Aim To Please Phlebotomy ~ C210012 CITY OF TIGARD-CONTRACT SUMMARY&ROUTING FORM
Contract Overview
Contract/Amendment Number: C210012
Contract Start Date: 07/23/2020 Contract End Date: 12/31/2023
Contract Title: Mobile Phlebotomy Services
Contractor Name: VenaCare NW
Contract Manager: Leigh Erickson
Department: PD
Contract Costs
Original Contract Amount: $1,500.00
Total All Previous Amendments:
Total of this Amendment: $5,000.00
Total Contract Amount: $6,500.00
Procurement Authority
Contract Type: Vendor Agreement (Non-TI'1
Procurement Type: PCR 10.070 Sole Source
Solicitation Number:
LCRB Date:
Account String: Fund-Division-Account Work Order—Activit):1=e Amount
FY 21-22 100-4100-54001 $2,500.00
FY 22-23 100-4100-54001 $2,500.00
FY
FY
FY
Contracts & Purchasing Approval
Purchasing Signature:
Comments: Extend the end date, add compensation
DocuSign Routing
Route for Signature Name Email Address
Contractor venacarenw@gmail.com
City of Tigard Steve Rymer stever@tigard-or.gov
Final Distribution
Contractor venacarenw@gmail.com
Project Manager Leigh Erickson Leigh.Erickson@tigard-or.gov
Project Manager Lisa Shaw Lisa.Shaw@tigard-or.gov
Buyer Toni Riccardi tonir@tigard-or.gov
DocuSign Envelope ID: 31EE1509-8E30-403E-93E9-F3FOE469C412
CITY OF TIGARD,OREGON
AMENDMENT TO CONTRACT NUMBER 0210012
FOR
MOBILE PHLEBOTOMY SERVICES
AMENDMENT #2
The Agreement between the City of Tigard,a municipal corporation of the State of Oregon,hereinafter called
City, and VenaCare NW,hereinafter referred to as Contractor,is hereby amended as follows:
1. EFFECTIVE DATE AND DURATION
The term of this agreement is extended until December 31, 2023
2. COMPENSATION
The compensation for Services as described in the original agreement is amended to add $5,000.00 for a
total not to exceed contract value of$6,500.00.
3. All other terms and conditions remain unchanged.
IN WITNESS WHEREOF, City has caused this Amendment to be executed by its duly authorized
undersigned officer and Contractor has executed this Amendment upon signature and date listed below.
CITY OF TIGARD VENACARE NW
50oewsi3'p�a or oewsipixe eye
�se�:ese emea.-
Signature Signature
Steve Rymer venacare NW
Printed Name Printed Name
12/22/2021 12/22/2021
Date Date
Rev.8/21
CITY OF TIGARTI OREGON-CONTRACT SUMMARY FORM
(TxrsFoRmMusxAccomPANYEvERYCoNTRAcr) C210012
Contract Title: Mobile Phlebotoiny Services Number:
Contractor: Aim to Please Phlebotomy Contract Total:
Contract overview: Drawing and�g of laboratory specimens.
Initial Risk Level: ❑ Extreme ❑ High ® Moderate ❑ Low
Risk Reduction Steps:
Risk Comments:
Risk Signature:
Contract Manager: Leiyh Erickson Ext: 2761 Department. Police
le—
Type: ❑ Personal Svc ❑ Professional Svc ❑ Public Imp ❑ General Svc ❑ Coop Purchase
® Other: Start Date: End Date:
Quotes/Bids/Proposal: FIRM AmOUNT/SCORE
N/A
Account String: Fund-Division-Account Work Order- ctivity Tyke Amount
FY 20-21 100-4100-54001 $1.500.
FY
FY
FY
FY
AF tovals- LCRB Date:
Department Comments:
Department Signature: '712-3 b7 4L tr y-x jo 2 z 3 GDEc-+
Purchasing Comments:
Purchasing Signature:
City Manager Comments:
City Manager Signature:
After securing aH required approvals, forward original copy to the Contracting and Purchasing 0INce along with a
completed Contract Checklist.
V Aim to Please Phlebotomy 6464
L SW Borland Road Suite c-5
0
Tualatin, OR 97062
0 Agreement to Perform Mobile Phlebotomy Services to Washington County,
Tigard Police
111 pate Services Performed By: Services Performed For:
[Tctobcr 13, _dim to Please Phlelx'rrrnmr 'tk ashtngrom Counh,•Tigarcd Itnlice
2011) !464 SW Borland Road titutr 'Tigard and Hillsbr)ro,()rgon
('�� r C-5 Tualatin,C)R 97['1(,2
W
V)
Fhj.,Stareme.nr of Work(14 %xY is L�;sued pursuant to the 1lolrile PhItboromY Sen•tces Master Agreenutiu between
Wasbingtnn Mount•,'Tigard Police("Chent") and Arrn to Please Phlebotomy{"{.crntrattrrr"j.effective contingent
nn approval(the"Agrcement'1. I Itis ti()LX'>s subject to rhe terms and cui�dirrrxts cont weed in rhe Agreernt.
between the patties and is made a part rhereof. Any rerrn not orherwise defined herein shall have ri.1e Meaning
specrtrcd in rhe .lgreetnent. In the event of amt Con llict nr rnclrrtsrstenci•Iwm•een the lerins rrf tltis SOV-and the
terms of rhi�Ag,teernent,the terms of rhi_s SOW shall govern and Prevail.
Testis SOW#1101 (hereinafter called the"N(ff"'),effective,v,of c❑nnugent of approval.is entered Into br•and
Itenreen Conrracror and[Beer,acrd is subject to ti)e terms and conditions spccified betow.The E:xhibir{s}to this
S(AN',I any,shall he deemed ro he a part hereof. In the elrent of any inconsistencies benveen rhe rerun~rif tIic laid%
of this SI)W and the terms of the Eshibir(s) hereto,the terms of the bndv of this SOW shall prev-ail.
Period of Performance
111 Smice S shrill cIlinrnrtic e 1)11 COIIiirtgestt on Appro%--J.Arid shall corrrLnue di rough clnttingenr ern sipprovaI
Term,A and Conditions
Aim to Please Mobile Phlebotomy Services,Inc.
Agree,mL t Form
Shile'limt nj ll"nrk jor 11'v.rf+int;7nn C a'n;tl'.Ti�drll N&r •Rw'brr 1 1
2019
skim to Plc:Lsc phlebotomy(A2P)is respenisihlc for thr
drawing anti handling of laboratory specimen;.
Aim to ple,ea(!11111cbotomy is
not rnrslut[cd to Lg a:let% medical advice,rre2t or
diagnosc 311�onC.
A2 handlLs the dclivery of all�;aniplc,tet their proper
l:abonitot}'or runes over uvidcncr To the authorities,
Aim to Please Phlebotomy is nut rcNpon_yiblc for any
errors that may occur at the laboratory.Any errors in
collection caused by A-11 will be corrected by rr-drawingu
at no additional charge.
if we arrive at the appointmc-,lt for the blood draw and
arc unable to collect rhe i pComcil due tcc circumstances
beyond our euntivl(the patient n!fuses,1s not available ret
be drawn etc)the client wiii remain responsible for the
Full charge n f the draw,Anr'errors in collection caused
by .12P[drawing the wrong tubes,utl:)blc to obtain a
tiltisfaetory blood I7ow to collect the tpccinicn crc.)will
not incur a charge to the client or will be rcdcmn at no
additional chargc to the client.
Payment For our services i.elite with 30 day terms to
the account.pny able departmear through em:111
invoicing, Lam to Plcasc Phlebotomy is an independeur
phlebotomy service. Under no circumstances will-121'
divulge client information,Personal or other,to any'
autlunized perxannel.All clicnrs'information L�Awwe�t
kept confide-renal.We are frilly 1 TIPAA compliant and
respcct tlu'p17V:lCy'Yet the it idivid uals w sen,c,
1 understand the above terms and conditions.
Print Name
W 11 '.irk.per
'rr!e
Signaturc Katt
Notxcc of Atm to Please Phlebotomy Prtvaey Practices
'11-11S NOTICI )HSC€2.1131sS HOW MEDICAL
INFORIII.ATiON:IBC}UT YOU MAYBE USED AND
DISCLOSED AN13 I IOW YOU CAN GFT ACCESS
TO THIS INFORTMATION.PLEASE REVIEW IT
CAREFULLY.
A2P respects your privacy and understands that your
personal health information is sensitive.According the
Ifc-alth Insurance Portabiliry and Accountability Act of
1996(HIPAA),we cannot disclose your"protected health
information"to others unless we have your permission
or unless the law authorizes or requires us to do so.
LNcs and Disclosures
-Treatment.Your health information may be used by staff
members;or disclosed to other Inealth care professional,
for the purpose of evaluating your health,ch4no3ing
medical ccmchtions,and ptwoding tre.atmcnt.For
ex.tmple,results of laboratory tests and procedures will be
:wadable in your nnedical record to all health prufessir+nals
who may provide treatment or who mai be consulted by
staff members.
.S'laii-wal of ff-oi k jar If-ash Amn Cewun-.Tr and PYA'? -Orffjlur 13. 1
1019
Law enforcenicnt.Your hL.dth inf wnuttuhn muv he
discicsscd to law enforcement agencies,without your
pci-insxsicnt,rn support government audits and
inkpccmis,to faciiitatc law-enforcrnrnr ut�rstigatinshs,
mid to comply with govtrnment mandated mpornng-
lhiev».v+r0?it nrd:p,r 1!' r.ri..ri,PlNei C.4rll;r1, 17{r)rr1
201'
We are required by law to maintain the privacy of your
protected health information and to provide you with this
notice of privacy practices.
We An are required to abide by the prvacy policies and
pcaeticcs char are ontluicd in this notice.
Right to Revise Privacy Practices
As permitted by law,we reserve the right to amend or
modify our privacy policies and practices.These changes
in our polities anti practices may be required by changes
in feder..d and state law=and regulation.Whatever tltc
reason For these revision,,we will pnwide you with a
revised notice on your next office vtsit.The revised
policies and practice=will be applied to all protected
health information that we maintain.
Requests to InspectProtected Health In formation
As permitted by federal regulation,we require that
requests to inspect or copy protected health information
be submirttid in writing.You may obtain a form to
request access to your records by contacting the oFfice.
Please make all requests through Frank Capobianco.
Complaints/Contact Person
if you would like to submit a comment or complaint
al>s+ut our privacy pracrice s,you can do so by sending a
letter outlining your concems to:
Frank Capobianco
Ailln to Picric Phlebotom}/Ci O/Owncr
6464 SW Bofhuid Road Suite C-5
Tualatin,Oregon 97062
503-878-5412
if you believe that your privacy rights have been violated,
you should call the matter to our attention by sending a
letter describing the rause of your concern to the sam(.
address. You will not be penalized or otherwise reraltated
against for filing a complaint.
leilnwml r)01"ark Ibr If'arbhgioff Cwtith,.Tit urd P firer •f 7rralxr
1019
I'.ftcc•nve Date
I hLs Notlee t-cifcrnve on or after Johne 20115.
Client Responsibilifies
Chews will rrtlmlr}ma)-rtlrnt w'lthin terms of in days Ort rCI:CI LIg all clecryonIC 111v[MCe melee a numrh.-kin ul Ple;lse
11111ebosllmv will be om site ,virilm otiv hour for a Mood draw unless vvtanccr is huzardons otnd that ,vM Plc ba.ed rol a}ler
IlatilS IS111 tranme.
Fee Schedule
TI-tis h1pure is 1'i sc 9 ru S6D}ler draw for the first hour:irid$.mil per hour alter that rune frtme.
Number of
s ■ ■ Resources Rate Numberof ■
Verdpunclure draw l 560}mtr draw' 1
L•}xrrn eurml}llc rton rP rhi,llcrtormante PCritxl,1-etxlor and Chent will have Thr option to renew rhis Agreement for
;l=1 :tdilI -+Ital then .tared rltill her t)f hours a the rlle'11-current hourilrare for those resources ide rlriiicd.
Project -
- tkard and IWIshrIrn,()regim SVrgc:uu Mh1:e D,,tvis Iit11IlAAIIM11H111
Invoice Procedures
L'liellt will he invoked lnoarhh trtr rhs. phichwomy services, f.Unrs n111 rernit[32%'Mrllr u7thin remis 430 days of
1'ecelv1lls au elcctrnnle lnrcltce once :h tnrinrh. Parnmcnts tut service, tllvoiceci that:Ire nor received
within 3r1-si;sv's
tram datC ret invoice will he sit[sjcrr rr I a a" pellalrr per calendar in,nirIi.
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IN WITNESS WHEREOF,6-parsie,,licwtO Mare CAU.ed rhIN tis M-ru ht 6f"t:n•r as()f thr dIdl,ns(Irsth and
rear fust written alsnve.
Washington County, Tigard
Police Aim t❑ Please Phlebotomy
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