g. Number of days inpatient h. Number of days outpatient i. Date released as outpatient je Ship transportation and subsistence costs 'k,. Aircraft costs (per 3.c.f2)) 1. fotal costs (per invoice} m. Date vessel teft to return patient to home island n. Verification of above by signature of the Marshall Islands District Director of Health Services and review by Headquarters TIPLI oO. Date claim paid in full by TTPI 5. It is agreed and understood that the TfPI will indemnify and hold harmless the DOE, its contractors and employees from any and all liability (including third party liability) for any cause whatsoever arising out of implementation of this Agreement and resulting in injury, icss, or damage to a patient, person accompanying the patient or any other person; provided, however, that this tndemnification provision Shall not apply to the extent that such liability, injury, loss, or damage shall have resulted from the fault or negligence of the DOE, its contractors, or employees. Ph. on . . 6. Appendix : , dated , and covering standard DOE requirements in connection with the DOE's interagency agreements, is annexed hereto and hereby made part of this Agreement." UG. S&S. DEPARTMENT OF ENGRGY BY: TRUST Mrmr TRARITORY OF mine Te PACIFIC ISLANDS BY: Manager, Nevada Operations Office DATE HighCommissioner DATE :