HomeMy WebLinkAbout1663 Company Care Provider Agrmt i
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1877-4 '1;
OFFICE OF HUMAN RESOURCES AND RISK MANAGEMENT T.
TRANSMITTAL MEMORANDUM
To: City Clerk
RE: Request for Services
The item(s) noted below is/are attached and forwarded to your office for the following action(s):
❑ Development Order ❑ Mayor's signature
❑ Final Plat(original mylars) ❑ Recording
❑ Letter of Credit ❑ Rendering
❑ Maintenance Bond ❑ S fe keeping (Vault)
❑ Ordinance ecord Custodian
❑ Performance Bond
❑ Resolution
Once completed, please:
❑ Return original
❑ Return copy
Special Instructions:
414-41-eAiler747
Please advise if you have any questions regarding the above.
Thank ou!
/6011/ ; 6-k/
From Date
T:\Dept_forms\City Clerk Transmittal Memo-2009.doc
COMPANY CARE/CITY OF SANFORD
PROVIDER LETTER OF AGREEMENT
THIS AGREEMENT, effective the 29th day of April, 2014, by and between the facilities named below
(collectively referred to hereinafter as"Providers") and the City of Sanford, a Florida municipality, whose
mailing address is 300 North Park Avenue, Sanford,Florida 32771, (hereinafter referred to as "Client"), is
as follows:
1. Scope of Services; Terms and Conditions. Providers shall perform the services listed, and Client
shall pay the respective Provider in accordance with the fees set forth, in the"Profile Sheet,"which is
attached hereto and incorporated herein by this reference. Service locations are set forth in Attachment
A, which is attached hereto and incorporated herein by this reference. Unless specifically excluded in
this document, all"Standard Contractual Terms and Conditions", as provided on the Client's website,
apply to this Agreement. Such Terms and Conditions may be found at the Client's website
(www.SanfordFL.gov).
2. Term. This Agreement shall be for a term one (1)year commencing the 29th day of April, 2014 and
shall automatically renew for additional terms of one(1)year,unless terminated pursuant to section 5.
3. Chances. Any changes to this Agreement shall be made by mutual written consent of both Parties.
4. Compensation. Client shall pay each respective Provider within thirty(30)days of the date of invoice
for services rendered.
5. Termination. This Agreement may be terminated by either party, at any time, upon sixty (60) days
prior written notice.
6. Insurance and Indemnification. Each respective Provider shall maintain, at its sole cost and
expense,professional liability insurance with an insurer satisfactory to Client, with minimum limits of
one million dollars ($1,000,000) per occurrence, three million dollars ($3,000,000) in the aggregate
and shall at the request Client, provide written evidence of said insurance coverage. In the event said
coverage is changed materially,the Provider shall, within ten(10)days of such material change,notify
Client in writing. The Provider shall indemnify,defend and save Client harmless from and against any
and all losses, claims, damages, liabilities and expenses (including, without limitation, reasonable
attorney's fees) based upon, arising out of attributable to any acts or omissions arising from the
Provider's performance hereunder.
7. Licensure/Compliance. Each Provider warrants and represents that it is licensed to perform the
services provided under this Agreement and shall maintain all such licenses for the duration of the
Agreement. In addition, each Provider represents that the services provided hereunder are in
compliance with any and all applicable federal and state statutes,laws and/or regulations.
8. Resolution of Disputes. In the event that a dispute between the parties arises out of or related to this
Agreement, the parties shall meet and negotiate in good faith to attempt to resolve this dispute. It the
meeting of the parties is not successful in resolving the dispute, the parties agree to engage in
mediation before a mutually agreed upon mediator authorized to practice in the State of Florida with
the parties agreeing to equally share the costs of such mediation. Only after the mediator has declared
an impasse in the mediation process may a party file a lawsuit in pursuit of a claim.
9. Hold Harmless and Indemnification. Each party shall be responsible for any and all claims,
liabilities, damages or judgments that may arise as a result of their own negligence or intentional
wrongdoing. Each party shall hold harmless and indemnify the other party against any such claims,
liabilities, damages or judgments which may be asserted against, imposed or incurred by the other
party.
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10. Assignment. This Agreement shall not be assigned by any of the Providers without the prior written
consent of Client.
11. Governing Law; Sunshine Laws. This Agreement shall be governed by and construed in accordance
with laws of Florida. In order to comply with Section 119.0701,Florida Statutes,public records laws,
the Providers must keep and maintain public records that ordinarily and necessarily would be required
by the Client in order to perform the service; provide the public with access to public records on the
same terms and conditions that the Client would provide the records and at a cost that does not exceed
the cost provided in Chapter 119,Florida Statutes, or as otherwise provided by law; ensure that public
records that are exempt or confidential and exempt from public records disclosure requirements are not
disclosed except as authorized by law; and meet all requirements for retaining public records and
transfer, at no cost, to the Client all public records in possession of the Providers upon termination of
the contract and destroy any duplicate public records that are exempt or confidential and exempt from
public records disclosure requirements.All records stored electronically must be provided to the Client
in a format that is compatible with the information technology systems of the Client. If the Providers
do not comply with a public records request; the Client shall enforce the contract provisions in
accordance with the contract. Failure by the Providers to grant such public access and comply with
public records request(s) shall be grounds for immediate unilateral cancellation of this Agreement by
the Client. The Providers shall promptly provide the Client with a copy of any request to inspect or
copy public records in possession of the Providers and shall promptly provide the Client a copy of the
Providers' response to each such request. Venue for any lawsuit shall be in the Eighteenth Judicial
Circuit Court in and for Seminole County,Florida.
12. Independent Contractors. For all purposes hereunder, the relationship between Client and each
respective Provider is solely that of independent contractors and this Letter of Agreement does not
create a partnership,joint venture or other association between any of the Providers and Client. The
employees and agents of each respective Provider shall be considered to be under exclusive
management and control of each respective Provider.
13. Notices. Any and all notices sent pursuant to this Agreement shall be given in writing via certified
mail or overnight courier and shall be delivered to the following addresses:
To Providers: Company Care To Client: City of Sanford
6002 49th Street North 300 N.Park Ave.
St.Petersburg,FL 33709 Sanford,FL 32772
Attn.: Barb Maxwell,Division Director ATTN: Fred Fosson
14. HIPAA Requirements. The parties agree to comply with the Health Insurance Portability and
Accountability Act of 1996, as codified at 42 U.S.C. §1320d ("HIPAA") and any current and future
regulations promulgated thereunder including without limitation the federal privacy regulations
contained in 45 C.F.R. Parts 160 and 164 (the "Federal Privacy Regulations"), the federal security
standards contained in 45 C.F.R. Part 142 (the "Federal Security Regulations"), and the federal
standards for electronic transactions contained in 45 C.F.R. Parts 160 and 162, all collectively referred
to herein as "HIPAA Requirements." The parties agree not to use or further disclose any Protected
Health Information(as defined in 45 C.F.R. §164.501)or Individually Identifiable Health Information
(as defined in 42 U.S.C. §1320d), other than as permitted by HIPAA Requirements and the terms of
this Agreement. To the extent applicable under HIPAA, each party shall make its internal practices,
books, and records relating to the use and disclosure of Protected Health Information available to the
Secretary of Health and Human Services to the extent required for determining compliance with the
Federal Privacy Regulations. Each party agrees also to comply with any state law and regulations that
govern or pertain to the confidentiality, privacy, security of, and electronic transactions and code sets
related to, information related to patients.
15. Warranty of Non-Exclusion. Each party represents and warrants to the other that the party, its
officers, directors and employees (i) are not currently excluded, debarred, or otherwise ineligible to
participate in the federal health care programs as defined in 42 U.S.C. § 1320a-7b(f) (the "federal
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healthcare programs"), (ii) have not been convicted of a criminal offense related to the provision of
healthcare items or services, and (iii) are not, to the best of its knowledge, under investigation or
otherwise aware of any circumstances which may result in the party or any such individual being
excluded from participation in the federal healthcare programs. This shall be an ongoing
representation and warranty during the term of this Agreement and each party shall immediately notify
the other of any change in the status of the representations and warranty set forth in this section.
Notwithstanding any provision of this Agreement to the contrary, any breach of this section shall give
the other party the right to terminate this Agreement immediately.
IN WITNESS WHEREOF,the Parties have set their hands the date and year first writte abo e.
Attest: THE CITY OF SANFO' 0
By: 1`1 i
OJeff Triplett IMF Cynthia orter,City Clerk Mayor
Dated: 5 - (Z-l`'r . '
Approved as to form and legality only for
use and reliance by the City of Sanford,Florida
y'�I,�IAiA fA!
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Wiliam L. Colbert 4dA
_�C ity Attorney /0 A
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Wendy Bra 1 on
Chief Executive Offcer
Date: I F
• Central Florida Regional Hospital,Inc. d/b/a Central Florida Regional Hospital
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COMPENSATION SCHEDULE
This attachment when executed by Provider and Client,shall become part of the agreement between the parties as of the Effective Date of the
Agreement,and shall remain in Full Force and Effect as long as the Agreement is in Force. Any annual increase in pricing of services will
be considered and reviewed annually;any specific year annual increase must be mutually agreed upon in writing by both parties.
CLINICAL SUMMATION SHEET
Company: City of Sanford
SERVICES TO BE PERFORMED:
Urine Drug Screen(Quick Dip) $20.00
(Pre-employment only)
Urine Drug Screen (NIDA Panel) $40.00
Pre-employment,Post Accident,Random,Reasonable suspicion
Urine Drug Screen (5 or 8 Panel) $40.00
Pre-employment,Post Accident,Random,Reasonable suspicion
EBT Evidential Breath Testing-(Initial) $25.00
EBT Evidential Breath Testing-(Confirmation) $25.00
SKIN TB-PPD $ 15.00
Chest X-ray(known+TB Test) $60.00
(Includes radiologist interpretation)
DOT Physical $60.00
Post Exposure
Counseling HIV 15 MIN $45.00
Counseling HIV 30 MIN $85.00
Lab Testing for Post Exposure Current Lab Cost
Workers Compensation State Fee Schedule
Company Contact:
Contact Name: Fred Fosson Phone#: (407)688-5025 Cell—(407)314-3693
Mailing Address: 300 N. Park Ave.
City: Sanford State: FL Zip: 32772-1788
Fax#: (407)688-5131
EMAIL: Fossonf @sanfordFL.gov
W/C Carrier: Johns Eastern Company,Inc.
Company Care Contact:
Contact Name: Andrea Schwaderer Phone#: (727)328-6255 Fax#: (727)328-6159
Mailing Address: 2191 9th Avenue North,Suite 260
City: St. Petersburg State: FL Zip: 33713
EMAIL: andrea.schwaderer @hcahealthcare.com
bbm 3/13
COMPANY CARE
Occupational; Hem k_
HCA West Florida Division - Company Care Site Locations
Injury Management Only-Emergency Room
Edward White Hospital Northside Hospital St Petersburg General Hospital
2191 9th Avenue North,Suite 260 6002 49th Street North 6500 38th Avenue North
St.Petersburg,FL 33713 St.Petersburg,FL 33709 St.Petersburg,FL 33710
Phone: (727)328-6261 Phone:(727)521-5485 Phone:(727)521-5485
FAX: (727)328-6260 Fax: (727)521-5484 Fax: (727)521-5484
Injury Management Only-Emergency Room
Largo Medical Center Largo Medical Center-Indian Rocks Campus Regional Medical Center Bayonet Point
201 14th Street SW 2025 Indian Rocks Road 14100 Fivay Road, Suite 140
Largo,FL 33774 Largo,FL 33774 Hudson,FL 34667
Phone:(727)587-7661 Phone:(727)587-7661 Phone:(727)819-2941
Fax: (727)518-0723 Fax: (727)518-0723 Fax: (727)819-2944
Blake Medical Center Fawcett Memorial Hospital Central Florida Regional Hospital
2010 59th Street West,Suite 3600 3280 Tamiami Trail,Suite 11 1401 West Seminole Blvd.
Bradenton,FL 34209 Port Charlotte,FL 33952 Sanford,FL. 32771
Phone:(941)798-6158 Phone: (941)625-3047 Phone:(407)302-7322
Fax: (941)798-6475 Fax: (941)625-3607 Fax: (407)302-7323
Injury Management Only-Emergency Department Injury Management Only-Emergency Department
Englewood Community Hospital Palms of Pasadena
700 Medical Blvd 1501 Pasadena Ave. So
Englewood,FL 34223 St.Petersburg,FL 33707
Phone:(941)473-5028 Phone: (727)341-7568
Account Managers
Andrea Schwaderer-South Pinellas County Robyn Vandevander-North Pinellas County Lisa Nikirk-Manatee County
Phone:(727)328-6255 Phone: (727)587-7682 Phone: (941)798-6073
Pager: (727)419-4528 Pager: (727)402-0667 Fax: (941)798-6081
Fax: (727)328-6159 Fax: (727)518-0723
Sheri Miller -Charlotte County Seminole/Osceola County Paula Gallagher-Hernando/Pasco County
Phone: (941)625-3047 Phone:(407)302-7322 Phone:(727)819-2941
Pager: (941)613-7768 Fax: (407)302-7323 Fax: (727)819-2944
Fax: (941)625-3607
Division Director Company Care
Barb Maxwell RN,MHA,COHN-S,CCM,CWCP,QRP,FAAOHN
Occupational Health Services-HCA—West Florida Division
6002 49th Street North
St.Petersburg,Florida 33709
Phone: (727)528-5932
Fax: (727)528-5933
Cell: (727)560-7252
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