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Home My WebLink AboutCommunity View Use Agreement - Michiana Health Information Network Inc. - Access to MHIN Clinical Data Repository for Ambulance Billing1316 COUNTY -CITY BUILDING 227 W JEVVERSON BOULEVARD SOUTi-i BEND. INDIANA 46601-1830 'Z-1iTy OF SOUTH BEND PETE BuTTiGIEG, MAY BOARD OF PUBLIC WORKS I January 23, 2018 Tony Cochrane Michiana Health Information Network, Inc. 220 W Colfax Ave., Suite 200 South Bend, IN 46601 RE: Community View Use Agreement Dear Mr. Cochrane: PHONE 574/235-9251 FAX 574/ 235-9171 The Board of Public Works, at its meeting held on January 23, 2018, approved the above referenced agreement regarding access to MHIN clinical data repository for ambulance billing in the amount of $2,400. Enclosed please find a copy of the agreement for your records. If you have any further questions regarding this matter, please call this Office at (574) 235- 9251. Sincerely, Linda M. Martin, Clerk Enclosure c: Andrew Myer, Fire Department GARY A. GIL01' SUZANNA M, FRITZBERG Et,17ABE'Ili A. MARADIK JAMFs A. MUF?LLM THERE SE J. DORAU MI-11AI's Clinical Data Repository Prepared For South Bend Fire Department Mr. Andrew J. Myer Assistant Chief of EMS Delivered To South Bend Fire Department amyerCasouthbendin.gov (574)235-7562 Delivered Date April 18, 2017 AGREEMENT 1D# SBFD041182017 Tony Cochrane M H IN, Director of Business Development Prepared By cochranetomhin.com 574-968-4347 COMMUNITY VIEW USE AGREEMENT This Use Agreement ("this Agreement") is entered into as of January 9, 2017, by and between MHIN Inc. ("MHIN") and the City of South Bend acting by and through its Board of Public Works, on behalf of the South Bend Fire Department (collectively, "the Participant"). MHIN and Participant are each referred to individually herein as a "Party" or collectively as the "Parties." NOW, THEREFORE, for and in consideration of the mutual covenants herein contained, MHIN and Participant agree as follows: AGREEMENT AND EFFECTIVE DATE As of the Effective Date, the Parties hereby agree that (i) Participant will have the rights and obligations relating to the use of the Health Information Exchange ("HIE") data set forth in the Agreement; and (0) MHIN will make the HIE data available and fulfill the other obligations of the Agreement subject to scheduled and unscheduled downtime as set forth in this Agreement. The Agreement is effective as of the date on which it is executed by both Parties, as set forth in the signature lines on Page 3 of this document ("Effective Date"). SCOPE OF MHIN SERVICES 1. MHIN will continue to provide access to its clinical data repository (named "Community View") to identified Users at Participant's organization for the Term of this Agreement 2. MHIN will create, administer, and manage all User accounts on behalf of Participant 3. MHIN will provide 24-hour monitoring and maintenance of the clinical data repository 4. MHIN will provide ongoing Helpdesk support and assistance PARTICIPANT RESPONSIBILITIES 1. Identify key staff to have access to Community View given their role and function 2. Engage Security Officer with the process of role/function determination within the organization as well as involving in the ongoing User management. 3. Manage the number of Users for whom access is granted and/or requested to only clinically or operationally appropriate staff members. 4. Help to manage the active User List by alerting MHIN when Users terminate or changes position to a position that does not require access to Community View. 5. Provide space, computer equipment, and Internet access for Participant's Users to access Community View FORMAL ANNUAL AUDIT Each year, the Parties will collaborate to perform a User Audit ("Annual Audit") of the Participant's Users. MHIN will perform and share the result of the Audit with Participant. Participant will review the Audit results for the purposes of reconciling and requesting the activation/deactivation of Users. Additionally, throughout the course of the year, and between the Annual Audits, informal audits may be performed during the regular course of providing access to Community View for Participant's Users. 617I74MIN-► OVA ASSUMPTIONS The existing Business Associates Agreement("BAA") between the Parties remains in place and active throughout the duration of this Agreement. The respective rights and obligations of the Parties as set forth in the BAA are incorporated herein. Users are employees or agents of Participant, and as such, receive regular HIPAA and Security training. MHIN shall provide access to Community View as described in this Agreement commencing upon the Effective Date and continuing to December 31, 2019 (the "Initial Term"). Upon expiration of the Initial Term, MHIN shall continue to provide the access on a year-to-year basis ("Renewal Term") unless termination notice is provided 60 days prior to the expiration of the Initial Term or 60 days prior to the expiration of any one-year Renewal Term. At the start of each one-year Renewal Term, MHIN reserves the right to invoke a 3% increase to the Fee. FEES AND BILLING Beginning January 1, 2018, Participant agrees to pay a Fee (the "Fee") for Community View of two - hundred ($200.00) dollars per month which is based upon the number of Users. Participant agrees that if the Annual Audit, or any informal User audit results in the number of Users exceeding fifteen (15) Users then the Fees of this Agreement increase to four -hundred ($400.00) dollars per month. MHIN will invoice Participant each month for the monthly Fee which provides access to Community View for the month of the dated invoice. Payment of the invoice is due within 30 days of the date of the Invoice. The invoice for Community View will be sent separate from any other invoice for any other Agreement executed between the Parties. [ Signature Lines on next page ] Agreed to: CITY OF SOUTH BEND BOARD OF PUBLIC WORKS Gary A. Gilot James A. Mueller Elizabeth A. Maradik G Therese J. Dora ATT ST: �].- a Martin, Clerk IVIHIN, Inc. By; Kelly Ha j 116 Date G97tiilly, FEWOr/ 1222. S, MICHIGAN STREXT SouTH BFND, INDIANA 466ol-2,82T CITYOF Soij�rH BEND PETF Bu'r'ricIEG, MAYOR SOUTHBENDFIREDEPARTMENT STEPHEN F. COX Fim, Cttm,' January 8, 2018 Board of Public Works 227 W, Jefferson Blvd Suite 1300 N. South Bend, IIN 46601 Dear Members of the Board, PTIONE 574/ 235-9M FAX 5741735-9305 II am requesting the approval of The Community View use Agreement between the South Bend Fire Department and Michiana Health Information Network (MHIN)l. The information exchange would benefit the South Bend Fire Department by letting us receive data of patients that we have transported to local hospitals. That data would allow us to evaluate many aspects of our responses. Those aspects are including, but not limited to, response times in critical time sensitive incidents, outcomes of drug administrations, and recognition of strokes and heart attacks. This partnership could also assist in future delivery in EMS care for the City of South Bend and St. Joseph County. Thank you for the consideration. Respectfully, Andrew J. Myer Assistant Chief of EMS JAMEs Lu(,CKI ToDD L SKWARCAN ANDRF-Wj. MYRR JOHN CORf'HIRR Fl,DFRi(,o RoDRIGUEZ, JR Ass,r. Cfuu OPF.RArmNs Ass`r% CmmSFtwicm Ass'n CHIFF EMS Assr, CITIFT'T'RAINING FIRE MARSHAL 1316 COUNTY -CITY BUILDING 227 W. JEF!'ERSON BOUL13VAIZD SOUT11 BEND. INDIANA 40001-1830 CITY OF SOUTI4 BEND PETE BUTTIGIEG, MAYOR BOARD OF PUBLIC WORKS October I I, 2016 DRONE 574/235-9251 FAX 574/235-9171 Michiana Health Information Network, Inc. Attn: Waldo Mikels-Carrasco Suite 200 220 West Colfax Ave South .Bend, IN 46601 RE: Business Associate Agreement - Exchange of Access to Medical Data with Fire EMS Personnel Dear Mr. Mikels-Carrasco: The Board of Public Works, at its meeting held on October 11, 2016, approved the above referenced agreement. Enclosed please a copy of the agreement for your records. If you have any further questions regarding this matter, please call this office at (574) 235- 9251. Sincerely, Linda M. Martin, Clerk Enclosure c: Andrew Myer, Fire Department GARY A. GiLOT DAVI€1 P. RELOs ELIZABeTH A, MARAM JAMEs A, MV13LLER TIiERESE J. DORALI BOARD OF PUBLIC WORKS AGENDA, ITEM REVIEW RE' QUEST FORM Date 10/04/2016 Department Fire BPW Date 10/11/2016 Phone 9255 Name Andrew Mver Legal Attorney Name Michael Srnidt Controller review is required for all Contracts $5,000.00 or more Controller [] and greater than one year in length per the City Purchasing Policy o;-:. Purchasing ❑ Iii� Mir�,�:= Agreement ❑ Contract J El Proposal -- - - Addendum ❑ Claim ❑ Bid Opening ❑Bid Award ❑ Re , to Advertise I ❑ Title Sheet Ll Quote Opening Quote Award ❑ Chq Order No. ❑ C/O & PGA No. El PCA ❑ Ease./Encroach. ❑ Traffic Control ❑ Resolution Other: Company or Vendor Name Michiana Health Information Network New Vendor F1 Yes LJ No El If Yes, Approved by Purchasing MBENVBE Contractor MBE I WBE Project Name N/A Project Number N/A -Funding Source NIA Account No. N/A Amount $ 00.00 Terms of Contract Purpose/Description The purpose of this a reement is to obtain medical data to improve EMS Res onses for the City of South Bend. There will be no mongy exhan ed for this agreement. y Amount of D ❑ Increase Decrease $ $ Previous Amount $ Current Percent of Change: % New Amount $ Total Percent of Change: % PO No. .,::uIs ... persa :. er•• pprova;....,::.:��.::::::.:::..::..:�::.:-��;:�.:�:�.:��:;�.:::'.;�:;::::��•�:�:•:.:::�:� Copy Original ❑ ❑ ❑ ❑ JI222 S. MIC.HIGAN STREET SDVYH BEND, INDIANA 466oI-2821 CITY OF SOUTH BEND PETS Bu'i-rIGIEV., MAYOR SOUTH BEND FIRE DEPARTMENT STFPHEN F. Cox FIRE CHiir Board of Public Works 227 W. Jefferson Blvd Suite 1300 N. South Bend, IN 46601 Dear Member of the Board, PHONE 574/ 235-9255 FAX 574/ 235-9305 I am requesting the approval of The Business Associate Agreement between The South Bend Fire Department and Michlana.Health Information Network (MHIN). The information exchange would benefit the South Bend Fire Department by letting us receive data of patients that we have transported to local hospitals. That data would -allow us to evaluate many aspects of our responses. Those aspects are including but not limited to, response times is critical time sensitive incidents, outcomes of drug administrations, and recognition of strokes and heart attacks. This partnership could also assist in future delivery in EMS care for the City of South Bend and St. Joseph County. Thank you for the consideration. Respectfull Andrew J. Myer Assistant Chief of EMS JAMEs Luccin TODD L. SK\`VARCAN AWI)RIm J. MYER JOHN CoKrHIER ft=uco RODRIGUM, JR ASs'r. CHiEP OPERAi,ioNs &sT, CHIEF+ SERvIcRs AssT. CHmP EMS Assn. Cmxi1 TRAINING FIRF. MARSHAL BUSINESS ASSOCIATE AGREEMENT This BUSINESS ASSOCIATE Agreement (this "Agreement") is entered into this 13' day of September 2016, by and between City of South Bend, Indiana ("City"), acting by and tiv_ough its Board of Public Works, (`Board") on behalf of the City's Fite Department ("SBFD") (collectively "Covered Entity") and Michiana Health Information Network, Inc. ("Business Associate" or "MHIN"). WHEREAS, Covered Entity has contracted with Business Associate to provide Products and Services to the Covered Entity and the Coveted Entity is required by law to enter into this Agreement with Business Associate; and WHEREAS, the fatties wish to disclose to each other certain information which may constitute Protected Health Information; and WHEREAS, the purpose of this Agreement is to satisfy certain obligations under the Federal Health Insurance Portability and Accountability Act of 1996 and its related regulations (HIPAA"), the Health Information Technology for Economic and Clinical Health Act, Title XIII of the American Retovety and Reinvestment Act of 2009 and xelated regulations promulgated by the Secretary (the "HITECH Act'). These provisions of the HITECH Act and the regulations applicable to Business Associate are collectively referred to as the "HITECH BA Provisions." NOW, THEREFORE, in consideration of the mutual promises below, and for other good and valuable consideration,. the receipt and sufficiency of which is hereby acknowledged, the Parties agree as follows: 1. Interpretation oftMs Agreement, Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits the Parties to comply with HIPAA. 2. Definitions. All capitalized terms used herein and not further defined below shall have the meanings set forth: in the HIPAA Regulations (as such term is defined below). (a) Administrative Safeguards. "Administrative Safeguards" shall have the same meaning as the term "administrative safeguards" in 45 C.F.R. § 164.304. (b) Electronic Protected Health. Information (EPHI), "Electronic Protected Health Information" shall have the same meaning as the term "electronic protected health information" in 45 C.F.R. § 160.103, limited to the information created, received, maintained or transmitted by Business Associate on behalf of Covered Entity. (c) HIPAA Regulations. "141PAA Regulations" are those regulations codified under Parts 160, 162 and-164 of Title 45 of the Code of Federal Regulations (C.F.R) relating to privacy and security of PHI, including specifically the Standards for Privacy of individually Identifiable Health Information at 45 C.F.R. part 160 and part 164, subparts A and E (the Trivacy Rule") and the Health Insurance Reform: Security Standards at 45 C.F.R. parts 160,162, and 164 (the "Security Rule') without limitation any amendments or successor statutes, rules or regulations to the Privacy Rule and Security Rule. (d) Individual. "Individual" shall mean the person who is the subject of the PHI, and has the same meaning as the term "individual" as defined by 45 C M 164.501 and shall include a person who qualifies as a personal representative in accordance -with 45 C,RR, 164.502(g). (e) Minimum Necessary. '`Minimum Necessary" shall mean the principle that PHI should only be used and disclosed to the extent needed for the purpose of the Use or Disclosure in accordance with 45 C.F.R. 164,502(b). ( Protected Health Information (PHI) "Protected Health Information" shall have the same meaning as the term "protected health information" in 45 CFR § 160.103, limited to, but only to the extent such regulatory definition includes, the information created, received, and/or retained by Business Associate from or on behalf of Covered Entity. (g,) Physical Safeguards. "Physical Safeguards" shall have the same meaning as the term "Physical safeguards" in 45 C.F.R. § 164.304. (h) Security Incident. "Security Incident" shall have the same meaning as the term "security incident" in 45 C.F.R. § 164.304. (i) Technical Safeguards. "Technical Safeguards" shall have the same meaning as the term "technical safeguards" in 45 CY.R. § 164.304, Treatment, Payment, and Health Cate Operations. "Treatment," "Payrnent" and "Health Care Operations" shall have the same meanings given under 45 CER Section 164.501 3.Obligations of Covered Entity (a) Covered Etitity sliall provide the Business Associate with any changes in, or revocation of, permission by the individual to use or disclose PHI, if such changes affect Business Associate's permitted or required uses and disclosures. (b) Covered Entity shall notify Business Associate of any restriction to the use or disclosure of PHI that the Covered Entity has agreed to in accordance with 45 CFR §164.522, (c) Covered Entity shall not request Business Associate to Use or Disclose PHI in any manner that would not be permissible under 45 CFR §164.520 if done by Covered Entity, except for those Uses or Disclosures for Data Aggregation or management and administrative activities of Business Associate. (d) Covered Entity shall use reasonable and appropriate safeguards to maintain, and ensure the confidentiality, privacy and security of the PHI transmitted to or received from the Business Associate, (e) Coveted Entity shall provide the Business Associate with the Notice of Privacy Practices it produces in accordance with 45 CFR �164.520, as well as any material changes to'such .notice. (0 Coveted Entity shall notify Business Associate of any limitation(s) in the Notice of Privacy Practices of Coveted Entity under 45 CPR §164,520, to the extent such limitation may affect Business Associate's use or disclosure of PHI. 4. Obligations of Business Associate (a) Business Associate will establish and maintain appropriate safeguatds and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information to prevent any Use or Disclosure of PHI, other than as provided fox by this Agreement or as .required by law. In accordance with 45 CFR §164.502 (e)(1)(R) and 164.308(b)(2), if applicable Business Associate shall ensure that any subcontractors that create, receive, maintain or transmit protected health information on behalf of the Business Associate agree in writing to the same terms, conditions, restrictions and mquitements that apply to Business Associate with respect to such information. (b) Coveted Entity shall not delegate to Business Associate the determination and processing of an Individual inembees request for amendments to his or hex PHI in a Designated Record Set, Business Associate shall promptly forward all requests fox amendments to PHI: to Coveted Entity upon receipt. Covered Entity will make the final determination to grant or deny amendments and complete all requited processing. Business Associate hereby agrees to make amendments to PHI in a Designated Record Set as and when approved by Coveted Entity so as to permit Covered Entity to timely comply with the requirements of 45 C.F.R. 164,526. (c) Covered Entity shall not delegate to Business Associate the determination and processing of Individual member requests for an accounting of Disclosures of PHI. Business Associate shall promptly forward all requests for an accounting of Disclosures of PHI to Covered Entity upon receipt. Covered Entity Nvili complete all required processing in connection with such request. Business .Associate hereby agrees to promptly make available information collected relating to applicable accountings of PHI Disclosures to Covered Entity, so as to permit Coveted Entity to timely respond to a request by an Individual for an accounting of Disclosures of Protected Health in accordance with 45 C.F.R.164.528 (d) Covered Entity shall not delegate to Business Associate the determination and processing of an Individual's request for access to his or her PHI in a Designated Record Set. Business Associate shall pxompdy forward all, requests for access to PHI to Covered Entity upon receipt. Coveted Entity will mane the final determination to grant or deny access to PHI in a Designated Record Set and complete allrequired processing in connection with such access. Business Associate hexeby agrees to promptly make available PHI in a Designated Record Set to Coveted Entity so as to permit Covered Entity to timely comply with the requirements of 45 C.F.R. 164,524. 2 (e) Business Associate agrees to make available to the Secretary (i) Business .Associate's internal practices, books and records relating to the Use and Disclosure of PHI for the purposes of determining Covered Entity's compliance with the Privacy Rule; and (u) Business Associate's policies, procedures and documentation relating to the safeguards described herein, for the purposes of determining Covered Entity's compliance with the Security Rule. (0 To the extent the Business As is to carry out one or more of Cornered Entity's obligation(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to the Covered Entity in the performance of such obligation(s). (g) Business Associate shall have procedures in place for mitigating any injurious or harmful effect from the Use or Disclosure of PHI in a manner contrary to this Appendix. (h)'Business Associate agrees that it will; (1) Implement Administrative Safeguards, Physical Safeguards, and Technical Safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of EPHI; (2) Ensure that any agent, including a subcontractor, to whom it provides such information agrees to implement reasonable and appropriate safeguards to protect it; and (3) Report to Covered Entity any use or disclosure of protected health information not provided for by the Agreement of which it becomes aware, including breaches of unsecured protected health information as required by 45 CFR §164.410 and any Security Incident of which it becomes aware. S. Permitted Uses and Disclosures by Business Associate (a) Minimum Necessary. Business Associate and its agents and subcontractors shall only request, Use and Disclose the minimum amount of PHI necessary to accomplish the purpose of the request, Use or Disclosure. (b) limits on Use and Disclosure of Information. Business Associate hereby agrees that the PHI shall not be further Used or Disclosed other than as permitted or required by this Appendix, or as Required by Law. (c) Stated Purpose for Use and Disclosure. Except as otherwise limited in this Agreement, Business Associate may Use and Disclose PHI to perform the functions, activities, obligations and services required to be performed as requested by the Covered Entity. Subject to section 5(b) above, Business Associate is permitted to disclose PHI received from Covered Entity for purposes of Tieatment, Payment, and Health Care Operations relating to members. 3 (d) Data Aggregation Services. Business Associate is permitted to Use or Disclose PHI; to provide "data aggregation services," as that teem is defiined'by 45 C.F.R. 164.501 relating to the Health Care Operations of Covered Entity. (e) Management and Administration of Business Associate. Except as otherwise limited in this Agreement, Business Associate may use and/or disclose PHI.for the proper management and administration of the Business Associate, or as required by Law. 6. HITECH Act Compliance The HITECH BA Provisions small apply commencing on February 17, 2010, or such other date as may be specified in the applicable regulations, whichever is later ("Applicable Effective Date"), Business Associate hereby aclrtiowledges and agrees that, to the extent it is functioning as a Business s Associate of Covered Entity, it will comply with the HITECH BA Provisions and with the obligations of a Business Associate as prescribed by HIPAA and the HITECH Act commencing on the Applicable Effective Date of each such provision. Business Associate and Cornered Entity further agree that the provisions of HIPAA and the HITECH Act that apply to business associates and that are required to be incorporated by reference in a business associate agreement are incorporated into this Agreement between Business Associate and Covered Entity as if set forth in this Agreement in their entirety and are effective as of the Applicable Effective Date. 7. Term and Termination (a) Term. The Term of this Agreement shall be effective as of the Effective Date, and shall terminate when all of the PHI provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is not feasible to return or destroy PHI, protections axe extended to such information, is accordance with the termination provisions in this Section. (b) Termination for Cause By Covered Entity, Upon the Coveted Entity's lmowledge of a material breach by Business Associate of this Agreement, the Covered Entity shall have the right to immediately terminate this Agreement. (c) Termination without Cause. This Agreement may be terminated by Covered Entity at any time upon thirty (30) day written notice. (d) Effect of Termination (1) Except as provided in patagitaph (2) of this Section 7(d), upon termination of this Agreement for any reason, the Business Associate shall return or destroy all PHI received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. Business Associate shall retain no copies of the PHI except as required by any applicable statute of limitations applicable to data retention. (2) In the event that Business Associate determines that returning or destroying the PHI is not feasible, the Business Associate shall provide in writing to Covered Entity 0 notification of the conditions that mane return or destruction infeasible, Business, Associate shall extend the protections of this Agreement to such PHI and limit Further uses and disclosures of such PHI to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such PHI. S. Regulatory References. A reference in this -Agreement to a section in the Privacy We means the section as in effect ox as amended, and fox which compliance is required. 9. Automatic Amendmennt. Upon the Applicable Effective Date of any amendment to the regulations promulgated by Health and Duman Services (HHS) with respect to PHI, this Agreement shall automatically amend such that the obligations unposed on Business Associate as a Business Associate remain in compliance with such regulations. 10, Survival. The respective rights and obligations of Business Associate and Covered Entity under this Agreement shall survive the termination of this Agreement. 11. Choice of Law. This Agreement shall be governed and construed under the laws of Indiana, without regard to choice of law rules. 12. Entire Agreement. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof, and supersedes all prior oral or written agreements, commitments or understandings with respect thereto, 13. Assignment. Either fatty shall be pexmitted to assign its rights and interests under this Agreement to an entity that purchases the assets of the Company or merges with the company, so long as (i) the . assignee agrees to be bound by all of the terms and conditions of this Agreement and (h) the assignee operates the business as a continuation of that Patty's business, 14, State Law Preemption. Pursuant to 45 CPR Section 160,203, certain provisions of state laws relating to the privacy of PHI may supersede the applicable similar provision(s) within the H2AA. Regulations (hereinafter referred to each as a "State Lava"). Business Associate shall comply with provisions of such State Laws applicable to Business Associate, I5. Notice. All notices or communications required or permitted pursuant to the tens of this Agreement'shall be in writing and will be delivered in pets on or by paeans of cettified or registered mail, postage paid, return ,receipt requested, to such patty at its address as set forth below, ox such other person or address as such party way specify by similar notice to the other party hereto, or by telephone facsimile with a hard copy sent by mail with delivery on the next business day. All such notices will be deemed given upon delivery or delivered by hand, on the third business day after deposit with the U.S. Postal Service, and on the first business day after sending if by facsimile. As to Covered Entity: South Bend Fire Deputiment 1222 South Michigan Street Attn: Andy Myer South Bend, Indiana 46601 With a copy to: . 5 City of South Bend Corporation Counsel 1200 County -City Building 227 West Jefferson Boulevard South Bend, Indiana 46601 As to Business Associate: .MAIN, Inc, Attn: Waldo hmels-Carrasco 220 West Colfax Avenue, Suite 200 South Bend, Indiana 46601 IN WITNESS WHEREOF, the parties hereto have executed this Agreement. CITY OF SOUTH BEND BOARD OF PUBLIC W RKS y Gary A. Gilot J es . Mueller r Elizabeth A. Maradik David P. Relos Therese J. Dora A ST: Linda Martin, Clerk MHIN, Inc. ih, lj-&, By: Date 0 BOARD OF PUBLIC WORKS AGENDA ITEM RE' VIEW REQUEST FORM Date 1/8/20 - 1 - 8 Department Fire BPVV Date 1/23/2018 Phone 9255 Name Andrew Myer, Assistant Chiief, EMS 0 Legal Z Attorney Name Elliott Anderson a) 0 2 Controller review is required for all'Contracts $5,000.00 or more -2 7t-- m Controller and greater than one year in length per the City Purchasing .2 E 0 W L- -0 co r0-y a_ :3 Policy Purchasing F] Check the Annronriatp Item TvnP — Perujimd fnr All .Rijhmi.cz.-qinn.,z 01=- El Contract El Proposal M� Addendiu—r�—1 Bid Opening F-1 Bid Aw-a-r-d" Req. to Advertise Title Sheet El Quote Opemng Quote Award Immirmr-RAi4 der No. C/O & PCA No. El PCA 16JE61*611 Traffic Control Resolution— Reauired Information ._or Vendor Name Compapy Mi'chiana Health Information Network New Vendor — [9. Yes D, No El If Yes, Approved by Purchasing MBE/WBE Contractor [] MBE Lj WBE Project Name PDo'eqt_Number Funding Source Other Professional Service Account No. 288.0902.422.31-06 Amount $2400 Terms of Contract Annual Purpose/Description Access and use of the MIN clinical data repositorV for ambulance billing.. For Chnnnp Orders 0n1v Amount of IElIncrease E] Decrease Previous Amount $ Current Percent of Change: New Amount % $ Total Percent of Change: % PO No. Dispersal After Approval Copy Original F-1 El R 1-1