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1663 Company Care Provider Agrmt i Sfliff0111) 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. 3/13 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 6/13 Page 2 of 3 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! 7,6-- Wiliam L. Colbert 4dA _�C ity Attorney /0 A i #/ a ‘ 4 '1 A ;it Ai 0/ •,_,' Wendy Bra 1 on Chief Executive Offcer Date: I F • Central Florida Regional Hospital,Inc. d/b/a Central Florida Regional Hospital 6/13 Page 3 of 3 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 Rev 6-13