884-North Seminole Family Practice 2001-03 AGREEMENT BETWEEN
NORTH SEMINOLE FAMILY PRACTICE
AND
CITY OF SANFORD, FLORIDA
T sAGREE iseateredintothis dayof d d2:; :72;o
TI-IE CITY OF SANFORI, a political subdivision of the Flori
North Park Avenue, Sanford, Florida 32771, hereinai~er referred to as "CITY," and NORTH
SEMINOLE FAMILY PRACTICE, a Professional Association organized under the laws of the
State of Florida, whose Professional Association address is 2209 French Avenue, Sanford,
Florida 32771, hereinafter referred to as City Physician Services.
WITNESSETH:
WItEREAS, the City finds that provision of services for City Physician Services is a
valid CITY purpose under the laws of the State of Florida; and
WHEREAS, the CITY has selected North Seminole Family Practice through City
approved Procurement Procedures; and
WItEREAS, it is the desire of the parties to enter into a contract setting forth the duties
and responsibilities of the parties.
NOW, THEREFORE, in consideration of the mutual covenants contained herein and
for other goods and valuable consideration provided by each party her~to, the parties agree as
follows:
Section 1. Recitals. The above recitals are true and correct and from a material part of
this Agreement upon which the parties have relied.
Section 2. Services to 'be provided by North Seminole Family Praetiee:
a. North Seminole Family Practee shall provide or cause to be provided the goods and
services as provided for in Exhibit A. Scope of Services
Section 3. Payments and Billing. The CITY shall pay to North Seminole Family
Practice the fees for medical services as provided for in Exhibit B. Fees For Services.
Section 4 Term. The term of this Agreement shall be from March 14,2001 to September
30, 2003, notwithstanding the date the parties signed this Agreement.
Section 5 Assignment. North Seminole Family Practice may refer responsibilities of a
medical specialty nature to qualified medical professionals.
Section 6. Indemnification. North Seminole Family Practice agrees to indemnify and
hold harmless the CITY from and against any claim, demand, or cause of action of
whatsoever kind or nature arising out of, allegedly arising out of or related to the
performance of services under this Agreement by North Seminole Family Practice, its
officers, agents or employees.
Section 7. Insurance. North Seminole Family Practice shall procure and maintain during
the life of the Agreement certificates of insurance to protect against claims for injuries to
persons or damages to property which may arise from or in connection with the
performance of the work hereunder by North Seminole Family Practice, its agents,
representatives, or employees. Certificates from the insurance carrier staling the types of
enverage provided, limits of liability, and expiration dates, shall be filed with the City
evidencing the insurance required by this section (Professional Liability, Medical
Malpmetice, Employer's Liability, Workers' Compensation).
Section 8. Alterations, Variations, Etc., Reduced to Writing. Any alterations,
variations, modificatinns or waivers of provisions of this Agreement shall only be valid
when they have been reduced to writing, duly signed and attached to the original of this
Agreement. The parties agree to renegotiate this Agreement if revision of any applicable
laws or regulations make changes in this Agreement necessary.
Section 9. Notice. Whenever either party desires to give notice unto the other, notice may
be sent to:
CITY OF SANFORD
Anthony M. VanDerworp, AICP
City Manager
P.O. Box 1788
Sanford, Florida 32772-1788
North Seminole Family Practice
2209 French Avenue
Sanford, Florida 32771
Section 10. Compliance with Laws and Regulations. North Seminole Family Practice
shall obtain and posses.s, throughout the term of this Agreement all licenses and
certifications applicable to its operations.
Section ll.Governing Law; Severability. This Agreement shall be construed in
accordance with the laws of the State of Florida. It is agreed by and between the parties
that if any covenant, condition or provision contained in this Agreement is held to be
invalid by any court of comPetent jurisdiction, such invalidity shall not affect the validity
of any other covenants, conditions, or provisions herein contained to the extent the CITY
derives anticipated benefits from this Agreement.
Section 12. Failure to Enforce Not Waiver of Right. Failure by the CITY to enforce
any provision contained herein shall not be deemed a waiver of the right to do so
thereafter as to the same breach or as to any breach occttrring prior or subsequent thereto.
Section 13. Conflict of Interest.
a. North Seminole Family Practice agrees that it will not engage in any action
that would create a conflict of interest in the performance of its obligations
pursuant to this Agreement with the CITY or which would violate or cause
others to violate the provisions of Part III, Chapter 112, Florida Statutes,
relating to ethics in Government. North Seminole Family Practice hereby
certifies that no officer, agent, or employee of the City has any material
any material interest (as defined in Section 112.3 12(15), Florida Statutes, as
over 5%) either directly or indirectly, in the business of North Seminole
Family Practice to be conducted here, and that no such person shall have any
such interest at any time during the term of this Agreement.
Exhibit A: Scope of Services.
Exhibit B. Fees For Services.
IN WITNESS WHEREOF, the parties hereto have made and executed this
agreement for the purposes stated herein.
ATTEST: NORTH SEMINOLE FAMILY PRACTICE
By: ~ 5
STATE OF FLORIDA )
COUNTY OF SEMINOLE )
I HEREBY CERTIFY that on this C]~_ _day of Y'~ ,2001, before me, an officer duly
authorized in the State and County aforesaid to take a~ckt~wledgements, personally appeared
~'~ (b~ct cxn of North Seminole Family Practice who is personally known to me or who
has produced as identification. He/she acknowledged before me that
he/she executed the foregoing instntrnent as officer in the name and on behalf of North Seminole
Family Practice.
Notary Public in and for the County and State
ATTEST: City Commission of the CITY OF SANFORD,
Florida
City Clerk As authorized by the City Commission of the City
~,//~/ of Sanford at its February 26, 2001 regular
meeting.
CITY OF SANFORD (CITY PHYSICIAN SERVICES)
RFP 00/01-15
l. PURPOSE
It is the purpose of this ILF.P. to determine competitive fees for board certified physicians capable
and willing to provide medical services as described in the following qualifications.
II. SPECIFICATIONS
1. Medical Services are defined and consist of the following:
a) Performing-routine, pre-employment and ~tue~ for duty evaluations to determine
the capability of performing ate job requirements for specific jobs v~th the City of
Sanford. This shall include determinations involving andiome~ic testing, vision and
other physical capabilities relative to the requirements stated in the position
description. Medical Evaluations for Fire~Jaters must meet NFPA standards.
b) Conduetingevaluatianandtreatmetuofworkerscompensalionillnessesorinjuries.
This shall include immediate attention, evaluation, progrtosis and referrals for
specialized treatment if needed.
Conducting pre-employment law enforcement medical examinations required by the
Criminal Justice Standards and Training Conmaission. In addition to the physical
examination, an electrocardiogram, a skin test for tuberculosis, and blood testing
which includes an analysis of blood cells and chemistry are included.
d) Prorid'me for x-my, EKG, Laboratory Service, or other extraordinax-j medical
service. If these services cannot be provided directly by the physician, the physician
must be able to coordinate such services with charges for same billed to the
physician and subsequently billed to the City as outlined in Section V Billing
Procedure.
e) Administer ?mnual flu shots to City employees.
f) Provide for Hepatitis injection and Hepatitis Exclusionary Testing for Police Officer
and Fire fighter applicants as a part of their pre-employment medical cert'tficatiom
g) Provide for TB Exclusionary Testing for Police Officer and Firefighter applicants as
a part of their pre-employment medical certification.
2. Preference will be given to the Physician whose services are in the City of Sanford.
3. Strong consideration will be given to physician responsiveness in scheduling medical
services. The physician must be available and must be prepared to act as the primary
health care provider involving work related injuries. Pre-employment and fitness for duty
evaluations shall be scheduled within five working days of calling for an appointment.
111. CITY PHYSICIAN
It shall be understood that the slams of City Physician shall in no way be construed to mean that
the City Physician is an employee of the City of Sanford. As such, there is no entitlement to City
benefits whatsoever. The status of City Physician is strictly a contractual arrangement to provide
medical services as described above.
Page Two "RFP City Physician Service/'
IV. COORDINATION WITH CITY STAFF
The primary contact with the City of Sanford shall be the Human Resources Director. Secondary
contacts may consist of inquiry by authorized staff as follows:
City Manager
Risk Manager
Human Resources Analyst
Human Resources Technician
All other contact with City staff is prohibited in order to protect the con~dentiality of the
patient/Doctor relationship.
V. BILLING PROCEDURE
I. Bills for City Physician medical services shall be submitted to:
City of Sanford
Accounts Payable
PO Box 1788
Sanford, Horida 32772-1788
The bill must specify the name of the person receiving service, date of service and individual
charge associated with this service. A notation indicating the type of service such as (Pre-
employment Physical, Hu Shot, and Hepatitis Panel Test) must be reflected on the hill.
2. Bills for medical services performed which result fi~om workers compensation illnesses
and/or injury must be billed to:
JLT insurance ~ervices Company
P.O. Box 166005
Altamonte Springs, F1. 32716-6005
VI. COMPLETION OF FORMS
It shall be the responsibility of the City Physician to provide medical services including any
coordination of same by providing proper doctmaentatien an the following forms:
1. One copy of the Pre-employment Physical Form is to be retumed to the City aRer
certification of fimess for duty. The Police, Fire or General employee applicant will be
instructed to hand carry this form back to the City in a sealed envelope. The original is to
be retained in the City's file.
2. A summary of medical history contained in the medical history questionnaire form is
completed and signed by the applicant. It is to be used by the City Physician as a basis for
determining potential problem areas. A copy is to be retained by the City Physician end
the original is to be sent back to the City in a sealed envelope with the applicant.
3. A consent form for drug/alcohol screening is signed by the applicant and kept by the
City.
Page Three "RFP City Physician Services"
PROPOSAL FORM
VII. CITY PHYSICIAN PROPOSAL
1. It is understood that this proposal is being submitted in response to the specifications as
outlined in RFP00/01-15 "City Physician Services".
2. It is understood that the CITY OF SANFORD is under no obligation to accept this proposal in
whole or in part.
3. It is understood that if this proposal is accepted by the CITY OF SANFORD 1 will be
responsible for fulfilling all aspects of this proposal as outlined in RFP 00/01-15 City
Physician Services and that the fees for medical services that I have quoted as follows will be
binding for the period March 14, 2001 through September 30, 2003.
4. It is understood that this agreement may be severed by either party for any reason provided a
Ninety- (90) day notice, in writing, has been issued to all concerned parties.
5. It is understood that I am primarily responsible for performing the medical services as
outlined in RFP 00/01-15 but, in the event I am not available, back up medical services will
be provided by:
Physician's name: 225'62XJh~\,~5 E .(~)L,C_,CXV'X, ~;-XC3_f VC~..I (i) -~C~,~C~-'K-~} ,¥XA, 22~.
Address: ,h ~ O 6~ ' "3r( Cy'x e_\-x ~ Y<
Telephone: ~kO"l- '5~4- %Z36)
6. Fees for Medical Services: Costs
A) Routine Pre-employment and Fimess For Duty Evaluations $ .5 G. ca.
B) FDLE Lab Work
C) EKG's $
D) Hepatitis Injection $
· ca.
E) Flu Shot Injection $ / t~ ,CO ca.
F) TB Excfusionary Testing $ \ ~ .Oo ea.
G) Hepatitis Exclusionary Testing $ _~_~._:~oo ea.
H) Audiometric Testing $ 9D30°ea.
1) Medical Clcarnncc lbr Respirato~ Use ' ' ~ ' $ ~,e~ea.
Page Four (4) "RFP City Physician Services"
7. My office hours are: Monday
Tuesday
Sunay
g. I can provide the following services:
a) X Ray ~i) No
b) EKG ~': No
c) Lab Work ~"~/ No
If no, who will provide these services'?.
Physician's Name:
Address:
Telephone:
NOTE: RETURN PROPOSAL FORM ALONG WITH OTHER REQUIRg. D FORMS.
PLEASE MARK EXTERIOR OF SEALED ENVELOPE CONTAINING YOUR
PROPOSAL W1TH YOUR RETURN ADDRESS AND THE FOLLOWING:
CFFY OF SANFORD (CITY PHYSICIAN SERVICES)
RFP 00/01 - 15 (DUE February 6, 2001 )
LICENSE NO, LrF~E' OO~oo
lo