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1313 North Seminole Family PracticeTo: 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 ❑ Final Plat (original mylars) ❑ Letter of Credit ❑ Maintenance Bond ❑ Ordinance ❑ Performance Bond ❑ Resolution J G; C /e v-k cckfe s'�" 4/ Once completed, please: ❑ Return original I�turr3 � Special Instructions: ❑ Mayor's signature ❑ Recording ❑ Rendering ❑ Safe keeping (Vault) Record Custodian Original Agreements for Physician Services, General and Workers Compensation for both North Seminole Family Practice and Florida Hospital Centra Care. Please advise if you have any questions regarding the above. Thank you! / From - 1d Date TADept_ forms \City Clerk Transmittal Memo - 2009.doc I 3i3 City Of Sanford Agreement For General Physicians Services (RFP 09/10 -07) This Agreement made and entered into this I day of Juk. , 2010 by and between the: City of Sanford, Florida City Hall 300 North Park Avenue Sanford, Florida 32771 a municipal corporation of the State of Florida, holding tax exempt status, hereinafter referred to as the "City," and: North Seminole Family Practice Associates, P.A. 2209 French Ave. Sanford, FL 32771 a medical facility licensed and elgilble to practice medicine in the State of Florida and authorized to do business in the State of Florida, hereinafter referred to as the "Physician ". The City and the Physician are collectively referred to herein as the "parties ". WITNESSETH: Whereas, the City desires to retain the Physician for the work identified in the specifications outlined in City RFP 09/10 -07 for the provision of medical services related to the general needs of the City and in support of the City's programs, projects and operations which require diverse medical services on an intermittent, but ongoing, basis; and Whereas, attached hereto as Exhibit "A" along with the certain other documents relating thereto are the City's documents relating to RFP 09/10 -07; and Whereas, the City desires to employ the Physician for the performance of medical services to support the activities, programs, and projects of the City upon the terms and conditions hereinafter set forth herein and in the City's RFP 09/10 -07 pertaining to the provision of medical services pertaining to the various programs and projects of the City upon said terms and conditions; and Whereas, the Physician hereby warrants and represents to the City that it is competent and otherwise able to provide professional and high quality medical and related services to the City; and D IIII 0 Physicians Services Agreement — General Medical Services Page No. 1 Whereas, the references to the provisions of services to the City shall include to provision of goods and the term "Work Order" shall include the term "Purchase Order" herein; Now, Therefore, in consideration of the mutual covenants and agreements hereinafter contained and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, it is agreed by and between the parties hereto as follows: Section 1: Definitions. Ad valorem - In proportion to the estimated value of the goods taxed. Agreement — This document and all subsequent Work Orders between the City and Physician. Each exhibit, even if not physically attached, shall be treated as if it is a part of this Agreement. The effective date of this Agreement is the date that the City Commission approves the selection of the Physician and the Agreement is executed by the City. Billing Period — The period of time between project commencement to the close of the current period, (inclusive); or from the close of the previous billing period, (exclusive), to the close of the current period, usually concurrent with the month. In no case shall this period be less than one calendar month except for the final billing period. Bona Fide - Made or carried out in good faith; sincere. City — The City of Sanford, a municipal corporation of the State of Florida holding tax exempt status. Physician - To include all principals of the Physician including, but not limited to, full and part time employees, professional or otherwise, and all other agents employed by or for Physician to perform its obligations hereunder. Description of Services - Shall be written in paragraph form reasonably describing those services the City can expect the Physician to provide. The description shall be written in such a manner that the type of service is clearly provided, but broad enough that all services reasonably expected of the Physician, including services provided by partners, subcontractors, and other supporting professionals, can be provided to the City. Designated Representative — A person who administers, reviews and coordinates the provision of services. This definition applies equally to the City and to the Physician. Exhibit "A" — City RFP 09/10 -07 and related documents as determined by the City Exhibit "B" — Project Status Report Form. Exhibit "C" — Certificate of Insurance Coverages. Physicians Services Agreement — General Medical Services Page No. 2 Exhibit "D" — Physician pricing sheet or schedule for services. Force Majeure - Force Majeure shall include, but not be limited to, hostility, revolution, civil commotion, terrorism, strike, epidemic, fire, flood, wind, earthquake, explosion, any law, proclamation, regulation, or ordinance or other act of government, or any act of God or any cause whether of the same or different nature, existing or future; provided that the cause whether or not enumerated in this Agreement is beyond the control and without the fault or negligence of the party seeking relief under this Agreement. Law - Said phrase shall include statutes, laws, codes, ordinances, rules and regulations of whatsoever type or nature enacted or adopted by a governmental entity of competent jurisdiction. Pari Materia — Of the same matter; on the same subject. Laws pari materia must be construed with reference to each other /together when related to the same matter or subject. The provisions of a contract/agreement shall be construed together with no isolated construction of a particular provision such that it would defeat the overall intent of the contract/agreement. Submittals —Any item required by this agreement that the Physician must provide the City either for inclusion as part of this Agreement or not. Type of Service — The services are generally related to the provision of various and diverse medical and related services pertaining to the multiplicitious programs and projects of the City in accordance with the controlling provisions of law. Work Order - A detailed description of quantities, services and a completion schedule for the provision of such goods and /or services issued by the City on it's approved form which, on occasion, may contain documents published, on Physician letterhead, describing all work associated with the goods /services to be provided by the Physician to the City for an agreed price referencing this Agreement by title and date. Section 2: Captions. The Section headings and captions of this Agreement are for convenience and reference only and in no way define, limit, describe the scope or intent of this Agreement or any part thereof, or in any way affect this Agreement or construe any provision of this Agreement. Section 3: Extent Of Agreement /Integration /Amendment. (a). This Agreement, together with the exhibits, constitutes the entire integrated Agreement between the City and the Physician and supersedes all prior written or oral understandings in connection therewith. This Agreement, and all the terms and provisions contained herein including, without limitation, the exhibits, constitute the full and complete agreement between the parties hereto and supersede and controls over any and all prior Physicians Services Agreement — General Medical Services Page No. 3 agreements, understandings, representations, correspondence and statements regardless of whether written or oral. (b). This Agreement may only be amended, supplemented, or modified by a formal written amendment. (c). Any alterations, amendments, deletions, or waivers of the provisions of this Agreement shall be valid only when expressed in writing and duly signed by the parties. Section 4: No General City Obligation. (a). In no event shall any obligation of the City under this Agreement be or constitute a general obligation or indebtedness of the City, a pledge of the ad valorem taxing power of the City or a general obligation or indebtedness of the City within the meaning of the Constitution of the State of Florida or any other applicable laws, but shall be payable solely from legally available revenues and funds. (b). The Physician shall not have the right to compel the exercise of the ad valorem taxing power of the City. Section 5: Physician Understanding Of Services Required (a). Execution of this Agreement by the Physician is a representation that the Physician is familiar with local conditions and with the services to be performed. The Physician shall make no claim for additional time or money based upon its failure to comply with this Agreement. The Physician has informed the City, and hereby represents to the City, that it has extensive experience in performing and providing the services and /or goods described in this Agreement and to be identified in the Work Orders, and that it is well acquainted with the components that are properly and customarily included within such projects and the requirements of statutes, laws,codes, ordinances, rules, regulations, or orders of any public authority or licensing entity having jurisdiction over City projects. Execution of a Work Order shall be an affirmative and irrefutable representation by the Physician to the City that the Physician is fully familiar with any and all requisite work conditions of the provisions of the services and /or goods to be provided. (b). The recitals herein are true and correct and form and constitute a material part of this Agreement upon which the parties have relied. (c). It is agreed that nothing herein contained is intended or should be construed as in any manner creating or establishing a relationship of co- partners between the parties, or as constituting the Physician (including, but not limited to, its officers, employees, and agents) the agent, representative, or employee of the City for any purpose, or in any manner of whatsoever type or nature. The Physician is to be and shall remain forever an independent contractor with respect to all services performed under this Agreement. (d). Persons employed by the Physician in the provision and performance of the Physicians Services Agreement — General Medical Services Page No. 4 services and functions pursuant to this Agreement shall have no claim to pension, workers' compensation, unemployment compensation, civil service or other employee rights or privileges granted to the City's officers and employees either by operation of law or by the City. Section 6: General Provisions. (a). Each party hereto represents to the other that it has undertaken all necessary actions to execute this Agreement and that it has the legal authority to enter into this Agreement, and to undertake all obligations imposed on it. The persons executing this Agreement for the Physician certify that they are authorized to bind the Physician fully to the terms of this Agreement. (b). This Agreement is for the services as described in this Agreement which shall be accomplished in accordance with the controlling provisions of law and as directed by the City to include all labor and materials that may be required. (c). The Physician acknowledges that the City may retain other physicians to provide the same types of services for City projects. The City reserves the right to select which physician shall provide services for City projects. (d). The Physician acknowledges that the City has retained, or may retain, other physicians and the coordination between said physicians and the Physician may be necessary from time -to -time for the successful completion of each Work Order. The Physician agrees to provide such coordination as necessary. (e). The Physician agrees to provide and ensure coordination between goods /services providers. (f). Time is of the essence of the lawful performance of the duties and obligations contained in this Agreement to include, but not be limited to, each Work Order. The parties covenant and agree that they shall diligently and expeditiously pursue their respective obligations set forth in this Agreement and each Work Order. (g). The Physician shall maintain an adequate and competent staff and professionally qualified persons throughout the performance of this Agreement to ensure acceptable and timely completion of each Work Order. (h). Requirements for signing and sealing plans, reports and documents prepared by the Physician shall be governed by the laws and regulations of Seminole County and State regulatory agencies. (i). The Physician hereby guarantees the City that all material, supplies, services and equipment as listed on a Purchase Order or Work Order meet the requirements, specifications, and standards as provided for under the Federal Occupations Safety and Health Act of 1970, from time -to -time amended and in force on the date hereof. Physicians Services Agreement — General Medical Services Page No. 5 Q). No claim for services furnished by the Physician not specifically provided for herein shall be honored by the City. Section 7: Codes And Design Standards. (a). All the services to be provided or performed by the Physician shall in the minimum be in conformance with commonly accepted industry and professional codes and standards, standards of the City, and the laws of any Federal, State, or local regulatory agencies. (b). The Physician shall be responsible for keeping apprised of any changing laws applicable to the services to be performed under this Agreement. Section 8: Subcontractors. (a). Any Physician proposed subcontractor shall be submitted to the City for written approval prior to the Physician entering into a subcontract. Subcontractor information shall include, but not be limited to, State registrations, business address, proof of payment of the local business tax and insurance certifications. (b). The Physician shall coordinate the provision of services and work product of any City approved subcontractor and remain fully responsible for such services and work under the terms of this Agreement. (c). Any subcontract shall be in writing and shall incorporate this Agreement and require the subcontractors to assume performance of the Physician's duties commensurately with the Physician's duties to the City under this Agreement it being understood that nothing herein shall in any way relieve the Physician from any of its duties under this Agreement. The Physician shall provide the City with executed copies of all subcontracts. Section 9: Assignability. The Physician shall not sublet, assign, or transfer any interest in this Agreement, or claims for the money due or to become due out of this Agreement to a bank, trust company, or other financial institution without written City approval. When approved by the City, written notice of such assignment or transfer shall be furnished promptly to the City. Section 10: Commencement/implementation Schedule Of Agreement. (a). The Physician shall commence the provision of services as described in this Agreement immediately upon execution of this Agreement and a notice to proceed with the work set forth in the subject RFP. Thereafter Work Orders will be issued for work to be accomplished hereunder. Physicians Services Agreement — General Medical Services Page No. 6 (b). The Physician shall adhere to the City's time requirements relative to the work to be accomplished as set forth in the RFP to ensure timely completion of services to the City. (c). The Physician and the City agree to make every effort to adhere to the schedules established for the various Work Orders as described in each Work Order. However, if the Physician is delayed at any time in the provision of services by any act or omission of the City, or of any employee of the City, or by any other Physician employed by the City, or by changes ordered by the City, or by strikes, lock outs, fire, unusual delay in transportation, unavoidable casualties, or any other causes of force majeure not resulting from the inactions or actions of the Physician and beyond the Physician's control which would not reasonably be expected to occur in connection with or during performance or provision of the services, or by delay authorized by the City pending a decision, or by any cause which the City shall decide to justify the delay, the time of completion shall be extended for such reasonable time as the City may decide in its sole and absolute discretion. (d). It is further expressly understood and agreed that the Physician shall not be entitled to any damages or compensation, of any type or nature, or be reimbursed for any losses on account of any delay or delays resulting from any of the aforesaid causes or any other cause whatsoever. Section 11: Length Of Agreement. (a). The term of this Agreement shall be for a period beginning on the date of the full execution of this Agreement and terminating on December 31, 2011 and shall be renewable, at the option of the City, for one (1) year periods thereafter for an additional year or years. (b). The Physician's services shall begin upon written notification to proceed by the City. (c). Thereafter, the Physician's services shall be on a Work Order basis. (d). Services may include matters such as serving as an expert witness. Section 12: Description Of Services. (a). The Physician agrees to provide the services as outlined and described in this Agreement all of which are to be provided to the City in accordance with the controlling provisions of law as more specifically outlined in the exhibits and Work Orders issued hereunder; provided, however, without limiting the generality of the foregoing: (1). Performing- routine, pre - employment evaluations and fitness for duty evaluations to determine the capability of performing the job requirements for specific jobs with the City of Sanford. This shall include, but not be limited to, determinations involving audiometric testing, vision and other physical capabilities relative to the requirements stated in the position description. Medical Evaluations for firefighters must meet National Fire Protection Association (NFPA) standards. Other standards may be prescribed for particular types of Physicians Services Agreement — General Medical Services Page No. 7 employees consistent with controlling legal requirements relating thereto or sound and generally accepted public employment management practices and principles. (2). Conducting pre - employment law enforcement medical examinations required by the Criminal Justice Standards and Training Commission or other regulatory bodies or agencies. In addition to the physical examination, an electrocardiogram, a skin test for tuberculosis (TB), and blood testing which includes an analysis of blood cells and chemistry are included. (3). Provide for x -ray, EKG, laboratory service and or other extraordinary medical services. If these services cannot be provided directly by the Physician, the Physician must be able to coordinate such services with a medical provider; and charges for such services will be billed to the Physician and, subsequently, billed to the City. (4). Act as a medical provider to administer annual flu shots to City employees. (5). Provide for Hepatitis Injection and Hepatitis Exclusionary Testing for law enforcement officer and firefighter applicants as a part of their preemployment medical certification as well as to such other applicants as the City may require. (6). Provide for TB Exclusionary Testing for law enforcement officer and firefighter applicants as a part of their pre - employment medical certification as well as to such other applicants as the City may require. (7). Providing pre - employment and /or fitness for duty evaluations within five (5) working days of the initial making the appointment for the services. (8). In addition to the foregoing and such other services as may be prescribed in Work Orders from time -to -time, provided any and all documentation required by the City and, to that end, it shall be the responsibility of the Physician to provide and maintain documentation applicable patients treated. (b). The Physician shall diligently and in a professional and timely manner perform and provide the services outlined herein or as included in each subsequently entered Work Order. Unless modified in writing by the parties hereto, the duties of the Physician shall not be construed to exceed the provision of the services pertaining to this Agreement. (c). The City and the Physician agree that there may be certain additional services required to be performed by the Physician during the performance of the work in the RFP or Work Orders that cannot be defined sufficiently at the time of execution of this Agreement. Such services shall be authorized in writing as a Change Order. The Work Orders may contain addititonal instructions or provide specifications upon certain aspects of this Agreement pertinent to the work to be undertaken. Such supplemental instructions or provisions shall not be construed as a modification of this Agreement. Section 13: Physician Responsibilities. Physicians Services Agreement — General Medical Services Page No. 8 (a). The Physician shall be responsible for the professional quality, accepted standards, technical accuracy, neatness of appearance of employees, employee conduct, safety, and the coordination of all services furnished by the Physician under this Agreement as well as the conduct of its staff, personnel, employees and agents. All Physician employees shall at all times when performing work wear identification badges which, at a minimum, provides the name of the employee and the Physician. (b). The Physician shall provide to the City a list of employees working on the project. The Physician shall provide to the City a list of employee working days, times and assignments within forty -eight (48) hours of the City's written request for such information. This information, when requested by the City, shall be provided to the City prior to the employees of the Physician entering the City's premises. (c). The Physician shall comply with the Sanford City Code as it relates to security screenings of private contractors and employees of private contractors. The Physician recognizes that its employees are functioning in a position critical to the security and /or public safety of the City by reason of access to a City owned facility and, thus, all employees accessing a City owned facility shall undergo the following inquiries and procedures conducted by the City: (1) fingerprinting in accordance with the City's pre- employment procedures, (2) submission of the fingerprints to the Florida Department of Law Enforcement for State criminal history evaluation, and (3) submission of the fingerprints to the Federal Bureau of Investigation for a national criminal history evaluation. Such information shall be used by the City to determine a person's eligibility to function in such critical employment positions as described. Additionally, the Physician shall provide the name, address and social security number and licenses (driver's, commercial drivers license, or other operator's license) for its employees. The Physician shall release such information upon approval of the employees. If an employee refuses to authorize the release of their address, social security number and /or licenses they shall not be allowed to work or continue to work for the City's projects. (d). The Physician shall work closely with the City on all aspects of the provision of the services. The Physician shall be responsible for the professional quality, technical accuracy, competence, methodology, accuracy and the coordination of all of the following which are listed for illustration purposes only and not as a limitation: documents, analysis, reports, data, plans, plats, maps, surveys, specifications, and any and all other services of whatever type or nature furnished by the Physician under this Agreement. The Physician shall, without additional compensation, correct or revise any errors or deficiencies in his /her /its plans, analysis, data, reports, designs, drawings, specifications, and any and all other services of whatever type or nature. The Physician's submissions in response to the subject bid or procurement processes are incorporated herein by this reference thereto. (e). Neither the City's review, approval or acceptance of, nor payment for, any of the services required shall be construed to operate as a waiver of any rights under this Agreement or of any cause of action arising out of the performance of this Agreement and the Physician shall be and remain liable to the City in accordance with applicable law for all Physicians Services Agreement — General Medical Services Page No. 9 damages to the City caused by the Physician's negligent or improper performance or failure to perform any of the services furnished under this Agreement. (f). The rights and remedies of the City, provided for under this Agreement, are in addition to any other rights and remedies provided by law. (g). Time is of the essence in the performance of all services provided by the Physician under the terms of this Agreement and each and every Work Order. (h). The Physician shall cooperate with the City in the implementation of the City's tax recovery program and, to that end, the City may make purchases directly under its purchase order processes relative to various materials, supplies and equipment that may be part of the services provided under this Agreement. The Physician hereby recognizes the right of the City to engage in tax recovery/savings through direct purchases. Section 14: City Rights And Responsibilities. (a). The City shall reasonably cooperate with the Physician in a timely fashion at no cost to the Physician as set forth in this Section. (b). The City shall furnish a City designated representative to administer, review, and coordinate the provision of services under each Work Order. (c). The City shall make City personnel available where, in the City's opinion, they are required and necessary to assist the Physician. The availability and necessity of said personnel to assist the Physician shall be determined solely at the discretion of the City. (d). The City shall furnish the Physician with exisitng data, records, maps, plans, specifications, reports, fiscal data and other engineering information that may be available in the City's files that is necessary or useful to the Physician for the performance of the work provided for in this Agreement. All such documents conveyed by the City to the Physician shall be, and always remain, the property of the City and shall be returned to the City upon completion of the work to be performed by the Physician. (e). The City shall examine all Physician reports, sketches, drawing, estimates, proposals and other documents presented to the City and indicate the City's approval or disapproval within a reasonable time so as not to materially delay the provisions of the services of the Physician. (f). The City shall provide access to and make provisions for the Physician to enter upon public and private lands as required for the Physician within a reasonable time to perform work as necessary to complete work. (g). The City shall transmit instructions, relevant information, and provide interpretation and definition of City policies and decisions with respect to any and all materials and other matters pertinent to the services covered by this Agreement. Physicians Services Agreement — General Medical Services Page No. 10 (h). The City shall give written notice to the Physician whenever the City designated representative knows of a development that affects the services provided and performed under this Agreement, timing of the Physician's provision of services, or a defect or change necessary in the services of the Physician. (i). The rights and remedies of the City provided for under this Agreement are in addition to any other rights and remedies provided by law. The City may assert its right of recovery by any appropriate means including, but not limited to, set -off, suit, withholding, recoupment or counterclaim, either during or after performance of this Agreement. Q). The City shall be entitled to recover any and all legal costs including, but not limited to, attorney fees and other legal costs that it may incur in any legal actions it may pursue in the enforcement of the terms and conditions of this Agreement or the responsibilities of the Physician in carrying out the duties and responsibilities deriving from this Agreement. (k). The failure of the City to insist in any instance upon the strict performance of any provision of this Agreement, or to exercise any right or privilege granted to the City hereunder, shall not constitute or be construed as a waiver of any such provision or right and the same shall continue in force. (1). Neither the City's review, approval or acceptance of, nor payment for, any of the services required shall be construed to operate as a waiver of any rights under this Agreement nor for any cause of action arising out of the performance of this Agreement and the Physician shall be and always remain liable to the City in accordance with applicable law for any and all damages to the City caused by the Physician's negligent or wrongful provision or performance of any of the services furnished under this Agreement. (m). All deliverable analysis, reference data, survey data, plans and reports or any other form of written instrument or document that may result from the Physician's services or have been created during the course of the Physician's performance under this Agreement shall become the property of the City after final payment is made to the Physician. (n). In the event the City fails to comply with the terms and conditions of this Agreement, the Physician shall notify the City's designated representative in writing in order that the City may take remedial action. Section 15: Waiver. The failure of the City to insist in any instance upon the strict performance of any provision of this Agreement, or to exercise any right or privilege granted to the City hereunder, shall not constitute or be construed as a waiver of any such provision or right and the same shall continue in force. Section 16: Force Majeure. Physicians Services Agreement — General Medical Services Page No. 11 Neither party shall be considered in default in performance of its obligations hereunder to the extent that performance of such obligations, or any of them, is delayed or prevented by force majeure. Section 17: Standards Of Conduct. (a). The Physician warrants that it has not employed or retained any company or person, other than a bona fide employee working solely for the Physician, to solicit or secure this Agreement and that the Physician has not paid or agreed to pay any person, company, corporation, individual, or firm other than a bona fide employee working solely for the Physician, any fee, commission, percentage, gift, or any other consideration, contingent upon or resulting from the award of making this Agreement. (b). If the City determines that any employee or representative of the Physician is not satisfactorily performing his or her assigned duties or is demonstrating improper conduct pursuant to any assignment or work performed under this Agreement, the City shall so notify the Physician, in writing. The Physician shall immediately remove such employee or representative of the Physician from such assignment. (c). The Physician hereby certifies by this writing that no undisclosed conflict of interest exists with respect to the Agreement including, but not limited to, any conflicts that may be due to representation of other clients, customers or vendees, other contractual relationships of the Physician, or any interest in property that the Physician may have. The Physician further certifies that any conflict of interest that arises during the term of this Agreement shall be immediately disclosed in writing to the City. Violation of this Section shall be considered as justification for immediate termination of this Agreement. (d). The Physician shall not engage in any action that would create a conflict of interest for any City employee or other person during the course of performance of, or otherwise related to, this Agreement or which would violate or cause others to violate the provisions of Part III, Chapter 112, Florida Statutes, relating to ethics in government. (e). The City shall not intentionally award publicly- funded contracts to any Physician who knowingly employs unauthorized alien workers, constituting a violation of the employment provisions contained in 8 U.S.C. Section 1324a(e) Section 274A(e) of the Immigration and Nationally Act (INA)]. The City shall consider the employment by the Physician of unauthorized aliens, a violation of Section 274A (e) of the INA. Such violation by the Physician of the employment provisions contained in Section 274A (e) of the INA shall be grounds for immediate termination of this Agreement by the City. (f). The Physician shall comply with the requirements of the Americans with Disabilities Act (ADA), and any and all related Federal or State laws which prohibits discrimination by public and private entities on the basis of disability. Physicians Services Agreement — General Medical Services Page No. 12 (g). The Physician shall not discriminate on the grounds of race, color, religion, sex, or national origin in the performance of work under this Agreement or violate any laws pertaining to civil rights, equal protection, or discrimination. (h). If the Physician or an affiliate is placed on a discriminatory vendor list, such action may result in termination by the City. The Physician shall certify, upon request by the City, that it is qualified to submit a bid under Section 287.134 (2) (c), Florida Statutes. (i). If the Physician or an affiliate is placed on the convicted vendor list following a conviction for a public entity crime, such action may result in termination by the City. The Physician shall certify, upon request by the City, that is qualified to submit a bid under Section 287.133 (2)(a), Florida Statutes. 0). The Physician shall certify, upon request by the City, that the Physician maintains a drug free workplace policy in accordance with Section 287.0878, Florida Statutes. Failure to submit this certification may result in termination. (k). The Physician agrees to comply with Federal, State and local environmental, health and safety laws and regulations applicable to the services provided to the City. The Physician agrees that any program or initiative involving the work that could adversely affect any personnel involved, citizens, residents, users, neighbors or the surrounding environment shall ensure compliance with any and all employment safety, environmental and health laws. (1). If applicable, in accordance with Section 216.347, Florida Statutes, the Physician shall not use funds provided by this Agreement for the purpose of lobbying the Legislature, the judicial branch, or a State agency. (m). The Physician shall not publish any documents or release information regarding this Agreement to the media without prior approval of the City. (n). The Physician shall ensure that all services are provided to the City after the Physician has obtained, at its sole and exclusive expense, any and all permits, licenses, permissions, approvals or similar consents. (o). The Physician shall ensure that all taxes due from the Physician are paid in a timely and complete manner including, but not limited to, the local business tax. Section 18: Notices. (a). Whenever either party desires to give notice unto the other, it must be given by written notice, sent by registered United States mail, with return receipt requested, addressed to the party for whom it is intended, at the place last specified, and the place for giving of notice shall remain such until it shall have been changed by written notice in compliance with the provisions of this Section. Physicians Services Agreement — General Medical Services Page No. 13 (b). For the present, the parties designate the following as the representative places for giving of notice, to -wit: (1). For the City: Fred Fosson, Director of Human Resources /Risk Management City of Sanford City Hall 300 North Park Avenue Sanford, Florida 32771 Telephone Number: (407) 688 -5025 Facsimile Number: (407) 688 -5131 Email Address: fossonf @sanfordfl.gov (2). For the Physician Denise McCabe Office Manager 2209 French Ave. Sanford, FL 32771 Telephone Number: 407 - 321 -4230 Facsimile Number: 407 - 324 -7642 Email address dmccabe @nsfp.org (c). Written notice requirements of this Agreement shall be strictly construed and such requirements are a condition precedent to pursuing any rights or remedies hereunder. The Physician agrees not to claim any waiver by City of such notice requirements based upon City having actual knowledge, implied, verbal or constructive notice, lack of prejudice, or any other grounds as a substitute for the failure of the Physician to comply with the express written notice requirements herein. Computer notification (e -mails and message boards) shall not constitute proper written notice under the terms of the Agreement. Section 19: Designated Representatives. (a). The City Manager, or designated representative, represents the City in all matters pertaining to and arising from the work and the performance of this Agreement. (b). The City Manager or designated representative shall have the following responsibilities: (1). Examination of all work and rendering, in writing, decisions indicating the City's approval or disapproval within a reasonable time so as not to materially delay the work of the Physician; 14 Physicians Services Agreement — General Medical Services (2). Transmission of instructions, receipt of information, and interpretation and definition of City's policies and decisions with respect to design, materials, and other matters pertinent to the work covered by this Agreement; (3). Giving prompt written notice to the Physician whenever the City knows of a defect or change necessary in the project; and (c). Until further written notice, the City's designated representative for this Agreement is: Fred Fosson, Director of Human Resources /Risk Management City of Sanford City Hall 300 North Park Avenue Sanford, Florida 32771 Telephone Number: (407) 688 -5025 Facsimile Number: (407) 688 -5131 Email Address: fossonf @sanfordfl.gov (d). Prior to start of any work under this Agreement, the Physician shall submit to the City detailed resumes of key professional personnel that will be involved in performing services described in the work. The City hereby acknowledges its acceptance of such personnel to perform services under this Agreement. At any time hereafter that the Physician desires to change key professional personnel in an active assignment, it shall submit the qualifications of the new professional personnel to the City for prior approval. Key professional personnel shall include the principal -in- charge, project managers and others interfacing with City personnel. (e). Until further written notice, the Physician's designated representative for this Agreement is: Denise McCabe Office Manager 2209 French Ave. Sanford, FL 32771 Telephone Number: 407 - 321 -4230 Facsimile Number: 407 - 324 -7642 Email address dmccabe @nsfp.org Section 20: Work Orders. (a). The provision of services to be performed under this Agreement may commence immediately upon the execution of this Agreement and a notice to proceed. Thereafter, a Work Order issued by the City shall direct work under this Agreement. Services to be provided by the Physician to the City under Work Orders shall be negotiated between the 15 Physicians Services Agreement — General Medical Services Physician and the City. Each Work Order shall reference this Agreement by title and date, include a detailed description of quantities, services, and a completion schedule, and will be provided on Physician letterhead. Services described in said Work Orders will commence upon the full execution of a Work Order or as specified in a Work Order. (b). If the services required to be performed by a Work Order is clearly defined, the Work Order shall be issued on a "Fixed Fee" basis. The Physician shall perform all services required by the Work Order but in no event shall the Physician be paid more than the negotiated Fixed Fee amount stated therein. (c). The Physician and the City agree to make every effort to adhere to the schedules established for the various Work Orders. (d). If the services are not clearly defined, the Work Order may be issued on a "Time Basis Method" and contain a Not -to- Exceed amount. If a Not -to- Exceed amount is provided, the Physician shall perform all work required by the Work Order; but in no event shall the Physician be paid more than the Not -to- Exceed amount specified in the applicable Work Order. (e). For Work Orders issued on a "Fixed Fee Basis," the Physician may invoice the amount due based on the percentage of total Work Order services actually performed and completed; but in no event shall the invoice amount exceed a percentage of the Fixed Fee amount equal to a percentage of the total services actually completed. (f). For Work Orders issued on a "Time Basis Method" with a Not -to- Exceed amount, the Physician may invoice the amount due for actual work hours performed; but in no event shall the invoice amount exceed a percentage of the Not -to- Exceed amount equal to a percentage of the total services actually completed. (g). Each Work Order issued on a "Fixed Fee Basis" or "Time Basis Method" with a Not - to- Exceed amount shall be treated separately for retainage purposes. If the City determines that work is substantially complete and the amount retained, if any, is considered to be in excess, the City may, at its sole and absolute discretion, release the retainage or any portion thereof. (h). For Work Orders issued on a "Time Basis Method" with a Limitation of Funds amount, the Physician may invoice the amount due for services actually performed and completed. The City shall pay the Physician one hundred percent (100 %) of the approved amount on Work Orders issued on a "Time Basis Method" with a Limitation of Funds amount. (i). Invoices for work under the RFP shall be invoiced as if for a Work Order issued on a "Fixed Fee Basis ". Section 21: Change Orders. 16 Physicians Services Agreement — General Medical Services (a). The City may revise the description of services set forth in any particular Work Order or the RFP. (b). Revisions to any work shall be authorized in writing by the City as a Change Order. Each Change Order shall include a schedule of completion for the services authorized. Change Orders shall identify this Agreement and the appropriate Work Order number. The Change Orders may contain additional instructions or provisions specific upon certain aspects of this Agreement pertinent to the services to be provided. Such supplemental instructions or provisions shall not be construed as a modification of this Agreement. An agreement between the parties on and execution of any Change Order shall constitute a final settlement and a full accord and satisfaction of all matters relating to the change of work and /or services and to the impact of the change on unchanged goods and /or work including, but not limited to, all direct and indirect costs of whatever nature and all adjustments to the Physician schedule. (c). If instructed by the City, the Physician shall change or revise work that has been performed, and if such work is not required as a result of error, omission or negligence of the Physician, the Physician may be entitled to additional compensation. The Physician must submit for City approval a revised proposal with a revised fee quotation. Additional compensation, if any, shall be agreed upon before commencement of any such additional work and shall be incorporated into the work by Change Order to the Work Order. Section 22: Compensation. (a). Compensation to the Physician for the services set forth in the RFP shall be in accordance with the fee schedule as set forth in Exhibit "D ".. (b). Compensation to the Physician for the services performed on each Work Order shall be as set forth the Work Order /Change Order. (c). The City shall not pay for reimbursable items such as gas, tolls, mileage, meals, etc. and other items not directly attritbutable to items produced for each Work Order. (d). Work performed by the Physician without written approval by the City's designated representative shall not be compensated. Any work performed by the Physician without approval by the City is performed at the Physician's own election. (e). In the event the City fails to provide compensation underthe terms and conditions of this Agreement, the Physician shall notify the City's designated representative in orderthat the City may take remedial action. Section 23: Invoice Process. (a). Payments shall be made by the City to the Physician when requested as work progresses for services furnished, but not more than once monthly. Each Work Order shall be invoiced separately. The Physician shall render to the City, at the close of each 17 Physicians Services Agreement — General Medical Services calendar month, an itemized invoice properly dated, describing all services rendered as Exhibit "B ", the Project Status Report Form, the cost of the services, the name and address of the Physician, Work Order Number, Contract Number and all other information required by this Agreement. (b). Invoices which are in an acceptable form to the City and without disputable items will be processed for payment within thirty (30) days of receipt by the City. (c). The Physician will be notified of any disputable items contained in invoices submitted by the Physician within fifteen (15) days of receipt by the City with an explanation of the deficiencies. (d). The City and the Physician will make every effort to resolve all disputable items contained in the Physician's invoices. (e). Each invoice shall reference this Agreement, the appropriate Work Order and Change Order if applicable, the billing period, and include the Project Status Report for the period being billed. A Project Status Report form is attached as Exhibit "B ". (f). The Florida Prompt Payment Act shall apply when applicable. (g). Invoices are to be forwarded directly to: Finance Director City Hall City of Sanford 300 North Park Avenue Sanford, Florida 32771 Section 24: Termination Of Agreement. (a). The City may terminate this Agreement or any Work Order for convenience at any time. (b). The City may also terminate this Agreement or any Work Order for one or more of the reasons as follows: (1). If, in the City's opinion, adequate progress under this Agreement, or a Work Order, is not being made by the Physician; or (2). If, in the City's opinion, the quality of the services provided by the Physician is /are not in conformance with commonly accepted professional standards, standards of the City, the requirements of Federal or State regulatory agencies, and the Physician has not corrected such deficiencies in a timely manner as reasonably determined by the City; or 18 Physicians Services Agreement — General Medical Services (3). The Physician or any employee or agent of the Physician is indicted or has a direct charge issued against him for any crime arising out of or in conjunction with any work that has been performed by the Physician; or (4). The Physician becomes involved in either voluntary or involuntary bankruptcy proceedings, or makes an assignment for the benefit of creditors; or (5). The Physician violates the standards of conduct provisions herein or any provision of State or local law or any provision of the City's ethical rules or codes of conduct. (c). In the event of any of the causes described in this Section, the City's designated representative may send a certified letter requesting that the Physician show cause why the Agreement or any Work Order should not be terminated. If assurance satisfactory to the City of corrective measures to be made within a reasonable time is not given to the City within fourteen (14) calendar days of the receipt of the letter, the City may consider the Physician to be in default, and may immediately terminate this Agreement or any Work Order in progress under this Agreement. (d). In the event that this Agreement or a Work Order is terminated for cause and it is later determined that the cause does not exist, then this Agreement or the Work Order shall be deemed terminated for convenience by the City and the City shall have the right to so terminate this Agreement without any recourse by the Physician. (e). Termination for convenience shall occur upon fifteen (15) days advance notice consistent with the notice provisions of this Agreement or immediately if the City determines that such termination is necessary to protect the public health, safety or welfare. Section 25: Termination By Physician For Cause. (a). The Physician may terminate this Agreement if: (1). The City materially fails to meet its obligations and responsibilities as contained in Section 14; City Rights and Responsibilities; or (2). The City fails to pay the Physician in accordance with this Agreement. (b). In the event of either of the causes described in Subsection (a), the Physician shall send a certified letter requesting that the City show cause why the Agreement should not be terminated. If adequate assurances are not given to the Physician within fourteen (14) calendar days of the receipt of said show cause notice, the Physician may consider the City to be in default and may immediately terminate this Agreement. Section 26: Termination By The City Without Cause. 19 Physicians Services Agreement — General Medical Services (a). Notwithstanding any other provision of this Agreement, the City shall have the right at any time to terminate this Agreement in its entirety without cause, or terminate any specific Work Order without cause, if such termination is deemed by the City to be in the public interest, provided that fifteen (15) calendar days prior written notice is given to the Physician of the City's intent to terminate. (b). In the event that this Agreement is terminated, the City shall identify any specific Work Order(s) being terminated and the specific Work Order(s) to be continued to completion pursuant to the provisions of this Agreement. (c). This Agreement will remain in full force and effect as to all authorized Work Order(s) that is /are to be continued to completion. Section 27: Payment In The Event Of Termination. In the event this Agreement or any Work Order is terminated or canceled prior to final completion payment for the unpaid portion of the services provided by the Physician to the date of termination and any additional services shall be paid to the Physician. Section 28: Action Following Termination. Upon receipt of notice of termination, given by either party, the terminated party shall promptly discontinue the provision of all services, unless the notice provides otherwise. Section 29: Suspension. (a). The performance or provision of the Physician services under this Agreement or any Work Order under this Agreement may be suspended by the City at any time. (b). In the event the City suspends the performance or provision of the Physician's services hereunder, the City shall so notify the Physician in writing. Such suspension becoming effective upon the date stated in the notice. The City shall pay to the Physician within thirty (30) days all compensation which has become due to and payable to the Physician to the effective date of such suspension. The City shall thereafter have no further obligation for payment to the Physician for the suspended provision of services unless and until the City's designated representative notifies the Physician in writing that the provision of the services of the Physician called for hereunder are to be resumed by the Physician. (c). Upon receipt of written notice from the City that the Physician's provision of services hereunder are to be resumed, the Physician shall continue to provide the services to the City. Section 30: Alternative Dispute Resolution (ADR). 20 Physicians Services Agreement — General Medical Services (a) In the event of a dispute related to any performance or payment obligation arising under this Agreement, the parties agree to exhaust any alternative dispute resolution procedures reasonably imposed by the City prior to filing suit or otherwise pursuing legal remedies. (b) The Physician agrees that it will file no suit or otherwise pursue legal remedies based on facts or evidentiary materials that were not presented for consideration to the City in alternative dispute resolution procedures or which the Physician had knowledge and failed to present during the City procedures. (c). In the event that City procedures are exhausted and a suit is filed or legal remedies are otherwise pursued, the parties shall exercise best efforts to resolve disputes through voluntary mediation. Mediator selection and the procedures to be employed in voluntary mediation shall be mutually acceptable to the parties. Costs of voluntary mediation shall be shared equally among the parties participating in the mediation. Section 31: Severability /Construction. (a). If any term, provision or condition contained in this Agreement shall, to any extent, be held invalid or unenforceable, the remainder of this Agreement, or the application of such term, provision or condition to persons or circumstances other than those in respect of which it is invalid or unenforceable, shall not be affected thereby, and each term, provision, and condition of this Agreement shall be valid and enforceable to the fullest extent permitted by law when consistent with equity and the public interest. (b). All provisions of this Agreement shall be read and applied in pari materia with all other provisions hereof. (c). Violation of this Agreement by the Physician is recognized by the parties to constitute irreparable harm to the City. (d). The use of the term "Work Order" shall also mean "Purchase Order" in this Agreement when appropriate in the context and, likewise, the terms "work" or "services" shall include the provision of goods in the appropriate context. Section 32: Controlling Laws/Venue /Interpretation. (a). This Agreement shall be governed by the laws of the State of Florida. (b). Venue for any legal proceeding related to this Agreement shall be in the Eighteenth Judicial Circuit Court in and for Seminole County, Florida. (c). This Agreement is the result of bona fide arms length negotiations between the City and the Physician and all parties have contributed substantially and materially to the preparation of the Contract. Accordingly, this Agreement shall not be construed or interpreted more strictly against any one party than against any other party. 21 Physicians Services Agreement — General Medical Services Section 33: Indemnity. (a). To the fullest extent permitted by law, the Physician shall indemnify, hold harmless, and defend the City, its agents, servants, officers, officials, and employees, or any of them, from and against any and all claims, damages, losses, and expenses including, but not limited to, attorneys fees and other legal costs such as those for paralegal, investigative, and legal support services, and the actual costs incurred for expert witness testimony arising out of or resulting from the performance or provision of services required under this Agreement, provided that same is caused in whole or part by the error, omission, negligent act, failure to act, malfeasance, misfeasance, conduct, or misconduct of the Physician, its agents, servants, officers, officials, employees, or subcontractors. The City does not waive its right to assert consquential damages against the Physician. (b). In accordance with Section 725.06, Florida Statutes, adequate consideration has been provided to the Physician for this obligation, the receipt and sufficiency of which is hereby specifically acknowledged. (c). Nothing herein shall be deemed to affect the rights, privileges, and immunities of the City as set forth in Section 768.28, Florida Statutes. (d). In claims against any person or entity indemnified under this Section by an employee of the Physician or its agents or subcontractors, anyone directly or indirectly employed by them or anyone for whose acts they may be liable, the indemnification obligation under this Section shall not be limited by a limitation on amount or type of damages, compensation, or benefits payable by or for the Physician or its agents or subcontractors, under workers compensation acts, disability benefits acts, or other employee benefit acts. (e). The execution of this Agreement by the Physician shall obligate the Physician to comply with the indemnification provision in this Agreement; provided, however, that the Physician shall also comply with the provisions of this Agreement relating to insurance coverages. Section 34: Insurance. (a). The Physician shall obtain or possess and continuously maintain the following insurance coverage, from a company or companies, with a Best Rating of A- or better, authorized to do business in the State of Florida and in a form acceptable to the City and with only such terms and conditions as may be acceptable to the City: (1). Workers Compensation /Employer Liability: The Physician shall provide Worker Compensation insurance for all employees engaged in the work under this Agreement in accordance with the laws of the State of Florida. Employers' Liability Insurance shall be provided with limits not less than the following: 22 Physicians Services Agreement — General Medical Services $100,000 Each Accident $100,000 Disease Each Employee $500,000 Disease Aggregate (2). Comprehensive General Liability: The Physician shall provide coverage for all operations including, but not limited to, contractual, independent Physician, products and complete operations and personal injury with limits, coverage and form acceptable to the City. (3). Comprehensive Business Automobile Liability: If required by the City, the Physician shall provide complete coverage with a combined single limit with limits, coverage and form acceptable to the City. (4). Professional Liability: The Physician shall provide professional liability insurance as well as errors and omission insurance in limits, coverage and form acceptable to the City protecting the Physician against claims of the City for negligence, errors, mistakes, or omissions in the performance of services to be performed and furnished by the Physician. (5) Other Required Insurance Coverage: Where unusual operations are necessary to complete the work, such as Longshoremen and Harbor Workers' Exposures, use of aircraft or watercraft, use of explosives, and any high risk circumstances. No aircraft, watercraft or explosives shall be used without the express advance written approval of the City which may, thereupon, required additional insurance coverages. (b). All insurance other than Workers Compensation and Professional Liability that must be maintained by the Physician shall specifically include the City as an additional insured. All insurance minimum coverages extend to any subcontractor, and the Physician shall be responsible for all subcontractors. The Physician shall ensure that the City is named as an insured party in each pertinent insurance policy. (c). The Physician shall provide Certificates of Insurance to the City evidencing that all such insurance is in effect prior to the issuance of the first Work Order under this Agreement. These Certificates of Insurance shall become part of this Agreement. Neither approval by the City nor failure to disapprove the insurance furnished by a Physician shall relieve the Physician of the Physician's full responsibility for performance of any obligation including the Physician's indemnification of the City under this Agreement. If, during the period which an insurance company is providing the insurance coverage required by this Agreement, an insurance company shall: (1) lose its Certificate of Authority, (2) no longer comply with Section 440.57, Florida Statutes, or (3) fail to maintain the requisite Best's Rating and Financial Size Category, the Physician shall, as soon as the Physician has knowledge of any such circumstance, immediately notify the City and immediately replace the insurance coverage provided by the insurance company with a different insurance company meeting the requirements of this Agreement. Until such time as the Physician 23 Physicians Services Agreement — General Medical Services has replaced the unacceptable insurer with an insurer acceptable to the City, the Physician shall be deemed to be in default of this Agreement. (d). The insurance coverage shall contain a provision that requires that prior to any changes in the coverage, except increases in aggregate coverage, thirty days prior notice will be given to the City by submission of a new Certificate of Insurance and appropriate policy modification. (e). The Physician shall provide Certificate of Insurance directly to the City's designated representative. The certificates shall clearly indicate that the Physician has obtained insurance of the type, amount, and classification required by this Agreement. (f). Nothing in this Agreement or any action relating to this Agreement shall be construed as the City waiver of sovereign immunity beyond the limits set forth in Section 768.28, Florida Statutes. (g). The City shall not be obligated or liable under the terms of this Agreement to any party other than the Physician. There are no third party beneficiaries to this Agreement. (h). The Physician is an independent Physician and not an agent, representative, or employee of the City. The City shall have no liability except as specifically provided in this Agreement. (i). All insurance shall be primary to, and not contribute with, any insurance or self - insurance maintained by the City. Q). The provision of insurance coverage shall not in any way cause the Physician's indemnification of the City to be reduced in any way or in any respect. Section 35: Equal Opportunity Em ployment/Non- Discrimination. The Physician agrees that it will not discriminate against any employee or applicant for employment for work under this Agreement because of race, color, religion, sex, age, national origin, or disability and shall take affirmative steps to ensure that applicants are employed and employees are treated during employment without regard to race, color, religion, sex, age, national origin, or disability. This provision shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment advertising; layoff or termination; rates of pay or their forms or compensation; and selection for training, including apprenticeship. The Physician, moreover, shall comply with all the requirements as imposed by the Americans with Disability Act, the regulations of the Federal government issued thereunder, and any and all requirements of Federal or State law related thereto. Section 36: Access To Records /Audit/Public Records. 24 Physicians Services Agreement — General Medical Services (a). The Physician shall maintain books, records, documents, time and costs accounts, and other evidence directly related to its provision or performance of services under this Agreement. All time records and cost data shall be maintained in accordance with generally accepted accounting principles. (b). The Physician shall maintain and allow access to the records required under this Section for a minimum period of five (5) years after the completion of the provision or performance services under this Agreement and date of final payment for said services, or date of termination of this Agreement. (c). The City reserves the right to unilaterally terminate this Agreement if the Physician refuses to allow public access to all documents, papers, letters, or other materials subject to provisions of Chapter 119, Florida Statutes, and other applicable law, and made or received by the Physician in conjunction, in any way, with this Agreement. (d). The City may perform, or cause to have performed, an audit of the records of the Physician before or after final payment to support final payment under any Work Order issued hereunder. This audit shall be performed at a time mutually agreeable to the Physician and the City subsequent to the close of the final fiscal period in which services are provided or performed. Total compensation to the Physician may be determined subsequent to an audit as provided for in this Section, and the total compensation so determined shall be used to calculate final payment to the Physician. Conduct of this audit shall not delay final payment as required by this Section. (e). In addition to the above, if Federal, State, County, or other entity funds are used for any services under this Agreement, the Comptroller General of the United States or the Chief Financial Officer of the State of Florida, or the County of Seminole, or any representative, shall have access to any books, documents, papers, and records of the Physician which are directly pertinent to services provided or performed under this Agreement for purposes of making audit, examination, excerpts, and transcriptions. (f). In the event of any audit or inspection conducted reveals any overpayment by the City under the terms of the Agreement, the Physician shall refund such overpayment to the City within thirty (30) days of notice by the City of the request for the refund. (g). The Physician agrees to fully comply with all State laws relating to public records. (h). The Physician agrees that if any litigation, claim, or audit is started before the expiration of the record retention period established above, the records shall be retained until all litigation, claims, or audit findings involving the records have been resolved and final action taken. Section 37: Counterparts. 25 Physicians Services Agreement — General Medical Services This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, but all of which, taken together, shall constitute one and the same document. Section 38: Submittals. This Agreement describes each item that must be provided by the Physician to the City. All documents provided to the City by the Physician must be accurate and updated certifying that the Physician is proceeding correctly. Section 39: Exhibits. Each exhibit referred to and attached to this Agreement is an essential part of this Agreement. The exhibits and any amendments or revisions thereto, even if not physically attached hereto, shall be treated as if they are part of this Agreement. In Witness Whereof, the parties hereto have made and executed this Agreement on the respective dates under each signature with the City acting through its City Commission and the Physician signing by and through its duly authorized corporate officer having the full and complete authority to execute same. Attest. North Seminole Family Pr�c�ice Services Associates/ P. A. Ivv � enise McCabe , NSFP Office Manager James t E. ,Quinn NSFP resident Date: Attest. 46 net Dougherty, Cit Clerk For use and reliance of the Sanford City Commission only. AtmroAil as to form and leaak y Attorney OAMIG A , 6t a &A City Of Sanford Linda Ku , Mayor Date: l '411a 26 Physicians Services Agreement — General Medical Services CITY OF SANFORD EXHIBIT "B" PROJECT STATUS REPORT Project Name: Project Manager: Status Report Period; From: To: Phase: Planning ❑ Design ❑ Bidding ❑ Construction ❑ 1. In paragraph form, list the current status of the project and work completed this Billing Period. 2. In paragraph form, list all milestones reached this Billing Period. 3. In paragraph form, list any pending issues or items of note. Project Manager Signature: Date: 27 Physicians Services Agreement — General Medical Services Phone: (407) 321 -4230 Fax: (407)324 -7642 Tax ID 59- 2634830 May S, 201.0 City of Sanford Florida Attn: Fred Fosson RE: Fee Schedule Dear Fred, PAGE 01 Attached. for your review is the price list that was forwarded to us with regard to the City of Sanford Bid for Physician. Services. As has been the case in the past, our facility will be unable to provide initial exposure counseling, but will be available to do the follow up visits as needed. In addition, we will be unable to provide random DOT, Chain of Custody, Pre - Employ and Post Accident drug screen as well as Breath Alcohol Testing, as these require the involvement of a Medical Review Officer. Please note that these prices will remain in effect for a period of one year and will be revised annually on the first week of ,Tune. At that time they will be re- adjusted based on any increase -reflected on the consumer price index summary for May of that year. (Any cost of living increase will have a 3% cap. This is unchanged from previous years.) As always, we look forward to continuing the relationship that has been built between. North Seminole Family Practice and the City of Sanford, for more than the past two decades. Sincerely, Denise H. McCabe Office Manager 05/05/2010 10:10 4073247642 N SEM FAMILY PRACTIC North Seminole Family Practice .Associates P,A, 2209 S French Avenue Sanford, Florida 32771 05/05/2010 10:10 4073247642 N SEM FAMILY PRACTIC PAGE 02 City of Sanford Physician. Services -RFQ 09/10 -07 Cost Sheet Routine Pre - Employment Physical Evaluation $ r 7 0. J Routine Fitness for Duty Physical Evaluations 6 j Typical Law Enforcernent/Fire Fighter Physical Evaluation -- Typica] Law EnforcemenUFi.re Fighter Fitness for Duty Eval. $ 9a - EKG FDLE Lab Work $ 2/ . — Hepatitis injection. $ !R Seasonal Flu Shot: roviders location At l p $ G1'`o�.r�•c. o•..c.C.ev� � r� At City site $ TB Exclusionary Testing Hepatitis Exclusionary Testing $ r > - a Audiometric Testing $ Medical Clearance for Respirator. Use $ 1?0 .�- Lumbar X -Ray (`Fv - *iews ) $ Drug Screening (5 panel): $ n I Drug Screening (10 Panel) $ / l,�a Drug Screening Rapid Test (preliminary before MRO review) $ r A (not all employees subject to this, primarily Public Safety, but others at times) Breath Alcohol Testing $ �A 1 Blood Alcohol Testing ,Administration of DOT Raindom Testing List $ /I l Significant Exposure Counseling Diabetes Testing: -� ►^17/ S�-t� k location, $ r At providers , At City site'• North Seminole Family Practice Associates PA 2209 S French Avenue Sanford, Florida 32771 Phone: (407) 321 -4230 Fax: (407)324 -7642 April 15, 2010 Respectfully Submitting Proposal For: Solicitation Number: RFQ 09/10 -07 Physician Services — General Due Date and Time: April 19, 2010 at 2:00pm North Seminole Family Practice Associates PA 2209 S French Avenue Sanford, Florida 32771 Phone: (407) 321 -4230 Fax: (407)324 -7642 April 15, 2010 City of Sanford Florida ATTN: F. William Smith, Purchasing Agent RE: Proposal for Physician Services — General / RFQ 09/10 -07 Dear Mr. Smith, North Seminole Family Practice Associates PA is a medical facility that has been responding to the medical needs of the Sanford Community since 1983. We have three Board Certified Family Practice physicians. Dr. James Quinn has 26 years of relevant experience as he has been in private practice here in Sanford since 1983. Dr. Harvey Schefsky has been a primary care physician for 36 years and has been in private practice here in Sanford since 1994. Dr. Daniel Monette has been in practice here in Sanford for 8 years. Together they have over 70 years of combined experience in medicine. North Seminole Family Practice Associates PA currently employs 13 medical assistants (including 5 certified X -ray technicians and a Registered Nurse) along with nine administrative personnel who strive to maintain the business functions of this office. This facility currently performs in- office testing which includes but is not limited to x -rays, EKG's, phlebotomy, physician performed urinalysis, laceration repairs, excisions and minor surgeries, annual physicals, immunizations and illness evaluations. We are more than prepared to handle your work comp injuries with ease. We offer same day appointments for any initial work comp injury. We have successfully provided medical care and offered medical recommendations to the City of Sanford and its employees for over 20 years and look forward to continuing this relationship. Please feel free to contact me with any questions or concerns. Sincerely, J es E. Qui , M.D. James E. Guinn, nD. Curriculum Vitae Date of Birth 2 -18 -51 LOCATION: Cleveland, Ohio COLLEGE: Ohio State University 1969 to 1973 Social Sciences; B.A. Medical College of Ohio at Toledo 1973 to 1976 M.D., Lange Book Award INTERNSHIP: Naval Aerospace Regional Medical Center ( NARMC) 1976 to 1977 FAMILY PRACTICE RESIDENCY: Naval Aerospace Regional Medical Center 1977 to 1979 Board Certified in Family Medicine 1979 FAMILY PRACTICE TEACHING STAFF: Naval Aerospace Regional Medical Center 1979 to 1982 A. Clinic Supervisor B. Intern Coordinator C. ACLS Instructor and Course Director for NARMC D. Teacher in the NARMC MIT, BCLS, ICU and Alcohol Rehabilitation Program. E. Teacher of the Year NARMC Family Practice Residency 1979 to 1980 Past Chariman Emergency Cardiac Care Committee of the AHA for the Panhandle Region 1982 -1983 Trauma Physician at Sacred Heart Hospital Trauma Center - Pensacola, Florida October 1983 - Present Private Family Practice - Sanford, Florida HOSPITAL PRIVILEGES Columbia Medical Center - Sanford, Florida AHA ACLS Affiliate Faculty for the State of Florida Team Physician for Seminole High School 1983 -1994 (Volunteer) Seminole County Medical Society - President 1987 Friends of the St. Johns - Board of Directors Sanford Unit AHA - President Lakeview Nursing Home - Medical Director 1984- 1997 Seminole County School - Partners in Excellence All Souls School - Board Member 1988 -1994 / Chairman 1994 -1995 Sanford Rotary - Board of Directors 1987 -1992 / President 1990 -1991 Chamber of Commerce - Executive Committee / Board of Directors Central Florida Integrated Physicians Assoc. - Chairman of the Board & President Central Florida Regional Hospital - Chairman of Family Practice Dept 1985 & 1998 / Board of Trustees 1985 -1998 / Chief of Staff 1991 / Chairman of Credentials Committee 1992 -1997 / Vice Chairman 1995 I Chairman of the Board 1995 -1998 Harvey W. Schefsky B.S. Ohio State University 1962 M.S. University of Wisconsin 1963 M.D. Ohio State University 1968 Rotating Internship, U.S. Naval Hospital Jacksonville, Florida 1968 -69 Family Practice Residency, U.S. Naval Hospital Jacksonville, Florida 1969 -71 Chief of Family Practice, U.S. Naval Hospital Memphis, Tennessee 1971 -74 Family Practice, Deltona, Florida Emergency Room Physician, Central Florida Regional Hospital, Sanford, Florida Family Practice, Sanford, Florida President, Seminole County Medical Society Secretary/Treasurer, Central Florida Regional Hospital, Sanford, Florida Vice Chief of Staff Central Florida Regional Hospital, Sanford, Florida Chief of StafL Central Florida Regional Hospital Sanford, Florida Board Certified A.B.F.P. Member A.A.F.P. Member F.A.F.P. Member F.M.A. Member A.O.A. Medical Society Member F.P.A. Member A.C.E.P. 1974 -91 1991 -94 1994- present 1988 1989 1990 1572 Shadowmoss Circle Lake Mary, FL. 32746 Phone (407)333 -1914 E -mail drmonette( )hotmail coot Daniel R. Monette, M.D., CAQSM Education Teaching and Professional Activities Publications/ Projects/ Presentations 7/01 — 7/02 Halifax Medical Center, Sports Medicine Fellowship Daytona Beach, Florida BC Sports Medicine, April 2003 7/98 — 7/01 Catholic Health Care West, St. Joseph's Family Practice Residency Phoenix, Arizona BC Family Practice, July 2001 8/94 — 5/98 University of Colorado Health Sciences Center Denver, Colorado Medical Doctorate, May 1998 8/90 — 5/94 University of Colorado at Boulder Boulder, Colorado Bachelor of Arts, African American Studies, May 1994 2003 - Pres. Associate Clinical Professor Florida State University 2001 - 2002 Preceptor for Residents and Students in Sports and Family Medicine 2000-2001 Co -Chief Family Practice Resident 2000-2001 Catholic Health Care West Leadership Committee 1999-2001 Family Practice Clinical Operations Committee 1999-2001 CHW Family Practice Admissions Committee 1995- 1998 Medical Student Council Representative 2003 Overuse Injuries, 2002 Knee Exam Workshop, Conference on the Beach 2001 Head and Neck Injuries, Annual Volusia County Coaches Workshop 2000 Preparticipation Exams, Family Practice Grand Rounds 1998 Jones Fractures, Orthopedic Grand Rounds 1998 Osteoporosis lecture, O.B. Grand Rounds 1997 - 1998 "Total Knee Arthroplasty in Hemophilia Patients: Long -Term Follow- Up." Submission to The Journal of Bone and Joint Surgery 1995 - 1996 NIH project with University of Colorado Sports Medicine, "Clinical vs. Surgical Evaluation of Chondromalacia Patella" Professional Memberships Sports Medicine Activities 2002 - Present American Medical Society for Sports Medicine 1999 - Present American Medical Association 1998 - Present American Academy of Family Physicians 2002 - Pres, University of Central Florida Team Physician 2002 - Pres. Seminole High School Team Physician 2003 - Pres. Seminole Community College Team Physician 2001 - 2002 Bethune Cookman College Team Physician 2001 - 2002 Embny Riddle Aeronautical University Team Physician 2001 - 2002 Daytona Beach Community College Team Physician 2001 - 2002 Daytona International Speedway Attending Physician 2001 - 2002 Atlantic High School Team Physician 1998 - 2001 Bourgade Catholic High School Team Physician 2000 - 2001 Coordinator for Resident coverage of High School sports 1999 - 2002 Physicals for High School, College, and Professional Athletes 1999 NASCAR Spectator Urgent Care Physician at P.I.R. EXtraWrrlcular Medical 2001 — 2002 Attending Physician for Exercise Treadmills, Halifax Medical Ctr. Activities 2001 - 2002 Moonlight Halifax Medical Center 2000 - 2001 Moonlighting St. Joseph's Emergency Department 2000 - 2001 Moonlighting Coordinator with E.D. Director Awards Received Voted 2006 Best Doctor in Seminole County Atlantic High School community service award Bourgade Catholic High School community service award Sachs Foundation Scholarship recipient Colorado Masonic Benevolent Scholarship Foundation Recipient University of Colorado, Arnold Weber Scholarship Recipient Golden Key National Honor Society Employment 2002 - Pres. North Seminole Family Practice and Sports Medicine 2209 French Avenue Sanford, FL, 32771 STATE AGE 57 cni OF D .....A:RT.MENT.!�7F. DIV ISION PF MEDICAL QUAL**ITY.ASSURANr.r- The MEDICAL. DOCT :..: .. .... : % .; : . . ..... 6 e .. . s - m W . b name 10 ha ki ali� requirements 'of DATE LI CENSE NO 0 1/08/2009 ME31886- TE SU < m� z C) O XT o D - n x m c m 0 D < r Dz D cn E3 c z� O� m� O z° G) K . z b M - D� D ND X � CD > — W o cn _ � m v 0 C D z N < m CD CD � r v V m m -4 z rn m 0 r €".':D �m7D J v --q CA > v CD N m C D m CD CD CD fn < - C O z W°� n O� "0 cn U) N O O _ r v ;o > N — g 0 M m z N C/) o m N z to O (; 0 w z N 0' z O o .9 m m O r z .,, p0 D O �D� D r . D C/)� C D z n m I ✓LOROA F DE W :e kk 0 HEALTH DIVISION OF-MEDICAL QUALITY. ..ASSURANCE : DATE t ICENSE C 0. Po 01/08/2000 ME 813013 272170 DISPLAY LAW Submission Form PART 1 General 1.01 Description The following Request for Statements of Qualifications, for the 1 RFQ 09/10 -07 Physicians Services - General This Response is submitted by (2) () orb y_m, Halt +�+ Pro- -4, 4 Ot cra PA 1.02 The Undersigned: A. Acknowledges receipt of: Addenda: Number Dated Number Dated B. Has examined the Solicitation Documents and understands that in submitting his /her Response, he /she waives all right to plead any misunderstanding regarding the same. C. Understands that the responsibility for delivering the submission to the City on or before the specified date and time will be solely and strictly the responsibility of the Respondent. The City will not be responsible for delays; caused by the United States Postal Office or a delay caused by any other occurrence. Offers by telephone, fax, email or other electronic means will not be accepted. It is understood that any deviation from a completed, signed (original signatures) proposal delivered on or before the designated time, date and place, as provided herein, to the City will be resolved against the individual or firm submitting the response. D. Agrees: 1. To hold this Offer open for 60 calendar days after the opening date. 2. By signing this document the responding individual or firm hereby agrees to negotiate in good faith, to be bound by specifications, terms, conditions, scheduling, pricing and representations as stated and submitted with this form and /or as established by subsequent negotiations. However, it is understood that the City, reserves the right to declare any submission nonresponsive if exceptions to specifications, terms, conditions, etc. of the solicitation are not acceptable in the opinion of the City to meet the requirements of said solicitation. 3. To enter into and execute a contract with the City, if awarded on the basis of this Offer and /or subsequent negotiations agreed lupon by the City and the Bidder /Proposer. RFQ 09/10 -07 Physicians Services - General. 1 A01 -32.1- 4 ' - I o - I -3a4 -- 0 (1) Title and Solicitation number as shown in the Invitation (2) Name, address, telephone, fax number and email of Proposer. 4. To accomplish the work or service in accordance with any Contract resulting from this request. 1.03 Miscellaneous Requirements and Affirmations Statements of Qualifications shall be submitted using the attached forms and in compliance with the instructions provided with this request. • Number of originals and complete copies to submit: GL�,a�t� a. One original and 4 copies and an electronic disc in pdf format all in one package, to City of Sanford as indicated below- see items 2 and 3 of the solicitation for details. 1.04 Protests Protests, if any, shall be submitted in compliance with City of Sanford Purchasing Policy in all respects. Failure to file protest to the Purchasing Manager within the requirements a and time prescribed by the City's Purchasing Policy, shall constitute a waiver of proceedings. 1.05 SUBMITTED, signed an sealed this day of A or ► � o I O 0y Bidder /Propo er By (Signatu ) Date Printed Name and Title Corporate /Company Seal On the Envelope Containing Your Submission: The Return address — Your Company Name and Address Address or Deliver To: William Smith, Purchasing Manager City of Sanford P.O. Box 1788 (300 N. Park Avenue, Room 236) Sanford, FL 32772 In the Lower Left Corner of the Envelope, Provide the Following: RFQ Number: RFQ 09/10 -07 Physicians Services - General Open Date: April 19, 2010 Open Time: 2:00 p.m. (Nonpublic Opening) This Form Must Be Completed and Returned with your Submission RFQ 09/10 -07 Physicians Services - General. Disputes Disclosure Form Answer the following questions by answering "YES" or "NO ". If you answer "YES ", please explain in the space provided, please add a page(s) if additional space is needed. 1. Has your firm, or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulation or any other regulatory agency or professional association within the last five (5) years? 00 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? n D 3. Has your firm had filed against it or filed any requests for equitable adjustment, contract claims or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? n D If yes, the explanation must state the nature of the request for equitable adjustment, contract claim or litigation, a brief description of the case, the outcome or status of suit and the monetary amounts or extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation or falsification of facts shall be cause for forfeiture of rights for further consideration of the project identified. rm re o y I I sO a o)o Date C rr P re ss Printed or Typed Name and Title FORM NO. DSPT 12.204 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -07 Physicians Services - General. Drug -Free Work Place The undersigned, in accordance with Florida Statute 287.087 hereby certifies that the company named below does: 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the commodities or contractual services that are proposed a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later : than five (5) days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug -free workplace through implementation of this section. P t - V` 1.1 Sian Date _ Pr e Printed or Typed Name and Title FORM NO. DFWP 14.204 This Form Must Be Completed and Returned with your Submission irm O LA I 'S i 1x- 0 10 RFQ 09/10 -07 Physicians Services - General. Conflict of Interest Statement 1. �p� ��, nyN of �t5� �rn� rwlR ^^� 1'"ra" ce deposes and states that Name of Affiant Name of Company 2. The above named entity is submitting an Expression of Interest for the City of Sanford project identified below. 3. The Affiant has made diligent inquiry and provides the information contained in this Affidavit based upon his own knowledge. 4. The Affiant states that only one submittal for the above project is being submitted and that the above named entity has no financial interest in other entities submitting proposals for the same project. 5. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in connection with the entity's submittal for the above project. This statement restricts the discussion of pricing data until the completion of negotiations and execution of the Agreement for this project. 6. Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participating in contract lettings by any local, state, or federal agency. 7. Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 8. 1 certify that no member of the entity's ownership, management, or staff has a vested interest in any aspect of or Department of the City of Sanford. 9. 1 certify that no member of the entity's ownership or management is presently applying for an employee position or actively seeking an elected position with City of Sanford. 10. In the event that a conflictnterest is identified in the provision of services, I, on behalf of the above named entity, will immedi tel notify the City of Sanford in writing. W` P / l Signature of Affiant Date 0 Typed or Printed Name of Affiant Title State of Florida, County of On this I S day of (�;P� �, 201 D, before me, the undersigned Notary Public of the State of Florida, personally - appeared �!. S0.�rn �l and �Q��S -Z `( (Name(s) of individuals who appeared before notary) whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they executed it. WITNESS my hand and official seal. ARY PUBLI E O ORIDA NOTARY PUBLIC �d e CUnQ.. SEAL OF OFFICE: (Name of Notary Public: Print, Stamp, or Type', as Commissioned.) N"r AIDA CARBONE Notary PAMo - State of Florida . My CW dWon Expiroa Mar 11', 2011 Comndsaron 0 DD 620255 B=WThmugh 11 l NotwyAssn. F N I 78.7)7 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -07 Physicians Services - General. MEMORANDUM FINANCE DEPARTMENT - PURCHASING DIVISION Provide evidence of insurance coverage and levels thereof for: a. General liability b. Auto liability Yl� C. Professional liability d. Workers comp RFQ 09/10 -07 Physicians Services - General. State Farm Florida Insurance Company 7401 Cypress Gardens Blvd. Winter Haven, FL 33888 -0007 V -19- 1924 -F612 0008W NORTH SEMINOLE FAMILY PRACTICE ASSOCIATION PA 2209 S FRENCH AVE SANFORD FL 32771 -4245 Location: 2209 S FRENCH AVE SANFORD FL 32771 -4245 Mortgagee: WACHOVIA MORTGAGE FSB NO 526 ITS SUCCESSORS AND /OR ASSIGNS Loan No: N/A -Print on Paystub Forms, Options, and Endorsements U 3 F Special Form 3 FP -6153 Exterior Signs $4,300 OPT ES Amendatory Endorsement FE 6210.3 Tree Debris Removal FE - 6451 Business Policy Endorsement FE -6464 Physicians and Surgeons FE -6407 Glass Deductible Deletion FE- 6538.1 Hurricane Deductible FE- 6537.4 Fungus (Including Mold) Excl FE - 6566 Subcontractor Pd Exclusion FE -6598 Amendatory Collapse FE - 6839 Inc Cost and Demolition Cov FE - 6587 Continued on back of page RENEWAL CERTIFICATE business- umce roncy NOV 04 2009 to NOV 04 2010 NOV 04 2009 1,221.45 Coverages and Limits Section I A Buildings B Business Personal Property C Loss of Income Deductibles - Section I Basic Hurricane Other deductibles may apply - refer to policy Section II L Business Liability M Medical Payments Gen Aggregate (Other than PCO) Products - Completed Operations (PCO Aggregate) Annual Premium' Forms, Opts, & Endrsmnt Bus Liability - Cove L FL Guaranty Fund 07 Citizen 05 Reg Asmt FL Guaranty Fund EM * *Adl Surchg(See'Below) Amount Due Premium Reductions Renewal Year'Discount Yrs in Business Discount Claim Record Discount Cov. A - Inflation Index: N/A Cov. B - Consumer Price: 220.0 Excluded 129,900 Actual Loss 500 2.00% $500,000 5,000 1,000,000 1,000,000 $830.00 285.00 33.00 22.96 7.69 5.63 37.17 $1,221.45 ** FL Guaranty Fund 4.48 FHCF Assessment 11.48 FL Trust Fund Surchg 1.14 FL EMPA Fund Surcharge 4.00 2005 Citizens EM Asmt 16.07 NOTICE: Information concerning changes in your policy language is included. Please call your agent if you have any questions. 2744 2018 i Agent CLIFF MILLER INS AGENCY INC * S8,S9 TM nhnnn tA07) 490 -ri d.0 If you have moved, please contact your agent. See reverse side for important information. REB Prepared .1L11. 17 POOP ate Farm Florida Insurance Company 7401 Cypress Gardens Blvd. Winter Raven, FL 33868 -0007 V -19- 1924 -F612 000889 QUINN, JAMES E & JOAN 2209 S FRENCH AVE SANFORD FL 32771 -4245 - ocation: 2209 S FRENCH AVE SANFORD FL 32771 -4245 U 3 F Mortgagee: WACHOVIA BANK NA ITS SUCC WOR ASSIGNS ATIMA COMMERCIAL INSURANCE SUPPORT Loan No: 114932929 Forms, Options, and Endorsements FP -6153 Special Form 3 Amendatory Endorsement FE- 6210.3 Tree Debris Removal FE -6451 FE -6464 Business Policy Endorsement FE- 6538.1 Glass Deductible Deletion FE- 6537.4 Hurricane Deductible Fungus (Including Mold) Excl FE -6566 Subcontractor Pd Exclusion FE -6598 FE -6839 Amendatory Collapse Inc Cost and Demolition Cov FE -6587 Policy Endorsement - Business FE -6610 FE -6655 Dist Mat Violat Statues Excl 73.10 7 Continued on back of page $2,935.23 RENEWAL CERTIFICATE Business Vmce —1-Y NOV 04 2009 to NOV 04 2010 NOV 04 2009 $2,935.23 Coverages and Limits Section I A Buildings $683, 500 B Business Personal Property Excluded C Loss of Income Actual Loss Deductibles - Section 1 500 Basic 2.00% Hurricane Other deductibles may apply - refer to policy Section If L Business Liability $500,000 5 000 M Medical Payments Gen Aggregate (Other than PCO) , 1,000,000 Products - Completed Operations 1,000,000 (PCO Aggregate) Annual Premium $2,714.00 50.00 Bus Liability - Cov L 10.78 FL Guaranty Fund 55.28 FL Guaranty Fund 07 18.52 Citizen 05 Reg Asmt 3.55 FL Guaranty Fund EM 73.10 7 * *Adl Surchg(See Below) $2,935.23 Amount Due Premium Reductions Renewal Year Discount Yrs in Business Discount Claim Record Discount Cov. A - Inflation Index: 230.2 Cov. B - Consumer Price: N/A ** FHCF Assessment 27.64 FL Trust Fund Surchg 2.76 FL EMPA Fund Surcharge 4.00 2005 Citizens EM Asmt 38.70 NOTICE: Information concerning changes in your policy language is included. Please call your agent if you have any questions. 2748 2018 I Agent CLIFF MILLER INS AGENCY INC * S8,S9 Tafanhnna (4n7) '199 -.ri1 49 If you, have moved, please contact your agent. See reverse side for important information. REB Prepared JUL 17 2009 First Professionals Insurance Company FIRST PROFESSIONALS INSURANCE COMPANY, INC. MEMORANDUM OF INSURANCE North Seminole Family Practice Associates, P.A. 2209 French Ave. Sanford, FL 32771 POLICY INFORMATION Named Insured: North Seminole Family Practice Associates, P.A. Coverage Applicable To: James E. Quinn, M.D. Policy Number: CL099281 Policy Period: 01/01/2010 to 01/01/2011 Retroactive Date: 03/01/1988 Limits of Liability: $250,000 per claim /$750,000 aggregate Classification: Family Practice - No Surgery Memorandum of Insurance Issue Date: 12/18/2009 First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we have issued a medical professional liability insurance policy to the above named insured with coverage and limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above named insured. SPECIAL NOTICE TO INSURED The Policyholder has been provided a copy of the policy. We recommend that you, as an additional insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully understand the terms, definitions, exclusions, conditions and coverage provided. There may also be endorsements to the policy which should be read carefully because they affect coverage. If you are unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at (904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728. FPIC CONTACT INFORMATION The following information may be used to contact our company: First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728. xet�-- Authorized Representative FPIC -MPL- 103 -FL (12/08) 1000 Riverside Avenue, Suite 800 • Jacksonville, Florida 32204 • (904) 354 -5910 • 1 -800- 741 -3742 • Fax (904) 358 -6728 P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com V & . I P.W First Professionals Insurance Company FIRST PROFESSIONALS INSURANCE COMPANY, INC. MEMORANDUM OF INSURANCE North Seminole Family Practice Associates, P.A. 2209 French Ave. Sanford, FL 32771 POLICY INFORMATION Named Insured: North Seminole Family Practice Associates, P.A. Coverage Applicable To: Harvey W. Schefsky, M.D. Policy Number: CL099281 Policy Period: 01/01/2010 to 01 /01/2011 Retroactive Date: 06/01/1994 Limits of Liability: $250,000 per claim /$750,000 aggregate Classification: Family Practice - No Surgery Memorandum of Insurance Issue Date: 12/18/2009 First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we have issued a medical professional liability insurance policy to the above named insured with coverage and limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above named insured. SPECIAL NOTICE TO INSURED The Policyholder has been provided a copy of the policy. We recommend that you, as an additional insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully understand the terms, definitions, exclusions, conditions and coverage provided. There may also be endorsements to the policy which should be read carefully because they affect coverage. If you are unable to obtain a copy of the policy from the Policyholder, please feel free t6 request a copy of the policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at (904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728. FPIC CONTACT INFORMATION The following information may be used to contact our company: First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728. Authorized Representative FPIC -MPL- 103 -FL (12/08) 1000 Riverside Avenue, Suite 800 • Jacksonville, Florida 32204 • (904) 354 -5910 • 1- 800 - 741 -3742 • Fax (904) 358 -6728 P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com �t. First. Professionals Insurance Company FIRST PROFESSIONALS INSURANCE COMPANY, INC. MEMORANDUM OF INSURANCE North Seminole Family Practice Associates, P.A. 2209 French Ave. Sanford, FL 32771 POLICY INFORMATION Named Insured: North Seminole Family Practice Associates, P.A. Coverage Applicable To: Daniel R. Monette, M.D. Policy Number: CL099281 Policy Period: 01/01/2010 to 01/01/2011 Retroactive Date: 07/15/2002 Limits of Liability: $250,000 per claim /$750,000 aggregate Classification: Family Practice - No Surgery Memorandum of Insurance Issue Date: 12/18/2009 First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we have issued a medical professional liability insurance policy to the above named insured with coverage and limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above named insured. SPECIAL NOTICE TO INSURED The Policyholder has been provided a copy of the policy. We recommend that you, as an additional insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully understand the terms, definitions, exclusions, conditions and coverage provided. There may also be endorsements to the policy which should be read carefully because they affect coverage. If you are unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the policy from us. Such request maybe made: in writing mailed to the address listed below; or by phone at (904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728. FPIC CONTACT INFORMATION The following information may be used to contact our company: First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728. '�Kw Authorized Representative FPIC -MPL- 103 -FL (12/08) 1000 Riverside Avenue, Suite 800 • Jacksonville, Florida 32204 • (904) 354 -5910 • 1- 800 -741 -3742 • Fax (904) 358 -6728 P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com r First Professionals Insurance Company FIRST PROFESSIONALS INSURANCE COMPANY, INC. MEMORANDUM OF INSURANCE North Seminole Family Practice Associates, P.A. 2209 French Ave. Sanford, FL 32771 POLICY INFORMATION Policyholder: North Seminole Family Practice Associates, P.A. Policy Number: CL099281 Policy Period: 01/01/2010 to 01/01/2011 Retroactive Date: 03/01/1988 Limits of Liability: See Schedule Classification: N/A Memorandum of Insurance Issue Date: 12/18/2009 First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we have issued a medical professional liability insurance policy to the above named policyholder with coverage and limits of liability as set forth below for each additional insured. This Memorandum of Insurance shall not be construed in any way whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above named policyholder. State License Number Name of Additional Insured C9281 North Seminole Family Practice Associates, P.A. 83013 Daniel R. Monette, M.D. 31886 James E. Quinn, M.D. 20023 Harvey W. Schefsky, M.D. Limits of Liability Per Claim /Aggregate $250,000/$750,000 $250,000/$750,000 $250,000/$750,000 $250,000/$750,000 Retroactive Date 03/01/1988 07/15/2002 03/01/1988 06/01/1994 FPIC CONTACT INFORMATION The following information may be used to contact our company: First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728. X vo Authorized Representative FPIC -MPL -I 10 -FL (12/08) 1000 Riverside Avenue, Suite 800 • Jacksonville, Florida 32204 • (904) 354 -591.0 • 1- 800 -741 -3742 • Fax (904) 358 -6728 P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com POLICY INFORMATION PAGE WC 00 00 01 A Insurer: POLICY NO. Comp Options Insurance Company, Inc. d /b /a OptaComp 01CA1- 219D520 -01 P. O. Box 44291 Jacksonville, FL 32231 -4291 _ Individual _ Partnership 1. The Insured: North Seminole Family Practice Associates, PA X Corporation or Mailing address: 2209 S. French Avenue Sanford, FL 32771 Other workplaces not shown above: 2. The Policy Period is from 19- Mar -10 to 19- Mar -11 12:01 A.M. at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: FL B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 each accident Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: WC 99 06 03, WC 00 04 02, WC 00 04 06 A, WC 00 04 14, WC 09 06 06, WC 09 04 03 A, WC 00 03 08 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. REFER TO CLASSIFICATION SCHEDULE WC 99 06 03 Premium Basis Rate Per Estimated Code Total Estimated $100 of Annual Classifications No. Annual Remuneration Remuneration Premium Total Estimated Annual Premium $2,270 Minimum Premium $235 Expense Constant 00 . Countersigned by: WC 00 00 01 A (Ed. 5 -88) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY tem 4 of the Information Page is amended to include the following classifications. CLASSIFICATION SCHEDULE Classifications Code Premium Basis Rate Per No. Total Estimated $100 of Annual Remuneration Remuneration Physician and clerical 8832 $492,758 0.4 Total Manual Premium Increased Employer Limits Deductible Credit Drug Free Discount 0.95 Safety Program Credit 0.98 Total Estimated Annual Standard Premium Experience Modification 1.00 Modified Premium FCCAP Credit Premium Discount Expense Constant Terrorism Risk Insurance Act 2002 Total Estimated Premium WC 99 06 03 (Ed. 01 -01) Estimated Annual Premium $1,971 $1,971 $0 $0 $0 $0 $1,971 $0 $1,971 $0 $0 $200 $99 $2,270 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. the information below is required only when this endorsement is issued subsequent to preparation of the policy.) iorsement Effective Date: 19- Mar -10 Policy Number: 01CA1- 219D520 -01 Endorsement No.: ured Name: North Seminole Family Practice Associates, PA Premium: $2,27C urance Company: Comp Options Insurance Company, Inc. d /b /a OptaComp IC 99 06 03 Countersigned by: =d. 1 -01) Florida Statutes On Public Entity Crimes THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted to The City of Sanford by on behalf ofol�-�SRm�ndtew.�4� P��i flssocl whose business address is: S e.Y, S -G-f-d 3 a and (if applicable) its Federal Employer Identification Number (FEIN) is S9-Z63 Li g' 3 0 (if the entity has no FEIN, include the Social Security Number of the individual signing this statement: n) A ) . understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly: related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services, any lease for real property, or any contract for the construction or repair of a public building or public work, involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. 1 understand the "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilt or nolo contendere. 4. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes. means: 1. A predecessor or successor of a person convicted of a public entity crime: or 2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not fair market value under an arm's length agreement, shall be a prima', facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States! with the legal power to enter into a binding contract and which bids or applies to bid on contracts let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 6. Based on information and belief, the statement which I have marked below is true in relation to the entity subm itting this sworn statement. (Please indicate which statement applies.) / Neither the entity submitting this sworn statement, nor any of its officers, director, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity were charged with and convicted of a public entity! crime after July 1, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity was charged with and convicted of a public entity crime after July 1, 1989. The entity submitting this sworn statement, or one of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any RFQ 09110 -07 Physicians Services - General. affiliate of the entity was charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN CTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION AINED IN THIS FORM. (signatu e) 0 LA I I s` X_0 I ID (date) State of Florida County of On this ` S +-c day of tic 1 y 20 /D, before me, the undersigned Notary Public of the State of Florida, personally appeared and Cn- to (Name(s) of individuals who appeared before notary) whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they executed it. WITNESS my hand and official seal. NOTARY PUBLIC ARY PUBLICS ORIDA SEAL OF OFFICE: 1 - 1 i dko - 0 b � ,,, Q i;w — (Name of Notary Public: Print, Stamp, or Type as Commissioned.) Vr� AVACAAbM _ Personally known to me, or NNW Pubk M Ffotip Produced identification: • MrcmwwM 6�MrH,�011 — Q411110 1IN I1 0o 42M NIr11MM�1�Wf1�yA�R (Type of Identification Produced) DID take an oath, or e l— DID NOT take an oath. FORM NO. PEC 15.204 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -07 Physicians Services - General. Certification of Non - Segregated Facilities By affixing his signature to this form, the Offeror /Bidder certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The Bidder certifies further that he will not maintain or provide for his employees any segregated facilities at any location under his control where segregated facilities are maintained. The Bidder agrees that a breach of this certification will be a violation of the Equal Opportunity clause in any contract resulting from acceptance of this Bid. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage and dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation and housing facilities provided for employees which are segregated by explicit directive, or are in fact segregated on the basis of race, color, religious disability or national origin, because of habit, local custom, or otherwise. The Bidder agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files. The nondiscriminatory guidelines as promulgated in Section 202, Executive Order 11246, and as amended by Executive Order 11375 and as amended, relative to Equal Opportunity for all persons and implementations of rules and regulations prescribed by the United States Secretary of Labor are incorporated herein. NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001. \5, ,�L(U \O By' o F - W _. r1 Pr e Si d �P_rA - Name Title Official Address: \0rah rni���2�c�rn P ro- c*C} 9 l i 3 a.- --) --) FORM NO. SFAC 16.204 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -07 Physicians Services - General. ��#z�tr #xrt.ertt .n l' ��az,e I certify that the at is a true and correct ccipy of the Articles of Amendment, filed can June 19, 1497, to Articles of lncgrporation for JAMES E, - QUINN, M.D., P.A., ch2rIging its name to _ NORTH �EM:tNOLE F4iV1(Ly PRACT(CS ASSOCIATES,'' P.A:, a Florida cgrpQra�(pfj; '4s shown by the records of this' office_ The document "nvmber''af .this corporation. is J01333. - �i bert tuTaer tttp �iar�b and cf�� _ _- Omit —`�)raI of tf)r — 4tatr of- floriba at Tallaba —g5cr, the Capital, tl)is .the 1 gth b ?tJ of June, 1591. ;�f int �rrti�f� - ____ - Serretar -r of ,' -- tatr 0 n y CR2E022 (2 - 97) City Of Sanford Agreement For Workers Compensation Physicians Services (RFP 09/10 -06) This Agreement made and entered into this I day of ftkL , 2010 by and between the: City of Sanford, Florida City Hall 300 North Park Avenue Sanford, Florida 32771 a municipal corporation of the State of Florida, holding tax exempt status, hereinafter referred to as the "City," and: Florida Hospital Centra Care 901 N. Lake Destiny Rd., Suite 400 Maitland, FL 32751 a a medical practice that employs medical doctors licensed to practice medicine in the State of Florida and authorized to do business in the State of Florida, hereinafter referred to as the "Physician ". The City and the Physician are collectively referred to herein as the "parties ". WITNESSETH: Whereas, the City desires to retain the Physician for the work identified in the specifications outlined in City RFP 09/10 -06 for the provision of medical services related to the State laws pertaining to workers compensation and the City's programs, projects and operations which interact with those laws; and Whereas, attached hereto as Exhibit "A" along with the certain other documents relating thereto are the City's documents relating to RFP 09/10 -06; and Whereas, the City desires to employ the Physician for the performance of medical services to support the activities, programs, and projects of the City upon the terms and conditions hereinafter set forth herein and in the City's RFP 09/10 -06 pertaining to medical services pertaining to the application and implementation of the workers compensation laws of the State of Florida upon said terms and conditions; and Whereas, the Physician hereby warrants and represents to the City that it is competent and otherwise able to provide professional and high quality medical and related services to the City; and Physicians Services Agreement — Workers Compensation Page No. 1 Whereas, the references to the provisions of services to the City to the City shall include to provision of goods and the term "Work Order" shall include the term "Purchase Order" herein; Now, Therefore, in consideration of hereinafter contained sufficiency of which is hereto as follows: and other good and hereby acknowledged, Section 1: Definitions. the mutual covenants valuable consideration. it is and the agreed by and betwee n Ad valorem - In proportion to the estimated value of the goods taxed. agreements receipt and the parties Agreement — This document and all subsequent Work Orders between the City and Physician. Each exhibit, even if not physically attached, shall be treated as if it is a part of this Agreement. The effective date of this Agreement is the date that the City Commission approves the selection of the Physician and the Agreement is executed by the City. Billing Period — The period of time between project commencement to the close of the current period, (inclusive); or from the close of the previous billing period, (exclusive), to the close of the current period, usually concurrent with the month. In no case shall this period be less than one calendar month except for the final billing period. Bona Fide - Made or carried out in good faith; sincere. City — The City of Sanford, a municipal corporation of the State of Florida holding tax exempt status. Physician - To include all principals of the Physician including, but not limited to, full and part time employees, professional or otherwise, and all other agents employed by or for Physician to perform its obligations hereunder. Description of Services - Shall be written in paragraph form reasonably describing those services the City can expect the Physician to provide. The description shall be written in such a manner that the type of service is clearly provided, but broad enough that all services reasonably expected of the Physician, including services provided by partners, subcontractors, and other supporting professionals, can be provided to the City. Desiqnated Representative — A person who administers, reviews and coordinates the provision of services. This definition applies equally to the City and to the Physician. Exhibit "A" — City RFP 09/10 -06 and related documents as determined by the City. Exhibit "B" — Project Status Report Form. Exhibit "C" — Certificate of Insurance Coverages. Physicians Services Agreement — Workers Compensation Page No. 2 Exhibit "D" — Physician pricing sheet or schedule for services. Force Majeure - Force Majeure shall include, but not be limited to, hostility, revolution, civil commotion, terrorism, strike, epidemic, fire, flood, wind, earthquake, explosion, any law, proclamation, regulation, or ordinance or other act of government, or any act of God or any cause whether of the same or different nature, existing or future; provided that the cause whether or not enumerated in this Agreement is beyond the control and without the fault or negligence of the party seeking relief under this Agreement. Law - Said phrase shall include statutes, laws, codes, ordinances, rules and regulations of whatsoever type or nature enacted or adopted by a governmental entity of competent jurisdiction. Pari Materia — Of the same matter; on the same subject. Laws pari materia must be construed with reference to each other /together when related to the same matter or subject. The provisions of a contract/agreement shall be construed together with no isolated construction of a particular provision such that it would defeat the overall intent of the contract/agreement. Submittals — Any item required by this agreement that the Physician must provide the City either for inclusion as part of this Agreement or not. Type of Service — The services are generally related to the provision of medical and related services pertaining to the workers compensation laws of the State of Florida in accordance with the controlling provisions of law. Work Order - A detailed description of quantities, services and a completion schedule for the provision of such goods and /or services issued by the City on it's approved form which, on occasion, may contain documents published, on Physician letterhead, describing all work associated with the goods /services to be provided by the Physician to the City for an agreed price referencing this Agreement by title and date. Section 2: Captions. The Section headings and captions of this Agreement are for convenience and reference only and in no way define, limit, describe the scope or intent of this Agreement or any part thereof, or in any way affect this Agreement or construe any provision of this Agreement. Section 3: Extent Of Agreement/integration /Amendment. (a). This Agreement, together with the exhibits, constitutes the entire integrated Agreement between the City and the Physician and supersedes all prior written or oral understandings in connection therewith. This Agreement, and all the terms and provisions contained herein including, without limitation, the exhibits, constitute the full and complete agreement between the parties hereto and supersede and controls over any and all prior Physicians Services Agreement — Workers Compensation Page No. 3 agreements, understandings, representations, correspondence and statements regardless of whether written or oral. (b). This Agreement may only be amended, supplemented, or modified by a formal written amendment. (c). Any alterations, amendments, deletions, or waivers of the provisions of this Agreement shall be valid only when expressed in writing and duly signed by the parties. Section 4: No General City Obligation. (a). In no event shall any obligation of the City under this Agreement be or constitute a general obligation or indebtedness of the City, a pledge of the ad valorem taxing power of the City or a general obligation or indebtedness of the City within the meaning of the Constitution of the State of Florida or any other applicable laws, but shall be payable solely from legally available revenues and funds. (b). The Physician shall not have the right to compel the exercise of the ad valorem taxing power of the City. Section 5: Physician Understanding Of Services Required. (a). Execution of this Agreement by the Physician is a representation that the Physician is familiar with local conditions and with the services to be performed. The Physician shall make no claim for additional time or money based upon its failure to comply with this Agreement. The Physician has informed the City, and hereby represents to the City, that it has extensive experience in performing and providing the services and /or goods described in this Agreement and to be identified in the Work Orders, and that it is well acquainted with the components that are properly and customarily included within such projects and the requirements of statutes, laws,codes, ordinances, rules, regulations, or orders of any public authority or licensing entity having jurisdiction over City projects. Execution of a Work Order shall be an affirmative and irrefutable representation by the Physician to the City that the Physician is fully familiar with any and all requisite work conditions of the provisions of the services and /or goods to be provided. (b). The recitals herein are true and correct and form and constitute a material part of this Agreement upon which the parties have relied. (c). It is agreed that nothing herein contained is intended or should be construed as in any manner creating or establishing a relationship of co- partners between the parties, or as constituting the Physician (including, but not limited to, its officers, employees, and agents) the agent, representative, or employee of the City for any purpose, or in any manner of whatsoever type or nature. The Physician is to be and shall remain forever an independent contractor with respect to all services performed under this Agreement. (d). Persons employed by the Physician in the provision and performance of the Physicians Services Agreement — Workers Compensation Page No. 4 services and functions pursuant to this Agreement shall have no claim to pension, workers' compensation, unemployment compensation, civil service or other employee rights or privileges granted to the City's officers and employees either by operation of law or by the City. Section 6: General Provisions. (a). Each party hereto represents to the other that it has undertaken all necessary actions to execute this Agreement and that it has the legal authority to enter into this Agreement, and to undertake all obligations imposed on it. The persons executing this Agreement for the Physician certify that they are authorized to bind the Physician fully to the terms of this Agreement. (b). This Agreement is for the services as described in this Agreement which shall be accomplished in accordance with the controlling provisions of law and as directed by the City to include all labor and materials that may be required. (c). The Physician acknowledges that the City may retain other physicians to provide the same types of services for City projects. The City reserves the right to select which physician shall provide services for City projects. (d). The Physician acknowledges that the City has retained, or may retain, other physicians and the coordination between said physicians and the Physician may be necessary from time -to -time for the successful completion of each Work Order. The Physician agrees to provide such coordination as necessary. (e). The Physician agrees to provide and ensure coordination between goods /services providers. (f). Time is of the essence of the lawful performance of the duties and obligations contained in this Agreement to include, but not be limited to, each Work Order. The parties covenant and agree that they shall diligently and expeditiously pursue their respective obligations set forth in this Agreement and each Work Order. (g). The Physician shall maintain an adequate and competent staff and professionally qualified persons throughout the performance of this Agreement to ensure acceptable and timely completion of each Work Order. (h). Requirements for signing and sealing plans, reports and documents prepared by the Physician shall be governed by the laws and regulations of Seminole County and State regulatory agencies. (i). The Physician hereby guarantees the City that all material, supplies, services and equipment as listed on a Purchase Order or Work Order meet the requirements, specifications, and standards as provided for under the Federal Occupations Safety and Health Act of 1970, from time -to -time amended and in force on the date hereof. Physicians Services Agreement — Workers Compensation Page No. 5 0). No claim for services furnished by the Physician not specifically provided for herein shall be honored by the City. Section 7: Codes And Design Standards. (a). All the services to be provided or performed by the Physician shall in the minimum be in conformance with commonly accepted industry and professional codes and standards, standards of the City, and the laws of any Federal, State, or local regulatory agencies. (b). The Physician shall be responsible for keeping apprised of any changing laws applicable to the services to be performed under this Agreement. Section 8: Subcontractors. (a). Any Physician proposed subcontractor shall be submitted to the City for written approval prior to the Physician entering into a subcontract. Subcontractor information shall include, but not be limited to, State registrations, business address, proof of payment of the local business tax and insurance certifications. (b). The Physician shall coordinate the provision of services and work product of any City approved subcontractor and remain fully responsible for such services and work under the terms of this Agreement. (c). Any subcontract shall be in writing and shall incorporate this Agreement and require the subcontractors to assume performance of the Physician's duties commensurately with the Physician's duties to the City under this Agreement it being understood that nothing herein shall in any way relieve the Physician from any of its duties under this Agreement. The Physician shall provide the City with executed copies of all subcontracts. Section 9: Assignability. The Physician shall not sublet, assign, or transfer any interest in this Agreement, or claims for the money due or to become due out of this Agreement to a bank, trust company, or other financial institution without written City approval. When approved by the City, written notice of such assignment or transfer shall be furnished promptly to the City. Section 10: Commencement/Implementation Schedule Of Agreement. (a). The Physician shall commence the provision of services as described in this Agreement immediately upon execution of this Agreement and a notice to proceed with the work set forth in the subject RFP. Thereafter Work Orders will be issued for work to be accomplished hereunder. Physicians Services Agreement — Workers Compensation Page No. 6 (b). The Physician shall adhere to the City's time requirements relative to the work to be accomplished as set forth in the RFP to ensure timely completion of services to the City. (c). The Physician and the City agree to make every effort to adhere to the schedules established for the various Work Orders as described in each Work Order. However, if the Physician is delayed at any time in the provision of services by any act or omission of the City, or of any employee of the City, or by any other Physician employed by the City, or by changes ordered by the City, or by strikes, lock outs, fire, unusual delay in transportation, unavoidable casualties, or any other causes of force majeure not resulting from the inactions or actions of the Physician and beyond the Physician's control which would not reasonably be expected to occur in connection with or during performance or provision of the services, or by delay authorized by the City pending a decision, or by any cause which the City shall decide to justify the delay, the time of completion shall be extended for such reasonable time as the City may decide in its sole and absolute discretion. (d). It is further expressly understood and agreed that the Physician shall not be entitled to any damages or compensation, of any type or nature, or be reimbursed for any losses on account of any delay or delays resulting from any of the aforesaid causes or any other cause whatsoever. Section 11: Length Of Agreement. (a). The term of this Agreement shall be for a period beginning on the date of the full execution of this Agreement and terminating on December 31, 2011 and shall be renewable, at the mutual agreement of the City and the Physician, for one (1) year periods thereafter for an additional year or years. (b). The Physician's services shall begin upon written notification to proceed by the City. (c). Thereafter, the Physician's services shall be on a Work Order basis. (d). Services may include matters such as serving as an expert witness. Section 12: Description Of Services. (a). The Physician agrees to provide the services as outlined and described in this Agreement all of which are to be provided to the City in accordance with the controlling provisions of law as more specifically outlined in the exhibits and Work Orders issued hereunder; provided, however, without limiting the generality of the foregoing: (1). Medical services associated with work related injuries are defined by and shall be furnished to the City in full compliance with Chapter 440, Florida Statutes. (2). The Physician shall be the City's Medical Care Coordinator (MCC) who shall be the primary care provider within a provider network who is responsible for managing the medical care of injured workers including, but not limited to, referrals for types of specialists Physicians Services Agreement — Workers Compensation Page No. 7 or treatments to which the injured employee will be referred for evaluation or treatment (3). As MCC, the Physician may be required by the City or the City's Third Party Claims Administrator (TPA) to intercede or communicate, consult, teleconference, etc., with providers to whom the MCC or each Primary Care Providers (PCP) may have referred an injured employee. Activities may also involve a review of medical files of any and all providers that may provide care to the injured employees. (4). As MCC, the Physician shall be the PCP for all work related injuries unless the MCC refers the injured employee to a type of specialist within the City's provider network. All referrals shall first be made to the City's TPA for authorization. Even with this referral, the Physician still remains the MCC on the work related injury. (5). The Physician understands that the City has an active Transitional Duty Program for those employees that have a work related injury, but have been determined to be able to work only a modified duty in lieu of full or regular duty for a specified period of time. The Physician understands only a very small number of injured employees have injuries that would prevent the employee from returning to work to at least Transitional or Light Duty. (6). The Physician understands that that by placing an employee Out -of- Work (OOW) for any period of time for a work related injury that the employee is to be determined Totally Disabled, either temporarily or permanently. A full written explanation for the reason the employee has been determined to be Totally Disabled shall be provided by the Physician to the City. (7). The Physician shall work harmoniously and in tandem with the City's TPA and the City. All referrals by the MCC for other providers or treatment will be presented to the TPA for authorization. (8). The Physician understands that the State of Florida has a Workers Compensation Fee Schedule and agrees no fees will exceed that fee schedule, but the City may enjoy further reductions in fees if mutually agreed upon through various means including, but not limited to, Preferred Provider Discounts. (9). The Physician agrees, at the City's option, to have scheduled meetings with the City to discuss current claims or other employee work related injury issues at least three times per year. Each meeting will be at least one (1) hour in duration, but no more than two (2) hours in duration. (10). The Physician understands that all referrals must be for providers within the City's Network of Providers as provided by the City's TPA under the City's Managed Care Arrangement. (11). The Physician understands that all initial treatment for a work related injury must first be approved by the City, otherwise treatment costs, expenses, fees, etc., will not be reimbursed. The City will only reimburse providers for authorized treatment. Authorization Physicians Services Agreement — Workers Compensation Page No. 8 for treatment must be obtained from the City's Risk Manager or his /her designee, but if the Risk Manager is not available to provide authorization, supervisory personnel within that employee's Department may provide authorization. (12). The Physician shall provide a Duty Status Report after each and every work related injury visit by CITY employees. This shall be faxed to the City's Risk Manager at telephone number 407 - 330 -5622, or such other telephone number(s) as may be provided to the Physician, immediately after an employee visits the Physician. (13). The Physician shall immediately report any unusual activity, statements, etc. by an injured City employee as well as the cause of injury that contradicts the original statement as to claim cause. (14). The Physician shall address causality of employee work related injuries, occupational, as opposed to, personal medical condition /injury. (15). The Physician understands that all invoices for services rendered will be submitted on proper form and in timely manner to the City's TPA. (16). The Physician shall provide and maintain documentation applicable to all patients treated under this Agreement. (b). The Physician shall diligently and in a professional and timely manner perform and provide the services outlined herein or as included in each subsequently entered Work Order. Unless modified in writing by the parties hereto, the duties of the Physician shall not be construed to exceed the provision of the services pertaining to this Agreement. (c). The City and the Physician agree that there may be certain additional services required to be performed by the Physician during the performance of the work in the RFP or Work Orders that cannot be defined sufficiently at the time of execution of this Agreement. Such services shall be authorized in writing as a Change Order: The Work Orders may contain addititonal instructions or provide specifications upon certain aspects of this Agreement pertinent to the work to be undertaken. Such supplemental instructions or provisions shall not be construed as a modification of this Agreement. Section 13: Physician Responsibilities. (a). The Physician shall be responsible for the professional quality, accepted standards, technical accuracy, neatness of appearance of employees, employee conduct, safety, and the coordination of all services furnished by the Physician under this Agreement as well as the conduct of its staff, personnel, employees and agents. All Physician employees shall at all times when performing work wear identification badges which, at a minimum, provides the name of the employee and the Physician. (b). The Physician shall provide to the City a list of employees working on the project. The Physician shall provide to the City a list of employee working days, times and Physicians Services Agreement — Workers Compensation Page No. 9 assignments within forty -eight (48) hours of the City's written request for such information. This information, when requested by the City, shall be provided to the City prior to the employees of the Physician entering the City's premises. (c). The Physician shall comply with the Sanford City Code as it relates to security screenings of private contractors and employees of private contractors. The Physician recognizes that its employees are functioning in a position critical to the security and /or public safety of the City by reason of access to a City owned facility and, thus, all employees shall undergo the following inquiries and procedures conducted by the City: (1) fingerprinting in accordance with the City's pre - employment procedures, (2) submission of the fingerprints to the Florida Department of Law Enforcement for State criminal history evaluation, and (3) submission of the fingerprints to the Federal Bureau of Investigation for a national criminal history evaluation. Such information shall be used by the City to determine a person's eligibility to function in such critical employment positions as described. Additionally, the Physician shall provide the name, address and social security number and licenses (driver's, commercial drivers license, or other operator's license) for its employees. The Physician shall release such information upon approval of the employees. If an employee refuses to authorize the release of their address, social security number and /or licenses they shall not be allowed to work or continue to work for the City's projects. (d). The Physician shall work closely with the City on all aspects of the provision of the services. The Physician shall be responsible for the professional quality, technical accuracy, competence, methodology, accuracy and the coordination of all of the following which are listed for illustration purposes only and not as a limitation: documents, analysis, reports, data, plans, plats, maps, surveys, specifications, and any and all other services of whatever type or nature furnished by the Physician under this Agreement. The Physician shall, without additional compensation, correct or revise any errors or deficiencies in his /her /its plans, analysis, data, reports, designs, drawings, specifications, and any and all other services of whatever type or nature. The Physician's submissions in response to the subject bid or procurement processes are incorporated herein by this reference thereto. (e). Neither the City's review, approval or acceptance of, nor payment for, any of the services required shall be construed to operate as a waiver of any rights under this Agreement or of any cause of action arising out of the performance of this Agreement and the Physician shall be and remain liable to the City in accordance with applicable law for all damages to the City caused by the Physician's negligent or improper performance or failure to perform any of the services furnished under this Agreement. (f). The rights and remedies of the City, provided for under this Agreement, are in addition to any other rights and remedies provided by law. (g). Time is of the essence in the performance of all services provided by the Physician under the terms of this Agreement and each and every Work Order. (h). The Physician shall cooperate with the City in the implementation of the City's tax Physicians Services Agreement — Workers Compensation Page No. 10 recovery program and, to that end, the City may make purchases directly under its purchase order processes relative to various materials, supplies and equipment that may be part of the services provided under this Agreement. The Physician hereby recognizes the right of the City to engage in tax recovery/savings through direct purchases. Section 14: City Rights And Responsibilities. (a). The City shall reasonably cooperate with the Physician in a timely fashion at no cost to the Physician as set forth in this Section. (b). The City shall furnish a City designated representative to administer, review, and coordinate the provision of services under each Work Order. (c). The City shall make City personnel available where, in the City's opinion, they are required and necessary to assist the Physician. The availability and necessity of said personnel to assist the Physician shall be determined solely at the discretion of the City. (d). The City shall furnish the Physician with exisitng data, records, maps, plans, specifications, reports, fiscal data and other engineering information that may be available in the City's files that is necessary or useful to the Physician for the performance of the work provided for in this Agreement. All such documents conveyed by the City to the Physician shall be, and always remain, the property of the City and shall be returned to the City upon completion of the work to be performed by the Physician. (e). The City shall examine all Physician reports, sketches, drawing, estimates, proposals and other documents presented to the City and indicate the City's approval or disapproval within a reasonable time so as not to materially delay the provisions of the services of the Physician. (f). The City shall provide access to and make provisions for the Physician to enter upon public and private lands as required for the Physician within a reasonable time to perform work as necessary to complete work. (g). The City shall transmit instructions, relevant information, and provide interpretation and definition of City policies and decisions with respect to any and all materials and other matters pertinent to the services covered by this Agreement. (h). The City shall give written notice to the Physician whenever the City designated representative knows of a development that affects the services provided and performed under this Agreement, timing of the Physician's provision of services, or a defect or change necessary in the services of the Physician. (i). The rights and remedies of the City provided for under this Agreement are in addition to any other rights and remedies provided by law. The City may assert its right of recovery by any appropriate means including, but not limited to, set -off, suit, withholding, recoupment or counterclaim, either during or after performance of this Agreement. Physicians Services Agreement — Workers Compensation Page No. 11 Q). The City shall be entitled to recover any and all legal costs including, but not limited to, attorney fees and other legal costs that it may incur in any legal actions it may pursue in the enforcement of the terms and conditions of this Agreement or the responsibilities of the Physician in carrying out the duties and responsibilities deriving from this Agreement. (k). The failure of the City to insist in any instance upon the strict performance of any provision of this Agreement, or to exercise any right or privilege granted to the City hereunder, shall not constitute or be construed as a waiver of any such provision or right and the same shall continue in force. (1). Neither the City's review, approval or acceptance of, nor payment for, any of the services required shall be construed to operate as a waiver of any rights under this Agreement nor for any cause of action arising out of the performance of this Agreement and the Physician shall be and always remain liable to the City in accordance with applicable law for any and all damages to the City caused by the Physician's negligent or wrongful provision or performance of any of the services furnished under this Agreement. (m). All deliverable analysis, reference data, survey data, plans and reports or any other form of written instrument or document that may result from the Physician's services or have been created during the course of the Physician's performance under this Agreement shall become the property of the City after final payment is made to the Physician. (n). In the event the City fails to comply with the terms and conditions of this Agreement, the Physician shall notify the City's designated representative in writing in order that the City may take remedial action. Section 15: Waiver. The failure of the City to insist in any instance upon the strict performance of any provision of this Agreement, or to exercise any right or privilege granted to the City hereunder, shall not constitute or be construed as a waiver of any such provision or right and the same shall continue in force. Section 16: Force Majeure. Neither party shall be considered in default in performance of its obligations hereunder to the extent that performance of such obligations, or any of them, is delayed or prevented by force majeure. Section 17: Standards Of Conduct. (a). The Physician warrants that it has not employed or retained any company or person, other than a bona fide employee working solely for the Physician, to solicit or secure this Agreement and that the Physician has not paid or agreed to pay any person, company, corporation, individual, or firm other than a bona fide employee working solely for the Physicians Services Agreement — Workers Compensation Page No. 12 Physician, any fee, commission, percentage, gift, or any other consideration, contingent upon or resulting from the award of making this Agreement. (b). If the City determines that any employee or representative of the Physician is not satisfactorily performing his or her assigned duties or is demonstrating improper conduct pursuant to any assignment or work performed under this Agreement, the City shall so notify the Physician, in writing. The Physician shall immediately remove such employee or representative of the Physician from such assignment. (c). The Physician hereby certifies by this writing that no undisclosed conflict of interest exists with respect to the Agreement including, but not limited to, any conflicts that may be due to representation of other clients, customers or vendees, other contractual relationships of the Physician, or any interest in property that the Physician may have. The Physician further certifies that any conflict of interest that arises during the term of this Agreement shall be immediately disclosed in writing to the City. Violation of this Section shall be considered as justification for immediate termination of this Agreement. (d). The Physician shall not engage in any action that would create a conflict of interest for any City employee or other person during the course of performance of, or otherwise related to, this Agreement or which would violate or cause others to violate the provisions of Part III, Chapter 112, Florida Statutes, relating to ethics in government. (e). The City shall not intentionally award publicly- funded contracts to any Physician who knowingly employs unauthorized alien workers, constituting a violation of the employment provisions contained in 8 U.S.C. Section 1324a(e) Section 274A(e) of the Immigration and Nationally Act (INA)]. The City shall consider the employment by the Physician of unauthorized aliens, a violation of Section 274A (e) of the INA. Such violation by the Physician of the employment provisions contained in Section 274A (e) of the INA shall be grounds for immediate termination of this Agreement by the City. (f). The Physician shall comply with the requirements of the Americans with Disabilities Act (ADA), and any and all related Federal or State laws which prohibits discrimination by public and private entities on the basis of disability. (g). The Physician shall not discriminate on the grounds of race, color, religion, sex, or national origin in the performance of work under this Agreement or violate any laws pertaining to civil rights, equal protection, or discrimination. (h). If the Physician or an affiliate is placed on a discriminatory vendor list, such action may result in termination by the City. The Physician shall certify, upon request by the City, that it is qualified to submit a bid under Section 287.134 (2) (c), Florida Statutes. (i). If the Physician or an affiliate is placed on the convicted vendor list following a conviction for a public entity crime, such action may result in termination by the City. The Physician shall certify, upon request by the City, that is qualified to submit a bid under Section 287.133 (2)(a), Florida Statutes. Physicians Services Agreement — Workers Compensation Page No. 13 (j). The Physician shall certify, upon request by the City, that the Physician maintains a drug free workplace policy in accordance with Section 287.0878, Florida Statutes. Failure to submit this certification may result in termination. (k). The Physician agrees to comply with Federal, State and local environmental, health and safety laws and regulations applicable to the services provided to the City. The Physician agrees that any program or initiative involving the work that could adversely affect any personnel involved, citizens, residents, users, neighbors or the surrounding environment shall ensure compliance with any and all employment safety, environmental and health laws. (1). If applicable, in accordance with Section 216.347, Florida Statutes, the Physician shall not use funds provided by this Agreement for the purpose of lobbying the Legislature, the judicial branch, or a State agency. (m). The Physician shall not publish any documents or release information regarding this Agreement to the media without prior approval of the City. (n). The Physician shall ensure that all services are provided to the City after the Physician has obtained, at its sole and exclusive expense, any and all permits, licenses, permissions, approvals or similar consents. (o). The Physician shall ensure that all taxes due from the Physician are paid in a timely and complete manner including, but not limited to, the local business tax. Section 18: Notices. (a). Whenever either party desires to give notice unto the other, it must be given by written notice, sent by registered United States mail, with return receipt requested, addressed to the party for whom it is intended, at the place last specified, and the place for giving of notice shall remain such until it shall have been changed by written notice in compliance with the provisions of this Section. (b). For the present, the parties designate the following as the representative places for giving of notice, to -wit: (1). For the Citv: Fred Fosson, Director of Human Resources /Risk Management City of Sanford City Hall 300 North Park Avenue Sanford, Florida 32771 Telephone Number: (407) 688 -5025 Facsimile Number: (407) 688 -5131 Physicians Services Agreement — Workers Compensation Page No. 14 Email Address: fossonf @sanfordfl.gov (2). For the Physician Scott Brady, M. D., Chief Medical Officer Florida Hospital Centra Care 901 N. lake Destiny Rd., Suite 400 Maitland, FL 32751 Telephone Number: 407 - 200 -2862 Facsimile Number: 407 - 200 -1363 (c). Written notice requirements of this Agreement shall be strictly construed and such requirements are a condition precedent to pursuing any rights or remedies hereunder. The Physician agrees not to claim any waiver by City of such notice requirements based upon City having actual knowledge, implied, verbal or constructive notice, lack of prejudice, or any other grounds as a substitute for the failure of the Physician to comply with the express written notice requirements herein. Computer notification (e -mails and message boards) shall not constitute proper written notice under the terms of the Agreement. Section 19: Designated Representatives. (a). The City Manager, or designated representative, represents the City in all matters pertaining to and arising from the work and the performance of this Agreement. (b). The City Manager or designated representative shall have the following responsibilities: (1). Examination of all work and rendering, in writing, decisions indicating the City's approval or disapproval within a reasonable time so as not to materially delay the work of the Physician; (2). Transmission of instructions, receipt of information, and interpretation and definition of City's policies and decisions with respect to design, materials, and other matters pertinent to the work covered by this Agreement; (3). Giving prompt written notice to the Physician whenever the City knows of a defect or change necessary in the project; and (c). Until further written notice, the City's designated representative for this Agreement is: Fred Fosson, Director of Human Resources /Risk Management City of Sanford City Hall 300 North Park Avenue Sanford, Florida 32771 15 Physicians Services Agreement — Workers Compensation Telephone Number: (407) 688 -5025 Facsimile Number: (407) 688 -5131 Email Address: fossonf @sanfordfl.gov (d). Prior to start of any work under this Agreement, the Physician shall submit to the City detailed resumes of key professional personnel that will be involved in performing services described in the work. The City hereby acknowledges its acceptance of such personnel to perform services under this Agreement. At any time hereafter that the Physician desires to change key professional personnel in an active assignment, it shall submit the qualifications of the new professional personnel to the City for prior approval. Key professional personnel shall include the principal -in- charge, project managers and others interfacing with City personnel. (e). Until further written notice, the Physician's designated representative for this Agreement is: Scott Brady, M. D., Chief Medical Officer Florida Hospital Centra Care 901 N. lake Destiny Rd., Suite 400 Maitland, FL 32751 Telephone Number: 407 - 200 -2862 Facsimile Number: 407 - 200 -1363 Section 20: Work Orders. (a). The provision of services to be performed under this Agreement may commence immediately upon the execution of this Agreement and a notice to proceed. Thereafter, a Work Order issued by the City shall direct work under this Agreement. Services to be provided by the Physician to the City under Work Orders shall be negotiated between the Physician and the City. Each Work Order shall reference this Agreement by title and date, include a detailed description of quantities, services, and a completion schedule, and will be provided on Physician letterhead. Services described in said Work Orders will commence upon the full execution of a Work Order or as specified in a Work Order. (b). If the services required to be performed by a Work Order is clearly defined, the Work Order shall be issued on a "Fixed Fee" basis. The Physician shall perform all services required by the Work Order but in no event shall the Physician be paid more than the negotiated Fixed Fee amount stated therein. (c). The Physician and the City agree to make every effort to adhere to the schedules established for the various Work Orders. (d). If the services are not clearly defined, the Work Order may be issued on a "Time Basis Method" and contain a Not -to- Exceed amount. If a Not -to- Exceed amount is provided, the Physician shall perform all work required by the Work Order; but in no event shall the Physician be paid more than the Not -to- Exceed amount specified in the applicable 16 Physicians Services Agreement — Workers Compensation Work Order. For Work Orders issued a a "Fixed Fee Basis," the of total Work Order services am ount due based on the percentage g performed ually performed and am completed; but in no event shall the invoice amount exceed a percentage of the Fixed Fee amount equal to a percentage of the total services actually completed. (fl. For Work Orders issued on a "Time Basis Method" with a Not -to- Exceed amount, the Physician may invoice the amount due for actual work hours performed; but in no event shall the invoice amount exceed a percentage of the Not -to- Exceed amount equal to a percentage of the total services actually completed. (g). Each Work Order issued on a "Fixed Fee Basis" or "Time Basis Method" with a Not - to- Exceed amount shall be treated separately for retainage purposes. If the City determines that work is substantially complete and the amount retained, if any, is considered to be in excess, the City may, at its sole and absolute discretion, release the retainage or any portion thereof. (h). For Work Orders issued on a "Time Basis Method" with a Limitation of Funds amount, the Physician may invoice the amount due for services actually performed and completed. The City shall pay the Physician one hundred percent (100 %) of the approved amount on Work Orders issued on a "Time Basis Method" with a Limitation of Funds amount. (i). Invoices for work under the RFP shall be invoiced as if for a Work Order issued on a "Fixed Fee Basis ". Section 21: Change Orders. (a). The City may revise the description of services set forth in any particular Work Order or the RFP. (b). Revisions to any work shall be authorized in writing by the City as a Change Order. Each Change Order shall include a schedule of completion for the services authorized. Change Orders shall identify this Agreement and the appropriate Work Order number. The Change Orders may contain additional instructions or provisions specific upon certain aspects of this Agreement pertinent to the services to be provided. Such supplemental instructions or provisions shall not be construed as a modification of this Agreement. An agreement between the parties on and execution of any Change Order shall constitute a final settlement and a full accord and satisfaction of all matters relating to the change of work and /or services and to the impact of the change on unchanged goods and /or work including, but not limited to, all direct and indirect costs of whatever nature and all adjustments to the Physician schedule. (c). If instructed by the City, the Physician shall change or revise work that has been performed, and if such work is not required as a result of error, omission or negligence of 17 Physicians Services Agreement — Workers Compensation the Physician, the Physician may be entitled to additional compensation. The Physician must submit for City approval a revised proposal with a revised fee quotation. Additional compensation, if any, shall be agreed upon before commencement of any such additional work and shall be incorporated into the work by Change Order to the Work Order. Section 22: Compensation. (a). Compensation to the Physician for the services set forth in the RFP shall be in accordance with the fee schedule as set forth in Exhibit "D ".. (b). Compensation to the Physician for the services performed on each Work Order shall be as set forth the Work Order /Change Order. (c). The City shall not pay for reimbursable items such as gas, tolls, mileage, meals, etc. and other items not directly attritbutable to items produced for each Work Order. (d). Work performed by the Physician without written approval by the City's designated representative shall not be compensated. Any work performed by the Physician without approval by the City is performed at the Physician's own election. (e). In the event the City fails to provide compensation under the terms and conditions of this Agreement, the Physician shall notify the City's designated representative in order that the City may take remedial action. Section 23: Invoice Process. (a). Payments shall be made by the City to the Physician when requested as work progresses for services furnished, but not more than once monthly. Each Work Order shall be invoiced separately. The Physician shall render to the City, at the close of each calendar month, an itemized invoice properly dated, describing all services rendered as Exhibit "B ", the Project Status Report Form, the cost of the services, the name and address of the Physician, Work Order Number, Contract Number and all other information required by this Agreement. (b). Invoices which are in an acceptable form to the City and without disputable items will be processed for payment within thirty (30) days of receipt by the City. (c). The Physician will be notified of any disputable items contained in invoices submitted by the Physician within fifteen (15) days of receipt by the City with an explanation of the deficiencies. (d). The City and the Physician will make every effort to resolve all disputable items contained in the Physician's invoices. (e). Each invoice shall reference this Agreement, the appropriate Work Order and Change Order if applicable, the billing period, and include the Project Status Report for the Physicians Services Agreement — Workers Compensation 18 period being billed. A Project Status Report form is attached as Exhibit "B ". (f). The Florida Prompt Payment Act shall apply when applicable. (g). Invoices are to be forwarded directly to: Finance Director City Hall City of Sanford 300 North Park Avenue Sanford, Florida 32771 Section 24: Termination Of Agreement. (a). The City may terminate this Agreement or any Work Order for convenience at any time. (b). The City may also terminate this Agreement or any Work Order for one or more of the reasons as follows: (1). If, in the City's opinion, adequate progress under this Agreement, or Work Order, is not being made by the Physician; or (2). If, in the City's opinion, the quality of the services provided by the Physician is /are not in conformance with commonly accepted professional standards, standards of the City, the requirements of Federal or State regulatory agencies, and the Physician has not corrected such deficiencies in a timely manner as reasonably determined by the City; or (3). The Physician or any employee or agent of the Physician is indicted or has a direct charge issued against him for any crime arising out of or in conjunction with any work that has been performed by the Physician; or (4). The Physician becomes involved in either voluntary or involuntary bankruptcy proceedings, or makes an assignment for the benefit of creditors; or (5). The Physician violates the standards of conduct provisions herein or any provision of State or local law or any provision of the City's ethical rules or codes of conduct. (c). In the event of any of the causes described in this Section, the City's designated representative may send a certified letter requesting that the Physician show cause why the Agreement or any Work Order should not be terminated. If assurance satisfactory to the City of corrective measures to be made within a reasonable time is not given to the City within fourteen (14) calendar days of the receipt of the letter, the City may consider the 19 Physicians Services Agreement — Workers Compensation Physician to be in default, and may immediately terminate this Agreement or any Work Order in progress under this Agreement. (d). In the event that this Agreement or a Work Order is terminated for cause and it is later determined that the cause does not exist, then this Agreement or the Work Order shall be deemed terminated for convenience by the City and the City shall have the right to so terminate this Agreement without any recourse by the Physician. (e). Termination for convenience shall occur upon fifteen (15) days advance notice consistent with the notice provisions of this Agreement or immediately if the City determines that such termination is necessary to protect the public health, safety or welfare. Section 25: Termination By Physician For Cause. (a). The Physician may terminate this Agreement if: (1). The City materially fails to meet its obligations and responsibilities as contained in Section 14; City Rights and Responsibilities; or (2). The City fails to pay the Physician in accordance with this Agreement. (b). In the event of either of the causes described in Subsection (a), the Physician shall send a certified letter requesting that the City show cause why the Agreement should not be terminated. If adequate assurances are not given to the Physician within fourteen (14) calendar days of the receipt of said show cause notice, the Physician may consider the City to be in default and may immediately terminate this Agreement. Section 26: Termination By The City or Physician Without Cause. (a). Notwithstanding any other provision of this Agreement, the City shall have the right at any time to terminate this Agreement in its entirety without cause, or terminate any specific Work Order without cause, if such termination is deemed by the City to be in the public interest, provided that fifteen (15) calendar days prior written notice is given to the Physician of the City's intent to terminate. (b). In the event that this Agreement is terminated, the City shall identify any specific Work Order(s) being terminated and the specific Work Order(s) to be continued to completion pursuant to the provisions of this Agreement. (c). This Agreement will remain in full force and effect as to all authorized Work Order(s) that is /are to be continued to completion. Section 27: Payment In The Event Of Termination. 20 Physicians Services Agreement — Workers Compensation In the event this Agreement or any Work Order is terminated or canceled prior to final completion payment for the unpaid portion of the services provided by the Physician to the date of termination and any additional services shall be paid to the Physician. Section 28: Action Following Termination. Upon receipt of notice of termination, given by either party, the terminated party shall promptly discontinue the provision of all services, unless the notice provides otherwise. Section 29: Suspension. (a). The performance or provision of the Physician services under this Agreement or any Work Order under this Agreement may be suspended by the City at any time. (b). In the event the City suspends the performance or provision of the Physician's services hereunder, the City shall so notify the Physician in writing. Such suspension becoming effective upon the date stated in the notice. The City shall pay to the Physician within thirty (30) days all compensation which has become due to and payable to the Physician to the effective date of such suspension. The City shall thereafter have no further obligation for payment to the Physician for the suspended provision of services unless and until the City's designated representative notifies the Physician in writing that the provision of the services of the Physician called for hereunder are to be resumed by the Physician. (c). Upon receipt of written notice from the City that the Physician's provision of services hereunder are to be resumed, the Physician shall continue to provide the services to the City. Section 30: Alternative Dispute Resolution (ADR). (a) In the event of a dispute related to any performance or payment obligation arising under this Agreement, the parties agree to exhaust any alternative dispute resolution procedures reasonably imposed by the City prior to filing suit or otherwise pursuing legal remedies. (b) The Physician agrees that it will file no suit or otherwise pursue legal remedies based on facts or evidentiary materials that were not presented for consideration to the City in alternative dispute resolution procedures or which the Physician had knowledge and failed to present during the City procedures. (c). In the event that City procedures are exhausted and a suit is filed or legal remedies are otherwise pursued, the parties shall exercise best efforts to resolve disputes through voluntary mediation. Mediator selection and the procedures to be employed in voluntary mediation shall be mutually acceptable to the parties. Costs of voluntary mediation shall be shared equally among the parties participating in the mediation. 21 Physicians Services Agreement — Workers Compensation Section 31: Severability /Construction. (a). If any term, provision or condition contained in this Agreement shall, to any extent, be held invalid or unenforceable, the remainder of this Agreement, or the application of such term, provision or condition to persons or circumstances other than those in respect of which it is invalid or unenforceable, shall not be affected thereby, and each term, provision, and condition of this Agreement shall be valid and enforceable to the fullest extent permitted by law when consistent with equity and the public interest. (b). All provisions of this Agreement shall be read and applied in pari materia with all other provisions hereof. (c). Violation of this Agreement by the Physician is recognized by the parties to constitute irreparable harm to the City. (d). The use of the term "Work Order" shall also mean "Purchase Order" in this Agreement when appropriate in the context and, likewise, the terms "work" or "services" shall include the provision of goods in the appropriate context. Section 32: Controlling Laws/Venue /Interpretation. (a). This Agreement shall be governed by the laws of the State of Florida. (b). Venue for any legal proceeding related to this Agreement shall be in the Eighteenth Judicial Circuit Court in and for Seminole County, Florida. (c). This Agreement is the result of bona fide arms length negotiations between the City and the Physician and all parties have contributed substantially and materially to the preparation of the Contract. Accordingly, this Agreement shall not be construed or interpreted more strictly against any one party than against any other party. Section 33: Indemnity. (a). To the fullest extent permitted by law, the Physician shall indemnify, hold harmless, and defend the City, its agents, servants, officers, officials, and employees, or any of them, from and against any and all claims, damages, losses, and expenses including, but not limited to, attorneys fees and other legal costs such as those for paralegal, investigative, and legal support services, and the actual costs incurred for expert witness testimony arising out of or resulting from the performance or provision of services required under this Agreement, provided that same is caused in whole or part by the error, omission, negligent act, failure to act, malfeasance, misfeasance, conduct, or misconduct of the Physician, its agents, servants, officers, officials, employees, or subcontractors. The City does not waive its right to assert consquential damages against the Physician. 22 Physicians Services Agreement — Workers Compensation (b). In accordance with Section 725.06, Florida Statutes, adequate consideration has been provided to the Physician for this obligation, the receipt and sufficiency of which is hereby specifically acknowledged. (c). Nothing herein shall be deemed to affect the rights, privileges, and immunities of the City as set forth in Section 768.28, Florida Statutes. (d). In claims against any person or entity indemnified under this Section by an employee of the Physician or its agents or subcontractors, anyone directly or indirectly employed by them or anyone for whose acts they may be liable, the indemnification obligation under this Section shall not be limited by a limitation on amount or type of damages, compensation, or benefits payable by or for the Physician or its agents or subcontractors, under workers compensation acts, disability benefits acts, or other employee benefit acts. (e). The execution of this Agreement by the Physician shall obligate the Physician to comply with the indemnification provision in this Agreement; provided, however, that the Physician shall also comply with the provisions of this Agreement relating to insurance coverages. Section 34: Insurance. (a). The Physician shall obtain or possess and continuously maintain the following insurance coverage, from a company or companies, with a Best Rating of A- or better, authorized to do business in the State of Florida and in a form acceptable to the City and with only such terms and conditions as may be acceptable to the City: (1). Workers Compensation /Employer Liability: The Physician shall provide Worker Compensation insurance for all employees engaged in the work under this Agreement in accordance with the laws of the State of Florida. Employers' Liability Insurance shall be provided with limits not less than the following: $100,000 Each Accident $100,000 Disease Each Employee $500,000 Disease Aggregate (2). Comprehensive General Liability: The Physician shall provide coverage for all operations including, but not limited to, contractual, independent Physician, products and complete operations and personal injury with limits not less than the following: $1,000,000 Bodily Injury & Property Damage - each occurrence $1,000,000 Personal & Advertising Injury - each occurrence $2,000,000 General Aggregate $2,000,000 Products /Completed Operations Aggregates limit $ 5,000 Medical Payments $ 100,000 Fire Damage Legal Liability 23 Physicians Services Agreement — Workers Compensation (3). Comprehensive Business Automobile Liability: The Physician shall provide complete coverage with a combined single limit of not less than $1,000,000 Bodily Injury and Property Damage in accordance with the laws of the State of Florida, as to the ownership, maintenance, and use of all owned, non - owned, leased or hired vehicles. (4). Professional Liability: The Physician shall provide professional liability insurance as well as errors and omission insurance in a minimum amount of $1,000,000 CSL or its equivalent, with a combined single limit of not less than $1,000,000, protecting the Physician against claims of the City for negligence, errors, mistakes, or omissions in the performance of services to be performed and furnished by the Physician. (5) Other Required Insurance Coverage: Where unusual operations are necessary to complete the work, such as Longshoremen and Harbor Workers' Exposures, use of aircraft or watercraft, use of explosives, and any high risk circumstances. No aircraft, watercraft or explosives shall be used without the express advance written approval of the City which may, thereupon, required additional insurance coverages. (b). All insurance other than Workers Compensation and Professional Liability that must be maintained by the Physician shall specifically include the City as an additional participant. All insurance minimum coverages extend to any subcontractor, and the Physician shall be responsible for all subcontractors. The Physician shall ensure that the City is named as an insured party or participant in each pertinent insurance policy for a subcontractor. (c). The Physician shall provide Certificates of Insurance to the City evidencing that all such insurance is in effect prior to the issuance of the first Work Order under this Agreement. These Certificates of Insurance shall become part of this Agreement. Neither approval by the City nor failure to disapprove the insurance furnished by a Physician shall relieve the Physician of the Physician's full responsibility for performance of any obligation including the Physician's indemnification of the City under this Agreement. If, during the period which an insurance company is providing the insurance coverage required by this Agreement, an insurance company shall: (1) lose its Certificate of Authority, (2) no longer comply with Section 440.57, Florida Statutes, or (3) fail to maintain the requisite Best's Rating and Financial Size Category, the Physician shall, as soon as the Physician has knowledge of any such circumstance, immediately notify the City and immediately replace the insurance coverage provided by the insurance company with a different insurance company meeting the requirements of this Agreement. Until such time as the Physician has replaced the unacceptable insurer with an insurer acceptable to the City, the Physician shall be deemed to be in default of this Agreement. (d). The insurance coverage shall contain a provision that requires that prior to any changes in the coverage, except increases in aggregate coverage, thirty days prior notice will be given to the City by submission of a new Certificate of Insurance and appropriate policy modification. 24 Physicians Services Agreement — Workers Compensation (e). The Physician shall provide Certificate of Insurance directly to the City's designated representative. The certificates shall clearly indicate that the Physician has obtained insurance of the type, amount, and classification required by this Agreement. (f). Nothing in this Agreement or any action relating to this Agreement shall be construed as the City waiver of sovereign immunity beyond the limits set forth in Section 768.28, Florida Statutes. (g). The City shall not be obligated or liable under the terms of this Agreement to any party other than the Physician. There are no third party beneficiaries to this Agreement. (h). The Physician is an independent Physician and not an agent, representative, or employee of the City. The City shall have no liability except as specifically provided in this Agreement. (i). All insurance shall be primary to, and not contribute with, any insurance or self - insurance maintained by the City. The provision of insurance coverage shall not in any way cause the Physician's indemnification of the City to be reduced in any way or in any respect. Section 35: Equal Opportunity Employment/Non- Discrimination. The Physician agrees that it will not discriminate against any employee or applicant for employment for work under this Agreement because of race, color, religion, sex, age, national origin, or disability and shall take affirmative steps to ensure that applicants are employed and employees are treated during employment without regard to race, color, religion, sex, age, national origin, or disability. This provision shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment advertising; layoff or termination; rates of pay or their forms or compensation; and selection for training, including apprenticeship. The Physician, moreover, shall comply with all the requirements as imposed by the Americans with Disability Act, the regulations of the Federal government issued thereunder, and any and all requirements of Federal or State law related thereto. Section 36: Access To Records /Audit/Public Records. (a). The Physician shall maintain books, records, documents, time and costs accounts, and other evidence directly related to its provision or performance of services under this Agreement. All time records and cost data shall be maintained in accordance with generally accepted accounting principles. (b). The Physician shall maintain and allow access to the records required under this Section for a minimum period of five (5) years after the completion of the provision or 25 Physicians Services Agreement — Workers Compensation performance services under this Agreement and date of final payment for said services, or date of termination of this Agreement. (c). The City reserves the right to unilaterally terminate this Agreement if the Physician refuses to allow public access to all documents, papers, letters, or other materials subject to provisions of Chapter 119, Florida Statutes, and other applicable law, and made or received by the Physician in conjunction, in any way, with this Agreement. (d). The City may perform, or cause to have performed, an audit of the records of the Physician before or after final payment to support final payment under any Work Order issued hereunder. This audit shall be performed at a time mutually agreeable to the Physician and the City subsequent to the close of the final fiscal period in which services are provided or performed. Total compensation to the Physician may be determined subsequent to an audit as provided for in this Section, and the total compensation so determined shall be used to calculate final payment to the Physician. Conduct of this audit shall not delay final payment as required by this Section. (e). In addition to the above, if Federal, State, County, or other entity funds are used for any services under this Agreement, the Comptroller General of the United States or the Chief Financial Officer of the State of Florida, or the County of Seminole, or any representative, shall have access to any books, documents, papers, and records of the Physician which are directly pertinent to services provided or performed under this Agreement for purposes of making audit, examination, excerpts, and transcriptions. (f). In the event of any audit or inspection conducted reveals any overpayment by the City under the terms of the Agreement, the Physician shall refund such overpayment to the City within thirty (30) days of notice by the City of the request for the refund. (g). The Physician agrees to fully comply with all State laws relating to public records. (h). The Physician agrees that if any litigation, claim, or audit is started before the expiration of the record retention period established above, the records shall be retained until all litigation, claims, or audit findings involving the records have been resolved and final action taken. Section 37: Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, but all of which, taken together, shall constitute one and the same document. Section 38: Submittals. This Agreement describes each item that must be provided by the Physician to the City. All documents provided to the City by the Physician must be accurate and updated certifying that the Physician is proceeding correctly. 26 Physicians Services Agreement — Workers Compensation Section 39: Exhibits. Each exhibit referred to and attached to this Agreement is an essential part of this Agreement. The exhibits and any amendments or revisions thereto, even if not physically attached hereto, shall be treated as if they are part of this Agreement. In Witness Whereof, the parties hereto have made and executed this Agreement on the respective dates under each signature with the City acting through its City Commission and the Physician signing by and through its duly authorized corporate officer having the full and complete authority to execute same. T Name WVi 1— ef✓ Title: ; Florida Hospital Centra Care By: '::�& Scott Brady, ., Chief Medic fficer Date: \s a 'D ' /Lo Attest. Janet Dougherty, Clerk For use and reliance of the Sanford City Commission only. AaDroved as to form and le -q4W. �r 'Colbert \-' V t Attorney d J J/C 0)' &10V j A eh City Of Sanford Linda Ku , Mayor Date: 4(r� 27 Physicians Services Agreement — Workers Compensation CITY OF SANFORD EXHIBIT "B" PROJECT STATUS REPORT Project Name: Project Manager: Status Report Period; From: To: Phase: Planning ❑ Design ❑ Bidding ❑ Construction ❑ 1. In paragraph form, list the current status of the project and work completed this Billing Period. 2. In paragraph form, list all milestones reached this Billing Period. 3. In paragraph form, list any pending issues or items of note. Project Manager Signature: Date: 28 Physicians Services Agreement — Workers Compensation Centm Care FLORIDA HOSPITAL URGENT CARE nfofd. X ¢ d Injuries TABLE OF CONTENTS Section I Letter of Interest Section 2 General Information 1. Organizational Chart 2. Curriculum Vitae of Key Personnel Section 3 Florida Department of Professional Regulation Licenses Section 4 Additional Information • Centra Care Centers and Hours of Operation • Additional Program Offerings Section 5 Required Forms • Proposal Submission Form • Disputes Disclosure Form • Drug Free Work Place Form • Conflict of Interest Statement • Insurance Requirements Form • Florida Statutes on Public Entity Crimes • Certification on Non Segregated Facilities 0 April 19, 2010 C&nbu C,,.am FLORIDA HOSPITAL URGENT CARE F. William Smith Purchasing Agent City of Sanford ----- :----------- ... - -- _- - - -__. City Hall 300 North Park Avenue Sanford, Florida 32771 -1244 Dear Mr. Smith: It is with great interest that Florida Hospital Centra Care is responding to Solicitation Number: RFQ 09110 -06. Centra Care has had the privilege of working closely with Central Florida employers as well as local, state and federal governments to deliver work related injury treatment services and looks forward to the opportunity to provide workers' comp services to the City of Sanford. Centra Care recognizes the needs of the City of Sanford as outlined in this bid request and is committed to providing excellence in our service delivery. We are pleased to present our proposal that will not only meet the bid requirements as outlined, but which will continue to greatly enhance the resources and overall management of your workers' comp program. Centra Care has had a long -term commitment to workers' comp injury treatment services and has serviced the needs of thousands of Central Florida employers for the past twenty -five years. The true strength of our program is in our medical staff that has extensive experience in workers' comp treatment. Our physicians utilize clinical best practices and provide quality medical care, focusing on returning the injured employees to work in a timely manner with normal functioning. The following personnel are authorized to make representation for Florida Hospital Centra Care: Debbie Swartwood, Senior Sales Manager 901 North Lake Destiny Road, Suite 400 Maitland, Florida 32751 (407) 200 -2844 Email address: deborah.swartwood@flhosp.or Kim Tolley, District Manager 901 North Lake Destiny Road, Suite 400 Maitland, Florida 32751 (407) 200 -2844 Email address: kim.tolley@flhosp.or� On behalf of Centra Care, I thank you for consideration of our proposal and I look forward to the opportunity to discuss our program with you further. Sincerely, Scott C. Brady, M.D. President and Senior Medical Director KEYPERSONNEL Centra Care currently offer eighteen convenient locations throughout Central Florida. Our Sanford location is the closest location to the City of Sanford. Additionally, our Longwood, Altamonte and Oviedo locations are convenient to the City of Sanford and can also be utilized for workers' compensation injury treatment services. All of our Centra Care locations are staffed with Board Certified Physicians who have extensive experience in both occupational and workers' compensation injury treatment. The following is a listing of the dedicated physicians at the locations most easily accessible to the City of Sanford: SANFORD Physicians: Dr. Timothy W. Hendrix and Dr. Robert T. Williams Hours of Operation: M -F 8 a.m. — 8 p.m. S &S 8 a.m. — 5 p.m. Center Manager: Debbie Campbell 4451 West 1 St Street Sanford F132771 Phone (407) 320 -0734 Fax (407) 320 - 0866/320 -0957 ALTAMONTE: Physicians: Dr. Esaias W. Giorgis and Dr. John Felix Hours of Operation: M -F 8 a.m. — 8 p.m. S &S 8 a.m. — 5 p.m. Center Manager: John Del Rio 440 W. Highway 436 Altamonte Springs, FL 32714 Phone (407) 788 -2000 Fax (407) 788 - 2024/1026 LONGWOOD Physicians: Dr. Vandana B. Rao and Dr. Bernie Biltek Hours of Operation: M -F 8 a.m. — 8 p.m. S &S 8 a.m. — 5 p.m. Center Manager: Jill Justiniano 855 S. US Highway 17 -92 Longwood, FL 32750 Phone (407) 699 -8400 Fax (407) 699 - 4258/695 -2842 OVIEDO Physicians: Dr. John P. Feenburg and Dr. John M. Herberth Hours of Operation: M -F 8 a.m. — 8 p.m. S &S 8 a.m. — 5 p.m. Center Manager: Alex Figueroa 8010 Red Bug Road Oviedo, FL 32765 -8084 Phone (407) 200 -2512 Fax (407) 200 -2514 The following personnel are Key Personnel who are oversee our occupational health programs and will serve as additional support to the City of Sanford. Scott Brady. M.D. Dr. Scott Brady, Centra Care Administrator and Senior Medical Director, is Board Certified in Internal Medicine. Dr. Brady is a graduate of Davidson College and the Bowman Gray School of Medicine in Winston -Salem, North Carolina. He practiced Emergency Medicine for five years and urgent care /occupational medicine for the past twelve years. Dr. Brady has been the Florida Hospital Centra Care Senior Medical Director for the past eight years and Administrator for the past three years. In addition, Dr. Brady serves as Medical Director for Get Healthy Florida, a team of medical professionals that bring health education and health screenings to Central Florida; including mass -flu shot vaccination events, heart health education, colon cancer education and screening and women's health education. Tim Hendrix, M.D. Dr. Tim Hendrix, Centra Care Assistant Medical Director, is Board Certified in Family Practice. Dr. Hendrix is a graduate of Loma Linda University and completed his residency training in Family Practice at Florida Hospital. Dr. Hendrix has extensive experience in occupational medicine as a physician with Centra Care and with Walt Disney World Employee Health. He has also served on the Medical Team for the NBA Orlando Magic. Prior to his career in medicine, Dr. Hendrix served as a Volunteer Firefighter with the San Bernardino County Fire Department and California Department of Forestry. Elias Giorgis, M.D., MSPH Dr. Giorgis graduated from medical school in 1983. After his residency in 1986, he worked as an Emergency Room physician for two years. In 1988, he joined Florida Hospital Centra Care as a full time staff physician and has been practicing in the area of occupational medicine and family medicine since then. He is board certified in Occupational Medicine by the American Board of Preventive Medicine. His occupational medicine duties and experiences include treatment of work related injuries and illnesses; annual physical examinations for safety sensitive occupations such as fire fighters, police officers and corporate executives; fitness for duty evaluations; and post -offer physical examinations. He currently works at the Altamonte and Executive Services clinics of Florida Hospital Centra Care. Dr. Giorgis has worked in his current capacity as a staff physician for 18 years and served on the medical executive committee of Florida Hospital Centra, Care for four years. Byron Thames, M.D. Dr. Byron Thames is a graduate of the Duke University Medical School. He served as medical officer in the United States Air Force until he opened his practice in Occupational and Family Practice in Orlando in 1958. He has served as President of the Florida Occupational Association, Florida Academy of Family Physicians and the Florida Medical Association. He has served as the Chief of Staff at Orlando Regional Medical Center. Additionally, he has served as the Medical Director and/or Chief Medical Consultant for many businesses in Central Florida including Walt Disney World, Siemens Westinghouse, Orlando Utilities Commission, Lockheed Martin, Coca Cola Company Foods Division, Orange County Sheriff s Office, Orlando Police Department and numerous others. In these positions, he has provided occupational and general medical services. He is recognized today as the Dean of Occupational Medicine in Orange County by his peers. Additionally, he is certified as a Medical Review Officer and currently serves as the Medical Director for Florida Hospital Compnet. Barry Portnoy, M.D. Dr. Barry Portnoy is board certified in Internal Medicine and Gastroenterology and has a Masters in Public Health. Dr. Portnoy currently serves as the primary Medical Director for Orange County Government and actively serves as their Medical Review Officer. Dr. Portnoy has been a practicing physician for thirty years with a specialization during the past fifteen years in occupational and preventative medicine. His emphasis within his practice is on bringing prevention, wellness and fitness to our municipal clients. His goal is to promote a wellness initiative with every patient he sees and help employers achieve a healthy and fit work force. As a member of the American College of Occupational and Environmental Medicine, he serves on the Public Health committee. By attending meetings and keeping informed through professional contacts with other leaders in Occupational Medicine, he brings the latest information and state of the art medical practice to use for all of our municipal clients. Bonnie Sypolt, BSN, RN, NMCC, LHRM Bonnie Sypolt currently serves as the Director of Business Health Services for Florida Hospital Centra Care. Bonnie maintains licenses as a registered nurse and health risk manager in the State of Florida. In addition, she maintains certifications in risk management and managed care and continues membership in the National and State American Association of Occupational Health Nurses. Bonnie has expertise in consulting at the local, state and national level in the areas of occupational health, integrated disability, self insurance and administration, physician practice management and managed workers' compensation. Bonnie serves as an Internal Expert for the Malcolm Baldridge Healthcare quality criteria within the Florida Hospital System. Lorraine McInerney, BSN, RN As an RN, Lorraine spent the first five years of her career in primary health care. This included specific areas of medical - surgical nursing, maternal and pediatric health, family practice and ophthalmic nursing where job - related injuries were a daily occurrence. With this experience, Lorraine moved into areas of establishing medical practices as well as practice management with other medical emphasis such as chemical / drug dependency and call center nursing. While serving as the Florida Hospital Ask A Nurse Call Center for ten years, Lorraine developed the telephonic Notification of Injury line and revamped the Exposure Hotline into a 24/7 call center format. In addition, she served as the initial contact for employee catastrophic injuries. Since joining Florida Hospital Centra Care, Lorraine has completed the HIV /AIDS Counselor Certification course to compliment her experience with the Exposure Hotline and the all Line Accredited Claims Adjusted certification for additional skill and expertise in handling workers' compensation cases. In 2005, Lorraine also received her licensure as a Healthcare Risk Manager from the University of Central Florida. 1 LJ L I ' m m • CL V O M M 0 11 N L L l u Q (i) ,%V � L— . 0 c� N •� H O 0 �o CURRICULUM VITAE Timothy Wayne Hendrix, M.D. Address.._------ -_ -_ -_ Home: 711 Centenary Loop 4203 Lake Mary, FL 32746 Practice: Seminole Towne Plaza 308 North Entrance Road Sanford, FL 32771 Medical License: Florida - ME 65142 Telephone: Home: (407) 619 -3865 Office: (407) 629 -9281 Employment: 7/2004- present Medical Director, Centra Care 10/99- present Staff physician 7/94 - present 11/96 - 10/99 1996- 1999 1999 7/95 to 10/96 Residency: 7/93 to 6/95 Internship: 7/92 to 6/93 Florida Hospital Centra Care Sanford, FL -also worked part-time 11/96-10/99 Walt Disney Co. Occupational Medicine clinic, part-time RDV Sportsplex Family Practice - formerly College Park Family Practice, Orlando, Florida Medical Staff, NBA Orlando Magic Medical Staff, WNBA Orlando Miracle Orlando Health Care Group (Prucare) Orlando, Florida Family Practice Residency Florida Hospital Orlando, Florida Family Practice Residency Florida Hospital Orlando, Florida Medical School: 8/88 to 6/92 Loma Linda University Loma Linda, California Degree: M.D. Work Experience: 8/87 to 7/88 Research Assistant David Baylink, MD College: 9/83 to 5/87 Pepperdine University Malibu, California Degree: B.S. Biology Certifications: Fellow American Academy of Family Practice, 1999 Board Certified in Family Practice, 1995 Certified Firefighter I, California Dept. of Forestry, 1983 Angelus Oaks Volunteer Fire Dept. Licensure Exam: National Board of Medical Examiners 1993 Activities: 2001 - present Medical Executive Committee, Florida Hospital CentraCare 2002 - present Bioethics Committee Hospice of the comforter 1996 Peer Review Committee, . Orlando Heath Care Group Educational Affiliations: 1995 to 1997 Preceptor at Florida Hospital Family Practice Residency, Dr. Richard Milholm, Director Personal Data: Date of Birth January 11, 1965 Place of Birth Tracy, California Bibliography: Hendrix, T. and Evans, C. Does prior pelvic surgery effect the depth of insertion during flexible sigmoidoscopy? Poster presentation, 1994 Annual_ Scientific_ _ Assembly_of the American __ Academy of Family Physicians. Lundy, M, T. Hendrix, J. Wergedal, D. Baylink. Growth factor - induced proliferation of osteoblasts measured by bromodeoxyuridine immunocytochemistry. Growth Factors. 4(4): 257 -64, 1991. Simmons, D., L. Manson - Gieseke, T. Hendrix, K. Morris, S. Williams. Postnatal maturation of spiral ganglion neurons: a horseradish peroxidase study. Hearing Research. 55(1): 81 -91, 1991. Simmons, D., L. Manson - Gieseke, T. Hendrix, S. McCarter. Reconstructions of efferent fibers in the postnatal hamster cochlea. Hearing Research. 49(1 -3): 127 -39, 1990 Hendrix, T. Neuroanatomical features of the postnatal guinea pig cochlea. Honors Research Thesis. Pepperdine University, 1987. CURRICULUM VITAE Robert T. Williams, M.D. 102 Idyllwilde Drive Sanford, FL 32771 Home: (407) 322 -4629 Office (407) 322 -7906 EDUCATION Pre - Medical School: University of Florida Gainesville, FL Graduated June 1966 (B.S.) Medical School: University of Miami School of Medicine Miami, FL Graduated June 1970 (M.D.) Internship: Board Eligible: EMPLOYMENT EXPERIENCE August 1981 - Present July 1976 - December 1981 September 1973 - July 1976 September 1971 - August 1973 Duval Medical Center (Now University Hospital) Jacksonville, FL Straight Rotating July 1970 - June 1971 General Practice Family Practice Centra Care Medical Centers Sanford, FL (Acquired by Florida Hospital- 12190 Emergency Medicine Jess Parrish Memorial Hospital Titusville, FL Emergency Medicine Hialeah Hospital Hialeah, FL Family Practice Early Memorial Hospital Blakely, GA July 1971 - August 1971 Vacation i-urricuium vitae Robert T. Williams, M.D. Page 2 MEDICAL SOCIETIES: STATE­LICENSES Florida Medical Association Seminole County Medical Society American Academy of Family Physicians ----- -- Florida ME 0018673 Georgia Not Current C:0808971CVSAMLLLAMS o h D j'*)' - — u e r h e ir j b, D 508 Ridgeway Blvd. Deland Florida 32724 i'viamed with two adull children Juiy 2007 EDUCATION 1-1P1 'Ns High Qcbn , Mp q a qeilols h� co lle� Ohio. OrPT Kent State University, Kent, Ohio: 9/70-3/71 B.S. in Biological Sciences Kern Stale Unive]` vent. Ohio: 3/73-6175: M.S. in JAI'CT01)3010�v The Chvldjen's Hospital of Akron, Akron Ohio: School of Medical Tech-nolog) 775-7/76: MT(ASC-P) c-rj, uhlo. 9/7 & Elocloral ievel cou-Tsei,voj;, M, Curriculum and Instruction for post secondary schools 1_)hlo Unix els.'ry Coileo - c c 01 ljsleo-a ic medicipe Athens, C)h'(y Doctor of Osieopaihv -2, POST GRADUATE EDUCATION Jf)lemshjp at Brentwood ) 4) 10 Waijen-svffle Censer Road, WajTensv Nei phis, Ohjo44122: 2/83-1/84 n , 7- ra) P ) -riacl)cealbjej 4))O'y Wai-Ten5vdje Heighis. Ohio 44122 2/ Certification of Completion for ihe CuM for Occupational Medicine by the A-i College Of Occupa tional College V a ion-a] Medicine CeJ1jfiCa60D Of Completion for a Medical Revlc'%Nl Officer by the American College of Occupaiiortai Medicine C 0 n 6 1- j UJ)3 g JV, e, di c a! E du c a 'u"o j- c j e ", s , I 2 ITJ)1-3)j-TjUTT) c 3 1.) GJ ha ve aveyned hows Pei year since 1 985 i LICENSE Doctor of Osieopalbic Ivedicine licensed by: the State Medical hoard of Ohio 0036()4 the State of Flonda GS 9280 CER TIFIC A TI OT c A.irierican Osteopathic Board of Family Practice ' r Amercan Society or Clinical Pathn)e lv)eeiic,,l T ech.,olc,`�;st ORGANIZATIONS Aj- -enc °n OsleopailLc American College of Family Pr3cii70ners EMPLOYMENT Family Practice Medicine: Westshore Primary Cale Associates, Nonhndgeville, Ohio: 11,'06;02 io 8/3]/04 nr; 1, nr: A„ '/0 -7 Heahhways, Avon Lake, Ohio: 5/95 to 8/15/97 Westshore Primary Care Associates, Avon Lake Ohio 5/94 -4/95 I�E1j a i_ i U. _ n_��.:� A_.__ 7 nom: �,oc �, ai,d ,,, ,cr1Rht , a,,,r, y r 1 ac rC_ ry mow, La F_ v„3v. -to - „J Ernereency and Urgent Care Florida nosprtal Centea Care 90) 1 oi Lake Destiny Road, Suite 400, Maitlar;cl_ Florida- 12/9/04 to p ieseni Med Center, North Olmsted_ Ohio: 9/93 -5/94 Ohio Emergency Af diaies, 9/91 -8/93 occ Medic -i —e Co- Medicai Director of Occupaiionai Medicine USS/nOBE Sied, Lorain, Ohio: 0 8 /9I CURRICULUM VITAE JOHN PAUL FEENBURG D.O. Binh date: August 3, 1953 Wife: Laurie Beth Address: 335 Birchwood Court Son: Leigh Adam Lake Mary, Fl 32746 Daughter: Lisa Brooke Telephone: Home (407) - 330 -1751 SSAN 4 upon request Work (407) - 200 -2512 e -mail: Jfeenburg @aol.com - -- Cell (407)= 4-15=040 -1 - -- _.. ..___ _ urandsoh _._ _ __ _ - Zacliary (pending 7 -09) 1 "Utvrestp. .._ ._____ _.. '1 w Jpoi�S -- PROFESSIONAL To continue my constant learning and enjoyment in the practice of Family Medicine. OBJECTIVE: EDUCATION: Tatem - Brown Family Practice Residency Program Voorhees, New Jersey July '83 - June '86 Collage of Osteopathic Medicine and Surgery Des Moines, Iowa August '79 - June '83 Doctor of Osteopathic Medicine Manhattanville College Purchase, New York September '76 - January '78 Bachelor of Arts, Cwn Laude, Biology Major Rockalnd Community College Suffern, New York June '74 - June ' 76 Associate of Arts and Associate of Applied Science, Honors Avon Community College Award in Chemistry Biology, Chemistry and Math Majors Spring Valley Senior High School Spring Valley, New York September '69 - June '72 LICENSE: Medical - New Jersey ( 8/84 ) - 45005 Florida ( 9/86) OS 0005148 Workers comp cer 4/24/96 DEA 4 AF2862286 UPIN4 C59668 Blue Cross / Shield 4 80063 Medicare #t 0483303 - 00 Basic Life Support 7/83,6/85,10/86, 5/88,9/89,10/90,11/91,3/94, 11/07 Advanced Cardiac Support: 7/83,11/86,9/88,11/90,11/92,11/94,11/96,11/98, 8/00, 8/02 Pediatric Life Support 4/92, 5/94, 3/96 3/00 3/02 Advanced Trauma Life Support 12/84,1/87 /96, 8/00 Diagnostic Radiology Tech. ( NY. ) 1/75 Emergency Medical Tech. ( NY. ) 7/77 BOARD Diplomat - American CERTIFICATION: Board of Family Practice Certified 7/86 Rectified 7/93, 7/99, 7/2006 Fellow American Board of Family Practice 1999 MEMBER: American Academy Family Physicians MILITARY MacDill AFB, Florida EXPERIENCE: July'86 - July'90 Staff Physician - Family Practice USAF HPSP Scholarship Program Au -ust '79 - 3uly'83 - _ New York Air National Guar March '74 - November'78 Radiology Technician Emergency Medical Technician Pease AFB, New Hampshire November'73 - M3rch'74 Radiology Technician Westover AFB, Massachusetts January '73 - November '73 Radiology Technician Sheppard AFB, Texas School of Health Care Sciences August'72 - January'73 Radiology Technology Course, Honors Lakland AFB, Texas June '72 - August '72 Basic Training, United States Air Force WORK: Florida Hospital / Centra Care Oviedo Winter Park, Florida 32789 February '99- present University of Central Florida Student Health Center 4000 Central Florida Blvd. Orlando, Florida 32816 October 01 — June '08 Collegiate Health Care Director of Student Health Rollins College Winter Park, Florida August `95 — May '99 Orlando Health Care Group 300 North Lake Destiny Drive Maitland, Florida 32751 July 1 90 — February '9 Family Practice PhyAmertca November '88 — April '03 Emergency Room Physician / First Care Plant City Hospital: Plant City, Florida EM Care Emergency Room Group October '92 - September '93 South Seminole Hospital Longwood, Florida Emergency Room Physician Medicus Medical Group January'92 - September'9 South Seminole Hospital Longwood, Florida Emergency Room Physician Spectrum Emergency Room Group July'88 - June '90 Ed White Hospital St. Petersburg, Florida Emergency Room Physician Our Lady of Lourdes Hospital Camden, New Jersey September '85 - June '86 Emergency Room Physician West jersey Health System, Northern Division Camden, New Jersey September '84 - June '86 House Doctor (Intensive Care Unit) Tuxedo Memorial Hospital Tuxedo, NeW York January '77 - May '79 Staff Radiology Technician Curriculum Vitae John L. Felix, M.D. Education: 1998 ..2002 11111ledical- Doctor ___..._ University of South Florida College of Medicine Tampa, Florida 1994 -1997 Bachelor of Science in Molecular Biology Chemistry Minor University of Central Florida, Orlando, Florida 1987 Commercial Pilot, Single and Multiengine, Instrument Rating Flight Instructor American Flyers Academy, Fort Lauderdale, Florida 1982 -1986 Bachelor of Arts in History Aerospace Studies Minor University of Central Florida, Orlando, Florida Post Graduate Training: 7/07- Present Halifax Family Practice Residency Program Daytona Beach, Florida Sports Medicine Fellow 6/04-6/07 Florida Hospital Family Practice Residency Orlando, Florida Resident in Family Practice 7/02-5/04 Louisiana State University New Orleans, Louisiana Resident in Orthopaedic Surgery Licensure: Florida ME 96095 6/06 — present Louisiana 4026222 6/03— 10/05 Experience: 9/06- Present U. of Central Florida Student Health Clinic Orlando, Florida Urgent Care Physician 8/97-6/98 Florida Department of Law Enforcement Orlando, Florida Forensic Technologist 5/90-5/94 Atlantic Coast Airlines - SterTiizg; Virginia Line Captain 12/87 — 5/90 Flight Express Orlando, Florida Line Pilot Honors and Awards: President's List — University of Central Florida President's List — Seminole Community College Dean's List — University of Central Florida Dean's List — Seminole Community College Outstanding Freshman Chemistry Student — Seminole Community College Special Skills: Special interest in musculoskeletal and sports medicine Use of computers (desktop, laptop, PDA) in medicine Use of electronic medical records Research: Citations available upon request References: Available upon request Home Address: 1046 Big Oaks Boulevard Oviedo, Florida, 32765 Work Address: 303 North Clyde Morris Blvd. Daytona Beach, Florida 32114 (407) 254 -4167 Ext. 1538 CURRICULUM VITAE NAME: _ _ __ Esaias iniofde Viorgis� nn D, NiSPH DATE OF BIRTH: PRESENT ADDRESS: PRESENT POSITION: November 9, 1953 Florida Hospital Centra Care 440 West Highway 436 Altamonte Springs, Fl 32714 Staff Physician Florida Hospital Centra Care 440 West Highway 436 Altamonte Springs, Fl 32714 August 1986 to present PRESENT JOB DESCRIPTION: Board Certified in Occupational Medicine: Includes, but not limited to evaluation and treatment of workers compensation injuries and illnesses; minor surgical and orthopedic procedures; pre - placement and fitness for duty physicals for DOT, DEA, Immigration, Postal Inspection, Customs, Border Patrol and several local private companies; annual executive physicals for state and federal governmental agencies, fire, po-lice and other safety - sensitive positions as well as local companies; administration of routine and travel immunizations; performing on site of x -rays, EKG, Bruce protocol cardiac exercise stress testing, blood and urine analysis, eudiometry, tonometry, titmus, spirometry. Primary Care: Includes, but not limited to, evaluation, diagnosis and treatment of pediatric, adult,. and geriatric chronic and acute illnesses and minor injuries in an urgent care setting; minor surgical and orthopedic procedures; school and sports physicals; administration of routine and travel immunizations; performing on site of x -rays, EKG, blood and urine analysis. Curriculum Vitae Esaias W. Giorgis, AD, MSPH Page 2 EDUCATION: Doctor of Medicine Meharry Medical College 1005 Dr. D.B. Todd Blvd. __rvasnviire Tennessee _ 372 0 zi _. May 1983 Master of Science in Public Health Biostatistics Major Loma Linda University Loma Linda, California June 1979 Bachelor of Arts Chemistry Major Southern Adventist University Collegedale, Tennessee May 1977 TRAINING: Diplomate, American Board of Preventive Medicine: Board certified in Occupational medicine Surgery Resident Jacksonville Health Education Programs And the J. Hills Miller Health Center of the University of Florida Department of Surgery 580 West 8th Street Jacksonville, Florida 32209 July 1983 to June -1986 Anesthesia Resident University of South Florida Department of Anesthesiology 12901 Bruce B. Downs Blvd. Tampa, Florida 33612 July 1987 to March 1988 Curriculum Vitae Esaias W. Giorgis, M.D, MSPH Page 3 EXPERIENCE. - Sfaft 'Physician August 1986 to Present Florida Hospital Centra Care 440 West Highway 436 Altamonte Springs, Fl 32714 See my present job description above Member of Medical Executive Committee Florida Hospital Centra Care March 1993 - April 1997 A policymaking body of the Florida Hospital Centra Care Clinics, working with the medical director. Staff Physician July 1986 to December 1992 Coastal Emergency Services 475 Montgomery Place, suite 100 Altamonte Springs, Florida 32714 As an Emergency Room physician through Coastal Emergency Services Anesthesia Resident July 1987 to March 1988 University of South Florida Tampa, Florida I did not complete the program current position. resigned to take my General Surgery Resident July 1983 to June 1986 Jacksonville - Health -Education ffiPa Hospitals Of the University of Florida Jacksonville, Florida Post graduate training program in the department of Surgery Curriculum Vitae Esaias W. Giorgi', M.D, MSPH Page 4 Teaching and Research Assistant June 1980 to June 1983 Meharry Medical College Nashville, Tennessee _ S -ummer programs ofi ivic a y •'��"' liege Research Assistant September 1977 to June 1979 Loma Linda University Loma Linda, California Graduate school research assistant SPITAL PRIVILEGES: Florida Hospital C436a Care HO 440 West Highway Altamonte Springs A 32714 August 1986 to present See my present job description above Bartow Memorial Hospital Emergency Department 1239 E. Main Street Bartow, Florida 33830 March 1988 to July 1992 services Through Coastal Emergency South Florida Baptist Hospital Emergency Department 301 North Alexander 33566et Plant City, Florida i 1990 May 1989 to May services Through Coastal Emergency Humana Hospital - Sun Bay Emergency Department 3030 6th Street F ° 33705 St. Petersburg, March 1990 to December 199 Through Coastal Emergency es Highlands Regional Medical Centers Emergency Department Curriculum Vitae Esaias W. Giorgis, AD, MSPH Page 5 3600 South Highlands Avenue Sebring, Florida 33870 August 1986 to December 1989 Through. Coastal Emergency services Lykes Memorial Hospital Emergency Department 100 South State Road 700 Brooksville, Florida 33512 July 1986 to June 1988 Through Coastal Emergency services LICENSURE: To Practice Medicine in the State of Florida Department of Professional Regulation Board of Medicine 1940 North Monroe Street Tallahassee, Florida 32399 Medical License No. ME0046718 July 1985 to Current CERTIFICATION: Diplomate American Board of Preventive Medicine (Board Certified in Occupational Medicine) January 2006 to January 2016 National Board of Medical Examiners #285716 1984 American Heart Association Basic Life Support July 2007 — July 2009 American Heart Association Advanced Cardiac Life Support July 2005 — July 2007 I i i,� Curriculum Vitae 1v1SPH Esaias W. Giorgis, M-D, Page 6 American College of Surgery .Advanced _ma Life Support _._... June 1986 Controlled Substance Registration DEA #-. AG32019 November 2003 Advance Pediatric Life Support July 1985 ORGANIZATIONAL American College of Occupational and EMBERSHIPS: Environmental Medicine M 1114 North Arlington Heights Rd. Arlington Heights, IL 60004 Florida Association of Occupational and Environmental Medicine 30402 USF Holly Drive Tampa, Florida 33620 American Medical ation 535 North Dearborn Street Chicago, Illinois 60610 American Professional Practice Association 292 Madison Avenue New York, New Y-or-k -10 Meharry Medical College Alumni Association 1005 Dr. D.B. Todd Nashville, Tennessee Curriculum Vitae Esaias W. Giorgis, M•D, MSPH Page 7 Loma Linda University Alumni Association Loma Linda, California 92354 t" r Southern A ven , , ISL -- u Alumni Association Collegedale, Tennessee 37315 1 L BERNARD BILTEK, M.D. — Curriculum Vitae EDUCATION AND QUALIFICATIONS Bachelor of Medical Science, University of Alberta, May 1976 (graduated with distinction). Awarded the Robert Tegler Scholarship for academic standing May 1974. - Doctor of Medicine (M.D. degree) University of Alberta, June 1978 (graduated with distinction — class standing 8th out of 120). - L.M.C.C. exams (Licentiate of Medical Council of Canada) written in June 1978. - Completed one year Rotating Internship, June 1979, at the Royal Alexandra Hospital in Edmonton, Alberta and became a licentiate of the Medical Council of Canada. - Completed Second Year Prelicensure Residency, June 1980, at the Royal Alexandra Hospital in Edmonton, Alberta and became registered as a member of the College of Physicians and Surgeons of Alberta. (At that time Alberta was the only province that Required two years post graduate training for licensure.) - Wrote the College of Physicians and Surgeons examination in EKG interpretation to qualify me as a family practitioner to interpret EKG's, 1981. - 1986 - Completed the oral and written examination for Certification in Family Medicine, College of Family Physicians of Canada (finished in top 25 %). - 1995 - Completed the USMLE Step I — Score 214 (above average) and Step 11— Score 262 ( >3 standard deviations above the mean). - 1996 — Completed the USMLE Step III — Score 255 ( >2 standard deviations above the mean). - 1996 — Completed the American Board of Family Practice Certification Examination. Score - above the 99` percentile. - 2002 — Completed the American Board of Family Practice Recertification Examination. Score - above the 99` percentile. - 2009 - Completed the American Board of Family Medicine Recertification Examination. Score- above the 99 percentile. - 2009 - Completed the American Board of Urgent Care Certification Examination EXPERIENCE - 19 72 - Worked as "a nursing orderly on C7rthopedics for 4 months at the Roya't Alexandra Hospital to finance university training. -1973 — Worked as a nursing orderly for 4 months on Medicine at the Royal Alexandra Hospital. -1974 — Spent 4 months researching cutaneous blood flow in diabetics at the Department of Physiology — University of Alberta. -1980 to 1983 — Worked as consulting physician to the Alberta Alcoholism and Drug Abuse Commission on a part time basis. Work involved facilitating substance abusers' withdrawals and evaluating them for any general medical problems. -1980 to 1995 — Member of the active staff of the Royal Alexandra Hospital, Department of Family Medicine, Edmonton, Alberta, Canada. Responsibilities included treatment of medical and pediatric admissions to hospital from my medical practice. - Served on the Pharmacy and Therapeutics Committee. - Participated in teaching of clinical skills to medical students. -1980 to 1986 — Worked frequent shifts in the Royal Alexandra Hospital Emergency Department on a part time basis as an emergency physician. -1980 to 1995 — Member of the active staff of Capital Care Group Chronic Care Facilities, Edmonton, Alberta, Canada. Responsibilities largely geriatric care. - Served on the Medical Liaison Committee. -1980 to 1995 — Solo family medical practice in northern Edmonton, Canada. Same location for 15 years. Good mixture of pediatrics, adult medicine, geriatrics and gynecology. Patient volume 30 —35 patients per day. Did obstetrics at the Royal Alexandra Hospital until 1988 when I decided to devote more time to my family. Shared call rotations with six other family physicians from the Royal Alex. -1995 to 2000 —Family Practice in Peoria, Illinois. General Family Practice, no obstetrics. Medical staff member of Peoria's three major hospitals. Responsibilities included inpatient and outpatient care. Did occasional shifts in urgent care centers in Peoria. Also worked some shifts in a family practice in the underserved area of Stark County. - Served on the quality care committee. - Learned flexible sigmoidoscopy. -2000 to 2003 — Family Practice in Orlando with Physician Associates of Florida, a large primary care group in the Orlando area. Member of the active staff of the Orlando ... ... _.._. _ _ �_ F -"a TT...,�:a,. _.. yst D utie s n ero_n itxvoe t Only with the-grou ..._. Regional I`lorid Hospi al - sys t ems. vvt t� v2a�r vua) ... h t using hospitalists for inpatients. -2003 to present — Urgent Care with Florida Hospital Centra Care. PERSONAL DATA -Date of Birth: January 22, 1955 -Place of Birth: Edmonton, Alberta, Canada - Citizenship: U. S. citizen - Marital Status: Married. Two sons born in 1987 and 1989. My wife Erna, who is originally from Holland, is a veterinarian. - Interests: Music, bicycling, gardening, theater and travel. CURRICULUM VITAE Vandana Rao, D.O. Address and Telephone 573 Bent Pine Court Sanford, FL 32771 (40) � 8 1114 Education •Florida Hospital East Orlando Residency, July 2001 - June 2003 Internship, July 2000 —June 2001 •Midwestern University — Chicago College of Osteopathic Medicine (Downers Grove, Illinois) Doctor of Osteopathic Medicine, June 2000 *University of Illinois at Urbana /Champaign Bachelor of Science in Psychology, June 1995 Honors and Awards *Rich Central High School Hall of Fame Award, 2001 •Illinois Academy of Family Practitioners Externship Program Participant, 1997 *Psi Chi (Psychology Honorary). University of Illinois, 1993 -1995 •Deans List. University of Illinois, 1991 -1995 *Alpha Lambda Delta Honorary. University of Illinois, 1992 -1995 *James Scholar. University of Illinois, 1991 -1992 •Illinois State Scholar, 1991 Leadership and Extracurricular Activities • Florida OPTI Representative. AOA Convention, Las Vegas 2002 •Student Osteopathic Medical Association - Fundraising Committee. Chicago College of Osteopathic Medicine, 1997 -1998 •Freshman Orientation Student Representative. Chicago College of Osteopathic Medicine, 1997 *Volunteer Illini Projects - Blood Drive Public Relations Coordinator. University of Illinois, 1994 -1995 Career Related Employment and Volunteer Experience •Florida Hospital Centra Care. February 2004 - present •Volunteer. Centra Care Flu Shot Campaigns •Volunteer. Disney Marathon, 2003 •Mission Trip. Dominican Republic - Cervical Cancer Screening, March 2001 •Student Tutor. Chicago College of Osteopathic Medicine, 1998 •Pediatric Oncology Group Clinical Research Associate. Cook County Children's Hospital (Chicago, Illinois), 1996 Professional Society Membership *American Osteopathic Association, 1996 - present •American College of Osteopathic Family Physicians, 1996- present •American Academy of Family Physicians, 1996- present Certification *Board Certification Family Practice, 2003 -Basic Life Support Certification *Comprehensive Osteopathic Medical Licensing Examination (COMLEX) - LevelT: June 1998, passed -Level 2: March 2000, passed -Level 3: February 2001, passed References can be provided upon request CURRICULUM VITAE BARRY F. PORTNOY M.D., M.P.H. & T.M., F.A.C.P. CURRICULUM VITAE — BARRY PORTNOY, M.D. Paae 1 CURRICULUM VITAE BARRY F. PORTNOY M.D., M.P.H. & T.M. F.A.C.P. Address: P.O. Box 161416 Altamonte Springs, FL 32779 EDUCATIONAL BACKGROUND Post - Graduate Medical Education Fire Surgeon certification course Phoenix Fire Dept June 2006 International Assoc. of Firefigthters Redmond Conference, San Francisco, Sept. 2003 American Association of Medical Review Officers Certification #011021211 Oct. 21, 2001, re- certified Aug. 2004, July 2009 Master of Public Health and Tropical Medicine School of Public Health, Tulane University, New Orleans, Louisiana, Dr. D'Alessandro, Acting Chief, Department of Tropical Medicine, Master of Public Health and Tropical Medicine (M.P.H. & T.M.) 1986-1987 Fellow in Gastroenterology, Yale University, New Haven Medical Center, New Haven, Connecticut Dr. Howard Spiro, Chief 1969-1971 Senior Investigator Clinical Attending, National Heart Institute, Section of Experimental Therapeutics, National Institute of Health, Bethesda, Maryland, Dr. Albert Sjoerdsma, Chief 1967-1969 Resident in Internal Medicine, Albert Einstein College of Medicine, Bronx Municipal Hospital Center, New York, New York, Dr. Inning London, Chief 1966-1967 Intern in Medicine Albert Einstein College of Medicine, Bronx Municipal Hospital Center, New York, New York, Dr. Irving London, Chief 1965-1966 Medical School Columbia College of Physicians and Surgeons, New York, New York, M.D., Second in class of 120. 1965 Collegiate: New York University College of Arts and Sciences, New York, New York A.B, Cum Laude with honors 1961 Princeton University, Princeton, New Jersey 1958-1959 Pre - Collegiate Roscoe B. Jackson Memorial Laboratory research program, Bar Harbor, Maine 1957 Hiqh School Bronx High School of Science, Bronx, New York 1958 Honors Medical School Allen Fund Scholar Frederick P. Gay Award in Microbiology Merck Award Alpha Omega Alpha, Honorary Society College Class of 1918 Scholar, Princeton University Phi Beta Kappa, New York University Founder's Day Award, New York University High School Arista, National Honor Society Westinghouse Scholar - - New York Sfete Regents 8chola r CURRICULUM VITAE — BARRY PORTNOY M.D. Page 2 Medical Board Certifications Di lomate, Sub - Specialty Board of Gastroenterology, American Board of Internal Medicine 1972 Di lomate, American Board of Internal Medicine Di lomate, National Board of Medical Examiners 1971 1965 Fellowship Fellow American College of Physicians 1973 Current Medical Licenses State of Florida (ME 0015367) State of North Carolina (23646) Continuing Medical Education Advanced Cardiac Life Support Certification 2008 Advanced Trauma Life Support Certification 1990 Military Service Lieutenant Commander, United States Public Health Service Surgeon, National Heart Institute, National Institutes of Health, Bethesda, Maryland 1967-1969 Post - Graduate Non - Medical Education Stetson University enrolled in Art Department under Dan Gunderson doing independent studio ceramics, Deland, Florida 1986 Daytona Beach Community College enrolled in Art Department specializing in ceramics under the instruction of Stephen Marsh and Shiiko Alexander, Daytona Beach, Florida 1984-1986 Embry - Riddle Aeronautical University enrolled in aviation sciences department. Obtained private pilot's license, Daytona Beach, Florida 1982-1983 Society Memberships Medical American College of Occupational and Environmental Medicine (ACOEM) WORK EXPERIENCE: Occupational Medicine: Medical Director at Florida Hospital CentraCare Executive Services - (Oc. Med., Travel Med., Immigration) (Employed by Florida Hospital CentraCare, Orlando, FL, Dr. Brady, Administrator) 2001 — Present Occupational Medicine Physician at Florida Hospital CentraCare OC. Med. and ambulatory care clinics. Primary Care: (Employed by Florida Hospital CentraCare, Orlando, FL, Bill Haupt, Wally Welch, Administrators) 1995 — Present Physician at OC. Med. and ambulatory care clinic. (Employed by Mediclinic, Kissimmee, FL, Sandra White, President) 1991 — 1995 Emergency Director Emergency Department of Hardee County Memorial Hospital, Wauchula, Florida. Medicine: (Employed by Coastal Emergency Services, Orlando, FL, Dr. J. Williams, CEO) 1990-1991 Emergency Medicine Physician, South Florida Baptist Hospital, Plant City, Florida. (Employed by Coastal Emergency Service, Orlando, FL, Dr. J. Williams, CEO) 1989-1990 Emergency Medicine Physician, Lake City Emergency Center, Lake City, Florida. (Employed by Coastal Emergency Services, Orlando, FL, Dr. J. Williams, CEO) _ 1988 —1989 CURRICULUM VITAE -BARRY PORTNOY, M.D. Page 3 Emergency Medicine Physician, Cape Canaveral Hospital, Cocoa Beach, Florida. (Employed by Dr. W. Hyden, M.D.) 1989 Emergency Medicine Physician, Waterman Medical Center, Eustis, Florida. (Employed by St. John's Emergency Physicians Group, Stanford, FL, Dr. Toddy Husty, D.O.) 1988-1989 Emergency Medicine Physician, Central Florida Regional Hospital, Sanford, Florida. (Employed by Dr. Marek Voit, M.D.) 1988 Emergency Medicine Physician, Humana Hospital, Daytona Beach, Florida. (Employed by Emergency Medical Services Associates, Plantation, FL, Dr. Cecilia Johnson, M.D.) 1987-1988 Public Health Public Health Medical Officer, Volusia County Health Department. Acted as cardiologist in charge of Medicine: cardiovascular clinic, served as referral internist for staff; rendered primary care. (Employed by State of Florida, Department of Health and Rehabilitative Services, Daytona Beach, FL, Dr. W. Cox, M.D., Director). 1987-1988 Medical Practice: Internist and Gastroenterologist in a large comprehensive medical and surgical group practice serving 30,000 people in rural Virginia. Functioned at both the primary care level and as a consultant for patients and physicians in 100 mile referral area. Extensive endoscopy experience, out - patient, and in- patient acute hospital care. (Pulaski Medical Association, Pulaski, VA 24301) 1977-1980 Primary care internist and Gastroenterologist in my own solo office practice. Extensive geriatric practice with complex care. Large referral practice involving several hospitals; extensive in- patient care and endoscopy. (Barry F. Portnoy, M.D., P.A., Hollywood, FL 33021 — see managerial) 1972-1977 Internist - Gastroenterologist in sub - specialty medical practice group of four Internists. (Nitzberg & Rodensky, P.A., Hollywood, FL 33021) 1971 —1972 Conducted and managed clinical drug trial research while providing patient care as a Surgeon in the United States Public Health Service at the National Heart Institute, Bethesda, Md. and as a Fellow in Gastroenterology at Yale -New Haven, CT medical center. 1967-1971 Part -time employment as Internist - Generalist providing clinic, emergency, and in- patient hospital coverage while continuing graduate medical education. 1965-1971 Managerial Corporation: Barry F. Portnoy, M.D., P.A. Experience: 4490 Sheridan Street Hollywood, FL 33012 President/Chairman of Board of Directors Barry F. Portnoy, M.D. Description In 19721 started the corporation with less than 1000 patients and built an office of 1000 sq. ft. In 1974 1 of Corporation moved and built a 4000 sq. ft. office having expanded the practice to 5000 patients. I hired another Practice: physician who left after one year to join a large group, and I remained the sole practitioner. My office included examining rooms, consultation rooms, complete laboratory, X -ray equipment, business offices, library, staff lounge /kitchen, I recruited, selected, placed, and trained all employees of the corporation. I directed a staff consisting of a business /office manager, two nurses, receptionist, appointment clerk, Insurance person, X -ray technician, laboratory technician, typist/transcriptionist. Teaching Appointments: Clinical Instructor Departments of Internal Medicine and Gastroenterology, University of Miami Medical School and Miami Veterans Administration Hospital, Miami, Florida 1971 —1977 Staff of Broward Community College providing externship in clinical laboratory training at my medical practice as part of the required college course program, Hollywood, Florida 1973-1977 Instructor and founder of Gastroenterological Training Program at Hollywood Memorial Hospital, Hollywood, Florida, in conjunction with University of Miami Medical School 1973-1975 Clinical Attending Albert E_ ins_t_e College_ of Medicine, New York, New York 1969 -1971 CURRICULUM VITAE —BARRY PORTNOY. M.D. Page 4 Hospital Appointments: Clinical Fellow Yale University College of Medicine and West Haven Veterans Administration Hospital, New Haven, Connecticut 1969-1971 Clinical Attending Senior Investigator, National Heart Institute, National Institutes of Health, Bethesda, Maryland 1967-1969 Attending: Hardee Memorial Hospital, Wauchula, FL 1990-1991 South Florida Baptist Hospital, Plant City, FL 1989— 1990 Lake City Emergency Center, Lake City, FL 1988-1989 Cape Canaveral Hospital, Cocoa Beach, FL 1989 Waterman Medical Center, Eustis, FL 1988-1989 Central Florida Regional Hospital, Sanford, FL 1988 Human Hospital, Daytona Beach, FL 1987-1989 Pulaski Community Hospital, Pulaski, VA 1977-1980 Bennett Community Hospital, Plantation, FL 1975-1977 Pembroke Pines General, Pembroke Pines, FL 1975-1977 Lauderdale Lakes Hospital, Lauderhill, FL 1974-1977 Biscayne Medical Center, N Miami Beach, FL 1974-1977 Doctors Hospital, Hollywood, FL 1972-1977 Golden Isles Hospital, Hollywood, FL 1972-1974 Hollywood Memorial Hospital, Hollywood, FL 1971 —1975 University of Miami Med. Center, Miami, FL 1971 —1977' Johnson Memorial Hospital, Stafford Spgs., CT 1969-1971 Park City Hospital, Bridgeport, CT 1969-1971 Yale University Med. Center, New Haven CT 1969-1971 Albert Einstein College of Medicine, N.Y., NY 1969-1971 Holy Cross Hospital, Silver Springs, MD 1967-1969 Wadsworth Hospital, N.Y., NY 1966-1967 Research Experience: Research in clinical pharmacological studies of steroids and azathioprine in double blind crossover controlled studies of patients with ulcerative colitis and regional enteritis, at Yale University Medical Center, New Haven, Connecticut. 1969-1971 Research in biochemistry and pharmacology of catecholamines; development of new double - labeled radio - isotope assay method for measurement of blood levels of epinephrine and norepinephrine; its application in clinical studies of hypertension and mental depression in patients; clinical and pharmacological studies -of pheochromocytomas and carcinoid syndrome study -of new drugs -in -the therapy of pheochromocytomas , carcinoid syndrome and essential hypertension, at the National Hearth Institute and National Institute of Mental Health, Bethesda, Maryland 1967-1969 Research in biochemistry and pharmacology of biogenic amines at Geigy Pharmaceutical Laboratories, Ardsley, New York 1962-1963 Research in histochemistry of demyelinating disease in the "Wobbler- Lethal" mouse model of muscular dystrophy, at Bronx Veterans Administration Hospital, Bronx, New York, and Seton Hall College of Medicine, Jersey City, New Jersey 1957-1961 Research in histochemistry of muscle enzymes in genetically controlled mice, at the Roscoe B. Jackson Memorial Laboratory, Bar Harbor, Maine 1957-1958 Fields of Current Medical and Scientific Interests: Broad interests in Occupational Medicine (especially public safety positions), Travel and Geographic Medicine, Preventive Medicine, Emergency Medicine, Primary Care, Internal medicine, and Gastroenterology. Currently on the physician advisory panel to Sanofi- Pasteur for vaccines. - --- CURRICULUM VITAE -BARRY PORTNOY M.D. _ Page 5 Publications: Kaplan H., Portnoy B., Binder H., et al. A Controlled evaluation of Intravenous adrenocorticotropic hormone and hydrocortisone In the treatment of acute colitis. Gastroenterology 69:91- 95,1975 Kaplan H., Binder H., Portnoy B., et al. Double blind controlled study of ACTH and hydrocortisone In acute colitis. (Abstract) Gastroenterology 64:681,1971 Engelman K., Portnoy B.F., Kupfer D., et al. Resting plasma catecholamine concentration in patients with depression and anxiety. Arch. General Psych. 24:65- 70,1971 Engelman K., Portnoy B.F., Sjoerdsma A. Plasma catecholamine concentrations In patients with hypertension. Circulation Research 1:1- 141 -1 -146, 1970 Engelman K., Portnoy B.F. A sensitive double Isotope derivative assay for norepinephrine and epinephrine, Normal resting human plasma levels. Circulation Research 26:53- 57,1970 Portnoy B.F., Engelman K., Wyatt R. Plasma catecholamines In hypertensive and psychiatric disorders. (Abstract) Clinical Research 17:258,1969. (paper presented 5 -4 -69 at the Am. Fed. Clin. Res. National meeting in Atlantic City, New Jersey) Engelman K., Portnoy B.F., Lovenberg W. Untra- sensitive specific double isotope derivative method for the determination of catecholamines.. (Abstract) Clinical Research 16:228,1968 Engelman K., Portnoy B.F., Lovenberg W. A Sensitive and specific double isotope derivative method for the determination of catecholamines in biological specimens. American J. Med. Sciences 255:259- 268,1968 DEA Certificate DEA REGISTRATION THIS REGISTRATION FEE NUMBER - EXPIRES PAID BH3813537 10 -31 -2011 Paid SCHEDULES BUSINESS ACTIVITY DATE ISSUED 2,2N,3 PRACTITIONER 09 -05 -2008 3N,4,5 HENDRIX, TIMOTHY WAYNE MD FLORIDA HOSPITAL CENTRA CARE 308 NORTH ENTRANCE ROAD SEMINOLE TOWNE PLAZA SANFORD, FL32771 r r r r r r 1 t r r I 1 r Page 1 of 1 CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C. 20537 Sections 304 and 1008 (21 U.S.C. 824 and 958) of the Controlled Substances Act of 1970, as amended, provide that the Attorney General may revoke or suspend a registration to manufacturer, distribute, dispense, import or export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C, 20537 DEA REGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID SH3813537 10-31 -2011 Paid SCHEDULES BUSINESS ACTIVITY DATE ISSUED - 2,2N,3 PRACTITIONER OMS -2008 3N,4,5 c ° HENDRIX, TIMOTHY WAYNE MD iq Sections 304 and 1008 (21 U.S.C. 824 and 958) R FLORIDA HOSPITAL CENTRA CARE Controlled Substances Act of 1970, as amended. 1 N 308 NORTH ENTRANCE ROAD that the Attorney General may revoke or susl SEMINOLE TOWNE PLAZA registration to manufacture , distribute, dispense, in G w SANFORD, FL 32771 export a controlled substance. 0 E THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, BUSINESS ACTIVITY, OR LL AFTER THE EXPIRATION DATE. httDS: / /www.deadiversion.usdoi. eov /webfon /DrintCertlmag 9/5/9.008 DER The M. named ,TE OF FLORIDA TMENT.OF'%..HEALTH jr of n1-IAL!F.!(--ATI-0-N - t - 6 - of'Florida. - - _ "" DISPENSING PRAC'T ARY 31, 2012 ' w J Or z O V �t rn LU � y (n O Z ^ O N N a Z Lo a w �r I LD a U m c o n U r W W E LL > w J �[ u _U O O w � S O L S p °' d Z V W � N a U W a _ t Q J axu LL Lam_ O E ° o OW O J 5 w m O _J f- Z LL0 w F LL w LL � < a U 3 C O O F CD O r L w 0 o w a o c 3 W 6 ~ a. a a > ¢ a m m E n z w UJ U O w 0 F- U_� H C L w Df O rn � a O Q w O li O LL n a w In w w O . 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ISSUED : o. r THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP,. CONTROL, LOCATION, OR BUSINESS ACTIVITY, ANDJS.NOT VALID AFTER THE. EXPIRATION DATE. that .the regis hat expon a v 0 in 0 M CN a w C) E 0 �L HERBERTH;:JOHN M, DO FLORIDA HOSPITAL CENTRA CARE 8010 RED BUG LAKE RD OVIEDO, FL 32765 THIS CERTIFICATE.IS NOT TRANSFERABLE ON CHANGE:OF Page l of a or IIR CONTROL, LOCATION, BUSINESS ACTIVITY, OR VALID CONTROLLED.SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES OF JUSTICE DRUG' ENFORCE MENT ADMINI.ST.RATION r WASHINGTON, D.C, 20537 PEA REGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID AH2384802 10 -31 =2011 Paid SCHEDULES BUSINESS ACTIVITY - .DATE . ISSUED : 2,2N,3 [ 3N,4,5 PRACTITIONER 09-15-2008: 5 v 0 in 0 M CN a w C) E 0 �L HERBERTH;:JOHN M, DO FLORIDA HOSPITAL CENTRA CARE 8010 RED BUG LAKE RD OVIEDO, FL 32765 THIS CERTIFICATE.IS NOT TRANSFERABLE ON CHANGE:OF Page l of a or IIR CONTROL, LOCATION, BUSINESS ACTIVITY, OR VALID �. T _0 > v 'O (A � -i _ - m m' mD -i ° 0 �o r ii CL m -Di o m. „ Q3 .,.:::� 0 . "o` c � z:r cp :m O m .` CD (� M D = uT (n M 3 D Z �/ o� Z 5. N N D D N n j a N o O Z C Z ! \. D — N a O > D C 2 m m �� '> ' ZK Ea•? � o z. CD O Lo el Cf) c 3 0 CD, T7. - 6 5 x' ::T E =3 (D m C:) > 0 m - 0 0 o: - 0 m 0 > p ) - n D C', c > r CO r-. 0 w :3 o m - 1 .-1 . C - n OL) m, G) m 0- 0 cn r m Cr , > ID N > LM 71 co m C: U) �o CD C) 0' C: C) CD Y-3 - 0 m ul r -Ti > 0 w O U. rT ."C (Y) m intable DEA Certificate DEA REGISTRATION - THIS REGISTRATION FEE NUMBER ..,:., ;EX ?IRES. PAID AFZI 862286 09 3D 201b Paid � SCHEDULES ,BUSINES.S;ACT,IVITY _ DATE ISSUED 13N,4,5 _ FEENBURG JOHN_P DO FLORIDA HOSPITAL CENT CARE 8010 RED BUG LAKE .ROAD OVIEDO, FL 3276A CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES . DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C. 20537 Sections 304 and 1008 (21 U.S.C. 824 and 958) of the Controlled Substances Act of 1970, as .amended, provide that the Attorney General may revoke or suspend a registration to manufacturer, distribute, dispense, import or export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IS,NOT VALID AFTER THE EXPIRATION DATE. Page 1 of 1 CONTROLLED SOBSTANCE:REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D:C, 20537 v 0 LO ! M N ud E 0 LL °k. DEA REGISTRATION THIS REGISTRATION FEE `- NUMBER EXPIRES PAID AF2862286 0930 -2010 Raid: SCHEDULES BUSINESSACTIVITY DATE ISSUED . 2 PRACTITIONER 0"1 -2007 3N 4,5 FEENBURG; JOHN P DO Sections 304 and 1008 (21 U S C 824 and 958) of the: FLORIDA HOSPITAL CENTRA CARE Controlled Substances Actof.1970 as amended; "provide 4010RED'BUG LAKE ROAD that the; Attomey Gener61 may revoke or suspend a OVIEDO, FL 32765 registration to manufacture distribute dispense ,import or export a controlledsubstance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, BUS I NESS ACTIVITY, OR VALID AFTER THE EXPIRATION DATE EA Certificate Page 1 of 1 CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C. 20537 v 0 0 Ch N c w E b LL DEAREGISTRATION THIS REGISTRATION CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE I UNITED STATES DEPARTMENT OF JUSTICE I DRUG ENFORCEMENT ADMINISTRATION DEA REGISTRATION THIS REGISTRATION FEE NUMBER NUMBER EXPIRES PAID PAID I WASHINGTON. D.C. 20537 BF9809142 BF9809142 09 -30 -2012 Paid Paid r 1 I I SCHEDULES BUSINESS ACTIVITY DATE ISSUED BUSINESS ACTIVITY 2,2N,3 PRACTITIONER 08 -27 -2009 3 N,4,5 Sections 304 and 1008 (21 U.S.C. 824 and 958) of the Controlled 3 N,4,5 FELIX, JOHN`L':fND I Substances Act of 1970, as amended, provide that the Attorney CENTRACARE' Sections 304 and 1008 (21 U.S.C. 824 and 958) of the I General may revoke or suspend a registration to manufacturer. 440 WEST HIGHWAY 436 r distribute, dispense, import or export a controlled substance. ALTAMONTE SPRINGS, FL 32714 CENTRACARE that the Attorney General may revoke or suspend a 440 WEST HIGHWAY 436 I registration to manufacture , distribute, dispense, import or ALTAMONTE SPRINGS, THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF export a controlled substance. I OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND 15 NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C. 20537 v 0 0 Ch N c w E b LL DEAREGISTRATION THIS REGISTRATION FEE - - NUMBER EXPIRES PAID BF9809142 09 -30 -2012 Paid SCHEDULES BUSINESS ACTIVITY DATE ISSUED F 2,2N,3 PRACTITIONER 08.27 -2009 3 N,4,5 Sections 304 and 1008 (21 U.S.C. 824 and 958) of the FELIX, JOHN L, MD Controlled Substances Act of 1970, as amended, provide CENTRACARE that the Attorney General may revoke or suspend a 440 WEST HIGHWAY 436 registration to manufacture , distribute, dispense, import or ALTAMONTE SPRINGS, FL 32714 export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, BUSINESS ACTIVITY, OR VALID D r 0. O M D i� � m z io T IS M 'D ,r S o o � n p w � c. ". CD M Z r o w p w ,p w o G w �'n n c) rn o " o n n C n n a u ' w' n� 0 r 0 0 o n o r a o n• n a c n v 7C r- l 0 n n � 7 � n — G 0. E m m named kelow has:met all requirements of. tj n � 0 " N ° " G N 7 zj O ° 7 CL w Y c w cD. nr z n L n N 7 n n o n - 0 p o n n d O n w 3 7 n ED 0. 7 y a o O, l0 w d " -. d yy L O n x o o < o � - 7 ^ , _ C 0 O n 0 o n w n o .^ n 1 w ^ - v n n rl S. o o c r 0 0 � g � ^ r. w Cr o _ W O o. o c. n N n n " w — " F m E m — n N o - ' , ai w w o so w- c p CD M Z r :1 -i p a E w o O CD rn C D o� a n ' w' n� DATE LICENSE NO. CONTROL NO Z r 61115/2010 ME 96095 a o D m C .. C _n n o n m m named kelow has:met all requirements of. tj n s . - . . rules of.the stale. of Florida._ C 0 �o �z zj 3 b C. _ n' �'S TI !D m'.r cD. nr z mod. <m �:.. z p 3 7 = tTl �. n ED 0. Z 'C7 T CD w O. •�, C o n C; 7 . 1 N (D p (D .. w n o c p .; :...1...:�...': 4 :l n n W (D o. o c. v N tv O n w — � °o ^ ° �C. n d o o n c 7 to w a o 1 •, w n � o � C o ° n m N a 5: D � M n rn M ! :;! C Or: W ��-•��•• m o f p ° S2 p a E w o (n; nl..: `_` rn C D o� a n ' w' n� DATE LICENSE NO. CONTROL NO Z r 61115/2010 ME 96095 a o D m C .. C _n n o n m m named kelow has:met all requirements of. n n o . - . . rules of.the stale. of Florida._ C 0 �o � D zj n n 0 7 n a _m x �:cD m 0 cn n 'o z JOHN LOGAN FELIX o z m G o n 93 . c. v °o ^ ° �C. N a 5: D � M n rn M ! :;! C Or: W ��-•��•• m ° QUALIFICATION(S): STATE OF FLORIDA'< ACit = i:.:"' ;:; </ ' t t " ` DEPARTMENT O.F 9 ..., `_` a. ,�� Dispersing Practitioner DIVISION ME. ICAL OUALITY ASSURANCE+ >'-- :�_'': n ' w' n� DATE LICENSE NO. CONTROL NO R o w 5 61115/2010 ME 96095 309058 an "a c a o The . ":MEDICAL DOCTOR m m named kelow has:met all requirements of. j . - . . rules of.the stale. of Florida._ Expiration Date. JANUARY 31, 2012 w �. F JOHN LOGAN FELIX STATE OF FLORIDA DEPARTMENT OF HEALTH nIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. CONTROL NO. 01/0912009 ME 46718 272909 IL TO: DEPARTMENT OF HEALTH 0 QUALIFICATION(S) DISPENSING PRACTITIONER ; DIVISION OF.MEDICAL QUALITY ASSURANCE LICENSING AND AUDITING SERVICES UNIT P.O. BOX 6320: TALLAHASSEE, FLORIDA 32314 -6320 NAME CHANGE (ATTACH LEGAL DOCUMENTATION) OM: LAST FIRST MIDDLE AST FIRST MIDDLE 3,5198 n W' _ m — E !t CD o� z Q W O E o p° ui E Q L .. m x:. Page l of ] DEA REGISTRATION NUMBER THIS REGISTRATION FEE I CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE NUMB - ".,;EXPIRE.$ PAID r UNITED STATES DEPARTMENT OF JUSTICE AG3201958 DRUG ENFORCEMENT ADMINISTRATION 09 -30- 201.2' Paid 1 WASHINGTON, D.C. 20537 r SCHEDULES 1 Bl - t DATE ISSUED 2,2N,3 PRACTITIONER 09 -14 -2009 r 3N,4,5 r t S, ESAIAS W MD 440 W _ Sections 304 and 1008 (21 U.S.C. 824 and 958) of the Controlled 440 W HIGHWAY 436 ALTAMONTE SPRIN GS, FL 32714 r Substances Act of 1970, as amended, provide that the Attorney I General may revoke or suspend a registration to manufacturer, 1 distribute, dispense, import or export a controlled substance. 1 i THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C, 20537 DEA REGISTRATION THIS REGISTRATION NUMBER EXPIRES FEE - PAID AG3201958 09 30 -2b12 Paid SCHEDULES BUSINESS ACTIVITY DATE - ISSUED 2,2N,3 PRACTITIONER 3N,4,5 09 -14 -2009 ° GIORGIS, ESAIAS W MD ° 440 W HIGHWAY 436 Sections 304 and 1008 (21 U.S-C. 824 and 958) ro ALTAMONTE SPRINGS, FL 32714 Controlled Substances Act of 1970 as amended, N Q that the Attorney General may revoke. of susf LU registration to manufacture,, distribute, dispense, in export a Controlled substance; L° THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION BUSINESS ACTIVITY, OR AFTER THE EXPIRATION DATE. AC# '`' ` '' ` STATE OF FLORIDA DEPARTMENT:OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE ' - LICENSE NO. 'CONTROL NO. 10/22/2009 ME 80296 290858 BILTEK, BERNARD MD FLORiDA HOSPiTAL ENTRAL'CAR € KISSIMMEE, FL 34746- 0000 -000 Irrllrrl�rllrrrlrlrrlrllrrllrrrllrrrlllrllirr ,llrrrlirrrllrrrl DEA REGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID BB4605284 07 -31 -2010 FEE PAID SCHEDULES BUSINESS ACTIVITY, ISSUE DATE 2,2N, PRACTITIONER 0778-2007 3,3N,4,5, BILTEK, BERNARD MD BUSINESS ACTIVITY FLORIDA HOSPITAL CENTRAL CARE 2,2N, 4320 W VINE ST 07 -18 -2007 KISSIMMEE, FL 34746 -0000 CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 Sections 304 and 1008 (21 USC 824 and 958) of the Controlled Substances Act of 1970, as amended, provide that the Attorney General may revoke or suspend a registration to manufacture, distribute, dispense, import or export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY AND IT IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 DEA REGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID r B4605284 07 -31 -2010 FEE PAID SCHEDULES BUSINESS ACTIVITY ISSUE DATE 2,2N, PRACTITIONER 07 -18 -2007 3,3N,4,5, BILTEK, BERNARD MD Sections 304 and 1008 (21 USC 824 and 958) of the FLORIDA HOSPITAL CENTRAL CARE Controlled Substances Act of 1970, as amended, 4320 W VINE ST provide that the Attorney General may revoke or KISSIMMEE, FL 34746 -0000 suspend a registration to manufacture, distribute, dispense, import or export a controlled substance. 03/11/2010 14:26 4076952842 CENTRACARE PAGE 02 �#09 9 z `SjI &TE Q.F?FL RI> i4 D!✓PAR7M ''H.'�ALTH i�IVISION.. ©F 11llEDI AL OUAl -- t- - : ASSL�:jZAt±� CE . N CE S L N` F - . G. O]' ��1 O 02124120'10. OS-8479..:. `' °`; 30860 table DEA Certificate Page I of I DEA REGISTRATION THIS REGISTRATION FEE CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE NUMBER c.EXPIRES UNITED STATES DEPARTMENT OF JUSTICE t ,. - PAID DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C. 20537 BR7427568 04 -30- 2010` Paid t t SCHEDULES - BUSINESSACTIVITY DATE ISSUED 2,2N,3 PRACTITIONER 03 -13 -2007 3 N,4,5 i Sections 304 and 1008 (21 U.S.C. 824 and 958) of the Controlled RAO, VAN DANA B FLORIDA HOSPITALCENTRA CARE t Substances Act of 1970, as amended, provide that the Attorney 855 S US HWY 17192: a General may revoke or suspend a registration to manufacturer, LONGWOOD, FL 32750 distribute, dispense, import or export a controlled substance. r t THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF r OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, 1 AND IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON, D.C, 20537 v 0 co 0 co w 0 E `0 L DEAREGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID BR7427568 04-30 -2010 Paid SCHEDULES BUSINESS ACTIVITY . DATE ISSUED 2,2N,3 PRACTITIONER 03 -13 -2007 3N,4,5 RAO, VANDANA B FLORIDA HOSPITAL CENTRA CARE 855 S US HWY 17192 LONGWOOD, FL 32750 THIS CERTIFICATE 1S NOT TRANSFERABLE ON CHANC;F Or nwNrRSi 12/02/2009 16:x9 4079164535 CENTRA CARE RDV PAGE 02/02 PORTNOY, BARRY F MD 8701 MAITLA�JD. BL VD -- ORLANDO, FL 32810- 0000 000- Irrll I I., Illlr rllrrrllrrrllrrllirrllirr ,Il DEA REGISTRATION NUMBER THIS REGISTRATION EXPIRES FEE AID P I CONTROLLED SUBSTANCE REGISTRATION AP9609299 03 -31 -2011 FEE PAID CERTIFICATE I UDRUGENFORCEEMENTADMINIOSTRATIONE SCHEDULES BUSINESS ACTIVITY PORTNOY, BARRY F MD I WASHINGTON D.C. 20537 I 212N, PRACTITIONER ISSUE DATE 3,3N,4,5, 03-12-2008 I - PORTNOY, BARRY F MD 8701 MAITLAND SUMMIT BLVD I Sections 304 and 1008 (21 USC 824 and 958) of the Controlled ) - — Substances Act of 1970, ORLANDO, FL 32810 -0000 as amended; provide -that- the Attorney I General may revoke or suspend a registration to manufacture, distribute, dispense, import or export a controlled substance. I THIS CERTIFICATE IS NOT TRANS FERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IT IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 DEA REGISTRATION THIS REGISTRATION NUMBER FEE EXPIRES AP9609299 03 -31 -2011 PAID FEE PAID SCHEDULES BUSINESS ACTIVITY 2,2N, ISSUE DATE PRACTITIONER F3,3N,4,5, 03 -12 -2008 PORTNOY, BARRY F MD 8701 MAITLAND SUMMIT BLVD ORLANDO, FL 32810 -0000 Sections 304 and 1008 (21 USC 824 and 958) of the Controlled Substances Act of 1970, as amended, provide that the Attorney General may revoke or suspend a registration to manufacture, distribute, dispense. imnnri nr Pl-rV CENTRA CARE EXPERIENCE AND PROGRAMS Florida Hospital Centra Care Business Health Services (BHS) is honored that so many of Central Florida's municipalities and progressive corporate entities have afforded us the opportunity and privilege of delivering ethical, state of the art Occupational Medical care to their employees and applicants. We feel that our Occupational Medicine role in the community is consistent with our hospital's tradition of offering high quality faith based medical care. Florida Hospital Centra Care has successfully provided similar occupational health services to local municipalities and corporate clients for the past twenty five years. Additionally, Centra Care oversees Florida Hospital's Employee Clinic which provides occupational health services to our own 16,000 employees. Our staff serves as occupational consultants to our large parent corporation, Adventist Health Systems (AHS). As one of the largest health care systems in our nation, AHS Southern Region operates thirty seven hospitals in ten States serving both our own employee population and external companies and municipalities Our staff, through ongoing networking and monitoring of regulatory bodies and professional associations, stay up to date and aligned. Some of our "touchstones" include but are not limited to: ACOEM, AAOHN, State of Florida guidelines, ADA, AHCA, ADA, FMLA, HIPAA, DOT, OSHA, FDLE, NFPA, CDC, DFWP, and ODG. Our team strives for excellence in all areas to promote a healthier work force, assist in managing costs, increase productivity, reduce risk and meet compliance and audit requirements. Florida Hospital Centra Care is the only Urgent Care Occupational Health provider in Central Florida that provides ongoing physician and clinical oversight by a Medical Executive Committee board. The Medical Executive Committee (MEC) is the clinical governing body of Centra Care and is therefore responsible for ongoing physician education, establishment of best clinical practices, quarterly physician chart audits to assure clinical expertise and general clinical oversight. The MEC is composed of six -seven Board - Certified physicians with expertise in occupational Health and Primary/Urgent care. The MEC is chaired by the Senior Medical Director. Centra Care is dedicated to working closely with the City of Sanford to aggressively reduce the number of workers' compensation claims and costs associated with on- the -job injuries. Our team of occupational health specialist works with the employee to restore optimal physical state and return the employee safely to competitive and productive employment. We tailor the plan of care to each patient's specific needs, including injury evaluation, management and prevention. For most employees, a delay in getting started on the right medicine will mean increased time off work and light duty. To ensure the highest level of patient care, Centra Care offers prescription medicine dispensing at the time of visit, allowing the treating physician and the employer to rest assured that the injured worker has medications in hand when they leave the center. By dispensing onsite, our physicians are able to ensure that patients are counseled appropriately and comply with their medical treatment. This allows for increased overall patient safety, convenience and continuity of care by dispensing medication at the post of diagnosis. Our physicians are able to address any questions in person and in most cases the employee is able to start their medications within 20 minutes of receiving their diagnosis. Our program has proven to increase compliance with filling the medication, reducing non - compliance of prescribed medical treatment and eliminating pharmacy errors. The medical professionals at Florida Hospital Centra Care have a wealth of collective knowledge and "real world" experience with the hazards and job requirements of municipalities. Centra Care has successfully provided similar occupational health services to local municipalities and corporate clients for the past twenty five years. With that in mind we work closely with each agency when an employee has a concerning medical problem or demonstrates work characteristics which may raise doubt regarding their fitness for duty. The appropriate determination of each individual's fitness for duty is paramount to each agency maintaining a safe and effective workplace. The safety of the individual employee, their coworkers and that of the public are at stake. We have extensive experience with difficult and complex fitness for duty exams. Our staff utilizes a comprehensive approach through history and physical exam, review of medical records, review of job description and physical requirements of the job along with supporting documentation from treating specialists and vocational experts as needed. Communication between all parties is managed in a timely and confidential manner. If and when work restrictions are necessary, our goal is to make those restrictions as specific as possible so that the agency may determine modified or alternate duty potential. OPTIONAL CENTRA CARE PROGRAMS 1. Exposure Hotline Service Options: A, Exposure Hotline: The Hotline is staffed by specially trained RNs who utilize a database that incorporates CDC guideline for evaluation and treatment recommendation of exposure events. Blood, Body Fluid and Communicable Disease Exposure counseling is available on a 24/7 hotline basis for work - related occupational exposure. Initial Hotline Counseling: $150 Per Call B. Occupational Medical Surveillance: Surveillance includes 6 -12 mos. of follow - up by a surveillance coordinator who is a certified HIV counselor. Regularly scheduled contacts with the exposed ensure the appropriate CDC recommended periodic, ongoing evaluation through appropriate lab work by the health care provider. Prompt lab results are reported to the exposed and the physician. Surveillance: $250 Per Case C. Post Exposure Nurse (PEN): Post Exposure Nurse services includes immediate on- site response to all significant exposures by the Post Exposure Nurse who is a certified HIV counselor. The PEN functions under the auspices of the CC Medical Director, offering immediate on -site testing of both exposed and source to confirm HIV status as well as administering HIV anti -viral meds which may be prescribed through consultation with the Medical Director. 1. During Business Hours: Normal Business hours are 8:00 AM -11:00 PM weekdays and 8:00 AM- 4:00 PM Saturday and Sunday for significant exposures. Please note that major holidays fall under the after hours and holiday rates as outlined in Section 2. 1. Hotline call and total cost of case management including all testing of exposed and source, with HIV medications: $599 per case 2. Hotline call & total cost of case management including all testing of exposed and source, without HIV medications: $499 per case 2. After hours and holidays: After hours are defined as 11:00 PM - 8:00 AM weekdays and 4:OOPM -8:00 AM Saturday and Sunday. All major holidays are billed under this category, regardless of the time of day. i. Hotline call + total cost of case management including all testing of exposed and source, with HIV medications: $699 per case ii. Hotline call + total cost of case management including all testing of exposed and source, without HIV medications: $599 per case 3. Cost of PEN Service + Administration of Hepatitis B Immune Globulin HBIG In rare cases if exposed is not immune to HEP B and source is HEP B positive, HBIG may be required. Due to the dosage of this medication being based on body mass /weight, the cost of the medication is a variable. Also, there is a 72 hr window for its administration after a positive Hepatitis B exposure. Therefore, it will not be included in the PEN process. However, the PEN will arrange for the procurement and administration of HBIG to be given at a Centra Care location within the appropriate time frame. 4. Meningitis Exposure Hotline call + PEN working with infection control to determine type of meningitis exposure. PEN will maintain contact with exposed until source diagnosis is confirmed and exposed is advised. Prophylactic medication may or may not be needed. If prophylactic medication is needed, PEN will meet exposed on —site or at designated Centra Care to administer. $350 per case 2. Telephonic Reporting of Florida Report of Injury (FROI) Cost: $30 per call 3. Medical Directorship Services: $250 Hour 4. Nurse Case Management Services: Nurse Case Management Services may be contracted through agreed upon annual fee, which depends on the WC case load volume and responsibility shared with the employers' WC adjuster. Or, individual nurse case management is offered at $75.00/hr, with any necessary medical consultation at $136.00 /hr. 5. Drug and Alcohol Testing • 5 Panel Urine Drug Screen $40 • 10 Panel Urine Drug Screen $40 • Breath Alcohol Test $25 • Blood Alcohol Test $40 6. Fitness For Duty Evaluations: Simple: $75 Moderate: $175 Complex: $275 Submission Form PART 1 General 1.01 Description The- following Request for Statements -of Quali Ecations; for the (1) RFQ 00/10 =06 Physicians 1.02 The Undersigned: A. Acknowledges receipt of: Addenda: Number Dated Number Dated B. Has examined the Solicitation Documents and understands that in submitting his /her Response, he /she waives all right to plead any misunderstanding regarding the same. C. Understands that the responsibility for delivering the submission to the City on or before the specified date and time will be solely and strictly the responsibility of the Respondent. The City will not be responsible for delays caused by the United States Postal Office or a delay caused by any other occurrence. Offers by telephone, fax, email or other electronic means will not be accepted. It is understood that any deviation from a completed, signed (original signatures) proposal delivered on or before the designated time, date and place, as provided herein, to the City will be resolved against the individual or firm submitting the response. D. Agrees: 1. To hold this Offer open for 60 calendar days after the opening date. 2. By signing this document the responding individual or firm hereby agrees to negotiate in good faith, to be bound by specifications, terms, conditions, scheduling, pricing and representations as stated and submitted with this form and /or as established by subsequent negotiations. However, it is understood that the City reserves the right to declare any submission nonresponsive if exceptions to specifications, terms, conditions, etc. of the solicitation are not acceptable in the opinion of the City to meet the requirements of said solicitation. 3. To enter into and execute a contract with the City, if awarded on the basis of this Offer and /or subsequent negotiations agreed upon by the City and the Bidder /Proposer. (1) Title and Solicitation number as shown in the Invitation (2) Name, address, telephone, fax number and email of Proposer. 4. To accomplish the work or service in accordance with any Contract resulting from this request. 1.03 Miscellaneous Requirements and Affirmations Statements of Qualifications shall be submitted using the attached forms and in _ compliance with the instructions provided_ with-this _ request._ _ . Number of originals and complete copies to submit: a. One original and 4 copies and an electronic disc in pdf format all in one package, to City of Sanford as indicated below- see items 2 and 3 of the solicitation for details. 1.04 Protests Protests, if any, shall be submitted in compliance with City of Sanford Purchasing Policy in all respects. Failure to file protest to the Purchasing Manager within the requirements a and time prescribed by the City's Purchasing Policy, shall constitute a waiver of proceedings. G� o 1.05 SUBMITTED, sigLand a this ! day of A y� Bidder /Proposer By (Signature) — Date A C� V y11�' nI�V�i4� �1,�� <� Printed Name and - title Corporate /Company Seal On the Envelope Containing Your Submission: The Return address — Your Company Name and Address Address or Deliver To: William Smith, Purchasing Manager City of Sanford P.O. Box 1788 (300 N. Park Avenue, Room 236) Sanford, FL 32772 In the Lower Left Corner of the Envelope, Provide the Following: RFQ Number: RFQ 09/10 -06 Physicians Services- Workers Comp Open Date: April 19, 2010 Open Time: 2:00 p.m. (Nonpublic Opening) This Form Must Be Completed and Returned with your Submission Disputes Disclosure Form Answer the following questions by answering "YES" or "NO ". If you answer "YES ", please explain in the space provided, please add a page(s) if additional space is needed. 1. Has your firm, or any of its officers, received a reprimand of any nature or been ^^� suspend�d_by.- the- Dep?rtment of Profess Regulation te or an, other- r ,, g4la�cr,� ay��=cy or professional association within the last five (5) years? K%d 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? K-C-D 3. Has your firm had filed against it or filed any requests for equitable adjustment, contract claims or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? KJU If yes, the explanation must state the nature of the request for equitable adjustment, contract claim or litigation, a brief description of the case, the outcome or status of suit and the monetary amounts or extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation or falsification of facts shall be cause for forfeiture of rights for further consideration of the project identified. Firm M rized SignaturV Printed or Typed Name and Title FORM NO. DSPT 12.204 This Form Must Be Completed and Returned with your Submission Drug -Free Work Place The undersigned, in accordance with Florida Statute 287.087 hereby certifies that the company named below does: 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying ire- actions that will be taken against empioyees forvio(at ons of such prohibition. 2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the commodities or contractual services that are proposed a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug -free workplace through implementation of this section. Firm r Authoriz6d Signature �/ / Dafe &!xTl 1 �1L9�d 'tl !:b. '— pYGC , 1��� � �Gt 1X.VII)I m tGCt-A 1 G U Printed or Typed Name and Title FORM NO. DFWP 14.204 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -06 Physicians Services - Workers Comp. Conflict of Interest Statement of o� CWY'e, deposes and states that Name of A rant Name of Company 2. The above named entity is submitting an Expression of Interest for the City of Sanford project identified below and provides -the information contained in this Affidavit -based 3. The Affiant has made- di.ligent_inquiry upon his own knowledge. 4. The Affiant states that only one submittal for the above project is being submitted and that the above named entity has no financial interest in other entities submitting proposals for the same project. 5. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in connection with the entity's submittal for the above project. This statement restricts the discussion of pricing data until the completion of negotiations and execution of the Agreement for this project. 6. Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participating in contract lettings by any local, state, or federal agency. 7. Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 8. 1 certify that no member of the entity's ownership, management, or staff has a vested interest in any aspect of or Department of the City of Sanford. 9. 1 certify that no member of the entity's ownership or management is presently applying for an employee position or actively seeking an elected position with City of Sanford. 10. In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify the C ity of Sanford in writing. 1 �f �lv6 Signature o �� -- �xco \J L Dr me.() f Affian Date Typed or Printed Name of Affiant Title State of Florida, County of 0 y On this I day of V' , 20 A, before me, the undersigned Notary Public of the State of Ifid really appea ed �VdAy W1 and (Name(s) of individuals w ho appeared before notary) whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they p� Pue (i DIANE M. DEHMER executed it. z c MY COMMISSION # DD 925389 WITNESS my hand * * EXPIRES: September 15,2013 and official seal. sue on o ° Bonded Thru Budget Notary SWces FOF FL NO ARY PUBLIC, STATE OF FLORIDA NOTARY PUBLIC SEAL OF OFFICE: (Name of Notary Public: Print, Stamp, or Type as Commissioned.) FORM NO. CFI 18.204 This Form Must Be Completed and Returned with your Submission MEMORANDUM FINANCE DEPARTMENT - PURCHASING DIVISION Provide evidence of insurance coverage and levels thereof for: 1. General liability 2. Auto liability 3. Professional liability 4. Workers comp RFQ 09/10 -06 Physicians Services- Workers Comp. CERTIFICATE OF COVERAGE Issue Date: 04/01/2010 Adventist Health System Risk Management I 1 I North Orlando Avenue Winter Park, FL 32789 (407 ) 975 -1420 This certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This certificate does not amend, extend or alter the coverage afforded by the AHS Liability Trust or any insurance policies listed below. Named Participant: Florida Hospital Centra Care 901 Lake Destiny Road, Suite 375 Maitland, FL 32751 COMPANIES AFFORDING COVERAGE Company Letter A: AHS Liability Trust Com any Leiter E: Liberty Mutual Fire Insurance Com any Com an Leper F: Florida Hospital Self- Funded Worker's Compensation_. P..ro ram Coverages This is to certify that the coverage below has been issued to the Named Participant listed above for the time period indicated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions of such policies. Limits shown may have been reduced by aid claims. Co Ltr Type of Insurance Policy Number Policy Effective Date Policy Expiration Date Limits A X Comprehensive General Liability 8528 -2010 04101/2010 04/012011 Each Occurrence $1,000,000 A X Occurrence (CGL Only) E X Automobile Liability- All Vehicles AS2 -651- 286535 -029 11/0112009 11/01/2010 Combined Single Limit (Bodily Injury & Property Damage) $1 000,000 F X Worker's Compensation I Florida Hospital— and Employer's Liability Orlando Facilities FHWC09 08/01/2009 08/01/2010 $1,000,000 Description of Operations/LocationsNehicles /Special Items: All operations subject to the terms and conditions of the Trust or insurance policies listed above. . Coverage provided is a per occurrence aggregate and is not increased by the number of named participants or claimants involved. Certificate Holder Cancellation Florida Hospital Centra Care 901 Lake Destiny Road, Suite 375 Maitland, FL 32751 Should any of the above described policies be cancelled before the expiration date thereof the issuing company will endeavor to mail written notice to the Certificate Holder named to the left, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives or employees. _sent Authorized Representative: Date: 04/13/2010 Florida Statutes On Public Entity Crimes THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted to The City of Sanford by � /� ' f ` • on behalf of e wh business address is: ` � / ! a. I and (if applicable) its Federal Employer Identification Number (FEIN) is 3 2& i t111 9q (If the entity has no FEIN, include the Social Security Number of the individual signing this statement: 2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services, any lease for real property, or any contract for the construction or repair of a public building or public work, involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. 1 understand the "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilt or nolo contendere. 4. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes. means: A predecessor or successor of a person convicted of a public entity crime: or An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.) Neither the entity submitting this sworn statement, nor any of its officers, director, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity were charged with and convicted of a public entity crime after July 1, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity was charged with and convicted of a public entity crime after July 1, 1989. The entity submitting this sworn statement, or one of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any RFQ 09110 -06 Physicians Services - Workers Comp. 1 affiliate of the entity was charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND - THAT .-I AM REQUIRED TO INFORM- HE PUBLIC - ENTI T Y PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CO TAINED IN THIS FORM. ig ure) (date) State of Florida County of On this _9 day of ! Vi1 201x, before me, the undersigned Notary Public of the State of Florida, pers nally,apTred (( °Q,, jjya V and (Na e(s) of individuals who appeared before notary) whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they executed it. (Type of Identification Produced) _ ID take an oath, or V EID NOT take an oath. FORM NO. PEC 15.204 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -06 Physicians Services- Workers Comp. FY ? ,�" • • % DIANE M. DEHMER WITNESS my hand * MY COMMISSION # DD 925369 and official seal. r EXPIRES: September 15,2013 N 9 r . Flv Bonded Thru Budget Notary Services NOTARY PUBLIC, STATE OF F ORIDA NOTARY PUBLIC SEAL OF OFFICE: (Name of Notary Public: Print, Stamp, or Type as Commissioned.) V" known to me, or Produced identification: (Type of Identification Produced) _ ID take an oath, or V EID NOT take an oath. FORM NO. PEC 15.204 This Form Must Be Completed and Returned with your Submission RFQ 09/10 -06 Physicians Services- Workers Comp. Certification of Non - Segregated Facilities By affixing his signature to this form, the Offeror /Bidder certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The Bidder certifies further that he will not maintain or provide for his employees any segregated facilities at any location under his control where segregated facilities are maintained. The Bidder a rges that a breach of this certification will he a violation of the Equal'Opporfunity clause in any contract resulting from ac As used in this certification, the term ceptance of this Bid. "segregated facilities" means any waiting rooms work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage and dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation and housing facilities provided for employees which are segregated by explicit directive, or are in fact segregated on the basis of race, color, religious disability or national origin, because of habit, local custom, or otherwise. The Bidder agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files. The nondiscriminatory guidelines as promulgated in Section 202, Executive Order 11246, and as amended by Executive Order 11375 and as amended, relative to Equal Opportunity for all persons and implementations of rules and regulations prescribed by the United States Secretary of Labor are incorporated herein. NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001. Date: ,/ f io �& Print L �1, Titles Official Address: L�e ( A� 1 TI 3,-) l FORM NO. SFAC 16.204 This Form Must Be Completed and Returned with your Submission RFQ 09110 -06 Physicians Services- Workers Comp. \lam ! J WD V ( STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. CONTRQL NO. 0112312010 ME 65142 311525