9046_Keefe_Canteen_QSO.docx.pdf

DEPARTMENT OF CORRECTIONS State of Wisconsin

QUALIFIED SERVICE ORGANIZATION AGREEMENT

The Qualified Service Organization Agreement (“QSO Agreement”) is made between

Keefe Commissary Network, LLC (Keefe) (Contractor) and the Wisconsin

Department of Corrections (DOC), as the parties to this QSO Agreement. This QSO

Agreement is specific to the services, activities, and functions provided by Keefe to

DOC in relation to the parties’ agreement identified as Contracted Canteen Services

(“Underlying Contract.”) This QSO Agreement is effective between the parties beginning on the date when all parties affixed their respective signatures to

Underlying Contract and terminates any prior existing QSO Agreements between the parties.

The Contractor agrees to the following:

1. To receive Substance Use Disorder Records, defined as including information relating to the identity, diagnosis, prognosis, or treatment of any records created, received or acquired in connection with the performance of any federally assisted program or activity relating to a patient who has applied for or been given diagnosis, treatment, or referral for treatment for a substance use disorder at a Part 2 program as defined in 42 C.F.R s. 2.11, only for the purposes intended under this QSO

Agreement and in conformity with all applicable provisions of 42 USC §

290dd-2 and the underlying federal regulations, 42 CFR Part 2; and

2. To resist any efforts in judicial proceedings to obtain access to the

Substance Use Disorder Records except as expressly provided for in the regulations governing the Confidentiality of Substance Use Disorder

Records, 42 C.F.R. Part 2.

Both parties agree to the following termination provisions related to the Substance

Use Disorder Records:

1. Either party may terminate this QSO Agreement by mutual consent or unilaterally by providing 30 day’s written notice to the other party. In addition to that, the DOC may terminate this QSO Agreement immediately if it is determined that Contractor has violated any terms of this QSO

Agreement.

2. Upon termination of this QSO Agreement for any reason, Contractor shall return or destroy all Substance Use Disorder Records received from DOC, or created or received by Contractor on behalf of DOC. This provision shall apply to Substance Use Disorder Records that is in the possession of subcontractors or agents of Contractor. The Contractor shall retain no copies of the protected information.

Docusign Envelope ID: D6D4CEC2-188A-4687-A4D1-66D10CB1E900

DEPARTMENT OF CORRECTIONS State of Wisconsin

3. In the event that Contractor determines that returning or destroying the

Substance Use Disorder Records is infeasible, Contractor shall notify DOC of the conditions that make return or destruction infeasible within the time frame and in the manner as requested by the DOC.

4. Upon notification that return or destruction of Substance Use Disorder

Records is infeasible, Contractor shall extend the protections of this QSO

Agreement to such Substance Use Disorder Records and limit further uses and disclosures of the Substance Use Disorder Records to those purposes that make the return or destruction infeasible, as long as Contractor maintains the

Substance Use Disorder Records.

In Witness Whereof, the undersigned have caused this QSO Agreement to be duly executed by their respective representatives.

Name: Jared Hoy Name: John Purcelli

Title: Secretary Title: Executive Vice President

Department of Corrections Keefe Commissary Network, LLC

Dated: Dated:

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