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Home My WebLink AboutPublic Safety Medical/CPDSERVICE DESCRIPTION Code Cost Sworn Civilian Blood and Lab Work Blood Panel (CMP, CBC, Lipid, Veni.) 3500 CBC (Comp. Blood Count) 3083 $17.68 X CMP (Comp. Metabolic Panel) 3522 $19.52 X Lipid Panel (total chol., HDL, LDL, ratio) 3523 $20.74 X Venipuncture 3000 $3.06 X X Quantiferon -Tb (Blood) 3545 $51 X X Hep B SAb Titer Quantitative (if no record) 3119 $35.70 X Venipuncture 3000 $3.06 X Vaccinations Hepatitis B (3- shots) 6161 -63 $214.20 X Injection Fee (3- shots) 6170 $10.20 X Td Vacc (tetanus, diphtheria) (optional) 6168 $20.40 X Injection Fee 6170 $10.20 X Medical Testing Wellness Med. Testing: 12412 Vital Signs -ht, wt, BMI, BP, resp., pulse 6000 $0 X Vision Titmus 6050 $26.52 X PFT Pulmonary Function Test 6110 $33.66 X Audiometry 6090 $14.28 X EKG w /interp 6120 $20.40 X Urinalysis Dipstick 6020 $3.06 X Tonometry (Glaucoma Test) 6040 $36.72 X Physical Exam Respirator /Medical Review 6304 $16.32 X Comprehensive Physical Exam 12500 $99.96 X Health Risk Appraisal (Motivation) 7000 $0 X Fitness Services Treadmill Submax 2080 $156.00 X Muscular Strength Endurance Test 2040 $26.52 X Flexibility Test 2030 $10.20 X Waist Hip Ratio 2018 $3.06 X Body Fat Test BIA 2019 $14.28 X Web -Based Services OnMed Program 8135 $0 X Admin Fees No Show Fee 8080 $40 X SUBTOTAL Estimated Subtotal (per person): $572.98 $54.06 Optional, Voluntary, Gender -Based Testing HIV 1 2 (offered to all 3125 $13.26 X PSA- Prostate Specific Ag (ages 40 3115 $35.70 X Rectal /hemoccult (men: ages 40 6130 Included X This Agreement is entered Contract No. 09.15.10.03, as Scope of Services PSM agrees to provide the following services: F: marketing /Goldmine templates into and subject to the terms of that certain City of Carmel executed by the parties effective as of September 15� MD 324 E. New York Street, Ste 300 6 Indianapolis, IN 46204 2011 Service Agreement 317.972.1180 Phone 317.972.1190 FAX ®Occ. Health Delivery Location: PSM Fishers Office 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 Civic Square, Carmel, IN 46032 will constitute our agreement for delivery of the services described below under the following terms and conditions. 1 of 4 Method of Payment The Carmel Police Department will compensate for services rendered in the following manner: Method of Payment Department Budget Sworn X Civil X Billing Bills are generated weekly. Net 15 days. Invoices will be sent to: Timothy Green, Carmel Police Department, 3 Civic Square, Carmel, IN 46032 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: Quartly Location: 3 Civic Square, Carmel, IN 46032 Time: 0730 1630 Examinations- Dates: by Appt Location: PSM Fishers Officer Departmental Information Contact person: Name: Timothy Green Title: Chief Phone: (317)571 -2529 E -mail: tgreen @carmel.in.gov Address: 3 Civic Square, Carmel, IN 46032 Number of personnel: Total: 132 Sworn: 111 Civilian: 21 Shift structure: F: marketing /Goldmine templates Law Enforcement: 12 -hour shifts 2 of 4 Price Increases Price increases for the following year will be made known by June of the current year. 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 and No Shows Cancellations should be made at least 1 day prior to the scheduled appointment. This enables PSM with enough notice to offer the appointments to another department and properly prepare. Any scheduled appointment that results in a No Show, or if the cancellation is less than a 3 -day notice, will result in a No Show penalty fee of $40 per person. The Carmel Police Department representative will be contacted prior to any fees being assessed. 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. 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. F: marketing /Goldmine templates 3 of 4 Board of Public Works and Safety City of Carmel ayor James Brainard lam/ M.ry A urke, Member Term of Agreement This agreement will be reviewed and updated annually. Questions regarding this Agreement may be directed to the Client Manager below at 317.972.1180. Public Safety Medical Carmel Police Department Lora L. Lex Name Printed n. Name Signed Client Manager Title January 19, 2011 Date Date Your Public Safety Medical Contact Client Manager: Lora Lex Office: 317.972.1180, ext. 345 F: marketing /Goldmine templates 4 of 4 Name Printed Name Signed Title Mobile: 317.331.6806)