PROVIDER LETTER OF AGREEMENTCOMPANY CARE
PROVIDER LETTER OF AGREEMENT
THIS AGREEMENT, effective the 8th day of February, 2010 , by and. between the facilities named
below (collectively referred to hereinafter as "Providers") and City of Clearwater (hereinafter referred to as
"Client"), is as follows:
1. Scone of Services. Providers shall perform the services listed, and Client shall pay the respective
Provider in accordance with the fees set forth, in the "Profile Sheet," which is attached hereto and
incorporated herein by this reference. Service locations are set forth in Attachment A, which is
attached hereto and incorporated herein by this reference.
2. Term. This Agreement shall be for a term one (1) year commencing the 8h day of February, 2010
and shall automatically renew for additional terms of one (1) year, unless terminated pursuant to
section 5.
3. Changes. Any changes to this Agreement shall be made by mutual written consent of both Parties.
4. Compensation. Client all a the invoice in accordance with the Florida Prom Pa ent Act F.S.
Secs. 255.0705-255.078
5. Termination. This Agreement may be terminated by either party, at any time, upon sixty (60) days
prior written notice.
6. Insurance and Indemnification. Each respective Provider shall maintain, at its sole cost and
expense, professional liability insurance with an insurer satisfactory to Client, with minimum limits of
one million dollars ($1,000,000) per occurrence, three million dollars ($3,000,000) in the aggregate
and shall at the request Client, provide written evidence of said insurance coverage. In the event said
coverage is changed materially, the Provider shall, within. ten (10) days of such material change, notify
Client in writing. The Provider shall indemnify, defend and save Client harmless from and against any
and all losses, claims, damages, liabilities and expenses (including, without limitation, reasonable
attorney's fees) based upon, arising out of attributable to any acts or omissions arising from the
Provider's performance hereunder.
7. Licensure/Compliance. Each Provider warrants and represents that it is licensed to perform the
services provided under this Agreement and shall maintain all such licenses for the duration of the
Agreement. In addition, each Provider represents that the services provided hereunder are in
compliance with any and all applicable federal and state statutes, laws and/or regulations.
8. Hold Harmless and Indemnification. Each party shall be responsible for any and all claims,
liabilities damages or judgments that may arise as a result of their own negligence or intentional
wrongdoing. Each party shall hold harmless and indemnify the other party against any such claims,
liabilities, damages or judgments which may be asserted against, imposed or incurred by the other
party.
9. Assignment. This Agreement shall not be assigned by any of the Providers without the prior written
consent of Client.
10. Governing Law. This Agreement shall be governed by and construed in accordance with laws of
Florida.
11. Independent Contractors. For all purposes hereunder, the relationship between Client and each
respective Provider is solely that of independent contractors and this Letter of Agreement does not
create a partnership, joint venture or other association between any of the Providers and Client. The
employees and agents of each respective Provider shall be considered to be under exclusive
management and control of each respective Provider.
12. Notices. Any and all notices sent pursuant to this Agreement shall be given in writing via certified
mail or overnight courier and shall be delivered to the following addresses:
To Provider: Company Care To Client: City of Clearwater
Northside Annex Building Human Resources Director
6002 49`h Street North 100 South Myrtle Avenue
St. Petersburg, FL 33709 Clearwater, FL 33756
Attn.: Barb Maxwell, Division Director
13. HIPAA Requirements. The parties agree to comply with the Health insurance portability and
Accountability Act of 1996, as codified at 42 U.S.C. §1320d ("HIPAA") and any current and future
regulations promulgated thereunder including without limitation the federal privacy regulations
contained in 45 C.F.R. Parts 160 and 164 (the "Federal Privacy Regulations"), the federal security
standards contained in 45 C.F.R. Part 142 (the "Federal Security Regulations"), and the federal
standards for electronic transactions contained in 45 C.F.R. Parts 160 and 162, all collectively referred
to herein as "HIPAA Requirements." The parties agree not to use or further disclose any Protected
Health Information (as defined in 45 C.F.R. §164.501) or individually Identifiable Health Information
(as defined in 42 U_S_C. §1320d), other than as permitted by HIPAA Requirements and the terms of
this Agreement. To the extent applicable under HIPAA, each party shall make its internal practices,
books, and records relating to the use and disclosure of Protected Health Information available to the
Secretary of Health and Human Services to the extent required for determining compliance with the
Federal Privacy Regulations. Each party agrees also to comply with any state law and regulations that
govern or pertain to the confidentiality, privacy, security of, and electronic transactions and code sets
related to, information related to patients.
14. Warranty of _Non-Exclusion. Each party represents and warrants to the other that the party, its
officers, directors and employees (i) are not currently excluded, debarred, or otherwise ineligible to
participate in the federal health care programs as defined in 42 U.S.C. § 1320a-7b(f) (the "federal
healthcare programs"), (ii) have not been convicted of a criminal offense related to the provision of
healthcare items or services, and (iii) are not, to the best of its knowledge, under investigation or
otherwise aware of any circumstances which may result in the party or any such individual being
excluded from participation in the federal healthcare programs. This shall be an ongoing
representation and warranty during the term of this Agreement and each party shall immediately notify
the other of any change in the status of the representations and warranty set forth in this section.
Notwithstanding any provision of this Agreement to the contrary, any breach of this section shall give
the other party the right to terminate this Agreement immediately.
15. Appropriation Clause. The City, as an entity of government, is subject to the appropriation of funds
by its legislative body in the amount sufficient to allow continuation of its performance in accordance
with the terms and conditions of this contract for each and every fiscal year following the fiscal year in
which this contract shall remain in effect. Upon notice that sufficient funds are not available in the
subsequent fiscal years, the City shall therefore be released of all terms and other conditions.
12/09 Page 2 of 3
IN WITNESS WHEREOF, the Parties have set their hands the date and year first written above.
"Client"
Lag--ak-? u? ?. Pa?
Title: Q
Date:
"Providers"
J. Daniel Miller, Senior Vice esident, on behalf of the following "Providers"
Date: 5 I !? 1 I)
• New Port Richey Hospital, Inc., d/b/a Community Hospital New Port Richey
• Edward White Hospital, Inc., d/b/a Edward White Hospital
• Fawcett Memorial Hospital, Inc., d/b/a Fawcett Memorial Hospital
• Galencare, Inc., d/b/a Northside Hospital
• Galen of Florida, Inc., d/b/a St. Petersburg General Hospital - "InjuryIntake Site"
• Largo Medical Center, Inc., d/b/a Largo Medical Center
• HCA Health Services of Florida, Inc. d/b/a Blake Medical Center
• Osceola Regional Hospital, Inc. d/b/a Osceola Regional Medical Center
• HCA Health Services of Florida, Inc. d/b/a Regional Medical Center Bayonet Point - "Injury Intake
Site"
• Largo Medical Center, Inc., d/b/a Sun Coast Hospital, a facility of Largo Medical Center- "Injury
Intake Site"
12/09 Page 3 of 3
COMPENSATION SCHEDULE
This attachment when executed by Provider and Client, shall become part of the agreement between the parties as of the Effective
Date of the Agreement, and shall remain in Full Force and Effect as long as the Agreement is in Force.
CLINICAL SUMMATION SHEET
Company: City of Clearwater
SERVICES TO BE PERFORMED:
Physical Examination * $ 50.00
Medical History * Included
Vision Test. * Included
Audiogram $ 20.00
Urinalysis $10.00
Drug Screen HRS 5-panel $ 35.00
Drug Screen HRS 8-panel $ 35.00
All above drug testing includes.... lab, MRO services, and record keeping
Back Screen (positions w/heavy physical requirements only) $ 55.00
Pulmonary Function $ 30.00
Chest X-Ray One-View $ 55.00
Lumbar AP & Lateral $ 65.00
EKG $ 25.00
EKG Stress Treadmill $195.00
Hemocult $12.00
CMP $ 25.00
Lipid Panel $ 28.00
CBC w/Differential $ 10.00
Thyroid Profile $ 25.00
TB Test $ 18.00
Hepatitis Profile $ 88.00
Cardiologist Review Included $ -------
Spirometry $ 30.00
Hepatitis ABC (A-Antibody/Total;
A-IGM; B-Core Antibody/Total & Q ual;
B-Antigen; C-Antibody $ 88.00
Workers Compensation State Fee Schedule
Carrier Name: City of Clearwater / Risk Management Phone: 727-562-4650
Mailing Address: PO Box 4748
City: Clearwater State: FL Zin: 33758
Employer Contact Name: Allen Del Prete, HR Manager Phone: 727-562-4876 Fax: 727-562-4877
Mailing Address: 100 South Myrtle Avenue
Ci#v; Clearwater State: FL Zip: 33756
_Company Care Contact:
Robyn Vandevander, Account Manager
1345 West Bay Drive, Suite 401
Largo, FL 33770
P: 727-518-8324 F: 727-518-0723
12"
COMPANY CARE
Occupo!;ongl Health Setvlr_eq
HCA West Florida Division - Company Care Site Locations
Injury Management Only - Emergency Room
Edward White Hospital Northside Hospital St. Petersburg General Hospital
Case Manager- Pat Petit RN, CMS Case Manager- Carol Robinton RN Case Manager- Carol Robinton RN
21919 th Avenue North, Suite 260 600249 th Street North 6500 38th Avenue North
St. Petersburg, FL 33713 St. Petersburg, FL 33709 St. Petersburg, FL 33710
Phone: (727) 328-6261 Phone; (727)521-5485 Phone: (727) 521-5485
FAX: (727) 328-6260 Pager: (727) 468-6401 Pager: (727) 468-6401
Pager: (727) 570-0292 Fax: (727) 521-5484 Fax: (727) 521-5484
Community Hospital Blake Medical Center Fawcett Memorial Hospital
Case Manager - Corrine DeJarnette RN, CMS Case Manager - Veronica Lichtenstein RN Case Manage' - Sheri Miller RN
5400 School Road 2010 59th Street West, suite 3600 3280 Tamiami Trail, Suite 11
New Port Richey, FL. 34652 Bradenton, FL 34209 Port Charlotte, FL 33952
Phone: (727) 834-5908 Phone: (941) 798-6158 Phone: (941) 625-3047
Fax: (727) 834-5680 Fax: (941) 798-6081 Fax: (941) 625-3607
Pager: (727) 956-0356
Largo Medical Center
Case Manager - Francine Dunning, RN
1345 West Bay Dr. Ste 401
Largo, FL 33770
Phone: (727) 518-8324
Fax: (727) 518-0723
Central Florida Regional Hospital
Case Manager - Karen S. Campbell, RN, COHN
1401 W. Seminole Blvd
Sanford, FL 32771
Phone: (407) 302-7322
Fax: (407)302-7323
Injury Management Only -'Emergency Room
Regional Medical Center-Bayonet Point
Case Manager - Corrine DeJarnette RN, CMS
14000 Fivay Road
Hudson, Florida 34667
Phone: (727) 834-5908
Fax: (727) 834-5680
Pager: (727) 956-0356
Andrea Schwaderer - South Pinellas County
Phone: (727) 328-6255
Pager: (727) 570-0419
Fax: (727) 328-6260
Dianna Ross -Charlotte County
Phone: (941) 625-3047
Pager. (941) 613-7768
Fax: (941) 625-3607
Osceola Regional Medical Center
Case Manager - Betty Christ, RN
1508 Village Oak Lane
Kissimmee, FL 34746
Phone: (407) 846-3047
Fax: (407) 847-2051
Account Managers
Raechel Hancock - Pasco County
Phone: (727) 834-5672
Cell: (727) 809-1950
Fax: (727) 834-5680
Laura Lenzen - Manatee County
Phone: (941) 798-6073
Fax: (941) 798-6081
Melonie Ramey - Osceola County
Phone: (407) 946-3047
Fax: (407) 847-2051
Robyn Vandevander - North Pinellas County
Phone; (727) 518-8324
Pager: (727) 402-0667
Fax: (727) 518-0723
Division Director Comm Care
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP
Occupational Health Services - HCA - West Florida Division
6002 49th Street North
St. Petersburg, Florida 33709
Phone: (727) 528-5932
Fax: (727) 528-5933
Cell: (727) 560-7252
12123=
CITY OF CLEARWATER, FLORIDA
By:
William B. Horne II
City Manager
Approved as to form: Attest:
L slie K. Dougal - es
Assistant City At ey