Exclusion Lists Screening. School shall screen all of its current and prospective owners, legal entities, officers, directors, employees, contractors, and agents (“Screened Persons”) against (a) the United States Department of Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities (available through the Internet at xxxx://xxx.xxx.xxx.xxx), (b) the General Services Administration’s System for Award Management (available through the Internet at xxxx://xxx.xxx.gov); and (c) any applicable state healthcare exclusion list (collectively, the “Exclusion Lists”) to ensure that none of the Screened Persons are currently excluded, debarred, suspended, or otherwise ineligible to participate in Federal healthcare programs or in Federal procurement or nonprocurement programs, or have been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible (each, an “Ineligible Person”). If, at any time during the term of this Agreement any Screened Person becomes an Ineligible Person or proposed to be an Ineligible Person, School shall immediately notify Hospital of the same. Screened Persons shall not include any employee, contractor or agent who is not providing services under this Agreement. XXXXX HOSPITALS LIMITED D/B/A THE HOSPITALS OF PROVIDENCE By: _ Name: Xxxxxxxx X. Xxxxxx Title: Market Chief Executive Officer Date: Address: 0000 X. Xxxxxx Xxxxxx Xx Xxxx, Xxxxx 00000 CANUTILLO INDEPENDENT SCHOOL DISTRICT By: _ Name: Xxxxxxxx Xxxxx Title: Superintendent Date: Address: 0000 Xxxxxxxx Xxxx Xx Xxxx, Xxxxx 00000 EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and treatment of patients of (“Hospital”), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the Program operated by (“School”) at Hospital unless such injury or loss arises solely out of Hospital’s gross negligence or willful misconduct. Dated this day of _ , 20 . Program Participant Witness EXHIBIT B
Appears in 1 contract
Samples: Affiliation Agreement
Exclusion Lists Screening. School shall screen all of its current and prospective owners, legal entities, officers, directors, employees, contractors, and agents (“Screened Persons”) against (a) the United States Department of Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities (available through the Internet at xxxx://xxx.xxx.xxx.xxx), (b) the General Services Administration’s System for Award Management (available through the Internet at xxxx://xxx.xxx.gov); and (c) any applicable state healthcare exclusion list (collectively, the “Exclusion Lists”) to ensure that none of the Screened Persons are currently excluded, debarred, suspended, or otherwise ineligible to participate in Federal healthcare programs or in Federal procurement or nonprocurement programs, or have been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible (each, an “Ineligible Person”). If, at any time during the term of this Agreement any Screened Person becomes an Ineligible Person or proposed to be an Ineligible Person, School shall immediately notify Hospital of the same. Screened Persons shall not include any employee, contractor or agent who is not providing services under this Agreement. XXXXX HOSPITALS LIMITED DXxxxx Hospitals Limited d/Bb/A THE HOSPITALS OF PROVIDENCE a The Hospitals of Providence By: _ Name: Xxxxxxxx X. Xxxxxx Title: Market Chief Executive Officer Date: Address: 0000 X. Xxxxxx Xxxxxx Xx Xxxx, Xxxxx 00000 CANUTILLO INDEPENDENT SCHOOL DISTRICT Canutillo Independent School District By: _ Name: Xxxxxxxx Xxxxx Title: Superintendent Date: Address: 0000 Xxxxxxxx Xxxx Xx Xxxx, Xxxxx 00000 EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and treatment of patients of (“Hospital”), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the Program operated by (“School”) at Hospital unless such injury or loss arises solely out of Hospital’s gross negligence or willful misconduct. Dated this day of _ , 20 . Program Participant Witness EXHIBIT B
Appears in 1 contract
Samples: Affiliation Agreement
Exclusion Lists Screening. School shall screen all of its current and prospective owners, legal entities, officers, directors, employees, contractors, and agents (“Screened Persons”) against (a) the United States Department of Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities (available through the Internet at xxxx://xxx.xxx.xxx.xxx), (b) the General Services Administration’s System for Award Management (available through the Internet at xxxx://xxx.xxx.gov); and (c) any applicable state healthcare exclusion list (collectively, the “Exclusion Lists”) to ensure that none of the Screened Persons are currently excluded, debarred, suspended, or otherwise ineligible to participate in Federal healthcare programs or in Federal procurement or nonprocurement programs, or have been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible (each, an “Ineligible Person”). If, at any time during the term of this Agreement any Screened Person becomes an Ineligible Person or proposed to be an Ineligible Person, School shall immediately notify Hospital of the same. Screened Persons shall not include any employee, contractor or agent who is not providing services under this Agreement. XXXXX HOSPITALS LIMITED D/B/A THE HOSPITALS OF PROVIDENCE Doctors Medical Center of Modesto, Inc. dba Doctors Medical Center: By: _ Name: Xxxxxxxx X. Xxxxxx Xxxx Title: Market Chief Executive Officer Date: Address: 0000 X. Xxxxxxx Xxxxxx Xxxxxx Xx XxxxXxxxxxx, Xxxxx XX 00000 CANUTILLO INDEPENDENT SCHOOL DISTRICT Xxxxxx-Las Positas Community College District dba Las Positas College: By: _ Name: Xxxxxxxx Xxxxx Xxxx Xxxxxxx Title: Superintendent Vice Chancellor, Business Services Date: Address: 0000 Xxxxxxxx Xxxxxx Xxxx Xxxxxx, Xx Xxxx, Xxxxx 00000 EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and treatment of patients of Doctors Medical Center (“Hospital”), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the Program operated by Las Positas College (“School”) at Hospital unless such injury or loss arises solely out of Hospital’s gross negligence or willful misconduct. Dated this day of _ , 20 . Program Participant Witness EXHIBIT BB CONFIDENTIALITY STATEMENT The undersigned hereby acknowledges his/her responsibility under applicable federal law and the Agreement between Las Positas College (“School”) and Doctors Medical Center (“Hospital”), to keep confidential any information regarding Hospital patients and proprietary information of Hospital. The undersigned agrees, under penalty of law, not to reveal to any person or persons except authorized clinical staff and associated personnel any specific information regarding any patient and further agrees not to reveal to any third party any confidential information of Hospital, except as required by law or as authorized by Hospital. The undersigned agrees to comply with any patient information privacy policies and procedures of the School and Hospital. The undersigned further acknowledges that he or she has viewed a videotape regarding Hospital’s patient information privacy practices in its entirety and has had an opportunity to ask questions regarding Hospital’s and School’s privacy policies and procedures and privacy practices. Dated this day of _ , 20 . Program Participant
Appears in 1 contract
Samples: Affiliation Agreement
Exclusion Lists Screening. School shall screen all of its current and prospective owners, legal entities, officers, directors, employees, contractors, and agents (“Screened Persons”) against (a) the United States Department of Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities (available through the Internet at xxxx://xxx.xxx.xxx.xxx), (b) the General Services Administration’s System for Award Management (available through the Internet at xxxx://xxx.xxx.gov); and (c) any applicable state healthcare exclusion list (collectively, the “Exclusion Lists”) to ensure that none of the Screened Persons are currently excluded, debarred, suspended, or otherwise ineligible to participate in Federal healthcare programs or in Federal procurement or nonprocurement programs, or have been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible (each, an “Ineligible Person”). If, at any time during the term of this Agreement any Screened Person becomes an Ineligible Person or proposed to be an Ineligible Person, School shall immediately notify Hospital of the same. Screened Persons shall not include any employee, contractor or agent who is not providing services under this Agreement. XXXXX HOSPITALS LIMITED DDoctors Medical Center of Modesto, Inc. d/Bb/A THE HOSPITALS OF PROVIDENCE a Doctors Medical Center By: _ Name: Xxxxxxxx X. Xxxxxx Xxx Xxxxxxxxxxxx Title: Market Chief Executive Officer President Date: Address: 0000 X. Xxxxxxx Xxxxxx Modesto, CA 95352 Xxxxxx-Las Positas Community College District d/b/a Xxxxxx Xx Xxxx, Xxxxx 00000 CANUTILLO INDEPENDENT SCHOOL DISTRICT College and/or Las Positas College By: _ Name: Xxxxxxxx Xxxxx Title: Superintendent Date: Address: 0000 Xxxxxxxx Xxxx Xx Xxxxxx Xxxx., Xxxxx 00000 0xx Floor Dublin, CA 94568 EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and treatment of patients of Doctors Medical Center (“Hospital”), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the Program operated by Xxxxxx-Las Positas Community College District dba Xxxxxx College and/or Las Positas College (“School”) at Hospital unless such injury or loss arises solely out of Hospital’s gross negligence or willful misconduct. Dated this day of _ , 20 . Program Participant Witness EXHIBIT B
Appears in 1 contract
Samples: Affiliation Agreement
Exclusion Lists Screening. School shall screen all of its current and prospective owners, legal entities, officers, directors, employees, contractors, and agents (“Screened Persons”) against (a) the United States Department of Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities (available through the Internet at xxxx://xxx.xxx.xxx.xxx), (b) the General Services Administration’s System for Award Management (available through the Internet at xxxx://xxx.xxx.gov); and (c) any applicable state healthcare exclusion list (collectively, the “Exclusion Lists”) to ensure that none of the Screened Persons are currently excluded, debarred, suspended, or otherwise ineligible to participate in Federal healthcare programs or in Federal procurement or nonprocurement programs, or have been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible (each, an “Ineligible Person”). If, at any time during the term of this Agreement any Screened Person becomes an Ineligible Person or proposed to be an Ineligible Person, School shall immediately notify Hospital of the same. Screened Persons shall not include any employee, contractor or agent who is not providing services under this Agreement. XXXXX HOSPITALS LIMITED D/B/A THE HOSPITALS OF PROVIDENCE Signatures on following page Doctors Hospital of Manteca, Inc. dba Doctors Hospital of Manteca By: _ Name: Xxxxxxxx X. Xxxxxx Xxxxxx, FACHE Title: Market Chief Executive Officer Date: Address: 0000 X. Xxxxx Xxxxxx Xxxxxx Xx XxxxXxxxxxx, Xxxxx XX 00000 CANUTILLO INDEPENDENT SCHOOL DISTRICT Xxxxxx-Las Positas Community College By: _ Name: Xxxxxxxx Xxxxx Xxxxxxx X. Xxxxxxx Title: Superintendent Vice Chancellor, Business Services Date: Address: 0000 Xxxxxxxx Xxxxxx Xxxx Xx XxxxDublin, Xxxxx 00000 CA 94568 Attn: Xxxxxxx X. Xxxxxxx Vice Chancellor, Business Services EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and treatment of patients of Doctors Hospital of Manteca (“Hospital”), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the Program operated by Xxxxxx-Las Positas Community College District (“School”) at Hospital unless such injury or loss arises solely out of Hospital’s gross negligence or willful misconduct. Dated this day of _ , 20 . Program Participant Witness EXHIBIT B
Appears in 1 contract
Samples: Affiliation Agreement
