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Home My WebLink About264874 OCCUPATIONAL HEALTH SERVICES - CONTRACT - RFP - P1089 MEDICAL PROVIDER - WORKERS COMPENSATIONSERVICES AGREEMENT THIS AGREEMENT made and entered into the day and year set forth below by and between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter referred to as the "City" and Occupational Health services Poudre Valley Health System, hereinafter referred to as "Service Provider" WITNESSETH In consideration of the mutual covenants and obligations herein expressed, it is agreed by and between the parties hereto as follows 1 Scope of Services The Service Provider agrees to provide services in accordance with the scope of services attached hereto as Exhibit "A", consisting of two (2) pages and incorporated herein by this reference 2 Contract Period This Agreement shall commence January 1, 2008, and shall continue in full force and effect until December 31, 2008, unless sooner terminated as herein provided In addition, at the option of the City, the Agreement may be extended for additional one year periods not to exceed four (4) additional one year periods Renewals and pricing changes shall be negotiated by and agreed to by both parties The Denver Boulder Greeley CPIIJ published by the Colorado State Planning and Budget Office will be used as a guide Written notice of renewal shall be provided to the Service Provider and mailed no later than ninety (90) days prior to contract end 3 Delgy If either party is prevented in whole or in part from performing its obligations by unforeseeable causes beyond its reasonable control and without its fault or negligence, then the party so prevented shall be excused from whatever performance is prevented by such cause To the extent that the performance is actually prevented, the Service Provider must provide written notice to the City of such condition within fifteen (15) days from the onset of such condition SA rev06/07 14 Conduct return to work (fitness for duty) examinations as requested by the City's TPA Claim Administrator, Risk Management or Human Resources department, and provide appropriate feedback to staff regarding employees' work restrictions vis-a-vis the employees'job duties 15 Employees may be given a "Patient Satisfaction Survey" upon completion of medical services or when they reach MMI The City of Fort Collins may conduct an in-house survey to assess services by the medical provider 16 Ensure medical and office staff are current with certifications per DOT requirements and drug and alcohol testing regulations 17 Conduct Non -DOT and DOT drug screens and alcohol breath tests Perform DOT tests according to FMCSA and FTA regulations Work with CCOM, third party administrator and Risk Management and Human Resources departments 18 Perform DOT medical exams by a certified medical examiner as specified in Section 390 5 of the Federal Motor Carrier Safety regulations Medical examiner retains the examination form and if determines the driver is qualified, provides a certificate to the driver and one to the Risk Management department SA rev06/07 10 EXHIBIT B INSURANCE REQUIREMENTS 1 The Service Provider will provide, from insurance companies acceptable to the City, the insurance coverage designated hereinafter and pay all costs Before commencing work under this bid, the Service Provider shall furnish the City with certificates of insurance showing the type, amount, class of operations covered, effective dates and date of expiration of policies, and containing substantially the following statement "The insurance evidenced by this Certificate will not be cancelled or materially altered, except after ten (10) days written nonce has been received by the City of Fort Collins " In case of the breach of any provision of the Insurance Requirements, the City, at its option, may take out and maintain, at the expense of the Service Provider, such insurance as the City may deem proper and may deduct the cost of such insurance from any monies which may be due or become due the Service Provider under this Agreement The City, its officers, agents and employees shall be named as additional insureds on the Service Provider's general liability and automobile liability insurance policies for any claims arising out of work performed under this Agreement 2 Insurance coverages shall be as follows A Workers' Compensation & Employer's Liability The Service Provider shall maintain during the life of this Agreement for all of the Service Provider's employees engaged in work performed under this agreement Workers' Compensation insurance with statutory limits as required by Colorado law Employer's Liability insurance with limits of $100,000 per accident, $500,000 disease aggregate, and $100,000 disease each employee B Commercial General & Vehicle Liability The Service Provider shall maintain during the life of this Agreement such commercial general liability and automobile liability insurance as will provide coverage for damage claims of personal injury, including accidental death, as well as for claims for property damage, which may arise directly or indirectly from the performance of work under this Agreement Coverage for property damage shall be on a "broad form" basis The amount of insurance for each coverage, Commercial General and Vehicle, shall not be less than $500,000 combined single limits for bodily injury and property damage In the event any work is performed by a subcontractor, the Service Provider shall be responsible for any liability directly or indirectly arising out of the work performed under this Agreement by a subcontractor, which liability is not covered by the subcontractor's insurance SA rev06/07 11 EXHIBIT "C" FEE SCHEDULE SA rev06/07 12 N M N M. l L N E 0 9 M FEE LIST BY COST CENTER CUSTOM Cost Ctr Fee Code Description Amount A/G/R E&M Evaluation & Management 99024 99082 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99241 99242 99243 99244 99245 99255 99271 99272 99273 99274 99275 99354 99355 99358 90359 99361 99362 99371 99372 99373 99401 99402 99403 99404 99455 99456 99499 99750 99910 99960 99961 99962 99963 Post -op f/u visit - global service Travel Time/hr ' New Patient Brief Visit New Patient Limited Visit New Patient Intermediate Visit New Patient Extended Visit New Patient Comprehensive Visit Established Patient Brief Visit Established Patient Limited Visit Established Patient Intermediate Visit Established Patient Extended Visit Established Patient Comprehensive Visit Consultation Limited Consultation Intermediate Consultation Extended Consultation Comprehensive Consultation Complex Inpatient Consultation Comprehensive Confirmatory Limited Confirmatory Intermediate Confirmatory Extended Confirmatory Comprehensive Confirmatory Complex Prolonqed Sery Direct Contact 1 hr Prolonqed Sery Direct Cant (add 30 min) Prolonqed Sery w/o Dir Cant (1 hr) Prolonqed Sery w/o Dir Cant (30 min) Medical Conference (30 minutes) Medical Conference Complex Telephone Brief Telephone Intermediate Telephone Complex Counselinq on Exposure Risk Factor 15min Counselinq on Exposure Risk Factor 30min Counselinq on Exposure Risk Factor 45min Counselinq on Exposure Risk Factor 60min Medical Impair Ratinq Treatinq Phv/ 5hr Medical Impair Ratinq Consultinq Phv 5h Independent Medical Evaluation Physical Demand Classification Cancellation Fee Initial Report (M1) Proqress Report (Paver Requested) Closinq Report (M3) Initial & Closmq Report same DOS Records printed 45 0 00 22500 5343 7809 11508 16440 21372 2377 4932 7398 11097 16029 98 64 13974 18084 23016 31236 32880 6576 9864 131 52 18084 23838 16440 8220 131 52 6576 8220 14796 1644 3288 4932 3288 6576 9864 131 52 10686 12330 67500 4000 C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C 000 C 4200 C 4200 C 4200 C 42 00 C 0 10/27/2007 LJ I F. r r: I 9 K t V FEE LIST BY COST CENTER CUSTOM Cost Ctr Fee Code Description Amount XC/R MEDI Medicine 90371 Hep B Immune Globulin 56000 90375 Rabies Immune Globin (mil) 12500 90471 Immunization Administration 1500 90632 Hepatitis A Vaccine 5600 90636 Twinnx Vaccine, Hep A & Hep B 9000 90658 Influenza Vaccine 1500 90675 Rabies Vaccine (Pre & Post) 14200 90692 Typhoid 3500 90707 Measles/Mumps/Rubella 3500 90718 Tetanus & diphthena toxoids (Td) adults 1512 90746 Hep B Vaccine 4600 90772 Injection Administration 1890 93000 EKG & Read 7250 93005 EKG Only 3250 93010 EKG Interpretation 4000 94010 Pulmonary Function Test - physical 3000 94010-26 Pulmonary Function Test 4404 95851 ROM Measurement&Report/extremity 31 75 95852 ROM Measurement&Report/hand 4763 95860 EMG One Extremity 13230 95861 EMG Two Extremities 18749 95863 EMG Three Extremities 24268 95864 EMG Four Extremities 29786 95870 EMG Limited 5670 95872 Single Fiber EMG each Muscle --- 22680 95900 Motor NCS w/o F Wave 7938 95903 Motor NCS w/ F Wave 10206 95904 Sensory NCS 7560 95925 Upper Extremity SSEP 25704 95926 Lower Extremity SSEP 25704 95927 Head/Neck SSEP 25704 95934 H-Reflex Tibial 9450 95936 H-Reflex Other 10206 97597 Wound Care -Selective Debridement 2800 97598 Wound Care -Non -selective Debridement 21 00 98925 Osteopathic Manjpulation(1-2) 5670 98926 Osteopathic Manipulation(3-4) 7560 98927 Osteopathic Manipulation(5-6) 9072 98928 Osteopathic Manipulation(7-8) 10584 99058 Office services I Emerqency basis 3024 99075 Deposition / 5 hr 13230 99080 Special Report/Procedure / 5 hr 11250 99080-01 Insurance Documentation 2000 99085 Testimony /hour 40000 99091 Collection/Interp of physiologic data 7560 99901 Non -Medical Conference/15 min 5625 99901-00 Sam Conference /15 min /Max $225/hr 5625 99911 Copy Fee pq 1-40 $ 50/page 050 ZZ90782 Injection Administration 1890 Records printed 49 10/27/2007 C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C I I I 9j r t.� It. A I 7!3 FEE LIST BY COST CENTER CUSTOM Cost Ctr Fee Code Description Amount A/C/R PHYM Physical Medicine 97001 97002 97003 97004 97010 97012 97014 97016 97018 97022 97026 97032 97033 97035 97110 97112 97113 97116 97124 97140 97150 97530 97535 97537 97537-14 97750 97760 DNU97504 Initial Eval PT 8656 C Reeval PT 5843 C Initial Eval OT 8656 C Re-eval OT 5843 C Hot or Cold Pack Application 1082 C Mechanical Traction 2435 C E-Stim Unattended 1894 C Vasopneumatic Device 2435 C Paraffin Bath 1623 C WhirlpooliFluidotherapy 2435 C Infrared, Supervised 1 or more areas /15' 10 82 C Manual E-Stim (15 min) 2435 C lontophoreses (15 min) 2705 C Ultrasound (15 min) 21 64 C Therapeutic Exercise (15 min) 2705 C Neuromuscular Re-ed (15 min) 2705 C Aquatic Therapy 2435 C Gad Trainmq (15 min) 21 64 C Massaqe (15 min) 2976 C Manual Therapy (15 min) 3246 C Therapeutic Procedure qroup 2 or more 2705 C Therapeutic Activity (15 min) 2705 C Self Care/Home Manaqement Traininq 4058 C Job Site Analysis (15miN 4058 C Ranqe of Motion (per 15 min) 4000 C Physical Performance Test (15 min) 5140 C Orthotics Fit/Train (15 min) 2597 C Orthotics F TTam (15 min) 2496 C Records printed 28 MA 0 10/27/2007 1 N. Dj E R N Lf 0 South Clinic 1330 Oakridge Drive Ft Collins, CO 80525 POUDRE VALLEY HOSPITAL OCCUPATIONAL HEALTH SERVICES North Clinic Lovland Clinic 1025 Pennock St. 121 2500 Rocky Mtn Ave Suite 330 Ft Collins, CO 80524 Loveland, CO 80538 .PHYSICALS' FEE ;�• a ,;.' �:, DRUGS iCREENS; ^ FEE heasicI�r n't?v�,r ,d�,w;� sr,r.fi�i,,. ., i $60.00, Collection, Lab Analysis, & MRO $40 00 History & Physical Collection Only $15 00 Height Weight Vital Signs On -site Drug Screen (rapid test) $30 00 Whisper Test Snellen Eye Chart 'Alcohol Te'sting�;l;7`id�)'y '' `; ; Y $6500` Breath Alcohol Testing $25 00 History and Physical Confirmation of positive BAT $25 00 Height Weight Vital Signs Snellen Eye Chart 'Immu, nizations,.;_,�'`F� Whisper Test TB Skin Test $18 00 Dip Unnalysis Hepatitis A $70 00 Hepatitis B per injection (series of 3) $60 00 Corporate t_ f ,a i' i„n„ :' ; "' $115 00' Tetanus Toxoid $20 00 Comprehensive History & Physical Diphtheriafretanus Toxoid $20 00 Height, Weight, Vital Signs Snellen Eye Chart Whisper Test ;,Olher.Charges,�' " ' Dip Unnalysis Dipstick Unnalysis $ 5 00 Titmus Vision $12 00 Asbestos $65 00 Pulmonary Function Test $30 00 Includes Basic Exam Hearing Screen (w/audiometrics) $20 00 OSHA Questionnaire (N/C) EKG $68 00 Other if indicated EKG and Interpretation $118 00 Pulmonary Function Test $30 00 Chest X-Ray (PA & Lat) Interpretation $45 00 Chest X-ray (PA & Lat) per PVH Blood Bourne Pathogen Coordination Fee $30 00 Laboratory testing per PVH Occupational Exposure History Review $20 00 X-Ray Interpretation $55 00 Fit for Duty Exam (non work related, includes Medical Record review and exam up to one hour, as well as Completion of ADA or FMLA documentation and recommendation for duty ) $225 00 (each add I hour sharoalhmdadmlWohslohsiamislchsphysicnlpnces"el 1072007 for 200E M s1 $112 00) Lead $65 00 Respiratory Clearance Includes Basic Exam OSHA Questionnaire, no physical exam $15 00 Other if indicated Lead/ZZP Panel (OCH-1 Panel) per Per PVH PVH Lab Per PVH UA Microscopic per PVH Lab Per PVH Wo�kSteps'f n `��'!'r,� hr ✓.`;P " 'M, Set up and program education N/C Post Offer Comprehensive Testing $95 00 Respiratory $45'00 Carpal Tunnel Testing $95 00 Includes OSHA Questionnaire with Post Offer Basic & Carpal Tunnel Testing $130 00 Medical Exam Other if Indicated Pulmonary Function Test (additional) $30 00 shared/hmc/admiNohs/ehsfQMslohsphysicafpncesheat 10/2007 for 2008 Flood & Peterson Ins 12/21/2007 11 25 PAGE 002/003 Fax Server rll..w 41XIM LI/MCA ACORD. CERTIFICATE OF LIABILITY INSURANCE °"Y"' 12010 PRODUCER Flood & Peterson Insurance Inc 4821 Wheaton Drive 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 POLICIES BELOW p O Box 270370 Fort Collins, CO 80527 INSURERS AFFORDING COVERAGE NAIC 9 INSURED INSURER CopicCompanies Occupational Health Services clo Poudre Valley Health System 2809 E Harmony Rd, Suite 200 Fort Collins, CO 80528 INSURER B Safety National Casualty Comp_RFry INSURER C. Federal Insurance Company INSJRER D INSURER E (',OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEFITIRCATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR TYPE OF INSURANCE POLICYNUMBER POLICYEFFECTIVE POUCYEXPIRATION LIMITS A GENERAL LIABILITY HCC0008522 04/01/07 04/01/08 EACH OCCURRENCE $1000000 DAMAGE TO RENTED E500000CLAMSMADE kMERGPLGENERALLIPBIUTY FROCCUR Includes MED EXP me mm $5 000 PERSONAL&ADVINJURY $1000000 00.000Deductible Professional 1practice GENE RALAGGREGATE $3000000 Liability GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $1000000 POLICY E� LOG AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Ea aca ) $ BODILY INJURY (Pe DeAm) S ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Pe amdeM) $ HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE (PeamdW) $ GARAGE LIABILITY AUTO ONLY -EAACCIDENT $ OTHERTHAN EAACC $ PNY AUTO S AOTOONLY PGG A EXCESSMMBRELLALIABILTTY UCC0009293 04/01/07 04/01/08 EACH OCCURREN CE $10.000,000 X1 OCCUR CLAIMS MADE AGGREGATE $10000000 $ b DEDUCTIBLE S X RETENTION $10 000 B WMI(ERSCOMPENSATIONAND SPIN19CO 04/01/07 04/01/08 X WCSTATU OTH- EMPLOYERCLIABILJTY ANY PROPRIETOR/PARTNERJEXECUTNE EL EACH ACCIDENT $1000000 E L DISEASE - EA EMPLOYEE $1 000 000 OFFICERIMEMBER EXCLUDED? m, de PRbeunde a I, a ix Ed- DISEASE -POLICY LIAR $1000000 C OTHER Directors& 68006562 04/01/07 04/01/08 $11,000,000Limit Officers Liab $ 100,000 Retention DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES / EXCLUSIONSADDED BY ENDORSEMENT / SPECIAL PROVISIONS Health Professional Liability • Persons Included (N applicable) Professional employees of the named insured, other than physicians Professional students of the named Insured, other than residents Volunteers of the named Insured, other than physicians and residents City of Fort Collins 256 W Mountain Ave PO Box 580 Ft Collins, CO 80522 ANYOF THE ABOVE DESCRIBED POJCIESBE CANCELLED BEFORE THE EXPIRATION IEREOF, THE ISSUING INSURERWILL ENDEAVOR TOMAL 'A0-_ DAYSwRrrrEN TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT, BUT FAIWRE TO DO SO SHALL NOOBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITSAGENTS OR ACORD 25 (2001/08)1 Of 2 #S401556/M375758 NIK 0 ACORD CORPORATION ISM Flood & Peterson Ins 12/21/2007 11 25 PAGE 003/003 Fax Server IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the polwy(ies) must be endorsed A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) DISCLAIMER The Certiricate of Insurance on the reverse side of this form does not constitute a contract between the issuing msurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or after the coverage afforded by the policies listed thereon ACORD 25.5 (2001/08) 2 of 2 NS401555/M375758 4 Early Termination by City/Notice Notwithstanding the time periods contained herein, the City may terminate this Agreement at any time without cause by providing written notice of termination to the Service Provider Such notice shall be delivered at least fifteen (15) days prior to the termination date contained in said notice unless otherwise agreed in writing by the parties All nctices provided under this Agreement shall be effective when mailed, postage prepaid and sent to the following addresses City: City of Fort Collins Attn Purchasing PO Box 580 Fort Collins, CO 80522 Service Provider: Occupational Health Services Poudre Valley Health System Attn Michael G Hollthouser, MD, MPH 1330 Oakridge Drive Fort Collins, CO 80525 In the event of early termination by the City, the Service Provider shall be paid for services rendered to the date of termination, subject only to the satisfactory performance of the Service Provider's obligations under this Agreement Such payment shall be the Service Provider's sole right and remedy for such termination 5 Compensation In consideration of the services to be performed pursuant to this Agreement, the City agrees to pay Professional according to Exhibit "C" Fee Schedule consisting of five (5) pages and incorporated herein by this reference Monthly partial payments based upon the Professional's billings and itemized statements are permissible The amounts of all such partial payments shall be based upon the Professional's City -verified progress in completing the services to be performed pursuant hereto and upon the City's approval of the Professional's actual reimbursable expenses, Final payment shall be made following acceptance of the work by the City Upon final payment, all designs, plans, reports, specifications, drawings, and other services rendered by the Professional shall become the sole property of the City 6 City Representative The City will designate, prior to commencement of the work, its representative who shall make, within the scope of his or her authority, all necessary 2 SA rev06/07 and proper decisions with reference to the services provided under this agreement All requests concerning this agreement shall be directed to the City Representative 7 Independent Service provider The services to be performed by Service Provider are those of an independent service provider and not of an employee of the City of Fort Collins The City shall not be responsible for withholding any portion of Service Provider's compensation hereunder for the payment of FICA, Workmen's Compensation or other taxes or benefits or for any other purpose 8 Personal Services It is understood that the City enters into the Agreement based on the special abilities of the Service Provider and that this Agreement shall be considered as an agreement for personal services Accordingly, the Service Provider shall neither assign any responsibilities nor delegate any duties arising under the Agreement without the prior written consent of the City g, Acceptance Not Waiver The City's approval or acceptance of, or payment for any of the services shall not -be -construed to operate as a waiver of any rights or benefits provided to the City under this Agreement or cause of action arising out of performance of this Agreement 10 Warranty (a) Service Provider warrants that all work performed hereunder, shall be performed with the highest degree of competence: and care in accordance with accepted standards for work of a similar nature (b) Unless otherwise provided in the Agreement, all materials and equipment incorporated into any work shall be new and, where not specified, of the most suitable grade of their respective kinds for their intended use, and all workmanship shall be acceptable to City (c) Service Provider warrants all equipment, materials, labor and other work, provided under this Agreement, except City -furnished materials, equipment and labor, against defects and nonconformances in design, materials and workmanship/workwomanship for a period beginning with the start of the work and ending twelve (12) months from and after final acceptance under the Agreement,, regardless whether the same were furnished or performed by Service Provider or by any of its subcontractors of any tier Upon receipt of written notice from City of any such defect or non conform ances, the affected item or part thereof shall be redesigned, 3 SA rev06/07 repaired or replaced by Service Provider in a manner and at a time acceptable to City 11 Default Each and every term and condition hereof shall be deemed to be a material element of this Agreement In the event either party should fad or refuse to perform according to the terms of this agreement, such party may be declared in default thereof 12 Remedies In the event a party has been declared in default, such defaulting party shall be allowed a period of ten (10) days within which to cure said default In the event the default remains uncorrected, the party declaring default may elect to (a) terminate the Agreement and seek damages, (b) treat the Agreement as continuing and require specific performance, or (c) avail himself of any other remedy at law or equity It the non -defaulting party commences legal or equitable actions against the defaulting party, the defaulting party shall be liable to the non -defaulting party for the non -defaulting party's reasonable attorney fees and costs incurred because of the default 13 Binding Effect- - This -writing, together with the exhibits hereto, constitutes the entire agreement between the parties and shall be binding upon said parties, their officers, employees, agents and assigns and shall inure to the benefit of the respective survivors, heirs, personal representatives, successors and assigns of said parties 14 Indemnity/Insurance a The Service Provider agrees to indemnify and save harmless the City, its officers, agents and employees against and from any and all actions, suits, claims, demands or liability of any character whatsoever brought or asserted for injuries to or death of any person or persons, or damages to property ansing out of, result from or occurring in connection with the performance of any service hereunder b The Service Provider shall take all necessary precautions in performing the work hereunder to prevent injury to persons and property 4 SA rev06/07 c Without limiting any of the Service Provider's obligations hereunder, the Service Provider shall provide and maintain insurance coverage naming the City as an additional insured under this Agreement of the type and with the limits specified within Exhibit B, consisting of one (1) page, attached hereto and incorporated herein by this reference The Service Provider before commencing services hereunder, shall deliver to the City's Director of Purchasing and Risk Management, P O Box 580 Fort Collins, Colorado 80522 one copy of a certificate evidencing the insurance coverage required from an insurance company acceptable to the City 15 Entire Agreement This Agreement, along with all Exhibits and other documents incorporated herein, shall constitute the entire Agreement of the parties Covenants or representations not contained in this Agreement shall not be binding on the parties 16 Law/Severabtlity The laws of the State of Colorado shall govern the construction interpretation, execution and enforcement of this Agreement In the event any provision of this Agreement shall be held -invalid -or -unenforceable by any court of competent jurisdiction, such holding shall not invalidate or render unenforceable any other provision of this Agreement 17 Prohibition Against Employing Illegal Aliens This paragraph shall apply to all Contractors whose performance of work under this Agreement does not involve the delivery of a specific end product other than reports that are merely incidental to the performance of said work Pursuant to Section 8-17 5-101, C R S , et seq , Contractor represents and agrees that a As of the date of this Agreement 1 Contractor does not knowingly employ or contract with an illegal alien, and 2 Contractor has participated or attempted to participate in the basic pilot employment verification program created in Public Law 208, 104th Congress, as amended, and expanded in Public Law 156, 108th Congress, as amended, administered by the United States Department of Homeland Security (the "Basic 5 SA rev06/07 Pilot Program") in order to confirm the employment eligibility of all newly hired employees b Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or knowingly enter into a contract with a subcontractor that knowingly employs or contracts with an illegal alien to perform work under this Agreement. c Contractor shall continue to apply to participate in the Basic Pilot Program and shall in writing verify same every three (3) calendar months thereafter, until Contractor is accepted or the public contract for services has been completed, whichever is earlier The requirements of this section shall not be required or effective if the Basic Pilot Program is discontinued d Contractor is prohibited from using Basic Pilot Program procedures to undertake pre -employment screening of job applicants while this Agreement is being performed e If Contractor -obtains actual knowledge that a subcontractor performing work under this Agreement knowingly employs or contracts with an illegal alien, Contractor shall 1 Notify such subcontractor and the City within three days that Contractor has actual knowledge that the subcontractor is employing or contracting with an illegal alien, and 2 Terminate the subcontract with the subcontractor if within three days of receiving the notice required pursuant to this section the subcontractor does not cease employing or contracting with the illegal alien, except that Contractor shall not terminate the contract with the subcontractor if during such three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien SA rev06/07 f Contractor shall comply with any reasonable request by the Colorado Department of Labor and Employment (the "Department') made in the course of an investigation that the Department undertakes or is undertaking pursuant to the authority established in Subsection 8-17 5-102 (5), C R S g If Contractor violates any provision of this Agreement pertaining to the duties imposed by Subsection 8-17 5-102, C R S the City may terminate this Agreement If this Agreement is so terminated, Contractor shall be liable for actual and consequential damages to the City arising out of Contractor's violation of Subsection 8-17 5-102, CRS h The City will notify the Office of the Secretary of State if Contractor violates this provision of this Agreement and the City terminates the Agreement for such breach 7 SA rev06/07 CITY OF FORT COLLINS, COLORADO a municipal corporation Jame's B O'Neill II, CPPO, FNIGP COL4.�s Direr of Purchasing and Risk Management Date .O Clerk Occupational Health Services Poudre Val�ley Health Systems - lZl�l�OtJ �. cST►�L.�,y PRINT NAME G F-0 CORPORATE PRESIDENT OR VICE PRESIDENT ATTEST /`/ QJf !?QICvNM� CORPO TE SECOtETARY SA rev06/07 EXHIBIT A SCOPE OF WORK 1 Provide appropriate medical care and case management at a minimum of five (5) days a week from 8 00 a m to 5 00 p m , for City of Fort Collins employees that have injuries or illnesses alleged to have occurred as a result of their employment 2 Provide medical opinion to assess work relatedness in each case to diminish the possibility of fraudulent claims 3 Maintain accurate medical records for every City employee receiving medical care Individual patient records and reporting systems necessary to carry out program administrative, planning, and legal requirements will be established and maintained 4 Notify City TPA and Risk Management after medical treatment is rendered The report will include information on the accident/exposure, work restrictions, and prognosis for return to work This information should be transmitted to the city's electronic mail system or Risk Management fax If electronic notification is not available as of January 1, 2008, it shall be available by June 1, 2008 5 Notify Risk Management or City TPA for approval prior to referral of employee from your facility to another physician, or upon admission to a hospital or other facility All information for on -going treatment shall be sent promptly to the receiving physician, hospital or other facility 6 Provide employee with written "status" report outlining work restrictions, if any, for every visit 7 Provide a written dictation / summary report within TWO (2) days of initial treatment to Risk Management and TPA claim administrator 8 Provide specialty services as requested such as physical examinations, audiograms, x- rays, EKG's, immunizations, physical therapy, drug and alcohol testing, DOT physicals, pre -employment physicals and other medical services as may be deemed beneficial to City employees and the employer 9 Be familiar with Workers' Compensation laws and provide hearing testimony when needed 10 City employees shall be treated only by Level II accredited physicians on weekdays and upon entry with appointment and follow-up visits post walk-in Examinations and treatments by PA are acceptable for minor first aid and other insignificant procedures 11 Cooperate with the City's TPA claim administrator and risk management staff in submitting information upon request in a timely manner 12 Participate in consultations with employer and TPA claim administrator as requested to discuss specific cases and procedures 13 Provide a written medical treatment plan when requested