLICY PERIOD- 06/25/18 TO 06/25/19 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. ---------------------------------------------------------------------------------- ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- NC. -------------------------------------------------------------------- B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT -------------------------------------------------------------------- C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. -------------------------------------------------------------------- D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. -----_------------------------------------_____----_------------------------------------- ITEM 4. THE PREMIUM FOR THIS P❑LICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. --------------------------------------------------------------------------- CLASSIFICATION OF OPERATIONS I EST I ANNUAL SEE ATTACHED SCHEDULE OF OPERATIONS i PREMIUM I 1,812 I MINIMUM PREMIUM $261 EXPENSE CONSTANTI 210 PREMIUM FOR TERRORISM I $44 PREMIUM FOR CATASTROPHE I $73 TOTAL ESTIMATED ANNUAL PREMIUM I $2,139 DEPOSIT PREMIUMI $2,139 COUNTERSIGNED THIS DAY OF - - - - - - - - - - - - - - -- AUTHORIZED REPRESENTATIVE BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. 000e��orm 331-0226 (9-03) WC000001 B Date Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL wcDEc+ DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D �• Hanover Insumlicc Group- WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 EXTENSION OF INFORMATION PAGE RENEWAL OF WZ6-AO04288-04 CARRIER CODE NO. 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6-AO04288-05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address Agent Telephone: 844-367-7899 TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF NC LLC ATTN: ❑AVIN BROWN CL HANOVER CSCISTE 350 205 FRASIER ST 4505 FALLS OF NEUSE R❑ ❑URHAM, NC 27704 RALEIGH, NC 27609 Federal ID No. 561205950 POLICY ** A D D I T I 0 N A L L O C A T I O N S ** SCHEDULE PAGE 2 PAGE I LOCATION ADDRESS NUMBER -__.._------------------------------------------------------------------ 001 205 FRASIER STREET DURHAM NC 27704 --------------------------------------------------------------------- wc,8a arm 331-0226 0-03) WC000601B Date Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL wcaEC1 DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D r„ Hanover Insurance GrouP._ WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 EXTENSION OF INFORMATION PAGE RENEWAL OF WZ6-AO04288-04 CARRIER CODE NO. 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6-A004288-05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address Agent Telephone. 844-367-7899 TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF NC LLC ATTN: DAVIN BROWN CL HANOVER CSCISTE 360 205 FRASIER ST 4505 FALLS OF NEUSE RD DURHAM, NC 27704 RALEIGH, NC 27609 Federal ID No. 561205950 POLICY ** S C H E D U L E O F 0 P E R A T I 0 N S ** SCHEDULE PAGE 3 PAGE 1 ITEM 4. CLASSIFICATION OF OPERATIONS EST RATE EST ST LOCT CODE TYP TOT-ANN PER$100 ANNUAL Y NO RSK REMUNERATION PREMIUM ----------------------------------------------------------------------------------- I I I NC 001 8832 H PHYSICIAN & CLERICAL 1 734,2001 .271 $1 ,982 1 1 1 PREMIUM SUBJECT TO MODIFICATIDN I I 1 1 ,982 -------------------------------------------------------------- I ------ I - 0930 PREMIUM FOR WAIVER OF SUBROGATION 1 .0501 100 9807 PREMIUM FOR INCREASED COV B LIMITS 1 .00801 16 9848 BALANCE TO MINIMUM FOR COV B LIMITS 1 1 59 9887 NC SCHEDULE MODIFICATION 1 .8401 345- 0032 LDSS CONSTANT 1 1 0 I I TOTAL FOR NORTH CAROLINA 1 I 1,812 ---------------------------------------------------------------------- I TOTAL SCHEDULE OF I OPERATIONS PREMIUM I $1,812 9740 TERRORISM .0061 44 9741 CATASTROPHE (OTHER THAN TERRORISM) . 0101 73 ---------------------------------------------------------------------------------- 000a, orm 331-0226 {9-03) WC000001B Date Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL wcoEcl DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D Hanover 111suralice Group- WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 EXTENSION OF INFORMATION PAGE RENEWAL, OF WZ6-A004288-04 CARRIER CODE NO. 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6-A004288-05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address Agent Telephone' 844-367-7899 TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF INC LLC ATTN: DAVIN BROWN CL HANOVER CSCISTE 350 205 FRASIER ST 4505 FALLS OF NEUSE RD DURHAM, NC 27704 RALEIGH, NC 27609 Federal ID No. 561205950 POLICY * E N D 0 R S E M E N T ■ F 0 R M S C H E D U L E * SCHEDULE PAGE 4 PAGE I STATE NUMBER EFFECTIVE DATE ---------------------------------------------------------------------------------- NC *000308 0484 PARTNERS, OFFICERS AND OTHERS EXCLUSION END. 06/25/18 NC *000424 0117 AUDIT NONC❑MPLIANCE CHARGE ENDORSEMENT 06/25/18 NC *320301C0114 NORTH CAROLINA AMENDED COVERAGE ENDT 06/25/18 NC *000414 0790 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT 06/25/18 NC *000419 0101 PREMIUM DUE DATE ENDORSEMENT 06/25/18 NC *000422BO115 TRIPRA DISCLOSURE ENDORSEMENT 06/25/18 NC *000311A0891 VOLUNTARY COMP. 8 EMPL , LIAR. COV. END. 06/25/18 NC *000313 0484 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 06/25/18 NC *00000000115 WORKERS COMP AND EMPLOYERS LIABILITY INS POLICY 06/25/18 NC *000404 0484 PENDING RATE CHANGE END. 06/25/18 NC *000421D0115 CATASTROPHE (NON-TERRORISM) PREMIUM ENDT 96/25/18 ---------------------------------------------------------------------------------- S arm 331-0226 (9-03) WC000001B ate Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL WCOECI DocuSign Envelope ID:COE92964-lD40-431E-B3C2-48EE5F39527D insurance Group- Fv BUSINESSOWNERS DECLARATION BUSINESSOWNERS RENEWAL DECLARATIONS RENEWAL OF OD6 A005679 EOD6-A005679-05 cy Number Policy Period Coverage is Provided in the Agency Code From To 06/2512018 06/25/2019 MASSACHUSETTS BAY INSURANCE COMPANY 190282000 Named Insured and Address Agent TRIANGLE UROLOGY ASSOCIATES, 844-367-7899 ATTN: ❑AVIN ASSUREDPARTNERS OF NC LLC 205 FRASIER ST. CL HANOVER CSCISTE 350 DURHAM, NC 27704 4505 FALLS OF NEUSE RD RALEIGH, NC 27609 Policy Period: Beginning and Ending at 12:01 a.m. Standard Time at the Location of the Described Premises. Business Type: CORPORATION (SINGLE). Mortgagee/Loss Payable- SEE ADDITIONAL INTEREST SCHEDULE Business of the Named Insured: OFFICE, In consideration of the premium, insurance is provided the Named Insured with respect to those premises described in the Schedule below and with respect to those coverages and kinds of property for which a specific Limit of Insurance is shown, subject to all of the terms of this policy including forms and endorsements made a part hereof: LOCATION SCHEDULE Described Premises: NO.001 001 205 FRASIER ST., ❑URHAM,NC 27704 NO.002 001 10321 LUMLEY RD. #201, RALEIGH, NC 27617 NO. 003 001 101 CONNER DRIVER,SUITE 201,CHAPEL HILL, NC 27514 SECTION I- PROPERTY LIMITS OF INSURANCE Loc No Oat Bldg No 001 Loc No 002 Bldg No 001 Loc No 003 Bldg No 001 Deductible Amount $ 11000 $ 11000 $ 11000 Building Amount $ 2,825,207 NOT COVERED NOT COVERED Valuation RC Business Personal $ 540,750 $ 129,780 $ 189,000 Property Valuation RC RC RC Business Income ACTUAL BUSINESS LOSS SUSTAINED NOT EXCEEDING 12 CONSECUTIVE MONTHS Business Interne Excluded 1 None 124 hours 148 hours 172 hours Waiting.Period 48 HOURS ^^_ SECTION II -LIABILITY LIMITS OF INSURANCE _--_—_ Liability and Medical Expenses Limits of Insurance: Except for Damage to Premises Rented to You, each paid claim for the following coverages reduce the Amount of Insurance we provide during the applicable annual period. Please refer to SECTION If - LIABILITY, D. LIABILITY AND MEDICAL EXPENSES LIMITS OF INSURANCE, paragraph-4. of the Businessowners Coverage Form. Liability and Medical Expenses Li1nit $ 1,000,000 Per Occurrence $2,000,000 A re ate Medical Expenses $ 10,000 Each Person Fama a to Premises Rented to You 1 $ 500,000 All Perils M 'ate Issued: 06/13/2018 ORIGINALIINSURED Payment Type: CUST SERV CTR-DIRECT BILL 003404 391-1002 08 16 Page 1 of 2