Public 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:
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James Brainard, Presiding Officer
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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
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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
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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.
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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
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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