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PROVIDER LETTER OF AGREEMENT (2)COMPANY CARE PROVIDER LETTER OF AGREEMENT THIS AGREEMENT, effective the ls` day of January, 2012, by and between the facilities named below (collectively referred to hereinafter as "Providers") and City of Clearwater (hereinafter referred to as "C1ienY'), is as follows: 1. Scope 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 15t day of January, 2012, and shall automatically renew for additional terms of one (1) year, unless terminated pursuant to section 5. 3. Chanees. Any changes to this Agreement shall be made by mutual written consent of both Parties. 4. Compensation. Client shall pay each respective invoice in accordance with the Flarida Prompt Payment Act, F.S. Secs. 225.0705-225.078. 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 Indemni�cation. 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. Assi�nment. This Agreement shall not be assigned by any of the Providers without the prior written consent of Client. 10. Governin� 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 6002 49`h Street North 100 S. 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 ReGuirements." 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 shalt 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. Warrantv of Non-Exdusion. 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(fl (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. 01�12 Page 2 of 4 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 & Qual; 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 Citv: Clearwater State: FL Zlp: 33758 Emplover Contact Name: Allen Del Prete, HR Manager Phone: 727-562-4876 Fax: 727- 562-4877 Mailing Address: 100 South Myrtle Avenue Citv: Clearwater State: FL Zlp: 33756 Companv Care Contact: Robyn Vandevander, Account Manager 1345 West Bay Drive, Suite 401 Largo, FL 33770 P:727-518-8324 F:727-518-0723 o1n2 Page 3 of 4 IN WITNESS WHEREOF, the Parties have set their hands the date and year first written above. "Provider " � v� � Peter Marmerstein, Senior Vice President, on behalf of the following "Providers" Date: '1 �Z3 �l? • 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 —"Injury Intake 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 Largo Medical Center, Inc., d/b/a Largo Medical Center, Indian Rocks Campus -`�Injury Intake Site" "Client" Countersigned: . �eo��t n C� ��C�►S George N. Cretekos Mayor Approved as to form: Leslie K. Doug - i es Assistant City A ey ot/12 CITY OF CLEARWATER, FLORIDA By: �J . /IA.�L�'a. William B. Horne II City Manager Attest: Page 4 of 4 .�,� x ��7�PA1'�Y �A►F�,E ����tzg��`a�<�ni:-�> i�,=��lt�t ��rk�i�-�ti HCA West Florida Division - Company Care Site Locations Injury Management Only-Emergency Room Edward White Hospital Northside Hospital St Petersburg General Hospital 2191 9`h Avenue North, Suite 260 6002 49`h Street North 6500 38th Avenue North St. Petersburg, FL 33713 St. Petersburg, FL 33709 St. Petersburg, FL 33710 Phone: (727) 328-6261 Phone: (727) 521-5485 Phone: (727) 521-5485 FAX: (727) 328-6260 Fax: (727) 521-5484 Fax: (727) 521-5484 Largo Medical Center 1345 West Bay Dr. Ste 40] Largo, FL 33770 Phone: (727) 518-8324 Fax: (727)518-0723 Blake Medical Center 2010 59th Street West, Suite 3600 Bradenton, FL 34209 Phone: (941) 798-6158 Fax: (941)798-6475 Andrea Schwaderer - South Pinellas County Phone:(727)328-6255 Pager: (727) 570-0419 Fax: (727)328-6260 Injury Management Only-Emergency Room Largo Medical Center - Indian Rocks Campus 2025 Indian Rocks Road Largo, FL 33774 Phone: (727) 518-8324 Fvc: (727) 518-0723 Fawcett Memorial Hospital 3280 Tamiami Trail, Suite 11 Post Charlotte, FL 33952 Phone: (941) 625-3047 Fax: (941)625-3607 Central Florida Regional Hospital 1401 W. Seminole Blvd. Sanford, FL 32771 Phone:(407)302-7322 Fa�c: (407) 302 -7323 Account Managers Robyn Vandevander - North Pinellas County Phone:(727)518-8324 Pager: (727)402-0667 Fax: (727)518-0723 Regional Medical Center Bayonet Point 14100 Fivay Road, Suite 140 Hudson, FL 34667 Phone: (727) 819-2941 Fax: (727)819-2944 Osceola Regional Medical Center 720 West Oak Street, Suite 102 Kissimmee, FL 34741 Phone: (407) 846-3047 Fax: (407)847-2051 Cheryl Hymel -Manatee County Phone: (941)798-6073 Fax: (94l)798-6081 Dianna Ross - Charlotte County Melonie Ramey - Osceola County Paula Gallagher - Hernando/Pasco County Phone: (941)625-3047 Phone:(407)846-3047 Phone:(727)819-2941 Pager: (941)613-7768 Fax: (407)847-2051 Fax: (727)819-2944 Fax: (941)625-3607 Division Director Company Care Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP, FAAOHN Occupational Health Services - HCA — West Florida Division 6002 49th Street North St. Petersburg, Florida 33709 Phone: (727)528-5932 Fax: (727)528-5933 Cell: (727) 560-7252