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Agreement for Ambulance Transport Billing Services Page 3 of 7 <br /> 15. Upon termination or expiration of this Agreement, Systems Design shall provide follow-up private <br /> billings and payment posting as necessary for a period of 1 additional month. Within 30 days of this <br /> 0 additional month of service, Systems Design shall return all materials,Medical Incident Reports and • <br /> 1 other documentation provided to it by the City under this Agreement. Systems Design shall also provide a <br /> detailed report of the current status of all outstanding accounts. <br /> B. City <br /> 1. The City will apply for'Provider Status' with Medicare, DSHS, Labor& Industries and any private <br /> insurance companies to be billed. <br /> 2. The City will complete the Medical Incident Report (MIR), including patient name, address and pertinent <br /> billing information. <br /> 3. The City will send MIRs, hospital ER forms and copies of payments received by the City to Systems <br /> Design on a weekly basis. <br /> 4. The City will provide additional information as may be required by insurance companies or agencies in <br /> order to complete the processing of billing ambulance charges. <br /> 5. The City will obtain patient signature for Assignment of Benefits and Responsibility for payment. The <br /> City will keep a record of such signature and make it available to Systems Design and/or insurance <br /> companies upon request. <br /> 6. The City will establish billing rates and the City services to which such rates apply. <br /> V. TERMINATION <br /> A. Breach <br /> If either party fails to fulfill one or more of its material obligations under this Agreement, the other party may <br /> give the breaching party written notice specifying any such breach. If the material breach is not cured within a <br /> commercially reasonable period of time, the non-breaching party may terminate this Agreement by giving <br /> written notice to the breaching party. <br /> B. No Breach <br /> City reserves the right to terminate this Agreement at any time for any reason by sending written notice <br /> ("Notice") of termination to Systems Design. The Notice shall specify a termination date("Termination Date") <br /> at least thirty (30)days after the date the Notice is issued. The Notice shall be effective("Notice Date")upon <br /> the earlier of either actual receipt by Systems Design (whether by fax, mail, delivery or other method <br /> reasonably calculated to be received by Systems Design in a reasonably prompt manner) or three calendar days <br /> after issuance of the Notice. Upon the Notice Date, Systems Design shall immediately commence to end work <br /> in a reasonable and orderly manner. Unless terminated for Systems Design's material breach, the Systems <br /> Design shall be paid or reimbursed for: (a) all pay points completed up to the Notice Date, less all payments <br /> previously made; and (b) a reasonable amount for work after the Notice Date, but prior to the Termination Date, <br /> that was reasonably necessary to terminate the Work in an orderly manner. The Notice shall be sent by the <br /> United States Mail to Systems Design's address provided herein, postage prepaid, certified or registered mail, <br /> return receipt requested, or by delivery. In addition, the Notice may also be sent by any other method <br /> reasonably believed to provide Systems Design actual notice in a timely manner, such as fax. The City does not <br /> by this section waive, release, or forego any legal remedy for any violation, breach, or non-performance of any <br /> of the provision of this Agreement. <br /> VI. INDEMNIFIWION <br /> Each party shall defend and indemnify the other from any and all claims arising out, in connection with, or <br /> incident to, its performance of this Agreement to the extent of its fault. Solely and expressly for the purpose of <br /> http://mail.systemsdesignnw.com/view.php?Horde=c87c3 5b021 a04ee6a615aad99c4c0d8f&thismai... 3/7/2005 <br />