Common use of Client Satisfaction Clause in Contracts

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  Proof of insurance Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 Date: Signature: Printed name of above signature and title: Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm Edmonton: NHSF Contract Manager 780.342.0008 Severe Harm (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event Edmonton: NHSF Contract Manager 780.342.0008 Moderate and Minimal Harm To be reported in complete detail within 72 hours of event NHSF Contract Manager Edmonton: 780.342.0008 No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event NHSF Contract Manager Edmonton: 780.342.0008 Definitions

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  Proof of insurance Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 Date: Signature: Printed name of above signature and title: Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm EdmontonCalgary: Director 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 0000 Xxxxxxxx: NHSF Contract Manager 780.342.0008 Severe Harm (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event EdmontonCalgary: Director 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 0000 Xxxxxxxx: NHSF Contract Manager 780.342.0008 Moderate and Minimal Harm To be reported in complete detail within 72 hours of event NHSF Contract Manager Calgary: 403.944.2927 Edmonton: 780.342.0008 No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event NHSF Contract Manager Calgary: 403.944.2927 Edmonton: 780.342.0008 Definitions

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  ⬜ Proof of insurance Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 Date: Signature: Printed name of above signature and title: Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm Calgary: Director 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 8888 Edmonton: NHSF Contract Manager 780.342.0008 Severe Harm Xxxxxx Xxxx (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event Calgary: Director 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 8888 Edmonton: NHSF Contract Manager 780.342.0008 Moderate and Minimal Harm To be reported in complete detail within 72 hours of event NHSF Contract Manager Calgary: 403.944.2927 Edmonton: 780.342.0008 No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event NHSF Contract Manager Calgary: 403.944.2927 Edmonton: 780.342.0008 Definitions

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  Proof of insurance ⬜ Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) the following: Intra-operatively Postoperatively Procedure Type Procedure Type Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 14.3 Date: Signature: Printed name of above signature and title: _ Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm Calgary: NHSF Contract Manager 403.944.2927 and /or Lead Surgical Contracts 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 8888 Edmonton: NHSF Contract Manager 780.342.0008 Severe Harm Xxxxxx Xxxx (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event Calgary: NHSF Contract Manager 403.944.2927 and /or Lead Surgical Contracts 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 8888 Edmonton: NHSF Contract Manager 780.342.0008 Moderate and Minimal Harm To be reported in complete detail within 72 hours of event Calgary: NHSF Contract Manager Edmonton: 780.342.0008 403.944.2927 and /or Lead Surgical Contracts 403.944.2927 on week days No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event Calgary: NHSF Contract Manager Edmonton: 780.342.0008 403.944.2927 and /or Lead Surgical Contracts 403.944.2927 on week days Definitions

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  ⬜ Proof of insurance Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 Date: Signature: Printed name of above signature and title: Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm Edmonton: NHSF Contract Manager 780.342.0008 Severe Harm Xxxxxx Xxxx (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event Edmonton: NHSF Contract Manager 780.342.0008 Moderate and Minimal Harm To be reported in complete detail within 72 hours of event NHSF Contract Manager Edmonton: 780.342.0008 No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event NHSF Contract Manager Edmonton: 780.342.0008 Definitions

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirmed  Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  Proof of insurance Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 Date: Signature: Printed name of above signature and title: Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm EdmontonAHS Admin on Call after hours: 000-0000 pager# 8888 NHSF Contract Manager 780.342.0008 on week days Severe Harm (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event EdmontonAHS Admin on Call after hours: 000-0000 pager# 8888 NHSF Contract Manager 780.342.0008 on week days Moderate and Minimal Harm To be reported in complete detail within 72 hours of event NHSF Contract Manager Edmonton: 780.342.0008 on week days No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event NHSF Contract Manager Edmonton: 780.342.0008 on week days Definitions

Client Satisfaction. To the best of your knowledge, have any Clients treated in your Facility under the AHS Agreement experienced any unplanned hospital admissions or emergency room visits? Yes No If yes, please provide a summary (including Client PHN and reason for admission) as per requirements in Schedule D Reporting Requirements Annual Reporting Template (Continued) Unplanned Hospital Admissions and/or Emergency Room visits Annual Reporting Template (Continued) Complication rates (including nosocomial infections and major surgical complications): Please provide the following: Intra-operatively Postoperatively Procedure Type Procedure Type Change of Ownership or Control Confirm that there has not been any change of ownership or control of your Facility since this Agreement with AHS was originally signed? Confirmed  Proof of insurance ⬜ Please provide AHS with your current certificate of insurance (refer to section 15.3 for specific coverage requirements) Insurance Declaration The signature below will confirm that the Facility is in compliance with the contractual insurance requirements as described in section 15.3 Datefollowing: Signature: Printed name of above signature and title: Intra-operatively Postoperatively Procedure Type Procedure Type Preventative Maintenance of Equipment Declaration The signature below will confirm that the Equipment involved in the delivery of Services under the Agreement with AHS has been maintained, as per manufacturer specifications and guidelines, and that your Facility would be willing to have AHS audit your records in this area. Date: Signature: Printed name of above signature and title: Schedule “D” Appendix 4 Incident Management Process Process Operators are required to report all situations where Clients have suffered harm or experienced close calls and any hazards that could lead to Client harm in accordance with the following grid: Event When to Report Contact Person/Info Hospital Transfers To be reported immediately, irrespective of level of Harm Calgary: Director 403.944.2672 and /or NHSF Contract Manager 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 8888 Edmonton: NHSF Contract Manager 780.342.0008 Severe Harm (critical incident) To be reported immediately in reasonable detail, with follow up report in complete detail to be submitted within 24 hours of event Calgary: Director 403.944.2672 and /or NHSF Contract Manager 403.944.2927 on week days AHS Admin on Call after hours: 000-0000 pager# 8888 Edmonton: NHSF Contract Manager 780.342.0008 Moderate and Minimal Harm To be reported in complete detail within 72 hours of event NHSF Contract Manager Calgary: 403.944.2927 Edmonton: 780.342.0008 No Apparent Harm, Hazards and Close Calls To be reported in complete detail within 30 days of event NHSF Contract Manager Calgary: 403.944.2927 Edmonton: 780.342.0008 Definitions