Scope of Professional Services 3.1 On the terms and conditions set forth in this Agreement, COUNTY hereby engages CONTRACTOR to provide all labor, materials and equipment to complete the Project/Service in accordance with the Scope of Services, attached hereto and incorporated herein as Attachment A, as modified or clarified by Addendum(s) # , dated , attached hereto and incorporated herein by reference as Attachment B. It is understood that the Scope of Services may be modified by change order as the Project/Service progresses, but to be effective and binding, any such change order must be in writing, executed by the parties, and in accordance with the COUNTY’s Purchasing Policies and Procedures. A copy of these policies and procedures shall be made available to the CONTRACTOR upon request.
AGREEMENT SIGNATURES By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signed by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signed by Person Responsible: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: SignaĒure on behalf of FighĒing Chance: Signature of Person(s) responsible: Date: Name: Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invoices to: Please see Appendix 3 for Self-Management Payment Options. ☐ PLAN-MANAGED Please send invoices to my plan manager: Plan management organisatio Contact Name Email Address Phone number ☐ OTHER FUNDING (eg. self-funded, iCare or other insurance funding) Please email invoices to: Appendix 3 Self-Managed Payment Options Participants who are self-managed have a number of payment options with Fighting Chance: ☐ DIRECT DEPOSIT (preferred option) Payment of Fighting Chance invoices can be made by Electronic Funds Transfer (EFT) through your bank. Fighting Chance’s bank account details are as follows: Bank: Commonwealth Bank of Australia Account Name: Fighting Chance Australia Ltd BSB: 062-438 Account Number: 00000000 To ensure all payments are correctly allocated to your account, please include the full invoice number in the reference field. ☐ CREDIT CARD Payments can be made by credit card by clicking the ‘pay by credit card’ link included on the invoice. Please note that a service fee for this option will be imposed. ☐ PAYPAL Payment of your invoices can also be made via our PayPal account. To make payment via PayPal, please access the following link: xxxxx://xxxxxx.xx/FightingChanceAus?locale.x=en_AU To ensure your payment is correctly allocated, please enter the full invoice number in the reference field. Appendix 4 Non Face to Face Time Breakdown - Jigsaw Standard Non Face-to-Face Supports Delivered to every Jigsaw Participant daily, weekly, annually Writing the Board (i.e. preparing and writing up each person’s individualised program for the following day). Reviewing Trainee records/journal notes/medical or other key information to be able to best support the person during their day. Parent/Guardian/Carer Updates, i.e. emails, phone calls. Pre- and post-shift sta briefings. Zone setup (setting up workstations, boxes, visuals and group training areas) Resource development to support each Trainee to progress towards their employment goals (adapting training resources, creating visual aids and cheat sheets, etc). Research/Coordination to implement support strategies (disability, behavioural and learning strategies). Family reviews and the development of training plans (planning, delivery and follow up). Planning social events and extra curricular training (e.g. TAFE). Standard NDIS Annual Support Review Letter. Standard Ǫuarterly Reports - Upon Request. Complex Non Face-to-Face Supports - Delivered to Jigsaw Participants with High Intensity Support Needs (in addition to supports outlined in Standard) Allied health meetings, phone calls, correspondence. Specialist/additional sta training (internal or external), i.e. BSP implementation training. Creation of additional/detailed social stories/visuals. Data collection requested by behaviour therapists. Incident follow up or crisis meetings (seperate to regular family updates or regular allied health meetings). Development/review/discussion of medication forms/transfer plans/mealtime assistance plans etc. Detailed and regular sta training on individual complex behaviour/medical/transfer/mealtime support plans. Extended daily pre-brief and debrief. Additional Non Face-to-Face Supports - billed separately upon request Detailed NDIS Review Letters One-o engagement or training with Allied Health. Detailed Ǫuarterly Reports.
EMPLOYEE SIGNATURES Signature: Phone # / Personal E-mail: Signature: Phone # / Personal E-mail: Signature: Phone # / Personal E-mail:
Professional Services Bodily injury" or "property damage" arising out of the rendering of or failure to render profes- sional services;
Professional secrecy The Fund Operator and its staff shall maintain professional secrecy for the duration of this Agreement and after completion thereof. In this connection, except with the prior written consent of the FMO, neither the Fund Operator nor the personnel employed or engaged by it shall at any time communicate to any person or entity any confidential information disclosed to them or discovered by them, or make public any information as to the recommendations formulated in the course of or as a result of implementation of this Agreement. Furthermore, they shall not make any use prejudicial to the FMO, of information supplied to them and of the results of studies, tests and research carried out in the course and for the purpose of performing this Agreement.
Provision of Professional Services We will provide any Professional Services set out in a relevant Order Form in a professional and workmanlike manner, using reasonable skill and care in accordance with industry practice and any relevant SOW. Where it is necessary for Us or Our Group to visit your sites in order to perform Professional Services you shall at no cost to Us or Our Group: (a) provide reasonable access to any relevant sites at times to be agreed; (b) inform Us of health and safety, and security policies applicable at the sites; (c) ensure the sites are safe;
Investigational Services This plan covers certain experimental or investigational services as described in this section. Clinical Trials This plan covers clinical trials as required under R.I. General Law § 27-20-60. An approved clinical trial is a phase I, phase II, phase III, or phase IV clinical trial that is being performed to prevent, detect or treat cancer or a life-threatening disease or condition. In order to qualify, the clinical trial must be: • federally funded; • conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or • a drug trial that is exempt from having such an investigational new drug application. To qualify to participate in a clinical trial: • you must be determined to be eligible, according to the trial protocol; • a network provider must have concluded that your participation would be appropriate; and • medical and scientific information must have been provided establishing that your participation in the clinical trial would be appropriate. If a network provider is participating in a clinical trial, and the trial is being conducted in the state in which you reside, you may be required to participate in the trial through the network provider. Coverage under this plan includes routine patient costs for covered healthcare services furnished in connection with participation in a clinical trial. The amount you pay is based on the type of service you receive. Coverage for clinical trials does not include: • the investigational item, device, or service itself; • items or services provided solely to satisfy data collection and that are not used in the direct clinical management; or • a service that is clearly inconsistent with widely accepted standards of care.
Student Signature By signing this contract, Resident agrees to pay the contract amount (room, board and association fees) in accordance with Addendum B: Rate and Payment Schedule. Resident may pay the full amount due prior to the due date, at the Resident’s election.
Other Professional Services We will provide you the various implementation-related services itemized in the Investment Summary and described in the Statement of Work.
Care Professional to complete From the date of this assessment, the above will apply for approximately: 6-10 days 11- 15 days 16- 25 days 26 + days Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicable): Regular full time hours Modified hours Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No Yes No 4: Recommended date of next appointment to review Abilities and/or Restrictions: dd mm yyyy Completing Health Care Professional Name: (Please Print) Date: Telephone Number: Fax Number: Signature: LETTER OF AGREEMENT #1 BETWEEN The Ontario Public School Boards’ Association (hereinafter called ‘OPSBA’) AND The Ontario Secondary School Teachers’ Federation (hereinafter called the ‘OSSTF’)
