This document is for reference only and should not be used without legal consultation from an attorney in your state.

Memorandum of Understanding between [INSERT NAME] Hospital and [INSERT NAME] SANE Program

This CLINICAL AGENCY memorandum of understanding entered into this [DAY] of [MONTH], [YEAR} by and between the [INSERT NAME]Hospitaland [INSERT NAME]SANE Program, a private non-profit organization, sets forth the intent of both parties to mutually cooperate in providing skilled clinical personnel for medical forensic services.

  1. SANE PROGRAM SERVICES AND RESPONSIBILITIES
  2. The [INSERT NAME] SANE Program shall provide skilled clinical personnel, including at least one nurse practitioner (the “Coordinator”), hereinafter referred to as “Nurses”, to provide, on an as-needed basis, the following types of services in the [INSERT NAME] Hospital:

1.1.AAppropriate medical forensic evaluation of the patient

1.1.BInterview of patients who have a complaint of sexual assault within 60 minutes of receiving notification of such arrival.

1.1.CObtaining appropriate patient consent for all medical forensic care

1.1.DIdentifying, obtaining, packaging and preserving possible forensic evidence.

1.1.EGenerating and maintaining confidential records of the medical forensic examination

1.1.FCommunicating with law enforcement officers and other agencies, as appropriate.

1.2The[INSERT NAME] SANE Program will maintain acceptable standards and procedures for selection, training, assignment and evaluation of Nurses.

1.3The [INSERT NAME] SANE Program shall assure that all Nurses and Coordinator(s) assigned by the [INSERT NAME] SANE Program to provider services are appropriately licensed and trained to perform the services required for the position being staffed. The Coordinator(s) shall apply for and maintain hospital privileges at [INSERT NAME] Hospital. All services shall be performed in a competent, professional and careful manner, consistent with the [INSERT NAME] Hospital’spolicies and procedures (including the joint Hospital-Contractor Medical Referral Protocol and consistent with the International Association of Forensic Nursing Sexual Assault Nurse Examiner Standards of Practice attached hereto as Exhibits 1 and 2, respectively, and incorporated herein by reference),and in accordance with applicable state and federal laws, rules and regulations, including any applicable THE JOINT COMMISSION and OSHA standards.

1.4The Nurses shall be assigned to provide such services at the [INSERT NAME] Hospitalonly after they have completed minimum standard training as a sexual assault nurse examiner (SANE). The [INSERT NAME] SANE Program shall maintain and make available for the [INSERT NAME] Hospital’sreview upon reasonable request, copies of each Nurses’ current license and SANE training documentation.

1.5The [INSERT NAME] SANE Program agrees to abide by any current and future applicable privacy standards provided by the Health Insurance Portability and Accountability Act (HIPAA).

1.6If the [INSERT NAME] SANE Program is unable to maintain Nurse staffing levels adequate to provide services at the [INSERT NAME] Hospitalwithin twenty-four (24) hours.

1.7In the event a Nurse violates hospital policy, does not demonstrate competency to perform assigned services, or does not meet the [INSERT NAME] Hospital’sstandards, the [INSERT NAME] Hospitalreserves the right in the [INSERT NAME] Hospital’ssole discretion to restrict or prevent that Nurses access to the [INSERT NAME] Hospital.

1.8The [INSERT NAME] SANE Program will not subcontract any services described with this memorandum of understanding to a third party unless otherwise authorized in writing by the [INSERT NAME] Hospital.

1.9The [INSERT NAME] SANE Program shall be responsible for providing the equipment and supplies specified in Exhibit 2 (attached hereto and incorporated herein by reference), necessary for identifying, obtaining, packaging and preserving forensic evidence. The [INSERT NAME] SANE Program shall be responsible for maintaining its own equipment and agrees to submit such equipment for a safety and electrical inspection by the [INSERT NAME] Hospital’sbiomedical department before using the equipment on the [INSERT NAME] Hospital’sproperty. Furthermore, the [INSERT NAME] SANE Program acknowledges that the [INSERT NAME] Hospitalassumes no product liability for the [INSERT NAME] SANE Program’s supplies and equipment.

1.10 When the Nurse has completed the medical forensic examination, the Nurse shall notify the [INSERT NAME] Hospital’semergency department physician or nurse so that the patient can then receive any additional and appropriate medical treatment and either be admitted to the [INSERT NAME] Hospitalor discharged.

  1. HOSPITAL RESPONSIBILITIES
  2. The [INSERT NAME] Hospitalagrees to provide emergency department and other appropriate job-specific orientation to the Nurses who are assigned to provide SANE services at the [INSERT NAME]Hospital.
  3. The [INSERT NAME] Hospitalemergency department staff shall supervise the provision of patient care and treatment at the [INSERT NAME] Hospital. For every patient with the complaint of sexual assault who reports to the [INSERT NAME] Hospital, the emergency department staff shall promptly, and in a private setting, perform a medical screening, if indicated, in accordance with federal and state law and with the [INSERT NAME] Hospital’spolicy. As soon as the [INSERT NAME] Hospital’semergency department staff determines that the patient is medically ready to have the medical forensic examination, they shall then refer the patient o the Nurse then assigned to provide such services. The [INSERT NAME] Hospitalshall notify the [INSERT NAME] SANE Program’s answering service at: XXX-XXX-XXXX.
  4. Because the[INSERT NAME] Hospitaland the [INSERT NAME] SANE Program both recognize the need for heightened privacy for sexual assault patients, the [INSERT NAME] Hospitalwill undertake it’s best efforts to provide physical facilities which are physically separated from the rest of the [INSERT NAME] Hospital’semergency department by a door (as opposed to a curtained examination area), for the medical forensic care of the patient, so that such services can be provided in a confidential setting. The [INSERT NAME] Hospitalshall alsoprovide in such facilities an examination table appropriate for gynecological examination, patient drapes and patient gowns, blood-drawing equipment and other supplies and/or equipment not included in Exhibit 3.
  5. Any reports received by the [INSERT NAME] Hospitalregarding the Nurses’ performance of services shall be communicated directly to the [INSERT NAME] SANE Program’s Director.
  6. RELATIONSHIP OF THE PARTIES
  7. The parties hereto agree that the [INSERT NAME] SANE Program is and throughout the term of this Memorandum of Understanding will remain an independent entity performing certain duties and obligations under this Memorandum of Understanding and that the relationship created by this Memorandum of Understanding is not intended, nor shall it be construed, to create a joint venture, a partnership, or any other employer-employee relationship between the[INSERT NAME]Hospitaland the [INSERT NAME] SANE Program. Further, the Nurses will neither be, nor be deemed to be, employees of the [INSERT NAME] Hospitalfor any purpose.
  8. The [INSERT NAME] SANE Program shall be responsible for the payment to the Nurses of any and all wages, salaries, federal, state and municipal withholding taxes and Social Security taxes.
  9. The [INSERT NAME] SANE Program and the Nurses are not entitled to any benefits provided by the [INSERT NAME] Hospitalto its employees, including, but not limited to, group health insurance, dental insurance, unemployment insurance benefits, workers’ compensation and disability insurance.
  10. Except as otherwise provided herein, the [INSERT NAME] SANE Program assumes all the responsibility for all of its normal operating expenses for performance of its obligations under this Memorandum of Understanding. The [INSERT NAME] Hospitalshall not be responsible for workers’ compensation insurance for the [INSERT NAME] SANE Program’s benefit, nor will it carry the Nurses as employees on the [INSERT NAME] Hospital’sworkers’ compensation policy.
  11. The parties agree that none of the acts of either party, or the employees or agents of either party shall be construed to be acts by, or on the behalf of, the other party.
  12. LIABILITY AND INSURANCE
  13. The [INSERT NAME] SANE Program shall, at its own cost and expense, secure and shall maintain in effect at all times during which this Memorandum of Understanding is in effect Professional Liability Insurance with limits of liability in an amount not less than one million ($1,000,000) per occurrence and three million dollars ($3,000,000) aggregate.
  14. The [INSERT NAME] SANE Program shall indemnify and hold harmless the [INSERT NAME] Hospital, its officers, directors and agents from and against any and all damages, claims, losses, costs and liabilities, including without limitation reasonable attorney’s fees, arising from the negligent acts or omissions of the [INSERT NAME] SANE Program’s employees or agents. In like manner, the [INSERT NAME] Hospitalshall indemnify and hold harmless the [INSERT NAME] SANE Program, its officers and directors from and against any and all damages, claims, losses and liabilities including without limitation reasonable attorney’s fees, arising from the negligent acts or omissions, of the Hospital’s agents and employees. Notwithstanding the foregoing, [INSERT NAME] SANE Program and[INSERT NAME] Hospital agree that [INSERT NAME] Hospital is a governmental entity [if applicable].Nothing in this Agreement shall be construed as a waiver of any rights or defenses otherwise applicable.
  15. TERM AND TERMINATION
  16. This Memorandum of Understanding shall be effective for a term of two years from the effective date set forth herein but may be terminated at any time by either party by giving ninety (90) days written notice.
  17. Any of the terms of this Memorandum of Understanding may be renegotiated and the provision hereof revised, buy any such changes must be made in writing and signed by both parties to be effective.
  18. The [INSERT NAME] Hospital may terminate this Memorandum of Understanding immediately upon the occurrence of any of the following by giving written notice to the [INSERT NAME] SANE Program setting forth the reason for the termination:

5.3.AMaterial breach of this Memorandum of Understanding

5.3.BActions or omissions of the [INSERT NAME] SANE Program or the Nurses which jeopardize the health, safety or welfare of any of the [INSERT NAME] Hospital’s patients

5.3.CDishonest or fraudulent conduct of the [INSERT NAME] SANE Program.

5.3.DThe [INSERT NAME] SANE Program’s admission of insolvency, making of an assignment for the benefit of its creditors, or filing of a voluntary petition for bankruptcy.

5.3.EThe filing of an involuntary petition of bankruptcy against the [INSERT NAME] SANE Program for which petition is not stayed or discharged within 60 days, and

5.3.FThe indictment of the [INSERT NAME] SANE Program on criminal charges.

  1. GENERAL PROVISIONS

Any written notice required or permitted under this Memorandum of Understanding shall be delivered by hand or by certified mail, return receipt requested, and directed to the representative party at its last known address. Unless and until the address of the [INSERT NAME] Hospital shall be:

Street Name
Other Address
City, State Zip Code

The address for the [INSERT NAME] SANE Program shall be:

Street Name
Other Address
City, State Zip Code

6.1This Memorandum of Understanding cannot be changed or modified except by an instrument in writing executed by both parties.

6.2The [INSERT NAME] SANE Program shall not assign this Memorandum of Understanding or delegate any of its responsibilities hereunder. Subject to the foregoing, this Memorandum of Understanding shall be binding on the parties, their successors and legal representative.

6.3The headings of the various articles of this Memorandum of Understanding are inserted for convenience and do not expressly or by implication limit, define or extend the specific terms of the articles so designated.

6.4The Memorandum of Understanding shall be deemed to have been made and shall be construed and interpreted in accordance to the laws of the state of [INSERT NAME].

6.5This Memorandum of Understanding constitutes the entire understanding and Memorandum of Understanding between the parties hereto and supersedes all prior Memorandum of Understandings, arrangements and understandings between the parties with respect to its subject matter.

6.6The waiver by either party of a breach or violation of any provision of this Memo of Understanding shall not operate as, or be construed to be, a waiver of any subsequent breach of the same or other provision hereof.

6.7Whenever the context hereof requires the gender of all words shall include the masculine, feminine and neuter and the number of all words shall include the singular and plural.

6.8In the event any provision of the Memorandum of Understanding is held to be unenforceable for any reason, the unenforceability thereof shall not affect the remainder of this Memorandum of Understanding, which shall remain in full force and effect and enforceable with its terms.

6.9This memorandum of Understanding may be executed in multiple counterparts, each of which shall be deemed to be an original instrument, but all of which taken together shall constitute one instrument

IN WITNESS WHEREOF, the parties hereto have executed and delivered this Memorandum of Understanding as of the date and year first written above.

For [INSERT NAME]HOSPITAL: For[INSERT NAME]SANE PROGRAM :

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NameDate Name Date

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