HomeMy WebLinkAboutSamer Alaiti, MD - 2021-04-01 PROP'ESSONAL SERVICES CONTRACT BETWEEN
THE CITY OF HUNTINGTON BEACH AND
Amer Alaiti, mp
POR
INDEPENDENT MEDICAL EVALUATIONS WITH
RESPECT TO WORKERS' COMPENSATION CLAIMS
THIS AGREEMENT("Agreement") is trade and entered into by and between the City of
Huntington Bcach, a municipal corporation of the State of California, hereinafter referred to as
"CITY,"and Sa r.4 A--a<� Nn
an Individual, hereinafter referred to as PHYSICIAN.„
WHEREAS, CITY desires to engage the services of a physician to provide independent
medical evaluations with respect to workers' conpetlsation Claims; and
Pursuant to documentation on file in the office of the City Clerk, the provisions of the
Huntington Beach Municipal Code, Chapter 3,03, relating to procurement of professional service
contracts have been complied with; and
PHYSICIAN has been selected to perform said services,
NOW, THEREFORE, it is agreed by CITY and PHYSICIAN as follows:
1. SCOPE OF SERVICES
PHYSICIAN shall provide all services as described in Exhibit "A," which is
attached hereto and incorporated into this Agreetucnt by this reference. These services shall
sometimes hereinafter be referred to as the "PROJECT." /1k0
PHYSICIAN hereby designates AL,A� Vwho sliall represent it
and be its sole contact and agent in till consultations with CITY during the performance of this
Agreement. J
APPROVED AS TO FORM/ Fc,M- tQQ�tp
BY
11CHAEL E. GATES
CITY ATTORNEY
12-3137/tME Standard Contract- Revised I CITY OF HUNTINGTON BEACH
2. CITY STAFF ASSISTANCE
CITY shall assign a staff coordinator to work directly with PHYSICIAN in the
performance of this Agreement,
3. TIME OF PERFORMANCE
Time is of the essence of this Agreement, The services of PHYSICIAN are to
conuuenee on gb 1 I 11 2 07 ] (the "Commencement Date"). This Agreement shall
automatically renew three (3) years from the Commencement Date, unless terminated as provided
herein. The time for pet formance of the tasks identified in Exhibit"A" are generally to be shown
in Exhibit "A." This schedule may be amended to benefit the PRO.IEC'T if mutually agreed to in
writing by CITY and PHYSICIAN,
In the event the Commencement Date precedes the Effective Date, PHYSICIAN
shall be bound by all terms and conditions as provided herein.
4. COMPENSATION
In consideration of the performance of the services described herein, CITY agrees
to pay PHYSICIAN, on a time and materials basis at the rates specified in Exhibit "I3," attached
hereto and incorporated by reference into this Agreement, a fee, including all costs and expenses,
riot to exceed Twenty-nine Thou sand Nine-Hundred Dollars ($29,900.00).
5; F,X'1'RA WORIC
In the event CITY requires additional services not included in Exhibit "A", or
changes in the scope of services described in Exhibit"A," PIYSICIAN will undertake such work
only after receiving written authorization ffonr CITY. Additional compensation for such extra
work shall be allowed only if the prior written approval of CITY is obtained.
12-3187I1MB Standard Contract - Revised 2
G, METHOD OF PAYMENT
PHYSICIAN shall be paid pursuant to the terms of Cxhibit "B."
7, DISPOSITION OF PLANS, ESTIMATES AND OTHER DOCUMENTS
PHYSICIAN agrees that title to till materials prepared hereunder, including, but not
limited to: all original drawings, designs, reports, both field and office notices, calculations,
computer code, language, data or programs, maps, memoranda, letters find other documents, shall
belong to CITY, and PHYSICIAN shall turn these materials over to CITY upon termination of
this Agreement or upon PROJECT completion, whichever shall occur first, These materials may
be used by CITY as it sees fit,
S. HOLD HARMLESS
PHYSICIAN hereby agrees to protect,defend, indemnify and hold harmless CITY,
its officers, elected or appointed officials, employees, agents and volunteers front and against ally
and all claims,damages,losses,expenses,judgments,demands and defense costs (including without
limitation, costs and fees of litigation of every nature or liability of any kind or nature) arising out
of or in connection with PHYSICIAN's (or PHYSICIAN's subcontractors, if any) negligent (or
alleged negligent)performance of this Agreement or its failure to comply with tiny of its obligations
contained in this Agreement by PHYSICIAN, its officers, agents or employees except such loss or
damage which was caused by the sole negligence or willful misconduct of CITY. PHYSICIAN will
conduct till defense at its sole cost and expense and CITY shall approve selection of PHYSICIAN's
counsel. This indemnity shall apply to all claims and liability regardless of whether ally insurance
policies are applicable, The policy limits do not act as limitation upon the amount of indemnification
to be provided by PHYSICIAN.
19.-s 187/1ME Standard Contract- Revised 3
9. PROFESSIONAL LIABILITY INSURANCE
PHYSICIAN shall obtain and furnish to CITY a professional liability insurance
policy covering the work performed by it hereunder. This policy shall provide coverage for
PI-IYSICIAN's professional linhilily in an amount not less than One Million Dollars
($1,000,000.00) per occurrence and in the aggregate. The above-mentioned insurance shalt not
contain a self:insured retention without the express written consentof CITY; however an insurance
policy "deductible" of Ten Thousand Dollars ($10,000,00) or less is permitted. A claims-made
policy shall be acceptable if the policy further provides that:
A. The policy retroactive date coincides with or precedes the initiation of the
scope of work (including subsequent policies purchased as renewals or
replacements).
B. PHYSICIAN shall notify CITY of circumstances or incidents dial might
give rise to fixture claims.
PHYSICIAN will make every effort to maintain similar insurance during the
required extended period of coverage following PROJECT completion, If insurance is terminated
for any reason,PHYSICIAN agrees to purchase an extended reporting provision o(-at least two (2)
years to report claims arising from work performed in connection with this Agreement.
If PHYSICIAN fails or refuses to produce or maintain the insurance required by
this section or fails or refuses to furnish the CITY with required proof that insurance has been
procured and is in force and paid for, the CITY shall have the right, at the CITY's election, to
forthwith terminate this Agreement. Such termination shall not affect PHYSICIAN's right to be
paid for its time and materials expended prior to notification of termination. PHYSICIAN waives
12-3 t87/INIF Standard Contract- Revised 4
the right to receive compensation and agrees to indemnify the CITY for any work performed prior
to approval of insurance by the CITY.
10, CERTIFICATES OF INSURANCE
Prior to commencing performance of the work hereunder, PHYSICIAN shall
furnish to CITY certificates of insurance subject to approval of the City Attorney evidencing the
foregoing insurance coverage as required by this Agreement;the certificate shall:
A. provide the name and policy number of each carrier and policy;
D. state that the policy is currently in force; and
C. promise that such policy shall not be suspended, voided or canceled by
tither party, reduced in coverage or in limits except after thirty (30) days'
prior written notice; however,ten(10)days' prior written notice in the event
of cancellation for nonpayment of premium.
PHYSICIAN sliall maintain the foregoing insurance coverage in force until the
work under this Agreement is fully completed and accepted by CITY.
The requirement for carrying the foregoing insurance coverage shall not derogate
from PHYSICIAN'S defense, hold harmless and indemnification obligations as set forth in this
Agreement. CITY or its representative shall at all times have the right to demand the original or a
copy of (lie policy of insurance, PHYSICIAN shall pay, in a prompt and timely manner, the
premiums on [lie insurance liereinabove required.
11, INDEPENDENT CONTRACTOR
PHYSICIAN is, and shall be, acting at all tines in the performance of this
Agreement as an independent contractor herein and not as an employee of CITY. PHYSICIAN
shall secure at its own cost and expense, and be responsible for any and all payment of all taxes,
12.3187/1ME Standard Contract- Revised 5
social security, state disability insurance compensation, unemployment compensation and other
payroll deductions for PHYSICIAN and its officers, agents and employees and all business
licenses, if any, in connection with the PROJECT and/or the services to be performed hereunder.
12, TERMINATION OF AGREEMENT
All work required hereunder shall be performed in a good and workmanlike
manner. CITY may terminate PHYSICIAN's services hereunder at any time with or without cause,
and whether or not the PROJECT is fully complete. Any termination of this Agreement by CITY
shall be made in writing, notice of which shall be delivered to PHYSICIAN as provided herein.
In the event of termination, all finished and unfinished documents, exhibits, report, and evidence
shall, tit (lie option of the CITY, become its properly and shall be promptly delivered to it by
PHYSICIAN,
13. ASSIGNMENT AND DELEGATION
This Agreement is a personal service contract and the work hereunder shall not be
assigned, delegated or subcontracted by PHYSICIAN to any other person or entity without the
prior express written consent of CITY. If an assignment, delegation or subeontraet is approved,
all approved assignees, delegates and subcontractors must satisfy the insurance requirements as
set forth in Sections 9 and 10 liereinabove.
14. COPYRIGHTS/PATENTS
CITY shall own all rights to ally patent of,copyright on any work, itenn or material
produced as a result of this Agreement.
15, CITY EMPLOYEES AND OFFICIALS
PHYSICIAN shall employ no CITY official nor any regular CITY employee in the
work performed pursuant to this Agreement. No officer or employee of CITY shall have any
12-3187/IMB Standard Conti-act- Revised 6
Financial interest iii this Agreement in violation of llie applicable provisions of the California
Government Code,
16. NOTICES
Any notices, certificates, or other communications hereunder shall be given either
by personal delivery to PHYSICIAN's agent(as designated in Section I hereinabove) or to CITY
as (lie situation shall warrant, or by enclosing the same in a sealed cnvelope,.postage prepaid, and
depositing the same in the United States Postal Service, to the addresses speeifled below. CITY
and PITYSICIAN may designate different addresses to which subsequent notices, certificates or
other communications will be sent by notifying the other party via personal delivery, a reputable
overnight carrier or U.S. certified mail-return receipt requested:
TO CITY: TO 111-IYSICIAN:City of Huntington Beach •I 4LAi 6 TTn`0
ATTN: Risk Manager e o _�a�, , �ry /jLv d .
2000 Main Street L„ A -, r d Y o�
Huntington Beach, CA 92648 3'r
17. CONSENT
When CfTY's consent/approval is required under this Agreement, its
consent/approval for one transaction or event sliall not be deemed to be a consent/approval to any
subsequent occurrence of the same or any other transaction or event.
18. MODIFICATION
No waiver or modificntion of any language in this Agreement shall be valid unless
in writing and duty executed by both parties.
12-3187/1ME Standard Contract - Revised 7
19. SECTION HEADINGS
The titles, captions, section, paragraph and subject headings, and descriptive
phrases at the beginning of the various sections in this Agreement are merely descriptive and are
included solely for convenience of reference only and are not representative of matters included
or excluded from such provisions, and do not interpret, define, limit or describe, or construe the
intent of the parGcs av affect the construction or interpretation of tiny provision of this Agreement.
20. INTERPRETATION OF THIS AGREEMENT
The language of all parts of this Agreement shall in all cases be construed as a
whole, according to its fair n.cauing, and not strictly for or against any of the parties. If any
provision of this Agreement is held by an arbitrator or court of competent jurisdiction. to be
unenforceable, void, illegal or invalid, such holding shall not invalidate or affect the remaining
covenants and provisions of this Agreement. No covenant or provision shall be deemed dependent
upon any other unless so expressly provided here. As used in this Agreement, the maseuline or
neuter gender and singular or plural number shall be deen.ed to include the other whenever the
context so indicates or requires. Nothing contained herein shall be construed so as to require the
commission of any act contrary to law, and wherever there is any conflict between any provision
contained herein and any present or future statute, law, ordinance or regulation contrary to which
the parties have no right to contract, then the latter shall prevail, and the provision of this
Agreement which is hereby affected shall be curtailed and limited only to the extent necessary to
bring it within the requireutcnts of the law.
21. DUPLICATE ORIGINAL
'fhc original of this Agreement and are or more copies hereto have been prepared
and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of
12.31 B7AME Standard Contract - Revised 8
the date of its execution and delivery, be deemed an original. Each duplicate original shall be
deemed an original instrument as against any party who has signed it.
22, IMMIGRATION
PHYSICIAN sliall be responsible for full compliance with the immigration and
i
naturalization laws of the United States and shall, in particular, comply with the provisions of the
Untied States Code regarding employment verification.
23. LEGAL SERVICES SUBCONTRACTING PROHIBITED
PHYSICIAN and CITY agree that CITY is not liable for payment of any
subcontractor work involving legal services, and that such legal services are expressly outside the
scope of services contemplated hereunder. PHYSICIAN understands that pursuant to Flwrlington
Beach 0 1y Charter Section 309, the City Attorney is the exclusive legal counsel for CITY and
CITY shall not be liable for payment of any legal services expenses incurred by PHYSICIAN.
24, ATTORNEY'S FEES
In the event suit is brought by either party to construe, interpret and/or enforce the
terms and/or provisions of this Agreement or to secure the perfornnance hereof, each party sliall
bear its own attorncy's fees, such that file prevailing party shall not be entitled to recover its
attorney's fees from the non-prevailing party,
25. SURVIVAL
Terms and conditions of this Agreement, which by their sense and context survive
(lie termination of this Agreement, shall so survive,
26, GOVERNING LAW
This Agreement shall be governed and construed in accordance with the laws of the
State of California.
12.3187/IML Standard Contract- Revised 9
27. SIGNATORIES
Each undersigned represents and warrants that its signature herein below has tile,
power, authority anti right to bind their respective parties to each of the terms of this Agreement,
and shall indemnify CPfY fully for any injuries or damages to CITY in the event that such
I
authority or power is riot, in fact, held by the signatory or is withdrawn.
PHYSICIAN's initials
28. ENTIRETY
The parties acknowledge and agree that they are catering into this Agreement freely
and vohmtarily following extensive arm's length negotiation, and that each has had the opportunity
to consult with legal counsel prior to executing this Agreement. The.parties also acknowledge and
agree that no representations, induccments, promises, agreements or warrantics, oral or otherwise,
have been made by that party or anyone, acting on that party's behalf, which are not embodied in
this Agreement, and that that party has not executed this Agreement in reliance on any
representation, iaducenieul, promise, agreement, warranty, fact or circumstance not expressly set
forth in this Agreement. This Agreement, and the attached exhibits, contain the ortire agreement
between the parties respectirig the subject matter of this Agreement and supersede all prior
understandings and agrcctueuts whether oral or in writing between the parties respecting the
subject matter hereof.
29. EFFECTIVE"DATE
This Agreement shall be effective on the date of its approval by the City Attorney.
This Agreement shall expire when terminated as provided hereof.
IN WITNESS WHEREOF, the parties hercto have caused this Agreement to be executed
by and through their authorized officers.
12-3 t8711MB Standard Contract -Revised 10
PHYSICIAN
:57a v^a A CITY OF HUNTINGTON BEACH, a
TYPOPrtiNT PPHHYSSTLIAN'S`MAW municipal corporation of the State of California
--- S�g11fl�UPE
biI etor of Human Resources
APPROVED AS TO FORM;
`KCity Attorney
Receive and File�> -
_
City Clerk
I2-3I87/IMB Standard Contract- Revised 11
PROFESSIONAL SERVICES CONTRACT' BETWEEN
THE CITY OF HUNTINGTON BEACI.1 AND
S4mer Aluifi ff p
FOR
INDEPENDENI'MEDICALEVALUATONS WITH
RESPECT TO WORKERS' COMPENSATION CLAIMS
Table of Contents
1 Scope of Services.....................................................................................................1
2 City Staff Assistance................................................................................................2
3 Time of Performance ...............................................................................................2
4 Compensation ..........................................................................................................2
5 Extra Work.............................................. *..........
.....................
....
...........
............I...2
6 Method of Payment...................................................................... ...........................3
7 Disposition of Plans,Estimates and Other Documents ...........................................3
8 Hold Harmless ..........................-........................,...............;....................................3
9 Professional Liability Insurance..............................................................................4
10 Certificates of Insurance.......................................... ...........................r...................5
11 Independent Contractor............................................................................................5
12 Termination of Agreement.......................................................................................6
13 Assignment and Subconlracting ...........................................-.................................6
14 Copyrights/Patents...................................................................................................6
15 City Employees and Officials..................................................................................6
16 Notices ...................................................................................... „.......7
17 Consent ....................................................................................................................7
18 Modification.............................................................................................................7
19 Section Ileadings .....................................................................................................8
20 Interpretation of this Agreement..............................................................................8
21 Duplicate Original....................................................................................................8
22 Immigration................................................................... ............. ............................9
23 Legal Services Subcontracting Prohibited.....*.......................I...—I.....II—I,.....I.....,.19
24 Attorney's Fees...................................................I.............................I.......................9
25 Survival....................................................................................................................9
26 Governing Law ................................................................................................ .......9
27 Signatories................................................................................................................10
28 Faitirety.....................................................................................................................10
29 Effective Date ..........................................................................................................10
12-3187/75880
EXIII131T "A"
STATEMENT OF WORK:
1) AOE—COE EXAMS (exams for the determination of industrial causation).
i
2) Evaluation for necessity of approprinte medical treatment.
3) Assessment of employee's present ability to return to work, whether fiill duty or
modified.
4) Advise on condition of maximum medical improvement status,
5) Determinc nature and extent of permanent disability, including factors of apportionment
and need for iimue medical care.
6) Resolve utilization review disputes.
7) Determine the need for spinal surgery pursuant to Labor Code section 4062(b).
PHYSICIAN shall perform the evaluation in frill accordance with the standards dcfiried by the
Division of Workers' Compensation of the State of California and tlic AMA Guides to the
Evaluation of Permanent Impnirment, Fifth Edition, This requires a report of the injury, prior
status, clinical chronotogy, current status, and past medical history. The physical examination
will document all pertinent positive, negative, and non-physiological findings. For extremity
injuries, measurements must be documented bilaterally. Additionally, PHYSICIAN agrees to:
(i) provide that medical exams will be set within thirty (30) days of the(into of appointment
request, and (ii) prepare a written report of findings within thirty (30) days of the date of exam or
evaluation and provide a copy to (lie parties within said time frame,
12-3187/"15880
EXHIBIT "B"
Payment Schedule
1. Missed Appointments
• Fee: $503.75
• Code: MI,200
Aj)]Mes when:
• Interpreter does not appear for evaluation.
• Injured worker leaves before completion of the evaluation.
• Cancellation within 6 business days of the scheduled appointment.
2. Comprehensive Medical-Legal Evaluations
• Fee: $2,015.00
Code: M1,201
Applies to the initial evaluation or the first evaluation in an 18-month period.
• The evaluation includes review of up to 200 pages of records.
• It Must involve an examination of the employee.
• Review of records in excess of 200 pages is reimbursed at a rate of$3.00 per page.
3. Follow-up Medical-Legal Evaluations
• Fee: $1,316.25
• Code: ML202
Applies to any subsequent comprehensive evaluation within 18 months of the initial
evaluation.
• This fee includes review of up to 200 pages of records that were not reviewed as part of
the initial evaluation.
• Review of records in excess of 200 pages (records not reviewed at initial evaluation)
reimbursed at a rate of$3.00 per page.
4. Supplemental Medical-Legal Evaluations
Feet $650.00
• Code: M203
Does not involve an examination of the patient.
• Results in preparation of a narrative medical report.
• Review of records in excess of 50 pages reimbursed at a rate of$3.00 per page.
• Fees for a supplemental report are not allowed if:
o Records reviewed were provided to the physician for review before the initial or
follow-up evaluations.
o Supplemental report addresses an issue the parties asked the physician to address
in a prior coed-legal evaluation,
12-3197175880 1
5. Medical-Legal Testimony
• Pee: $455.00 per hour (or physician's usual and customary fee, if lower)
• Code: ML204
• Physician is entitled to.bill a minimum of 2 hours for deposition.
• If the deposition is canceled within fewer than 8 calendar days prior notice, physician is
entitled to bill I hour of time.
6. Medical-Legal Review of Sub Rosa Evidence
• Fee: $325.00 per hour (or physician's usual and customary fee, if lower)
• Code: ML205
• No minitnum time allotment.
• Physician must capture time spent reviewing evidence to the nearest quarter-hour,
verified wider penalty of perjury.
• The fee does not include production of a medical-legal report. The fee for time spent
reviewing the recording will be included in the billing for the initial, follow-up or
supplemental medical- report.
7. Court-Ordered Evaluations
• When a medical-legal evaluation is ordered by a Workers' Compensation Judge, the
Judge has authority and discretion to apply the appropriate modifier to that evaluation.
8. The parties agree that the City is not obligated to pay compensation to the PHYSICIAN
except for• agreed upon medical services and care. Failure of PHYSICIAN to provide a
written medical report within 30 days of the date of the exam subjects PHYSICIAN to non-
payment for services rendered.
9. PHYSICIAN billing shall conform to the requirements listed in section 9795 of Title 8 of
the California Code of Regulations. Charges for services rendered will be reviewed in
accordance with section 9795 to determine appropriate level of service.
10. City shall pay PHYSICIAN within forty-five (45) days following receipt from
PHYSICIAN of invoices for services rendered and for which payment has not previously
been made, provided that PHYSICIAN' shall submit all invoices within ninety (90) days
after the date of service.
12-3187/75880 2
AU
�\THEDOCTORSCOMPANY
CERTIFICATE OF INSURANCE Issue Date: 11/17/2020
Effective Date: otlov2M A Claims-Made Professional Liability Policy
First Named Insured: IMPORTANT NOTICE: This document is issued as
Samer Alalti MD a matter of information and does not confer rights
1100 S La Cienega Boulevard to any recipient. This document is not binding, is
Los Angeles, CA 90035 not part of the Policy described below, and does
not change or extend the coverage provided by that
Policy.
Insured: Samar Alaitl MD
Specialty: DER01 -Dermatology APPROVED AS TO FORM51
— —
Policy Number._ ®�nrFs
0073706 CrpF � To. 01101FAM
Retroactive Date: Departure Period:
01101/2003 From: WA To: WA
The Insured above is: Agency and Address:
® A Named Insured The Doctors Insurance Agency
❑ A Locum Tenens of California
❑ An Additional Insured 7700 Irvine Center Dive, Suite B00
Irvine, CA 92618
(800)720-9828
--- — LIMITS OF LIABILITY — —
Claim Limit: $1,000,000
Aggregate Limit: $3,000,000
I. locum Tenens and Additional Insureds share Limits of Liability with the applicable Named Insured.
It. Individuals who occupy a "slot"share Limits of Liability with all others who occupy the same "slot"during the
Policy Period.
III. Photocopies of this document are deemed as valid as the original.
IV. The Policy, including Endorsements, determines the coverage provided. Some Claims may not be covered
by the terms of the Policy, or may be subject to restrictions such as lower Limits of Liability.
V. If the Policy, or coverage for any person, is canceled for any reason or if the terms of the Policy are
changed, we will notify the First Named Insured (and any additional Named Insureds as required by
applicable state law). Coverage is not in effect unless and until all payments are received when due.
VI. If a Departure Period is indicated, the Policy will not respond to Probable Claim Events arising from
Professional Services Incidents or Review Incidents that take place during the designated period; however,
the Policy will respond if we receive a Claim Report during this period.
8
8
S
MPL003 (04/15) 104 Pagel of 1 MCO2003 31236704-00 Insured
185 Greenwood Head:P.O.Box 2900:Napa,CA 94558-0900:(707)226-0100:(800)421-2368:www.thedoctors.corn