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HomeMy WebLinkAboutFD04-075 - Original - Virginia Mason Occupational Medicine - Kent Fire Medical Examinations - 06/01/2001 ann math - '�dica hysical Contract doc age 1 PROFESSIONAL SERVICES AGREEMENT BETWEEN THE CITY OF KENT AND Virginia Mason Occupational Medicine FOR MEDICAL EXAMINATIONS FOR KENT FIRE & life safety THIS AGREEMENT is made by and between the CITY OF KENT, a Washington municipal corporation, ("City") and Virginia Mason Occupational Medicine, a Washington , whose address is 6720 Fort Dent Way, Tukwila, Washington 98188 ("Contractor") RECITALS WHEREAS, the City desires to retain services for medical examinations for the City's Fire and Life Safety Department as set forth in Exhibit "A" attached hereto and incorporated herein by this reference, and WHEREAS, Contractor agrees to perform said services under the terms and conditions set forth in the Scope of Work and Exhibit"A", NOW, THEREFORE, in consideration of the mutual promises set forth herein, it is agreed by and between the City and Contractor AGREEMENT 1 Contractor Responsibilities Contractor agrees to provide to City the medical examination services set forth in Exhibit "A" attached to this Agreement and incorporated herein by this reference 2 Pavment For said services City shall pay Contractor in accordance with the compensation schedule set for in Exhibit `B" attached to this Agreement and incorporated herein by this reference PROFESSIONAL SERVICES AGREEMENT FOR MEDICAL EXAMINATIONS FOR KENT FIRE&life safety (B1wn City of Ken!and Virginia Mason Occupational Medicine) ann Sr 9ifh-Medical ysica ontract doc Page 2 The Contractor is to submit periodic invoices The periodic invoices shall contain an itemized breakdown of the medical services actually performed during the time covered by the invoice The City will pay Contractor by check within 30 days of receipt of an invoice. 3 Status of Contractor This Agreement calls for the performance of the services of the Contractor as an independent contractor and Contractor will not be considered an employee of the City for any purpose The Contractor and/or its subcontractor(s) shall secure at its own expense, and be responsible for any and all payment of income tax, social security, state disability insurance compensation, unemployment compensation, Worker's Compensation, and all other payroll deductions for the Contractor and its officers, agents and employees and the costs of all business licenses, if any, in connection with the services to be performed hereunder. Contractor will be solely responsible for its acts and the acts of Contractor's agents, employees, servants, and subcontractors during the performance of this contract 4 Discrimination In the hiring of employees for the performance of work under this Agreement or any sub- contract hereunder, the Consultant, its sub-contractors, or any person acting on behalf of such Consultant or sub-contractor shall not, by reason of race, religion, color, sex, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is qualified and available to perform the work to which the employment relates Consultant shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 12, and upon completion of the work required of this Agreement, file the attached Compliance Statement 5 Indemnification The Contractor shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits This includes all legal costs and attorney fees, arising out of or in connection with the performance of this Agreement, except for injuries and damages caused by the sole negligence of the City IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONTRACTOR'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION THE PARTIES PROFESSIONAL SERVICES AGREEMENT FOR MEDICAL EXAMINATIONS FOR KENT FIRE&life safety (Btwn City of Kent and Verranra Mason Occupational Medicine) Dann math edica ysical ontract doc Page 3 FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER The provisions of this section shall survive the expiration or termination of this Agreement 6 Term of Agreement Performance under this Agreement shall commence on the I ,�U ALC ZCX�)L and shall terminate on the 30,Unl t 1,50 + Notwithstanding the foregoing, this Agreement may be terminated by either party with or without cause upon giving 30 days written notice of termination Said termination shall be effective as of the time stated in the written notice, provided that Contractor shall be entitled to compensation under the terms of this Agreement to the extent of the actual work performed hereunder Upon termination, the City may thereafter take possession of all records and data pertaining to this Agreement 7 Insurance The Contractor shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property that may arise from or in connection with the performance of the work hereunder by the Contractor, or subcontractors Before beginning the work described in this Agreement, the Contractor shall provide a Certificate of Insurance evidencing 1 Comprehensive General Liability insurance written on an occurrence basis with limits no less than $1,000,00000 combined single limit per occurrence and $2,000,000 00 aggregate for personal injury, bodily and property damage 2 Professional Liability - insurance covering medical services provided under this Agreement with limits no less than$1,000,000 00 limit per occurrence Coverage shall include but not limited to, blanket contractual, products/completed operations, broad form property damage, explosion, collapse and underground (XCU) if PROFESSIONAL SERVICES AGREEMENT FOR MEDICAL EXAMINATIONS FOR KENT FIRE&life safety (Btivn City of Kent and Dr¢mm Mason Occupational Medicine) Dann Q edica ysical ontract oc Page 4, applicable, and employers liability, and any payment of deductible or self insured retention shall be the sole responsibility of the Contractor The City shall be named as an additional insured on the comprehensive general liability insurance policy, for work performed by or on behalf of the Contractor for the City and a copy of the endorsement naming the City as additional insured shall be attached to the certificate of insurance The City reserves the right to receive a certified copy of all required insurance policies The Contractor's insurance shall contain a clause stating that coverage shall apply separately to each insured against whom a claim is made or suit is brought, except with respect to the limits of insurers' liability Contractor and insurance shall be primary insurance, as respect the City and the City shall be given thirty- (30) days prior written notice of any cancellation, suspension or material change in coverage 8 Ownership of Records and Drawings Original documents, drawings, designs and reports developed under this Agreement shall belong to and become the property of the City All written information submitted by the City to the Contractor in connection with the services performed by the Contractor under this Agreement will be safeguarded by the Contractor to at least the same extent as the Contractor safeguards like information relating to its own business If such information is publicly available, is already in Contractor's possession or known to it, or is rightfully obtained by the Contractor from third parties, Contractor shall bear no responsibility for its disclosure, inadvertent or otherwise 9 Entire Agreement The written provisions and terms of this Agreement shall supersede all prior verbal statements of any officer or other representative of the City and Contractor, and such statements shall not be effective or be construed as entering into or forming a part of, or altering in any manner whatsoever, this Agreement or the Agreement documents The entire agreement between the parties with respect to the subject matter herein is contained in this Agreement, its Exhibits, any addenda attached hereto, and all bid related documents, if any, which may or may not have been executed prior to the execution of this Agreement All of the above documents are hereby made a part of this Agreement and form the Agreement document as fully as if the same were set forth at length herein 10 Waiver and Modification No waiver, alteration or modification of any of the provisions of this Agreement shall be PROFESSIONAL SERVICES AGREEMENT FOR MEDICAL EXAMINATIONS FOR KENT FIRE&life safety (Btwn City of Kent and Vwguna Mason Occupational Medicine) Darin init - e ical hysica Contract oc Page 5 binding unless in writing and signed by a duly authorized representative of the City and Contractor 11 Amendments Any amendment to this Agreement shall not be effective until both parties have agreed to it in writing A copy of the written amendment, including signatures of the parties, shall be attached to the original of this Agreement 12. Assignment Any assignment of this Agreement by the Contractor without the written consent of the City shall be void 13 Written Notice All communications regarding this Agreement should be sent to the parties at the addresses below, unless notified to the contrary If to City If to Consultant City of Kent Vtr�qinio, Mason Occup&+,o c.l Akedtcine. Fire and Life Safety Department A*V. Darin sm"'K 24611 - 116th Avenue SE lop 20 FO,-t ()eint Way , Su,fc 150 Kent, WA 98031 Tukwila, wA 9 818 s Any written notice hereunder shall become effective on the date personally served or, if marled, as of the date of marling, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may hereafter be specified in writing 14 Disputes Any disputes arising between the parties shall first be referred to the City for resolution Any dispute that cannot be settled between the parties after the City's determination shall only be brought within the venue and jurisdiction of the King County Superior Court subject to the laws of the State of Washington and to the Rules of Practice and Procedure for King County, Washington 15 Miscellaneous The Contractor shall not assign, transfer, pledge as collateral or otherwise encumber any PROFESSIONAL SERVICES AGREEMENT FOR MEDICAL EXAMINATIONS FOR KENT FIRE&life safety (Btivn City of Kent and Virginia Mason Occupational Medicine) grin Smif6- Medical Rhysical Contract oc Page 6 rights, duties, or interest accruing from this Agreement without the written consent of City City makes no commitment and assumes no obligation for support of Contractor, except as specifically set forth in this Agreement This Agreement represents the entire and integrated agreement between the parties hereto and supersedes all prior negotiations, representations, or agreements, either written or oral This agreement is binding on the parties hereto, their heirs, successors, and assigns IN WITNESS WHEREOF, the parties below have executed this Agreement CONTRACTOR THE CITY OF KENT Virginia Amon OCCupaiioaa.l hi�ciac- lnT2o For't Oeni Way, Swfe Iso TuKu4a, WA QSISR 0 By yYL"axt 73 LL+c wt By Jim White Its Mornycr Its Mavor DATE DATE -Q� APPROVED AS TO FORM: ATTEST: Kent City sy Attorney City Clerk P\C v111FILE51pPmFilcs\01 N\MW W PM1ymolConwcl 4oc PROFESSIONAL SERVICES AGREEMENT FOR MEDICAL EXAMINATIONS FOR KENT FIRE&life safety (Blwn City ofKenl and Vmzmm Mason Occuaakonal Medicine Occuaakonal Medicine) ann_m7fl page 2; DECLARATION CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity As such all contractors, subcontractors and suppliers who perform work with relation to this contract shall comply with the regulations of the City's equal employment opportunity policies The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or supplier on this specific contract to adhere to An affirmative response is required on all of the following questions for this contract to be valid and binding If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the contract, The questions are as follows 1 I have read the attached City of Kent administrative policy number 1.2. 2 During the time of this contract I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability 3 During the time of this contract the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer 4 During the time of the contract I, the prime contractor, will actively consider hiring and promotion of women and minorities 5 Before acceptance of this contract, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above By signing below, I agree to fulfill the five requirements referenced above Dated this 1'± day of 4�� 2001 By lKatga t &aluttiV For Virginja Mason OC_LL paii0rL&k Aedlune, Title `m"ctl EEOC DOCUMENTS ahn niith - Medica hysical ontract doc Page 8 Date 6/1 Jol EEOC DOCUMENTS Darin rrufh - Medical ysica ontract doc age CITY OF KENT ADMINISTRATIVE POLICY NUMBER 12 EFFECTIVE DATE. January 1, 1998 SUBJECT MINORITY AND WOMEN SUPERSEDES April 1, 1996 CONTRACTORS APPROVED BY Jim Wlute, Mayor POLICY Equal employment opportunity requirements for the City of Kent will conform to federal and state laws All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding contracts with the City amounting to $10,000 or more within any given year, must take the following affirmative steps 1 Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer 2 Actively consider for promotion and advancement available minorities and women Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the contract Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments 1 Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunity policy 2 Monitoring to assure adherence to federal, state and local laws, policies and guidelines EEOC DOCUMENTS Bann $mdfi - edical Physical ontract doc Page 10 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the contract 1, the undersigned, a duly represented agent of Company, hereby acknowledge and declare that the before-mentioned company was the prime contract for the contract known as that was entered into on the date between the firm I represent and the City of Kent I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 12 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned contract Dated this day of 2001 By For Title Date EEOC DOCUMENTS FROM 'BUSINESS & OCC HEALTH 20S 223 GS 9 2001.05-2S 12:2S #SG3 F.02/02 May 2�. 2001 Re. Employees of Virginia Mason Medical Center(VMMC) Professional Liability Insurance To Whom It May Concern The employees of Virginia Mason Medical Center(VMMC), acting within the scope and during the course of their employment with VMMC are covered by VNIMC's self-Lnsured Professional Liability Program VMMC is substantially self-insured for professional liability with a retention of$1.0 mullion per occurrence and $7 0 million in the annual aggregate- E.\eess professional liabLlin co%erake is pro-,ided by various domestic insurance companies Renewal dates are May 31, 2001 to May 31. 2002, and continuous Copies of this letter should be considered as valid as the original. If%ou have any questions_ please contact the Risk Management Department at (206)583-6057 $inc: rely I Mic ael D O terman Dire or. Risk Management F:\data\nskmgmt\insumncelp Iltrgeninsur 1100 Ninth Avenue P.O.Bn 900.MS: MID-RM Seelde,N a 99111.0960 Telephone No.. 2069113 6057 PROFESSIONAL SERVICES AGREEMENT BETWEEN THE CITY OF KENT AND VIRGINIA MASON OCCUPATIONAL MEDICINE FOR MEDICAL EXAMINATIONS FOR KENT FIRE & LIFE SAFETY Exhibit "A" Medical Physical Services Criteria Annual Member Medical Examination Criteria 9. Medical History Questionnaire $ 135.00 An initial pre-employment history questionnaire must be completed to provide baseline information with which to compare future medical concerns A periodic medical history questionnaire must be completed to provide follow-up information.Periodic questionnaires focus on changes in health status 10.Hands-on Physical Examination INCLUDED Vital Signs Head,Eyes,Ears,Nose, and Throat Neck Cardiovascular Inspection, auscultation,percussion and palpation Pulmonary Inspection, auscultation,percussion and palpation Gastrointestinal Inspection, auscultation,percussion and palpation Genitourmary Hernia exam (Also, see cancer screening) Rectal (See cancer screening) Lymph Nodes The examination of organ systems must be supplemented with an evaluation of lymph nodes in the cervical, auxiliary, and inguinal regions Neurological The neurological exam for un formed personnel must include a general mental status evaluation and general assessment of the major cranial/peripheral nerves (motor, sensory, reflexes) Musculoskeletal Includes an overall assessment of range of motion (ROM of allloints Additionally, observation of the personnel performing certain standard office exercises or functions is helpful in assessingloint mobility and function 11.Blood Analysis $ 70.00 The following are components of the blood analysis At a minimum, laboratory services must provide these components in their automated chemistry panel(a k a SMAC 20)and complete blood count(C13Q protocols White Blood Cell Count Differential Red Blood Cell Count(Hematocrit) Platelet Count Liver Function Tests Includes SGOVAST, SGPT/ALT, LDH,Alkaline Phosphatase, and Bdirubm Triglycerides Glucose Blood Urea Nitrogen Creatinine Sodium Potassium Carbon Dioxide Total Protein Albumin Calcium Cholesterol Includes Total Cholesterol Low Density Lipoprotein (LDL-C) level, High Density Lipoprotein (HDL-C) level, and Total Cholesterol/HDL Ratio 12.Urinalysis Dip Stick INCLUDED WABOVE Includes pH, Glucose, Ketones, Protein, Blood, and Bilirubin Microscopic INCLUDED WABOVE Includes WBC, RBC, WBC Casts, RBC Casts, and Crystals 13.Vision Tests $ 15.00 Assessment of vision must include evaluation of distance, near,peripheral,and color vision Evaluate for common visual disorders including cataracts,macular degeneration,glaucoma, and diabetic retmopathy 14.Hearing (Audiogram) $ 29�00 15.Pulmonary (Spirogram) $ —0.00 16.Chest x-ray - Every five years — mandatory $ 50.00 17.EKG (Resting) $ 55.00 18.Cancer Screening Elements Prostate Specific Antigen $_60.00_ Annual on all male unformed personnel who have a positive family history of prostate cancer or are African-Americans beginning at age 40 All male uniformed personnel beginning at age 50 Digital Rectal Exam N/C Fecal Occult Blood Testing $ 27.00 Skin Exam N/C Testicular Exam N/C 19.Immunizations and Infectious Disease Screening Tuberculosis Screen-Annual $ 20.00 Tetanus/Diphtheria Vaccine(Booster every 10years) $ 20.00 Hepatitis A Vaccine $ 65.00 Vaccine shall be offered to high risk(HazMat, USAR, and SCUBA) and other uniformed personnel with frequent or expected frequent contaminated water exposures i (Required to be offered)HIV Screening $ 75.00 + 75.00/Hr pre/post HIV testing should be offered on a confidential basis as part of post-exposure protocols and as requested by the physician and patient 20.Annual Fitness EVal nation-Identified at risk members and any member over the aee of46 Aerobic Capacity Gerken Protocol(Treadmill) $ 225.00 Maximal cardiopulmonary test with EKG $ 100.00 Hazardous Materials Team Member Medical Examination Criteria 1. Medical History Questionnaire $ 135.00 An initial pre-employment history questionnaire must be completed to provide baseline information with which to compare future medical concerns A periodic medical history questionnaire must be completed to provide follow-up information Periodic questionnaires focus on changes in health status 2. Hands-on Physical Examination INCLUDED WABOVE Vital Signs Head, Eyes,Ears,Nose, and Throat Neck Cardiovascular Inspection, auscultation,percussion and palpation Pulmonary Inspection, auscultation,percussion and palpation Gastrointestinal Inspection, auscultation,percussion and palpation Genitourinary Hernia exam (Also, see cancer screening) Rectal (See cancer screening) Lymph Nodes The examination of organ systems must be supplemented with an evaluation of lymph nodes in the cervical, auxiliary, and ingumal regions Neurological The neurological exam for uniformed personnel must include a general mental status evaluation and general assessment of the major cramabperipheral nerves (motor, sensory, reflexes) Musculoskeletal Includes an overall assessment of range of motion (ROAD of allloints Additionally, observation of the personnel performing certain standard office exercises or functions is helpful in assessingloint mobility and function " 4. Blood Analysis $ 70.00 The following are components of the blood analysis At a minimum, laboratory services must provide these components in their automated chemistry panel(a k a SMAC 20)and complete blood count(CBC) protocols White Blood Cell Count Differential Red Blood Cell Count(Hematocrit) Platelet Count Liver Function Tests Includes SGOVAST,SGPTIALT, LDH,Alkaline Phosphatase, and Blhrubm Triglycerides Glucose Blood Urea Nitrogen Creatinine Sodium Potassium Carbon Dioxide Total Protein Albumin Calcium Cholesterol Includes Total Cholesterol Low Density Lipoprotein (LDL-C) level, High Density Lipoprotem (HDL-C) level, and Total Cholesterol/HDL Ratio 5. Urinalysis Dip Stick INCLUDED WABOVE Includes pH, Glucose, Ketones, Protein, Blood, and Bilirubin Microscopic INCLUDED WABOVE Includes WBC, RBC, WBC Casts, RBC Casts, and Crystals 6. Heavy Metal and Special Exposure Screening Baseline testing, for heavy metals may be assessed on the initial physical but is not required under the Initiative since the utility of such testing has not been medically established However, evaluations are required to be done under special circumstances, such as following a known exposure,for recurrent exposures, or where required under federal, state or provincial regulations (e g, OSHA standards) Arsenic (urine) $ 110.00 Mercury(urine) INCL.INMETALS Lead(urine) $ 19.00 Lead(blood) $ 19.00 Aluminum ALL INCL.INMETALS Antimony « Bismuth « Cadmium « Chromium « Copper « Nickel « Zinc « Organophosphates(RB cholinesterase) $ 42.00 Polychlorinated Biphenyls(blood) $ 75.00 + handling 21.0 3. Vision Tests $ 15.00 Assessment of vision must include evaluation of distance, near, peripheral, and color vision Evaluate for common visual disorders including cataracts, macular degeneration, glaucoma, and diabetic retmopathy 4. Hearing (Audiogram) $ 29.00 5. Pulmonary (Spirogram) $ 50.00 6. Chest x-ray - Every five years — mandatory $ 50.00 7. EKG (Resting) $ 55_00 8. Cancer Screening Elements ** May be provided to medical record by members personal physician Prostate Specific Antigen $ 60.00 Annual on all male unformed personnel who have a positive family history ofprostate cancer or are African Americans beginning at age 40 All male uniformed personnel beginning at age 50 Digital Rectal Exam N/C Fecal Occult Blood Testing $ 27,00 Skin Exam N/C Testicular Exam N/C 13.Immunizations and Infectious Disease Screening Tuberculosis Screen-Annual $ 20�_00 Hepatitis C Virus Screen-OPTIONAL $ 55,00 HepadtisA Vaccine $ 65.00 Vaccine shall be offered to high risk(HazMat, USA$ and SCUBA) and other un formed personnel with frequent or expected frequent contaminated water exposures (Required to be offered)HIV Screening $ 75.00 + 75.0O/Hr pre/post HIV testing should be offered on a confidential basis as part of post-exposure protocols and as requested by the physician and patient 14.Annual Fitness Evaluation Aerobic Capacity Gerkin Protocol(Treadmill) $ 225,00 Maximal cardiopulmonary test with EKG $ 100,00 Pre-Employment Medical Examination Criteria 1. Medical History Questionnaire $ 135.00 An initial pre-employment history questionnaire must be completed to provide baseline information with which to compare future medical concerns A periodic medical history questionnaire must be completed to provide follow-up information Periodic questionnaires focus on changes in health status 2. Hands-on Physical Examination INCLUDED WABOVE Vital signs Head, Eyes,Ears,Nose, and Throat Neck Cardiovascular Inspection, auscultation,percussion and palpation Pulmonary Inspection, auscultation,percussion and palpation Gastrointestinal Inspection, auscultation,percussion and palpation Genitourinary Hernia exam (Also, see cancer screening) Rectal (See cancer screening) Lymph Nodes The examination of organ systems must be supplemented with an evaluation of lymph nodes in the cervical, auxiliary, and ingumal regions Neurological The neurological exam for uniformed personnel must include a general mental status evaluation and general assessment of the major cranial/peripheral nerves (motor, sensory, reflexes) Musculoskeletal Includes an overall assessment of range of motion (ROB of allloints Additionally, observation of the personnel performing certain standard office exercises or functions is helpful in assessingloint mobility and function 4. Blood Analysis $ 70.00 The following are components of the blood analysis At a minimum, laboratory services must provide these components in their automated chemistry panel (a k a SMAC 20) and complete blood count(CBC)protocols White Blood Cell Count Differential Red Blood Cell Count(Hematocrit) Platelet Count Liver Function Tests Includes SGOVAST,SGPT/ALT, LDH, Alkaline Phosphatase, and Bdirubm Triglycerides Glucose Blood Urea Nitrogen Creatinine Sodium Potassium Carbon Dioxide Total Protein Albumin Calcium Cholesterol Includes Total Cholesterol Low Density Lipoprotein (LDL-C) level, High Density Lipoprotein (HDL-C) level, and Total CholesterollHDL Ratio 5. Urinalysis Dip Stick INCLUDED WABOVE Includes pH, Glucose, Ketones, Protein, Blood, and Bihrubin Microscopic Includes WBC, RBC, WBC Casts, RBC Casts, and Crystals INCLUDED WABOVE 6. Heavy Metal and Special Exposure Screening Baseline testing,for heavy metals may be assessed on the initial physical but is not required under the Initiative since the utility of such testing has not been medically established However, evaluations are required to be done under special circumstances,such as following a known exposure, for recurrent exposures, or where required under federal,state or provincial regulations (e g,OSHA standards) Arsenic (urine) $ 110.00 Mercury (urine) INCL.IN METALS Lead(urine) $ 19.00 Lead(blood) Aluminum ALL INCL.INMETALS Antimony « Bismuth « Cadmium « Chromium « Copper « Nickel « Zinc « Organophosphates (RB cholinesterase) $ 42.00 Polychlorinated Biphenyls (blood) $ 75.00 + handling1321.00T— 7. Vision Tests $ 15.00 Assessment of vision must include evaluation of distance,near,peripheral, and color vision Evaluate for common visual disorders including cataracts,macular degeneration,glaucoma,and diabetic retinopathy 8. Hearing (Audiogram) $ 29.00 9. Pulmonary (Spirogram) $ 50.00 10.Chest x-ray -Initial Baseline $ 50.00 11.EKG (Resting) $ 55.00 12.Cancer Screening Elements ** May be provided to medical record by members personal physician **Clinical Breast Examination NIC **Mammogram $ 120.00 **Pap Smear $ 2'7 QQ Prostate Specific Antigen $_60.00_ Annual on all male uniformed personnel who have a positive family history of prostate cancer or are African-Americans beginning at age 40 All male uniformed personnel beginning at age 50 Digital Rectal Exam NIC Fecal Occult Blood Testing $ 2'7,QQ Skin Exam NIC Testicular Exam NIC 13.Immunizations and Infectious Disease Screening Tuberculosis Screen $ 20.00 (Entry Baseline)Hepatitis C Virus Screen-OPTIONAL $ 55.00 (Mandatory at initial) Hepatitis B Virus Vaccine $ 65.QQ (Booster every 10 years ver fy or provide) Tetanus/Diphtheria Vaccine $ 25.0U (Entry Baseline Verify or Provide)Measles,Mumps, Rubella Vaccine(MMR)Measles Vaccine $ 24.00 Vaccine is required for all uniformed personnel born in or after 1957 if there is no medical contraindication and no evidence of at least one dose of live vaccine on or after one's first birthday (Entry Baseline Verfy or Provide)Mumps Vaccine $ 24.00 Vaccine is required for all unformed personnel born in or after 1957 f there is no documentation ofphysician-diagnosed mumps, no adequate immunization with live mumps after their first birthday and no evidence of laboratory immunity (Entry Baseline Vert&or Provide)Rubella Vaccine $_10.00 Vaccine is required unless proof of immunity is available (Entry Baseline Verify or Provide)Polio Vaccine $ 24.00 Vaccine shall be given to uniformed personnel if vaccination or disease is not documented (Required to be offered) Varicella Vaccine $ 10.00 (Required to be offered)Influenza Vaccine $ 10.0Q (Required to be offered)HIVScreening $ 75.00 + 75 00/Hr pre/post HIV testing should be offered on a confidential basis as part ofpost-exposure protocols and as requested by the physician and patient 14. Fitness Evaluation Aerobic Capacity Gerkin Protocol(Treadmill) $ 225.00 Maximal cardiopulmonary test with EKG $ 100.00 One Fee of$45.00 Push-up Evaluation « Leg Strength Evaluation « Arm Strength Evaluation Grip Strength Evaluation « Curl-up Evaluation « Flexibility Evaluation « Follow-Up and Referral by Health Care Practitioner 1. Follow-Up or Consultation by Health Care Practitioner 80.00 The Wellness-Fitness Initiative recognizes the importance of consultation and/or referral to outside health care providers and/or specialists Aspects of the follow-up and referral program include • Abnormal findings on the annual physical must be addressed by follow-up or referral • Revaccination or intervention following exposures must be managed by follow-up or referral • Managed care or other provider referrals are appropriate for non-service connected problems • Return to work determinations require clearance by the fire department physician or other provider following a consult with an outside physician or after extended leave • Follow-up on findings from annual examinations must be reviewed by the fire department physician 2. Individualized Health Risk Appraisal $ 80.00 The health care provider (organization or individual) shall provide written documentation regarding their follow-up/referral program or procedures. Written feedback to uniformed personnel concerning health risks and health status is required following the annual examination Reporting findings and risks and suggesting plans for modifying risks improve the physician-patient relationship and helps uniformed personnel claim ownership of their health status. Individualized health risk appraisals also must include questions that attempt to accurately measure the uniformed personnel's perception of their health Health perception can be a useful indicator of potential problems PROFESSIONAL SERVICES AGREEMENT BETWEEN THE CITY OF KENT AND VIRGINIA MASON OCCUPATIONAL MEDICINE FOR MEDICAL EXAMINATIONS FOR KENT FIRE & LIFE SAFETY Exhibit "B" The Contractor is to submit periodic invoices The periodic invoices shall contain an accounting of the medical services actually performed, reference Exhibit "A" for approved services and costs, and the names of members receiving services for reference The City agrees to pay the Contractor by check within 30 days of receipt of an invoice. Vendor information and Set-up form attached JUN. S.2001 9:32AM KENT FIRE DEPT NO 822 P 1/1 ' RECENED JUN 4 NewVanclor ❑ Reactivate Vendor KENT Vendor Set-WF@IMDEPT. ❑ Address Change WAa"14 OTap To be filled out by Vendor ONLY Vendor Number FINANCE 220 Fourth Avenue South • Kent,WA 98032-5895 a Phone: (253) 856-5231 • Fax: (253) 856-6200 An Incomplete form will preate a delay in our payment(s)to you and your payment(s) could be subject to the IRS required back-up withholding. N as it will appear on check (NO A86REW4TIONS) Doing Business As(If different than name on check) D. Fo,C 9/0 �G , Payment Address Business Address CI n State- / Zip City state Zip Accounts Receivau Contact Phone Number check the appropfixte box 10'Inorporation ❑ Government Agency ❑ Individual/Sole Proprietor ❑ Non-Profit ❑ Partnership This business is ❑ Minority Owned ❑ Women Owned ❑ Both Minority and women Owned ❑ Neither Will you provide medical services to the City of Kent? ............. .............................. .. ........ ...... Yes No WIII you provide legal services to the City of KentO..................................................... ...... ........ Yes No Will you provide services other than medical or legal to the City of Kent? ........................ ........ Yes No Will you provide parts,supplies or materials to the City of Kerrt?.... ..... ...................................... Yes No Do you pay sales tax to the State of Washington? .... .. ........ .. .... ......... .......... Yes No if exempt from Form 1099 reporting, and check your qual"ng exemption reason below: 1. Corporation, except there is no exemption for medical and healthcare payments or payments for legal services 2 Tax Exempt Chanty under 501(a), or IRA ❑ 3. The United States or any of Its agencies or instrumentalities II 4. A state,the Distrfet of Columbia, a possession of the United States, or any of their political subdivisions ❑ S. A foreign government or any of its political subdivisions PaymentTerms: Social Security#: or Federal TIN: c �o Under penalties of peaury, I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding,or(b) I have not been notified by the Internal Revenue Service (IRS)that I am subject to backup withholding as a result of a failure to report all Interest or dividends. or(a)the IRS has notified me that 1 am no longer subject to backup withholding. Signature► Date ► 1IM2727 p65.91ef 01-06-08 08: 32 RECEIVED FROM: 253 859 3281 P 01 Form W-9 \ Request for Taxpayer 9941 Gkre lean b � ""'�"" T Identification Number and Certification requester.Do NOT °i '".°'�FW e ee send to the IRS. Name Is pan nines.M fist and arde,e name of the Pawn or emery whew names,you smsr n Pan I below Sea Instructions as/rye 1 I year some he thaslae.) 3 SuSI as name(Sole PRIPnerors see instruction+on Pay.24 Name changed as of June 1, 1994, Virginia Mason Medical Center a formerly Virginia Mason Hospital Please Cheek iWordPnate box. ❑ IndmtluallSPle Proprietor X Cdrooation ❑ Partnership ❑ Other ► Address(number,svam.and apt,Or was no.) Requaeara name and address ldPbpaal P.O. Box 91046 CL CRY,state.and LP code Seattle, WA 98111-9146 Taxpayer idenwication Number frIM tin account m,mbertq hem ppbonal) Enter your TIN in Va appropriate box. For individuals,this is your social security number Social ramp camber (SSN). For sole proprietors,see the Instructions on page 2. For other entitles, it Is your employer identification number(EIN). If you do not have a OR LMIII For Payees Exempt From Backup number, see Now To Got a TIN below. Wtftok*V(See Pan p Nob:n the account Is in more than one name, Err~idrmacatlon mniser instructions on page 2) see the chart on page 2 for gudelriea on »ease 9 1 0 5 6 5 5 3 9 nurr9w to Great. EXEMPT Certification Under penalties of per)uy,I certify that: 1. The number shown on dvs form a my coned taxpayer Identification nunter(or I am waiting for a number to be issued to mail.wed 2. 1 am not KA440 to backup weMolding beaus..(a)1 am exempt from backup withholding,or(b)I have not bean n id by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report as Interest or tlividarhda,or(q the IRS has natabd me that I am no longer stibpq to backup withholding.g. —certilleation InsbucUOnsryeu must cross out ftem 2 above d you hew been notified by the IRS that you re o rrrdly subject to backup wdMdding because of underreponkg into Of dividends On you tax return. For real estate transactions,tam 2 aloes not apply.For mortgage interest paid.the acquisition or abandonment of secured property.daricssation of debt.contributions to an individual retirement arrangamrd (IRA).and generally payments othw than ntrast and dividends.you are not required to sign the Certification,but you mail provide your correct TIN.(Also ape Part IN Instructions an page 24 Sign _Here Signature /Ji Date ► Sectron references are ro th lft 0r / eCSJ Revenue-Code Payments u certain conditions This is interest and dividend accounts opened called `backup withholding.' Payments after 1983 only),or Purpose of Form.—A person who is that could be subject to backup S. You tl0 not ceiiy your TIN. See the required to file an information return with withholding include interest. dividends, Part IN u do not c b yourexce IN. the IRS must get your correct TIN to report broker and barter exchange transactions, income pad to you. real estate rertb,royalties,nonempicrinse pay, and Certain payees and payments are the aadbtxs.mortgage merest you pad, certain payments from flashing boot exempt from oParetore. Real estate tranSWOorm are not information backup'M acquisition r abandonment of severed -reporting. See thholdirM III properly,cancellation of debt,or subject to backup withholding. Instructions and the separate Instructions contributions you made to an IRA. Use If you give the requester year correct for the Requiesterr at Form We• Form W-9 to give your cored TN to the TIN, make the proper certlfk-atlors, and How To Gat a TIN.—If you do not have a requester(the person requesting your TIN) report all you taxable interest and TIN, apply for one immediately. To apply. and,when applicable. (1)to cart y the TIN dividends on you tax return.your get Form SS.S,Application for a Social you are giving is correct(or you are waiting Payments w2 not be subject to badwp Severity Number Card(for hndMduals), for a number to be awed),(2) to eerey withholding. Payments you receive will be from you loal office of the Social Security you are not subject to backup wMkholding, subject to backup withholding If: Administration,or Form SS-4,Applicat on or(3) to claim exemption from backup for Employer Identification Number(for withholding d you are an exempt payee. 1. You do not famish your TIN to the Giving you correct TIN and making the requester, or businesses and a2 other enbdas).from appropriate cerefications will lue tens the 2 The IRS te the requester that you your local IRS offia. certain payments from being subject to furnished an Incorrect TIN,or If you do not have a TIN, write'Applied backup wrthhoWing. For' in the span for the TIN In Part I,sign 3.The IRS tells you that you are subject and date the form,and give it to the Nob:If a mquester gives you a form other to backup withholding because you did not requester. Genaraly,you will then have So then a W-9 to request your TIN, you must report all you interest and dividends on days to get a TIN and give it to the use the mquester s form if d Is substanhaNy your tax return(for reportable interest and requester If the requester does not receive sh7ww to this Form W-9. dmdends only), or your TN wit an 80 days,backup What Is Backup WithhopkgT—Persons 4. You do not cently to the requester wdhhokhrig•d applicable,will begs and making certain payments to you must that you are not subject to backup continue and you furnish your TIN. withhold and pay to the IRS 31% of such withholding under 3 above(for reportable Form W-9 (Bair.3-94) , Rf • - , Force W-9 1Re 3.941 paw 2 , Nots: Wnhng Apphed for"on the Joan If you are exempt from backup TIN whether or not you are required to file means that you have already applied for a withholding, you should sub complete this a tax return. Payers must generally TIN OR that you intend to apply for one form to avoid possible erroneous backup withhold 31% of taxable interest, dividend, soon. vnthholdmg. Enter your correct TIN in Part and certain other payments to a pays& As soon as you receive your TIN, I, write-Exempt- In Part 11, and sign and who does not glue a TIN to a payer. complete another Forth W-9, include your data the forth. if you are a nonresident Certain penalties may also apply. TIN, sign and date the form, and give it to alien or a foreign entity not subject to the requester backup withholding, give the requester a What Name and Number To completed ig W 8 Certificate of Give the Requester Penalties 'g FsBnrs To Furnish TIN.—If you fall to Part II6-CoerWieation For aid We of scoring Give nrae and UN ee tumnh your correct TIN to a requester, you For a joint account. only the person whom 1• 1111 no 1111119001111.1111 are subject to a penalty of$SO for each TIN Is Shown in Par I should sign. a. Two er note iM se"eenr ea to such failure unless your falure is der m baertsab lava axxxi m s.9 oanetrd reasonable cause and not to vatiful neto 1.intend,Dividend'and Barter BMUM Exchange Accourft Opened get" Is" ae s We*Aae11�r Chill Penafly for False Information With arid Brokerceonrts Considered Active L ciabwm+moue of lb ever t Respect to Withholding.—If you make a During 1983. You must mmvjlkeae,ntlN give your correct b ra,m Aso false statement with no reasonable base TIN, but you do not have to sign the • nr nu Ttr ems ear that results inithhism no backup wcding,you certification. er��is subject to a$500 penalty. 2.Intend Dividend, Broker, and are tn.bn Criminal Penalty for Falsifying Barter Exchange Aeeourrb Opened After n soerbd inrt mr ear ewer Information.—Willfully faisdy&q 1983 and Broker Accounts Considered NOW%eatrINS orvuld certifications or affirmations may subject Inactive During 1983.You must sign the �SIM rwy" you to criminal penalties including fines certification or backup wdhholdng will L Sou.Powrerro The ermrr amlfor imprisonment. apply. If you are subject to backup Misuse of TINS.--If the requester withholding and you are merely providing Per Ines trim of&eomee firm rune rid ON of discloses or uses TINS in violation of your correct TIN to the requester, you mud a sob pop■a a,e n.mnur+ Federal law, the requester may be subject cross out Item 2 inthe certification before 7. A vaba emit rum,r L&W on" to civil and criminal penalties. st99 the form. P". am LCoaerm The em,oreerm 3. Mal Estate Transactions.You must S. aaeocoox%aA The Specific Instructions sign the certification. You may cross out +.mart.,r.aatir p ns ons Ram 2 of the certification. md,rrear.r err Narne:—If you are an individual.you must 4. Other Payments. You must give your oee mr generally enter the name shown an your correct TIN. but you do not have to sign >d Pill The prnwano social security card. However,it you hew the certification unless you have been 11. A rekr r w9wr,ed The rrrr r changed your last name, for instance,due notified of an incorrect TIN Other 'Neer' to manage, without informing the Social tb ��wawe� The Pere rent Secunty Administration of the name payments Include paymetU made m the change. Please enter your first name, the course of the requester's trade t business of�e'er h for rents, royalties,goods(other than fills last name shown on your social seamy for merchandise), medical and health clan r a mr r am card• and your new last name. services, payments to a ronemployes for �u r paid er Sole Proprietor—You must enter your services lncldding attorney and accounting nrtr mpn.+aur ndivkhnl name. (Enter either your SSN or fees), and payments to eeran fishing boat Porrr,pvv b - EIN in Part 1.) You may also enter your crow members. , W bw art sort er ar,r of art Pr.•w weer business name or'long business as' 6. Mortgage Wtsred Pled by You, 'xi°r 7oa emir. name on the business name line. Enter Acquisition or Abandonment of sealed 'ciRb s mrh war re&ran ti nr,a,•e 88K your name as shown on your SocW prey, Cancellation of Debt, or IRA ,yw mar rea security card and business name as N was eM, You must give your Cana rnbr lea bsermtr-111"a�a nnom YYw used to apply low yaw EIN an Forth SS-4. TIN, but you do not have to sign the nrr'm'e'r yaw am or E s Part Taxpayer WerrtlBcodan Number certification. o&w a m aim to err CO Sw buys eat sin. RIM rP�e.er�or e�ww tier s��law Is Privacy Ad Notice w mrarre e to arm.&Seal You must enter your TIN In the appropriate Section 6109 requires you to give yaw NOW a no romo is ercied Wan ma's anew one box. If you are a sole proprietor, you may correct TIN to persons who must file none a bated,aw number wd he Coaaadrad tr enter your SSN or EIN Mao see the Cheri information realms with the IRS to report be OW of the first came bated on this page for further clarification of interest, drvdenls, and certain other name and TIN combinations. If you do not income pad to you, mortgage Interest you have a TIN, follow the instructions under paid, the acquisition or abandonment of How To Got a TIN on page 1 secured property, cancellation of debt, or Part II—For Payees Exempt From c°mtnbu4ons you made to an IRA.The IRS Backup fJfltinfnpldirng uses the numbers for identification purposes and to help verily the accuracy Individuals pncludng sob prcprfston)are of your tax return. You must provide your not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments.such as interest and dividends. For a complete list of exempt payees, see the separate Instructions for the Requester of Form W-9