HomeMy WebLinkAboutFD Nordian Medicare Part B LetterApril 20, 2018
Noridian -Medicare Part B
Attn: Provider Enrollment
900 42 nd St S
Fargo, ND 58103
To whom it may concern:
The City of San Rafael attests that it will be legally and financially responsible for
Medicare payments received including any potential overpayments. The City of San
Rafael further attests that it will be legally and financially responsible in the event that
there is any outstanding debt owed to CMS.
Very truly yours,
~HUTZ
City Manager
CITY OF SAN RAFAEL! 1400 FIFTH AVENUE, SAN RAFAEL, CALIFORNIA 94901 I CITYOFSANRAFAEL.ORG
Gary 0 Phillips . Mayor· John Gamblin . Vice Mayor· Kate Colin , Councllmember • Maribeth Bushey, Councilmember • Andrew Cuyugan McCullough . Councilmember
CONTRACT ROUTING FORM
INSTRUCTIONS: Use this cover sheet to circulate all contracts for review and approval in the order shown below.
TO BE COMPLETED BY INITIATING DEPARTMENT PROJECT MANAGER:
Contracting Department: Fire Department
Project Manager: David Catalinatto
Extension: CIiGk here to enter text.
Contractor Name: Medicare
Contractors Contact: Click here to enter text.
Contact's Email: Click here to enter text.
o FPPC: Check if Contractor/Consultant must file Form 700
Step RESPONSIBLE DESCRIPTION
DEPARTMENT
1 Project Manager a. Email PINS Introductory Notice to Contractor
b. Email contract (in Word) & attachments to City
Atty c/o Laraine.Gittens@cityofsanrafael.org
2 City Attorney a. Review, revise, and comment on draft agreement
and return to Project Manager
b. Confirm insurance requirements, create Job on
PINS, send PINS insurance notice to contractor
3 Project Manager Forward three (3) originals of final agreement to
contractor for their signature
4 Project Manager When necessary, * contractor-signed agreement
agendized for Council approval
*PSA > $20,000; or Purchase> $35,000; or
Public Works Contract> $125,000
Date of Council approval
PRINT CONTINUE ROUTING PROCESS WITH HARD COPY
5 Project Manager Forward signed original agreements to City
Attorney with printed copy of this routing form
6 City Attorney Review and approve hard copy of signed
agreement
7 City Attorney Review and approve insurance in PIN~) and bonds
(for Public Works Contracts) II ~
8 City Manager / Mayor Agreement executed by Council auth 6 rized official
9 City Clerk Attest signatures, retains original agreement and
forwards copies to Project Manager
COMPLETED
DATE
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enter a date.
4/17/2018
4/19/2018
4/19/2018
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enter a date
0 N/A
Or
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enter a date.
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REVIEWER
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