Outline of Memorandum of Understanding Between the Shiley Eye Center, UC San Diego, And

MEMORANDUM OF UNDERSTANDING

This Memorandum of Understanding is made July 1, 2012 by and between UC Davis Student Health and Counseling Services (UCD SHCS) at the Davis campus and the Eye Center at the UC Davis Health System (EC UCDHS) and sets forth the relationship and obligations relating to provision for optometry services provided by EC UCDHS to UCD SHCS patients at the UC Davis Student Health and Wellness Center.

Recitals

Whereas UCD SHCS and the EC at UCDHS are both owned and operated by the Regents of the University of California and

Whereas UCD SHCS is operated for the purpose of providing highly accessible and affordable excellent health care to their patients, and

Whereas EC UCDHS is a top-rated provider of vision care, operated for the purpose of providing excellent health care to their patients, and

Whereas UCD SHCS seeks to fulfill its mission by providing access to optometric services for UCD SHCS patients, and

Whereas the EC UCDHS seeks to serve the needs of the campus student population, and

Whereas UCD SHCS and the EC UCDHS seek to maximize the efficient use of University resources by intra-campus cooperation in meeting the needs and mission of these respective campus entities and the goals and objectives of UC.

Now, therefore, UCD SHCS and the EC UCDHS agree as follows:

1. Responsibilities of UCD SHCS:

a) In consultation with EC UCDHS, site shall determine the type and scope of services that may be provided at UCD SHCS by EC UCDHS.

b) UCD SHCS shall designate an on-site liaison as a point-of-contact to coordinate the delivery of optometric services by EC UCDHS and the UCD SHCS business and

of 8 facility operational needs on optometry service-days. Initially, for set up of the clinic, this shall be Cheryl Boney, Director of Administrative Services. Once implementation of the clinic begins, this shall be Sandy Santiago, Director of Clinical Support Services.

c) UCD SHCS shall provide and maintain facilities, including security, sufficient and appropriate to delivering optometric services.

d) UCD SHCS shall supply the necessary staff support for the scheduling, reception, clinical record keeping, collection of co-payments, ordering and dispensary management for UCD SHCS patients.

e) UCD SHCS shall be responsible for all costs involved in the set up and daily operations of the optical dispensary including, but not limited to, optical displays, inventory, optical supplies, ophthalmic products, labor, etc.

2. Responsibilities of EC UCDHS:

a) EC UCDHS shall appoint a member of its faculty to be responsible for delivery of optometric services. Initially, this shall be Dr. Barnett. When Dr. Barnett is not available, EC UCDHS will provide a substitute member of its faculty to be responsible for delivery of optometric services. It is the intention of UCDHS to quickly establish a rotation of optometrists that are credentialed at SHCS in order to provide a seamless system of clinical care.

b) EC UCDHS shall be solely responsible for the general conduct of its staff while assigned to the UCD SHCS facility. General conduct shall be in conformance with the UCD SHCS facility’s policies, rules and regulations while at the UCD SHCS facility.

c) EC UCDHS shall provide refractory and contact lens fitting and follow up services within the mutually agreed on scope of services. Refer to Attachment I for Scope of Services.

d) EC UCDHS shall ensure that staff complete all required UCD SHCS administrative and clinical training programs and participate in quality assurance activities to ensure that compliance and accreditation standards are met.

e) EC UCDHS will provide optometric services at the UCD SHCS Student Health and Wellness facility on days to be mutually agreed upon by UCD SHCS and EC UCDHS. Initially this will be two days per week to commence on or before July 1, 2012.

f) EC UCDHS optometrists shall participate in the delivery of optometric services. EC UCDHS optometrists shall be duly licensed and in good standing with the California State Board of Optometry and within EC UCDHS.

g) EC UCDHS shall provide on-call ophthalmology consultation to EC UCDHS, as necessary.

of 8 h) EC UCDHS’s staff will be present for service-days, between the hours of 8:00 a.m. to 5:00 p.m. in order to provide optometric services as necessary. Service-days and/or service may be expanded, by mutual agreement, based upon increased UCD SHCS patient demand for vision services.

i) EC UCDHS care providers shall produce letters, reports, or documents regarding patient care for the patient’s file, referring doctor, rehabilitation counselor, or similar purpose.

j) EC UCDHS staff will document clinical services in Point and Click, the UCD SHCS electronic health record. UCDHS will then transfer notes from Point and Click via mutually agreed on method, to its own EMR for the purpose of creating its own patient file and for the purpose of patient billing.

k) EC UCDHS will supply equipment and supplies (including DPAs—diagnostic pharmaceutical agents) as necessary to deliver optometric services. This will include, but not be limited to: all equipment, such as power chair and stand, phoropter and slit lamp, hand-held ophthalmoscope, binocular indirect and assorted lenses, and lens sets. EC UCDHS will be responsible for the maintenance, repair and replacement of equipment as necessary to deliver optometric services. EC UCDHS will be responsible to ensure that purchase, storage, and administration of DPAs will comply with all clinical and legal standards and all UCD SHCS program pharmaceutical policies and procedures. These will be provided at no cost to the UCD SHCS.

l) EC UCDHS will provide, at no charge, their expertise and assistance to UCD SHCS in setting up an optical shop that will coordinate with the clinical services. This expertise may include, but not be limited to: design of optical shop, vendor selection, inventory management, ordering, and billing.

m) EC UCDHS shall provide all information and documentation required for UCD SHCS to credential EC UCDHS optometrist(s) per UCD SHCS accrediting body guidelines.

n) EC UCDHS shall conduct annual chart review of records provided by EC UCDHS optometrist(s) to ensure high quality optometric services.

3. Mutual Considerations:

a) Patient files shall be the property of UCD SHCS. EC UCDHS shall have the right to access and duplicate any individual charts or records of patients receiving optometric services provided by EC UCDHS which are (1) necessary to assist in the defense of any malpractice or similar claim; (2) relevant to any disciplinary action or substantive adverse event; (3) for educational or research purposes and/or (4) billing purposes. Such inspection and/or duplication shall be permitted and conducted pursuant to commonly acceptable federal, state, and local laws. Files shall be retained at UCD SHCS.

of 8 b) EC UCDHS, in partnership with UCD SHCS, will provide and/or participate in quality improvement activities involving vision care services, including but not limited to: peer review, medical record completion review, patient safety, accreditation preparedness, etc.

4. Business and Operations Plan:

EC UCDHS shall retain all revenue from the provision of optometric services including but not limited to, reimbursement of claims, co-payments, and cash payments.

UCD SHCS shall retain all revenue deriving from the sales of eyeglasses, contact lenses, and other ophthalmic products at UCD SHCS optical dispensary.

UCD SHCS shall collect co-payments for optometric services provided by EC UCDHS using the EC UCDHS National Provider Identification (NPI) number. EC UCDHS shall cooperate in these processes by accurately completing entries in the EHR (electronic health record) system used by UCD SHCS and related linked websites of insurers covering patients served by UCD SHCS (such as VSP or EyeMed).

UCD SHCS will transfer copayments to EC UCDHS at least quarterly via intercampus transfer of funds within the UC accounting system.

EC UCDHS will be responsible for all other billing and collection services.

It is mutually agreed upon by both parties that after one year (or on any other mutually agreed upon point of time) the financial performance of both the clinic and the optical shop will be shared between both parties so as to negotiate mutually beneficial financial terms beyond the scope of this initial agreement.

EC UCDHS will be responsible for all clinical expenses related to providing optometric services at the UCD SHCS.

Operations:

Initially two service days per week, starting on or before July 1, 2012. The initial service providers will consist of one optometrist and one EC UCDHS health assistant. A maximum of 20 patients per day will be scheduled for the initial services team. Services shall be provided on a year-round basis. Service-days and/or service participants will be expanded, by mutual agreement, as UCD SHCS patient demand for vision services increases.

EC UCDHS, in collaboration with UCD SHCS, will determine mutually agreeable fees for services.

of 8 UCD SHCS and EC UCDHS must mutually approve waiver of fees for any service.

a) EC UCDHS may request waiver of fees for clinical educational purposes.

b) UCD SHCS may request waiver of fees for patient hardship or other similar purpose but is responsible for any “means testing” or similar testing of qualification for financial hardship.

5. Term

The term of this Memorandum of Understanding shall become effective upon final execution of this agreement and shall continue in effect for a maximum of five (5) years, through June 30, 2017 or until earlier terminated.

6. Termination

Termination Without Cause: Notwithstanding any other provision to the contrary, either party upon ninety days (90 days) prior written notice to the other party may terminate this Memorandum of Understanding without cause at any time.

7. General Terms

a) Professional and general liability insurance coverage for these activities is provided and governed by University policy, especially Business & Finance Bulletins (BUS-) 9, 63 and 75.

b) Disputes under any business agreement among the parties shall be resolved amicably and with mediation involving a third party from within the University, if necessary.

c) The term of a business agreement concluded from this memorandum of understanding shall begin on July 1, 2012 as mutually agreed and will continue thereafter until terminated, for any reason, by either party upon thirty (30) days advance written notice to the other.

d) Any notice required to be given pursuant to this letter of intent shall be in writing and shall be served by personal service or first class mail. When served by first class mail, service shall be conclusively deemed effective three (3) days after deposit thereof in the United States mail, postage prepaid, addressed to the party to whom such notice is to be given as herein provided:

of 8 Notice to EC UCDHS shall be addressed and mailed as follows:

Mark J. Mannis, M.D., F.A.C.S. Professor and Chair Department of Ophthalmology & Vision Science UC Davis Health System Eye Center 4860 Y St., Suite 2400 Sacramento, CA 95817

Notice to the UCD SHCS shall be addressed and mailed as follows:

Michelle S. Famula M.D. Executive Director, Student Health and Wellness One Shields Avenue University of California, Davis Davis, CA 95616

WHEREFORE, the parties have executed this Memorandum of Understanding as set forth below:

Mark J. Mannis, M.D., F.A.C.S Michelle S. Famula M.D. Professor and Chair Executive Director Department of Ophthalmology Student Health and Wellness & Vision Science University of California, Davis UC Davis Health System Eye Center One Shields Avenue 4860 Y St., Suite 2400 Davis, CA 95616 Sacramento, CA 95817

Date: Date:

Attachment I: Scope of Services

of 8 Attachment I

UC DAVIS STUDENT HEALTH AND COUNSELING SERVICES OPTOMETRY SCOPE OF PRACTICE

I. The practice of optometry includes the prevention and diagnosis of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as well as the provision of rehabilitative optometric services, and is the doing of any or all of the following:

(A) The examination of the human eye or eyes, or its or their appendages, and the analysis of the human vision system, either subjectively or objectively. (B) The determination of the powers or range of human vision and the accommodative and refractive states of the human eye or eyes, including the scope of its or their functions and general condition. (C) The prescribing or directing the use of, or using, any optical device in connection with ocular exercises, visual training, vision training, or orthoptics. (D) The prescribing of contact and spectacle lenses for, or the fitting or adaptation of contact and spectacle lenses to, the human eye, including lenses that may be classified as drugs or devices by any law of the United States or of this state. (E) The use of topical pharmaceutical agents for the purpose of the examination of the human eye.

II. An optometrist who is certified by California law to use therapeutic pharmaceutical agents to diagnose and treat the human eye or eyes, or any of its or their appendages may do so at U.C. Davis Student Health and Counseling Services under direct supervision of or in consultation with University of California Davis Medical Center (UCDMC) Ophthalmology for the following conditions:

(A) Infections of the anterior segment and adnexa (e.g., conjunctivitis, blepharitis). (B) Ocular allergies of the anterior segment and adnexa. (C) Non-vision threatening corneal surface disease and dry eyes.

In any condition in which the diagnosis is unclear, in which there the potential for vision threatening disease, or there is a lack of response to initial therapy, the optometrist must obtain immediate consultation with the supervising ophthalmologist and/or refer the patient to the community ophthalmologist for continuing care.

In any case where an optometrist consult with an ophthalmologist, the optometrist shall maintain in the patient’s Electronic Health Record (EHR) the information provided to the ophthalmologist, the ophthalmologist's response, and any other relevant information. Upon the consulting ophthalmologist's request and with the patient's consent, the optometrist shall furnish a copy of the record to the ophthalmologist.

of 8 III. The optometrist will initiate immediate/urgent referral to UCDMC or community ophthalmologist for any condition causing a sudden painful, often red eye, with reduced vision (e.g., acute glaucoma, corneal ulcer, traumatized eye, herpetic eye disease, scleritis, orbital cellulitis, etc.), conditions causing sudden and profound visual loss with or without pain (e.g., diabetic eye disease, retinal artery or vein occlusion, retinal detachment, ischemic optic neuropathy, wet macular degeneration, etc.), and conditions with gradual painless vision loss (e.g., cataract, macular degeneration, diabetic retinopathy, glaucoma, compressive optic neuropathy, etc.

Any immediate/urgent referral by the optometrist to UCDMC or community ophthalmologist will be documented in the patient’s EHR.