Section 8

External Coordination and Mutual Support

Table of Contents

8.1. Introduction 8 - 1

8.2 VA's Legal Authorities and Other References 8 - 1

8.2.1. VA Contingency Support for the Military Medical System 8 - 1

8.2.2. VA's Authority to Respond to Major Disasters and Emergencies 8 -
2

8.3. VA/DoD Contingency Plan 8 - 2

8.4. National Disaster Medical System 8 - 3

8.4.1. Federal Coordinating Centers 8 - 4

8.5. National Response Plan (NRP) 8 - 5

8.5.1. NRP Background 8 - 5

8.5.2. NRP Organization 8 - 5

8.5.3. NRP Provisions 8 - 7

8.5.4. Mission Tasking 8 - 7

Figure 8.1: Request For and Furnishing Support Under the FRP 8 - 8

8.5.5. Reimbursement under the FRP 8 - 9

8.6. Humanitarian Assistance 8 - 9

8.7. Developing Local Agreements 8 - 9

8.7.1. General 8 - 9

8.7.2. Sharing Agreements and MOUs 8 - 10

8.7.2.1. Sharing Agreements 8 - 10

8.7.2.2. Memoranda of Understanding (MOUs) 8 - 11

8.7.3. General Counsel Review 8 - 12

8.7.4. Reporting 8 - 12

Figure 8.2: Sample Format for VISN Inventory of MOUs 8 - 12

*Enclosures*

1\. VA Federal Coordinating Centers by VISN 8 - 13

2\. Regional General Counsel Contacts 8 - 14

Section 8

External Coordination and Mutual Support

8.1. ***Introduction***. As both federal hospitals and as part of a
local medical community, VA Medical Centers (VAMCs) may be called upon
to perform a variety of emergency management activities outside of their
primary mission to provide and ensure the continuity of healthcare
delivery services to eligible veterans. These external support roles may
be provided under statutory authority, memoranda of agreement or
understanding (MOAs/MOUs), sharing agreements, community disaster and
emergency plans or humanitarian conditions.

> It should be noted that at the time this Section is being updated
> (February 2005), there are a number of changes that are anticipated
> with regard to the various missions, plans and programs under which VA
> may be called upon to provide external support to other federal
> departments and agencies, as well as state and local governments and
> communities. Although current at the time of publication, users of the
> Guidebook should routinely check the Emergency Management Strategic
> Healthcare Group (EMSHG) and the Center for Engineering & Occupational
> Safety and Health (CEOSH) websites for updates to the information
> provided within this chapter.

8.2. ***VA's Legal Authorities and Other References Relating to External
Support***. What is frequently referred to as "VA's Fourth Mission"
relates to VA's provision of support to (1) the Department of Defense
(DoD) and (2) other federal departments and agencies, the states, and
local communities' disasters and other emergencies. Following are the
primary authorities and other references that support this fourth
mission.

8.2.1. *VA Contingency Support for the Military Medical System*.

a\. 38 U.S.C. § 8110, Operation of Medical Facilities, as amended.

b\. 38 U.S.C. § 8111 (Public Law 97-174), Sharing of Department of
Veterans Affairs and Department of Defense Health Care Resources.

c\. 38 U.S.C. § 8111A, Furnishing of Health-care Services to Members of
the Armed Forces During a War or National Emergency, as amended.

d\. Executive Order 12751, Health Care Services for Operation Desert
Storm, February 14, 1991.

e\. 38 C.F.R. § 17.230, Contingency backup to the Department of Defense.

f\. VHA Handbook 0320.1, Department of Veterans Affairs and Department
of Defense Contingency Hospital System Plan, May 1, 1997.

g\. Legislative History, Public Law 97-174, VA and DoD Health Resources.

h\. Memorandum of Understanding between VA and DOD (1982).

i\. Memorandum of Understanding between VA and DOD (1983).

j\. Memorandum of Understanding between VA and DOD, Billing Guidance
(2003).

8.2.2. *VA's Authority to Respond to Major Disasters and Emergencies*.

a\. National Response Plan (NRP), November 2004.

b\. 42 U.S.C. §§ 5170, 5190, The Stafford Act, et. seq.

c\. 42 U.S.C. §§ 5191-5195a, Emergency Assistance Programs.

d\. 42 U.S.C. §§ 5122, Definitions, 5144 et. seq.

e\. 42 U.S.C. § 247d-6, Public Health Countermeasures to a Bioterrorist
Attack.

f\. 42 U.S.C. §§ 300hh and 300hh-11, National Preparedness for
Bioterrorism and Other Public Health Emergencies.

g\. 31 U.S.C. § 1535, The Economy Act.

h\. 38 U.S.C. § 1784, Humanitarian Care.

i\. Department of Veterans Affairs Emergency Preparedness Act of 2002.

j\. U.S.C. § 8117, Emergency Preparedness.

k\. 38 U.S.C. §1785, VA Emergency Preparedness Act.

l\. Executive Order No. 12148, Federal Emergency Management, as amended.

m\. Homeland Security Presidential Directive No. 5, Management of
Domestic Incidents, February 2003.

n\. Homeland Security Presidential Directive No. 7, Critical
Infrastructure Identification, Prioritization and Protection, December
2003.

o\. Homeland Security Presidential Directive No. 8, National
Preparedness, December, 2003.

p\. 38 U.S.C. §§ 8152, 8153, Sharing of Health-care Resources.

q\. VHA Directive 1660.1, Enhanced Health Care Resources Sharing
Authority -- Selling.

> r\. Memorandum of Understanding between HHS, DVA, DoD and FEMA (1997).

8.3. ***VA/DoD Contingency Plan***. The VA/DoD Contingency Plan (VHA
Directive 1095.007 and VHA Handbook 0320.1) implements Public Law
97-174, and provides specific requirements for VAMCs regarding the
accomplishment of their individual roles to support this Plan. VAMCs are
either designated as a Primary Receiving Center (PRC) or Secondary
Support Center (SSC). Some facilities may have additional
responsibilities as Installation Support Center (ISCs).

In planning for the accomplishment of assigned roles under the VA/DoD
Contingency Plan, the following assumptions are made:

-   The Continental United States (CONUS) will not be attacked.

-   Contingency plans are based on existing manpower, supplies and other
    resources currently available at the PRC and SSC.

-   Mobilization of Guard and Reserve Units will have occurred or will
    be in process. (The Plan should account for diminished manpower due
    to a military call-up.)

-   Casualties could arrive at the primary receiving area within 24-48
    hours of initial notification of plan activation.

-   Demands for accommodation of active duty casualties could continue
    for 90 days post Plan activation.

In the event of war or national emergency, the VA/DoD Contingency Plan
would be activated by the Secretary, Department of Veterans Affairs,
based upon a request from the Assistant Secretary of Defense for Health
Affairs (HA). Upon activation of the Plan and when directed to do so,
only PRCs will report available beds to the Global Patient Movements
Requirement Center (GPMRC) for the direct receipt of active duty
casualties. This report is made via the U.S. Transportation Command
Regulating and Command and Control Evacuation System (TRAC^2^ES).

Beds available in SSCs will be reported to the PRC and used in the
planning and determination of maximum beds that could be made available
by the PRC for casualty reception. PRCs will develop their plans in
coordination with their supporting SSCs to not only maximize bed
availability for the receipt of active duty casualties, but also provide
support for accommodation of transferred Veterans.

In compliance with VHA Handbook 0320.1, all VAMCs must have a plan,
specific to their assigned role, as to how they will support the overall
VA/DoD Contingency Plan. These plans will include procedures for bed
reporting, patient reception, patient tracking and patient disposition.
An annual review and update of the plan is scheduled to be accomplished
in December of each year. After revisions have been completed, copies of
the revised plans will be sent to the Plans, Policy and Analysis Office
of EMSHG.

8.4. ***National Disaster Medical System (NDMS)***. The National
Disaster Medical System is a public/private partnership to provide both
emergency healthcare services and definitive medical care to disaster
victims when state and local resources are overwhelmed. The system can
also be used in wartime for the care of active duty military casualties,
if DoD and VA treatment capacity is exceeded. At the national level, the
partnership includes DoD, Department of Homeland Security (DHS)/Federal
Emergency Management Agency (FEMA) and VA. VA's role in NDMS is one of
coordination of various NDMS areas throughout the United States*. No VA
beds are provided as part of the NDMS.* There are three circumstances
under which the NDMS may be activated:

-   In response to an overseas military contingency (activated by the
    Secretary of DHS at the request of the Secretary of Defense).

-   Request for major medical assistance directly to the Secretary of
    DHS (activated by the Secretary DHS).

-   Presidential declaration of a disaster under the National Response
    Plan (activated by the Secretary DHS).

8.4.1. *Federal Coordinating Centers* **-** Only specific VAMCs have
responsibilities under the NDMS. These facilities are designated as
Federal Coordinating Centers (FCCs) for the system in their respective
NDMS area. A listing of VA FCCs by VISN is provided at the end of this
Section (See Enclosure 1). The principal responsibilities of the FCCs
are as follows:

-   Coordination of NDMS definitive medical care is assigned to local
    areas.

-   Solicitation and organization of local, private sector hospitals and
    community support services.

-   Enrollment of non-federal local hospitals in NDMS.

-   Coordination and reporting (to GPRMC) of NDMS area bed availability.

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-   Coordination with local/State authorities on:

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-   Preparing of local NDMS patient reception plans.

-   Planning and conducting annual NDMS exercises.

-   Management of NDMS operations during activation.

Those VAMCs that are designated as FCCs for the NDMS have specific
responsibilities for development, exercise and activation of supporting
plans. These VA FCCs must develop a plan with the community for the
reception, transportation, tracking and disposition of casualties being
evacuated from the site of a nationally declared disaster. The Office of
Emergency Preparedness, United States Public Health Services (USPHS) and
Department of Health and Human Services provide planning guidance in the
Federal Coordinating Center Guide that has been developed and published.
Copies of the guide can be obtained directly from them by calling
1-800-USA-NDMS or by writing to:

> Chief, NDMS Section
>
> Department of Homeland Security
>
> 500 C Street, SW
>
> Washington, DC 20472

In addition, EMSHG Area Emergency Managers have copies of the guide and
can arrange for additional copies if needed.

8.5. ***National Response Plan***. The Stafford Act (42 U.S.C., Section
5121 et. seq.) is the primary source of VA's and other federal agencies'
authority to respond to disasters and emergencies. The full title of
this act is The Robert T. Stafford Disaster Relief and Emergency
Assistance Act. (Refer to
<http://www.dhs.gov/interweb/assetlibrary/NRPbaseplan.pdf>.)

Following a Presidential declaration of a major disaster or emergency,
the President or the Secretary of the Department of Homeland Security
may request (and in some cases direct) VA to use its resources in
support of state and local assistance efforts, with or without
reimbursement (although normally VA is reimbursed for personnel and
other recourses provided). The plan under which this support is provided
is the National Response Plan (NRP) that was issued in CY 2004.

8.5.1. *The National Response Plan (NRP)* was published in 2004, and
replaces the Federal Response Plan (FRP) that was last issued in 1999.
The NRP incorporates and expands on the FRP, includes other plans
previously issued separately, but continues to be the principle document
to implement the Stafford Act (PL 93-288 as amended). The NRP is
designed to provide a coordinated federal response to state and local
requests for assistance in the event of a disaster or emergency. The
Secretary of DHS normally activates the NRP only when the President has
declared that a Federal disaster exists within a state. The disaster
declaration may include only specific portions of the state or encompass
the entire state, depending upon the extent of the disaster. However,
the President may direct activation of the NRP separate from or as a
prelude to a formal Presidential Disaster Declaration.

8.5.2. *NRP Organization*. The NRP is organized as follows:

8.5.2.1. [The Base Plan]{.underline} describes the structure and
processes comprising a national approach to a domestic incident and is
designed to integrate federal, state, local, tribal, private sector and
non-governmental organizations.

8.5.2.2. [Appendices]{.underline} provide other relevant and more
detailed supporting information. This includes terms, definitions,
acronyms, authorities and a compendium of national interagency plans.
These are the appendices included:

-   Glossary of Key Terms

-   List of Acronyms

-   Authorities and References

-   Compendium of National/International Interagency Plans

-   Overview of Initial Federal Involvement Under the Stafford Act

-   Overview of Federal-to-Federal in Non-Stafford Act Situations

8.5.2.3. [Support Annexes]{.underline} that provide guidance and
describe the functional process and administrative requirement necessary
to ensure efficient and effective implementation of the NRP. The
following is a listing of the Support Annexes:

-   Financial Management

-   Internal Coordination

-   Logistics Management

-   Private-Sector Coordination

-   Public Affairs

-   Science and Technology

-   Tribal Relations

-   Volunteer and Donations Management

8.5.2.4. [Incident Annexes]{.underline} address contingency or hazard
situation requiring specialist application of the NRP and cover a broad
spectrum of potential hazards and events. Incidents covered in these
annexes are:

-   Biological

-   Catastrophic

-   Cyber

-   Food and Agriculture

-   Nuclear/Radiological

-   Oil and Hazardous Materials

-   Terrorism

8.5.2.5. [Emergency Support Function (ESF) Annexes]{.underline} detail
the missions, policies, structures and responsibilities of federal
agencies for coordinating resources and program support to state and
local governments, as well as other federal agencies. Under the former
Federal Response Plan there were 12 ESFs. This has been expanded to 15
under the NRP. These ESFs are as follows:

-   ESF #1 Transportation

-   ESF \# 2 Communications

-   ESF \# 3 Public Works and Engineering

-   ESF \# 4 Firefighting

-   ESF \# 5 Emergency Management

-   ESF \# 6 Mass Care, Housing and Human Services

-   ESF \# 7 Resource Support

-   ESF \# 8 Public Health and Medical Services

-   ESF \# 9 Urban Search and Rescue

-   ESF \# 10 Oil and Hazardous Material Response

-   ESF \# 11 Agriculture and Natural Resources

-   ESF \# 12 Energy

-   ESF \# 13 Public Safety and Security

-   ESF \# 14 Long-term Community Recovery and Mitigation

-   ESF \# 15 External Affairs

Each of the ESFs has a lead agency, or ESF Coordinator, responsible for
overall ESF coordination and planning, and a number of supporting
agencies who, when requested, may provide support in specific
categories. The Department of Veterans Affairs does not have a lead role
in any of the ESFs. However, it does have a support role in seven (7) of
the ESFs. The ESFs for which VA has a support role, the applicable ESF
Coordinators and the areas for which VA can be requested to provide
support for each are as follows:

+------+-----------------------+--------------------------------------+
| **E  | **Description**       | ESF Coordinator(s)                   |
| SF** |                       |                                      |
+------+-----------------------+--------------------------------------+
| 3    | Public Works and      | US Army Corps of Engineers           |
|      | Engineering           |                                      |
+------+-----------------------+--------------------------------------+
| 5    | Emergency Management  | Department of Homeland Security/FEMA |
+------+-----------------------+--------------------------------------+
| 6    | Mass Care             | American Red Cross                   |
+------+-----------------------+--------------------------------------+
| 7    | Resource Support      | General Services Administration      |
+------+-----------------------+--------------------------------------+
| 8    | Health and Medical    | Dept. of Health and Human Services   |
|      | Services              |                                      |
+------+-----------------------+--------------------------------------+
| 13   | Public Safety and     | Department of Homeland Security      |
|      | Security              |                                      |
|      |                       | Department of Justice                |
+------+-----------------------+--------------------------------------+
| 15   | External Affairs      | Department of Homeland Security      |
+------+-----------------------+--------------------------------------+

8.5.3. *NRP Provisions*. It is important to note that under the NRP, the
supporting agencies are not under an obligation to provide the services
or resources that may be requested. These resources are only provided if
available. The NRP, as a plan, is an agreement between the Secretaries
of the various departments and agencies. (However, under the Stafford
Act the President may also specifically [direct]{.underline} federal
departments and agencies to provide resources and other support, and
this may be done with or without reimbursement.)

Under the NRP, departments and agencies are normally provided
reimbursement for costs incurred in the provision of the services or
resources, but this includes only those [additional]{.underline} costs
incurred by the department or agency in providing the services or
resources. For example, reimbursement for providing personnel does
[not]{.underline} include reimbursement of personnel salaries; but it
[does]{.underline} include costs of overtime, travel, housing and per
diem. It [can]{.underline} also include overtime or contact costs
associated with backfill of personnel that are deployed under the NRP in
a federal response.

8.5.4. *Mission Tasking*. VAMCs cannot respond to direct state, county
or local requests for assistance under the NRP. (Local VA medical
centers can respond to local requests for emergency assistance under
humanitarian assistance provisions, which are covered in paragraph 8.6.)
The process for requesting, tasking and provision of VA resources under
the FRP is provided in Figure 8.1 below.

**Figure 8.1:**

**Request For and Furnishing Support Under The Federal Response Plan
(FRP)**

![](media/image1.png)

-   The process begins with a request (1) from the local community to
    the state for assistance.

-   If the state cannot provide the assistance, a formalized Request for
    Assistance (RFA) is developed (2) and sent (3) to the FEMA Disaster
    Field Office (DFO).

-   At the DFO, the RFA is reviewed and, if approved, signed (4) by the
    Federal Disaster Coordinating Office (DCO) and sent (5) to the FEMA
    Emergency Support Team (EST), located at FEMA Headquarters in
    Washington, DC.

-   There, the approved RFA is translated into a Mission Assignment (6),
    funded, and forwarded (7) to the LFA for the applicable Emergency
    Support Function under whom the resource allocation is managed.

-   The ESF LFA may be able to furnish all requested support within its
    own agency but, if not, will send a Mission Tasking (8) to one of
    the ESF Support Agencies, in this instance the Department of
    Veterans Affairs.

-   These requests are normally channeled through the VA Readiness
    Operations Center (VA ROC) to the EMSHG/VHA Emergency Operations
    Center (9).

-   Following coordination with the Office of the Assistant Deputy Under
    Secretary for Health, the request is then forwarded in a VA
    Memorandum (10) to one or more VISNs to solicit the requested
    support from applicable VISN VAMCs.

8.5.5. *Reimbursement Under the* NRP. VAMCs that provide staff and other
resources in response to a request made under the FRP must carefully
track all costs associated with the mission assignment. Only costs of
the provision of those specific resources or services provided under the
mission assignment will be reimbursed.

-   Referring again to Figure 8.1, the VAMC providing resources to the
    community (11) under the Federal Mission Assignment must maintain
    careful records of the cost of the staff, services, supplies and
    other support provided.

-   EMSHG forwards the listing of deployed personnel and stations to VHA
    Office of Financial Management and Budget (173B). 173B forwards
    forms to participating stations requesting cost summary information.

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-   The individual stations complete and submit the cost summary
    information back to 173B for consolidation and submittal to FEMA.
    Reimbursement is then sent by 173B to individual facilities, with a
    copy of the summary to EMSHG.

-   If there are questions of what is covered under a particular
    assignment, contact should be made directly with EMSHG by calling
    304.264.4800 or through OUTLOOK by using the address: VHA EMSHG
    OPERATIONS.

8.6. ***Humanitarian Assistance***. Under the provisions of Title 38,
U.S.C., Section 1711(b), VA Medical Center Directors are authorized to
provide emergency care in mass casualty situations; however, patients
must be charged for these services at rates established by the
Secretary. Any questions relating to requests for assistance from local
and/or state governments in response to a disaster or other emergency
should be referred directly to EMSHG Operations at 304-264-4800.

8.7. ***Developing Local Agreements***.

8.7.l. *General.* Many times a VA facility may be asked to enter into
mutual aid agreements in which VA facilities and community hospitals
agree to assist each other during disasters or emergencies. The
agreements often include provisions to accept patients from the other
hospital, if the transferring facility has an overwhelming number of
patients or if the transferring facility does not have the resources for
patients who require specialized medical treatment. In addition to
patient referrals, the agreements often address sharing resources and
transmitting patient information between facilities. Notwithstanding the
title of the agreement, such provisions in effect are usually providing
for the sale of VA healthcare resources, which must be implemented
through a formal agreement.

8.7.2. *Sharing Agreements and MOUs*. VA facilities may negotiate
sharing agreements and MOUs, but they must do so within the parameters
of existing statutory and regulatory limits. Further, any agreement must
state that VA's ability to participate in the agreement is limited by
certain obligations under the Stafford Act, the National Disaster
Medical System (NDMS), the obligation to assist the Department of
Defense during a time of war or national emergency, and other
authorities and missions that may take precedence over an agreement to
assist a local, non-VA facility during a disaster.

VA Medical Centers have a duty to give a priority to the care of
veterans, and any agreement should take into account that the primary
mission of VA is to render healthcare services to veterans. VA, however,
may be called upon to perform a variety of emergency management
activities outside of its primary mission to provide and ensure the
continuity of healthcare delivery services to eligible veterans. VA also
has the authority to furnish hospital care or medical services to non-VA
beneficiaries as a humanitarian service in emergency cases (38 U.S.C. §
1784). The statute, however, requires VA to charge for such care at
rates prescribed by the Secretary. In local, limited emergencies where
an emergency is not declared under the Stafford Act or the National
Disaster Medical System (NDMS), VA may only provide emergency medical
care under this limited authority, and must charge for the care. (See
Section 8.6 above.)

8.7.2.1. *Sharing Agreements* are most appropriate for contractual
arrangements between a VA facility and a local, county, state department
or agency or a non-governmental organization. Sharing agreements will be
used when the exchange of resources involves a billing and payment
process between the two parties involved.

VAMC Directors will ensure that emergency management-related sharing
agreements developed within and by their facility conform to federal and
VA policy and regulations and receive appropriate Regional Counsel
review and approval before they are signed. VHA Directive 1660.1
(Enhanced Health Care Resources Sharing Authority -- Selling, dated
August 3, 2000) is a good guide for establishing Sharing Agreements. In
summary, the following steps, provided on page 2 of the VHA Directive
1660.1, will be followed when establishing a Sharing Agreement:

1.  Veterans will receive priority services.

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1.  Determination is made that the agreement is necessary to maintain an
    acceptable level and quality of service to veterans, or will result
    in improvement of services to veterans.

2.  The Contract file must include a certification from the Network
    Director or the medical center Director that the two preceding
    conditions have been met.

3.  All concept proposals to sell VA resources must be approved by the
    Rapid Response Team at VA Central Office consisting of staff from
    the Office of Finance Sharing and Purchasing Office, Office of
    General Counsel and Acquisition and Materiel Management.

4.  Contracts over \$500,000 must have VA Central Office legal and
    technical review.

5.  General Counsel field attorneys must have a final review of all
    contracts with a total value less than \$500,000 before they are
    executed.

6.  Proposals to sell inpatient services to non-veterans require the
    approval of the Secretary of Veterans Affairs and the Under
    Secretary for Health. This proposal might also require presentations
    to representatives of national veteran service organizations and
    congressional delegations.

8.7.2.2. *Memoranda of Understanding (MOUs)* or Memoranda of Agreement
(MOAs) are normally used between federal entities pursuant to the
Economy Act. All such inter-agency agreements have to be reviewed by the
Office of General Counsel and signed at VA Central Office. MOUs, while
rarely appropriate for local use because most local agreements call for
use of VA healthcare resources, may be used at the local level for
matters of planning, coordination and implementation of Stafford Act
disaster declarations where VA receives a specific tasking to provide
emergency services. Some MOUs and other agreements anticipate that the
VA facility will exchange information, including patient records, with
non-VA entities. If the MOU includes sending medical records between the
VA and non-VA facilities, the MOU should stipulate that any disclosure
of VA patient medical records must comply with all federal
confidentiality statutes, regulations and policy applicable to the
confidentiality of patient records.

VAMCs may also provide services and other resource support in an
emergency under Memoranda of Understanding (MOU) that are executed
between the facility and the federal, state or local agency or
department requesting the support. These agreements often include
provisions to accept patients from other hospitals or provision of
staff. They may also address sharing resources and transmitting patient
information between facilities. While VA facilities may enter into such
agreement, they must do what is within the parameters of existing
statutory and regulator limits. Further, such agreement must reflect
VA's existing obligations to act in major disasters and emergencies.

To assist local facilities in developing local MOUs, the following
general guidance is provided. However, specific questions should be
referred to the applicable VA Regional General Counsel's Office, which
must also review and approve all MOUs prior to signature of the
respective VAMC Director.

-   The MOUs must identify the parties to the agreement, the effective
    date of the agreement and the purpose of the agreement.

-   MOUs must state that VA's availability to participate in the
    agreement is limited by certain obligations (see Authorities and
    Agreements that require VA response to emergencies as provided in
    paragraph 8.2 above) that may take precedence over an (local)
    agreement to assist a local, non-VA facility or agency during a
    disaster.

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-   VAMCs [cannot]{.underline} use the prime vendor or other government
    procurement sources systems to purchase pharmaceutical, other
    supplies and equipment at discounted government rates for
    non-federal departments and agencies.

-   Services and other resources committed under the MOU must not
    detract from the capability and capacity of the VAMC to provide
    healthcare services to eligible veterans.

-   For resources or services to be provided at some future date (e.g.,
    in the event of...) the MOU should state that these resources or
    services will be provided [if]{.underline} available or
    [as]{.underline} available resources. MOUs that provide for the
    furnishing of VA resources for a future emergency response must be
    provisional and not commit the VA to providing these resources. VA
    mission requirements will always take precedence.

-   The other party to the MOU must reimburse VAMCs for services and
    resources provided. Reimbursement procedures and rates must be
    clearly stated in the MOU.

8.7.3. *General Counsel Review*. The Regional Counsel will review,
provide guidance and approve the establishment of sharing agreements
and/or MOUs. The Regional Counsel will coordinate the reviews and
approvals of sharing agreements and MOUs with the appropriate VA Medical
Center and/or VISN Office. A list of VA Regional Counsels is attached
(Enclosure 2) to assist AEMs and Medical Centers in the establishment of
MOUs and sharing agreements.

8.7.4. *Reporting*. Copies of all MOUs executed for services and
resources to be provided for mitigation, preparedness, response or
recovery in the event of a disaster or emergency will be sent to and
maintained by the applicable VISN. VISNs will maintain an inventory of
these MOUs and provide the Office of the Assistant Deputy Under
Secretary for Health (10N) a quarterly update. The inventory will be
provided in the following format (information listed is for illustrative
purposes only). See Figure 8.2.

Figure 8.2: Sample Format for VISN Inventory of MOUs

  ----------------- ----------------- ------------------ -----------------
  **Facility**      **Other           **Type of          **Expiration
                    Party(ies)**      Support**          Date**

  VAMC Houston      City of Houston   Storage of         Indefinite
                                      Pharmaceutical     
                                      Cache.             

  VAMC Little Rock, United States     Prophylaxis for    12/31/05
  AR                Postal Service    2000 employees in  
                                      the event of a     
                                      biological attack  
                                      or event.          
  ----------------- ----------------- ------------------ -----------------

Enclosures

1\. VA Federal Coordinating Centers by VISN

2\. Regional General Counsel Contacts