Signature of Authorised signatory. Signature of Authorised signatory OR WHERE PROVIDER IS AN INCORPORATED COMPANY Executed as a deed by the Provider ) acting by [insert name of Director], ) a director, in the presence of: ) …………………………………………………...Director Witness Signature: ……………………………………… Name: ……………………………………… Address: ……………………………………… Occupation: ……………………………………… OR WHERE PROVIDER IS A LIMITED LIABILITY PARTNERSHIP Executed as a deed by the Provider ) acting by [insert name of Member], ) member and [insert name of ) Member], Member ) …………………………………………………... Signature of Member …………………………………………………... Signature of Member OR Executed as a deed by the Provider ) acting by [insert name of Member], ) a Member, in the presence of: ) …………………………………………………... Member Witness Signature: ……………………………………… Name: ……………………………………… Address: ……………………………………… Occupation: ……………………………………… APPENDIX 1 Commissioner Requested Services and Essential Services Commissioner Requested Services Insert text locally or state Not Applicable Essential Services Insert text locally or state Not Applicable CRS Continuity Plan/Essential Services Continuity Plan Insert text locally or state Not Applicable APPENDIX 2 National Quality Requirements National Quality Requirement Threshold (2013/14) Method of Measurement (2013/14) Consequence of breach Monthly or annual application of consequence Applicable Service Category CB_A15 Zero tolerance MRSA >0 Review of monthly Service Quality Performance Report Non-payment of inpatient episode Monthly A CB_A16 Rates of Clostridium difficile [Insert Baseline Threshold identified for Provider] Review of monthly Service Quality Performance Report - Annual A CB_S6 Zero tolerance RTT waits over 52 weeks >0 Review of monthly Service Quality Performance Report £5,000 per patient waiting over 52 weeks Monthly A. C, MH where 18 weeks applies CB_S7a All handovers between ambulance and A & E must take place within 15 minutes Handover >15 minutes Review of monthly Service Quality Performance Report £200 per patient waiting over 30 minutes Monthly A+E CB_S7b All handovers between ambulance and A & E must take place within 15 minutes Handover > 15 minutes Review of monthly Service Quality Performance Report £1,000 per patient waiting over 60 minutes (in total, not aggregated with CB_S7a consequence) Monthly A+E CB_S8a Following handover between ambulance and A & E, ambulance crew should be ready to accept new calls within 15 minutes Crew ready to accept new call >15 minutes Review of monthly Service Quality Perf...
Signature of Authorised signatory. Executed as a deed by affixing the common seal of the PROVIDER in the presence of: [COMMON SEAL] .................................................
Signature of Authorised signatory. Executed as a deed by [DEVELOPER] acting by [ ], in the presence of: Witness sign Witness Name Witness Address Witness occupation ....................................... SIGNATURE OF [ ] Legal02#82105323v1[MZC1]
Signature of Authorised signatory. [Please delete as appropriate – mechanism for execution will be subject to the Authority’s constitution and Scheme of Delegation] SIGNED by [Insert Authorised Signatory’s Name] for and on behalf of the PROVIDER ………………………………………………………….. Signature ………………………………………………………….. Title ………………………………………………………….. Date
