HomeMy WebLinkAboutBrian Jacks, MD - 2021-04-01 FM fax Jul 29 2021 11:25am P001/015
PROFESSONAL SERVICES CONTRACT BETWEEN
THIS CITY OF HUNTINGTON BEACH AND
RriunjgGkS. MD
FOR
INDEPENDENT MEDICAL EVALUATIONS WITH
RESPECT TO WORKERS' COMPENSATION CLAIMS
THIS AGREEMENT("Agreement") is made 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 8At Asva)• IgC"/yGn individual, hereinafter referred to as"PHYSICIAN,"
WHEREAS, CITY desuxes to engage the services of a physician to provide independent
medical evaluations with respect to workors' compeosatiom claims; and
Pnrsuanl to documentation on file in the office of the City Clerk, the provisions of the
Hwrtington 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:
t. SCOPE OF SERVICES
PHYSICIAN shall provide all sccvices as described in Exhibit "A," which is
attached hereto Said incorporated into this Agreement by this reference, These services shall
sometimes hereinafter be referred to as the "PROJECT,"
PHYSICIAN hereby deuiguates Q�fw 7 t rn� , who shall represent it
and be its sole contact and agent in all consultations with CITY during the performance of tltis
Agreement.
APPROVED As To FORM
/�FOC
ev
�iICHAEr.E.GATES
CITY ATTORNEY
CITY OF HUNTINGTON aEACH
12-31671tME Standard Contract- Revised 1
Fax Jul 29 2021 11:25am P002/015
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 Agreeruertt. The services of PHYSICIAN are to
commence on April 2 Q? i (the "Commencement Date"). This Agreement shall
automatically renew three(3) years from the Commencement Date,unless tenninated as provided
herein. The time for performance of the tasks identified in Exhibit"A" are generally to be shown
in Exhibit "A." This schedule may be amended to benefit die PROJECT if mutually agreed to in
writing by CITY and PHYSICIAN.
In tlie event. the Coninieticenient Date precedes the Effective Dale, PHYSICIAN
shall be bound by all terms and conditions as provided herein-
4. CQMPENSAT10N
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 "B," attached
hereto and incorporated by reference into this Agreement, a fee, including all costs and expenses,
not to exceed Twenty-nine Thousand Nine-Hundred Dollars ($29,900.00).
S. EXTRA WORK
In the event CITY requires additional services not included in Exhibit "A", or
changes in the scope of services described in Exhibit"A," PHYSICIAN will undertake such work
only after receiving written authorization from CITY, Additional compensation for such extra
work shall M allowed only,if the prior written approval of CITY is obtained.
12-9187/itrt8 Standard Contract- Revised 2
Fax Jul 29 2021 11:25am P003/015
6. METHOD OF PAYMENT
PHYSICIAN shall be paid pursuant to die terms of Exhibit "$."
7. DISPOSITION OF PLANS ESTIMATES AND OTHER DOCUMENTS
PHYSICIAN agrees that title to all materials prepared hereunder,including,but not
I
limited to; all original drawings, desigus, reports, both field and office notices, calculations,
computer code,language, data or programs, maps, memoianda, letters and 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.
8. HOLD HARMLESS
PHYSICIAN hereby agrees to protect,defend, indemnify and hold harniless CITY,
its officers, elected or appointed officials, employees, agents and volunteers from and against any
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 subconbactors, if any) riogligsnt (or
alleged negligent)performance of this Agreement or its failure to comply with any of its obligations
contained in this Agreement by PHYSICIAN, its offeers, agents or employees except such loss or
damage which was caused by the sole negligence or willful misconduct of CITY. PHYSICIAN v U
conduct all 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 any insurance
policies are applicable. The policy limits do not act as limitation upon tine amount of inderunificatiott
to be provided by PHYSICIAN.
12-31 r/w Standard Contract -Revised 3
Fax Jul 29 2021 11:26am P004/015
9. PROFESSIONAL LIABILITY INSURANCE
PHYSICIAN shall obtain and furnish to CP}'Y a professional liability insurance
policy covering the work performed by it hereunder. This policy shall provide coverage for
PIIYSICIAN's professional liability in an amount not less than One Million Dollars
($1,000,0O0.00) per occurrence and in the aggregate. The above-mentioned insurance shall not
contahr a self-insured retent ion wit ho u t the express written consent of CITY,however all;11surs nce
policy "deductible" of Ten Tliousaad Dollars (SI0,000.00) or less is permitted. A claims-made
policy shall be acceptable if the policy fiuther 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. PHYSICIA14 shall notify CITY of circumstances or incidents that might
give rise to futtrte claims.
PHYSICIAN will make every effort to maintain similar insurance duriug tale
required extended period of coverage following PROJECT oon,pletlon. If insurance is terminated
for any reason,PHYSICIAN agrees to pinchase an extended reporling provision of 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 fitenish the CITY with required proof that insurance has been
procrtrej and is in `broc and paid for, the CITY shall have the right, at the CITY's election, to
forthwith terminate this Agreement- Sucl1 termination shall not affect PHYSICIAN's right u be
paid for its tune and materials expanded prior to notification of tenuinalion. PHYSICIAN waves
imi871IMl? Standard Contract- Revised 4
Fax Jul 29 2021 11:26am P005/015
the right to receive compensation and agrees to indemnify the CITY for any work performed prior
to approval of insurance by the CITY,
10. CERTIPICATIS OF INSURANCE
Prior to commencing performance of the work hereunder, PHYSICIAN shall
funiisli 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;
B. state that the policy is currently in force; and
C. promise that such policy shall not be suspended, voided or canceled by
either 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 shall 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 the policy of insurance. PHYSICIAN shall pay, in a prompt and timely manner, the
premiums on the insurance hereinabove required.
11. INDEPENDENT CONTRACTOR
PHYSICIAN is, and shall be, acting at all tines in the performance of this
Agreement as an Independent contractor herein arrd not as an employee of CITY. PHYSICIAN
shall secure at its own cost and expense, and be responsible for any and nll payment of all taxes,
12-3187/IIvIE Standard Contract- Revised 5
Fax Jul 29 2021 11:26am P006/015
social security, states disability insurance compensation, mlemployment 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 woric required hereunder shatl be performed in a good and workmanlike
manner. CITY pray terminate PHYSICIAN's services hereunder at any time with or without cause,
and whether or not the PROJECT is filly 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 tenmination,all finished and unfinished documents, exhibits, report, and evideocc
shall, at the option of the CITY, become its property and shall be promptly delivered to it by
PHYSICIAN,
13, ASSIGNMENT AND DELEGATION
This Agreement is a pctscml service contract and the work hereunder' shall not be
assigned, delegated or subcontracted by PHYSICIAN to any other person or entity without flee
prior express written consent of CITY. If an assignment, delegation or subcontract 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 sliail own all rights to any patent or copyright on any work, item or material
produced as a result of this Agreement.
15. CITY EMPLOYEES AND OFFICIALS
P1YSICIAN shall employ no CITY official nor any regular CITY employee in the
wori< performed pursuant to this Agreement. No officer or employee of CITY shall have any
12-3187nma Standard Contract- Revised 6
Fax Jul 29 2021 11:26am P007/015
financial interest in this Agreement in violation of the 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 the situation shall wan-ant,or by enclosing the same in a sealed envelope,postage prepaid, and
depositing the same in the United States Postal Service, to the addresses specified below. CITY
and P14YSICIAN may designate different addresses to which subsequent notices, certificates or
other commutueations will be sent by notifying the other patty via personal delivery; a reputable
overnight carrier or U.S, cettified mail-return receipt requested,
TO CITY: TO PHYSICIAN:
City of Huntington Beach Hnan P MD FAACP
ATIN: Risk Manager g,rn.Nina
2000 Main Street 90212
Huntington.Beach, CA 92648
17, CONSENT
When CFFY's consent/approval is required under [his Agreement, its
consent/approval for one transaction or event shall not be deemed to be,a consenilapproval to any
subsequent occurrence of the same or any other transaction or event.
18. MODWICATION
No waiver or modification of any language in this Agreement shall be valid unless
in writing and duly executed by both parties.
12-31 a7/tM8 Standard Contract- Revised 7
Fax Jul 29 2021 11 27am P008/015
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 parties or affect the construction or interpretation of any provision of this Agreement.
20. INTERPRETATION OF THIS AGREBINENT
The language of all parts of this Agreenent shall in ail cases be construed as a
whole, according to its fair meaning, and not strictly for a• against any of the parties. If any
provision of tlW 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 rcmauiing
covenants and provisions of this Agreement. No eoveuant or provision shall be deemed dependent
upon any other unless so expressly provided here. As used in this Agreement, the mesculinc or
neuter gender and singular or plural number shall be deemed to inclode the other whenever the
context so indicates or requires. Nothing contained herein shall be oonstnrcd 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 requirements of the law.
21, DUPLICATE ORIGlTIAL
The original of this Agreement and one or more copies hereto have been prepared
and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of
12-31871IMG Statxlard Contract - Revised 8
Fax Jul 29 2021 11:21am P009/015
the date of its execution and delivery, be deemed an original. Each duplicate original shall be
deemed all original instrument as against.any party who has signed it.
22. IMMIGRATION
PHYSICIAN shall be responsible for Rill compliance with the in»nigration and
naturalization laws of die United States and shall, in particular, comply with the provisions of the
United Stales -'ode regarding employment verification,
23. LEGAL SERVICES SUBCONTRACTING PROHIBITED
PHYSICIAN and CITY agree that CITY is net 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 Huntington
Beach City Chm-ter Seclion 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 runty to construe, interpret and/or enforce the
terns and/or provisions of this Agrceruent or to secure the performance hereof, each party shall
bear its own attorney's fees, such that the prevailing party shall not be entitled to recover its
attorney's fees from tile,non-prevailing party.
25. SURVIVAL
Terms and conditions of this Agreement, which by their sense and context survive
the termination of this Agreenierit,shall so survive.
26. GOVERNING LAW
This Agreement shall be governed and construed hi accordance with the laws of the
Stotc of California.
12-3137/liA13 Standard Contract-Revised 9
Fax Jul 29 2021 11:27am 1`010/015
27. SIGNATORIES
Each nrlderslgned represents and warrants that its signal ire herein below has line.
pourer, authority and right to bind their respective parties to each of the terms of this Agreement,
and shall indemnify CITY fully for any injuries or damages to CITY in the event that such
I
airthority or power is not, in fact,held by the signatory or is withdrawn.
PHYS1CIAN's initials
28. Egli TIRLTY
The parties acknowledge and agree that they are entering into this Agreement freely
and voltultariiy following extensive arm's length negotiation,and that each has had the opportunity
to consult with legal counsel prior to executing this tlgreernent, The parties also acknowledge and
agree that no representations, inducements,promises,agreements or warranties,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 auy
representation, 'Inducement, promise, agreement, warranty, fact or eircimtstance not expressly set
forth in this Agreement- This Agreement,and the attached exhibits, contain the entire agreentant
between the parties respecting the subject matter of this Agreement and srtpersede all prior
understandings and agreements whether oral or in writing between the parties respecting the
subject matter hereof.
29, ,FFECTIVEDATE
'finis 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 hereto have caused this Agreement to be executed
by and through their authorized officers,
12-31871tMe Standard Contract- Revised 10
fax Jul 29 2021 11:20am P011/015
P ICIAN
tfty/ 0, ,7gC/x r �� CITY OF HUNTINGTON BEACH,a
TrPEftKr F)1TWWY3 aAf 19 municipal corporation of the State of California
Sigiutrur
Di c►or of Human Resouroes
APPROVED AS TQ FORM:
ty Attorney �o
Receive and File
+1
Clty Clerk
12.7187/IME Standard Contract- Revised I I
Fax Jul 29 2021 11:28am P012/015
PROFESSIONAL SERVICES CONI'RACT BETWEEN
THE CITY OF HUNTINGTON BFACII AND
6ri4n ,-iack5 , mD
FOR
INDEPENDENT MEDICAL 1 VALUATONS WITH
RESPECT TO WORKERS' COMPENSATION CLAIMS
Table of Contents
tScope of Services.....................................................................................................1
2 City Staff Assistance............................................................•...................................2
3 Time of Perfomiance...............................................................................................2
4 Compensation ..........................................................................................................2.
5 Extra Wo[tc...............................................................................................................2.
6 Method ofPayment..................................................................................................3
7 Disposition of Plans,Estimates and other Documents ...........................................3
8 Hold Harmless .........................................................................................................3
9 Professional Liability Insurance.................•............................................................4
10 Certificates of Insurance......................................................................:..................15
11 Independent Con.tractor............................................................................................5
12 Termination of Agreement.......................................................................................6
13 Assignment and Subcontracting..............................................................................6
14 Copyrights/Patents...................................................................................................6
15 Cit;,Employees and Officials..................................................................................6
16 Notices .........•...........................................................................................................7
17 Consent ....................................................................................................................7
18 Modification.............................................................................................................7
I9Section Headings .....................................................................................................8
20 Interpretation of this Agreement..............................................................................8
21 Duplicate Original....................................................................................................8
22 Immigration..............................................................................................................9
23 Legal Services Subcontracting Prohibited...............................................................9
24 Attorney's Fees.........................................................................................................9
25 Survival....................................................................................................................9
26 Governing Law ..........................................................,.........,,,.................................9
27 Signatories................................................................................................................10
28 Entirety.....................................................................................................................10
29 Effective Date,..•......................................................................................................10
12.3187175880
Fax Jul 29 2021 11:2Bam P013/015
EXHIBIT "A"
STATEMENT OF WORD:
I) ACE—COE EXAMS (exams for the determination of indtostrial causation).
2) Evaluation for necessity of appropriate medical treatment.
3) Assessment of employee's present ability to retum to work, whether full duty or
modified.
4) Advise on condition of maximum medical iiuprovetnent status.
S) Determine nature and extent of permanent disability, inctuding factors of apportionment
and need for fimire medical care.
6) Resolve ntllization review disputes.
7) Determine the need for spinal surgery pursuant to Labor Code section 4062(b).
PHYSICIAN shall perform the evaluation in full accordance with the standards defined by the
Division of Workers' Compensation of the State of California and the AMA Guides to the
Evaluation of Permanent Impaimreut,Fifth Edition, This requires a report of the injury,prior
status, clinical clmronology,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 date of appointment
request,and(ii) prepnre a written report of findings within thirty(30) days of the date of exam:or
evaluation and provide a copy to the parties within said time frame.
12-3187/lc,880
Fax Jul 29 2021 11:28am P01d/015
EXHIIBIT "B"
Payment Schedule
L Missed Appointments
• Fee: $503.75
• Code: ML200
Applies 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: ML201
• 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.
• 1t 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
• Fee; $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 med-legal evaluation.
12-318 nsuo l
Fax Jul 29 2021 11:29am 1`015/015
5. Medical-Legal Testimony
• Fee: $455.00 per hour(or physician's usual and customary fee, if lower)
• Code: AI 204
• Physician is entitled to bill a minimum of 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 minimum time allotment.
• Physician must capture time spent reviewing evidence to the nearest quarter-hour,
verified under penalty of perjury.
• The fee does not include production of a medical-Iegal 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.
12-3187n5880 2
Aug 9 2021 05:35aa P003/003
0
COOPERATIVE OF
AMERICAN PHYSICIANS
I
CERTIFICATE OF COVERA�E
Coverage tbrotigh Dec®bes 31,2021
Member: Brian P.Jacks,MD
Address: 9730 Wilshire#108,Beverly Hills,CA 90212
I
TTtis certificate confirms that,effective on the coverage date below,the above-named physician is a member of the Cooperative
of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Tray (NWT). MPT is an unincorporated
interindemnity arrangement organized under California Insurance Code section 1280.7. is certificate confers no rights upon
the member and does not amend, extend or alter the coverage afforded under the terms, aditions and excl"cim;of the MPT
Agrament.
Mamberahlp Number Medical Specialty Coverage Data I11 Retroactive Coverage Date
13591 Psychiatry November 1,2003 None
Subspecialty
Psychiatry-Child&Adolescent
I
Coverage(Claims[rude and paten Current Limits of 1.1611hy
$1,000,000 for all Claims based
Medical Professional Liability Coverage upon an Occurrence
S3.000 POO each calendar year
e aggregate
The member must remain a Member in good standing or arrange for Tail Coverage for any[open or potential Claim that may arise
during the Coverage Period.l`leitber CAP nor MPT undertake any obligation to advise any party,other then the tamed mernber,
of any changes to or termination of this coverage. APPROVED AS TO FORM
Cooperative of American Physicians,Inc-
MICHAEL E.GATES
CITY ATTORNEY
crry OF NUNTINGTON BEACH
January 15,2021
Alfred De aeon Date
Vice Prmidmt,Membership Services _
Mutual Protection Trust
i
I