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South Bend Fire Department <br />2018 Service Agreement <br />Delivery Location: Z South Bend Fire Department <br />The following when signed by Public Safety Medical (PSM) at 6612 E. 751h Street, Indianapolis, INI 46250 and <br />South Bend Fire Department, 1222 South Michigan South Bend, IN 46601 will constitute our agreement for <br />delivery of the services described below under the following terms and conditions. <br />Scope of Services <br />PSM aarees to provide the followina services: <br />SERVICE <br />DESCRIPTION <br />Code <br />cost <br />Firefighters <br />Dive Team <br />Hazmat <br />Blood Panel (CMP, CBC,_Lipid, Veni.) <br />GMP (Comp. Metabolic Panel) <br />3500 <br />3522 <br />$22.97 <br />X <br />X <br />X <br />X <br />X <br />X <br />CBC (Comp. Blood Count) <br />3083 <br />$20,80 <br />X <br />X <br />X <br />Lipid Panel_ (total ch,ol., HDL, ILDL, ratio) <br />3523 <br />$24.42 <br />X <br />X <br />X <br />Blood and <br />TSH-Thyr6d Stim, Hormone (blood) <br />3126 <br />$28.71 <br />X <br />X <br />X <br />W Lab ork <br />- <br />3000 <br />$3,62 <br />X <br />X <br />X <br />-Venipuncture <br />High Sensitivity G-Reactive Protein (hsGRP) <br />(11'fflWTIMMOry Marker for GVD) <br />3568 <br />$41,25 <br />X <br />X <br />X <br />Insulin blood test <br />3527 <br />$24.75 <br />X <br />X <br />X <br />Quantiferon -Tb Blood <br />3545 <br />$60,01 <br />X <br />X <br />X <br />Wellness Med. Testing: <br />Vital Signs-ht, wt, BMI, 13P, resp., pulse <br />12416 <br />6000 <br />$0.00 <br />X <br />X <br />X <br />Vision -Acuity <br />6050 <br />$31.21 <br />X <br />X <br />X <br />Medical <br />PFT - Pulmonary Function Test <br />6110 <br />$44.62 <br />X <br />X <br />X <br />Testing <br />Audiometry <br />6090 <br />$16.81 <br />X <br />X <br />X <br />EKG, wfinterp <br />6120 <br />$24.01 <br />X <br />X <br />X <br />Urinalysis - Dipstick <br />6020 <br />$3.62 <br />X <br />X <br />X <br />Respirator/Medical Review <br />6304 <br />$19.21 <br />X <br />X. <br />X <br />Physical <br />Exam <br />Comprehensive Physical Exam <br />Health Risk AEpraisal <br />12500 <br />7000 <br />$117.64 <br />$6.00 <br />X <br />X. <br />-..--x <br />X <br />X <br />X <br />Fitness <br />Treadmill - Submax <br />2080 <br />$183.59 <br />X <br />X <br />X <br />Web -Based <br />Admin Fees <br />OnMed Program <br />Admin. (Your Site <br />8135 <br />3206 <br />$0.00 <br />$105.00 <br />X <br />X <br />X <br />X <br />X <br />X <br />."Fee <br />Subtotal <br />$77124 <br />$772.24 <br />$772,24 <br />Rectailhemoccult Green: agies 40+) <br />6130 <br />$0,00 <br />X <br />X <br />X <br />Cholinesterase - RBC & Plasma (Blood) <br />(B,,mefline Only) <br />3117 <br />$54,03 <br />X <br />X <br />Other Fees <br />and Testing <br />Chest X-ray - PA/LAT (Your Site) <br />(orfly ifrne&a��y �ndicated) <br />4010 <br />$90�04 <br />X <br />X <br />X <br />. ... ... <br />Urine Bladder lCancer Screen <br />(only if mn(,ficatrid by the urrwl)dsls) <br />6033 <br />$54.03 <br />It needed <br />If needled <br />If needed <br />PSA-Prostate Specific Ag (nenages 401­l.) <br />3115 <br />$,42,01 <br />X <br />X <br />X <br />Billing <br />Invoices are generated weekly. Payment terms are Net 30 days. <br />Invoices sent via e-mail to: Assistant Chief Todd S,kwarcan E-mail: tskwarca@sOLlthbend'in.gov <br />Address of contact: South Bend FD, 1222 South Michigan South Bend, IN 46601 <br />Accounts, Payable Contact: Shannon Fredline Title: Accounts Payable Supervisor <br />Phone: 574.235.9621 <br />e-mail: sfredIin@southbendin.gov <br />r: marketing/Goldmine templates 1 o f 4 <br />