PATIENT TRANSFER AGREEMENT This Patient Transfer Agreement (hereinafter "AGREEMENT") made and entered into this day of , 2011 by and between ST. RITA'S MEDICAL CENTER, an Ohio non-profit (hereinafter "HOSPITAL"). corporation (hereinafter "CENTER"), and WITNESSETH WHEREAS, St. Rita's Medical Center serves as a Regional Referral Center to provide immediate care and stabilization of Major Trauma related injuries, with appropriate transfer agreements for selected cases (Major bums, replants of extremities, and unstable Pediatric Trauma). WHEREAS, HOSPITAL is an acute care institution which may from time to time have a need to transfer a trauma patient to CENTER for treatment when it has been determined that such a transfer would be in the best interest of the patient: and WHEREAS, CENTER and HOSPITAL have determined that it would be in the best interest of patient care to enter into a transfer agreement to set forth the procedures for transfer of patients between the respective institutions when there is a need to transfer a patient pursuant to the Emergency Medical Treatment And Active Labor Act (EMTALA). NOW, THEREFORE, in consideration of the mutual covenants and agreements herein contained, and for other valuable consideration, the receipt and sufficiency of which is hereby acknowledged, CENTER and HOSPITAL agree as follows: 1. Purpose of Agreement: CENTER agrees to maintain a twenty-four (24) hour per day medical center to which HOSPITAL may transfer patients requiring treatment. CENTER's Medical Staff will provide medical care to trauma patients transferred to CENTER within their scope of service and will provide consultation to those persons at referring hospital who seek to transfer patients to the CENTER. A patient who has an emergency medical condition and that has not been stabilized may be transferred if the transfer is an appropriate transfer. 2. Patient Transfer: The need for transfer of a patient from HOSPITAL to CENTER shall be determined by the patient's attending or treating physician. When such a determination has been made, HOSPITAL shall immediately notify CENTER of the need for a transfer. If CENTER, for some reason, is not able to accept such transfer, it will immediately notify the HOSPITAL and/or the referring physician. Following the contact by HOSPITAL, the Emergency Physician will, in consultations with the referring physician, determine appropriateness of the patient's transfer based on the report and may assist with making the arrangements for the appropriate mode of transport. 3. Provision of Information: CENTER shall provide HOSPITAL with the names or classifications of persons authorized to initiate, confirm, and accept the transfer of patients on behalf of CENTER. CENTER shall state specifically where transferring patients are to be delivered at its premises. 4. Patient Records and Personal Effects: HOSPITAL agrees to provide medical and administrative information to accompany the patient to the CENTER. The information shall include, when appropriate, the following: A. B. C. D. E. F. G. H. I. J. K. Patient's name, address, hospital number, age, and name, address, and telephone number of next of kin; Patient's third party billing data; History of the injury or illness; Condition on admission; Vital signs pre-hospital, during stay, and at time of transfer; Treatment provided to patient, including medications given and route of administration; Laboratory and x-ray finds, including films; Fluids given, by type and volume; Name, address, and phone number of physician referring patient; Name of physician in HOSPITAL to whom patient is to be transferred; and Name of physician at HOSPITAL who has been contacted about patient. HOSPITAL agrees to supplement the above information as necessary for the maintenance of the patient during transport and treatment upon arrival at CENTER. The records described above shall be placed in the custody of the person in charge of the transport who shall sign a receipt for the medical records and the patient's valuables and personal effects and in turn shall obtain a receipt from the CENTER when it receives the records and the patient's valuables and personal effects. The HOSPITAL should also send copies of records that were not available at the time of transport. 5. Transfer Consent: HOSPITAL shall have responsibility for obtaining the patient's consent for the transfer to CENTER prior to the transfer, if the patient is competent. If the patient is not competent, HOSPITAL shall obtain a family member's, or significant other's consent; or the certification of the physician or qualified medical provider that the benefits of transfer outweigh the risk. A patient may also be transferred at his/her request. 6. Payment for Services: Each institution shall be responsible only for collecting its own payment for services rendered to the patient. No clause in this Agreement shall be interpreted to authorize either institution to look to the other institution to pay for services rendered to a patient transferred by virtue of the Agreement, except to the extent that such liability would exist separate and apart from this Agreement. 7. Transportation of Patient: HOSPITAL shall have responsibility for arranging transportation of the patient to the CENTER, including selection of the mode of transportation and providing appropriate health care practitioner (s) to accompany the patient. CENTER's responsibility for the patient's care shall begin when the patient is admitted to CENTER. After it has been determined that a transfer from HOSPITAL to CENTER is appropriate and necessary for the care of a patient, the CENTER, through its physicians and staff members, may assist the HOSPITAL in determining the appropriate method of transportation for and the level of care that will be necessary during the transfer. CENTER's Life Flight services may be considered by HOSPITAL in determining a mode of transport. 8. Confidentiality: C E N T E R a n d H O S P I T A L a g r e e t o m a i n t a i n t h e confidentiality of information pertaining to patients in accordance with all applicable laws. The termination of this agreement shall have no effect on the obligation contained in this clause. 9. Joint Commission: Hospital agrees that in performing services pursuant to this agreement, Hospital, its managers, employees, and contractors shall at all times act in accordance with (i) all applicable state and federal law, regulations, and requirements; (ii) generally acceptable industry standards, including without limitation, the Joint Commission and other applicable accrediting, regulating and licensing agencies or boards; (iii) the Ethical and Religious Directives for Catholic Healthcare Services; and all applicable Hospital Rules, regulations, standards, and policies. 10. Insurance: Each party agrees to maintain medical, professional, and general liability insurance or an equivalent program of self-insurance with minimum limits of $1 million per occurrence, with a general annual aggregate of $3 million applying. Evidence of insurance coverage shall be provided upon request. 11. Indemnification: Each party agrees that it shall indemnify and hold harmless the other parties, their corporate affiliates, officers, trustees, employees, agents, successors, and assigns, against any and all claims, injuries, demands or judgments arising out of the action or omission of the indemnifying party. 12. Independent Contractor Status: Both institutions are independent contractors. Neither institution is authorized or permitted to act as an agent or employee of the other. Nothing in this Agreement shall in any way alter the freedom enjoyed by either institution, nor shall it in any way alter the control of the management, assets, and affairs of the respective institutions. Neither part, by virtue of this Agreement, assumes any liability for any debts or obligations of either a financial or a legal nature incurred by the other party to this Agreement. 13. Liability: Each institution shall be responsible for its own acts and omissions and shall not be responsible for the acts and omissions of the other institutions. 14. Continuing Education: CENTER Trauma Service Physicians, Trauma Program Manager, specialists, such as respiratory therapists, developmental therapists, social workers, OT, PT, and nutritionists will be available to provide trauma educational programs at HOSPITAL. 15. 16. Referrals to Alternative Trauma Services: In those instances when CENTER trauma transports are necessary and CENTER is on Trauma Diversion, Center shall, in consultation with the referring physician, assist in arranging transportation of the patient to an appropriate alternative facility. Term: This Agreement shall commence on the day of and shall continue for a period of one year, and thereafter it shall be renewed automatically for successive periods of one (1) year, unless sooner terminated as herein provided. 17. Termination: A. Voluntary Termination: This. Agreement may be terminated by either party for any reason, by giving thirty (30) days' written notice of its intention to withdraw from this Agreement, and by ensuring the continuity of care to patients who already are involved in the transfer process. To this end, the terminating party will be required to meet its commitments under the Agreement to all patients for whom the other party has begun the transfer process in good faith. B. Involuntary Termination: This Agreement shall be terminated immediately upon the occurrence of any of the following: 1. 2. 3. 4. 18. Either institution is destroyed to such an extent that the patient care provided by such institution cannot be carried out adequately: Either institution loses its license or JCAHO accreditation: Either institution no longer is able to provide the service for which this Agreement was sought: Either institution is in default under any of the terms of this Agreement. Maintenance of Books and Records. To the extent Section 952 of the Omnibus Reconciliation Act of 1980 (Public Law 96-499) is found applicable to this Agreement, until the expiration of four years after the furnishing of service pursuant to this Agreement, Business Associate agrees to make available upon written request to the Secretary of Health and Human. Services, or upon request to the Comptroller General, or to any of their duly authorized representatives, this Agreement, and books, documents and records of the Business Associate that are necessary to certify the extent of any costs of Health Facility arising from this Agreement. Further, if Business Associate carries out any of its duties arising from this Agreement through a subcontractor, with a value or cost of Ten Thousand Dollars ($10,000) or more over a 12-month period, with a related organization, such subcontract shall contain a clause to the effect that until the expiration of four years after the furnishing of such services pursuant to such subcontract, the related organization shall make available, upon written request to the Secretary of Health and Human Services, or upon request to the Comptroller General, or any of their duly authorized representatives, the subcontract, books, documents, and records of such organization that are necessary to verify the nature of extent of such costs. 19. Non-waiver: No waiver of any term or condition of this Agreement by either party shall be deemed a continuing or further waiver of the same term or condition or a waiver of any other term or condition of this Agreement. 20. Governing Law: This Agreement is made and entered into in the State of Ohio and shall be governed and construed in accordance with the laws of Ohio. 21. Assignment: This Agreement shall not be assigned in whole or in part by either party hereto without the express written consent of the other party. 22. Invalid Provision: In the event that any portion of this Agreement shall be determined to be invalid or unenforceable, the remainder of this Agreement shall be deemed to continue to be binding upon the parties hereto in the same manner as if the invalid or unenforceable provision were not a part of this Agreement. 23. Amendment: This Agreement may be amended at any time by a written agreement signed by the parties hereto. 24. Notice: Any notice required or allowed to be given hereunder shall be deemed to have been given upon deposit in the United States mail, registered or certified, with return receipt requested and addressed to the party to this Agreement to whom notice is given. 25. Entire Agreement: This Agreement constitutes the entire agreement between the parties and contains all of the agreements between them with respect to the subject matter hereof and supersedes any and all other agreements, either oral or in writing, between the parties hereto with respect to the subject matter hereof. 26. Binding Agreement: This Agreement shall be binding upon the successors or assigns of the parties hereto. 27. Authorization for Agreement: The execution and performance of this Agreement by each institution has been duly authorized by all necessary laws, resolutions, or corporate actions, and this Agreement constitutes the valid and enforceable obligations of each institution in accordance with its terms. Headings: The headings to the various sections of this Agreement have been inserted for convenience only and shall not modify, define, limit, or expand express provisions of this Agreement. 28. 29. Gender: Throughout this instrument, wherever the context requires or permits, the neuter gender shall be deemed to include the masculine and feminine, and the singular number, the plural, and vice versa. 30. Counterparts: This Agreement may be executed simultaneously in one or more counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. IN WITNESS WHEREOF, CENTER and HOSPITAL have hereunto caused this Agreement to be executed as by law provided, the day and year first above written. ST. RITA'S MEDICAL CENTER., an Ohio non-profit corporation By: ________________________________________________ “CENTER” Title/Date By: ________________________________________________ "HOSPITAL" Title/Date
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