Walgreen Co./Flu Immunizations 158/27/2015
........
Walgreens Logo
;,Immunization Program
Walgreens Community Off -Site Agreement
Walgreens Community Outreach
Spanish Version I Print Contract
TWalgreens
COMMUNITY OFF-SITE CLINIC AGREEMENT
This COMMUNITY OFF-SITE CLINIC AGREEMENT ("Agreement") by and
between the party indicated below ("Client"), and Walgreen Co., on behalf of itself and
all of its subsidiaries and affiliates ("Walgreens") is made and entered into on the date
last signed by an authorized representative of both the Client and Walgreens (the
"Effective Date").
For good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, Client and Walgreens, by their signatures below, hereby agree that (i)
Walgreens will provide the Immunizations Immunizations listed below, consisting.of
dispensing and administering of a certain vaccine or vaccines to participants
("Participants") at mutually agreed upon dates and times at the Client's facility(ies)
listed below ("Covered Services"); and (ii) it will comply with the terms and conditions
of this Agreement, as shown on the following pages.
Immunization Payment Method Price
Influenza- Standard/PF Injectable Submit Claims to Medical Insurance N/A
(trivalent)
*Price includes vaccine and administration.
Client Facility Location(s)*:
CLINIC LOCATION A
Estimated Shots per Immunization
Influenza - Standard/PF Injectable (trivalent)
t (Submit Claims to Medical Insurance)
Local Contact Name Local Contact Phone
Local Contact Email
cdoran@la-
Caroline Doran 760-564-0096
quinta.org
Addressl Address2
City State Zip
78450 Avenida
La Quinta CA 92253
La Fonda
Clinic Date Start Time
End Time
11/16/2015 10:00am
12:00am
IN WITNESS WHEREOF, Client and Walgreens have electronically executed this
Agreement, as of the Effective Date.
CLIENT:dye \\� o La Qumta .GA WALGREEN CO.
NAME: usan Maysels NAME: John Henein
Carefully review the Community
Off -Site Agreement. Ifyou agree to
the conditions ofthe contract,
please check "Approve" below and
type your name into the Electronic
Signature field. If there are any
discrepancies in the Agreement,
reject the Agreement and provide
corrections in the notes field.
� ; Approve
Electronic Signature
Susan -Maysels
x Reject
Send email'.
file:///C:/Users/SMaysels/AppData/Local/Microsoft Windows/Temporary%201nternet%20Files/Content.Outlook/WXIA11UPM/algreens%20Co%201HH%20agr... 1/4
8/27/2015
Walgreens Community Outreach
TITLE: City Clerk TITLE: Store Manager
DATE:
Send Legal Notices To Client At:
Attention to:
Py'Clerk
Addressl:
8495 Calle:Tam0ico.
Address2:..
City:La
Quinta
State:
, CA i
Zip Code:
92253
DATE: 07/29/2015
DISTRICT NUMBER: 264
Send Legal Notices To Walgreens At:
Healthcare Innovations Group
200 Wilmot Rd
MS2222
Deerfield, IL 60015
Attn: Health Law— Divisional Vice
President
cc: clinicalcontracts@walgreens.com
WALGREENS COMMUNITY OFF-SITE CLINIC AGREEMENT
TERMS AND CONDITIONS
I. Walgreens' Responsibilities
Covered Services. Subject to the
limitations or restrictions imposed by
federal and state contracts, laws, and
regulations, and the availability of the
appropriate Immunization, Walgreens
will provide the Covered Services to
Participants. With respect to such
Covered Services, the parties will
comply with the procedures set forth
herein.
Provision of Health Care Professionals.
Walgreens will provide Client with the
appropriate number of qualified health
care professionals and technicians to
provide Covered Services.
Professional Judgment. Walgreens
may withhold Covered Services to a
Participant for good cause, including
but not necessarily limited to, the
Participant's failure to pay for Covered
Services rendered; requests by
Participant for services inconsistent
with the legal and regulatory
requirements; or where, in the
professional judgment of the health
care professional, the services should
not be rendered.
II. Client's Responsibilities
Coordination. Client will provide
Participants with notice of the time and
location in which Covered Services
will be provided and provide a private,
clean room location, tables and chairs
for Walgreens' personnel and
Participants. If applicable, Client will
provide Participants with Walgreens -
approved vouchers which Participants
may redeem at a participating
Walgreens store location.
Access. Client hereby grants to
Walgreens, and to no other person or
entity, access to its designated room or
areas for the provision of Covered
Services for the time and date(s)
mutually agreed upon by the parties, in
VI. Insurance
Insurance. Each party will self -insure
or maintain at its sole expense, and in
amounts consistent with industry
standards, Commercial General
Liability Insurance and such other
insurance as may be necessary to insure
each respective party, its employees,
and agents against any claim or claims
for damages arising out of or in
connection with its duties and
obligations under this Agreement.
Walgreens certifies it will maintain
adequate Professional Liability
Insurance during the term of this
Agreement. Walgreens will
automatically name Client as
Additional Insured under its
Commercial General Liability policy,
as per the terms of Walgreens'
insurance policy. Evidence of such
insurance can be obtained by
downloading the Walgreens
Memorandum of Liability Insurance
and Memorandum of Professional
Liability Insurance and other relevant
information regarding Walgreens'
insurance program at
httl2://www.walgieeiis.com/topic/about
insurancehn anagement ,isp.
VII. General Terms
Confidentiality of PHI. Both parties
warrant that they will maintain and
protect the confidentiality of all
individually identifiable health
information specifically relating to
Participants ("Protected Health
Information" or "PHI") in accordance
with the Health Insurance Portability
and Accountability Act of 1996 and all
applicable federal and state laws and
regulations. However, nothing herein
will limit either party's use of any
aggregated Participant information that
does not contain PHI. This section will
survive the termination of this
Agreement.
Advertising. Neither party may
file:///C:/Users/SM aysels/AppData/Local/M icrosoftMlindowslTemporary%201nternet%20Files/Content.OutlookNVXIAI I U PNValgreens%20Co%201H H %20agr... 214
8/27/2015
accordance with the provisions of this
Agreement.
III. Payment
Payment. For the provision of Covered
Services, Walgreens shall be
reimbursed by Client or, to the extent
agreed upon by the parties, by
Participants, as set forth below. As
used in this Agreement, "Usual and
Customary Charge" shall refer to the
amount charged to a cash customer for
an immunization by the administering
pharmacy at the time of administration,
exclusive of sales tax or other amounts
claimed.
Payment by Client. For those Covered
Services reimbursed by Client, if any,
Walgreens shall invoice Client
monthly for such Covered Services at
the lesser of the prices stated herein or
the Usual and Customary Charge.
Payments made by Client are due
within thirty (30) days from receipt of
the monthly invoice and must be sent
to the remittance address stated on the
invoice. The invoice will contain the
following data elements, and no further
information will be provided: Group
ID, store number, prescription number,
patient name, recipient number,
physician name, cost, service fee,
copayment amount, sales tax, total
charge, date of service, and drug
name/NDC.
Payment by Participant. For those
Covered Services for which Walgreens
will be reimbursed by Participant, if
any, Walgreens will request from
Participant evidence of coverage under
third -party insurance or a government
funded program (e.g., Medicare) prior
to the provision of Covered Services. If
such evidence is presented by the
Participant and Walgreens is
contracted with the third -party
insurance or government funded
program, Walgreens will submit the
claim for that Participant and any
copayment, coinsurance, deductible
owed by the Participant will be billed
at a later date. If such evidence is not
provided at the time of service,
Participant shall be responsible to
compensate Walgreens at the lesser of
the prices stated herein or the Usual
and Customary Charge.
IV. Term and Termination.
Term and Termination This Agreement
will commence as of the Effective
Date and will continue for one year.
Either party may terminate this
Agreement upon prior written notice to
the other party.
Effect of Termination. Termination
Walgreens Community Outreach
advertise or use any trademarks,
service marks, or symbols of the other
party without first receiving the written
consent of the party owning the mark
and/or symbol with the following
exceptions: Client may use the name
and the addresses of Walgreens'
locations in materials to inform
Participants and the general public that
Walgreens provides Covered Services.
Any other reference .to Walgreens in
any Client materials must be pre -
approved, in writing, by Walgreens.
Force Majeure. The performance by
either party hereunder will be excused
to the extent of circumstances beyond
such party's reasonable control, such as
flood, tornado, earthquake, or other
natural disaster, epidemic, war,
material destruction of facilities, fire,
acts of terrorism, acts of God, etc. In
such event, the parties will use their
best efforts to resume performance as
soon as reasonably possible under the
circumstances giving rise to the party's
failure to perform.
Compliance. The parties will comply
with all applicable laws, rules, and
regulations for each jurisdiction in
which Covered Services are provided
under this Agreement. Each party will
cooperate with reasonable requests by
the other party for information that is
needed for its compliance with
applicable laws, rules, and/or
regulations. Notices, All notices
provided for herein must be in writing
sent by U.S. certified mail, return
receipt requested, postage prepaid, or
by overnight delivery service providing
proof of receipt to the address set forth
following the signature blocks. Notices
will be deemed delivered upon receipt
or upon refusal to accept delivery.
Entire Agreement. This Agreement,
which includes any and all
attachments, exhibits, riders, and other
documents referenced herein,
constitutes the entire and full
agreement between the parties relating
to the subject matter herein and
'supersedes any previous contract and
no changes, amendments, or alterations
will be effective unless reduced to a
writing signed by a representative of
each party. Any prior agreements,
documents, understandings, or
representations relating to the subject
matter of this Agreement not expressly
set forth herein or referred to or
incorporated herein by reference are of
no force or effect.
file:///C:/Users/SM aysels/AppData/Local/M icrosoft/Wirxiows/Tem porary%201nternet%20Files/Content.OutlookM/XIA11 U P/Walgreens%20Co%201H H %20agr... 314
8/27/2015 Walgreens Community Outreach
will have no effect upon the rights or
obligations of the parties arising out of
any transactions occurring prior to the
effective date of such termination.
V. Indemnification
Indemnification. To the extent
permitted by law, each party will
indemnify, defend, and hold harmless
the other party, including its
employees and agents, from and
against any and all third -party claims
or liabilities arising from the
negligence or wrongful act of the
indemnifying party, its employees, or
agents in carrying out its duties and
obligations under the terms of this
Agreement. This section will survive
the termination of this Agreement.
02015 Walgreen Co. All rights reserved.
file:///C:/Users/SM aysels/AppData/Local/M icrosofVWindows/Tem porary%201nternet%20Files/Content.Oullook/WXIA11 U P/Walgreens%20Co%201H H %20agr... 4/4
MEMORANDUM'OF
PROPERTY INSURANCE ,`
Current as of:
�.,.. �;.
June 252015
PRODUCER
This Memorandum is issued as a matter of information only to authorized viewers for
their internal use only and confers no rights upon any viewer of this Memorandum
MARSH USA INC
other than those provide for in the policy. This Memorandum does not amend; extend
540 WEST MADISON
or alter the coverage described below. This Memorandum may only be copied, printed
CHICAGO, ILLINOIS 60661
UNITED STATES OF AMERICA
and distributed within an authorized viewer and may only be used and viewed by an
authorized viewer for its internal use. Any other use, duplication or distribution of this
Memorandum without prior written consent is prohibited.
INSURED
,COMPANY, AFFORDING COVERAGE "
ZURICH AMERICAN INSURANCE COMPANY
WALGREEN CO. AND SUBSIDIARIES
300 WILMOT RD., MS #3108
1400 AMERICAN LANE
DEERFIELD, ILLINOIS 60015-5223
SCHAUMBURG, ILLINOIS 60196
UNITED STATES OF AMERICA
NAIC #: 16535
PROPERTY"INFORMATION; <Locatioi! Descri tion
All Walgreens Owned and Leased/Contracted locations, including but not limited to, Buildings, Distribution Centers, Office Buildings, and Individual Store and Clinic
Locations.
COVERAGE INFORMATION
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MEMORANDUM MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS
SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
COVERAGES / PERILS / FORMS
POLICY
POLICY
AMOUNT OF
DEDUCTIBLE /
NUMBER
PERIOD
INSURANCE
RETENTION
"All Risks" of direct physical loss or damage to real or personal property on a 100% replacement
cost basis (unless otherwise stated in the Lease/Contract) subject to policy terms, conditions, and
ERP-9260941-08
7/1/2015
Per the
$ 100,000
exclusions. Coverage includes, but may not be limited to Fire and Extended Perils such as
to
Lease/Contract
Accidental Water Damage/Sprinkler Leakage, Accounts Receivable, Avalanche, Boiler &
7/1/2016
Machinery/Equipment Breakdown, Business Interruption, Collapse, Debris Removal,
Demolition/Increased Cost of Construction, Earthquake, Explosion, Extra Expense, Falling Objects,
Flood, Government Action, Hail, Landslide/Mud Flow, Law & Ordinance, Lightning, Loss of Rent (if
required in Lease/Contract), Mold, Named Storm/Hurricane%Typhoon, Broken Glass, Property in
Transit, Loss of Rent/Rental Insurance (if required in Lease/Contract), Riot or Civil Commotion,
Service Interruption, Sinkhole Collapse, Smoke, Subsidence, Terrorism, Tidal Action/Tsunami,
Valuable Papers & Records, Vandalism, Volcanic Action, Weight Of Ice/Sleet/Snow, Wildfire, Wind,
and Windstorm/Tomado.
REMARKS " Includin "-S ecialConditions
Any entity required to be named as Loss Payee/Mortgagee or Additional Insured is automatically covered per the terms of a written lease, contract, or other form of
signed agreement.
Waiver of Subrogation is included if required by the written agreement
ADDITIONAL INFORMATION
., The Memorandum of Insurance 64es:soleiy to list insurance policies, Iiinits and dates;of coverage Any modifications hereto`are notauthorixed.
r
The Pharmacy America Trusts • Since 1901'
DATE: July 1, 2012 and continuous until cancelled
FROM: Walgreens, its Affiliates, and Subsidiaries
TO: To Whom It May Concern
RE: PROFESSIONAL LIABILITY SELF-INSURANCE
This letter is being provided in lieu of a certificate of insurance.
Walgreens and its subsidiaries maintains a comprehensive program of commercial insurance
above significant self-insured retentions. Many of our signed contracts, leases, and/or other
agreements allow us the option to meet our professional liability insurance requirements by
self-insuring rather than purchasing insurance in the commercial insurance market. This allows
us to invest our premium dollars, enhancing shareholder value, while maintaining the ability to
respond to our financial obligations on our own rather than through an insurance company.
Our obligations to the business partners with whom we have contracted remain unchanged as if
insurance is in place.' Walgreens' Vendors, Clients, Customers, Owners, Landlords, Landlords
Agent(s), Landlords Lender(s), Ground Lessor(s), and any other party who requires it, per the
terms of a signed contract, lease, and/or agreement, are treated as Additional Insureds
and when applicable, Loss Payee, as their interests may apply. A Waiver of Subrogation also
applies, where applicable.
Walgreens will not issue individualized evidence of insurance. The information posted
on our website meets our obligations to provide insurance information under the terms of our
contracts.
PLEASE NOTE THAT THE TERMS OF OUR SIGNED CONTRACTS DETERMINE OUR FINANCIAL
OBLIGATIONS TO COUNTERPARTIES WHETHER INSURANCE IS IN FORCE OR NOT.
Please forward this letter to any party that may require the information_ as part of a signed
contract, lease, and/or agreement with Walgreens.
Sincerely,
Walgreens
Insurance & Risk Management Department
The Pharmacy America Trusts . Sime 1941'
DATE: July 1, 2012 and continuous until cancelled
FROM: Walgreens, its Affiliates, and Subsidiaries
TO: To Whom It May Concern
RE: PROPERTY SELF-INSURANCE
This letter is being provided in lieu bf a certificate of insurance.
Walgreens and its subsidiaries maintains a comprehensive program of commercial insurance
above significant self-insured retentions. Many of our signed contracts, leases, and/or other
agreements allow us the option to meet our property insurance requirements by self-insuring
rather than purchasing insurance in the commercial insurance market. This allows us to invest
our premium dollars, enhancing shareholder value, while maintaining the ability to respond to
our financial obligations on our own rather than through an insurance company.
Our obligations to the business partners with whom we have contracted remain unchanged as if
insurance is in place. Walgreens' Vendors, Clients, Customers, Owners; Landlords, Landlords
Agent(s), Landlords Lender(s), Ground Lessor(s), and any other party who requires it, per the
terms of a signed contract, lease, and/or agreement, are treated as Additional Insureds
and when applicable, Loss Payee, as their interests may apply. A Waiver of Subrogation also
applies, where applicable.
Walgreens will not issue individualized evidence of insurance. The information posted
on our website meets our obligations to provide insurance information under the terms of our
contracts.
PLEASE NOTE THAT THE TERMS OF OUR SIGNED CONTRACTS DETERMINE OUR FINANCIAL
OBLIGATIONS TO COUNTERPARTIES WHETHER INSURANCE IS IN FORCE OR NOT.
Please forward this letter to any party that may require the information as part of a signed
contract, lease, and/or agreement with Walgreens.
Sincerely,
Walgreens
Insurance & Risk Management Department