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South Bend Fire Department <br />2019 Service Agreement <br />The following when signed by Public Safety Medical (PSM) at 6612 E. 75th Street, Suite 200, Indianapolis, IN <br />46250 and South Bend Fire Department, 1222 South Michigan South Bend, IN 46601 will constitute our <br />agreement for delivery of the services described below under the following terms and conditions. <br />Scope of Services <br />PSM adrees to 0rovide the following services:. <br />SERVICE <br />Blood and <br />Lab Work <br />Medical <br />Testing <br />Physical <br />Exam <br />Fitness <br />Web -Based <br />Admix n Fees <br />Other Fees <br />and Testing <br />DESCRIPTION <br />Blood Panel (CMP, CBC, Lipid, Veni. <br />CMP (Comp. Metabolic Panel <br />Code <br />3500 <br />3522 <br />Cost <br />$23.66 <br />Firefighters <br />X <br />X <br />Dive Team <br />X <br />X <br />Hazmat <br />X <br />X <br />CBC Com . Blood Count <br />.. ...... <br />3083 <br />$21.42 <br />X <br />X <br />X <br />Li id Panel (total chol., HDL, LDL, ratio) <br />3523 <br />$25.14 <br />X <br />X _ <br />X <br />Insulin blood <br />3527 <br />$24.75 <br />X <br />X <br />X <br />hsCRP blood _ _ <br />3568 <br />$41.25 <br />_ X <br />X <br />X <br />TSH-Th mold Stim. Hormone blood <br />'re <br />3 226 <br />$29.57 <br />X <br />X <br />X <br />Veni unct <br />3000 <br />$3.72 <br />X <br />X <br />X <br />Quantiferon -Tb Blood <br />3545 <br />$61.82 <br />_.._ ...eX_._.....__ _ <br />X <br />X <br />Wellness Med. Testing: <br />12416 <br />__ <br />Vital Si ns-ht, wt, BMI, BP, res ., pulse <br />6000 <br />$0.00 <br />X <br />X <br />X <br />Vision -Acuity <br />_...... <br />6050 <br />$32.15 <br />_................_._____ <br />X <br />X <br />X <br />PFT — Pulmona Function Test <br />...... <br />6110 <br />$45.96 <br />X <br />X <br />X <br />Audiomet <br />6090 <br />$17.32 <br />WX — <br />X <br />X <br />_.. <br />EKG w/Interp <br />...._......_ <br />6120 <br />$24.73 <br />X <br />_._. �. <br />X <br />X <br />Urinal sis — Di stick <br />6020 <br />1 $3.72 <br />X <br />X <br />X <br />Respirator/Medical Review <br />6304 <br />$19.79 <br />X <br />X <br />X <br />Comprehensive Ph sical Exam <br />12500 <br />$121.17 <br />X <br />X <br />X <br />Health Risk AEpraisal <br />7000 <br />$0.00 <br />X <br />X <br />X <br />Treadmill — Max Indirect V02 <br />2082 <br />$189.09 <br />X <br />X <br />X <br />OnMed Program <br />8135 <br />$0.00 <br />X <br />X <br />X <br />Admin. Fee Your Site <br />3206 <br />$108.00 <br />X <br />X <br />X <br />Subtotal <br />$793.26 <br />$793.26 <br />$793.26 <br />Rectal/hemoccult (ii ne.im ages 40 �( <br />6130 <br />$0.00 <br />X <br />X <br />X <br />—..._........................................... <br />PSA-Prostate Specific Ag (Il�nn.Irn. ace 40-11( <br />-..... <br />3115 <br />............... w <br />$43.27 <br />X <br />X <br />�X <br />Cholinesterase — RBC &Plasma (Blood) <br />3.1.1.7....... <br />$55.65 <br />X <br />X <br />o-,�° elfi Ynn-'"„ oirfl fov �11ve and I' azirq'naat lecnnn.�.`v <br />Urine Bladder Cancer Screen <br />"nail <br />6033 <br />$55.65 <br />If needed <br />. ..................................... <br />If needed <br />If needed <br />( only if indicated by dine u.no ss <br />1 <br />Chest X-ray — PA/LAT (Your Site) <br />4010 <br />$92.74 <br />If needed <br />I.. needed <br />If needed <br />only lif onnedunAdli undlicatenl <br />Billing <br />Invoices are generated weekly. Payment terms are Net 30 days. <br />Invoices sent via e-mail scan to: Assistant Chief Todd Skwarcan <br />E-mail of Contact: tskwarca@southbendin.gov <br />Accounts Payable Contact: Shannon Fredline Title: Accounts Payable Supervisor <br />Phone: 574.235.9621 E-mail: sfredlin@southbendin.gov <br />F: marketing/Gold mine templates 1 of 4 <br />