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Medical Transport Agreement_Hospital Sample 07-13-2018

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Published by admin, 2018-07-13 12:51:29

Sky Nurses HOSPITAL Medical Transport Agreement - SAMPLE

Medical Transport Agreement_Hospital Sample 07-13-2018

MEDICAL TRANSPORT &
CASE MANAGEMENT
AGREEMENT WITH

HOSPITAL NAME

JUNE 1, 2018

SKY NURSES, LLC
6530 West Rogers Circle, Suite 31, Boca Raton, Florida 33487

1. GENERAL

1.1 SKY NURSES, LLC (hereinafter referred to as “Company”) and HOSPITAL NAME (hereinafter
referred to as the “Client”) (each a “Party” and collectively, the “Parties”) are entering into this
Medical Transport and Case Management Agreement (hereinafter referred to as “this Agreement”)
to offer non-emergency, medical, travel and other assistance services to Client.

1.2 Both Parties recognize that each has sufficient capacity to enter into this Agreement and are willing
to act as independent Companies for the provision of services, based on the terms outlined below.

2. OBJECTIVES

2.1 Client hereby grants Company the right to operate as an approved service partner, in order to
provide assistance to Client and its patient (hereinafter referred to as “the Patient”) as may be
requested by the Client. Company hereby undertakes to attend to all assistance requests from
Client covering such territories designated or of all continents, for the services described under
Section 14 “Services” (hereinafter referred to as “the Services”).

2.2 Within the framework of this Agreement, Company shall to the best of their abilities provide and
coordinate domestic and international assistance as specifically authorized by Client to any Patient
or entity referred by Client to Company.

3. OBLIGATIONS

3.1 Company agrees to provide services authorized by Client per the terms and conditions of this
Agreement.

3.2 Company shall establish and maintain for the duration of this Agreement a service center subject to
the following conditions, namely that the center will:
a) Operate twenty-four (24) hours a day, year-round inclusive of Sundays and public holidays;
b) Be operated by English-speaking coordinators; and
c) Be operated by coordinators specifically trained in dealing with non-emergency medical
situations.

3.3 The operating obligations of both Parties with regard to the provision of assistance services under
this Agreement are as follows:
a) To provide the other Party with precise instructions and particular details which may be
necessary or helpful to the other Party in discharging its obligations;
b) To ensure that both Parties have mutual telecommunication access to each other’s centers
or staff twenty-four (24) hours a day, seven days a week, as detailed under “services” for the
purpose of obtaining any and all information or authorization required by each other under
the terms of this Agreement.
c) Each Party reserves the right to contact the other Party twenty-four (24) hours a day during
a period of this Agreement in connection with the Services.

4. THE PROCESS

4.1 Client will inform Company of any new case by telephone, facsimile or email. The initial information
should have all necessary details concerning the Patient, together with the case reference and
contain precise instructions concerning the services required.

4.2 Company can provide an approximate price to complete a medical transport based upon preliminary
information submitted to Company. A firm price can be established with complete medical
information, specific patient location and destination, type of ground transport, required clinician

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
Assist[email protected]
www.SkyNurses.com

Page 1 of 10

qualifications, medical equipment needed, etc. Until the price is approved by the Client, Company
will not mobilize a clinician nor make any financial commitments such as the purchase of airfare.
4.3 As much as possible, Client will provide Company the most current and complete medical
information in order to complete its due diligence and assess the medical transport requirements. In
addition, the Client can specify its own requirements to accomplish the medical transport.
4.4 If the Client is unable to provide adequate medical information on the patient’s condition and health
status, Company is not obligated to provide services. If Company elects to proceed having notified
the Client that it has not received adequate medical information, it does so only at the Client’s risk
and with Client approval.
4.5 If applicable for a medical transport, it is the Client’s responsibility to obtain the fit for flight on
commercial air document from the treating physician prior to discharge from a medical facility. If this
document is not obtained prior to departure to an airport, Company, at its sole discretion, may elect
not to proceed with the medical transport. If Company proceeds with the transport without the fit for
flight document, it does so solely at the Client’s risk. Any and all costs that may result from a delay
or cancellation of a transport resulting from the Client’s failure to meet this obligation, will be the
responsibility of the Client.
4.6 If medical equipment is needed to safely complete the medical transport, a Medical Fitness for Air
Travel Form (“MEDIF”) must be approved by the respective air carrier. Depending upon the air
carrier, the MEDIF will be completed and submitted to the airline by Company. There may be a
situation in which the MEDIF must be signed by the treating Physician rather than the Company’
Medical Director and this document will also serve as the fit for flight document or medical clearance.
This MEDIF may take up to 72 hours for processing and approval by the air carrier. If the Client
wishes Company to proceed with the mobilization of the clinician and the medical transport in
advance of the MEDIF approval, Company may elect to do so but solely at the Client’s risk and
expense.
4.7 Company will ensure good performance of the assignment delegated to its Medical
Escorts/Clinicians. Company will keep Client fully informed of the course, progress and condition of
the Patient for each and every case handled.
4.8 Once a Clinician arrives at the patient’s location, he/she will complete a patient assessment and
submit this report to Company medical department. If applicable, the Clinician will also obtain any
patient medical information from the medical facility as needed to complete the assessment and
coordinate the patient’s travel schedule with the medical facility.
4.9 Company will inform Client of any event, strike, riots, etc., likely to affect the progress of the
assistance service.
4.10 Company will ensure that all said assignments will be performed with great care to protect the
Patient, Client and Company.
4.11 Company and its staff shall render the Services in a competent, professional and ethical manner at
all times in accordance with prevailing standards of practice, and all applicable statutes, regulations,
rules, orders and directives of any and all applicable governmental and regulatory bodies having
competent jurisdiction.

5. TERMS AND CONDITIONS

5.1 Client must send a separate Letter of Guarantee prior to purchase of transportation or mobilization of
the clinician unless a contractual agreement or arrangement stating otherwise is in place. Upon
completion of services, Client will be sent an invoice and payment is due 30 days from receipt of
invoice. Any payment after 30 days will be assessed a late fee of 2.0% per month.

5.2 If any unforeseen medical or transportation expenses are incurred outside of Company's control, it
will become the responsibility of Client to pay for any expenses incurred because of such events and

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 2 of 10

they will be charged accordingly. Client will be notified prior to Company paying any of these
additional costs only if it is reasonable to expect this communication and if there is adequate time
and the means for said communication for approval by Client.
5.3 Airfare prices are subject to change and are not guaranteed until time of purchase. If airfare is
requested and purchased, Client is subject to the air carrier's rules for that ticketing to include
charges and fees for cancellations or any changes in dates, locations, etc. Unless otherwise
requested, non-refundable tickets are always purchased for the Patient and the clinician as a
standard practice because of the lower prices and the significant savings to Client. Under certain
circumstances, transports that are scheduled well in advance of the travel dates may require
purchase of refundable airline tickets for the clinician. Company cannot guarantee seat availability
nor hold airfare rates for Client under any circumstances.
5.4 If there is a disruption, delay, change, or cancellation of any or all travel arrangements due to
unforeseen health issues, fit-to-fly concerns or changing health circumstances, Client is liable for all
charges, costs, and expenses to Company resulting from these events. Client specifically recognizes
that Company is merely arranging the air transportation and Client hereby acknowledges and freely
accepts liability and costs for delays, flight diversion, or failure of aircraft to depart from or arrive at
any point according to any schedule, agreement or otherwise, for whatever reason, including but not
limited to problems with the aircraft, airline, weather conditions, or acts of God, or any causes
beyond the control of Company. Company will notify Client to obtain approval prior to accepting or
making payment for any such costs caused by events outside the control of Company, unless it is
not reasonably possible to do so given time constraints, communication problems, and/or the
circumstances.
5.5 It is understood that trips may be canceled and/or rescheduled due to various reasons outside of
Client's control and any such notification must be in writing. However, the amount quoted and the
services to be provided are not transferable and are only to be provided for the person or persons
indicated in the quote provided. If a trip is rescheduled, there will be a minimum administrative fee of
$500.00 (USD) in addition to any cancellation fees for airfare, hotels, ground transportation, etc.
5.6 The medical management fee includes the review of the Patient's medical records by Company,
obtaining a medical report from the attending physician, on-call medical personnel, and monitoring of
the transport as it progresses. Most airlines require 48-72 hours for medical clearance approval. The
airlines will not approve medical clearance until tickets have been purchased. Company will make
every attempt to obtain medical clearance on a commercial airline, however, only the airline can
approve medical clearances. The airline has the right to deny passage to any passenger who
presents unwell and who they feel may pose a risk of diversion. A non-refundable deposit of $500.00
(USD) is required to begin the medical process. This non-refundable deposit will be applied to the
total balance due, should Company complete the transport.
5.7 Prior to and/or upon quote acceptance, Company will speak with Client to obtain information about
the Patient’s health and mobility needs. Client agrees to truthfully answer all questions regarding the
Patient’s current health conditions and mobility status as well as provide as much information as
possible to assist in the evaluation process. This is essential so that the appropriate Level of Service
and/or clinician will be assigned, and that the chosen clinician will have the necessary skills to
perform his/her job in the safest and best possible manner. Concealing or withholding information is
a very serious matter and can impact the Patient’s health and safety while travelling. It may also be
grounds for cancellation of this Service Agreement, immediate termination of services by Company,
and possible financial penalties for additional costs and expenses incurred by Company.
5.8 Client may pay by bank wire, check, or credit card. If paying by credit card, there will be a credit card
charge added to the quoted price. Furthermore, Client hereby agrees that if it makes payment by
credit card and has a dispute or disagreement with Company, Client will not raise this dispute with
Client's credit card company or seek adjudication of any dispute with Company through or by Client's

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 3 of 10

credit card company. Client agrees that if Client pays Company by credit card, Client will not instruct
Client's credit card company to reverse such charges.
5.9 Any dispute or disagreement arising out of or in connection with this Agreement will be amicably
settled between both Parties. If both Parties are unable to settle amicably any dispute within a
reasonable time, this Agreement shall be governed by and construed in accordance with the laws of
the State of Florida and will be litigated in that State or in the Federal Courts located in that State.
Any litigation commenced in accordance with the laws of the State of Florida will be instituted within
Palm Beach County. In any litigation between Company and Client, the prevailing Party will be
entitled to recover reasonable attorney's fees and costs at all levels.

6. INVOICE SUBMISSION AND PAYMENT

6.1 Upon completion of performing the Services, Company will submit the final invoice to Client via
email, facsimile or mail. Final invoices will be issued within 10 days from the date services were
rendered. Company’ invoice will include the following details: patient name, date of birth, service
dates, a breakdown of approved charges for service rendered as quoted and total balance due.
Invoice will be submitted to Client as follows:

Email Address: _________________________________________________________
Facsimile: _________________________________________________________
Mailing Address: _________________________________________________________

6.2 Payment of invoices or any unpaid balances shall be made in US Dollars by Company check, Credit
Card, Debit Card or ACH to Company within thirty (30) days of final invoice receipt or the agreed
duration. Any payment after 30 days will be assessed a late fee of 2.0% per month. A Credit Card
payment is only acceptable if this was established and approved by Company during the quote
submission and approval process as the method of payment for services.

7. Notices

7.1 All notices, requests, demands, waivers and other communication required or permitted to be given
under this Agreement, shall be in writing and may be delivered at or sent by registered mail,
facsimile or email transmission to the following address:

Notice to: ________________________________________________________
Address: ________________________________________________________
Telephone: ________________________________________________________
Facsimile: ________________________________________________________
Email: ________________________________________________________

Notice to: Sky Nurses, LLC
Attention: John Naccarelli
6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487
Email: [email protected]

8. CONFIDENTIALITY

8.1 Client and Company shall keep confidential all information disclosed to it pursuant to this
Agreement.

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 4 of 10

8.2 The Parties agree to comply with all relevant federal and state law with respect to the confidentiality,
privacy, and security of protected health information, including, but not limited to, the federal Health
Insurance Portability and Accountability Act, Subtitle D of Title XIII (Health Information Technology
for Economic and Clinical Health Act) of the American Recovery and Reinvestment Act of 2009 and,
together with their accompanying regulations, as each may be amended from time to time
(collectively “HIPAA”) and Client’s policies, as they may be amended or modified from time to time.

8.3 The obligations of confidentiality contained in this Agreement shall not apply to any information
which:
a) Is already known to the recipient without breach of this Agreement;
b) Becomes part of the public domain without breach of this Agreement;
c) Is obtained by the recipient from any third party who is under no obligation to the discloser to
keep the information confidential; or
d) Is disclosed as required by law.

9. LIABILITIES AND INDEMNITIES

9.1 Client agrees to release, defend, indemnify and hold Company, its directors, stockholders, officers,
employees or agents free and harmless from and against any and all claims, suits, actions, or
proceedings cost and expenses including attorney’s fees which may be filed, charged or adjudged
against Client or any of its medical staff, officers, employees or agent on account for or arising from
or in any way connected with the medical services provided by Client under this Agreement.

9.2 Company agrees to release, defend, indemnify and hold Client, its medical staff, officers, employees
or agents free and harmless from and against any and all claims, suits, actions, or proceedings, cost
and expenses including attorney’s fees, which may be filed, charged or adjudged against Company
or any of its directors, stockholders, officers, employees, or agents on account of or arising from the
Services provided by Company under this Agreement.

10. REPRESENTATIONS

10.1 This Agreement constitutes the complete understanding between Company and Client regarding its
terms and conditions, and terminates, cancels and supersedes all prior oral or written expression of
intent, representation and warranty, with respect to the subject matter hereof. In case this
Agreement conflicts with any other agreement, this agreement shall prevail. Each of the Parties
hereby represents and warrants to the other that it has the necessary power, approvals and authority
to enter into this Agreement and that it shall perform the obligation herein provided in a timely and
competent manner.

10.2 Nothing contained in this Agreement shall be construed as to make Client an employee, joint venture
partner or associate in any form of association with Company. Conversely, nothing contained in this
Agreement shall be construed as to make Company an employee, joint venture partner or associate
in any form of association with Client.

10.3 Company will perform the services described herein under the general direction of Client and in
compliance with applicable laws.

10.4 This Agreement shall be binding upon the Patient to the benefits of the Parties hereto and their
respective heirs, executors, administrators, principals, successors-in-interest and assigns. Neither
this Agreement nor any of the rights, interests or obligations hereunder shall be assigned by any
Party hereto without the prior written consent of the other Party.

10.5 This Agreement may be amended or modified only in writing and must be agreed upon and signed
by duly authorized representatives of both Company and Client.

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 5 of 10

10.6 Client and Company agree not to use or publish including electronic or other media each other’s
names or logo without prior written permission.

10.7 Each Party shall obtain and maintain appropriate professional liability and commercial general
liability insurance coverage in accordance with the minimum amounts required from time to time by
applicable federal and state laws and regulations, but at no time shall the terms or coverage
amounts of each Party’s professional liability insurance be less than $1 million per claim and
$3 million in the aggregate. Both Parties may request evidence of insurance from the other Party,
and the other Party shall promptly provide such evidence to the requesting Party in a timely manner.
Each Party shall ensure that the other Party receives at least 30 days’ notice prior to the termination
of any insurance policy required by this agreement.

11. DISPUTE RESOLUTION

11.1 The Parties will attempt to amicably settle any dispute or difference arising out of or in connection
with this Agreement. If both Parties are unable to settle amicably any dispute within a reasonable
time, this Agreement shall be governed by, and construed in accordance with the laws of the State
of Florida. This Agreement is drafted under the laws of the State of Florida and the venue for any
legal recourse under the laws as written in the State of Florida, and the venue for any legal recourse
shall take place under these laws and be adjudicated in Palm Beach County, Florida.

11.2 Further, the parties agree that any controversy or claim arising out of, or relating to, this Agreement,
or breach thereof, shall be settled by arbitration in accordance with the rules of the American
Arbitration Association in the State of Florida, under their auspices and the parties agree to have any
dispute heard and adjudicated under these rules in Palm Beach County, Florida and both parties
agree to be bound by the decision of the arbitrator and to pay their proportionate fees as required
under the rules of the association and judgment upon the award rendered by the arbitrator(s) may
be entered into any court having jurisdiction thereof.

11.3 In any litigation between the Parties, the prevailing Party will be entitled to recover reasonable
attorney’s fees and costs at all levels.

12. FORCE MAJEURE

12.1 Neither Party shall be responsible for any failure or delay to comply with the terms of this Agreement
where such failure or delay is due to force majeure. The term “force majeure” as used herein shall
include but not be restricted to acts of God, epidemics, tidal waves, explosions, fires, lightning,
earthquakes, hurricanes, wars, riots, civil disturbances, strikes, lawful orders, act of any government,
whether national municipal or otherwise or any agency thereof or juridical action or any other event
which is unpredictable, sudden, insurmountable and outside the control of the Parties.

13. TERMINATION OF AGREEMENT

13.1 This Agreement shall take effect from the date of the signing for a period of one (1) year and shall
automatically be renewed each year, unless sooner terminated by either Party. Both Company and
Client shall be entitled to terminate this Agreement by giving the other Party at least thirty (30) days
prior written notice. Client shall pay all outstanding undisputed claims and requests for payment to
Company within 15 days prior to the effective date of termination of this agreement.

13.2 Notwithstanding the above, this agreement may be terminated with immediate effect forthwith for
cause by a written notice to the Party in breach,
a) If the other Party becomes insolvent, is adjudged bankrupt or becomes the subject of
dissolution, liquidation or bankruptcy proceedings, whether voluntarily or involuntarily or

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 6 of 10

if the other Party applies for judicial or extra-judicial settlement with its creditors, makes
an assignment for the benefit of creditors;
b) If the other Party is in breach or default of any of the material terms or conditions of this
Agreement and shall fail to remedy such breach or default to the satisfaction of the
requesting Party within 14 days of receipt of written notice from the Party asserting the
breach or default.

14. SERVICES

Company Services may include the following depending upon Client’s request and the Patient’s needs:
1. 24/7 continuous operation and reporting
2. Booking air transport arrangements for the Patient, his/her relatives, and a medical escort
(clinician)
3. Performing Pre-determination assessment on-location for Patient transport
4. Coordination of hospital admissions and home health services
5. Reviewing Patient medical records
6. Bedside-to-bedside care
7. Performing medical and non-medical repatriations with qualified clinician, medication, and
equipment
8. Assistance in obtaining required travel documents and/or approvals for repatriation
9. Coordination with foreign embassies and/or consulates
10. Obtaining Medical Clearance (MEDIF) from respective airline
11. Obtaining fit-to-fly document from treating physician
12. Coordination of International Stretcher Service on commercial airline
13. Status reporting during the entire transport
14. Arranging customs and other airport assistance
15. Booking reservations for hotel accommodations
16. Organization of car transfers or ground transportation from/to hotels, airports, and other
destinations

15. PRICE LIST

15.1 Price List for Medical Escort Services and Unfunded/Uninsured Patient Case Management (See
Exhibit A)

[Signature Page to Follow]

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 7 of 10

Agreed and Accepted on behalf of Sky Nurses, LLC:

Signed: ____________________________________ Date: ________________________

Name: John Naccarelli
Title: CEO

Agreed and Accepted on behalf of Client:

Signed: ____________________________________ Date: ________________________
Name: ____________________________________
Title: ____________________________________

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 8 of 10

Exhibit “A”

Pricing for Medical Escort Services and Unfunded/Uninsured Patient Case Management

Associated Travel Cost

Company will quote estimated travel expenses (Flights, Hotel, and Ground), however, will bill the client based on
prices received from the supplier(s). There may be additional airline ticketing or service fees added to the Actual
Cost. The travel expense fee will not exceed the quoted amount, unless authorization is obtained in advance
from the client. At the client’s request, receipts can be furnished with an invoice.

Medical Personnel (Daily Rate)

Registered Nurse (Critical Care or Emergency Room) $ 900.00 - 1200.00

First Responder Paramedic $ 850.00 - 1000.00

Respiratory Therapist (must be accompanied by a Registered Nurse or Physician) $ 850.00 - 1000.00

Physician (Critical Care or Emergency Room) $ 1950.00 - 2800.00

Non-Medical Assistance $ 700.00 - 750.00

Non-Medical Assistant is an individual that has medical escort experience but does not have advanced medical training.

Non-Medical Assistant is used when an individual needs personal assistance only.

Daily rate is dependent upon the domicile of the Clinician, type of medical transport, and expertise of the Clinician.

Equipment $ 75.00 per day
$ 75.00 per day
Suction $ 250.00 per day
Portable Oxygen Concentrator $ 150.00 per day
Ventilator with O2 Monitor $ 500.00
Cardiac Monitor $ 350.00
Cardiac Monitor with Capnography $ 150.00 per day
IV Pump $ 25.00 per day
ACLS Bag $ 100.00
Nebulizer $ 1200.00 - 1500.00
Stretcher Supplies
Critical Care Equipment Package

Equipment costs can vary based on the location of the patient and/or clinician and equipment availability.

Travel Expenses $ 135.00 per day

Meals and Miscellaneous Expenses

Meals and Miscellaneous includes medications that may be required during a flight or supplies used such as incontinence
briefs.

Administrative and Medical Fees $ 175.00 - 195.00
$ 150.00- 250.00
Administrative Fee $ 125.00
Medical Management Fee $ 195.00
Medical Clearance – Domestic $ 750.00
Medical Clearance – International $ 500.00
Medical Clearance – Stretcher Service $ 600.00
Cancellation or Aborted Transport Fee (Minimum charge)
Clinician Assessment $ 2500.00

(Labor cost only to use a clinician nearby the patient to determine fit-to-fly status)
Undocumented/Uninsured Patient Processing Fee (Flat rate for each accepted case)

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 9 of 10

Concierge Services (Additional Services provided upon request)

Patient Case Management $ 125.00 per hour not to exceed $ 2000.00

(Medical document review, telephonic assessment based on documentation, locate a healthcare facility and coordinate

admissions and bed placement.)

Obtain International Travel Documents $ 125.00 per hour not to exceed $2000.00

(If the patient does not have the required travel documents to enter the destination country, our coordinators will obtain

the required documents for travel and legal entry. This may include obtaining birth records, finding family members or

relatives and working with an Embassy, Consulate and/or Government Agency having jurisdiction in the matter.)

Translator (Third-party) $ 50.00 - 125.00 per hour (typically)

Payment is due within 30 days of receipt of invoice. A late fee of 2.0% will be assessed per month on all late payments.

6530 West Rogers Circle, Suite 31
Boca Raton, Florida 33487

Toll Free: (866) 611-8434 Facsimile: (866) 633-4188
[email protected]
www.SkyNurses.com

Page 10 of 10


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