CONTRACT REQUEST FORM FOR COLLEGE OF MEDICINE (COM) UNITSREFERRED TO AS UNIVERSITY OF FLORIDA PHYSICIANS (“UFP UNIT”) (e.g., COM Clinics, B/AR or IS)

The VPHA Contracts Office appreciates your assistance in providing the following detailed information for purposes of drafting the proposed contractual document. If you have questions, please call 273-7007.

IMPORTANT - If this is a request for drafting or reviewing an agreement requiring payment through the University Purchasing Office, please direct your request to University Purchasing.

All fields in the Contract Request Form MUST be filled out, or marked “N/A” if not applicable. Please type answers. If you wish to hand-write answers, please print the PDF version:

NOTE: UFP Administration requires completed contract requests to be submitted to Heather Hoffman.

  1. SCOPE AND PURPOSE OF PROPOSED CONTRACT:
  1. Describe the purpose of the contract. (How will it benefit UFP?)
    [Education, Research, and/or Service mission of the University][This is a required field.]
  1. Describe the scope of services provided to UFP, or the type of equipment purchased/leased; or space leased:

Is there a COM clinic or other UFP Unit that already has an existing contract for this product or service?
Yes? No?

If yes, please identify the COM clinic or UFP unit:

II.TYPE OF DOCUMENT REQUESTED: Please check all that apply:

New Contract*: Amendment to Existing Contract**: Termination**: Renewal**:

*If new request is similar to an existing contract, attach sample document.
**Please attach a copy of the existing contract. Enter the Contract Office’s database number (if known): .

III.REQUESTING COM CLINIC OR OTHER UFP UNIT:

Name of COM Department, division and/or clinic:

Name, title, and complete address of person who should receive all official notices within UFP/COM:

IV.OTHER PARTY WISHING TO CONTRACT WITH UFP UNIT:

  1. Provide complete legal name of contracting entity(ies):

B.Is company registered to do business in the state of Florida? Yes No. If no, what state?

Name, title, and mailing address of outside party representative who should receive all official notices:

Name and title of legal signatory to the contract for the outside party:

  1. Identify complete address of where payments should be sent:

D.Is there any possibility, however remote, that the outside party will have access to patient health information for non-treatment purposes? Yes: No:

If Yes, enter the name and contact information for outside party’s HIPAA Compliance Officer:

E.If the contract involves the use of a device or product (e.g. software, hardware), will the device or productcollect or store PHI? Yes: No:

F.Will the device or product (e.g. software, hardware)be connected tothe network/EMR (wired or wireless)?
Yes:  No:

** If answer to either IV. E. or F. above is YES, a security evaluation is required; please confirm this has been reported to Heather Hoffman & Jake Bruck. Yes: No:

V.COMPLETE THIS SECTION IF SERVICES ARE TO BE PROVIDED TO COM CLINIC/ UFP UNIT

Check here if this section is not applicable (no service is provided in contract)

  1. Provide detailed description of services and/or obligations of the other party (ies). Provide a copy of each attachment to be incorporated:

B.Legal name of party who will provide services?

C.Who will services be provided to (usually a COM Clinic & Department needs to be identified)?

D.Amount to be paid for services:

E.Has analysis been done to determine whether amount to be paid is fair market value? Yes: No: .

Please attach any relevant documentation.

F.Provide times/hours/frequency and location of services by the other party (ies):

G.Provide name(s), title(s), and FTE(s) of personnel providing services:

H.Describe any licensure/qualification requirements or regulations:

I.Describe equipment, space, support personnel, access, and/or other tangibles required. Include information regarding requirements to purchase tangibles and funding of maintenance cost of said tangibles:

VI.COMPLETE THIS SECTION IF PRODUCT/PROPERTY IS TO BE PURCHASED/SOLD

Check here if this section is not applicable (no sale or purchase)

A.Describe in detail products to be purchased:

B.Is product medical equipment or supplies?Yes: No: .

If yes, has Medical director for the COM Clinic approved the purchase? Yes: No: .

C.Who will purchase products (usually a COM Clinic & Department needs to be identified)?

D.Identify legal name of outside party who will provide the product:

E.Amount to be paid for product:

F.Per unit price: Number of Units: Total price:

G.Has analysis been done to determine whether price is fair market value? Yes: No: .

Please attach any relevant documentation.

VII.COMPLETE SECTION IF PROPERTY OR EQUIPMENT IS TO BE LEASED

Check here if this section is not applicable (no lease)

  1. Describe property to be leased. If real property, include physical address of property.
  1. Which party is the lessee (usually FCPA)?
  2. Who will be the tenant(s) (usually a COM clinic & Department needs to be identified)?

For each tenant, identify how the space will be used:

  1. What is the legal name of the lessor?
  2. Has lessor’s ownership of property to be leased been verified? Yes: No: .
  3. Amount to be paid for lease:
  4. Will the leased space be used exclusively by the tenant identified or will there be shared use?

Exclusive use: Shared use: . If shared, please specify percentage time used by tenant.

H.Attach documentation verifying rate is fair market value for square footage and percentage of time used.

I.Complete Lease Summary form and attach to this Contract Request Form.

J. Obtain floor plan identifying portion of space to be leased and attach.

VIII.CONTRACT DATES:

A.Effective date of contract:

B.Duration/term of contract if other than for an indefinite period:

C. Do you want any renewal terms in the contract:

D.Days required for termination notice: With Cause:Without Cause:

May party cure a breach? Yes: No: .

OTHER IMPORTANT CONSIDERATIONS, IF ANY, PERTAINING TO THE PROPOSED CONTRACT:

WAIT!!! Before you submit your request, please respond to the following:(primary contact listed in parentheses)

1. If this is a purchasefor equipment used in a clinic location (regardless of funding source) - did you send quote to UFP Facilities Coordinator? (Becky Legate and Ivy Venters)

Yes No N/A

2. If this is to acquire new equipment, has a business analysis been done to determine purchase versus lease of equipment? If you plan to lease, please also forward a quote to purchase equipment so we can evaluate financing options. (Michael Richards)

Yes No N/A

3. If you are trading in old equipment on a new purchase, please indicate the decal number here:

4. If this is equipment or supplies for a new procedure, have you had this reviewed by the Clinical Safety Committee or submitted the application? (Anne Schentrup)

Yes No N/A Previously approved on: Pending

5. If this is an equipment purchase, has Shands evaluated quote to assure optimal pricing? (Heather Hoffman)

Yes No N/A

6. Is a Security/IT Review needed (networked/containing PHI/involve EMR/Radiology or Imaging Equipment)?

Yes No N/A

Forwarded to UFP Information Security Manager (Jake Bruck) on:

7. Is this a service UFP will bill for? Has BAR been informed of new services? (Dara Cangelosi)

Yes No N/A

8. Does this purchase require a budget variance form? (Heather Hoffman)

Yes No N/A Submitted on: Approved: Yes Pending

9. Has a proforma been completed? If so, please attach.

Yes No N/A

10. Have you attached all related documentation (quotes, service contract, security/safety approvals, etc.)

Yes No N/A

11. If UFP will be making a regular monthly payment, how do you want that paid?

By Invoice Automatic Recurring Payment

12. Please provide any additional information that will be helpful in expediting this request:

OPERATION APPROVAL AND CONTACT
Contact information of person providing the above information:
Name:
Telephone Number:
E-mail:
Other:
______
Signature of person providing the above Date
Information (Manager/Director)
______
Department Administratorapproval Date
LEADERSHIP APPROVAL: UFP ADMINISTRATION WILL OBTAIN SIGNATURES
______
UFP Financial Services Staff budget approval Date Associate Dean and CEO, UFP approval Date
______
Dean’s Office, Financial Services approval Date Funding Entity (to be completed by Dean’s office)

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