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Home My WebLink AboutService Agreement - Public Safety Medical - 2019 Firefighters' Annual Physicals1316 COUNTY -CITY BUILDING 227 W. JEFFERSON BOULEVARD SOI JTH BEND. INDIANA 46601-1830 186 5 CITY • • BEND PETE BUTTIGIEG, MAYOR BOARD OF PUBLIGWORYS April 9, 2019 Hannah Checkeye Public Safety Medical 6612 E. 75 Ih Street, Suite 200 Indianapolis, IN 46250 RE: Service Agreement Dear Ms. Checkeye: PHONE 574/235-9251 FAx 574/235-9171 The Board of Public Works, at its meeting held on April 9, 2019, approved the above referenced agreement regarding the 2019 Firefighters' annual physicals in the amount charged per service. Enclosed please find 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, Linda M. Martin, Clerk Enclosure GARY A. GILOT GENEVIEVE E. MILLER ELIZABETH A. MARADIK LAuRA L. O'SULLIVAN THERESE J. DoRAu South Bend Fire Department 2019 Service Agreement The following when signed by Public Safety Medical (PSM) at 6612 E. 75th Street, Suite 200, Indianapolis, IN 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 adrees to 0rovide the following services:. SERVICE Blood and Lab Work Medical Testing Physical Exam Fitness Web -Based Admix n Fees Other Fees and Testing DESCRIPTION Blood Panel (CMP, CBC, Lipid, Veni. CMP (Comp. Metabolic Panel Code 3500 3522 Cost $23.66 Firefighters X X Dive Team X X Hazmat X X CBC Com . Blood Count .. ...... 3083 $21.42 X X X Li id Panel (total chol., HDL, LDL, ratio) 3523 $25.14 X X _ X Insulin blood 3527 $24.75 X X X hsCRP blood _ _ 3568 $41.25 _ X X X TSH-Th mold Stim. Hormone blood 're 3 226 $29.57 X X X Veni unct 3000 $3.72 X X X Quantiferon -Tb Blood 3545 $61.82 _.._ ...eX_._.....__ _ X X Wellness Med. Testing: 12416 __ Vital Si ns-ht, wt, BMI, BP, res ., pulse 6000 $0.00 X X X Vision -Acuity _...... 6050 $32.15 _................_._____ X X X PFT — Pulmona Function Test ...... 6110 $45.96 X X X Audiomet 6090 $17.32 WX — X X _.. EKG w/Interp ...._......_ 6120 $24.73 X _._. �. X X Urinal sis — Di stick 6020 1 $3.72 X X X Respirator/Medical Review 6304 $19.79 X X X Comprehensive Ph sical Exam 12500 $121.17 X X X Health Risk AEpraisal 7000 $0.00 X X X Treadmill — Max Indirect V02 2082 $189.09 X X X OnMed Program 8135 $0.00 X X X Admin. Fee Your Site 3206 $108.00 X X X Subtotal $793.26 $793.26 $793.26 Rectal/hemoccult (ii ne.im ages 40 �( 6130 $0.00 X X X —..._........................................... PSA-Prostate Specific Ag (Il�nn.Irn. ace 40-11( -..... 3115 ............... w $43.27 X X �X Cholinesterase — RBC &Plasma (Blood) 3.1.1.7....... $55.65 X X o-,�° elfi Ynn-'"„ oirfl fov �11ve and I' azirq'naat lecnnn.�.`v Urine Bladder Cancer Screen "nail 6033 $55.65 If needed . ..................................... If needed If needed ( only if indicated by dine u.no ss 1 Chest X-ray — PA/LAT (Your Site) 4010 $92.74 If needed I.. needed If needed only lif onnedunAdli undlicatenl Billing Invoices are generated weekly. Payment terms are Net 30 days. Invoices sent via e-mail scan to: Assistant Chief Todd Skwarcan E-mail of Contact: tskwarca@southbendin.gov Accounts Payable Contact: Shannon Fredline Title: Accounts Payable Supervisor Phone: 574.235.9621 E-mail: sfredlin@southbendin.gov F: marketing/Gold mine templates 1 of 4 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 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 prior 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 This agreement will be reviewed and updated annually. Questions regarding this Agreement may be directed to the Client Manager below. Public Safety Medical Hannah Checkeye Name Printed Name Signed Regional Client Manager Title South Bend Fire Department Name Printed Board of prj� Name Signed Title March 20 2019 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 3/21/19 Department Fire BPW Date 4/9/19 Phone 9255 Name Todd Skwarcan, A/C Services gNMVNINOINVMVM1PfWi�u�90d%IH/.4�FtttNn�m+ +�+�p�RgWyy A9TitlAIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIW9WIWiiM1MMnhflfiJlUUVfA��Alo1)lG �u b'FpMI�MMMII�WIVIVIVIVIVIVIVIVWWIVIDYIN W,W,y,W,yyq,W,y,'�W�W�W��I�i�!AMMMSX#Nc'� o Legal o "= Controller a)cr �L m a U) Purchasing Check the A Agreement Claim Bid O,�.en.!.n.............. Quote Opening Chg_ Order No Ease./Encroach. Other: Attorney Name Elliot Anderson Controller review is required for all Contracts $5,000.00 or more and greater than one year in length per the City Purchasing Policy Michael Schmidt Submissions ro �� Prop /sal _.......... Addendm._"��.._u_.... `m f 1 Contract I- m Bid Award .......................... Quote Award C/ O & PCA No Traffic Control Required Information Public afety Medical Ej Yes No If Ye: M.BE..f.�1... .B.E......... . .... . to Advertise PCA Resolution roved by Purchasin Fire Personnel Services-Benefits/Medical 101.0901.422.31-06 $-Perv2019 Service Agreement; ree ...�....................��_ �..�..... g ent; invoiced weekly Title Sheet 2019 Service Ag reement--Firefi hters' Annual Physicals For Chance Orders Amount of H Increase Decrease Previous Amount $ Current Percent of Change_ New Amount $ Total Percent of Change PO No. Dispersal After Approval Copy Original ❑ ❑ ❑ ❑