HEALTH SERVICE EXECUTIVE HSE Community Healthcare Organisation Or National Office and [THE PROVIDER] Care Group: PRIMARY CARE SERVICE ARRANGEMENT PART 2 OF ARRANGEMENT – SERVICE SCHEDULES – 2022 Section 38 Health Act 2004 The Schedules include detailed instruction which form part of the conditions of funding and should not be removed, some detailed instruction for schedule completion and examples have been provided which may be deleted. Items in Blue should be deleted. Section 38 Non-Acute Primary Care Schedules 2022 FINAL – Revised November 2021 Alterations to legal clauses or official text in this contract are strictly prohibited 1 For 2022 CHO Care Group Schedules may be combined by including relevant individual schedules and indexing them as A, B, C, etc. for single sign off by Chief Officer and the Authorised Signatory of the Agency Section 38 Non-Acute Primary Care Schedules 2022 FINAL – Revised November 2021 Alterations to legal clauses or official text in this contract are strictly prohibited 2 TABLE OF CONTENTS SCHEDULE 1 - Contact Details Part A – The Executive Part B – The Provider SCHEDULE 2 - Quality and Safety SCHEDULE 3 - Service Delivery Specification SCHEDULE 4 - Performance Monitoring SCHEDULE 5 - Information Requirements SCHEDULE 6 - Funding SCHEDULE 7 - Insurance SCHEDULE 8 - Complaints SCHEDULE 9 - Staffing SCHEDULE 10 - Change Control Section 38 Non-Acute Primary Care Schedules 2022 FINAL – Revised November 2021 Alterations to legal clauses or official text in this contract are strictly prohibited 3 SCHEDULE 1 Contact Details Purpose The purpose of this schedule is to set out the key contact details of both the Executive and the Provider. Part A – The HSE Community Healthcare Organisation Name & Number Or National Office Name Chief Officer/Equivalent Name Chief Officer/Equivalent Address: Telephone Number: Fax Number: E-mail: Main contact person: (This is the nominated key contact person who will have operational responsibility for the contract) Authorised signatory: (This is the person who has been assigned responsibility for signing service arrangements. This should be in line with National Financial Regulations as appropriate) This should not be confused with the authorised signatory for Garda vetting. Service Lead: (Please expand as necessary, for each relevant service category and/or geographic area) Department/Specific area of responsibility: Address: Telephone Number: E-mail: H.R. Contact: Address: Telephone Number: E-mail: Finance Contact: Address: Telephone Number: E-mail: CHO’s Head of Service: Quality Safety and Service Improvement: (or where funding area is not a CHO, please insert the appropriate alternative) Address: Telephone Number: Section 38 Non-Acute Primary Care Schedules 2022 FINAL – Revised November 2021 Alterations to legal clauses or official text in this contract are strictly prohibited 4 E-mail: Emergency Contact: (Ref: Local emergency/crisis protocol) Address: Telephone Number: E-mail: 5 Section 38 Non-Acute Primary Care Schedules 2022 FINAL – Revised November 2021 Alterations to legal clauses or official text in this contract are strictly prohibited Part B – The Provider Registered Name: (Legal Entity) Trading Name: Address: Legal Status: Charity Status Are you a Charity? Yes No If yes is ticked above, you must be registered with the Revenue Commissioners and the Charities Regulator. Please provide the following information: Revenue Commissioners CHY Number  Charities Regulator Number If you are not registered, you must outline actions being taken to obtain registration. Registered Company Number: Tax Clearance Number : Tax Registration Number: (The Provider is deemed to give permission to the HSE to verify the Tax Cleared position on-line) Parent organisation Name and Address: (Where an organisation is a subsidiary of or controlled by another organisation) Franchise organisation Name and Address: (Where the legal entity is operating as a franchise) Main Contact Person: (This should be the person who has overall responsibility for execution of the contract and will be the key contact person with the Executive) Chief Officer/Director or appropriate senior official (please give title): Chairperson: Authorised signatory: (This should be the person authorised by the Board of the Provider to sign the Service Arrangements) CEO / Chairperson or Equivalent (Senior Person delegated by the Board) Address: Telephone Number: Email: 6 S

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