AFFILIATION AGREEMENT

THIS AFFILIATION AGREEMENT (this “Agreement”) is made as of [date] (the “Effective Date”) by and between the [insert name of corporation or other entity that owns/operates the clinical residency program] (the “Residency”), a [corporation/not-for-profit corporation/partnership] organized under the laws of [insert state of incorporation/organization] having its principle place of business at [insert address], and [insert name of corporation or other entity that owns/operates the clinical facility] (the “Center”), a [corporation/not-for-profit

corporation/partnership] organized under the laws of [insert state of incorporation/organization] having its principle place of business at [insert address].

WHEREAS, the Residency operates a post-professional clinical residency program in physical therapy (the “Program”) for residents who have met the clinical residency application criteria;

WHEREAS, the Program involves the residents’ managing patients under the supervision of physical therapists on the Center’s staff;

WHEREAS, the Center operates a clinical facility (the “Facility”) known as [insert name of facility] and located in [insert city and state] that offers physical therapy services to patients on an in-patient and/or out-patient basis;

WHEREAS, the Residency and the Center are interested in entering into an arrangement under which students in the Program would manage patients at the Facility under the supervision of physical therapists on the Center’s staff, subject to the terms and conditions set forth in this Agreement;

NOW, THEREFORE, in consideration of their respective agreements, the representations and warranties contained herein, and other good and valuable consideration, the parties agree as follows:

1. Joint Responsibilities

1.1 Neither the Residency nor the Center will show any discrimination on the grounds of sex, race, creed, or color in the admission of qualified residents to any affiliated program, nor in the provision of instruction for such residents.

1.2 The number of residents, their program of education with the Center, and the scheduling of their education at the Center will be determined by mutual agreement between the Center and its affiliate(s).

1.3 A copy of the printed rules and regulations, and a calendar for both the Residency and its affiliate(s)’ activities should be made available to both participants.

1.4 The dismissal of a resident for academic or disciplinary reasons will be the responsibility of the Center, but the affiliate(s) maintain the right to remove a resident from the clinical education portion of the program, if a resident’s behavior should violate existing rules and regulations of the affiliate in such matters as procedure, policies, patient contact, and in such other respects that the affiliate may require to prevent interference with its proper operation. Both the clinic and the affiliate should determine joint when and if a student, who has been removed from the clinical phase of the program, should be permitted to return to the clinical phase.

2. Responsibilities of Residency

2.1 The clinic shall have control over all phases of the administration of the program, curriculum content, evaluation, faculty appointments, admission requirements, promotion, and graduation,

and such other matters as are internal to the clinic. The clinic will maintain the necessary records of the residents.

2.2 The philosophy of the program will be determined by the clinic.

2.3 The clinic will assign students to an affiliate for their clinical education in accordance with the clinic’s calendar and the agreement reached on the capacity of the affiliate to accommodate residents for the necessary experience.

2.4 Where appropriate, and if required by accreditation or other considerations, clinical personnel will be given clinic appointments. The rights and responsibilities of the appointees will be those that are established by the clinic.

2.5 The clinic will provide a staff/faculty member who will serve as liaison with the clinical instructors.

2.6 The clinic will provide certain benefits and accord privileges to the clinical faculty, appropriate to their role in the Program. Reimbursement of expenses for clinical faculty will be based upon established clinic policies.

2.7 The clinic warrants that it carries professional and general liability insurance, with single limits of at least $1,000,000 per occurrence, to protect itself and its participating residents and faculty members, from the consequences of bodily injury arising out of negligence, malpractice, error, or mistake in the rendering or failure to render of any professional service by said residents or faculty members, with respect to this educational clinical experience program at the affiliate(s).

2.8 The clinic credentials will provide verification of each resident’s credentials.

3. Responsibilities of Clinical Center

3.1 The affiliate(s) shall provide emergency health services and routine medical and dental care on a space available basis for the students during assignment.

3.2 The affiliate(s) shall provide clinical instruction and supervision of the residents by qualified personnel, who meet the standards of recognized professionals accrediting agencies or state agencies and the stated objectives of the educational program.

3.3 The affiliate(s) shall provide emergency health services and routine medical and dental care on a space-available basis for residents during assignment.

3.4 The affiliate(s) shall permit residents and faculty to have use of cafeteria and parking facilities, if available, at the same rate of charges as for employees.

3.5 The affiliate(s) will provide time for clinical instructors to attend clinical supervisors’ meetings and conferences called by the clinic as part of the educational program.

3.6 The affiliate(s) will provide cooperation when asked, in formal evaluation of the resident and will maintain the records and reports required by the clinic for conducting the educational program. 3.7 The affiliate(s) warrant that it/they carry professional and general liability insurance with limits of

at least $1,000,000 per occurrence to cover itself and its personnel (including those who may also have clinical appointments at the clinic) from the consequences of negligence, malpractice, error, or mistake in the rendering or failure to render of any professional service, which includes the Program covered by this agreement.

Officials signing the agreement for the participating institutions:

________________________ _________________________

Director, Clinic Director, Affiliate

________________________ _________________________

Example 2

(From Kaiser Permanente Los Angeles Movement Science Fellowship, 2009)

There are no inter-facility legal agreements as all facilities are Kaiser Permanente facilities and all fellows in our program and clinical faculty of our program are employees of the Kaiser Permanente facility where the clinical supervision and clinical practice hours occur.

Example 3

(Adapted from Glendale Adventist Medical Center’s Orthopedic Physical Therapy Residency, 2009)

AGREEMENT BETWEEN GLENDALE ADVENTIST MEDICAL CENTER AND KAISER PERMANENTE

This is an agreement between Glendale Adventist Medical Center and Kaiser Permanente regarding their mutual participation in Glendale Adventist Medical Center Orthopedic Physical Therapy Residency program. Kaiser Permanente will provide the didactic training of the Glendale Adventist Medical Center residents at no cost for 2009, in return for the residents’ participation at Los Angeles Free clinic.

Glendale Adventist Medical Center Orthopedic Physical Therapy Program and its resident will be responsible for providing all liability coverage for its resident and their service, while participation at the Los Angeles Free Clinic. In 2009, the Community Benefits Program within Kaiser Permanente Southern California will cover the cost of thirty days (288 hours) of classroom and lab instruction in the principles and procedures of Orthopedic physical therapy as described in the current American Board of Physical Therapy Specialties’ Description of Specialty Practice in Orthopaedic Physical Therapy. This instruction meets the curriculum requirements for credentialing by the APTA’s American Board of Physical Therapy Residency and Fellowship Education. This financial agreement for subsequent years is dependent upon securing funding from the Community Benefits Program during its annual review of programs. The financial arrangement that is in place for 2009 will be requested for 2010 – and in subsequent years.

Example 4

(Adapted from The Ohio State University Medical Center Neurologic Physical Therapy Residency Program, 2009)

RESIDENCY EDUCATION AGREEMENT