St. Vincent Health, Wellness and Preventive Care Institute, Inc/Fire/93,000/2019 Firefighter Physicals St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00 QFtOii
t.
AGREEMENT FOR PROFESSIONAL �
SERVICES
THIS AGREEMENT FOR PROFESSIONAL SERVICES ("Agreement') is hereby made and entered into by
and between the City of Carmel, Indiana, acting by and through its Board of Public Works and Safety (hereinafter
"City"), and St. Vincent Health, Wellness and Preventive Care Institute, Inc.,(hereinafter"Professional").
RECITALS
WHEREAS City owns and is responsible for the operation and maintenance of its property, personnel, public
works and infrastructure; and
WHEREAS, from time to time, City needs professional assistance in fulfilling its foregoing responsibilities;
and
WHEREAS, Professional is experienced in providing and desires to provide to City the professional services
("Services") referenced herein; and
WHEREAS, City desires to engage Professional as an independent contractor for the purpose of providing to
City the Services referenced herein;
NOW, THEREFORE, in consideration of the foregoing recitals and the covenants and conditions set forth
herein, City and Professional mutually agree as follows:
SECTION 1 INCORPORATION OF RECITALS
The foregoing Recitals are hereby incorporated into this Agreement and made a part hereof.
SECTION 2 SCOPE OF SERVICES
2.1 City desires to engage Professional as an independent contractor for the Services set forth in attached
Exhibit A, incorporated herein by this reference.
2.2 Professional understands and agrees that City may, from time to time, request Professional to provide
additional or modified Services to City. When City desires additional Services from Professional, the City
shall notify Professional of such additional Services desired, as well as the time frame in which same are to
be provided. Only after City has approved Professional's time and cost estimate for the provision of such
additional Services, has encumbered sufficient monies to pay for same, and has authorized Professional, in
writing, to provide such additional Services, shall such Services be provided by Professional to City. A copy
of the City's authorization documents for the purchase of additional Services shall be numbered and attached
hereto in the order in which they are approved by City.
2.3 Time is of the essence of this Agreement.
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1
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
SECTION 3 CITY'S RESPONSIBILITIES
3.1 City shall provide such information as is reasonably necessary for Professional to understand the Services
requested.
3.2 City shall provide all data required for provision of Services. Professional may assume that all data so
provided is correct and complete.
3.3. City shall arrange for Professional to enter upon public and private property as reasonably required for
Professional to perform the Services.
3.4 City shall designate payment of the Services from City budget appropriation number 43-407.01 funds.
3.5 City shall designate the Mayor or his duly authorized representative to act on City's behalf on all matters
regarding the Services.
SECTION 4 PROFESSIONAL'S RESPONSIBILITIES
4.1 Professional shall perform the Services pursuant to the terms of this Agreement and within any applicable
time and cost estimate.
4.2 Professional shall coordinate with City its performance of the Services.
4.3 Professional shall provide the Services by following and applying at all times reasonable and lawful
standards as accepted in the industry.
SECTION 5 COMPENSATION
5.1 Professional estimates that the total price for the Services to be provided to City hereunder shall be no more
than Ninety Three Thousand Dollars ($93,000.00) (the "Estimate"). Professional shall submit an invoice to
City no more than once every thirty(30) days for Services provided City during the time period encompassed
by such invoice. Invoices shall be submitted on a form containing the same information as that contained on
the Professional Services Invoice attached hereto as Exhibit B, incorporated herein by this reference. City
shall pay Professional for all undisputed Services rendered and stated on such invoice within thirty five (35)
days from the date of City's receipt of same.
5.2 Professional agrees not to provide any Services to City that would cause the total cost of same to exceed the
Estimate, without City's prior written consent.
(s:`,CwRacts\Prof.svc&Goods svc,Wire Dept12019kAsceosion St Vincent Public safety Professional Services.doc:6/24/2019 10:56 AM]
2
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
SECTION 6 TERM
Unless otherwise terminated in accordance with the termination provisions set forth in Section 7.1
hereinbelow, this Agreement shall be in effect from the Effective Date through December 31, 2019, and shall,
on the first day of each January thereafter, automatically renew for a period of one (1) calendar year, unless
otherwise agreed by the parties hereto.
SECTION 7 MISCELLANEOUS
7.1 Termination
7.1.1 The obligation to provide all or any portion of the Services under this Agreement may be terminated
by City or Professional, without cause, upon thirty(30)days' notice.
7.1.2 The obligation to provide all or any portion of the Services under this Agreement may be terminated
by City, for cause, immediately upon Professional's receipt of City's"Notice To Cease Services."
7.1.3 In the event of full or partial Agreement termination, and as full and complete compensation
hereunder, Professional shall be paid for all such Services rendered and expenses incurred as of
the date of termination that are not in dispute, except that such payment amount shall not exceed
the Estimate. Disputed compensation amounts shall be resolved as allowed by law.
7.2 Binding Effect
City and Professional, and their respective officers, officials, agents, partners and successors in interest are
bound to the other as to all Agreement terms, conditions and obligations.
7.3 No Third Party Beneficiaries
Nothing contained herein shall be construed to give rights or benefits to anyone other than the parties
hereto.
7.4 Relationship
The relationship of the parties hereto shall be as provided for in this Agreement, and neither Professional nor
any of its agents, employees or contractors are City employees. Professional shall have the sole
responsibility to pay to or for its agents, employees and contractors all statutory, contractual and other
benefits and/or obligations as they become due. Professional hereby warrants and indemnifies City for and
from any and all costs, fees, expenses and/or damages incurred by City as a result of any claim for wages,
benefits or otherwise by any agent, employee or contractor of Professional regarding or related to the subject
matter of this Agreement. This indemnification obligation shall survive the termination of this Agreement.
(S:9Cwhacts\Prof.Svc &Good Svcs\Pire Dept\2019\Ascension St Viocmt Public Safety Professional Serviaes.doc:6242019 10:56 AM]
3
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
7.5 Insurance
Professional shall procure and maintain with an insurer licensed to do business in the State of Indiana such
insurance as is necessary for the protection of City and Professional from all claims under workers'
compensation, occupational disease and/or unemployment compensation acts, because of errors and
omissions, because of bodily injury, including, but not limited to, the personal injury, sickness, disease, or
death of any of Professional's employees, agents or contractors and/or because of any injury to or
destruction of property, including, but not limited to, any loss of use resulting therefrom. The coverage
amounts shall be no less than those amounts set forth on attached Exhibit C. Such insurance policies shall
not be canceled without thirty(30) days' prior written notice to City.
7.6 Liens
Professional shall not cause or permit the filing of any lien on any of City's property. In the event such a lien
is filed and Professional fails to remove it within ten (10) days after the date of filing, City shall have the right
to pay or bond over such lien at Professional's sole cost and expense.
7.7 Default
In the event Professional: (a) repudiates, breaches or defaults under any of the terms or conditions of this
Agreement, including Professional's warranties; (b) fails to perform the Services as specified; (c) fails to
make progress so as to endanger timely and proper completion of the Services and does not correct such
failure or breach within five (5) business days after receipt of notice from City specifying same; or (d)
becomes insolvent, files, or has filed against it, a petition for receivership, makes a general assignment for
the benefit of creditors or dissolves, each such event constituting an event of default hereunder, City shall
have the right to terminate all or any part of this Agreement, without liability to Professional and to exercise
any other rights or remedies available to it at law or in equity.
7.8 Government Compliance
Professional agrees to comply with all laws, executive orders, rules and regulations applicable to
Professional's performance of its obligations under this Agreement, all relevant provisions of which being
hereby incorporated herein by this reference, to keep all of Professionals' required professional licenses and
certifications valid and current, and to indemnify and hold harmless City from any and all losses, damages,
costs, liabilities, damages, costs and attorney fees resulting from any failure by Professional to do so. This
indemnification obligation shall survive the termination of this Agreement.
7.9 Indemnification
Professional shall indemnify and hold harmless City and its officers, officials, employees and agents from all
losses, liabilities, claims,judgments and liens, including, but not limited to, all damages, costs, expenses and
attorney fees arising out of any intentional or negligent act or omission of Professional and/or any of its
employees, agents or contractors in the performance of this Agreement. This indemnification obligation shall
survive the termination of this Agreement.
[Sf Contracts\ProfSvc&Goods Svcs\Fire Dept\2019\Ascension St Vincent Public Safety Professional Smices.doc:6242019 10:56 AM]
4
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
7.10 Discrimination Prohibition
Professional represents and warrants that it and each of its employees, agents and contractors shall comply
with all existing and future laws prohibiting discrimination against any employee, applicant for employment
and/or other person in the subcontracting of work and/or in the performance of any Services contemplated by
this Agreement with respect to hire, tenure, terms, conditions or privileges of employment or any matter
directly or indirectly related to employment, subcontracting or work performance hereunder because of race,
religion, color, sex, handicap, national origin, ancestry, age, disabled veteran status or Vietnam era veteran
status. This indemnification obligation shall survive the termination of this Agreement.
7.11 E-Verify
Pursuant to I.C. § 22-5-1.7 et seq., Professional shall enroll in and verify the work eligibility status of all of its
newly-hired employees using the E-Verify program, if it has not already done so as of the date of this
Agreement. Professional is further required to execute the attached Affidavit, herein referred to as Exhibit D,
which is an Affidavit affirming that: (i) Professional is enrolled and is participating in the E-verify program, and
(ii) Professional does not knowingly employ any unauthorized aliens. This Addendum incorporates by
reference, and in its entirety, attached Exhibit D. In support of the Affidavit, Professional shall provide the City
with documentation that it has enrolled and is participating in the E-Verify program. This Agreement shall not
take effect until said Affidavit is signed by Professional and delivered to the City's authorized representative.
Should Professional subcontract for the performance of any work under this Addendum, the
Professional shall require any subcontractor(s) to certify by affidavit that: (i) the subcontractor does not
knowingly employ or contract with any unauthorized aliens, and (ii) the subcontractor has enrolled and is
participating in the E-verify program. Professional shall maintain a copy of such certification for the duration
of the term of any subcontract. Professional shall also deliver a copy of the certification to the City within
seven (7)days of the effective date of the subcontract.
If Professional, or any subcontractor of Professional, knowingly employs or contracts with any
unauthorized aliens, or retains an employee or contract with a person that the Professional or subcontractor
subsequently learns is an unauthorized alien, Professional shall terminate the employment of or contract with
the unauthorized alien within thirty (30) days ("Cure Period"). Should the Professional or any subcontractor of
Professional fail to cure within the Cure Period, the City has the right to terminate this Agreement without
consequence.
The E-Verify requirements of this Agreement will not apply, should the E-Verify program cease to exist.
7.12 Severability
If any provision of this Agreement is held to be invalid, illegal or unenforceable by a court of competent
jurisdiction, that provision shall be stricken, and all other provisions of this Agreement that can operate
independently of same shall continue in full force and effect.
lcoatracts\PtoLSvc &Goods SvcsWire Dept\2019W.sceusiou St Vincent Public Safety Prof siwal Services.doc6242019 10.56 AM]
5
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
7.13 Notice
Any notice, invoice, order or other correspondence required or allowed to be sent pursuant to this Agreement
shall be written and either hand-delivered or sent by prepaid U.S. certified mail, return receipt requested,
addressed to the parties as follows:
CITY:
City of Carmel Douglas C. Haney
Department of Fire Department Corporation Counsel
Two Civic Square One Civic Square
Carmel, Indiana 46032 Carmel, Indiana 46032
PROFESSIONAL:
Ascension St. Vincent Public Safety Medical
6612 E 75th Street
Suite 200
Indianapolis, IN 46250
Notwithstanding the above, City may orally provide to Professional any notice required or permitted by this
Agreement, provided that such notice shall also then be sent as required by this paragraph within ten (10)
business days from the date of such oral notice.
7.14 Effective Date
The effective date ("Effective Date") of this Agreement shall be the date on which the last of the parties
hereto executes same.
7.15 Governing Law; Lawsuits
This Agreement shall be governed by and construed in accordance with the laws of the State of Indiana,
except for its conflict of laws provisions, as well as by all ordinances and codes of the City of Carmel,
Indiana. The parties agree that, in the event a lawsuit is filed hereunder, they waive any right to a jury trial
they may have, agree to file such lawsuit in an appropriate court in Hamilton County, Indiana only, and agree
that such court is the appropriate venue for and has jurisdiction over same.
7.16 Waiver
Any delay or inaction on the part of either party in exercising or pursuing its rights and/or remedies hereunder
or under law shall not operate to waive any such rights and/or remedies nor in any way affect the rights of
such party to require such performance at any time thereafter.
7.17 Non-Assignment
Professional shall not assign or pledge this Agreement nor delegate its obligations hereunder without City's
prior written consent.
[S^conb cts'Prof.Svc &Goods Svcs\Fve Dept\2019Wscensian St Vioceot Public Safety Professional Services.doc:6242019 10:56 AM]
6
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
7.18 Entire Agreement
This Agreement contains the entire agreement of and between the parties hereto with respect to the subject
matter hereof, and no prior agreement, understanding or representation pertaining to such subject matter,
written or oral, shall be effective for any purpose. No provision of this Agreement may be amended, added to
or subtracted from except by an agreement in writing signed by both parties hereto and/or their respective
successors in interest. To the extent any provision contained in this Agreement conflicts with any provision
contained in any exhibit attached hereto, the provision contained in this Agreement shall prevail.
7.19 Representation and Warranties
Each party hereto represents and warrants that it is authorized to enter into this Agreement and that any
person or entity executing this Agreement on behalf of such party has the authority to bind such party or the
party which they represent, as the case may be.
7.20 Headings
All headings and sections of this Agreement are inserted for convenience only and do not form a part of this
Agreement nor limit, expand or otherwise alter the meaning of any provision hereof.
7.21 Advice of Counsel
The parties warrant that they have read this Agreement and fully understand it, have had an opportunity to
obtain the advice and assistance of counsel throughout the negotiation of same, and enter into same freely,
voluntarily, and without any duress, undue influence or coercion.
7.22 Copyright
City acknowledges that various materials which may be used and/or generated by Professional in
performance of Services, including forms, job description formats, comprehensive position questionnaire,
compensation and classification plan and reports are copyrighted. City agrees that all ownership rights and
copyrights thereto lie with Professional, and City will use them solely for and on behalf of its own operations.
City agrees that it will take appropriate action with its employees to satisfy its obligations with respect to use,
copying, protection and security of Professional's property.
7.23 Personnel
Professional represents that it has, or will secure at its own expense, all personnel required in performing the
services under this agreement. Such personnel shall not be employees of or have any contractual
relationship with City. All of the services required hereunder will be performed by Professional or under his
supervision and all personnel engaged in the work shall be fully qualified to perform such services.
7.24 Records and Inspections
Professional shall maintain full and accurate records with respect to all matters covered under this
agreement for three (3) years after the expiration or early termination of this Agreement. City shall have free
access at all proper times to such records and the right to examine and audit the same and to make
transcripts there from, and to inspect all program data, documents, proceedings and activities.
[SAContracts\Prof.Svcs&Goods Svcs Tire Dept\2019Vsscensien St Vincent Public Safety Professional Savices.doc:6242019 10:56 AM]
7
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
7.25 Accomplishment of Project
Professional shall commence, carry on, and complete the project with all practicable dispatch, in a sound
economical and efficient manner, in accordance with the provisions thereof and all applicable laws. In
accomplishing the project, Professional shall take such steps as are appropriate to ensure that the work
involved is properly coordinated with related work being carried on within City's organization.
7.26 Debarment And Suspension
26.1 The Vendor certifies by entering into this Agreement that neither it nor its principals nor any of its
subcontractors are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from entering into this Agreement by any federal agency or by any department, agency or political
subdivision of the State of Indiana. The term "principal" for purposes of this Agreement means an officer,
director, owner, partner, key employee or other person with primary management or supervisory
responsibilities, or a person who has a critical influence on or substantive control over the operations of the
Vendor.
26.2 The Vendor certifies that it has verified the state and federal suspension and debarment status for all
subcontractors receiving funds under this Agreement and shall be solely responsible for any recoupment,
penalties or costs that might arise from use of a suspended or debarred subcontractor. The Vendor shall
immediately notify the City if any subcontractor becomes debarred or suspended, and shall, at the City's
request, take all steps required by the City to terminate its contractual relationship with the subcontractor for
work to be performed under this Agreement.
7.27 Access to Public Records Act
Professional understands and agrees that any"public record", as that term is defined in Indiana Code 5-14-3-
2(m), as amended, that is related to the subject matter of this Agreement, whether the same is in the
possession or control of the Professional or the City, shall be subject to release under and pursuant to the
provisions of Indiana's Access to Public Records Act, as codified in Indiana Code 5-14-3-1, et seq., as
amended.
(remainder of page intentionally left blank)
[S:\Contracts\Prof.Svo&Good Svcs Wire DepA2019Wscension St Vincent Public Safety Professional Services.doc:6242019 10:56 AM]
8
St.Vincent Health,Wellness and Preventive Care Institute,Inc.
Fire Department-2019
Appropriation#43-407.01;P.O.#102953
Contract Not To Exceed$93,000.00
IN WITNESS WHEREOF,the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA St. Vincent Health, Wellness and Preventive Care Institute,
by and through its Board of Public Inc.
Works and Safety
BY: BY:
06-. ArcaQta kAhl,04 44"
James Brainard, Presiding Officer Authorized Sign ture
Date: �/ �/
Printed Name: -k01G� )
Title • . C6y)
Ma An urke, M er fy
Date: FID/TIN: A, - (21 7 3 Z-7
Last Four of SSN if Sole Proprietor:
Lori S. Wa o /er Date: 4.4t414 2-1 20/
Date: 71/ 9
A ST:
jcjii
ristine S. Pau , Clerk-Treas
Date: y (/`7//
(S COYVaI't Wr d.Svcs&Goods Svc,'i,,Dep1l20191A5Cenwte,St Vincent Public Safety P,okesllerlil Servlees.dee:64/2O19 1(b56 AM)
9
`SpFETY,h.
J for Carmel Fire Department
2019-2020 Service Agreement
esT.1990
Delivery Location: ® Carmel Fire Department ® Public Safety Medical
The following when signed by ASCENSION ST.VINCENT PUBLIC SAFETY MEDICAL at 6612 E. 75th Street,
Suite 200, Indianapolis, IN 46250 and Carmel Fire Department, 2 Civic Square Carmel, IN 46032 will constitute
our agreement for delivery of the services described below under the following terms and conditions.
Scope of Services
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL agrees to provide the following services:
SERVICE DESCRIPTION Code 2019 2020(2%)
Blood Panel(CMP,CBC,Lipid,Veni.) 3500
CMP(Comp. Metabolic Panel) 3522 $23.66 $24.13
Blood and CBC(Comp. Blood Count) 3083 $21.42 $21.85
Lab Work Lipid Panel(total chol.,HDL,LDL,ratio) 3523 $25.14 $25.64
Quantiferon-Tb(Blood) (TB Testing) 3545 $61.82 $63.06
Boston Heart Blood Draw Study 3563 $172.00 $175.44
Venipuncture 3000 $3.72 $3.79
Wellness Med.Testing: 12416
Vital Signs-ht,wt,BMI,BP,resp.,pulse 6000 $0.00 $0.00
Vision-Acuity 6050 $32.15 $32.79
Medical Testing PFT-Pulmonary Function Test 6110 $45.96 $46.88
Audiometry 6090 $17.32 $17.67
EKG w/interp 6120 $24.73 $25.22
Urinalysis-Dipstick 6020 $3.72 $3.79
Respirator/Medical Review 6304 $19.79 $20.19
Physical Exam Comprehensive Physical Exam 12500 $121.17 $123.59
Health Risk Appraisal 7000 $0.00 $0.00
Fitness Treadmill-Max(Indirect V02) 2082 $189.09 $192.87
Services Body Fat Test-BIA 2019 $17.32 $17.67
Web-Based OnMed Program 8135 $0.00 $0.00
Services
Admin Fees Admin. Fee(Your Site)(Onsite Blood Draws)ONE 3206 $126.00 $144.90
TIME FEE
Subtotal $581.87 $619.14
Subtotal Men 40+Over $625.14 $663.28
PSA-Prostate Specific Ag(ages 40+ Men) 3115 $43.27 $44.14
Rectal/hemoccult(men:ages 40+) 6130 $0.00 $0.00
2019 Lipid Panel will not be performed (included in Boston Heart)
2019 Boston Heart will not be billed to Carmel Fire Department shall be billed to Clay Township
Trustee Acct.
2020 Boston Heart not included on the subtotal price (determined by physician only)
-'hibit___A___
F:marketing/Goldmine 1 of 4tempiates
Billing
Invoices are generated weekly. Payment terms are Net 30 days.
1. Invoices sent via: e-mail scan
To: Denise Snyder
E-mail of Contact: dsnyder@carmel.in.gov
Assignability
This Agreement is not assignable.
Right to Receive Notice of Breach
As required by the Health Insurance Portability and Accountability Act(HIPAA), ASCENSION ST. VINCENT
PUBLIC SAFETY MEDICAL will provide a written notice to all Carmel 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. ASCENSION ST. VINCENT PUBLIC SAFETY
MEDICAL will incur all expenses for notification and actions necessary to correct breach.
Policy on Additional Testing
In the event that ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL finds it necessary to perform additional
testing at Carmel Fire Department expense and at the request of the medical director, the Carmel Fire
Department representative will be notified in advance.
Policy on Repeat Testing
In the event that ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL finds it necessary to retest a patient
due to a positive test result or the recommendation of the ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL
medical director, the cost incurred will be billed to Carmel Fire Department if the retest was not based upon an
error on the original test. The Carmel Fire Department representative will be notified in advance. If the retest is
due to an error by ASCENSION ST.VINCENT PUBLIC SAFETY MEDICAL or a contracted laboratory or other
representative, ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL will absorb any additional retest costs. No
recommended actions will be made to Carmel Fire Department until ASCENSION ST. VINCENT PUBLIC
SAFETY MEDICAL has received accurate retest information.
Policy on Reporting Results
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL 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 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 ASCENSION ST.VINCENT PUBLIC SAFETY MEDICAL, 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.
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL 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:September Location: Carmel Fire Dept.
EXAMS Dates:October-November Location: IN HOUSE PUBLIC SAFETY MEDICAL
F:marketing/Goldmine 2 of 4templates
Exhibit A
Departmental Information
Contact person: Name: Mark Cromlich Title: Health &Safety Chief Phone: (317)409-0909
E-mail: mcromlich@carmel.in.gov
Address: 2 Civic Square Carmel, IN 46032
Number of Personnel: 161 Health &Safety Chief of Dept: Mark Cromlich
Price Increases
Pricing reflected above is valid through December 31, 2020.
Records and Accounts
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL 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 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
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL 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 ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL with enough notice to offer the appointments
to another department and properly prepare.
Liability and Indemnification
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL shall have no liability whatsoever to Carmel Fire
Department for any error, act or omission in connection with the services to be rendered by ASCENSION ST.
VINCENT PUBLIC SAFETY MEDICAL to Carmel Fire Department hereunder unless any such error, act or
omission derives from willful misconduct or gross negligence.
Insurance
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL maintains insurance to protect it and Carmel Fire
Department from the claims set forth below which may arise out of or result from ASCENSION ST. VINCENT
PUBLIC SAFETY MEDICAL operations under this Agreement,whether such operations be by ASCENSION ST.
VINCENT PUBLIC SAFETY MEDICAL 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
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL insurance shall be not less than the acceptable industry
standards for the performance of medical and occupational health-related services.
F:marketing/Goldmine 3 of 4templates
Exhibit A
Confidentiality
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL 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 Fire Department furnished to or obtained by ASCENSION ST. VINCENT PUBLIC SAFETY
MEDICAL in the course of providing the agreed-upon services. ASCENSION ST. VINCENT PUBLIC SAFETY
MEDICAL 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 ASCENSION ST.
VINCENT PUBLIC SAFETY MEDICAL performance under this Agreement or by the express written consent of a
Carmel Fire Department employee.
Proprietary Information
ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL 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 ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL, other fire or law enforcement
organizations, or unnecessary personnel within the Carmel Fire Department.
Termination for Convenience
Either ASCENSION ST. VINCENT PUBLIC SAFETY MEDICAL or Carmel Fire Department may terminate this
Agreement at any time by giving thirty(30)days written notice. ASCENSION ST. VINCENT PUBLIC SAFETY
MEDICAL 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. Questions regarding this Agreement may be directed
to the Client Manager below.
Ascension St.Vincent Public Safety Medical Carmel Fire Department
Rhonda Gallagher
Name Printed Name Printed
ra7/(et.
Name Signed Name Signed
Director of Client Services _ Title
Title
May 23, 2019
Date Date
Your Public Safety Medical Contact
Client Manager: Rhonda Gallagher Mobile: 317.437.4005
F:marketing/Goldmine 4 of 4templates
Exhibit 4
EXHIBIT B
Invoice
Date:
Name of Company:
Address &Zip:
Telephone No.:
Fax No.:
Project Name:
Invoice No.
Purchase Order No:
Goods Services
Person Providing Date Goods/Services Provided Cost Per Hourly Total
Goods/Services Goods/ (Describe each good/service Item Rate/
Service separately and in detail) Hours
Provided Worked
GRAND TOTAL
Signature
Printed Name
EXHIBIT C
INSURANCE COVERAGES
Worker's Compensation & Disability Statutory Limits
Employer's Liability:
Bodily Injury by Accident/Disease: $100,000 each employee
Bodily Injury by Accident/Disease: $250,000 each accident
Bodily Injury by Accident/Disease: $500,000 policy limit
Property damage, contractual liability,
products-completed operations:
General Aggregate Limit(other than
Products/Completed Operations): $500,000
Products/Completed Operations: $500,000
Personal &Advertising Injury
Policy Limit: $500,000
Each Occurrence Limit: $250,000
Fire Damage(any one fire): $250,000
Medical Expense Limit(any one person): $ 50,000
Comprehensive Auto Liability(owned,hired and non-owned)
Bodily Single Limit: $500,000 each accident
Injury and property damage: $500,000 each accident
Policy Limit: $500,000
Umbrella Excess Liability
Each occurrence and aggregate: $500,000
Maximum deductible: $ 10,000
EXHIBIT D
An,IDAVIT
at/V1da) 7 a i(Ot , being first duly sworn, deposes and says that
he/she is familiar with and has pdalsonal knowledge of the facts herein and, if called as a witness in this
matter, could testify as follows:
1. I am over eighteen (18) years of age and am competent to testify to the facts contained
herein.
2. I ain now and at all times rele9nt4rein have peen emplo ed by
Setel ei 34. Urtir«IS u6/c fa ai the"Employer")
in the position of:Dr. of C /r/ �co,'is
3. I am familiar with the employment policies, practices, and procedures of the Employer and
have the authority to act on behalf of the Employer.
4. The Employer is enrolled and participates in the federal E-Verify program and has
provided documentation of such enrollment and participation to the City of Carmel,
Indiana.
5. The Company does not knowingly employ any unauthorized aliens.
FURTHER AFFIANT SAYETH NOT.
EXECUTED on the 2? day ofIt/Itt) , 20 1
Printed: X!�!JY1A�C✓� �d�14C /r
I certify under the penalties for perjury under the laws of the United States of America and the State of
Indiana that the foregoing factual statements and representations are true and correct.
Printed: dr.44J �a /(Aj/L€ /"
INDIANA RETAIL TAX EXEMPT Page 1 of 1
Iity of Ciiirirrei1 CERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 102953
ONE CIVIC SQUARE 35-6000972 THIS NUMBER MUST APPEAR ON INVOICES,AIP
CARMEL, INDIANA 46032-2584 VOUCHER,DELIVERY MEMO,PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
6/17/2019 372939
Firefighter Physicals
ASCENSION ST VINCENT PUBLIC SAFETY Carmel Fire Department
VENDOR 6612 E 75TH STREET SHIP 2 Civic Square
SUITE 200 TO Carmel, IN 46032-
INDIANAPOLIS,IN 46250-
PURCHASE ID BLANKET CONTRACT PAYMENT TERMS FREIGHT
37170
I
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION 1
Department: 1120 Fund: 101 General Fund
Account: 43-407.01
1 Each 2019 Firefighter Physicals- Not to Exceed $93,000.00 $93,000.00
Sub Total $93,000.00
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Send Invoice To: r e,�-.... J r
Carmel Fire Department
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2 Civic Square
Carmel, IN 46032- LJ l
driv
PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNI PROJECT 1 PROJECT ACCOUNT AMOUNT
PAYMENT $93,000.00
SHIPPING INSTRUCTIONS 'ANP VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A
PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN
'SHIP PREPAID. AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED 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 LABEL /
'THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 �' _� � `�
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ORDERED BY
Denise Snyder James Crider
TITLE Accreditation Budget Administrator Administration
CONTROL NO. 102953 CLERK-TREASURER