HomeMy WebLinkAboutService Agreement - Public Safety Medical - 2018 Firefighters Annual Physicals1316 COUNTY -CITY BUILDING
DING
227 W. JEFF ERSON BoULEVARD
Sou'ri I BEND,1NDIANA 46601-1830
-ITY OF SOUTH BEND PETE i
BOARD OF PUBLIC WG I
June 26, 2018
Hannah Chuckeye
Public Safety Medical
6612 E. 75'h Street
Indianapolis, IN 46250
RE: Service Agreement
Dear Ms. Chuckeye:
PHONE 574/ 235-925
FAX 574/ 235-9171
The Board of Public Works, at its meeting held on June 26, 2018, approved the above
referenced agreement to provide the 2018 Firefighter's annual physicals to be billed per
service per employee.
Enclosed please Kind a copy of the agreement for your records.
If you have any further questions regarding this matter, please call this office at (574)
235-9251.
Sincerely,
y4c, 'I
Linda M. Markin, Clerk
Enclosure
South Bend Fire Department
2018 Service Agreement
Delivery Location: Z South Bend Fire Department
The following when signed by Public Safety Medical (PSM) at 6612 E. 751h Street, Indianapolis, INI 46250 and
South Bend Fire Department, 1222 South Michigan South Bend, IN 46601 will constitute our agreement for
delivery of the services described below under the following terms and conditions.
Scope of Services
PSM aarees to provide the followina services:
SERVICE
DESCRIPTION
Code
cost
Firefighters
Dive Team
Hazmat
Blood Panel (CMP, CBC,_Lipid, Veni.)
GMP (Comp. Metabolic Panel)
3500
3522
$22.97
X
X
X
X
X
X
CBC (Comp. Blood Count)
3083
$20,80
X
X
X
Lipid Panel_ (total ch,ol., HDL, ILDL, ratio)
3523
$24.42
X
X
X
Blood and
TSH-Thyr6d Stim, Hormone (blood)
3126
$28.71
X
X
X
W Lab ork
-
3000
$3,62
X
X
X
-Venipuncture
High Sensitivity G-Reactive Protein (hsGRP)
(11'fflWTIMMOry Marker for GVD)
3568
$41,25
X
X
X
Insulin blood test
3527
$24.75
X
X
X
Quantiferon -Tb Blood
3545
$60,01
X
X
X
Wellness Med. Testing:
Vital Signs-ht, wt, BMI, 13P, resp., pulse
12416
6000
$0.00
X
X
X
Vision -Acuity
6050
$31.21
X
X
X
Medical
PFT - Pulmonary Function Test
6110
$44.62
X
X
X
Testing
Audiometry
6090
$16.81
X
X
X
EKG, wfinterp
6120
$24.01
X
X
X
Urinalysis - Dipstick
6020
$3.62
X
X
X
Respirator/Medical Review
6304
$19.21
X
X.
X
Physical
Exam
Comprehensive Physical Exam
Health Risk AEpraisal
12500
7000
$117.64
$6.00
X
X.
-..--x
X
X
X
Fitness
Treadmill - Submax
2080
$183.59
X
X
X
Web -Based
Admin Fees
OnMed Program
Admin. (Your Site
8135
3206
$0.00
$105.00
X
X
X
X
X
X
."Fee
Subtotal
$77124
$772.24
$772,24
Rectailhemoccult Green: agies 40+)
6130
$0,00
X
X
X
Cholinesterase - RBC & Plasma (Blood)
(B,,mefline Only)
3117
$54,03
X
X
Other Fees
and Testing
Chest X-ray - PA/LAT (Your Site)
(orfly ifrne&a��y �ndicated)
4010
$90�04
X
X
X
. ... ...
Urine Bladder lCancer Screen
(only if mn(,ficatrid by the urrwl)dsls)
6033
$54.03
It needed
If needled
If needed
PSA-Prostate Specific Ag (nenages 401l.)
3115
$,42,01
X
X
X
Billing
Invoices are generated weekly. Payment terms are Net 30 days.
Invoices sent via e-mail to: Assistant Chief Todd S,kwarcan E-mail: tskwarca@sOLlthbend'in.gov
Address of contact: South Bend FD, 1222 South Michigan South Bend, IN 46601
Accounts, Payable Contact: Shannon Fredline Title: Accounts Payable Supervisor
Phone: 574.235.9621
e-mail: sfredIin@southbendin.gov
r: marketing/Goldmine templates 1 o f 4
Assignability
Th,isAgnement 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 Bond Fire Department employees in the event we learn ofany unauthorized uuqmisibun, use or
disclosure ofyour personal health information (PH|)as aresult nfnot being properly secured merequired byH|PAA.
We will notify employees of the breach as soon as possible but no later than sixty (60) days after the breach has
been discovered. PBN1 will incur aUU expenses for notification and actions necessary to correct breach.
Policy on Additional Testing
|nthe event that PSPNfinds hnecessary at South Bend Fire Department expense
and etthe request of the medical director, the South Bend Fire Department representative wflI be notified in
advance.
Policy oVRepeat Testing
[nthe event that P8kHfinds itnecessary toretestapatient due hmmpositive test result urthe recommendation mf
the PSPNmedical director, the cost incurred will be billed to South Bend Fire Department if the retest was not
based upon anerror onthe original test. The South Bend Fire Department representative will benotified 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
employeeis medicallyU d for duty,
representative without the written consent of the patient unless reguired by law (ie. OSHA). If during the
medical evaluation, findings are such that the patient cannot be medicalIy-cleared for duty, the patient will be
counseled aatothe medical concerns and the need tolimit duty assignment. The designated South Bend Fire
Department nspnmuanhaUve will be notified, in general tenny, of the need for duty restriction and any safety -
sensitive responsibilities, It will also be recommended that the patient be re-evaluated by PS[N^ after appropriate
medical treatment, to provide final clearance of return to full duty after a release is first made bythe patient's
treating physician. P5[N will assist the employee with, providing related medical information and their job
requirements hzthe treating physician to omoiot in their care.
Dates and Location of Services
Chief Initial
BLOOD DRAWS Dates: July 18m' uly20m&July24tu-Ju|y20m
Location: 1222South Michigan South Bend, |N40081
EXAMS Dates: Aug2Om-24m& September 100-14m&Nov121h_16m
Location: 1222Soum Michigan South Bend. |m46601
Departmental Information
Contact person: Name: ToddGkwanxan Ti'ltke Chief Phwnw:(574)235-A25?
E-mail: tskwama@aouthbexdim.gov
Address: 1222South Michigan South Bend, |N488O1
Number ofPersonnel: 3516 Chief of Dept: Chief Steve Cox
Price Increases
Price increases for the following year will bemade known byend iof April ofthe current year. Pricing reflected
above iavalid through December 31.2O1B.
F: marketing/GoMmine templates 2of4
Records and Accounts
PSM shall maintain accurate records and accounts of all transactions relating to the Services performed by it
pursuant to this Agreement.
Exam Arrival Time
To optimize the service provided to South Bend Fire Department personnel, we request that you send your
personnel 15 minutes p rior to their appointment time.
When Running Late
If your personnel are running late for their appointment(s), please call your client manager whose name and
number is listed on the signature page. This will ensure that appropriate arrangements may be made at PSM to
accommodate your.personnel or potential rescheduling.
Cancellations
Cancellations should be made at least 3 days (1 shift for fire departments) prior to the scheduled appointment.
This enables PSM with enough notice to offer the appointments to another department and properly prepare.
Liability and Indemnification
PSM shall have no liability whatsoever to South Bend Fire Department for any error, act or omission in
connection with the services to be rendered by PSM to South Bend Fire Department hereunder unless any such
error, act or omission derives from willful misconduct or gross negligence.
Insurance
PSM maintains insurance to protect it and South Bend Fire Department from the claims set forth below which
may arise out of or result from PSM operations under this Agreement, whether such operations be by PSM or by its
subcontractors or by anyone directly or indirectly employed by any of them, or by anyone directly for whose acts
any of them may be liable:
1. Claims under Workers' Compensation and Occupational Disease Acts, and any other
employee benefits acts applicable to the performance of the work;
2. Claims for damages because of bodily injury and personal injury, including death, and;
3. Claims for damages to property
PSM insurance shall be not less than the acceptable industry standards for the performance of medical and
occupational health -related services.
Confidentiality
PSM agrees to hold in strict confidence, and to use reasonable efforts to cause its employees and representatives
to hold in strict confidence, all confidential information concerning South Bend Fire Department furnished to or
obtained by PSM in the course of providing the agreed -upon services. PSM will not disclose or release any such
confidential information to any person, except its employees, representatives and agents who have a need to know
such information in connection with PSM performance under this Agreement or by the express written consent of a
South Bend Fire Department employee.
Proprietary Information
PSM asks that all information provided within this document be held confidentially and not shared with any related
providers, those organizations who could be considered competition to PSM, other fire or law enforcement
organizations, or unnecessary personnel within the South Bend Fire Department.
Termination for Convenience
Either PSM or South Bend Fire Department may terminate this Agreement at any time by giving thirty (30) days
written notice. PSM shall be entitled to payment for deliverables in progress, to the extent the work has been
performed satisfactorily.
F; marketing/Goldmine templates 3 of 4
Term of Agreement
Th�iis agreement will be reviewed and updated annually. Questions regarding this Agreement may be directed
to the Client Manager below.
Public Safety Medical
Hannah Checks
Name Printed
-H ww,,,aA avo cky
Name Signed
Regional Client Manager
Title
South Bend Fire Department
Name Printed!
NOW of
Name Signed IN 2
Title
June 6, 2018 Date
Date
Your Public Safety Medical Contact
Client Manager: Hannah Checkeye Mobile: (765)618-0223
F: marketing/Goldmine templates 4 of 4
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 6/7/2018 Department Fire
BPW Date 6/26/2018 Phone 9255
Name Todd Skwarcan, A/C Services
0 Legal Attorney Name Elliott Anderson
-0 4-
a) 2
0 — -2 Controller review is required for all Contracts $5,000.00 or more
4-
'- :t-- m Controller and greater than one year in length per the City Purchasing
0-.2
P CO) CL -0 CO Policy
0� :3
Purchasing Z Michael Schmidt
('hor.k fhp. Annrnnri:afp lfp.m Tvnp - Rpoifired for All Sul mhczsinnq
Z
Agreement
Contract
U Proposal
El Addendum
❑
❑
❑
Claim
Bid Opening
Quote Open
E] Bid Award Req. to Advertise ❑ TitleSheet
Quote Award
❑
El
Chg Order No.
Ease./Encroach.
El
C/O & PCA No.
Traffic Control
❑ PCA
Ej Resolution
El
Other:
Required Information
Company or Vendor Name
Public Safety Medical
New Vendor
E]Yes
Z
No ❑ If Yes, Approved by Purchasing
MBE/WBE Contractor
Project Name
❑ MBE [:] WBE
Project Number
Funding Source
Fire Personnel Services-Benefits/Medical
Account No.
101,0901.422.31-06
Amount
$ Per Agreement- as invoiced
Terms of Contract
Purpose/Description
2018 Service Agreement; Firefighters' exams/annual physicals
Amount of
❑
❑I
Increase
Decrease
$
$
Previous Amount
Current Percent of Change:
$
%
New Amount
$
Total Percent of Change:
PO No.
Dispersal After Approval
Copy Original
n n
n El