HomeMy WebLinkAbout2007-07-10; City Council; 19067; Ambulance Billing Services ExtensionCITY OF CARLSBAD - AGENDA BILL
AB# 19,067
MTG. 07/10/07
DEPT. FIN
EXTENSION AND AMENDMENT TO
AGREEMENT TO PROVIDE
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RECOMMENDED ACTION:
Adopt Resolution No. 2007-168 approving Extension and Amendment No. 3 to the
agreement between Wittman Enterprises, LLC and the City of Carlsbad to provide ambulance
billing services.
ITEM EXPLANATION:
Firefighter/paramedics in the Fire Department provide necessary emergency ambulance
services to City of Carlsbad residents, visitors, and businesses. In Fiscal Year 2005 - 2006,
Fire Department paramedics transported approximately 3,300 patients and billed $2,034,100 in
net ambulance revenues (gross revenues less Medicare, Medi-Cal and other contractual write
downs).
In June of 2002, the City contracted with Wittman Enterprises, LLC (Wittman) to provide
ambulance billing services. Over the past five years, Wittman has provided competent and
effective services. The City's agreement with Wittman expires in June 2007.
Staff started the request for proposal process for a new agreement in April 2007. In reviewing
the specifications and qualifications required for the proposal to retain an ambulance billing
contractor, staff determined that the ambulance billing and collecting process has become
much more technical and complicated over the past several years. It was decided that a
professional in the ambulance billing industry should be consulted to help develop and review
the request for proposal, ensuring that all necessary important aspects are considered; from the
information gathering process, to call intake, to assembling and submitting claims, as well as
follow-up and collections.
As a result of completing a more comprehensive request for proposal, it is not possible to
complete the selection process before the current contract with Wittman expires. Staff
recommends extending the current contract on a month to month basis, until a new contract is
awarded. This is expected to occur by the end of September 2007.
FISCAL IMPACT:
The annual contract with Wittman is estimated to cost the City approximately $8,000 per month.
This is calculated at 6.1% of the estimated net collections for ambulance billing. Sufficient
funds have been budgeted for this contract in the Finance Department's budget.
DEPARTMENT CONTACT: Colette Wengenroth 760-602-2468 cweng@ci.carlsbad.ca.us
FOR CITY CLERKS USE ONL Y. ,
COUNCIL ACTION:APPROVED
DENIED
CONTINUED
WITHDRAWN
AMENDED
H"
D
D
D
D
CONTINUED TO DATE SPECIFIC
CONTINUED TO DATE UNKNOWN
RETURNED TO STAFF
OTHER - SEE MINUTES
D
D
D
D
Page 2
ENVIRONMENTAL IMPACT:
None.
EXHIBITS:
1. Resolution No. 2007-168 . approving Extension and Amendment No. 3 to the agreement
between Wittman Enterprises, LLC and the City of Carlsbad.
2. Extension and Amendment No. 3 to the agreement between Wittman Enterprises, LLC and the
City of Carlsbad.
3. Original agreement and amendments between Wittman Enterprises, LLC and the City of Carlsbad.
a
Exhibit 1
1 RESOLUTION NO. 2007-168
2 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CARLSBAD, CALIFORNIA, AUTHORIZING THE
3 EXTENSION AND AMENDMENT NO. 3 TO THE
4 AGREEMENT WITH WITTMAN ENTERPRISES, LLC FOR
AMBULANCE BILLING SERVICES
5 :
6 WHEREAS, there is a need to contract with an ambulance billing service to
7 invoice fees to members of the public for emergency billing transport services; and
8 WHEREAS, the current contract with Wittman Enterprises, LLC expires in June
9 2007; and
10 WHEREAS, additional time is needed to prepare and evaluate the request for
11
proposals for ambulance billing services.
12
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
13
Carlsbad, California, as follows:
15 1. That the above recitations are true and correct.
16 2. That Extension and Amendment No. 3 to the agreement between Wittman
17 Enterprises, LLC and the City of Carlsbad is hereby approved and the Mayor
18 and City Clerk are hereby authorized and directed to execute said extension
19
and amendment.
20
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PASSED, APPROVED AND ADOPTED at a Regular Meeting of the City Council
of the City of Carlsbad on the 10th day of July, 2007, by the following vote to wit:
AYES: Council Members Lewis, Kulchin, Hall, Packard and Nygaard.
NOES: None.
ABSENT: None.
IIS, Mayor
ATTEST:
ORRAJNE M. WC@>D, City
Exhibit 2
AMENDMENT NO. 3
TO EXTEND AND AMEND AGREEMENT FOR
Ambulance Billing and Collection Services
Wittman Enterprises, LLC
This Amendment No. 3 is entered into and effective as of the II day of
(Qffc^y- , 2007, extending and amending the agreement
dated Jiine 1# 2002 (the "Agreement") by and between the City of Carlsbad, a
municipal corporation, ("City"), and Wittman Enterprises("Contractor"), (collectively, the
"Parties") for ambulance billing and collection services.
RECITALS
A. The June 10, 2002 Agreement provided for an initial three year term with
two additional one-year extensions; and
B. On June 10, 2005, the Parties executed Amendment No.1 to the
Agreement to extend the Agreement for one additional year on the same terms and
conditions; and
C. On June 13, 2006, the Parties executed Amendment No. 2 to the
Agreement to extend the Agreement for one additional year on the same terms and
conditions and expiring on June 10, 2007; and
D. The City is evaluating its ambulance billing and collection needs and
acknowledges that its current contract with Contractor will expire before a new Request
for Proposal ("RFP") for ambulance billing and collection services will be completed; and
E. The City, once the RFP is completed, will issue a new RFP for ambulance
billing and collection services; and
F. Even though the Agreement is due to terminate on its own terms,
Contractor is willing to continue providing ambulance billing and collection services to
the City pursuant to the same terms and conditions of the Agreement; and
G. The Parties desire to alter Paragraph 3 "Term" to the original Agreement
thereby extending this Agreement, as may have been amended from time to time, to a
month to month term, subject to thirty day notice of intent to terminate, and to provide
sufficient funding;
H. The Parties acknowledge and agree that the month to month term shall
not exceed a period of one year, ending on June 10, 2008; and
City Attorney Approved Version #05.22.01 *C
NOW, THEREFORE, in consideration of these recitals and the mutual covenants
contained herein, City and Contractor agree as follows:
1. That the above recitals are incorporated herein.
2. That the Agreement, as may have been amended from time to time, is
hereby converted to a month to month term, subject to thirty day notice of intent to
terminate the Agreement.
3. That the Agreement, as may have been amended from time to time, shall
not exceed one year ending on June 10, 2008.
4. That the compensation shall remain the same as provided for in
Amendment No. 2 and shall be pro-rated based on the actual number of months for
which ambulance billing and collection services are provide in an amount not to exceed
$100,000 for the period expiring on June 10, 2008.
5. Contractor will continue to provide the Scope of Services set forth in
Exhibit "A" to Amendment No. 2, on the same terms and conditions and shall complete
all services within thirty days of receipt of the notice of intent to terminate the Agreement
or by June 10, 2008, whichever occurs first.
6. All other provisions of the Agreement, as may have been amended from
time to time, will remain in full force and effect.
7. All requisite insurance policies to be maintained by the Contractor
pursuant to the Agreement, as may have been amended from time to time, will include
coverage for this Amendment.
8. The individuals executing this Amendment and the instruments referenced
in it on behalf of Contractor each represent and warrant that they have the legal power,
right and actual authority to bind Contractor to the terms and conditions of this
Amendment.
(Remainder of Page Intentionally Left Blank)
City Attorney Approved Version #05.22.01 (D
CONTRACTOR
*By;
CITY
corpon
ATTEST:
nicipal
(sign here)
n $•
(print name/tiname/title)
We Li 1 1 em.S.Com
(e-mail address)
If required by City, proper notary acknowledgment of execution by contractor must be attached.
If a Corporation. Agreement must be signed by one corporate officer from each of the following
two groups.
*Group A. **Group B.
Chairman, Secretary,
President, or Assistant Secretary,
Vice-President CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or assistant
secretary under corporate seal empowering the officer(s) signing to bind the corporation.
APPROVED AS TO FORM:
RONALD R. BALL, City Attorney
By:
Deputy City Arjorney
City Attorney Approved Version #05.22.01 ""7
Exhibit 3
AMENDMENT NO. 2
TO EXTEND AND AMEND AGREEMENT FOR
Ambulance Billing and Collection Services
Wlttman Enterprises, LLC
J*lThis Amendment No. 2 is entered into and effective as of the 15 day of
, 2006, extending and amending the agreement dated
June 10, 2002 (the "Agreement") by and between the City of Carlsbad, a municipal corporation,
("City"), and Wittman Enterprises,("Contractor") (collectively, the "Parties") for ambulance billing
and collection services.
RECITALS
A. On June 10, 2005, the Parties executed Amendment No.1 to the Agreement to
provide ambulance billing and collection services; and
B. The Parties desire to alter the Agreement's scope of work to extend and fund the
Agreement for a period of one year, ending on June 10,2007; and
NOW, THEREFORE, in consideration of these recitals and the mutual covenants
contained herein, City and Contractor agree as follows:
1. That the Agreement, as may have been amended from time to time, is hereby
extended for a period of one year ending on June 10,2007 on a basis not-to-exceed $100,000.
2. Contractor will complete all work described in Exhibit "A" by June 10,
2007.
3. All other provisions of the Agreement, as may have been amended from
time to time, will remain in full force and effect.
4. All requisite insurance policies to be maintained by the Contractor
pursuant to the Agreement, as may have been amended from time to time, will include
coverage for this Amendment.
City Attorney Approved Version #05.22.01 o*
5. The individuals executing this Amendment and the instruments referenced
in it on behalf of Contractor each represent and warrant that they have the legal power,
right and actual authority to bind Contractor to the terms and conditions of this
Amendment.
CONTRACTOR CITY OF CARLSBAD, a municipal
corporation of the State of California
(sign here)City Managers* Moyor
(print name/title)ATTEST:
(e-mail address)
By:
LORRAIN
City Clerk
(sign here)
(print name/title)
(e-mail address)
If required by City, proper notarial acknowledgment of execution by contractor must be
attached. If a Corporation. Agreement must be signed by one corporate officer from each of the
following two groups.
"Group A.
Chairman,
President, or
Vice-President
**Group B.
Secretary,
Assistant Secretary,
CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or assistant
secretary under corporate seal empowering the officer(s) signing to bind the corporation.
APPROVED AS TO FORM:
RONALD , City Attorney
Deputy City Attorney
City Attorney Approved Version #05.22.01
EXHIBIT "A"
SCOPE OF SERVICES AND FEE
WHITMAN'S FEE PROPOSAL
Wittman Enterprises, LLC is prepared to continue to provide to the City of Carlsbad
superior billing services for the current percentage rate of 6.1% of collections minus
refunds. Because we have been able to achieve and maintain such an excellent
collection rate for the City, we believe that even with the increased expenses of postage,
equipment, and personnel, this rate is fair.
Invoicing of fees will be produced with the Month End Reports 3 business days after the end of
each month. The method of payment by the City will be at the discretion of the City and its
payment procedures.
SPECIFICATIONS/SCOPE OF SERVICE
Wittman Enterprises, LLC is dedicated to production of a quality service, and demonstrates this
commitment to the City with ongoing training and updating of its staff. This is accomplished by
both in-house cross training, and by taking advantage of outside quality training in all aspects of
customer service and billing issues. To insure continuous quality of our service we have
measurements in place at each juncture of the billing process:
• Transport tickets, as well as cash receipts (whether original or copies) are received; date
stamped, and counted in double custody.
• Presently, Cash Receipts notifications are received from the City and balanced to our
posting records within one (1) day. If the City chooses to change the process, Wittman
Enterprises, LLC will notify patients of change of mailing address by special letter, and
set up process of receipt here as we do for over half of our 75 clients.
• Transport tickets are reviewed for completeness and coded for data entry and initial
billing within (3) three working days. Data entry is audited regularly for completion and
accuracy.
• All tickets where third party coverage is not determined are immediately referred to
Devona, your Account Representative, for calling and special letter handling.
• All calls, letters, and billing functions are audited to insure proper compliance with
collection procedures.
• Wittman Enterprises, LLC electronically transmits the City"3 billing information to
Medicare, Medi-Cal and all receiving insurance payers, thus resulting in a reduced time
to receipt of payment.
Wittman Enterprises, LLC will continue to provide the City with all supplies and equipment
necessary to perform the provisions of the contract.
• Computer hardware and software necessary to perform accurately and efficiently the
processes as described in this presentation. Our system hardware is "redundant,"
employing 5 hard drives to "mirror" the City's data. This significant effort insures that the
City will never have to fear the loss of its billing data.
• Additional tape backup of all files is performed daily and backup is kept off site.
• Our office is completely locked and secured by an alarm system tied to police dispatch.
City Attorney Approved Version #05.22.01
10
• Availability of a national toll free 800 number for patients, the City, Insurance companies,
attorneys, 3rd parties to call for information or discussion of account status.
• Monthly financial reports that balance to the penny are presently provided to the City
within three business days of the new month. Ad hoc reports, both statistical and
financial are provided on demand.
• Positive working relationship with all City utilized hospitals. We presently are receiving
weekly transmissions from Tri-City Hospital with patient billing information. This
relationship allows us to obtain billing information with no further imposition on the Fire
Department for additional reporting.
• We are providing all mailing forms, billing forms, insurance forms, lien forms, and
envelopes necessary to perform the billing functions for the City.
• Fully customized letters, in both Spanish and English reminding patients of their
promises and obligations. Our invoices contain customized language with up to 560
spaces for specialized messages and payment instructions. An additional 100 spaces
are available for one time or special messages on all statements and collection notices.
Each of the City's payment sources has an associated billing schedule that automatically sets
the timetable for billing events that are appropriate for each source.
After payment by the initial source, our system automatically transfers the balance into the next
appropriate accounts receivable pay source and sets up the next automatic billing functions.
Billing schedules associated with each account receivable pay source set up automatic follow
up.
PRESENT PRIVATE BILL SCHEDULE FOR THE CITY OF CARLSBAD
1. Invoice Immediately
2. Statement 30 days
3. Past Due 45 days
4. Final Demand 60 days
These billing schedules work in conjunction with our CollectPlus* program tracking accounts
receivable and assigning them to Devona, the City's Account Representative, for making follow
up calls. Our first call to a private account occurs immediately after data entry of the transport
ticket into the system. This 'Verification" call allows us to determine if the patient may have
insurance or any special circumstances that will make it difficult to pay the bill in a reasonable
amount of time. This early establishment of contact with the patient is most beneficial. At this
point, handling of the account becomes very individual. Promises to pay in installments,
litigation situations, and alternate pay sources can all be determined by personalized telephone
contact.
In addition, Devona has a database of letters appropriate to each collection situation. As part of
follow up, these letters can be scheduled to address a particular situation. This process adds a
personal touch to collections. Our computer program has fields that are filled with next of kin
information, as well as employer information, so that reaching the patient or family members for
additional information is routine. We are fully equipped to produce attorney liens and track
settlement of litigation.
If we are unsuccessful in obtaining payments, private accounts aging over 120 days are being
referred to the City for write off or referral to a collection agency for further action.
City Attorney Approved Version #05.22.01
Wittman Enterprises, LLC believes that part of our commitment to quality to the City includes
security and proper maintenance of the system utilized in processing billing.
We maintain a separate database for the City of accounts receivable maintenance programs
that allow for processing computerized billings for paramedic services. A data file for each
patient is established from which information regarding the transport, billing and payment can be
recorded and retrieved, and for which patient information can be updated. All patients are
referenced by name, date of service, transport ticket number, account number, social security
number and insurance identification number.
We store all pertinent information regarding transports and dry runs that might be needed by the
City for tracking response times, charge distribution, dispatch logs, call distribution, etc.
City Attorney Approved Version f 05.22.01
II
AMENDMENT NO. ONE
TO EXTEND AND AMEND AGREEMENT FOR
AMBULANCE BILLING AND COLLECTION SERVICES
WITTMAN ENTERPRISES, LLC.
This Amendment No. 1 is entered into and effective as of the /O day of
, 2005, extending and amending the agreement dated
June 10, 2002 (the "Agreement") by and between the City of Carlsbad, a municipal corporation,
("City"), and Wittman Enterprises, ("Contractor") (collectively, the "Parties") for Ambulance Billing
and Collection Services.
RECITALS
A. Whereas, the parties entered into an agreement on June 10, 2002 for the
professional ambulance billing and collection services for the City of Carlsbad as per Agenda
Bill 16,771; and
B. Whereas, The Parties desire to alter the Agreement's scope of work to extend
and fund the Agreement for a period of one year in an amount not to exceed $100,000; and
NOW, THEREFORE, in consideration of these recitals and the mutual covenants
contained herein, City and Contractor agree as follows:
1. That the Agreement, as may have been amended from time to time, is hereby
extended for a period of one year ending on June 10, 2006 on a time and materials basis not-to-
exceed One Hundred Thousand dollars ($100,000.00).
2. Contractor will complete all work described in Exhibit "A" by June 10, 2006.
3. All other provisions of the Agreement, as may have been amended from time to
time, will remain in full force and effect.
4. All requisite insurance policies to be maintained by the Contractor pursuant to the
Agreement, as may have been amended from time to time, will include coverage for this
Amendment.
5. The individuals executing this Amendment and the instruments referenced in it
on behalf of Contractor each represent and warrant that they have the legal power, right and
actual authority to bind Contractor to the terms and conditions of this Amendment.
City Attorney Approved Version #05.22.01
CONTRACTOR
*•&
(sign here)
(print name/title)
(e-mail address)
*By:
(sign here)
(print name/title)
CITY OF CARLSBAD, a municipal
corporation of the State of California
Manager er Mayor-
ATTEST:
UN
City Clerk
(e-mail address)
If required by City, proper notarial acknowledgment of execution by contractor must be
attached. If a Corporation. Agreement must be signed by one corporate officer from each of the
following two groups.
"Group A.
Chairman,
President, or
Vice-President
**Group B.
Secretary,
Assistant Secretary,
CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or assistant
secretary under corporate seal empowering the officer(s) signing to bind the corporation.
APPROVED AS TO FORM:
RONALD R. BALL, City Attorney
Deputy City Attorney
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of
ss.
On..before me,
Name and TUB of Officer (e.g., -Jane doe. Notary Public1)
personally appeared
Commission fi375B21
Notory Pubflc - California
Sacramento County
Namels) of Signer(s)
0 personally known to me
•B proved to me on the basis of satisfactory
evidence
to be the persorj^sfwhose namejftr" is^are"*
subscribed to the within instrument and
acknowledged to me that Jw/She/fceifexeculed
the same in .JriSTher/ihelr authorized
capacity^ieSjT and that by .b»s/fier/tb»tr*'"
signature^on the instrument the persorjj^or
the entity upon behalf of which the
acted, executed the instrument.
e cl NotaryPullIc
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachrnent of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date: Number of Pages:
Signers) Other Than Named Above:.
Capacity(ies) Claimed by Signer
Signer's Name:
D Individual
D Corporate Officer—Titlefs):
D Partner — O Limited D General
n Attorney-in-Fact
Q Trustee
D Guardian or Conservator
D Other.
Signer Is Representing:.
01999 National Notary Association • 9350 Do Solo Ave.. P.O. Box 2402 • Chalswonh. CA 91313-2402 • www.nationalnotaiy.org Reorder Call Toll-Fre> 1-800-«r6-6827
15
EXHIBIT "A"
SCOPE OF SERVICES AND FEE
WITTMAN'S FEE PROPOSAL
Wittman Enterprises, LLC is prepared to continue to provide to the City of Carlsbad
superior billing services for the current percentage rate of 6.1% of collections minus
refunds. Because we have been able to achieve and maintain such an excellent
collection rate for the City, we believe that even with the increased expenses of postage,
equipment, and personnel, this rate is fair.
Invoicing of fees will be produced with the Month End Reports 3 business days after the end of
each month. The method of payment by the City will be at the discretion of the City and its
payment procedures.
SPECIFICATIONS/SCOPE OF SERVICE
Wittman Enterprises, LLC is dedicated to production of a quality service, and demonstrates this
commitment to the City with ongoing training and updating of its staff. This is accomplished by
both in-house cross training, and by taking advantage of outside quality training in all aspects of
customer service and billing issues. To insure continuous quality of our service we have
measurements in place at each juncture of the billing process:
• Transport tickets, as well as cash receipts (whether original or copies) are received; date
stamped, and counted in double custody.
• Presently, Cash Receipts notifications are received from the City and balanced to our
posting records within one (1) day. If the City chooses to change the process, Wittman
Enterprises, LLC will notify patients of change of mailing address by special letter, and
set up process of receipt here as we do for over half of our 75 clients.
• Transport tickets are reviewed for completeness and coded for data entry and initial
billing within (3) three working days. Data entry is audited regularly for completion and
accuracy.
• All tickets where third party coverage is not determined are immediately referred to
Devona, your Account Representative, for calling and special letter handling.
• All calls, letters, and billing functions are audited to insure proper compliance with
collection procedures.
• Wittman Enterprises, LLC electronically transmits the City's billing information to
Medicare, Medi-Cal and all receiving insurance payers, thus resulting in a reduced time
to receipt of payment.
Wittman Enterprises, LLC will continue to provide the City with all supplies and equipment
necessary to perform the provisions of the contract.
• Computer hardware and software necessary to perform accurately and efficiently the
processes as described in this presentation. Our system hardware is "redundant,"
employing 5 hard drives to "mirror" the City's data. This significant effort insures that the
City will never have to fear the loss of its billing data.
lie
• Additional tape backup of all files is performed daily and backup is kept off site.
• Our office is completely locked and secured by an alarm system tied to police dispatch.
• Availability of a national toll free 800 number for patients, the City, Insurance companies,
attorneys, 3rd parties to call for information or discussion of account status.
• Monthly financial reports that balance to the penny are presently provided to the City
within three business days of the new month. Ad hoc reports, both statistical and
financial are provided on demand.
• Positive working relationship with all City utilized hospitals. We presently are receiving
weekly transmissions from Tri-City Hospital with patient billing information. This
relationship allows us to obtain billing information with no further imposition on the Fire
Department for additional reporting.
• We are providing all mailing forms, billing forms, insurance forms, lien forms, and
envelopes necessary to perform the billing functions for the City.
• Fully customized letters, in both Spanish and English reminding patients of their
promises and obligations. Our invoices contain customized language with up to 560
spaces for specialized messages and payment instructions. An additional 100 spaces
are available for one time or special messages on all statements and collection notices.
Each of the City's payment sources has an associated billing schedule that automatically sets
the timetable for billing events that are appropriate for each source.
After payment by the initial source, our system automatically transfers the balance into the next
appropriate accounts receivable pay source and sets up the next automatic billing functions.
Billing schedules associated with each account receivable pay source set up automatic follow
up.
PRESENT PRIVATE BILL SCHEDULE FOR THE CITY OF CARLSBAD
1. Invoice Immediately
2. Statement 30 days
3. Past Due 45 days
4. Final Demand 60 days
These billing schedules work in conjunction with our CollectPlus* program tracking accounts
receivable and assigning them to Devona, the City's Account Representative, for making follow
up calls. Our first call to a private account occurs immediately after data entry of the transport
ticket into the system. This "Verification" call allows us to determine if the patient may have
insurance or any special circumstances that will make it difficult to pay the bill in a reasonable
amount of time. This early establishment of contact with the patient is most beneficial. At this
point, handling of the account becomes very individual. Promises to pay in installments,
litigation situations, and alternate pay sources can all be determined by personalized telephone
contact.
In addition, Devona has a database of letters appropriate to each collection situation. As part of
follow up, these letters can be scheduled to address a particular situation. This process adds a
personal touch to collections. Our computer program has fields that are filled with next of kin
information, as well as employer information, so that reaching the patient or family members for
additional information is routine. We are fully equipped to produce attorney liens and track
settlement of litigation.
If we are unsuccessful in obtaining payments, private accounts aging over 120 days are being
referred to the City for write off or referral to a collection agency for further action.
Wittman Enterprises, LLC believes that part of our commitment to quality to the City includes
security and proper maintenance of the system utilized in processing billing.
We maintain a separate database for the City of accounts receivable maintenance programs
that allow for processing computerized billings for paramedic services. A data file for each
patient is established from which information regarding the transport, billing and payment can be
recorded and retrieved, and for which patient information can be updated. All patients are
referenced by name, date of service, transport ticket number, account number, social security
number and insurance identification number.
We store all pertinent information regarding transports and dry runs that might be needed by the
City for tracking response times, charge distribution, dispatch logs, call distribution, etc.
EXHIBIT 2
AGREEMENT FOR BILLING AND COLLECTION SERVICES
W1TTMAN ENTERPRISES, LLC
S AGREEMENT is made and entered into as of the -A> day of
2002, by and between the CITY OF CARLSBAD, a municipal
>n, ("City"), and WSttman Enterprises, a limited liability corporation,
("Contractor").
RECITALS
A. City requires the professional services of a billing and collection
Contractor that is experienced in consulting services for the preparation of invoices for
emergency ambulance transport being sent to private insurance companies,
government agencies, and patients; delinquent claim handling; receipts processing; and
monthly reports.
B. Contractor has the necessary experience in providing professional
services and advice related to emergency ambulance transport billing and collection.
C. Selection of Contractor is expected to achieve the desired results in an
expedited fashion.
D. Contractor has submitted a proposal to City and has affirmed its
willingness and ability to perform such work.
NOW, THEREFORE, in consideration of these recitals and the mutual covenants
contained herein, City and Contractor agree as follows:
1- SCOPE OF WORK
City retains Contractor to perform, and Contractor agrees to render, those services (the
"Services") that are defined in attached Exhibit "A", which is incorporated by this
reference in accordance with this Agreement's terms and conditions.
2- STANDARD OF PERFORMANCE
While performing the Services, Contractor will exercise the reasonable professional
care and skill customarily exercised by reputable members of Contractor's profession
practicing in the Metropolitan Southern California Area, and will use reasonable
diligence and best judgment while exercising its professional skill and expertise.
3. TERM
The term of this Agreement will be effective for a period of three (3) years from the date
first above written. The City Manager may amend the Agreement to extend it for two (2)
additional one (1) year periods or parts thereof in an amount not to exceed 6.1% of
collected revenue, less refunds or adjustments, not-to-exceed one hundred thousand
($100,000) dollars per agreement year. Extensions will be based upon a satisfactory
review of Contractor's performance, City needs, and appropriation of funds by the City
Council. The parties will prepare a written amendment indicating the effective date and
length of the extended Agreement.
CKy Attorney Approved Vented «04.01.02
4. TIME IS OF THE ESSENCE
Time is of the essence for each and every provision of this Agreement
5. COMPENSATION
The total fee payable for the Services to be performed during the initial Agreement term
will be 6.1% of collected revenue, less refunds or adjustments, not-to-exceed one
hundred thousand ($100,000) dollars per agreement year. No other compensation for
the Services will be allowed except for items covered by subsequent amendments to
this Agreement The City reserves the right to withhold a ten percent (10%) retention
until City has accepted the work and/or Services specified in Exhibit "A".
Incremental payments, if applicable, should be made as outlined in attached Exhibit "A".
6- STATUS OF CONTRACTOR
Contractor will perform the Services in Contractor's own way as an independent
contractor and in pursuit of Contractor's independent calling, and not as an employee of
City. Contractor will be under control of City only as to the result to be accomplished,
but will consult with City as necessary. The persons used by Contractor to provide
services under this Agreement will not be considered employees of City for any
purposes.
The payment made to Contractor pursuant to the Agreement will be the full and
complete compensation to which Contractor is entitled. City will not make any federal or
state tax wtthholdings on behalf of Contractor or its agents, employees or
subcontractors. City will not be required to pay any workers' compensation insurance or
unemployment contributions on behalf of Contractor or its employees or subcontractors.
Contractor agrees to indemnify City within thirty (30) days for any tax, retirement
contribution, social security, overtime payment, unemployment payment or workers'
compensation payment which City may be required to make on behalf of Contractor or
any agent, employee, or subcontractor of Contractor for work done under this
Agreement At the City's election, City may deduct the indemnification amount from any
balance owing to Contractor.
7. SUBCONTRACTING
Contractor will not subcontract any portion of the Services without prior written approval
of City. If Contractor subcontracts any of the Services, Contractor will be fully
responsible to City for the acts and omissions of Contractor's subcontractor and of the
persons either directly or indirectly employed by the subcontractor, as Contractor is for
the acts and omissions of persons directly employed by Contractor. Nothing contained
in this Agreement will create any contractual relationship between any subcontractor of
Contractor and City. Contractor will be responsible for payment of subcontractors.
Contractor will bind every subcontractor and every subcontractor of a subcontractor by
the terms of this Agreement applicable to Contractor's work unless specifically noted to
the contrary in tile subcontract and approved in writing by City.
City Attorney Approved Vmton f04.01.02
8. OTHER CONTRACTORS
The City reserves the right to employ other Contractors in connection with the Services,
upon written notice to the Contractor.
9. INDEMNIFICATION
Contractor agrees to indemnify and hold harmless the City and its officers, officials,
employees and volunteers from and against all claims, damages, losses and expenses
including attorneys fees arising out of the performance of the work described herein
caused in whole or in part by any willful misconduct or negligent act or omission of the
Contractor, any subcontractor, anyone directly or indirectly employed by any of them or
anyone for whose acts any of them may be liable.
The parties expressly agree that any payment, attorney's fee, costs or expense City
incurs or makes to or on behalf of an injured employee under the City's self-
administered workers' compensation is included as a loss, expense or cost for the
purposes of this section, and that this section will survive the expiration or early
termination of this Agreement.
10. INSURANCE
Contractor will obtain and maintain for the duration of the Agreement and any and all
amendments, insurance against claims for injuries to persons or damage to property
which may arise out of or in connection with performance of the services by Contractor
or Contractor's agents, representatives, employees or subcontractors. Trie insurance
will be obtained from an insurance carrier admitted and authorized to do business in the
State of California. The insurance carrier is required to have a current Best's Key Rating
of not less than "A-:V.
10.1 Coverages and Limits.
Contractor will maintain the types of coverages and minimum limits indicated below,
unless City Attorney or City Manager approves a lower amount. These minimum
amounts of coverage will not constitute any limitations or cap on Contractor's
indemnification obligations under this Agreement. City, its officers, agents and
employees make no representation that the limits of the insurance specified to be
carried by Contractor pursuant to this Agreement are adequate to protect Contractor. If
Contractor believes that any required insurance coverage is inadequate, Contractor will
obtain such additional insurance coverage, as Contractor deems adequate, at
Contractor's sole expense.
10.1.1 Commercial General Liability Insurance. $1,000,000 combined
single-limit per occurrence for bodily injury, personal injury and property damage. If the
submitted policies contain aggregate limits, general aggregate limits will apply
separately to the work under this Agreement or the general aggregate wiK be twice the
required per occurrence limit.
Crty Attorney Approwd Vtenion f04.01.02
10.1.2 Automobile Liability, (if the use of an automobile is involved for
Contractor's work for City). $1,000,000 combined single-limit per accident for bodily
injury and property damage.
10.1.3 Workers' Compensation and Employer's Liability. Workers'
Compensation limits as required by the California Labor Code and Employer's Liability
limits of $1,000,000 per accident for bodily injury. Workers' Compensation and
Employer's Liability insurance will not be required if Contractor has no employees and
provides, to City's satisfaction, a declaration stating this.
10.1.4 Professional Liability. Errors and omissions liability appropriate to
Contractor's profession with limits of not less than $1,000,000 per daim. Coverage must
be maintained for a period of five years following the date of completion of the work.
10.2. Additional Provisions. Contractor will ensure that the policies of insurance
required under this Agreement contain, or are endorsed to contain, the following
provisions:
10.2.1 The City will be named as an additional insured on General
Liability.
10.2.2 Contractor wilt obtain occurrence coverage, excluding Professional
Liability, which will be written as claims-made coverage.
10.2.3 This insurance will be in force during the life of the Agreement and
any extensions of it and will not be canceled without thirty (30) days prior written notice
to City sent by certified mail pursuant to the Notice provisions of this Agreement.
10.3 Providing Certificates of Insurance and Endorsements. Prior to City's execution
of this Agreement, Contractor will furnish certificates of insurance and endorsements to
City.
10.4 Failure to Maintain Coverage. If Contractor fails to maintain any of these
insurance coverages, then City will have the option to declare Contractor in breach, or
may purchase replacement insurance or pay the premiums that are due on existing
policies in order to maintain the required coverages. Contractor is responsible for any
payments made by City to obtain or maintain insurance and City may collect these
payments from Contractor or deduct the amount paid from any sums due Contractor
under this Agreement
10.5 Submission of Insurance Policies. City reserves the right to require, at anytime,
complete and certified copies of any or all required insurance policies and
endorsements.
11. BUSINESS LICENSE
CMy Attorney Approved Version #04.01.02
Contractor will obtain and maintain a City of Carlsbad Business License for the term of
the Agreement as may be amended from time-to-time.
12. ACCOUNTING RECORDS
Contractor will maintain complete and accurate records with respect to costs incurred
under this Agreement. Ail records will be clearly identifiable. Contractor will allow a
representative of City during normal business hours to examine, audit, and make
transcripts or copies of records and any other documents created pursuant to this
Agreement Contractor will allow inspection of ail work, data, documents, proceedings,
and activities related to the Agreement for a period of three (3) years from the date of
final payment under this Agreement.
13. OWNERSHIP OF DOCUMENTS
All work product produced by Contractor or its agents, employees, and subcontractors
pursuant to this Agreement is the property of City. In the event this Agreement is
terminated, ad work product produced by Contractor or its agents, employees and
subcontractors pursuant to this Agreement will be delivered at once to City. Contractor
will have the right to make one (1) copy of the work product for Contractor's records.
14. COPYRIGHTS
Contractor agrees that all copyrights that arise from the services will be vested in City
and Contractor relinquishes all claims to the copyrights in favor of City.
16. NOTICES
The name of the persons who are authorized to give written notices or to receive written
notice on behalf of City and on behalf of Contractor under this Agreement.
ForCHv; For Contractor.
Lisa Hiktebrand Dona VWtman
Director President
Finance Department Wittman Enterprises, LLC
City of Carlsbad 21 Blue Sky Court
1635 Faraday Avenue Suite A
Carlsbad, CA 92008-7314 Sacramento, CA 95828
760-602-2430 800-772-6552
Each party will notify the other immediately of any changes of address that would
require any notice or delivery to be directed to another address.
1*- CONFLICT OF INTEREST
City will evaluate Contractor's duties pursuant to this Agreement to determine whether
disclosure under the Political Reform Act and City's Conflict of Interest Code is required
of Contractor or any of Contractor's employees, agents, or subcontractors. Should it be
determined that disclosure is required, Contractor or Contractor's affected employees,
Ctty Attorney Approved Version f04.01.02
agents, or subcontractors will complete and file with the City Clerk those schedules
specified by City and contained in the Statement of Economic Interests Form 700.
Contractor, for Contractor and on behalf of Contractor's agents, employees,
subcontractors and consultants warrants that by execution of this Agreement, that they
have no interest, present or contemplated, in the projects affected by this Agreement
Contractor further warrants that neither Contractor, nor Contractor's agents, employees,
subcontractors and consultants have any ancillary real property, business interests or
income that will be affected by this Agreement or, alternatively, that Contractor will file
with the City an affidavit disclosing this interest.
17. GENERAL COMPLIANCE WITH LAWS
Contractor will keep fully informed of federal, state and local laws and ordinances and
regulations which in any manner affect those employed by Contractor, or in any way
affect the performance of the Services by Contractor. Contractor will at all times observe
and comply with these laws, ordinances, and regulations and will be responsible for the
compliance of Contractor's services with all applicable laws, ordinances and regulations.
Contractor will be aware of the requirements of the Immigration Reform and Control Act
of 1986 and will comply with those requirements, including, but not limited to, verifying
the eligibility for employment of all agents, employees, subcontractors and consultants
that the services required by this Agreement.
1«- DISCRIMINATION AND HARASSMENT PROHIBITED
Contractor will comply with all applicable local, state and federal laws and regulations
prohibiting discrimination and harassment
19. DISPUTE RESOLUTION
If a dispute should arise regarding the performance of the Services the following
procedure will be used to resolve any questions of fact or interpretation not otherwise
settled by agreement between the parties. Representatives of Contractor or City will
reduce such questions, and their respective views, to writing. A copy of such
documented dispute will be forwarded to both parties involved along with recommended
methods of resolution, which would be of benefit to both parties. The representative
receiving the letter will reply to the letter along with a recommended method of
resolution within ten (10) business days. If the resolution thus obtained is unsatisfactory
to the aggrieved party, a letter outlining the disputes will be forwarded to the City
Manager. The City Manager will consider the facts and solutions recommended by each
party and may then opt to direct a solution to the problem. In such cases, the action of
the City Manager will be binding upon the parties involved, although nothing in this
procedure will prohibit the parties from seeking remedies available to them at law.
20. TERMINATION
In the event of the Contractor's failure to prosecute, deliver, or perform the Services,
City may terminate this Agreement for nonperformance by notifying Contractor by
certified mail of the termination. If City decides to abandon or indefinitely postpone the
City Attonwy Approved Version f04.01.02
work or services contemplated by this Agreement, City may terminate this Agreement
upon written notice to Contractor. Upon notification of termination, Contractor has five
(5) business days to deliver any documents owned by City and all work in progress to
City address contained in this Agreement City will make a determination of fact based
upon the work product delivered to City and of the percentage of work that Contractor
has performed which is usable and of worth to City in having the Agreement completed.
Based upon that finding City will determine the final payment of the Agreement
Either party upon tendering thirty (30) days written notice to the other party may
terminate this Agreement. In this event and upon request of City, Contractor will
assemble the work product and put it in order for proper filing and dosing and deliver it
to City. Contractor will be paid for work performed to the termination date; however, the
total will not exceed the lump sum fee payable under this Agreement City will make the
final determination as to the portions of tasks completed and the compensation to be
made.
21. COVENANTS AGAINST CONTINGENT FEES
Contractor warrants that Contractor has not employed or retained any company or
person, other than a bona fide employee working for Contractor, to solicit or secure this
Agreement, and that Contractor has not paid or agreed to pay any company or person,
other than a bona fide employee, any fee, commission, percentage, brokerage fee, gift,
or any other consideration contingent upon, or resulting from, the award or making of
this Agreement For breach or violation of this warranty, City will have the right to annul
this Agreement without liability, or, in its discretion, to deduct from the Agreement price
or consideration, or otherwise recover, the full amount of the fee, commission,
percentage, brokerage fees, gift, or contingent fee.
22. CLAIMS AMD LAWSUITS
By signing this Agreement, Contractor agrees that any Agreement claim submitted to
City must be asserted as part of the Agreement process as set forth in this Agreement
and not in anticipation of litigation or in conjunction with litigation. Contractor
acknowledges that rf a false daim is submitted to City, it may be considered fraud and
Contractor may be subject to criminal prosecution. Contractor acknowledges that
California Government Code sections 12650 et sea., the False Claims Act applies to
this Agreement and, provides for civil penalties where a person knowingly submits a
false daim to a public entity. These provisions indude false claims made with deliberate
ignorance of the false information or in reckless disregard of the truth or falsity of
information. If City seeks to recover penalties pursuant to the False Claims Act, it is
entitled to recover its litigation costs, induding attorney's fees. Contractor acknowledges
that the filing of a false daim may subject Contractor to an administrative debarment
proceeding as the result of which Contractor may be prevented to act as a Contractor
on any public work or improvement for a period of up to five (5) years. Contractor
acknowledges debarment by another jurisdiction is grounds for City to terminate this
Agreement
23. JURISDICTIONS AND VENUE
City Attorney Approved Version *04.01.08
Any action at law or in equity brought by either of the parties for the purpose of
enforcing a right or rights provided for by this Agreement will be tried in a court of
competent jurisdiction in the County of San Diego, State of California, and the parties
waive all provisions of law providing for a change of venue in these proceedings to any
other county.
24. SUCCESSORS AND ASSIGNS
ft is mutually understood and agreed that this Agreement will be binding upon City and
Contractor and their respective successors. Neither this Agreement or any part of it nor
any monies due or to become due under ft may be assigned by Contractor without the
prior consent of City, which shall not be unreasonably withheld.
25. ENTIRE AGREEMENT
This Agreement, together with any other written document referred to or contemplated
by it along with the purchase order for this Agreement and its provisions, embody the
entire Agreement and understanding between the parties relating to the subject matter
of It. In case of conflict, the terms of the Agreement supersede the purchase order.
Neither this Agreement nor any of its provisions may be amended, modified, waived or
discharged except in a writing signed by both parties.
(Remainder of this page intentionally left blank)
C»y Attorney Approved Vvnton f04.01.OZ
8
26. AUTHORITY
The individuals executing this Agreement and the instruments referenced in it on behalf
of Contractor each represent and warrant that they have the legal power, right and
actual authority to bind Contractor to the terms and conditions of this Agreement
CITVW CAI&SJfer/a n/unitipal
California
(sign here)
(print name/Me) ATTEST:
^•(L^
(sigh here)
(print name/fitte)
if required by City, proper notarial acknowledgment of execution by contractor
must be attached, if a Corporation. Agreement must be signed by one corporate
officer from each of the following two groups.
*6roup A. "Group B.
Chairman, ' Secretary,
President or Assistant Secretary,
Vrce-Presiderrt CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or
assistant secretary under corporate seal empowering the officers) signing to bind the
corporation.
APPROVED AS TO FORM:
RONALD R. BALL, City Attorney
Bv:
//Deputy City Attorney
CHy Attorney Approved Vflrton «04.01.Q2
9
sn
EXHIBIT A
Wittmm Enterprises, LLC
FEE PROPOSAL
Wittman Enterprises, LLC is prepared to continue to provide to the City of Carlsbad superior
billing services for the current percentage rate of 6.1% of collections minus refunds. Because we
have been able to achieve and maintain such an excellent collection rate for the City, we believe
that even with the increased expenses of postage, equipment, and personnel, this rate is fair.
Invoicing of fees will be produced with the Month End Reports 3 business days after the end of
each month. The method of payment by the City will be at the discretion of the City and its
payment procedures.
Of course, this proposal includes all services we are presently providing for the City, and
outlined in this proposal. We would like to introduce the City to a new service that we offer that
has proven to be quite helpful to other clients. We would like the City to consider sending survey
letters to your patients. We would mail the surveys to all or a selected number of your patients.
We include "prepaid postage" envelopes for return of the surveys. We would then provide you
with the original responses and a report to make it easy for the Fire Department to review with
Quality Assurance in mind. A sample of a survey letter and report is included in the Reports
Attachment to this response. We and our clients who use this service have been pleasantly
surprised by the nearly 30% return of these inquiries.
The fee for this service is $1.00 per survey letter. This is strictly an optional service that can be
stopped and started at the City's discretion.
City of Carlsbad Fire Department
EXHIBIT A
Wittman Enterprises, LLC
SPECIFICATIONS / SCOPE OF SERVICE
Wittman Enterprises, LLC is dedicated to production of a quality service, and demonstrates this
commitment to the City with ongoing training and updating of its staff. This is accomplished by
both in-house cross training, and by taking advantage of outside quality training in all aspects of
customer service and billing issues. To insure continuous quality of our service we have
measurements in place at each juncture of the billing process:
• Transport tickets, as well as cash receipts (whether original or copies) are received; date
stamped, and counted in doubled custody.
• Presently, Cash Receipts notifications are received from the City and balanced to our posting
records within one (1) day. If the City chooses to change the process, Wittman Enterprises,
LLC will notify patients of change of mailing address by special letter, and set up process of
receipt here as we do for over half of our 75 clients.
• Transport tickets are reviewed for completeness and coded for data entry and initial billing
within (3) three working days. Data entry is audited regularly for completion and accuracy.
• All tickets where third party coverage is not determined are immediately referred to Devona,
your Account Representative, for calling and special letter handling.
• All calls, letters, and billing functions are audited to insure proper compliance with collection
procedures.
• Wittman Enterprises, LLC electronically transmits the City's billing information to
Medicare, Medi-Cal and all receiving insurance payers, thus resulting in a reduced time to
receipt of payment.
City of Carlsbad Fire Department
EXHIBIT A
Wittman Enterprises, LLC
Wittman Enterprises, LLC will continue to provide the City with all supplies and equipment
necessary to perform the provisions of the contract.
% Computer hardware and software necessary to perform accurately and efficiently the
processes as described in this presentation. Our system hardware is "redundant," employing 5
hard drives to "mirror" the City's data. This significant effort insures that the City will never
have to fear the loss of its billing data.
% Additional tape backup of all files is performed daily and backup is kept off site.
% Our office is completely locked and secured by an alarm system tied to police dispatch.
% Availability of a national toll free 800 number for patients, the City, Insurance companies,
attorneys, 3rd parties to call for information or discussion of account status.
% Monthly financial reports that balance to the penny are presently provided to the City within
three business days of the new month. Ad hoc reports, both statistical and financial are
provided on demand.
% Positive working relationship with all City .utilized hospitals. We presently are receiving
weekly transmissions from Tri-City Hospital with patient billing information. This
relationship allows us to obtain billing information with no further imposition on the Fire
Department for additional reporting.
% We are providing all mailing forms, billing forms, insurance forms, lien forms, and
envelopes necessary to perform the billing functions for the City.
% Fully customized letters, in both Spanish and English reminding patients of their promises
and obligations. Our invoices contain customized language with up to 560 spaces for
specialized messages and payment instructions. An additional 100 spaces are available for
one time or special messages on all statements and collection notices.
Each of the City's payment sources has an associated billing schedule that automatically sets the
timetable for billing events that are appropriate for each source.
After payment by the initial source, our system automatically transfers the balance into the next
appropriate accounts receivable pay source and sets up the next automatic billing functions.
Billing schedules associated with each account receivable pay source set up automatic follow up.
City of Carlsbad Fire Department
so
EXHIBIT A
Wittman Enterprises, LLC
Present Private Bill Schedule for the City of Carlsbad
1. Invoice Immediately
2. Statement 30 days
3. Past Due 45 days
4. Final Demand 60 days
These billing schedules work in conjunction with our CollectPlus® program tracking accounts
receivable and assigning them to Devona, the City's Account Representative, for making follow
up calls. Our first call to a private account occurs immediately after data entry of the transport
ticket into the system. This "Verification" call allows us to determine if the patient may have
insurance or any special circumstances that will make it difficult to pay the bill in a reasonable
amount of time. This early establishment of contact with the patient is most beneficial. At this
point, handling of the account becomes very individual. Promises to pay in installments,
litigation situations, and alternate pay sources can all be determined by personalized telephone
contact.
In addition, Devona has a database of letters appropriate to each collection situation. As part of
follow up, these letters can be scheduled to address a particular situation. This process adds a
personal touch to collections. Our computer program has fields that are filled with next of kin
information, as well as employer information, so that reaching the patient or family members for
additional information is routine. We are fully equipped to produce attorney liens and track
settlement of litigation.
If we are unsuccessful in obtaining payments, private accounts aging over 120 days are being
referred to the City for write off or referral to a collection agency for further action.
Wittman Enterprises, LLC believes that part of our commitment to quality to die City includes
security and proper maintenance of the system utilized in processing billing.
We maintain a separate database for the City of accounts receivable maintenance programs that
allow for processing computerized billings for paramedic services. A data file for each patient is
established from which information regarding the transport, billing and payment can be recorded
and retrieved, and for which patient information can be updated. All patients are referenced by
name, date of service, transport ticket number, account number, social security number and
insurance identification number.
We store all pertinent information regarding transports and dry runs that might be needed by the
City for tracking response times, charge distribution, dispatch logs, call distribution, etc.
City of Carlsbad Fire Department
ALL-PURPOSE ACKNOWLEDGMENT
State of California
S>County of
on 5-m-oa
> ss.
(DATE)
personally appeared
before me,urt-. HotfrT.IS!WTARY)
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SICNER(S)
personally known to me - OR-
Beverly A. HoeftCOMM. M2if ~"
•IOTARY PUBLIC-CAU,
SACRAMENTO COUNT.UyComm.EipMiAptiKZOOJ
proved to me on the basis of satisfactory
evidence to be the person(s) whose name(s)
is/are subscribed to the within instrument and
acknowledged to me thaLheTsJe/they executed
the same in jHS/her/thetf authorized
capacity(ies), and that by hw/tyw/fheir
signature(s) on the instrument the person(s),
or the entity upon behalf of which the
person(s) acted, executed the instrument.
WITNESS my hand and official seal.
OPTIONAL INFORMATION
The information below is not required by law. However, it could prevent fraudulent attachment of this acknowl-
edgment to an unauthorized document.
CAPACITY CLAIMED BY SIGNER (PRINCIPAL)
D INDIVIDUAL
I CORPORATE OFFICER
DESCRIPTION OF ATTACHED DOCUMENT
riE )
TITLaS
TITLE OR TYPE OF DOCUMENT
D PARTNER(S)
D ATTORNEY-IN-FACT
D TRUSTEE(S)
D GUARDIAN/CONSERVATOR
D OTHER:
NUMBER OF PAGES
-io;
DATE OF DOCUMENT
OTHER
SIGNER IS REPRESENTING:
NAME OFPERSt)N(S) OR ENTITY(IES)
RIGHT THUMBPRINT
OF
SIGNER
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APA 12/98 VALLEY-SIERRA, 800-362-3369