Signatures for Hospital Departments:
Please complete and send original to:
UC Davis Health System Contracts
Sherman Building, Suite 2300
Main Line: 734-3820 FAX: 734-3520
Signatures for School of Medicine/Nursing Departments:
DEPARTMENT ADMINISTRATOR/MANAGER (required) DATE DEPARTMENT CHAIR (required) DATE
DEPARTMENT CHAIR/ASSOCIATE DIRECTOR (required) DATE
INITIATING DEPARTMENT/DIVISION:
DEPARTMENT CONTACT PERSON:
Contact person should be knowledgable of contract details.
PHONE:
CHIEF ADMINISTRATIVE OFFICER (if applicable) DATE
EMAIL:
CONTRACTOR INFORMATION Start Date:
LEGAL NAME OF CONTRACTING ENTITY:
MAILING ADDRESS:
CONTACT INFORMATION: NAME & TITLE:
HAS THE CONTRACTING ENTITY PROVIDED A WRITTEN CONTRACT?
DESCRIPTION OF CONTRACTING ENTITY: Federal
End Date:
PHONE:
YES, please submit with request.
County
SOCIAL SECURITY # or FEDERAL TAX ID #:
EMAIL:
NO
Non-profit State
CONFLICT OF INTEREST
: IS THE CONTRACTING ENTITY A UNIVERSITY EMPLOYEE, OR A NEAR RELATIVE OF A UNIVERSITY EMPLOYEE?
DOES A UNIVERSITY EMPLOYEE OR HIS/HER NEAR RELATIVE OWN OR CONTROL MORE THAN 10% INTEREST IN THE CONTRACTING ENTITY?
If YES to either of the above, refer to P&PM 350-90.
For-profit or Individual
NO
NO
WHICH MISSION(s) DOES THIS AGREEMENT SUPPORT?
TEACHING / EDUCATION COMMUNITY / SERVICE PATIENT CARE
DESCRIBE HOW THIS AGREEMENT WILL BENEFIT THE UNIVERSITY or HOW IS IT RELATED TO THE UNIVERSITY MISSION:
Note: Research agreements are not processed by this office. Please submit projects which involve research at the
University to the UC Davis Office of Research.
WILL AN AFFILIATION AGREEMENT BE NEEDED?
YES NO
WILL RESIDENTS, FELLOWS or MEDICAL STUDENTS be PARTICIPATING in PATIENT CARE?
YES, specify:
For Residents and Fellows, an Authorization for Rotation Form must be submitted to the GME Program. Contact the Graduate Medical Education office for additional information.
INSURANCE COVERAGE
TO EXPEDITE REQUEST, PLEASE OBTAIN CERTIFICATE(s) OF INSURANCE FROM THE CONTRACTING ENTITY AND ATTACH WITH REQUEST.
* PROFESSIONAL LIABILITY IS NOT AVAILABLE FOR PROFESSIONAL CLINICAL ACTIVITIES THAT ARE NOT IN ACCORDANCE WITH BUS 81.
DEFINE POTENTIAL RISK TO UNIVERSITY:
NO
Updated: September 2014 Printed: 9 /15/201 4

d A
SPECIFIC SERVICE REQUIREMENTS: Will clinical services be provided by either party?
NATURE & PURPOSE OF AGREEMENT (Attach detailed scope of services to be performed as necessary.)
PLEASE LIST EACH SERVICE BEING PERFORMED:
NAME OF FACULTY/STAFF or SERVICE TIME COMMITMENT LOCATION or SITE OF WORK
YES NO
SERVICES ( I/P,O/P,Consults,Surgery,etc )
WILL ANY OTHER DEPARTMENT(S) BE INVOLVED?
YES
NO
IF YES, WHICH DEPARTMENT(S) and HOW?
WILL EITHER PARTY HAVE ACCESS TO THE OTHER'S PROTECTED HEALTH INFORMATION (PHI)?
YES, specify: NO
FINANCIAL
NO COST
EXPENSE
DAFIS ACCOUNT NUMBER:
INCOME
AMOUNT
*For applicability of UC required indirect costs please see:
http://www.research.ucdavis.edu/home.cfm?id=OVC,3,1463
FREQUENCY:
AMOUNT: (ATTACH RATE SCHEDULE OR BUDGET)
FUND SOURCE:
if applicable (agency, contract/grant title, and number)
AMOUNT:
SERVICES (I/P, O/p, Consulting, Surgery, etc)
(ATTACH RATE SCHEDULE OR BUDGET)
*** REIMBURSEMENT MUST BE MADE TO DEPARTMENT. DIRECT PHYSICIAN REIMBURSEMENT IS NOT ALLOWED. ***
ARE THERE ANY OTHER COSTS OR REIMBURSEMENTS TO BE INCLUDED IN AGREEMENT? (Staff, Supplies, Eqpt, Travel, etc.)
(If yes, please describe these additional costs in the rate schedule or budget)
YES
PATIENT ACCESS: The University must ensure that UC patients have adequate access to UC physicians and services.
Will existing patients continue to have adequate access to physicians and/or University resources if the services above are provided?
If NO, please explain why this agreement should be approved:
CLINICAL SERVICE AGREEMENT REVIEW:
YES
STOP -- DO NOT COMPLETE BEYOND THIS POINT.
Approval for School of Medicine/Nursing Departments:
J. Douglas Kirk, M.D., Chief Medical Officer DATE q Approved q Deferred q Denied
Dean/Designee DATE
Approval for Hospital Departments:
Ann Madden Rice, CEO, UC Davis Medical Center DATE
NO
NO
Printed: 9 /15/201 4
Approval for School of Medicine:
Approval for Hospital: