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HomeMy WebLinkAbout2019-643-E Health - Patagonia Health software amendment DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 .4 PatagoniaHealth http://www.patagoniahealth.com Sales Agreement Addendum Addendum:This is an add-on addendum to the Sales Agreement dated October 24, 2012 and holds all of the same terms and conditions therein. Customer:Orange County Health Department Date:August 7th, 2019. Addendum Effective Date:October 1st,2019. (OCHD has access to complete end to end EHR, as previously agreed,till 30th Sep 2019.Thus,this addendum effective date is after 30th Sep 2019.) Functionality Description:Orange County Health Department OCHD has been using Patagonia Health EHR software solution since 2012. OCHD has elected to switch to UNC affiliated EPIC EHR. However, OCHD wishes to continue to use Patagonia Health Pharmacy App only.This addendum and price only includes Pharmacy App and associated functionality which is only a subset of complete end to end EHR which OCHD has had access since 2012. This excludes the use of any billing or electronic prescription functionality. Term: This Agreement will run for an initial term of three months from the Service Effective Date. OCHD has a choice to use and pay for system on a month to month basis. Payment for first three months paid in advance. All fees including monthly subscription fees and training will increase by 4% at the beginning of each annual anniversary date.All payments made are non-refundable. Cancellation: OCHD may cancel the agreement at anytime with a three month written notice for October through December 2019 and with a 30 day written notice after that period. Reactivation post cancellation will incur an initiation fee. Functionality and Costs: Description One Time: Upfront Ongoing:Monthly Initial to Accept or Costs Costs mark"X'to Decline Functionality: $795.00 Initi os apt or Pharmacy App for the mar cline health department. Includes Surescript certified electronic prescription solution and support for up to fifteen (15)users. Additional users can be added at an additional cost of $30/month/user. Minimum cost is $795/month Page 1 of 2 �onfidential.Copyright© 2017 Patagon- . e� 15100 Weston Parkway,Suite 204,Cary, NC 27513 1 919.238.4780 En , info@patagoniaheaIth.com DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 .4 PatagoniaHealth http://www.patagoniahealth.com Implementation $0 Init Lel -ept or ma ecline Initial MArrept or Data Extraction $15,000 ma L6� cline Remote Training: Initial to Accept or $100/hr. Minimum 2 mark X to Decline hours to be purchased. X If applicable#of hours: Training: Initial to Accept or On site, in person, mark X to Decline Training:$1500/day. X If applicable#of days: Costs: • Initial payment(3 months at$795/month):$2,385. • On-going Monthly Payment: $795/month • Additional Cost for training, if selected will be added to Initial payment. Payment Terms: 1. Payment Plan:All costs paid in advance. Initial payment billed upon execution of this Addendum Agreement.All payments due within 30 days of invoicing. CUSTOMEP o Patagonia H--1 c 1e u dhy: E Signature:.16'Q �37s94e755E477.. Signature: S631E74E8790412 Name: Bonnie Hammersley Name:Amos Slaymaker Title: County Manger Title:Vice President, Sales& Marketing Page 2 of 2 Confidential.Copyright© 2017 Patagonia Hea'' 15100 Weston Parkway,Suite 204,Cary, NC 27513 1 919.238.4780 1 En , info@patagoniaheaIth.com DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 *4 PatagoniaHealth http://www.PatagoniaheaIth.com atago nialJ-li eal th Data Extract Options Contacts: Ashok Mathur, Patagonia Health Inc. CEO and Co-founder 15100 Weston Parkway, ashok(cDpatagoniahealth.com Suite 204, Ph: 919 622 6740 www.PatagoniaHealth.com Cary, NC 27513 DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 44 PatagoniaHealth http://www.patagoniahealth.com 1 Patient demographics in Excel spreadsheets Included in product maintenance CCDA export as required under Meaningful Use stage 2 guidelines. 2 Users can generate CCDA for complete patient Included in product medical history. maintenance Complete set of documents uploaded into Patagonia Health EHR. These are scanned and uploaded documents for 3 every patient. Documents will be uploaded to a SFTP site. Documents will be named to include patient name, MRN and document type. $5,500 $10,500 One-time database dump. MS SQL 2012 database backup uploaded to a SFTP site. $150/hour for additional consulting (minimum 8 4 See "Data Fields included" for included data hours) Assistance with data queries, data analysis, data comparison, migration review will consume consulting hours Monthly database dump - minimum 12 month $5,000 Setup fee contract $500 monthly fee $150/hour for additional See "Data Fields included" for included data consulting 5 Database backup files will be provided once month Includes data dictionary to explain tables Includes 8 hours of consulting support to help extract or map data Data Fields Included: Data extract will include database tables from following EHR elements 1. Patient demographics 2. Patient insurance 3. Patient Sliding fee scale 4. Appointments 5. Patient social, medical, family history (ICD-9, ICD-10 CM, CPT codes as applicable) Page 2 of )nfidential. CopyrightO 2018 Patagonia Health, Inc DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 44 PatagoniaHedlth http://www.patagoniahealth.com 6. Immunizations (CVX, CPT Codes as applicable) 7. Problems (ICD-9, ICD-10 CM codes as applicable) 8. Allergies (SNOMED, FDB codes as applicable) 9. Medications (FDB Codes) 10. Lab results 11. Orders and Procedures. lab, imaging orders (CPT codes) 12. Patient vitals 13. Encounter notes (free text, selected elements: Yes/No, Normal/Abnormal etc.) 14. TB Forms 15. Maternal Health forms 16. BCCCP forms 17. WISEWOMAN forms 18. Electronic super bills (ICD-9, ICD-10 CM, CPT codes as applicable) 19. Billing: Primary, secondary insurance. Amount charged for every service. Amount paid by public/private insurance for each service These tables correspond to the widgets and tables you see in the EHR. Data extract will be provided as a MS SQL 2012 database backup file. Page 3 of 3 Confidential. CopyrightO 2018 Patagonia Health, Inc. DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 r,2/15/2019 TE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MeliSSa Streeter NAME: Tompkins Insurance Agencies, Inc. VHCONNo Ext: (215)274-7408 F IC No;688-339-6337 1240 Broadcasting Road ADDRESS:mstreeter@tompkinsfinancial.com P.O. Box 6707 INSURER(S)AFFORDING COVERAGE NAIC# Wyomissing PA 19610 INSURERA:Sentinel Iris CO LTD 11000 INSURED INSURER B:Hartford Fire Insurance Co. 19682 PATAGONIA HEALTH INC. INSURER C: 15100 Weston Parkway INSURERD: Suite 204 INSURERE: Cary NC 27513 INSURERF: COVERAGES CERTIFICATE NUMBER:18-19 MASTER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR SD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DA AGE To RENTE A CLAIMS-MADE FX7 OCCUR PRE M IS ES Ea occur ence $ 50,000 39SBMUQ5601 6/17/2018 6/17/2019 MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (COMBINEDEa accidentS INGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS AUTOS 39SBMUQ5601 6/17/2018 6/17/2019 BODILY INJURY(Per accident) $ NON-OWNED Pera ciT DAMAGE HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECU I— E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Technology E&O/Cyber 39TE033492319 2/13/2019 2/13/2020 Each Wrongful Act $5,000,000 Aggregate $5,0 0 0,0 0 0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE David Boyce/MNS s_ -�J`'? ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025rgmami DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 4C__"" DATE(MM/DD/YYYY) llh� CERTIFICATE OF LIABILITY INSURANCE 05/19/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: TOMPKINS INSURANCE 39320246 PHONE (866)467-8730 Fax (888)443-6112 (A/C,No,Ext): (A/C,No): PO BOX 6707 E-MAIL ADDRESS: WYOMISSING PA 19610 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: The Sentinel Insurance Company 11000 INSURED INSURER B: PATAGONIA HEALTH,LLC INSURERC: 15100 WESTON PKWY STE 204 CARY NC 27513-2129 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED $1 000 000 PREMISES Ea occurrence X General Liability MED EXP(Any one person) $10,000 A 39 SBM UQ5601 06/17/2019 06/17/2020 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $2,000,000 JECT FXI OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1 000 000 Ea accident ANY AUTO BODILY INJURY(Per person) A ALL OWNED SCHEDULED 39 SBM UQ5601 06/17/2019 06/17/2020 BODILY INJURY(Per accident) AUTOS AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS X AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE MADE DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY AT ER ANY Y/N E.L.EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L.DISEASE-EA EMPLOYEE (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below A EMPLOYMENT PRACTICES 39 SBM UQ5601 06/17/2019 06/17/2020 Each Claim Limit $10,000 LIABILITY Aggregate Limit $10,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION Patagonia Health Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 202 MIDENHALL WAY BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED CARY NC 27513 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 PATAH EA-01 B B LOSS CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) `� 6/25/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: AP Intego Insurance Group,LLC PHONE FAX 1601 Trapelo Rd Suite 280 (A/C,No,Ext): (A/C,No): Waltham, MA 02451 ADDRESS:support@apintego.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Travelers*** 99999 INSURED INSURER B: Patagonia Health, Inc. INSURER C: 202 Midenhall Way INSURERD: Cary, NC 27513 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR IN SD W D COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F7 OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F7 JECOT- LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PerOaccitlenDAMAGE $ AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ A W KERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER UBON691503 5/1I2019 5l1/2020 100,000 ANY PROPRIMBER/PXCLUDE/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF COVERAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV E ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD