Service Agreement - Public Safety Medical - 2019 Firefighters' Annual Physicals

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Assignability This Agreement is not assignable. Right to Receive Notice of Breach As required by the Health Insurance Portability and Accountability Act (HIPAA), PSM will provide a written notice to all South Bend Fire Department employees in the event we learn of any unauthorized acquisition, use or disclosure of your personal health information (PHI) as a result of not being properly secured as required by HIPAA. We will notify employees of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered. PSM will incur all expenses for notification and actions necessary to correct breach. Policy on Additional Testing In the event that PSM finds it necessary to 2erform, additional testing at South Bend Fire Department expense and at the request of the medical director, the South Bend Fire Department representative will be notified in advance. Policy on Repeat Testing In the event that PSM finds it necessary to retest a patient due to a positive test result or the recommendation of the PSM medical director, the cost incurred will be billed to South Bend Fire Department if the retest was not based upon an error on the original test. The South Bend Fire Department representative will be notified in advance. If the retest is due to an error by PSM or a contracted laboratory or other representative, PSM will absorb any additional retest costs. No recommended actions will be made to South Bend Fire Department until PSM has received accurate retest information. Policy on Reporting Results PSM will provide a medical/respirator clearance letter for every patient. The letter will state whether or not the employee is medically cleared for duty. Nospecific medical test results for any atient are provided to an representative without the written consent of the patient unless required by law i,e. 0SHA1. If during the medical evaluation, findings are such that the patient cannot be medically -cleared for duty, the patient will be counseled as to the medical concerns and the need to limit duty assignment. The designated South Bend Fire Department representative will be notified, in general terms, of the need for duty restriction and any safety - sensitive responsibilities. It will also be recommended that the patient be re-evaluated by PSM, after appropriate medical treatment, to provide final clearance of return to full duty after a release is first made by the patient's treating physician. PSM will assist the employee with providing related medical information and their job requirements to the treating physician to assist in their care. Dates and Location of Services Chief Initial BLOOD DRAWS Dates: July 16t1-18th & July 315t-Aug 2nd Location: 1222 South Michigan South Bend, IN 46601 EXAMS Dates: Aug 26th-30th, Sept 10th-13th, Sept 16th-201h, & Nov 18th-22nd Location: 1222 South Michigan South Bend, IN 46601 Departmental Information Contact person: Name: Todd Skwarcan Title: Chief Phone: (574)235-9257 E-mail: tskwarca@southbendin.gov Address. 1222 South Michigan South Bend, IN 46601 Number of Personnel: 251 Chief of Dept: Chief Steve Cox Price Increases Price increases for the following year will be made known by end of April of the current year. Pricing reflected above is valid through December 31, 2019. F: marketing/Goldmine templates 2 of 4