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a Is the person a voting member of the board, a senior executive of the AHS entity, or an <br /> AHS management employee with total compensation greater than $90,000? <br /> [ )Yes <br /> b. Does the person hold a material financial interest in a provider - sponsored <br /> organization in which the AHS entity is a participant? <br /> I [Yes <br /> c. Is the contracting party an entity in which a disqualified person owns <br /> at least 35 %? <br /> ( [ Yes C, <br /> d. Did the person have any role in founding the organization or are they a substantial <br /> contributor (more than $5,000) to the AHS entity? <br /> 1 Yes <br /> e. Is the person's compensation primarily based on the revenues of a particular <br /> department or function of the AHS entity, which the person controls? <br /> ( [Yes <br /> f. Does the person manage a discrete segment or activity of the AHS entity that <br /> represents a substantial portion of the AHS entities overall operation <br /> - 1 I Yes <br /> 15. Legal Review <br /> a. Has AHS Corporate Legal Services previously reviewed this contract? <br /> If yes, name of attorney who reviewed: ®Ye <br /> b. Was external counsel used for this contract? <br /> If yes, name of attorney, firm & phone #: name 1 (Yes <br /> 16. Contract Approval <br /> By signing below, / acknowledge l have had an opportunity to read the materials <br /> prepared for the above contract and accept responsibility for their content. <br /> )Signature Date <br /> A) Preparers electronic signature <br /> 01/15/09 �;;s <br /> B) Entity CFO: electronic signature l <br /> ,01/15/09 iAj <br /> C) Entity CEO /COO: electronic signature i ` <br /> This Contract has been discussed with the Board or Finance -01/15/09 / <br /> (Exce0 COI <br /> Independent Contractor, Professional Services, Medical Directo Agreements, and Leases) [l Yes <br /> No <br /> Finance Committee Representative • <br /> (Except for Independent Contractor, Professional Services, and Medical Director Agreements) <br /> Contract Review Response <br /> Corporate Legal Se rvices <br /> Date: 01f01t0 t - - -- <br />