AGREEMENT REQUEST
Please complete and send original to:
UC Davis Health System Contracts
Sherman Building, Suite 2300
Main Line: 734-3820 FAX: 734-3520
Signatures for Hospital Departments:
Signatures for School of Medicine Departments:
DEPARTMENT ADMINISTRATOR/MANAGER (required)
DATE
DEPARTMENT CHAIR (required)
DATE
DEPARTMENT CHAIR/ASSOCIATE DIRECTOR (required)
DATE
DIVISION CHIEF (if applicable)
DATE
INITIATING DEPARTMENT/DIVISION:
DEPARTMENT CONTACT PERSON:
Contact person should be knowledgable of contract details.
CONTRACTOR INFORMATION
PHONE:
Start Date:
EMAIL:
End Date:
LEGAL NAME OF CONTRACTING ENTITY:
SOCIAL SECURITY # or FEDERAL TAX ID #:
MAILING ADDRESS:
CONTACT INFORMATION:
NAME & TITLE:
PHONE:
HAS THE CONTRACTING ENTITY PROVIDED A WRITTEN CONTRACT?
DESCRIPTION OF CONTRACTING ENTITY:
Federal
EMAIL:
YES, please submit with request.
State
County
NO
Non-profit
For-profit or Individual
NO
CONFLICT OF INTEREST : IS THE CONTRACTING ENTITY A UNIVERSITY EMPLOYEE, OR A NEAR RELATIVE OF A UNIVERSITY EMPLOYEE?
DOES
DOES A
A UNIVERSITY
UNIVERSITY EMPLOYEE
EMPLOYEE OR
OR HIS/HER
HIS/HER NEAR
NEAR RELATIVE
RELATIVE OWN
OWN OR
OR CONTROL
CONTROL MORE
MORE THAN
THAN 10%
10% INTEREST
INTEREST IN
IN THE
THE CONTRACTING
CONTRACTING ENTITY?
ENTITY?
If
If YES
YES to
to either
either of
of the
the above,
above, refer
refer to
to P&PM
P&PM 350-90.
350-90.
NO
WHICH MISSION(s) DOES THIS AGREEMENT SUPPORT?
TEACHING / EDUCATION
COMMUNITY / SERVICE
PATIENT CARE
RESEARCH *
*STOP. Service Agreements processed by this office do not cover research studies. Proposed research activities require a separate agreement and must be submitted to Deans Office of Research.
DESCRIBE HOW THIS AGREEMENT WILL BENEFIT THE UNIVERSITY or HOW IS IT RELATED TO THE UNIVERSITY MISSION:
WILL AN AFFILIATION AGREEMENT BE NEEDED?
YES
NO
WILL RESIDENTS, FELLOWS or MEDICAL STUDENTS be PARTICIPATING in PATIENT CARE?
YES, specify:
NO
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 9.
DEFINE POTENTIAL RISK TO UNIVERSITY:
Updated: June 2010
Printed: 6/15/2010
AGREEMENT REQUEST
SPECIFIC SERVICE REQUIREMENTS:
Will clinical services be provided by either party?
YES
NO
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
WILL ANY OTHER DEPARTMENT(S) BE INVOLVED?
YES
LOCATION or SITE OF WORK
SERVICES (I/P,O/P,Consults,Surgery,etc )
IF YES, WHICH DEPARTMENT(S) and HOW?
NO
WILL EITHER PARTY HAVE ACCESS TO THE OTHER'S PROTECTED HEALTH INFORMATION (PHI)?
YES, specify:
NO
FINANCIAL
NO COST
EXPENSE
AMOUNT:
DAFIS ACCOUNT NUMBER:
INCOME
AMOUNT
(ATTACH RATE SCHEDULE OR BUDGET)
FUND SOURCE:
if applicable (agency, contract/grant title, and number)
*For applicability of UC required indirect costs please see:
http://www.research.ucdavis.edu/home.cfm?id=OVC,3,1463
FREQUENCY:
(ATTACH RATE SCHEDULE OR BUDGET)
AMOUNT:
SERVICES (I/P, O/p, Consulting, Surgery, etc)
*** 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)
PATIENT ACCESS:
YES
NO
YES
NO
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:
STOP -- DO NOT COMPLETE BEYOND THIS POINT.
Approval for School of Medicine Departments:
CLINICAL SERVICE AGREEMENT REVIEW :
Allan Siefkin, M.D., Chief Medical Officer
DATE
q
q
q
Approved
Deferred
Denied
Dean/Designee
DATE
Approval for Hospital Departments:
Ann Madden Rice, CEO, UC Davis Medical Center
DATE
Printed: 6/15/2010