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Home My WebLink AboutPublic Safety Medical, Inc/Police/Adl Serv/66,835.72/Officer PhysicalsPublic Safety Medical, Inc. 41 Police Department - 2017 �F Appropriation #1110 43-407.01; P.O. # 100944 bi Contract Not To Exceed $66,835.72 ADDITIONAL SERVICES AMENDMENT TO AGREEMENT FOR PURCHASE OF GOODS AND SERVICES THIS AMENDMENT TO THE GOODS AND SERVICES AGREEMENT ("Agreement') entered into by and between the City of Carmel and Public Safety Medical, Inc. (the "Vendor"), as City Contract dated November 2, 2016 shall amend the terms of the Agreement by adding the additional services to be provided by Vendor consistent with the Scope of Work attached hereto and incorporated herein as Exhibit "A". The terms and conditions of the Agreement shall not otherwise be affected by this Additional Services Amendment and shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have made and executed this Amendment as follows: CITY OF CARMEL, INDIANA by and through its Board of Public Works and Safety By: � 0 -� P cc Cepq + James Brainard, Presiding Officer M6ry Anne urke, MeV Date: / Lori S Wat ' Me�r►ber Date: l l t 7 �x:r<n�ra�ri4d s.v. @ G.n�s swawMiwc Dc,N�2a�T29n Addi sect Amrnd Public safny Ma&d CPD.,,, :117X12017 Dazs A" PUBLIC SAFETY MEDICAL, INC. By: Autho ized Signatufe Pirinfed ame Title FID/TIN: 35 — Z0'T7 ? Last Four of SSN if Sole Proprietor: Date: //— 26 —/ —1 Carmel Police Department 2018 Service Agreement Delivery Location: ® Public Safety Medical 324 E. New York Street Indianapolis, IN 46204 317.972.1180 Phone 317.972.1190 FAX The following when signed by Public Safety Medical (PSM) at 324 E. New York Street, Suite 300, Indianapolis, IN 46204 and Carmel Police Department, 3 CivicSquare, Carmel, IN 46032 will constitute our agreement for delivery of the services described below under the following terms and conditions. Scope of Services PSM agrees to provide the following services: SERVICE DESCRIPTION Code Cost All Officers Blood and Lab Work Blood Panel CMP, CBC, Lipid, Veni. 3500 X CMP (Comp. Metabolic Panel 3522 522.97 X CBC (Comp. Blood Count 3083 $20.80 X Lipid Panel (total chol.. HDL, LDL, ratio) 3523 $24.42 X Veni uncture 3000 $3.62 X Wellness Med. Testing: 12416 Vital Signs -ht, wt, BMI, BP, resp., PUISe 6000 $0.00 X Vision -Acuity 6050 $31.21 X Medical Testing PFT— Pulmonary Function Test 6110 $44.62 X Audiometry 6090 $16.81 X EKG w/ince 6120 $24.01 X Urinalysis — Dipstick 6020 $3.62 X Respirator/Medical Review 6304 $19.21 X Physical Exam Comprehensive Physical Exam 12500 $117.64 X Health Risk Appraisal 7000 $0.00 X Treadmill — Submax 2080 $183.59 X Fitness Muscular Strength Endurance Test 2040 $31.21 X Services Flexibility Test 2030 $12.01 X Waist/ Hip Ratio 2018 $3.62 X Body Fat Test — BIA 2019 $16.81 X Web -Based Services OnMed Program 8135 $0.00 X Admin Fees Admin. Fee (Your Site) (One Time Fee Due at 15' of ear 3206 174.00 X Subtotal $$75.17 Other Fees Chest X-ray - PA/LAT (Digital) (every 4 years)' 4000 $72.02 X No Show Fee 8080 545.92 X and Testing HIV -4 'h Gen. (Rapid Test) (offered to all) 3526 $26.58 X PSA -Prostate Specific Age (ages 40 +) 3115 $42.01 X Rectal/hemoccult (men: ages 40+) 6130 $0.00 X Billing Invoices are generated weekly. Payment terms are Net 30 days. 1. Invoices sent via: To: Pat Young E-mail of Contact: e-mail scan pyoung@carmel.in.gov F: marketing/Goldmine 1 of 4 Workers' Compensation Contact Provider Name: Community Health Network Occupational Health Center Provider Phone: (317) 621-6704 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 Public Safety Medical Services 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 perform additional testing at Carmel Police Department expense and at the request of the medical director, the Carmel Police 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 Carmel Police Department if the retest was not based upon an error on the original test. The Carmel Police 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 Carmel Police 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. No specific medical test results for any patient are provided to anY representative without the written consent of the patient unless required by law (i.e. OSHA). 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 Carmel Police 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 BLOOD DRAWS Dates: TBD Location: 3 Civic Square Carmel, IN 46032 EXAMS Dates: TBD Location: Public Safety Medical Departmental Information Contact person: Name: James Barlow Title: Chief Phone: (317)571-2559 E-mail: jbarlow@carmel.in.gov Address: 3 Civic Square Carmel IN 46032 F: marketing/Goldmine 2 of 4i 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, 2018. 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 Carmel Police 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 Carmel Police Department for any error, act or omission in connection with the services to be rendered by PSM to Carmel Police Department hereunder unless any such error, act or omission derives from willful misconduct or gross negligence. Insurance PSM maintains insurance to protect it and Carmel Police 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 Carmel Police 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 Carmel Police 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 Carmel Police Department. F: marketing/Goldmine 3 of 4 Termination for Convenience Either PSM or Carmel Police 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. Term of Agreement This agreement will be reviewed and updated annually to the Client Manager below. Public Safety Medical Rhonda Gallagher Name Printed Name Signed Asst. Director Client Services Title September 12, 2017 Date Your Public Safety Medical Contact Questions regarding this Agreement may be directed Carmel Police Department Name Printed Name Signed Title Date Client Manager: Rhonda Gallagher Mobile: (317) 437-4005 F: marketing/Goldmine 4 of 4• C/(��r it Carm I' INDIANA RETAIL TAX EXEMPT CERTIFICATE NO. 003120155 002 0 P890 1 Of 1 -PURCHASE ORDER NUMBER �JJl JL FEDERAL EXCISE TAX EXEMPT 100944 ONE CIVIC SQUARE35-6000972 THIS NUMBER MUST APPEAR ONINVOICES. NP CARMEL, INDIANA 46032-2584 :FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL - 1997 PURCHASE ORDER DATE DATE REQUIRED rREQU1SIT10N N0. VENDOR NO. I — - - 11/1712017 I- -- -- - -- ---- - -----_ ....._ _._._.. PUBLIC SAFETY MEDICAL SERVICES VENDOR 324 E NEW YORK ST SUITE 300 INDIANAPOLIS, IN 46204 - PURCHASE ID -' --BLANKET , CONTRACT -- - - 28812 -------.- . _ ...... - - --- - -. _ ----- --- --- QUANTITY UN r OF MEASURE Department: 1110 Fund: 101 General Fund Account: 43-407.01 116 Each Officer physicals Send Invoice To: Carmel Police Department Accounts Payable 00350364 VOUCHER DELIVERY MENTO, PACKING SLIPS, SHIPPING LABELS AND ANY CORRESPONDENCE DESCRIPTION Carmel Police Department SHIP 3 Civic Square TO Carmel, IN 46032 - Blaine Mallaber PAYMENT TERMS FREIGHT i gESCRIPTK)N -_---_-,------•- --- UNIT PRICE =576.17 $66,835.72 Sub Total $66,835.72 3 Civic Square Carmel, IN 46032- ~•,..yam 11 - --- PLEASE INVOICE IN ------.--.__-- DEPARTMENT ACCOUNT — --PROJECT —----PROJECT ACCOUNT PAYMENT $66,835.72 SHIPPING INSTRUCTIONS ' AM VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A 'SHIP PREPAID. PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBUGATED BALANCE IN 'C.O.D. SHIPMENT CANNOT BE ACCEPTED THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER. 'PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABE 'THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 194' AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ORDERED BY _..____.... __. . ............... Jim Barlow James Crider TITLE Chief Administration CONTROL NO. 100944 CLERK -TREASURER