318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

TOWNSHIP OF WEST ORANGE THIRD PARTY BILLING FOR EMERGENCY AMBULANCE SERVICES PROPOSAL FORM The Township of West Orange is seeking an incentive based scale to maximize the collection of the billable ambulance services. An example is provided below. Example: Percentage Range of Collections by Vendor 5% $0 to $100,000.00 10 % $101,000.00 to $200,000.00 Percentage incteases to be paid by the Township would be based on total collections over a 12 month period. The undersigned hereby agrees to furnish all services, labor, materials, supervision, equipment, and other means as necessary to perform all the work in accordance with these specifications. ¢ 3 % $ 0 to 750,000.00 % $ 751,000.00 to 1,000,000.00 ff % $ 1,000,001.00 to 1,500,000.00 / [ % $ 1,551,000.00 and above Shite Lovee Easoborit AuthQriz Agtire Print Name & Title Corkés « Ubealb, POD Str UE by burne PML, eb -B Company Name Wa Address 4 [-19-QEZ. Morreale AST 2725 [ Date City, State, Zip ZI2Q-STE-AILTS Telephone Number 20

TOWNSHIP OF WEST ORANGE Email Address Business Registration Certification Effective September 1, 2004, the State has expanded its Contractor Registration Program to local Government contracts, P.L. 2004, c57. All business organizations that do business with a local government agency are required to be registered with the State. The business must provide proof of that registration to the local government agency before that local government agency can enter into a contract with the business. A copy of the Business Registration Certificate shall be provided at the time any bid or RFP is submitted; failure to do so is a fatal defect that cannot be cured. A copy of the Business Registration Certificate must also be on file before any purchase order/voucher or other contracting document can be issued. Contractors are responsible for notifying subcontractors. Further information and registration can be obtained online from the NJ Treasury, Division of Revenue or by calling (609) 292-1730. FE SIGS ICIISCISGE ICI ICR AIC P.L. 1999 Chapter 238. The Public Works Contractor Registration Act specifies that no contractor or subcontractor shall bid on or engage in any contract (or part thereof) for public work which is subject to the provisions of the “New Jersey Prevailing Wage Act”, P.L. 1963 C. 150 (c. 34:11-56.25 et seq.) for the construction, reconstruction, demolition, alteration, repair, or maintenance of a public building regularly open to and used by the general public or public institution, and includes any subcontractor or lower tier subcontractor of a contractor unless they are registered with the Commissioner of Labor. 21

STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE Taxpayer Name: Trade Name: Address: Certificate Number: Effective Date: Date of Issuance: CORONIS HEALTH RCM, LLC 5963 EXCHANGE DRIVE STE 114 SYKESVILLE, MD 21784 2600268 June 21, 2021 June 23, 2021 For Office Use Only: 20210623120113972

TOWNSHIP OF WEST ORANGE STATEMENT OF OWNERSHIP (OWNERSHIP DISCLOSURE CERTIFICATION) N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43) Name of Business: a Dy LS be Jf, ke LL eS Address of Business: $C> ¢/5 Hepla a GM £3 lol, (3 TV hore 29 | Le tT O77s/ Name of person completing this form: G2, ow Le Baa NVJ.S.A. 52:25-24.2: "No corporation, partnership, or limited liability company shall be awarded any contract nor shall any agreement be entered into for the performance of any work or the furnishing of any materials or supplies, unless prior to the receipt of the bid or proposal, or accompanying the bid or proposal of said corporation, said partnership, or said limited liability company there is submitted a statement setting forth the names and addtesses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. If one or more such stockholder or pattner or member is itself a corporation or partnership or limited liability company, the stockholders holding 10 percent or more of that corporation’s stock, or the individual partners owning 10 percent or greater interest in that partnership, or the members owning 10 percent or gteater interest in that limited liability company, as the case may be, shall also be listed. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member, exceeding the 10 percent ownership criteria established in this act, has been listed. To comply with this section, a bidder with any direct or indirect parent entity which is publicly traded may submit the name and addtess of each publicly traded entity and the name and address of each person that holds a 10 percent or greater beneficial interest in the publicly traded entity as of the last annual filing with the federal Securities and Exchange Commission or the foreign equivalent, and, if there is any person that holds a 10 percent or greater beneficial interest, also shall submit links to the websites containing the last annual filings with the federal Securities and Exchange Commission or the foreign equivalent and the relevant page numbers

eficial interest, also shall submit links to the websites containing the last annual filings with the federal Securities and Exchange Commission or the foreign equivalent and the relevant page numbers of the filings that contain the information on each person that holds a 10 percent or greater beneficial interest." The Attorney General has advised that the provisions of N.J.S.A. 52:25-24.2, which refer to corporations and partnerships apply to limited partnerships, limited liability partnerships, and Subchapter S corporations. This Ownership Disclosure Certification form shall be completed, signed and notarized. 22

TOWNSHIP OF WEST ORANGE Failure of the bidder/proposer to submit the tequired information is cause for automatic rejection of the bid or proposal Part I Check the box that represents the type of business organization: Disc. Proprietorship (skip Parts II and III, sign and notarize at the end) Dnon-Profit Corporation (skip Parts II and IIL, sign and notarize at the end) . Dpartnership Oo Limited Partnership Dhimitea Liability Partnership luimnitea Liability Company Dror-prost Corporation (including Subchapters C and S or Professional Corporation) Dloihes (be specific): Part II p= I certify that the list below contains the names and addresses of all stockholdets in the cotporation who own 10 Percent or mote of its stock, of any class, ot of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. OR Oo I certify that no one stockholder in the corporation owns 10 percent ot mote of its stock, of any class, or no individual partner in the partnershij ip Owns a 10 percent or greater interest therein, or that no member in the limited liability company owns a 10 percent or gteater interest therein, as the case may be. Complete, sign and notarize the form below. (Please attach additional sheets if more space is needed): 23

TOWNSHIP OF WEST ORANGE Name ¢ DeLuna s fh, SMe. LLCO Name J Address a ray aT pl Ait. Address Soe Ut, SLesulle MLZ 21784 Name Name Address Address Name Name Address Address 24

TOWNSHIP OF WEST ORANGE Part III- Any Direct or Indirect Parent Entity Which is Publicly Traded: “To comply with this section, a bidder with any direct or indirect parent entity which is publicly traded may submit the name and address of each publicly traded entity and the name and address of each person that holds a 10 percent or greater beneficial interest in the publicly traded entity as of the last annual filing with the federal Securities and Exchange Commission or the foreign equivalent, and, if there is any person that holds a 10 percent or greater beneficial interest, also shall submit links to the websites containing the last annual filings with the federal Securities and Exchange Commission or the foreign equivalent and the relevant page numbers of the filings that contain the information on each person that holds a 10 percent or greater beneficial interest.” Oo Pages attached with name and address of each publicly traded entity as well as the name and address of each person that holds a 10 percent or greater beneficial interest. OR Oo Submit here the links to the Websites (URLs) containing the last annual filings with the fedetal Securities and Exchange Commission or the foreign equivalent. AND psi Submit here the relevant page numbers of the filings containing the information on each person holding a 10 percent or greater beneficial interest. Esser LEI Tisbicratilato folebeny LLC (ool? rent et Corrs bell S16 O- Cxcbaage Lise Sait? My Side wile, (0D 2U78Y a Subscribed and sworn before me this [4 aay of Navenderc 208. ame 7 / (Notary Public) he oo “Le ete Tass whe Sp My Commission expires: A- 36-004 (Print name of affiant and title if applicable) Ske cf NIT oF NOON, (Corporate Seal if a Corporation) y 25

TOWNSHIP OF WEST ORANGE SCHEDULE A MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE NJ.S.A. 10:5-31 et seq. (P.L. 1975, C. 127) -- NJ.A.C. 17:27 -- GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS During the performance of this contract, the contractor agrees as follows: The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will take affirmative action to ensure that such applicants are recruited and employed, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Such action shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause. The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. The contractor or subcontractor, where applicable, will send to each labor union or representative or workers with which it has a collective bargaining agreement or other contract or understanding, a notice, to be provided by the agency contracting officer advising the labor union or workers' representative of the contractor's commitments under this act and shall post copies of the notice in conspicuous places available to employees and applicants for

r advising the labor union or workers' representative of the contractor's commitments under this act and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act. The contractor or subcontractor agrees to make good faith efforts to employ minority and women workers consistent with the applicable county employment goals established in accordance with N.J.A.C. 17:27-5.2, or a binding determination of the applicable county employment goals determined by the Division, pursuant to N.J.A.C. 17:27-5.2. (cont.) 26