STATE OF LOUISIANA
PARISH OF EAST BATON ROUGE
AGREEMENT
THIS AGREEMENT (“Agreement”) is made and entered into this _____ day of
________,
2008,
by
_____________________
Hospital,
represented
herein
by
_________________, duly authorized (the “Hospital”), the Louisiana Department of Health and
Hospitals (“DHH”) and the Louisiana Hospital Association (“LHA”).
RECITALS
A.
As a consequence of Hurricane Gustav, a state of emergency was declared
through Proclamation No. 51 BJ 2008 on August 27, 2008, and, as a consequence of Hurricane
Ike, a state of emergency was declared through Proclamation No. 52 BJ 2008 on September 7,
2008; and
B.
Louisiana hospitals, including Hospital, had the resources to respond to the
aforementioned emergencies, and Louisiana hospitals, including Hospital, did respond; and
C.
For the Louisiana hospitals, including Hospital, that assisted DHH in the
performance of the Emergency Support Function 8 (“ESF-8”) which involves public health and
medical services during a declared state of emergency for Hurricanes Gustav and Ike. DHH has
agreed to review the Louisiana hospitals, including Hospital, ESF-8 related expenditures and
reimburse the hospital out of funds specifically appropriated by the legislature, if any, to fulfill
the requirements of this agreement; and
D.
DHH is further requiring that Hospital agree to certain safeguards and other
requirements as a condition to its seeking reimbursement of qualifying ESF-8 related expense
from DHH for the benefit of Louisiana hospitals, including Hospital; and
E.
In accordance with the terms and conditions of a Cooperative Endeavor
Agreement between DHH and LHA, LHA has agreed to assist DHH in collecting all relevant
information and documentation from Louisiana hospitals which responded to the above
described emergencies, including Hospital, to establish the qualified ESF-8 related expenses
incurred by such hospitals, and to otherwise assist such hospitals, including Hospital, with the
task of applying for reimbursement of ESF-8 related expenses; and
F.
DHH and LHA have agreed to work together in the reviewing and processing of
the qualifying sheltering and related expenses incurred by Louisiana hospitals which responded
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to the described catastrophes, including Hospital, provided that such hospitals, including
Hospital, agree to the terms and conditions set forth herein.
NOW, THEREFORE, in consideration of the benefits to be obtained by Hospital through
submission of an application for reimbursement of qualifying ESF-8 related expenses, Hospital
hereby agrees as follows:
1.
Reimbursement Request.
Contemporaneously with its submission of this
Agreement to LHA, Hospital will furnish a completed “Reimbursement for Sheltering and
Related Costs LHA/DHA” form (the “Reimbursement Request”), together with all information
and documentation called for in the Reimbursement Request, and Hospital will further furnish
any other supplemental or additional information and documentation which may be requested by
LHA or DHH, to properly evaluate Hospital’s request that it be reimbursed for qualifying
expenses. Hospital accepts all of the reimbursement requirements, limitations, and conditions
which are set forth in the Reimbursement Request.
2.
Duplication of Benefits.
DHH must ensure that the reimbursement of ESF-8
related expenditures is not covered by any other source of funding.
Therefore, the hospital
must take reasonable steps to prevent such an occurrence, and provide documentation on a
patient-by-patient basis verifying that insurance coverage or any other source of funding
including private insurance, Medicaid, Medicare or other, has been pursued and does not exist
for these ESF-8 related cost.
3.
Repayment; Setoff.
In the event Hospital receives any funds pursuant to a
Reimbursement Request submitted on behalf of Hospital and it is determined that such funds
were paid improperly for any reason, Hospital agrees to immediately repay such funds to DHH,
together with interest on such funds if and to the extent that DHH is required to pay interest.
Hospital further agrees that DHH may retain any other funds due from it to Hospital from any
other source as an offset against any claim for reimbursement, fully reserving to Hospital all
rights of administrative and/or judicial review.
4.
Indemnification. Hospital will protect, indemnify and hold harmless LHA, the
State of Louisiana and DHH against any and all claims, losses, liabilities, demands, suits, causes
of action, damages, and judgments of sums of money to any party accruing against DHH or LHA
growing out of, resulting from, or by reason of any act or omission of Hospital or its agents,
servants, independent contractors, or employees while engaged in, about, or in connection with
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Hospital’s request for reimbursement and in connection with any incorrect, fraudulent, or
improper claims submitted by Hospital to LHA or to DHH. Such indemnification shall include
DHH and LHA fees and costs of litigation, including, but not limited to, reasonable attorney’s
fees. Hospital shall provide and bear the expense of all personal and professional insurance, if
any, related to its duties arising under this Agreement.
5.
Taxes. Hospital agrees that it is solely responsible for the payment of taxes, if
any, from any funds it receives as a result of a Reimbursement Request submitted on its behalf.
Hospital’s taxpayer identification number is _________________________.
6.
Property Rights. Hospital’s Reimbursement Request and any records, reports,
documents and other material delivered or transmitted by Hospital to LHA shall be and shall
remain the property of DHH. Hospital may retain copies of all such materials.
7.
Assignment.
If Hospital assigns or transfers its rights pursuant to a
Reimbursement Request to any bank, trust company, or other person or entity (if such
assignment or transfer is permitted by law), Hospital will promptly furnish written notice of such
assignment or transfer to LHA and DHH.
8.
Audit Rights. Hospital acknowledges that DHH, the Legislative Auditor of the
State of Louisiana, and/or the Office of the Governor, Division of Administration shall have the
rights to audit all accounts of Hospital which relate to its Reimbursement Request. This audit
right shall extend from the date a Reimbursement Request is submitted and shall continue for a
three-year period following final payment or other disposition of Hospital’s Reimbursement
Request or Reimbursement Requests.
9.
Partial Invalidity; Severability. If any term, covenant, condition, or provision of
this Agreement or the application thereof to any person or circumstances shall, at any time or to
any extent, be invalid or unenforceable, the remainder of this Agreement, or the application of
such term, covenant, condition or provision to persons or circumstances other than those as to
which it is held invalid or unenforceable, shall not be affected thereby, and each term, covenant,
condition, and provision of this Agreement shall be valid and be enforced to the fullest extent
permitted by law.
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10.
Conditions. This Agreement is subject to and conditioned upon the appropriation
of funds from the legislature specifically to fulfill the requirements of this agreement; and no
liability or obligation for payment will develop between the parties until this Agreement has been
approved by required authorities of DHH.
11.
Controlling Law. The validity, interpretation, and performance of this Agreement
shall be controlled by and construed in accordance with the laws of the State of Louisiana.
IN WITNESS WHEREOF, the Hospital has executed this Agreement on the day, month
and year first written above.
WITNESSES:
__________________ HOSPITAL
__________________________
BY:
Print Name: ________________
______________________________
Name: ________________________
Title: ________________________
__________________________
Print Name: ________________
WITNESSES:
DEPARTMENT OF HEALTH AND HOSPITALS
__________________________
BY:
Print Name: ________________
______________________________
W. Jeff Reynolds, Director
DHH-OMF-Division of Fiscal Management
__________________________
Print Name: ________________
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