STATE OF LOUISIANA
PARISH OF EAST BATON ROUGE
AGREEMENT
THIS AGREEMENT (“Agreement”) is made and entered into this _____ day of March,
2006, by _____________________ Hospital, represented herein by _________________, duly
authorized (the “Hospital”), for the use and benefit of the Louisiana Department of Health and
Hospitals (“DHH”) and the Louisiana Hospital Association (“LHA”).
RECITALS
A.
As a consequence of Hurricane Katrina, a state of emergency was declared
through Proclamation No. 48 KBB 2005 on August 26, 2006, and, as a consequence of
Hurricane Rita, a state of emergency was declared through Proclamation No. 53 KBB 2005 on
September 20, 2005; and
B.
Louisiana hospitals, including Hospital, had the resources to respond to the
aforementioned emergencies, and Louisiana hospitals, including Hospital, did respond; and
C.
DHH has agreed to apply to the Federal Emergency Management Agency
(“FEMA”) to seek payment for qualifying sheltered expenses which have been incurred by
Louisiana hospitals, including Hospital, that have entered into a Memorandum of Understanding
with DHH, as part of the State Emergency Operations Plan, in areas catastrophically impacted by
Hurricanes Katrina and Rita or in areas of refuge for Louisiana residents evacuating from the
catastrophically impacted locations; and
D.
FEMA rules prohibit a private hospital (such as Hospital) from directly seeking
reimbursement of qualifying sheltering expenses but permit a state agency (such as DHH) to
make application on behalf of such private hospitals, including Hospital, provided that DHH
agrees to indemnify FEMA for any amounts which are improperly paid by FEMA and provided
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that DHH agrees to certain other requirements, including audit rights; DHH is further requiring
that Hospital agree to certain safeguards and other requirements as a condition to its seeking
reimbursement of qualifying sheltering expense from FEMA 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 sheltering expenses incurred
by such hospitals, and to otherwise assist such hospitals, including Hospital, with the task of
applying for reimbursement of qualifying sheltering expenses; and
F.
DHH and LHA have agreed to work together in seeking reimbursement from
FEMA for qualifying sheltering expenses for the benefit of Louisiana hospitals which responded
to the described catastrophes, including Hospital, provided that all such hospitals, including
Hospital, agree to the terms and conditions set forth herein.
NOW, THEREFORE, in consideration of the potential benefits to be obtained by
Hospital through submission of an application for reimbursement of qualifying sheltering
expenses to FEMA, Hospital hereby agrees as follows:
1.
Reimbursement Request.
Contemporaneously with its submission of this
Agreement to LHA, Hospital will furnish a completed “Hurricane Katrina/Rita Reimbursement
for Sheltering and Related Costs” 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, DHH or FEMA, to properly evaluate Hospital’s request that it be
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reimbursed for qualifying sheltering expenses.
Hospital accepts all of the reimbursement
requirements, limitations, and conditions which are set forth in the Reimbursement Request.
2.
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.
Hospital shall also pay interest on such funds if and to the extent that DHH is required to pay
interest to FEMA. 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.
3.
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
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.
4.
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 _________________________.
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5.
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.
6.
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, DHH and the Office of Contractual Review.
7.
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.
8.
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.
9.
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.
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IN WITNESS WHEREOF, the Hospital has executed this Agreement on the day, month
and year first written above.
WITNESSES:
__________________ HOSPITAL
__________________________
Print Name: ________________
BY:
______________________________
Name: ________________________
Title: ________________________
__________________________
Print Name: ________________
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