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HomeMy WebLinkAboutRESPONSE - RFP - P1089 MEDICAL PROVIDER - WORKERS COMPENSATIONC 0- Poudre Valley Health System I 0 Proposal to the City of Fort Collins and 0 Poudre School District 'Designated Medical Provider for Workers 0 Compensation RFP: P1089 I I n OCCUPATIONAL HEALTH SERVICES 0 Locations in Loveland and Fort Collins Phone: 970-495-8450 Fax: 970-495-7620 0 0 October 2007 I I L n L Qthe patient opportunity to question and clarify his/her restrictions and allows our staff to emphasize the importance of following the restrictions in all aspects of their activities Patients are always given two copies of the M-164 work status prior to leaving our clinics They are instructed that one copy is for them and one copy for them to return immediately to their employer Whenever questions exist the OHS physician attempts to call the Risk Management staff on the first visit while the patient is still in the clinic to review findings, clarify any questions re mechanism of injury, lob requirements, witness information, and modified duty options The physician or case management staff will also call to notify the Risk Management department if admission to another facility is required or if authorization outside of the network is requested for a specialist visit OHS physicians feel that the injured worker's care and potential for improvement is significantly improved when the employer is able to provide modified duty options to ensure rapid return to work Our physicians educate the patient from the first visit on the value of remaining productive and on the job Our experience indicates the injured worker feels valued and will recover quicker when he/she is a productive member of the work group We believe it is essential the injured worker understand that prescribed work restrictions are inclusive of all activities of daily living, including recreation, and are not just limited to the workplace We also encourage an active rather than passive role in treatment and in rehabilitation Our intent is to provide the injured worker with a home program that he/she will do independently and that we will monitor for progression needs allowing us to advance work restrictions in conjunction with the home program We believe the injured worker is not unlike an injured athlete The focus must be on 5� individual's responsibility for adhering to modified duty requirements and in advancing the treatment program to meet the goals of performance and essential functions of the job When the goal is to return to the job in a productive capacity and the increments are measurable in specific job tasks the individual has greater ownership in his/her outcomes The OHS Medical Director and case management staff will meet monthly with the Risk Management staff, claims administrator, and other individuals as requested to review Q specific cases and discuss treatment plans Site visits to the employer's job site are also helpful to our physicians to assist in understanding specific job concerns These visits are arranged on an as needed basis The physician is the primary case manager in each OHS case Our case management staff works collaboratively with the physicians by reviewing charts daily for authorization Q needs, communication needs and "red flags " We do not assign a set number of cases to our staff, but rather, through cross training and specific delegation of tasks to improve work flow we assure the physician has the information required and authorizations in place to provide the patient the optimal care required in a timely manner Our case managers are responsible for assisting the physicians and Risk Management with the detail of keeping cases "on track " The case manager is both the employer's and the employee's resource when questions arise and additional information is needed to move a case along and bring it to closure Occupational Health Services aPoudre Valley Health System Na, I I M I I N 9 I C OHS uses an electronic case management program (SYSTOC) which tracks each Individual employee from Initial visit until the employee reaches Maximum Medical Improvement (MMI) The written Work Status Report (M-164) outlining the employee's functional gains or losses, changes in work status and/or work restrictions, and prognosis for return to work, will be provided to the employee and the Risk Management office via fax at the time of the visit The physicians' dictation, detailing medical treatment plans will be faxed within twenty-four (24) hours of the office visit or the next business day An Internet based version of our data base is available to the Risk Management department This service will give Risk Management authorized staff access to view patient specific injury and treatment information The data will be presented in a real time, interactive, on-line environment over a secure and encrypted connection Only designated employees would be able to view on line the status of an appointment (arrived, cancel, no show), the current and previous work status report information, and any referrals that have been made for the City or School District employees seen by OHS Should an injured employee miss a scheduled appointment both the employee and the Risk Management office receive a letter the following day indicating the importance of keeping appointments and the requirement to reschedule and the clarification that the employees work restrictions may no longer be applicable (Attachment 1) Each of our physicians encourage phone calls from the employer at any time to question, clarify, or provide additional information Our case managers are available as well, to meet your needs, and want to be certain we address any concerns or needs of the Risk Management department and of the City of Fort Collins and Poudre School District employees 6. References Occupational Health has been the designated provider of the majority of large Fort Collins employers over the last fifteen years We are proud to be the current primary designated provider for the City of Fort Collins, Poudre School District, Columbine Healthcare, Poudre Fire Authority, Colorado State University, Anheuser-Busch, Avago Technologies, WalMart Distribution Center, and the Poudre Valley Health System, among others Colorado State University has for many years offered their employees a choice of providers within the Fort Collins and Loveland communities, and we are proud to state that over seventy five percent of their employees choose the services of OHS when offered a choice of occupational medicine physicians QThe OHS client companies listed below have been chosen as references due to the variety of services they require of our program, and because they have similar occupational health management needs to those of the City and School District These companies are particularly concerned that they receive cost effective health care, and that the emphasis remain on safety and injury/illness prevention services for their employees and business Dan Pena, Risk Manger Colorado State University 970-491-6745 Occupational Health Services Poudre Valley Health System 9 10 BIII Clauser, Risk Management WalMart Distribution Center 970-679-4715 Terri Farella, Employee Health Services Poudre Valley Health System 970-495-7370 7 List of Referral Specialists (Attachment J) and description of use and time frames. OHS is a SelectNET provider with Pinnacol Assurance and uses the resources of this preferred provider network in making workers' compensation referrals when the employer does not have a specific provider group requirement Should the City or School District choose to designate certain specialty providers or groups, OHS will work within those requests Only OHS physicians can refer, the referral provider or specialist is restricted from making subsequent referrals If a specialist determines other services are needed, the OHS physician is to be contacted to obtain authorization The referral procedure will be initiated and scheduled by the OHS physician The majority of OHS referrals are for Orthopaedic consults, and the group our physicians utilize primarily is the Orthopaedic Center of the Rockies Occasional referrals are needed for neurosurgery, for these we utilize Front Range Center for Brain & Spine Surgery Both of these specialty groups have offices located in Loveland and Fort Collins OHS providers refer primarily to Ron Carbaugh, PhD for psychological evaluations, John Zimmerman and Scott Parker for chiropractic and Mike Asmus, RN, CMT (employee of OHS) and Katie Hines, CMT for massage therapy Jeffrey Wunder, M D is our staff Physiatrist specializing in delayed recovery and pain management 8. Mental Disability Protocol: A routine element of the OHS physician's initial examination of a patient includes a review the individual's psychosocial functioning Notation of pre-existing diagnosis, treatment and medications are included in the initial assessment, if relevant This information provides valuable base line data in cases where mental heath concerns are raised Assessment of psychosocial function continues throughout the course of treatment and includes routine visit questions re eating, sleeping and digestive habits that can be indications of psychosocial dysfunction When these symptoms are noted, or when a patient claims a mental disability as a result of a physical injury a psychological consult referral is made to Dr Ron Carbaugh, PHD for evaluation of the patient Dr Carbaugh's focus is on worker compensation claims and he is able to provide accurate, clear and defensible reports Based on his recommendations the OHS physician will determine a treatment plan, and if appropriate and may utilize Dr Carbaugh for short term treatment Addressing work related psychological issues is Occupational Health Services Poudre Valley Health System 1] Important to assure the case is on track and the patient understands the Issues and receives necessary treatment and support in a timely manner Rarely Is a claim a regarding mental disability, considered for mental Impairment, as the State has a narrow definition of what might constitute a legitimate claim Only psychologically traumatic events that are outside an employee's usual work experience and would evoke significant symptoms of distress to workers in similar circumstance are considered for a Impairment rating Stress, job changes, employer /employee differences are not considered ratable Q 9. Percent of Business pertaining to occupational injures. The OHS program is dedicated to the provision of occupational health and injury prevention services An estimated 85% of the OHS volume is management of work - related Injuries The remaining 15% of the OHS business is In the provision of other occupational specialty procedures such as DOT physicals, employment testing, Immunizations, drug testing, and annual surveillance testing Our therapists work only with Injured workers and are highly focused on the requirements of the job In design of the treatment plan 0 10 Maintaining Control of specialist referrals When Indicated, the OHS physician will determine which specialist to refer an Injured worker too, and will Initiate the appointment prior to the patient leaving OHS to promote follow through and to assure the appointment is set within a reasonable time OHS follow up visits are scheduled within three to five days of a specialist appointment to a assure we have received the documentation from the specialist and are able to act on findings rapidly Any change to the work status or work restrictions are only made by the OHS provider Referrals to specialists are determined by the primary OHS physician The referral procedure Is as follows The OHS Y medical provider selects an appropriate specialist from the SelectNET list or the preferred provider list supplied by the employer • The referral provider is asked to see the patient within five (5) working days unless Immediate consultation Is Indicated There are specialists access Issues in Fort Collins and frequently appointment access exceed the 5 days Due to this access concern OHS physicians meet routinely with our primary specialist to assure open communication and the ability to request "urgent" referral access �i when acuity of a case requires more immediate access OHS will fax the completed "Consultation Referral Letter" to the specialist (Attachment K) Y OHS will send all pertinent medical information (history, radiology, lab results and current medications) to the specialist • The patient must be referred back to the OHS physician for Q => Change In work status Occupational Health Services Poudre Valley Health System a 12 => Referral to other specialty services Final determination of MMI and if applicable, assessment of a permanent physical Impairment Release from care This procedure must be followed by OHS and by all specialty providers so that control of the case management is maintained by the OHS physician Failure to follow these procedures by a referral provider risks their exclusion from the OHS referral list 11 After hours care options and Emergency care Harmony Urgent Care Center (HUCC), 2127 E Harmony Road, Fort Collins is a available for urgent care needs when the OHS clinics are closed HUCC is open to OHS patients from 5PM-9PM Monday -Friday and on weekends 9 OOAM to 9 OOPM Full imagining and laboratory services on site a Medical Center of the Rockies Emergency Department, Level II Trauma Center 2500 Rocky Mountain Ave, Loveland Full service trauma hospital, state of the art diagnostic and imaging services on site Poudre Valley Hospital Emergency Department 1024 LeMay Ave, Fort Collins Full service hospital, diagnostic and imaging services on site As a benefit OHS clients well receive electronic copies of the physician visit notes and the M-164 from these locations above the following business day when an employee has a received services in any of our after hours locations We contact the injured employee to schedule any needed follow up visit at OHS, and we call/fax the Risk Management office to assure the office is aware of the injury and provide an update on the work status While the hospital emergency rooms are open to any employer, the services at HUCC and the immediate notification and forwarding of Workers Compensation paperwork is only available to employers designating OHS as one of their preferred providers Q12. Time allotted for office visits• OHS physicians see new injuries which are scheduled for 20, 30, or 40 minute time frames dependent on the individual physician's preference When a case is transferred to OHS, is a reopen of an injury more than six months old, or is a multiple problem case (such as an MVA, or multiple trauma case) the initial appointment is determined by the MD, but is generally 60 minutes for the initial visit New injuries seen on a walk in basis are triaged and based on severity may be seen head of a scheduled visit The clinics ' "block" four walk in appointment times into each physician's schedule, to allow a aeach buffer to the scheduled appointments so wait times are not generally longer than 15-20 minutes when required Revisit or follow up appointments are scheduled for 20 minutes al unless the physician requests additional time for the appointment Missed appointments are not well tolerated The injured employee is informed at the start of treatment at OHS and at the start of any therapy that it is essential to his/her arecovery to attend all appointment They are required to sign a form that indicates they Occupational Health Services Poudre Valley Health System a13 are aware of their role in active care to participate and attend all treatment sessions and appointments (Attachment L ) Repeat cancellations and rescheduling will be brought to the attention of the Risk Management dept OHS reserves the right to require a a "demand" appointment be set for patients who frequently miss appointments without 24 hour notice 13 Impairment ratings* All permanent impairment ratings are based on the American Medical Association Guidelines to the Evaluation of Permanent Impairment Third Edition (Revised ) This rule implements the Division's permanent impairment rating guidelines on how to appropriately utilize and report permanent impairment When the authorized OHS treating physician has determined that the injured worker is at maximum medical improvement (MMI) and has not returned to his/her pre injury status, physically and/or mentally, the physician determines a permanent medical impairment in accordance with Rule 12 If the treating physician is not Level II accredited, our Medical Director will determine permanent impairment on the last visit prior to placing the patient at MMI Any apportionment of permanent impairment rating of a pre-existing permanent medical impairment form a work -related injury or occupational disease will be explained in the dictation of the visit Our case manager will work with the claims administrator secure Q all previous medical records to assure adequate information is available at the time of the rating ' OHS physicians assure that when determining a permanent physical impairment they limit the rating to physical impairments not likely to remit despite medical treatment, use the AMA Guides as described above, convert the scheduled impairment to whole person impairments as indicated and report final whole person and/or scheduled impairment rating percentages in whole numbers per Rule 12 OHS physicians understand the tremendous financial implications of impairment ratings and continually review the regulations and work diligently to assure accurate measurement, and reporting to the employer and adjustor Most impairment ratings are available the following day ,I 14 Drug and Alcohol Testing services Each OHS clinic is a collection site for urine drug testing OHS employs a total of 9 certified collectors Emily Clark, our Lead Medical Assistant is a Certified Drug Collection Trainer Walk in drug test are done Monday -Friday from 8AM to 5PM at all three clinic locations WPCI, based out of Scottsbluff, Nebraska is our designated Medical Review Officer (MRO) service Certified by the American Association of Medical Review Officers, WPCI has six (6) MRO Board Certified Physicians in Anatomic and Clinical Pathology and two (2) of these MRO are Board Certified as Forensic Pathologists A secured Website is available for on line reporting to the employer designated representative WPCI is available as a third party administrator to address DOT program requirements such as random number generation, training, and report generation s. Occupational Health Services Poudre Valley Health System 0 14 I I Ll, I I I f I I I I [I J1 P I Johnson Drug Testing, INC , contracts with OHS to provide our after hours drug collections and breathe alcohol testing at Harmony Urgent Care and the Emergency Rooms at Poudre Valley Hospital and Medical Center of the Rockies They are a member of the Drug and Alcohol Testing Industry Association (DATIA) All collectors are certified and the owner is a certified trainer Breath Alcohol Testing (BAT) is also offered at each OHS clinic location A total of 6 OHS staff are certified BAT technicians on the PHONEIX The protocols followed are defined by the DOT Results of a BAT results are available immediately to the employer representative via secured fax Occupational Health Services Poudre Valley Health System z' a15 SUMMARY NOTE a Occupational Health Services has delivered locally -controlled and responsive Injury management services from a not -for -profit community hospital setting for more than two a decades We appreciate the opportunity to respond to the RFP for City of Fort Collins and Poudre School District for selection of one of your preferred medical provider for Workers' Compensation injuries We feel strongly that our proposal meets the requirements and intent of the RFP, and our relationship with your company as your current preferred provider demonstrates our expertise, customer focus and sincere interest in working as a partner to Improve the safety and productivity of your workforce I11 (I I I u L I I 01 I Occupational Health Sernces Poudre Valley Health System I 0 I I Ill Q I I I I 0 I a I I I I a A Occupational Health Services Organizational Chart M�D-�'� Heatlier;Kenney; LPT_ _ °Nled�cal'Asststant staff (2) m ' ,Secretary%<fteceptionlsta(2)6 Al v �.. P',oudre Valley, Health xSystemFnri '��=�.'PYEhVicekPres'�d`entrof-Operations `t =;D_an,Robuisont r e_ _ 1 Duector-of0ut�iaGenbClmlcs=`' 'Occupat�onaliHea Ith=Ser'vtces' r�Rcacttce�Manager�`�-rz_w_ �. =__ ;=LLemanJffl Fitzgeraiclr�,�=�=--s, _- 1 ,Oakndge NNhc FVIMoltho`uset;,M Yangat ;BarbaraAyalden--LPT '- �r�'`„Joy�Tandtierg,OTR'CHT ', 4' 'Thomas DeGmo emphoymeat_testing Medical AasistanYstaff 6 = Y`�t �?- '.SecretarylSchedulmg(3)`'yx ut ,;;t-=w,u 7 - Fr d< ZTnr ?EJea" 'A2 ` Kn'st `=--Secre I I I I a3 I u I I rbal u I I iI R I TABLE OF CONTENTS E=xecutive Summary 1 Qualifications and Experience 1. Qualifications of Firm 2 2. Qualifications of Staff 3 3. Fee Schedule 6 4. Description of Facilities 6 5. Scope of Service 7 6. References 9 7. Specialists 10 8. Mentall Disability 10 9. Business Focus 11 10. Specialist Referrals 11 11. New Injuries 12 12. Scheduling 12 13 Impairment Ratings 13 14. Drug and Alcohol testing 13 Attachments A Organization Chart B Michael Holthouser, MD, MPH resume C. William Basow, MD, MPH resume D. Jeffrey Wunder, MD resume E. Ann Y'anagi, MD resume F Fredorick Schorr, MD, MBA, resume G. Injury Fee Schedule per Rule 18 Fee Notices H. Client Billing (non injury) I. No Show Letter J. Specialist List K. Referral Letter I I I I I I II 0 0 iI I I I Attachment I MICHAEL G. HOLTHOUSER, M.D., M.P.H. _ 1017 Elbert Ave, Loveland, Colorado 80537, Telephones Work970-49.i-845Q Cell 502-727-2851, Fax 970-495-7620 EXPERIENCE OCCUPATIONAL HEALTH SERVICES, POUDRE VALLEY HEALTH SYSTEM, Fort Collins, Colorado �y May 03-present 4pJ� Medical Director for Occupational Health Service (OHS) chinas for the Poudre Valley health System which serves over 2300 employers in the Northern Colorado region The department services the community through operations in three clinic locations as well as on -site Services include injury management, medical surveillance, employment testing, and expert witness and testimony Provides medical direction and ongoing education to staffphysicians, rehabilitation staff and clinic staff Medical Director • Diagnose and treat occupational injuries and illnesses j Call on current and prospective client companies to market OHS, to be sure we understood the customer's needs and to add value to the service provided • Attend client company case management meetings on request to input and advice as appropriate (t Complete all required medical and administrative documentation through direct data input, written and dictated media means • Provide expert witness and depositions as requested • Supervise the clinical activities of the OHS staff, physician extenders and physicians • Review disability, medical leave applications and Family and Medical Leave Act as requested by client companies OProvide on -site medical surveillance services to area clients as requested s CONCENTRA HEALTH CENTERS, Denver, Colorado July 2002 — May 2003 The Concentra Medical Center, in Thornton, Colorado, is one of the busiest of the Centers in Colorado A physician, a physician's assistant, four medical assistants, a physical therapist, an assistant physical therapist, four front office employees and a Center chief administrator staff the Center 115 patients are seen for all conditions through the Center on a daily basis, about fifty of which are seen by the medical providers Specifically requested, non -injury or examination services for companies in the area are also provided by the Center medical director About 50% of the Center's patients are primarily Spanish speaking The client companies are from the information technology, telecommunications, governmental, transportation, retail, construction, medical, hospitality and other service industries Colorado's workers compensation system uses a concurrent care model In this model, the primary occupational physician maintains control of the case from start to fimsh and utilizes the services of specialty providers to deliver needed technical and medical services The primary occupational physician determines when a case is at maximum medical improvement and closes the case This physician is the principle interface for adjustors and case manages as well as the injured or ill employee's employer Bus mess has grown from about 85 cases a day, in July 2002, to the current 115 cases per day While many Concentra centers have experienced slight decreases in patient volume, the Thornton Center has managed to hold its own and has not lost volume I`L V I QCenter Medical Director • Diagnosed and treated occupational injuries and illnesses • Called on current and prospective client companies to market the Center's services, to be sure we understood the customer's needs and to add value to the services that were provided • Attended client company business meetings on request to Input and advice as appropriate • Completed all required medical and administrative documentation through direct data input, written and dictated media means • Provided expert witness and depositions as requested r" • Supervised the clinical activities of the Center's physician assistant • Reviewed disability, medical leave applications and Family and Medical Leave Act applications for T-Mobile communications can centers weekly with the c ompany's human resources manager • Provided on -site medical services for Swift and Company/ConAgra Health Services Department, in Greeley, Colorado, the nation's third largest slaughterhouse and beef processing facility aWas Concentra center of competence for hearing conservation and occupational hearing loss L3 I I I 0 LJ I 91 4 CONCENTRA HEALTH CENTERS, Louisville, Kentucky January 2001 — May 31, 2002 Concentra Health Centers is the largest national group of occupational health clinics in the United States Concentra also has other divisions such as case management Concentra clinics specialize in the clinical occupational needs of employers They use a standardized approach to patient examinations and injury treatment through the use of well communicated and managed policies, medical supervision, business and administrative affairs management and proprietary medical record software, which in combination makes Concentra very competitive in price, quality and consistency within the markets in which it competes Concentra purchased the two Caritas clinics from Catholic Health Initiatives effective January 1, 2002 To cut costs, a decision was made to close one of the clinics, reduce staff and consolidate patient care front both clinics under one physicians and a physician's assistant This permitted significant savings through lowered overhead and decreased head count Center Medical Director • Diagnosed and treated occupational Injuries and illnesses • Called on current and prospective customers with the Center marketer to maintain and develop new customers • Completed all required medical care documentation, correspondence and other communications • Maintained close association with company contacts, case managers, referral physicians and appropriate others within ethical and statutory confidentiality standards to improve patient outcome and foster confidence in the care provided • Performed the duties of a certified medical review officer for urine drug screening for clients requesting services • Performed immigration and naturalization examinations requested through the center • Provided coverage for the other center in its physician's absence • Provided expert consultation to client companies, perform walk-throughs and advise as appropriates on methods and processes to reduce employee illness, accidents and inefficiency and also on certain medical - legal questions and ergonomic concerns • Worked closely with physical and occupational therapy to maximize the rehabilitation speed and potential of injured or ill employees • Advised companies about fitness -for -duty of questionable employees • Served as Automated External Defibrillator (AED) Program Medical Director, as requited by regulation, for companies utilizing these devices • Developed and reviewed medical treatment guidelines and directives for company first responders and for C] I II I A I I I I certain medical testing devices such as glucometers • Conducted the medical aspects of company medical surveillance programs CARITAS OCCUPATIONAL HEALTH CENTER, Louisville, Kentucky August 2001 — January 2002 Caritas Occupational Health Centers were owned by Catholic Health Initiative, but werejust purchased by Concentra There were two centers in Louisville They were affiliated with the Caritas Medical Center They were full -service occupational health centers offering pre -placement examinations, medical surveillance, biological monitoring and a full scope of medical testing and diagnostic procedures as well as occupational injury and illness diagnosis and treatment The centers participated in most managed care workers compensation networks in Kentucky Contract Physician • Diagnosed and treated occupational injuries and illnesses • Called on customers and potential clients to help develop the business along with Caritas marketing staff • Completed all requned and appropriate medical documentai ion and medical records • Communicate with case managers, company contacts and employees within appropriate confidentiality boundaries • Performed the duties of Medical Review Officer for urine drug screens performed through the centers • Performed immigration and naturalization examinations requested through the center • Covered the other center when the medical director is away • Provided consultation to client companies and perform walk-throughs to help clients maximize preventive health efforts • Worked closely with physical and occupational therapy and referral physicians to optimize patient rehabilitation potential • Advised client companies about fitness -for -duty of employees and new hues aNORTON HEALTHCARE, Louisville, Kentucky 1996 — July 2001 Norton Heahhcare is a large integrated health care delivery system having five hospitals in the Louisville area and 8000 employees Norton Healthcare co -manages the University of Louisville Hospital Norton Health at Work, a grand of Norton Healthcare, is a regional center of excellence in occupational health services providing clinical evaluation and treatment for ill or injured workers, pre placement and disability assessment, independent medical evaluations, executive health programs, international travel and immunization programs, occupational and environmental health research, consulting and on -site medical services for 3000 employers, in the greater Louisville ai ea through four locations Norton Immediate Care Centers provide urgent care through five Louisville area locations, seven days per week and 365 days per year The Immediate Care Centers are the preferred provider of urgent care for many large local healthcare plans and physn,ian practice groups After-hours urgent occupational health services are also provided with next day follow up in Lrealth at Work Centers aMedical Director • Developed medical aspects of the business plans for Health at Work Centers, including equipment, staff naming and certification requirements, and continuing medical education • Marketed Health at Work to local employers • Provided expert c finical services to client company employees l 0 I iI 1, I I I LJ • Designed and conducted research projects as requested by local companies • Consulted and advised companies on specific health concerns • Developed standing orders and care guidelines for Health at Work Centers and client companies • Served as medical director for automated external defibrillator programs for client companies • Participated in the design of preventive health secvcces in new insurance product for area called, "Norton One," which combines medical benefits with workers compensation services, case management and administration • Served as Chnica4 Associate Professor, in Industrial Toxicology, in the Department of Medicine, of the University of Louisville School of Medicine GENERAL ELECTRIC COMPANY, Pittsfield, Massachusetts 1994 -1996 GE Plastics is a worldwide producer of engineered polymers, silicones, superabrasives (industrial diamonds) and electromaternals Medical Director • Developed the medical and toxicology business plans for GE Plastics • Improved staff caliber through recruiting board certified occupational physicians, toxicologists and occupational health nurses • Developed policies, changed staff as requued, reviewed and recommended disability cases to the Corporate Review Board, managed occupational health Issues for the company in the Americas, Asia and Europe, including new plant construction, substance abuse prevention programs and sensitive toxicology issues • Directed the standardization of on -site occupational health ,ervices utilizing both company and contract occupational medicine physicians and nurses • Developed medical standards and procedures for overseas travelers and international assignees • Provided clinical services to employees through the headquarters medical department and at the vai rous company medical departments around the U S • Developed plan to replace electronic data base and reviewed available apphc ations for selection WEYERHAE:USER COMPANY, Tacoma, Washington 1991 - 1994 A major paper, pulp, containerboard and packaging, structured and dimensional wood products, paper recycling and forest land management company with operations throughout North America and with large export operations aCorporate Medical Dcrectoi • Duected all occupational health services at headquarters, plants and mill sites throughout the U S and Canada This included direction of all North Amei scan wellness and employee assistance program (EAP) activities • Provided expert occupational medical technical advice to company workers compensation case managers and their attorneys and to the labor relations and legal staffs • Represented the c ompany on the Formaldehyde Institute's scientific panels and the American Paper institute's (APi) scientific panel's epidemiology sub -committee • Conducted epidemiological research into mortality causes foe the company and sei ved on the science advisory panel for the API -sponsored study of mortality in the paper and pulp industry, conducted by Johns Hopkins Unrveisdy • Completed maJot programs to facilitate the company's compliance with revisions to the OSHA Formaldehyde Standard, training in and implementation of the Department of Transportation (DOT) Anti -Drug Rule and the Americans with Disabilities Act, Title i k A I I I11 • Developed a corporate substance abuse prevention policy including training, implementation and tracking for all DOT -regulated and other employees ( Enlarged and refined EAP services and introduced managed care for mental health and substance abuse �j treatment services through EAP case management OWENS-CORNING FIBERGLAS, Toledo, Ohio 1988- 1991 A major manufacturer of fibrous glass insulation, structural glass fiber reinforcement products, underground fibrous glass storage tanks and specialty resins aCorpoiate MedreaIDnector • Responsible for developing all aspects of occupational and preventive health programs, including - industrial hygiene, foi headquarters and 46 manufacturing sites worldwide • Performed most medical surveillance, workers compensation and disability case management through site occupational health nurses and contract physicians • Participated as a member of the New Material Approval and the Environmental Protection Agency (EPA) Toxic Substances Control Act (TSCA) Reporting Committees • Collaborated with the company epidemiologist on company sponsored research through universities and on company mortality surveillance • Represented the company on the Styrene Information Research Council and the Organizational Resources Council • Provided expert witness services and technical advise to company attorneys in toxic tort, EEO, labor relations and disability litigation F1 IBM CORPORATION, While Plains, New York, Los Angeles, California, Dallas, Texas, ` Sydney, Australia, Tokyo, Japan, and Harrison, New York 1982 — 1988 A laige multinational corporation that researches, develops, manufactures, markets and services a full line of informational management hardware and sollware and specialty integrated cu cuit devices throughout the world Cross Group Medical Director 1987 — 1988 a• Dnected all U S iBM medical departments, Field Operations (Marketing and Customer Service), LLiidd Research and Development Labs, and company real estate • Participated in the design and approval of research into reproductive and developmental effects of working in the serxnconductor industry, performed by Johns Hopkins University • Directed all IBM U S Safety & Health activities • Directed all iBM U S Toxicology operations Medical Director 1985 — 1987 a Directed Medical, Safety & Health and Preventive Medicine programs for 113M Asia/Pacific Group, in Tokyo Japan OSenior Managing Physician 1983 — 1985 • E,,tablished and area medical department for the southwestern U S , in Dallas, Texas Q Successfully managed multi -million dollar ergonomics issues for the company in Australia and New Zealand • E,,tablished the first Asia/Pacific medical department and Safety & Health operations in Tokyo, Japan 0 Directed and recruited skilled practitioners for all 28,000 employees in 18 Asian countries ICI I 0 I I H If Physician Specialist 1982 — 1983 • Designed occupational health research projects of interest to the company, completed staff projects as assigned and functioned as administrative assistant to the corporate medical director HEWLETT-PACKARD CORPORATION, Loveland and Fort Collins and Greeley, CO 1977 — 1980 A large rnulturatzonal corporation that designs and manufacturer sophisticated electronic business machines, sczentic and medical instruments Company Physician 1978— 1980 • Treated mostly musculoskeletal cumulative trauma disorders associated with manufacturing, wumg and assembly hire ergonomics hazards • Provided workers compensation case management and assistance with health -related absence problems • Developed basic plant -oriented medical programs and advised Safety & Health, Human Resources and plant management on health issues 0 Contract Physician 1976 — 1978 • Employed as first full-time company physician with responsibility for three plants having a total of workforce of 7000 employees • Supervised of two occupational health nurses and two medical departments • Served on Larimer County Air Quality Advisory Board at the request of Hewlett-Packard and on the aCounty Department of Health's Family Planning Board j MOUNTAIN VIEW MEDICAL CENTER, Berthoud, Colorado 1976 — 1978 A full -service family practice clinic located in a small foothzlls community, in rural Colorado Family Physician, Owner • Established a full -service family practice clinic including business planning, Small Business Administration loan, clinic design and construction, equipment selection, business and clinic procedures and staff recruiting • Decreased hospitalization rate for patients in the practice by seventy-five percent through good preventive health, outpatient disease management and patient education efforts • Maintained high payment collection rates as well as patient satisfaction by charging fees that were among the lowest in the area • Recruited a dentist for the medical center to secure family dentistry for the town and also a neurologist for the southern half of the county who worked out of the center • Served as preceptor for students from the local vocational college during their practicum in medical office practices • Supervised Univei city of Colorado Family Practice Residents who rotated through the Clinic and once a month at their Residency Center • Managed all in gent care cases refer ed from Hewlett-Packar d through the Center or local hospital Emergency Department 0 NORTH FORK MEDICAL CLINICS, Paonia and Hotchkiss, Colorado 1975 — 1976 I 0 A full -service family practice group with clinics in Paoma and Hotchkiss, Colorado oStaff Physician I ICJ ICJ I • Provided Family Pi active acute and chronic health care services to residents of the North Fork Valley, the closest definitive or specialty care was at St Mary's Hospital, in Grand Junction, one hundred miles away • Provided occupational health services for the coal mines and fruit ranches of the valley ATSUGI NAVAL AIR FACILITY, Atsugi, Japan 1972 — 1975 Atsugi Naval Air Facility is a combined US Naval Air Corp and Japanese Maritime Self-defense Forces air Jac thry It has a large airfield, hangers, maintenance, administrative, recreational and living and service facilities Jot military staff and dependents There is a large dispensary and other amenities as the base was intended to be largely self-contained Its mission was to support the fleet air wing, carry out electronic surveillance of North Korea, China and the Soviet far -eastern coast, and submarme surveillance activities General Medical Officer • Provided primary care Services to military personnel, their families, civilian members of the Department of Defense and flight crews of carrier air groups when in port • Treatment emphasis was on acute self-limiting illness, psychiatry, pediatrics and preventive health services Served as functional flight surgeon due to lack of a designated flight surgeon at the facility Also was on temporary duty to Iwakum Marine Air Station, in Iwakum, Japan EDUCATION ROCKY MOUNTAIN CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL HEALTH, DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE, UNIVERSITY OF UTAH, Salt Lake City, Utah 1980 — 1982 The Rocky Mountain Center for Occupational and Environmental Health was a National Institute of Occupational Safety and Health (NIOSII) Educational Resource Center It trained occupational medicine residents, industrial hygienists and occupational health nurses Most of the faculty were highly experienced occupational physicians, epidemiologists, biostattsucians and industrial hygienists Medical Resident and Master of Public Health Degree Candidate • Completed occupational medicine residency in a National Institute of Safety and Health (NIOSH) Educational Resource Center, awarded Residency Certificate • Performed several Health Hazard Evaluations tot NIOSH • Completed the full nidusti nl hygiene program, receiving Master of Public Health (MPH) degree • Performed a pathology externship at St Maiy's Hospital, Grand Junction Colorado learning sputum cytology from Dr Geno Saccomanno • Performed preceptorship with Occupational Safety and Health Administration (OSHA) National Health Response Team, in Salt Lake City ' Worked ur a large HMO for pay in the Internal Medicine Walk -us Clinic and stood call evenings for the Salt Lake Valley • Worked as Clinic Physician one day per week at the Kenocott Copper Smelter and Mine Clinic l peiformmg general occupational health duties QUNIVERSITY of LOUISVILLE AFFILIATED HOSPITALS, Straight Medicine Intern, 1971 — 1972 L I I I I L!9I n I I 0 I tt Sh aight internal medicine inter nship performed in a large inner city hospital, Louisville General Hospital, and a Veterans Administration Ilospital Internal Medicine Intern • Completed Internal Medicine PG-1 and was awarded an Internship Certificate UNIVERSITY OF KENTUCKY COLLEGE OF MEDICINE, Lexington, Kentucky, 1967— 1971 The University of Kentucky College of Medicine was founded in 1960 As a relatively new medical school, the faculty was recruited from around the world Many professors were from the British Isles A fresh approach to medical curriculum, and teaching methods was undertaken The mission of the College was to train physicians for practice in a largely rural and agricultural state with severe pockets of poverty and under -served communities Prevention and innovative methods of caring for poorly educated populations without access to sophisticated medical technology through strong skills development in physical diagnosis, direct clinical care and public health were stressed Since its opening, the University of Kentucky has become recognized as the best US medical college form training family practice residents Medical Student • Completed the prescribed courses and was awarded the Doctor of Medicine degree (MD) • Sei ved as acting intern in general surgery during senior year • Completed cardiology rotation at the University of Edinburgh, Western General Hospital, Edinburgh, Scotland • Completed a Urology rotation at the Royal College of Surgeons, Trinity College, Jarvis Street Hospital, Dublin Ireland • Completed a comnnnuty medicine rotation in Sandy Hook, Kentucky, in Fannly Practice • Completed a preceptorship with the U S Navy Neuropsychiatric Research Unit, Point Loma, San Diego, California and Balboa Naval Hospital, also in San Diego, as an Ensign in the Navy Reserve, Ensign 1915 Program UNIVERSITY OF LOUISVILLE, Louisville, Kentucky 1964 — 1967 The University of Louisville is a large metropolitan research university with colleges of engineering, law, business, medicine, dentistry and many others It is the second largest university in Kentucky, but has the largest college of medicine ('yl Premedical Student IL�J�• Completed courses required in the premedical curriculum while working a full-timelob Was on Dean's list most of the time • Accepted into medical school after only three years of pre -medical coursework thus, no undergraduate degree PROFESS IONALCERTIFICATIONS/APPOINTMENTS/AFFILIATIONS Medical Licenses OActive Kentucky, Indiana and California Inactive Massachusetts, Ohio, Wyoming, Washington and Colorado I C I Certifications • Certified by the Ametican Board of Preventive Medicine, in Occupational Medicine • Certified by the Medical Review Officer Certification Council as a Certified Medical Review Officer aAppointments • Foi merly University of Louisville School of Medicine, Industrial Toxicology Section, Department of Medicine as Clinical Associate Professor • Former Member of the Council for Accreditation in Occupational Hearing Conservation representing the American College of Occupational and Environmental Medicine 3 Affiliations • American College of Occupational and Environmental Medicine — Master • Former Chairman of the Noise and Hearing Scientific Committee • Member of the Publications Committee Member of the Scientific Affairs Council • Member of the Corporate Medical Directors Section a• Member of the International Occupational Medicine Section • Instructor in "The role of the Professional Supervisor of an Occupational Hearing Conservation Program" course cosponsored by CAOHC and ACOEM given annually at the American Occupational Health Conference • Instructor in "How to improve your Hearing Conservation Program" course cosponsored by CAOHC and the American Academy of Occupational Health Nurses given annually at the QAmerican Occupational Health Conference a • American College of Preventive Medicine — Fellow • American Medical Association —Member • Kentucky Occupational and Environmental Medicine Association — Past President • Kentucky Medical Association — Past Member and Specialty Component Representative a• Jefferson County Medical Association — Member s • American Industrial Hygiene Association — Member Languages, written and spoken • German • Japanese • Spanish Recent Publications • Holthouser, M G The Role of the Professional Supervisor m an Occupanonal Hearng Conservation Program Councr{for Aecrecbtathon in Occupational Hearing Conservation, Cable 2000 • Holthouser, M G Noise Measurement Council for Accreditation in Occupational Hearing ConAervahon, Cable 2001 a Holthouser, M G Woikers Compensation Reform Workers Compensation Reform 15(2) 14-16 Feb 2001 • Guidotti, T L, Rose, S G , Holthouser, M G Woikers Compensation An Overview Science on the WilnesA Stand Evaluating Scient fe Evidence in Law, Adjudication and Policy, OEM Press, Beverly Farms, Massachusetts, 2001 I CI I I I u I LI CIS I ICJ II Il I I I 11 u II EXECUTIVE SUMMARY Poudre Valley Health System is committed to Its vision of providing World Class Health Care to our pa•ients and to the communities we serve That commitment in the area of Workers' Compensation extends to community employers designating Occupational Health Services (OHS) as their medical provider in the partnership of providing optimal health care in the most expedient manner possible with the goal of returning the injured worker to the job Occupational Health Services (OHS) would appreciate the opportunity to partner with the City of Fort Collins and Poudre School District as one of Its designated medical providers for workers' compensation injuries, post offer employment testing, medical surveillance, drug testing and preventive services Occupational Health Services represents a strong commitment to high quality, cost-effective, and Innovative occupational health services for your employees OHS medical care is provided by highly qualified physicians and staff wholly committed to occupational health and safety We feel that balance in meeting the employer and the injured employee's need is key to a successful outcome in any work related injury l hrough experience we believe our strong focus on ease management and communication with employer, employee, and carnei is the best way to ensure this balance and promote a healthy and productive focus on returning the employee to the workforce as soon as possible Key points addressed in the content of the RFP include • Provider staffing under the direction of an Occupational Medicine Board Certified physician with in depth experience in workers' compensation issues worldwide Our physicians practice only in the area of Occupational Medicine, are Board Certified, and Level II accredited (one physician will sit for his Level II certification test in November) • OHS offers three clinic locations, two in Fort Collins and one in Loveland • A prompt payment discount off the Colorado Medical Fee schedule for Occupational Health Clinic and Rehabilitation charges • Staff and procedures dedicated to assure consistent and timely communication with the injured employee, the employer, the claims administrator and all persons necessary to resolve the claim • Immediate access to information systems and documentation of services provided within the Poudre Valley Health System and all points of entry for medical decision making • Internet based computerized tracking of appointments, recheck dates, extent of treatment including lost time, time to closure, and drug testing results • Detailed and timely narratives from first visit to closure, with appropriate impairment assessment (as indicated) • Focus on Quality Improvement as OHS routinely monitors quality/ indicators and patient satisfaction, provider adherence to standard protocols, and outcome assessment as a JCAHO accredited institution • Average less than 1 3 lost days per claim in 2006-2007 working with employers with strong retui n to work/modified duty programs LI Occupational Health Services Poudre Valley Health System I 9 M a p Attachment C C CI I N 9 I 1 I u f ad u u L $`, n C! 0 I I u L' L1 I I I I Curriculum Vitae William M. Basow, MD 11054 W Coco PI Littleton, CO 90127-4117 (720) 922-7540 wmbasow@hotmail corn Last updated 8-1-05 Date of birth September 11, 1948 Place of birth Oklahoma City, Oklahoma Education Undergraduate Umv of Kansas, Lawrence, KS B A (Zoology) 1970 Medical School Univ of Kansas School of Medicine, Kansas City, KS M D , 1974 Masters Degree in Public Health, Medical College of Wisconsin, 2005 (all work completed 7/05, degree awarded 5/06) Internship/Residency Cedar Rapids (IA) Family Practice Medical Educ Program 1974-1977 Licensure Colorado, license 421621 Specialty Board Certification American Board of Family Practice Specialty Board Certification American College of Preventive Medicine --Occupational Medicine track Additional Certifications National Board of Medical Examiners 4159975 May 5, 1975 American Board of Family Practice Certified 1977 Recertified 1983, 1989, 1995, 2001 Certified Forensic Consultant, American College of Forensic Examiners, 2005 Advanced Cardiac Life Support, 1999 Advanced Trauma Life Support, 1997 Pediatric Advanced Life Support, 1997 Newborn Resuscitation Program, 1999 Colo Division of Workers Compensation, Level 11, 1998, recertified 2001, recertified 2004, will sit for exam Nov 2007 II fit I u 11 a I I 1 I I fi ,e u 1 I If Memberships American Academy of Family Practice Colorado Academy of Family Practice Latimer County Medical Society Colorado Medical Society Honors and Appointments Phi Beta Kappa, Alpha Omega Alpha, Colorado Advisory Commission on Family Medicine, Test item wiiter--American Board of Family Practice --Institutional Biosafety Committee, Colorado State University, 2004-current --Utilization Review Panel, Colorado Division of Workeis Compensation, 2004 WORK HISTORY William M Basow, M D October, 1997 to present Occupational Health Services, Poudre Valley Hospital, Staff Physician 1025 Pennock Place Ft Collins, CO 80524 References Michael Holthauser, MD, Director 1991-2001 Mountain Crest Hospital --part time, 4601 Corbett Dr Ft Collins, CO 80525 Medical evaluations & consultations --adult, adolescent, senior units References James Seeton, MD (address below) John Nagle, MD (Mountain Crest address above) 1998 to 2000 Northside Health Center, Poudre Valley Hospital -part time Bristlecone & College Ft Collins, CO 80526 Direct patient care and supervision of mid -level practitioner, part time References Mark Unger, MD (same address) October, 1997 John Volk, MD (address below), office coverage 10/8 David Ottolenghi, MD (address below), office coverage 10/3 Occupational Health Services (address above), 3 days/wk beginning 10/14/97 u I I September, 1997 Q John Volk, MD P 0 Box 520 Johnstown, CO 80534 (970) 587-2388 Office coverage, 9/26 David Ottolenghi, MD 2001 S Shields, Bldg L Ft Collins, CO 80526 (970) 221-3752 Office coverage, 9/25 August, 1997 Vacation July, 1997 (one month family practice (with OB) locum tenens) Wrangell General Hospital 310 Bennett St Wrangell, AK 99929 (907) 874-3356 Reference Lynn Prysunka, MD Tune, 1997 (three week family practice locum tenens) Mountain View Family Medicine ! 2001 S Shields, Bldg L Fort Collins, CO 80526 (970) 221-3752 QReference James Seeton, MD May, 1997 (one week family practice locum tenens) Haskell Health Center Haskell Service Unit, Indian Health Service P O Box 864 Lawrence, KS 66044 Reference Dr Steve Stevenson, Clinic Director a April -May, 1997 (five week urgent care locum tenens) Arcon Pahrump Medical Center 1501 Calvada Blvd Pahrump, NV 89048 (702) 727-9757 Reference Carma Kreitler, Director a I I a February, 1997 (one month family practice locum tenens) Mescalero Service Unit Q P O Box 210 Mescalero, NM 88340 (505)671-4441 Reference Verlyn Corbett, MD, Medical Director January, 1997 (temporary occupational medicine position) Bruce Belleville, MD Poudre Valley Hospital Occupational Health Services 1045 E Garfield Ft Collins, CO 80524 (970) 495-8450 December, 1996 Vacation November, 1996 (one month family practice (with OB) locum tenens) KANA Medical Clinic 3449 E Rezanof Kodiak, Alaska 99615-6938 (907) 496-9870 References Mr Frank Cramer, Clinic Director a John Kollar, M D October, 1985 to Octobei, 1996 Harmony Medical Center (formerly Shores Family Practice) --private family Q practice 1330 Oakndge Dr Ft Collins, CO 80525 (970) 225-1600 References James F Seeton, M D Poudre Valley Hosp Harmony Campus Ft Collins, CO 80528 (970) 221-3752 Margo J Geppert, M D 2818 McKeag, Ft Collins, CO July, 1981 to October, 1985 Fort Collins Family Practice Residency Education Program --residency director a 1982-85 (assistant director 1981-82) 1024 Lemay Ave Ft Collins, CO 80524 References James F Seeton, M D Austin Bailey, MD Poudre Valley Hosp 1024 Lein ay Ave Harmony Campus Ft Collins, CO 80524 Q Ft Collins, CO 80528 (970) 221-3752 (970) 495-8800 I I I I I u LI I I I I w I I C I 0 0 June, 1978 to June, 1981 Associates in Family Medicine, P C --private family practice 1221 E Elizabeth Fort Collins, CO 80524 References Jerome I Smith, M D 2025 Big Horn Dr, Ft Collins, CO 90525 (970)229-9800 Floyd V Stephens, M D 1113 Oakridge Dr, Ft Collins, CO 80525 (970) 225-0040 March, 1978 to May, 1978 Locum Tenens, Harlowton, MT, family practice Reference Glen Shrotam, M D Miles City, MT January, 1978 to March, 1978 Volunteer medical work in Nicaragua and Honduras (no references available) July, 1977 to December, 1977 Cedar Rapids Family Practice Medical Education Program --faculty St Luke's Hospital 1026 A Ave NE Cedar Rapids, IA 52402 (319)369-7211 References Ca11 R Aschoff, M D, Curt Reynolds, M D (same address) 0 I 0 0 I 0 Attachment 1 0 0 I 0 0 I I I 0 0 I 0 OCURRICULUM VITAE aNAME Jeffrey A. Wunder, M.D BATE/ PLACE OF BIRTH May 23, 1950 —Cincinnati, OH EDUCATION Undergraduate University of Cincinnati, CollegeofArts and Sciences 19t8-1972 Cincinnati, OH BS Degree University of Cincinnati, College of Medicine 19 , 6-1979 Department of Microbiology Cincinnati, OH Completed Master's Thesis Topic "The Effects of Malnutrition on Host Defense Parameters in the Guinea Pig " Medical School University of Cincinnati, College of Medicine 1979-1983 Q Cincinnati, OH Doctor of Medicine QGRADUATE ri TRAINING• Internship Riverside Methodist 1981-1984 Columbus, OH Residency Ohio State University 1981-1986 Department of Physical Medicine and Rehabilitation Columbus, OH PROFESSIONAL EXPERIENCE Poudre Valley Hospital — Occupational Health Services 1/2004 — present Rehabilitation and Performance Medicine Specialists 7/2(,04 - present Rehabilitation Associates of Colorado, PC 112C,04 —present 1 Koppenhoefer and Wunder, M.D.s Iric 112103 —1/2004 Anheuser-Busch 20011-1/2003 Medical Director/On-Site physician Q Industrial Rehabilitation Coordinator Longmont Foods Health Services 199 '-1/2003 a Medical Director/On-Site Physician Industrial Rehabilitation Coordinator North Colorado Occupational Medicine 199;.-1/2003 and Staff Physician 1/204 - present I Curriculum Vitae Jeffrey A. Wunder, M.D. Page 2 ConAgra Meat Packing 1993-1/2003 Medical Director/On-Site Physician Industnal Rehabilitation Coordinator PROFESSIONAL tXPERIENCE, Greeley Center for Independence 19S 8-2001 (continued) Staff Physician Greeley Medical Clinic 19S 5-1998 Corporate Health and Management Program, Inc (CHAMPS) Staff Physician Colorado Rehabilitation Institure Staff Physician 198 5-1995 Medical Director 1987-1994 Assistant Medical Director 1986-1987 Regional Medical Advisor for the Industrial Commission 1984-1986 of Ohio Columbus/Central and Southeastern Ohio Previous Employment The Proctor & Gamble Company 197 3-1975 Cincinnati, OH Microbiologist with the Dental Research Team investigating oral microbial ecology in animal models. Hilltop Research, Inc. 1971-1973 Miamiville, OH Microbiologist CERTIFICATION AND LICENSURE i 1. State of Ohio Licensure No 49804 01/10/2003 2 Colorado Licensure No. 27646 3 American Board of Physical Medicine and Rehabilitation — Board Certified 198, 4 DEA—No AW3147003 5 ABIME, American Board of Internal Medicine Examiners 2/2G 03 AMA Guidelines to the Evaluation of Permanent Impairment, Fourth and Fifth Edition Training Course C State of Kentucky Licensure No. TP535 4/07'03 I R aCurriculum Vitae Jeffrey A, Wunder, M.D. a Page 3 MEDICAL STAFF PRIVILEGES a1. McKee Medical Center, 2000 Boise, Loveland, CO 80538 2. Deaconess Hospital, 311 Straight St, Cincinnati, OH 45219 aProvisional Associate 3. North Colorado Medical Center, 1801 10 Street, Greeley, CO 80631 a4. Poudre Valley Hospital, 1024 S LeMay Ave., Fort Collins, CO 80524 a 5. Good Samaritan Hospital, 10500 Montgomery Rd, Cincinnati, OH 45242 Active privileges 6. Bethesda Hospital, 10500 Montgomery Rd., Cincinnati, OH 45242 Active privileges MEMBERSHIPS IN PROFESSIONAL SOCIETIES: O1. Ohio State Medical Association Q2. Academy of Medicine of Cincinnati 3 Rocky Mountain Rehabilitanon Society 4. Western Pain Society 5 American Pain Society 6. Amencan Academy of Pain Medicine Q7 Member, Board of Directors, Health at Home 8. Member, Task Force on Functional Capacity Evaluation, State of Colorado Division of Worker's Compensation 9. Member, Executive Medical Committee, Spalding Rehabilitation Hospital 10 Member, Christian Medical and Dental Society a IL Level I & 11 Accredited — Colorado Division of Worker's Compensation PRESENTATIONS a Treatment of Back in an Era of Managed Care 2 Colorado Department of Labor and Employment Medical Treatment Guidelines Seminar 3 State of the Art Spinal Rehabilitation, Dr. Jeffrey Saal at Ohio State University I /2i 04 - present 1/2(iO3 — 1/2004 1993 — present 1991) — present 7/0 /03—1/2004 7/0 /03—1/2004 .200t 200 Past Past Past Past past 199:,-1997 199 -1993 199b — present I o'1. Qualifications of firm Q Established in 1987, the Occupational Health Services department of Poudre Valley Hospital has grown in response to the needs of Northern Colorado area businesses Under the direction of a full-time Board Certified Occupational Medicine Physician, the program is designated a preferred provider by a number of workers compensation Insurance carriers Membership in these preferred provider networks is based on our ability to demonstrate quality care, to provide cost effective treatment, and to manage the case effectively to closure OHS offers a comprehensive occupational health program designed to assist the employer with the treatment, management, and prevention of work -related Injuries Our physician directed program assures an aggressive and highly managed treatment approach Collaboration with the employer to assure: an understanding of the work setting, job requirements and ability to place Individuals in a modified duty position, if Indicated, Is essential to assuring a rapid and productive return to duty for the Injured worker Communication is a key element In any workers' compensation case and OHS prides Itself on the accessibility of our providers and on the consistent and timely two way communication we establish with our Injured workers and our client companies As a part of Poudre Valley Health System our shared vision is to provide World Class Healthcare to 'Dur patients As one of the designated providers for the City of Fort Collins and Poudre School District, OHS assures provision of all medical services and treatments as required under the Colorado State Statutes for work -related illness and injuries for those employees choosing to use our service We assist in the prevention of work related Injuries through education, on site familiarity with the work settings, and review of injuni trends We work as a collaborative team with Risk Management and the claims administrator to ensure claims are managed from initial determination of work relatedness to early return to productive employment and case closure Our daily goals are 1 ) to deliver prompt, customer focused quality care to injured workers, 2 ) to communicate with our client companies so that they are Informed at each stage of the treatment process, 3 ) to return injured employees as quickly as possible to their pre - injury work status, and 4 ) to provide employers with additional assistance in the areas of prevention and pre -placement services Our business Is exclusive to medical management of Workers' Compensation injuries and services designed to assist the employer with medical surveillance and prevention to assure a safe work environment Our quantity assurance program monitors return to work days and patient understanding of their work restrictions as described on the M-164 form In the last year we returned 98 7% of our initial injury patients to work three days or less to modified or full duty, resulting in decreased lost time costs for our employers In addition our 2006-2007 a patient satisfactions surveys indicate 97% of our patients state that They understood their work restrictions as written and reviewed by the OHS physician Our average lost time per case is less than 1 5 days We feel this demonstrates our commitment to the employer and .he Injured worker to return the worker to a productive, safe work environment as rapidly as possible In 2001 Occupational Health Services expanded to two locations in Fort Collins The North Clinic location at 1025 Pennock Place, Suite 121, Is just two blocks north of Poudre Valley Hospital The South Clinic, our primary clinic, Is located at 1330 Oakridge Drive just off Harmony and Wheaton In June of 2007 we opened a third location at occupational Health Services F'oudre Valley Health System I P 0 p+ Curriculum Vitae Jeffrey A. Wunder, M D. Page 4 4 -.-Level l & II Accreditation Courses, Colorado Division of Worker's Compensation 1952, 1995, 1958,2001 5 CA1RE Industrial Rehabilitation Conference, Denver, CO 6. Problems in Worker's Comp Conference, Denver, CO a7 American Academy of Pain Medicine Meetings 8 Low Back Pain in the 1990s, Denver, CO lt1 9. American Pain Society Meeting, Washington, DC 10 Western Pam Society Meeting, Palm Springs, CA t 1 I Work Capacity Evaluation Workshop, Employment Rehabilitation Institute of California Chicago, IL 12 Sports Medicine Sympostum, Cleveland Clinic , 13. Upper and Lower Extremity Prosthetics, Northwestern University 14 CCLA—Symposium on Worker's Compensation Issues ARTICLES/PUBLICATIONS/LECTURES 1. Dirks, J.F., Wunder, J A., Reynolds,l , Basse, R., Kinsman, R , and Jones, N F A Scale for 'redreting Non - Physiologic Contributions to Pain. Psychotherapy and Psychosomatics 54.153-157, 1996 Q 2. Dirks, J.F., Wunder, J A., Kinsman, R, McElhinney, J., Jones, N F. A Pam Rating Scale and 3 Pain Behavior Checklist for Clinical Use: Development, Norms and the Consistency Score. Psychotherapy =d Psychosomatics 59.41-49, 1993. 3 Kinsman, R., Dirks, J F., Wunder, J A., Carbaugh, R., and Stteg, R. Multidimensional Analysis of Peak Pain Symptoms and Experiences. Psychotherapy and Psychosomatic 51.101-112, 1989. Q 4, Bnner, W.W., Wunder., J.A., Blair, D.W., Parran, JJ, Blaney, T.L., and Jordan, W.E Use of Spiral Bacterial Plating and Lasser Colon Counting Techniques in Studies of Microbial Ecology of Man, from Mechanizing Microbiology. Ed. by Sharpe and Clark, pp.154-169, 19-18. Charles C. Thompson Pub]. Spr ngfield, IL I I I I 0 I I I 0 0 I I iI I I II:J tli i 13, I I I aCurriculum Vitae I Ann K. Yanagi MD, PLLC 8277 Spinnaker Bay Dr s� Windsor, Colorado 80528 Education: 1986-1988 Emergency Medicine Residency, Valley Medical Center, Fresno, California (affiliate of University of California, San Francisco) ` 1985-1986 Transitional Internship, Valley Medical Center, Fresno, California a 1985 M.D., George Washington University School of Medicine, Washington, D.0 1977-1978 Medical Technology, California State University, Hayward, California 1976 Bacteriology, University of California, Berkeley, a Experience: California 12/2005- Present Physician, Occupational Health Clinic, Poudre Valley Hospital 12/2005- Present Physician, Wound Healing Clinic, Poudre Valley Hospital 1992- current Emergency Physician, Relief, Emergency Physicians of the Rockies, PC, Ft. Collins, Colorado 1988-1992 Emergency Physician, St. Joseph Hospital , St. Anthony Central, Denver, Colorado, Aurora Presbyterian Hospital, Aurora, Colorado, Longmont United Hospital and McKee Medical Center, Loveland, Professional: Board Certified Emergency Medicine, American Board of Emergency Medicine, 1990, Diplomate Level II Accreditation for Workmen's Compensation Injuries, 2007 American Academy of Emergency Medicine, Fellow iI I N I I I u a 0 I I I I iI 0 Colorado Medical Society, Member Larimer County Medical Society, Member Sexual Assault Nurse Examiner Program (SANE), Poudre Valley Hospital, Physician Advisor Victim's Compensation Board, Eighth Judicial District, Member 1992-1998 no M 11fi1 I a a Attachment F I Q I W pf I I HY I a Fol I 9 1900 B Ross Court Fort Collins Co 80526 FScherr@aol corn Frederick ick P. Sic herr IW , MBA QExperience May 7, 2007- Present Physician at Occupational Health Services Poudre Valley Health Systems and Harmony Urgent Care March 21, 2005 — September 5, 2006 Program Director Quad Cities Genesis Family Medicine Residency Prograr Responsible for the education, direction, operations and development of a Residency Program with 18 Family e Practice residents Developed strategic plan for the program and completed 70% of the plan within the first year December 21, 2004 - March 1, 2005 Interim Medical Director Cheyenne Community Health Center New �g Federal Community Health Center which received initial funding in December 2004 Assistance with organization of the clinic, establishing medical policies and procedures, hiring staff and preparing clinic to be open and seeing patients by March 301h, 2005 aMarch 24, 2003 — November 19, 2004 Faculty at the University of Wyoming Family Practice Residency Program Promoted to Associate Program Director September 21, 2003 Associate Program Director Position eliminated on 10-21-04 Responsible for the Business and Personnel operations of the Residency Program Wrote the 5-Year Practice Plan for the residency This addressed finances, marketing, raising revenue fiom non-traditional Residency resources and addressing the Residency Assistance Program Criteria for Excellence in a Residency Program Conducted Strategic Planning Retreats for the Residency Sefected as Faculty of the Year by the Residents-2003-2004 August 2000 - March 7, 2003 Numerous Positions wiih W Carlton Reckling, MD Responsible for Management of all aspects of his Orthopedic/Spine Practice and Ambulatory Surgical Center Served as Medical Director of the Ambulatory Surgical Center, Urgent Care and an Occupational Medicine Management responsibilities for 41 employees Created an outreach program for High School Athletics Outcomes research for the Practice based upon SF36 data Conducted Strategic Planning for the Practice and Ambulatory Surgical Center 1994 - January 2005 Service on the Wyoming Workman's Compensation Medical Commission This is a commission which hears disputed or appealed Workman's Compensation cases A panel of 3 physicians conduct a hearing and then serve as administrative fudges U In I I ]t d K U1 lJ I I 4 t4 I !fit l I j] N I 0 2002 - 2003 Consulting work at the Fort Washakie Service Unit via a grant from the Shoshone Tribe Consulting work focused on Medicare compliance, conducting self audits, working with providers on coding and documentation, billing processes, management training and strategic planning December 1999 - August 2000 Medical Director WINHealth Partners, an HMO in Cheyenne, Wyoming Utilization Review, Medical Management and Disease Management programs September 1991 - December 1999 Full time Private F amily Practice and Obstetrics in Laramie, Wyoming Started the practice and built it to include 2 other Family Physicians and one part-time Family Nurse Practioner Patient base of 8500 patients in a 40,000 population catch area 1993 - 1997 Helped to reopen and served as Medical Director of the North Park Medical Clinic in Walden, Colorado (population 800) Bachelor of Arts Hastings College, Hastings, Nebraska 1980 - 1984 Education With Distinction in History, With High Distinction in Biology Medical Degree University of Utah School of Medicine 1984 - 1988 Family Practice Honors Graduate Residency Phoenix Baptist Hospital, Phoenix Arizona 1988 - 1991 Served as Chief Resident for 3 months in the absence of Chief Resident MBA in Healthcare Administration University of Colorado at Denver, Executive Program 2000 - 2002 GPA 3 838 on 4 0 scale Professional American Academy of Family Physicians -Board Certified and Member 1988 - Present, Re -certified in 1998 - 2005 and for 2004 - 2011, Fellowship Status 1994 Hospital Arizona Chapter 1988 - 1991 Affiliations Wyoming Chapter 1991 - 2005 Iowa Chapter 2005 - Present Served as Alternate Delegate for the State of Wyoming 1996 - 1998 Served as President Elect for the State of Wyoming 1997 - 1999 Served as President for the State of Wyoming 1999 - 2001 ALSO Instructor 1995 - 1999 Graduate Fundamentals in Management Program 1997 Wyoming Medical Society Member 1991 - 2004 I aAmerican College of Physician Executives Member 2000 - Present Adjunct Professor University of Wyoming School of Medicine 'E 1995 - 2003 Clinical instruction for Medical Students NMAMI), Family Nurse Practioner Students and RUOP site for the University of Washington School of Medicine 1995-1999 Precepting for the University of Wyoming Family Practice Residency Program in Cheyenne, Wyoming Ivinson Memorial Hospital, Laramie, Wyoming Staff physician with active privileges including OB from September 1991 — December 1999 Served as Chief of Medicine from 1996 - 1998 and on the privileging and credentialing committee from 1992 - 1999 Served on the Board of Directors for the Laramie IPA and PHO acting as Contracts Chairman United Medical Center, Cheyenne, Wyoming Staff physician with active privileges including OB from April 2003 - November 2004 Serving on the Credentials committee Genesis Medical Center East and West Staff physician with active privileges in Family Practice including OB from March 2005- September 2006 Served on executive leadership team of Genesis Health System Licensure Arizona 18929 Inactive Colorado 32600 Active Wyoming 5030A Active Iowa 36033 Active Social Organizations Laramie, Wyoming Rotary Club 1992 - 1996 Cheyenne, Wyoming Kiwams 2001 - 2002 Redeemer Lutheran Church, Betlendorf Iowa Q Interests Sports, Weightlifting, Cooking, Playing the Piano, Healthcare Policy and �y Healthcare Education m Honors Faculty of the Year for 2003 - 2004 by the Residents at the University of Wyoming Family Practice Residency Program at Cheyenne Also given plaque by residents on 11-18-2004 which states "In sincere Appreciation for your commitment and dedication to the education of Us, the residents of the University of Wyoming Family Practice at Cheyenne" I I C u 0 I p Attachment G a 0 0 I I I C I G� 0 El FEE LIST BY COST CENTER CUSTOM Olt C K n I 0 I CI' I n III 1 Cost Ctr Fee Code Description Amount A/C/R E&M Evaluation & Management 99024 Post -op f/u visit - global service 000 C 99082 Travel Time/hr 22500 C 99201 New Patient Brief Visit 5343 C 99202 New Patient Limited Visit 7809 C 99203 New Patient Intermediate Visit 11508 C 99204 New Patient Extended Visit 16440 C 99205 New Patient Comprehensive Visit 21372 C 99211 Established Patient Brief Visit 28 77 C 99212 Established Patient Limited Visit 4932 C 99213 Established Patient Intermediate Visit 7398 C 99214 Established Patient Extended Visit 11097 C 99215 Established Patient Comprehensive Visit 16029 C 99241 Consultation Limited 9864 C 99242 Consultation Intermediate 13974 C 99243 Consultation Extended 18084 C 99244 Consultation Comprehensive 230 16 C 99245 Consultation Complex 31236 C 99255 Inpatient Consultation Comprehensive 32880 C 99271 Confirmatory Limited 6576 C 99272 Confirmatory Intermediate 9864 C 99273 Confirmatory Extended 131 52 C 99274 Confirmatory Comprehensive 18084 C 99275 Confirmatory Complex 23838 C 99354 Prolonqed Sery Direct Contact 1 hr 16440 C 99355 Prolonqed Sery Direct Cont (add 30 min) 8220 C 99358 Prolonqed Sery w/o Dir Cont (1 hr) 131 52 C 99359 Prolonqed Sery w/o Dir Cont (30 min) 6576 C 99361 Medical Conference (30 minutes) 8220 C 99362 Medical Conference Complex 14796 C 99371 Telephone Brief 1644 C 99372 Telephone Intermediate 3288 C 99373 Telephone Complex 4932 C 99401 Counselinq on Exposure Risk Factor 15min 32 88 C 99402 Counselinq on Exposure Risk Factor 30min 6576 C 99403 Counselinq on Exposure Risk Factor 45min 9864 C 99404 Counselinq on Exposure Risk Factor 60min 131 52 C 99455 Medical Impair Ratinq Treatinq Phy/ 5hi 10686 C 99456 Medical Impair Ratinq Consultinq Phy 5h 12330 C 99499 Independent Medical Evaluation 67500 C 99750 Physical Demand Classification 4000 C 99910 Cancellation Fee 000 C 99960 Initial Report (Ml) 4200 C 99961 Proqress Report (Payer Requested) 4200 C 99962 Closinq Report (M3) 4200 C 99963 Initial & Closinq Report same DOS 4200 C Records printed 45 0 10/27/2007 1 I 2500 Rocky Mountain Ave in Loveland in the south medical office building at Medical Center of the Rockies Each clinic location allow for curbside access, ease of parking, and a wellness -oriented environment which focuses the patient on quick return to work and prevention of further injury The continuum of services offered, from initial injury management to rehabilitation and prevention, provides a unique opportunity for our staff to communicate consistently and frequently with the Risk Management to assure quality a outcomes for injured workers An organizational chart is included (Attachment A) which describes the various functions within the department and the number of staff in each role at the three clinics aI Qualifications of staff Medical Director: Michael Holthouser, M D , MPH, (Attachment B) Occupational Medicine, Board Certified Level II accredited 25 years experience in occupational medicine 4 years with OHS Staff Physicians: William M Basow, M D (Attachment C) Occupational Medicine, Board Certified Family Medicine, Board Certified Level II accredited 10 years with OHS Jeffrey Wunder, M D (Attachment D) Physical Medicine and Rehabilitation Board Certified Level II accredited 25 yrs experience pain management and delayed recovery 4 years with OHS Ann Yanagi, M D (Attachment E) Emergency Medicine, Board Certified Level II accredited 17 years with PVHS 2 years experience in OHS Frederick Scherr, MD, MBA (Attachment F) Family Medicine, Board Certified Sits for Level II accreditation in November 07 11 years experience in occupational medicine OHS since May of 2007 Assuring we have adequate staffing is critical to our ability to provide quality care in a 1 imely mannei Our continued growth and the anticipated changes in 2007 as a result of Workers' Compensation legislation have prompted OHS to add and additional 1 5 FTEs to our physician staffing prior to January 2008 Information on Incumbents will be aavailable in mid November Occupational Health Services Poudre Valley Health System I FEE LIST BY COST CENTER CUSTOM 0 I I a u L I L k N J R l L�J III Cost Ctr Fee Code Description Amount AICIR MEDI Medicine 90371 90375 90471 90632 90636 90658 90675 90692 90707 90718 90746 90772 93000 93005 93010 94010 94010-26 95851 95852 95860 95861 95863 95864 95870 95872 95900 95903 95904 95925 95926 95927 95934 95936 97597 97598 98925 98926 98927 98928 99058 99075 99080 99080-01 99085 99091 99901 99901-00 99911 ZZ90782 Records printed Hep B Immune Globulin 56000 C Rabies Immune Globin (ml) 12500 C Immunization Administration 1500 C Hepatitis A Vaccine 5600 C Twinrix Vaccine, Hep A & Hep B 9000 C Influenza Vaccine 1500 C Rabies Vaccine (Pre & Post) 14200 C Typhoid 3500 C Measles/Mumps/Rubella 3500 C Tetanus & diphtheria toxoids (Td) adults 15 12 C Hep B Vaccine 4600 C Injection Administration 1890 C EKG & Read 7250 C EKG Only 3250 C EKG Interpretation 4000 C Pulmonary Function Test - physical 3000 C Pulmonary Function Test 4404 C ROM Measurement&Report/extremity 31 75 C ROM Measurem ent&Report/hand 4763 C EMG One Extremity 13230 C EMG Two Extremities 18749 C EMG Three Extremities 24268 C EMG Four Extremities 29786 C EMG Limited 5670 C Sinqle Fiber EMG each Muscle 22680 C Motor NCS w/o F Wave 7938 C Motor NCS w/ F Wave 10206 C Sensory NCS 7560 C Upper Extremity SSEP 25704 C Lower Extremity SSEP 25704 C Head/Neck SSEP 25704 C H-Reflex Tibial 9450 C H-Reflex Other 10206 C Wound Care -Selective Debridement 2800 C Wound Care -Non -selective Debridement 21 00 C Osteopathic Manipulation(1-2) 5670 C Osteopathic Manipulation(3-4) 7560 C Osteopathic Manipulation(5-6) 9072 C Osteopathic Manipulation(7-8) 10584 C Office services / Emergency basis 3024 C Deposition / 5 hr 13230 C Special Report/Procedure / 5 hr 11250 C Insurance Documentation 2000 C Testimony /hour 40000 C Collection/]nterp of phVsiologic data 7560 C Non -Medical Conference/15 min 5625 C Sam Conference /15 min /Max $225/hr 5625 C Copy Fee pq 1-40 $ 50/page 050 C Injection Administration 1890 C 49 n10/27/2007 1 I FEE LIST BY COST CENTER CUSTOM Iftl I lil iA W I I II 05 I a 0 0 a 0 0 Cost Ctr Fee Code Description PHYM Physical Medicine Amount A/C/R 97001 Initial Eval PT 8656 C 97002 Reeval PT 5843 C 97003 Initial Eva] OT 8656 C 97004 Re-eval OT 5843 C 97010 Hot or Cold Pack Application 1082 C 97012 Mechanical Traction 2435 C 97014 E-Stun Unattended 1894 C 97016 Vasopneumatic Device 2435 C 97018 Paraffin Bath 1623 C 97022 Whirlpool/Fluidotherapy 2435 C 97026 Infrared,Supervised 1 or more areas /15" 1082 C 97032 Manual E-Stim (15 min) 2435 C 97033 lontophoreses (15 min) 2705 C 97035 Ultrasound (15 min) 21 64 C 97110 Therapeutic Exercise (15 min) 2705 C 97112 Neuromuscular Re-ed (15 min) 2705 C 97113 Aquatic Therapy 2435 C 97116 Gait Traininq (15 min) 21 64 C 97124 Massaqe (15 min) 2976 C 97140 Manual Therapy (15 min) 3246 C 97150 Therapeutic Procedure qroup 2 or more 2705 C 97530 Therapeutic Activity (15 min) 2705 C 97535 Self Care/Home Manaqement Traininq 4058 C 97537 Job Site Analysis (15min) 4058 C 97537-14 Range of Motion (per 15 min) 4000 C 97750 Physical Performance Test (15 min) 51 40 C 97760 Orthotics Fit/Train (15 min) 2597 C DNU97504 Orthotics Fit/Train (15 min) 2496 C Records printed 28 0 10/27/2007 I 9 Al I 0 L] 1 I 0 M I I a 1 0 0 Cal 0 491 I I I L I U1 I K Ii 0 Ll I I I 01 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,,,' '',,' DRUCrSCREENS'r', ` FEE Basic..` _' $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,Testing' ,DOT +" 05 00' Breath Alcohol Testing $25 00 History and Physical Confirmation of positive BAT $25 00 Height Weight Vital Signs Snellen Eye Chart Immuriizationa ' Whisper Test TB Skin Test $18 00 Dip Urinalysis Hepatitis A $70 00 Hepatitis B per injection (series of 3) $60 00 Corporate '$1,15 00 Tetanus Toxoid $20 00 Comprehensive History & Physical Diphtheria/Tetanus Toxoid $20 00 Height, Weight, Vital Signs Snellen Eye Chart Whisper Test OtfierCharges, Dip Unnalysis Dipstick Urinalysis $ 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 sharedlhmcladm mlohs/ohsformslohsphyscaipncesheet 1012007 for 2008 I D u I Or< 0 LI, I I I I n 0 I $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 WorkSteps,,, 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/admm/chs/chsforms/ohsphysicalpncesheet LrrWJj 1012007 for 2008 II 0 OCCUPATIONAL HEATH SERVICES 1330 Oakridge Drive Fort Collins, CO 80525 TAX ID # 84-1262971 970-495-8450 FAX 970-495-7620 aSEND CHECK AND RECORDS TO 1330 OAKRIDGE DR, FORT COLLINS CO 80525 RECORDS TO BE SENT IN CHRONOLOGICAL ORDER STARTING WITH DATE OF INJURY TO PRESENT Patient Name SS#, a Date To VIA Facsimile at ( ) Phone Payer Name Phone Address RE a Dear FEES The fee for Samms Conferences involving Dr Q is $225 00 per hour A minimum fee representing one hour's time will be charged Doctor will need record review is $112 50 per half hour Record review costs are not refundable The deposit for testimony is $225 00 plus record review Calculation of time is portal to portal Your total deposit aPAYMENT A payment representing the cost of the conference is required and must be received in our office no later than two weeks from appointment date If payment is not received within this O time frame, the schedule will be cleared Should you need to cancel or reschedule, you must notify us Any portion of an advance payment in excess of time actually spent preparing will be refunded when the physician is notified of cancellation of conference at least three (3) business days prior to the scheduled deposition If there is no notice of cancellation with in three (3) days, { we keep all deposits Your signature where indicated below affirms that you acknowledge and accept these terms Please return an executed copy of this letter as soon as possible Please fax to 970-495-7620 Thank you for your prompt attention to this matter Please do not hesitate to contact me should you have any questions 0 Sincerely, OAcknowledged and receipted I B By Date Please sign ad fax back to 970-495-7620 I OCCUPATIONAL HEATH SERVICES 1330 Oakridge Drive Fort Collins, CO 80525 TAX ID # 84-1262971 970-495-8450 a FAX 970-495-7620 a SEND CHECK AND RECORDS TO 1330 OAKRIDGE DR, FORT COLLINS CO 80525 RECORDS TO BE SENT IN CHRONOLOGICAL ORDER STARTING WITH DATE OF INJURY TO PRESENT aPatient Name Date To VIA Facsimile at ( ) Payer Name Address RE Dear Phone Phone FEES The fee for depositions or conferences involving Dr _ is $264 60 per hour A minimum fee representing one hour's time will be charged Record review is $264 60 per hour per inch of records, a minimum fee representing one hour's time will be charged Record review costs are not refundable Participation at trail or court action is $400 00 per hour, a minimum of 4 hours of testimony time will be required Travel expense is $250 60 per hour portal to portal Your total deposit PAYMENT A payment representing the cost of the trial or deposition is required and must be received in our office no later than two weeks from appointment date If payment is not received within this time frame, the schedule will be cleared Should you need to cancel or reschedule, you must notify us Any portion of an advance payment in excess of time actually spent preparing and/or testifying, will be refunded when the physician is notified of cancellation of a depo or conference at least three (3) business days prior to the scheduled deposition If there is no notice of cancellation with in three (3) days, we keep all deposits There will be no refund if testimony is canceled less than five (5) business days from the date of the court appearance Your signature where indicated below affirms that you acknowledge and accept these terms Please return a an executed copy of this letter as soon as possible Please fax to 970-495-7620 Thank you for your prompt attention to this matter Please do not hesitate to contact me should you have any questions Sincerely, k, Acknowledged and receipted By a Marcia Ball 970-495-8469 Date QPlease sign and fax back to 970-495-7620 L� OCCUPATIONAL HEATH SERVICES 1330 Oakndge Drive Fort Collins, CO 80525 a TAX ID # 84-1262971 970-4685-8450 FAX 970-495-7620 r, SEND CHECK AND RECORDS TO 1330 OAKRIDGE DR, FORT COLLINS CO 80525 RECORDS TO BE SENT IN CHRONOLOGICAL ORDER STARTING WITH DATE OF INJURY TO PRESENT Patient Name: SS# Date: To VIA Facsimile at Phone: aPayer Name Phone RE: Dear FEES: The fee for Independent Medical Examination with Dr is $675 00 One hour of records review is included in cost If extensive records are received an additional payment will be requested Your total deposit. $ 675 00 aPAYMENT: A payment representing the cost of the [ME must be received in our office no later than 10 calendar days prior to the date of the scheduled IME If payment is not a received within this time frame, the schedule will be cleared Should you need to cancel or reschedule, you must notify us at least 3 business days prior to the scheduled [ME or $250 00 will be retained for the no show Your signature where indicated below affirms that you acknowledge and accept these terms Please return an executed copy of this letter as soon as possible Please fax to 970- 495-7620 Thank you for your prompt attention to this matter Please do not hesitate to contact me should you have any questions Sincerely, Acknowledged and receipted By I.� Marcia Ball 970-495-8469 Date Please sign and fax back I 970-495-7626 I CI iI I C' 0 0 0 IJ I L I iy I ,- . I I w Mb l aOctober 27, 2007 Mary Late SS 000-00-0091) 100 Out to Lunch Never never land, Claim # aDear Ms Late, You missed your appointment at Occupational Health Services at Poudre Valley Hospital on Q 10/26/2007 Therefore, any work restrictions may no longer be current If you have not already rescheduled, please call 495-8450, Mon -Fri, 8am - 5pm to schedule an appointment aMissing a medical appointment may affect your work status and Workers' Compensation claim PLEASE RESPOND as soon as possible to ensure continuation of medical care at Poudre Valley r Hospital Occupational Health Services r Occupational Health Services Poudre Valley Hospital acc Chart Insurance Carrier I u R] I Backup Physician coverage for vacation and Illness is generally provided by our own Provider staff We also have the ability to draw upon coverage from physicians within Q our Harmony Urgent Care physician group in the event of an unexpected extended absence or when volume requires recruitment of a new physician to our practice Once primary care has been established with a particular OHS physician, all efforts are a rnade to assure recheck appointments are made with the same provider through closure of the injury Consistency in seeing the same physician is often essential in reinforcing modified duty restrictions and in assuring proper education of the patient regarding diagnosis, and injury prevention If there are occasions when a change in provider is requested or required, changes will be made based on employer approval We also work to assure that the same consistency is available with our therapy appointments I'oudre Valley Health System, as a JCAHO accredited Institution, must verify employee credentials upon hire, and assume responsibility to assure ongoing competency for all Staff Yearly standards are established for life safety training as well as lob specific professional competencies for essential functions and critical job skills for all job categories All OHS Physicians must be Board Certified in their area of specialty and [{ attain Level II accreditation within one year of employment Level II accreditation is a Colorado requirement and as such, when qualified physicians are recruited from outside the state they may be highly trained in Occupational Medicine, but require a period of time to train, study and take the accreditation exam At OHS our Medical Director, Or Holthouser assumes the role of physician mentor to the physician who might not be Level II accredited, to assist with training and to assure consistency of follow through With the treatment guidelines Only Level II physicians may rate cases for Impairment We understand the concern of both the City and School District in assuring only qualified physicians see their employees, but would hope that the restriction to only have Level It physicians see City and School District employees be modified to acknowledge the time required for an out of state physician to obtain accreditation, knowing we will assure adherence to -he treatment guidelines and provide ongoing mentoring while accreditation is sought ,Administrative staff: Jill Fitzgerald -OHS Practice Manger Jill has worked at PVHS for over seventeen years, performing various supervisory and director roles in rehabilitation, wellness, and occupational health For the past eleven years, Jill has been focused primarily on Occupational Health Services in the role of Q practice manager As the practice manager, Jill is responsible for fiscal management of Occupational a Health Services, staff supervision, and program development and evaluation Jill works closely with Dr Holthouser, our Medical Director, assisting in establishing operational procedures and protocols for OHS within Poudre Valley Health System Jill is the primary contact for client companies regarding Issues of service delivery, quality assurance, communications and customer service Jill is a graduate of the Occupational Therapy program at Colorado State University She has extensive experience in rehabilitation, community health, and occupational medicine in Colorado and Wisconsin Occupational Health Services QPoudre Valley Health System I I I I 0 Attachment d I 0 0 0 I 0 I 0 I I 10127/2007 Occupational Health Services Page 1 Medical Staff Directory Baer, Robert 2500 E Prospect Rd aFort Collins, CO 80525 Beard, David 2500 E Prospect Fort Collins, CO 80525 Benz, Robert J. 2500 E Prospect Fort Collins, CO 80525 Biggs, Bill D 2500 E Piospect Rd Fort Collins, CO 80525 Chamberlain, Saturo 2500 E Prospect Fort Collins, CO 80525 t Duncan, Kenneth 2500 E Prospect Ft Collins, CO 80524 Durbin, Mark 2500 East Prospect Road Fort Collins, CO 80525 Girard, George 3744 S Timberline Rd 4102 FortFort Collins, CO 80525 Grey, Sean G 2500E Piospect Rd Fort Collins, CO 80525 Hecker, Thomas M Ortho Center of the Rockies 2500 E Prospect Road QFort r Collins, CO 80525 Houghton, Michael 2500 East Prospect Fort Collins, CO 80525 Jackson, Wes P 2500 E Pi ospect Rd Fort Collins, CO 80525 p� Martin, Dale 2500 E Prospect Rd Fort Collins, CO 80525 McFerran, Mark 2500 East Prospect Road Fort Collins, CO 80525 of No. Colo , Eye Center 1725 E Prospect Fort Collins, CO 80524 Parker, Scott 415 E Monroe, Suite 101 Fort Collins, CO 80525 Trumper, Rocci 2500 E Piospect Road Fort Collins, CO 80525 Vandenhoven, Raymond 2500E Piospect Ave iy Fort Collins, CO 80524 Zimmerman, John 1217 Riverside Ave Fort Collins, CO 80524 Ph 970-493-0112 Ortho Fax 970-419-7150 Ph 970-493-0112 R Ortho Fax 970-203-0586 Ph 970-493-0112 C Ortho Fax 970-419-7150 Ph 970-493-0112 Ortho Fax 970-419-7150 Ph 970-493-0112 R Ortho Fax 970-419-7150 Ph 970-493-0112 R Ortho Fax 970-419-7150 Ph 970-493-0112 R Oriho Fax 970-419-7150 Ph 970-495-0506 C Pam Fax 970-223-6058 Ph 970-493-0112 R Ortho Fax 970-419-7150 Ph 970-419-7123 Ortho Fax 970-203-0586 Ph 970-493-0112 C Ortho Fax 970-419-7150 Ph 970-439-0112 Ortho Fax 970-203-0586 Ph 970-493-0112 R Ortho Fax 970-203-0586 Ph 970-493-0112 R Ortho Fax 970-203-0586 Ph 970-484-5322 C Opthamology/ Fax 970-221-4286 Ph 888-834-3583 R Chiropractor/ Fax 303-788-1618 Ph 970-493-0112 R Ortho Fax 970-419-7150 Ph 970-493-0112 R Ortho Fax 970-419-7150 Ph 970-482-7800 C Chiropractor/ Fax 970-482-7802 O ASYSTOC712\REPORTSV[ ILE MAINTENANCEWEDICAL S I AFF DIRECTORY_v7 1+#0029 9 I 1I I I I I a I 0 HO 0 I C n a Occupational Health Services PO Box 270890 1330 Oakridge Dr Fort Collins, CO 80525-0890 a Phone 970-495-8450 Fax 970-495-7664 October 27, 2007 FqNotification of Workers' Compensation Referral Rocci Trumper, MD Phone 970-493-0112 2500 E Prospect Road Fax 970-419-7150 Fort Collins CO 80525 PVH Occupational Health Services has contractual arrangements as the case managers for this QWorkers' Comp Ins r company's Workers' Compensation cases If changes in the work status are in dicated, the patient must obtain anew Work Status Report from our office as soon as possible If you have any questions, contact the Nurse Case Manager at (970) 495-8450 Mail or fax consult summary to the address at the top of the referral letter Referral Appointment 10/27/2007 Patient Phone j� Patient Name Late, Mary Address 100 Out to Lunch Patient ID 000-00-0099 Never never land, aDOB 1/1/1901 Date of Inlury 10/27/2007 Diagnosis 717 83 ACL Tear Reason for Referral Patient taped while running to a meeting - R/O ACL injury Current Work Capacity Unknown Primary Physician Michael Holthouser, MD Referred By Michael Holthouser, MD Q Employer Ext �i Claim Number Ins Contact Person Insurance Phone Ext Insurance Fax Ext I 3) Prevention Consider a job site analysis, development of modified -duty programs, or prevention programs as part of your workers' y comp cost -containment efforts Call 495-8450 for more Information on OHS' prevention services '. 4) Notification of changesr g '1 r 4 g Notify our office of the following rhanges or issues __toa Ia • New company name • New company address/phone number 6 • New company contact person for workers' comp • New workers' comp insurance carrier or policy number 749 Ir if #' • New service requests (I e , drug screen information, post -offer employment testing, audiometric exams, etc)j y t r JL • Customer service problems or concerns Occupational OCCUPATIONAL Hzealth HEALTH SERVICES A SERVICE OF POLIDRE VALLEY HOSPITAL �2 V� South Fort Collins Clinic 1330 Oakridge Drive Fort Collins, CO 80525 970-495-8450 EMPLOYER North Fort Collins Clinic INFORMATION 1025 Pennock Place, Suite 121 Fort Collins, CO 80524 970-495-8450 Loveland Clinic OCCUPATIONAL HEALTH SERVICES Medical Office Building at Medical Center of the Rockies A SERVICE OF POLIDRE VALLEY HOSPITAL 2500 Rocky Mountain Avenue, Suite 330 Loveland, CO 80538 www pvhs org 970-495-8450 c2m7 Welcome Welcome to Occupational Health Services, a service of Poudre Valley Hospital Thank you for choosing OHS as your designated provider for workers' compensation injury treatment and case management services As your designated provider, our goals are to • deliver prompt, high quality care to your injured workers • communicate effectively so that you are informed at each stage of treatment • return your injured employees to their pre -injury work status as soon as possible • provide you with additional assistance with prevention and pre - placement services On -The -Job Injuries The following checklist can assist you with the steps that should be followed when a work -related injury occurs 1) Notify your employees That you have designated a provider for workers' comp injury treat- ment Sample notification forms are available to assist you OHS also provides employee ID cards (at no cost) for your use, as well as the poster required by the state of Colorado Call 495-8450 2) When an injury occurs • For emergency care after hours, direct your employees to either - Poudre Valley Hospital Emergency Department, 1024 S Lemay Ave , Fort Collins (south side of PVH off Lemay Avenue) - Harmony Urgent Care Center, 2127 E Harmony Road, Fort Collins (open 9 am to 9 pm) - Medical Center of the Rockies Emergency Department, 2500 Rocky Mountain Ave , Loveland (east side of MCR) Our OHS staff will begin the case management review after this initial visit, and employees will be directed to receive follow-up treatment in the OHS clinic Employees will receive a Work Status Report to return to you fol- lowing their visit to the PVH ER, the MCR ER, or Harmony Urgent Care The OHS staff will discuss this report with you when they call you back following each visit (or you may prefer to have the report faxed to you and then call us with any questions) • For non -emergency care, walk-in services are available at the OHS clinics from 8 a m to 5 p m Monday through Friday Please call 495-8450 to notify the clinic that an injured employee has been sent This will also serve as your authorization for us to treat your employee • When injuries do not require same -day treatment, please call the OHS clinic to schedule an appointment This would include repetitive injuries, for example • Employees must report an injury in writing to you within four days of the injury's occurrence Failure to do so can result in the loss of one day of compensation for each day of delay, except when the injured worker is physically or mentally unable to report the injury • Complete the First Report of Injury form (provided by your workers' comp insurance carrier) and send it to your insurer immediately after the injury occurs The law requires you to file the First Report within 10 days of your employee's notification • If you have any doubt about the events or the cause of the injury, or whether it should be covered by workers' compensa- tion, file the First Report with your insurer and attach a letter explaining the circumstances surrounding the alleged incident • Communicate regularly with your injured employee, your claims adjuster, and the OHS clinic • Provide modified duty work whenever possible, following the physician's guidelines Modified duties should be temporary and can include - Same job, reduced hours, same pay rate - Different or modified job, same hours, same pay rate - Different or modified job, reduced hours, same pay rate - Different or modified job, same hours, reduced pay rate - Different or modified job, reduced hours, reduced pay rate 0 OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL South Fort Collins Clinic 1330 Oakridge Drive Fort Collins, CO 80525 970-495-8450 North Fort Collins Clinic 1025 Pennock Place, Suite 121 Fort Collins, CO 80524 970-495-8450 Loveland Clinic Medical Office Building at Medical Center of the Rockies 2500 Rocky Mountain Avenue, Suite 330 Loveland, CO 80538 970-495-8450 Occupational Health Services ONLINE SOLUTION. . FUTURE SOLUTIONS NOW OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs org Online Service Please fill out the form, and send to Occupational Health Services Attn Online Service Access 1330 Oakridge Drive, Fort Collins, CO 80525 or Email ohsonline@pvhs org OHS offers a way to view and track your employee's information We provide you with a clinic -approved, third -party software program that gives you access 24/7 to an Internet view of your worker's injury and treatment details The data are interactive, and provided through a secure, encrypted connection Sign up today, via email ohsonline@pvhs org, or mail to the above address to get your online service started today What can I see online? • Employee Work Status • Employee Restrictions • Review past, present, and future appointments • Generate Trend Analysis Report • All activities are in real-time Find out about your employees before they return to work • 24/7 Internet Access © o 0 0 o a o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Please fill out the following information for Occupational Health Services' Online Service. Company Name (Access to company's information will be set up to view the entire company as a whole, unless specifically instructed not to ) Address City, State, Zip Phone Contact Name Contact Email Address a o 0 0 0 0 o a o c o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 IlljtlrA Occupational Health Services, a service of Poudre Valley Hospital, is committed to help employers prevent work -related injuries and maintain a healthy work force Our continuum of services Includes treatment, rehabilitation, case management, screening/testing, health promotion and education w MUIbeM/C01G E,tt R88 N 4 s o.ma sg� ._lT? � v�soa�i na ®a a U � 3 ,s fPff S `- 4j tm.n Boa m,.,m 1 c,�xmm M.a Back Safety Training 45-60 mmute educational session focusing on anatomy, body mechanics and wellness to prevent back injuries Includes Interactive demonstration and exercises $75 00 per hour Ergonomic Training 45-60 minute training geared towards workers who perform repetitive daily tasks using their upper extremi- ties Included hands-on activities related to workstation setup, Importance of body mechanics and stretches $75 00 per hour Job Site Analysis Consists of a visit to the job site to analyze job -specific activities and Identify risk factors Recommendations are given concerning adaptations and corrective actions to reduce musculoskeletal injuries $85 00 per hour Customized Injury Prevention Education Tailored to specific job sites, upon request Requires a therapist to evaluate on -site job tasks, exposures, and employee behavior For information, call (970) 495-8465 www pvlhs org OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs Oi g *South Fort Collins Chmc O North Fort Collins Clinic 0 Loveland CLnic 1330 Oakndge Drive 1025 Pennock Place, Suite 121 Medical Office Building at Medical Center of the Rockies Fort Collins, CO 80525 Fort Collins CO 80524 2500 Rocky Mountain Avenue, Suite 330 (970) 495-8450 (970) 495-8450 Loveland, CO 80538 (970) 495-8450 c aa/07 E 3004 Page is too large to OCR. M Mike Asmus, R N -Team Leader and Case Manager Mike's experience at PVHS spans thirty one years and three departments providing him wealth of experience and skills in managing work -related injuries/Illnesses His ER Qa { nurse background is essential for his role in education of our Medical Assistant staff in patient care skills As Poudre Valley Hospital's Employee Health Nurse for nine years, Mike gained valuable experience and knowledge in all aspects of Workers' Compensation risk management for a large self -insured entity From this experience he is able to provide employers with educational programs in such topic as Blood Borne Pathogens and administration of immunization programs Over ten years ago, Mike joined the OHS Department in the role of RN Case Manager His responsibilities include evaluating and monitoring the progress of care for injured workers, obtaining authorization for services recommended by the treating physician, and coordinating case reviews either in the context of formal meetings or in one-on-one sessions with parties to a claim Kacee Bagley —Case Manager Kacee is a 2003 graduate of University of Northern Colorado with a degree in Kinesiology and Sports Medicine She joined the OHS department shortly after her graduation as Coordinator of our post offer employment testing service Kacee's last two years in OHS have been in our case management area where she works closely with Mike Asmus and the physicians to monitor cases and assure timely communications with employers, insurers and specialists Kacee's responsibilities include evaluating and monitoring the progress of the care for work -injured employees, obtaining authorization for services recommended by the treating physician, and coordinating case reviews either in the context of formal meetings or in one-on-one sessions with parties to a claim to assure authorizations are expedited and communicated clearly to all parties OHS Rehabilitation Staff. Working solely with the industrial population, our rehabilitation staff provides services including work -injury rehabilitation, employment testing, job -site analysis and injury prevention training The rehabilitation staff at OHS is a top-notch team of physical, occupational, and massage therapists, and an exercise and wellness specialist ho work a closely with the providers, patient, and the employer to assure treatment is progressing rapidly and addressing the essential physical demands of the individual's job description They have experience and expertise in evaluating work -injuries, assessing the impact the injury has on specific work environments, and in recommending and providing treatment to allow the worker to be responsible for his/her own exercise program, body mechanics and preventive knowledge The OHS rehabilitation staff includes 5 Licensed Physical Therapists 3 Registered Occupational Therapists (One Certified Hand Therapist) 1 Coordinator of Post Offer Testing 1 Massage Therapist 1 Rehabilitation Tech i Two of our physical therapists, Paul Braunlln and Heather Kenney are trained In conducting functional capacity evaluations Our exercise specialist and all therapists are trained and qualified to conduct our employment testing protocols (WorkSTEPS ) Occupational Health Sernces F Poudre Valley Health System Page is too large to OCR. The Occupational Health program is designed to assist you with the prevention, treatment, and management of work -related injuries I i � 1� W / / �J cE< Our goals are to: • Deliver prompt, quality care to injured workers • Communicate with the client company at each stage of treatment • Return injured employees as quickly as possible to their pre -injury work status • Provide area employers with additional assistance in the areas of prevention and pre -placement services Occupational Injury Management • Walk-in/urgent care • Minor injury (trauma) treatment • Treatment of work -related injuries & illnesses • Comprehensive, in-house nurse case management • Expertise in toxic exposures, epidemiology, indoor air quality • Delayed recovery treatment • Physical, occupational, and massage therapies on -site Diagnostic Services • Pulmonary function testing • Comprehensive blood testing • EKG (electrocardiogram) • Nerve Conduction Tests • EMG Tests (electromyogram, for muscles' electrical activity) • Pain Management & Injections • Audiogram (booth) es I I l Occupational Health Services, a service of Poudre Valley Hospital, is committed to helping employers prevent work -related Injuries and maintain a healthy work force Our continuum of services includes treatment, rehabilitation, case management, screening/testing, health promotion and education v Job Site Analysis Consists of a visit to the job site to analyze job -specific activities, identify risk factors, and evaluate physical requirements of the job Includes photographing body positions/equipment used to perform job tasks, and measuring/weighing objects to determine the essential job functions Recommendations are given concerning adaptations and corrective actions that could alleviate cumulative trauma and prevent injuries at the job site Cost $75 00/hour WorkSTEPS Post -Offer Employment Testing Tests are administered post -offer, with employment being contingent upon passing the essential job functions and/or medical risk criteria for the position Comprehensive Test 2-hour post -offer test which gathers data on more than 30 measures to determine a candidate's ability to safely perform job -specific activities Gives a "capable" or "not capable" recommendation based upon ability to meet job -specific requirements, or medical risk criteria The musculoskele- tal information can be used by medical providers to establish pre -injury status to avoid paying for rehabilitation services that are fraudulent or not based upon achievable functional goals Cost $110 00 Basic Back Evaluation 30-45 minute post -offer evaluation to assess current cardiovascular fitness, safe lifting capacity, and job specific activities Does not include musculoskeletal evaluation Cost $50 00 When you choose Occupational Health Services to perform drug/alcohol testing, you are assured that stringent chain -of -custody steps are carefully followed These Include DOT, and non -DOT collections, as well as MRO services upon request For more Information, call 970-495-8450 Conventional Lab Testing • Requested by employers requiring a complete drug screen, using lab analysis and MRO services as required • DOT testing procedures are followed on all collections • Typically used for pre -employment, post -accident, random, and reasonable suspicion situations • OHS uses Quest/SmithKline Beecham as its SAMHSA-certified laboratory • Results are available online with employer -specific passwords within 24 - 48 hours • OHS can also collect and send specimens to an employer's designated lab when kits, chain of custody forms, and mailing supplies are provided at the time of collection On -Site Drug Screening • Requested by employers requiring immediate results for non -DOT pre employment or post -accident screening • RESULTS ARE AVAILABLE WITHIN 15 — 30 MINUTES • Non -negative results are sent to SAMHSA-certified lab to confirm analysis • Offers the benefit of immediate finding that job applicants and/or employees are drug -free Breath -Alcohol Testing • DOT -approved screening to measure concentration of alcohol in the body • Nearly 100% accurate, all positive tests are repeated after 15 minutes to confirm results • Results are available immediately for the employer's designated contact II11�II-11 I)IctomulIloll IM-11 1 $1 1111 Occupational Health Services, a service of Poudre Valley Hospital, is committed to help employers prevent work -related injuries and maintain a healthy work force Our continuum of services Includes treatment, rehabilitation, case management, screening/testing, health promotion and education m,....i..-1.i Ra ry Hwy 34 Vlw Exit Back Safety Training 45-60 minute educational session focusing on anatomy, body mechanics and wellness to prevent back Injuries Includes Interactive demonstration and exercises $75 00 per hour Ergonomic Training 45-60 minute training geared towards workers who perform repetitive daily tasks using their upper extremi- ties Included hands-on activities related to workstation setup, Importance of body mechanics and stretches $75 00 per hour Job Site Analysis Consists of a visit to the job site to analyze job -specific activities and Identify risk factors Recommendations are given concerning adaptations and corrective actions to reduce musculoskeletal Injuries $85 00 per hour Customized Injury Prevention Education Tailored to specific job sites, upon request Requires a therapist to evaluate on -site job tasks, exposures, and employee behavior For information, call (970) 495-8465 www.pvhs.org OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs or +South Fort Collins Clinic O North Fort Collins Clinic C Loveland Clinic 1330 Oakridge Drive 1025 Pennock Place Suite 121 Medical Office Building at Medical Center of the Rockies Fort Collins, CO 80525 Fort Collins, CO 80524 2500 Rocky Mountain Avenue, Suite 330 (970) 495-84',0 (970) 495-8450 Loveland, CO 80538 (970) 495-8450 a 04/07 E 3004 OCCUPATIONAL HEALTH SERVICES A 5ef v,, Of Poudre Valley Hospital October 27, 2007 Mr Lance Murray, Risk Manger Project Manger Proposal P1089 City of Fort Collins 215 N Mason Fort Collins, CO 80524 Dear Mr Muray, It is with great pleasure that Occupational Health Services (OHS) as a service of Poudre Valley Health System submits a response to Proposal No P 1089, for the provision of medical treatment to employees injured in the course of employment, and other such medical and preventive programs as required by the City of Fort Collins and Poudre School District as one of its designated medical providers Our Vision as a System is to provide world class health caie to our patients and the community we serve We would welcome the opportunity to continue our partnership with the City and the School District to provide its workers with optimal injury care in the most expedient and cost effective manner possible to assure a rapid return to work Occupational Health Service's comprehensive program concentrates not only on aggressive injury management, but also on prevention, education and wellness The key dimension of our program in providing quality injury management is the high priority we place on communication between the injured worker, the employer, the claims admmistiator and OHS which assures the best possible medical care for the injured employee As an expanding System we feel we aie able to offer the employees ofthe City and the School District comprehensive service delivery and ease of access OHS offer s a new clinic location in Loveland and two clinics in Fort Collins After hours and weekend care for contracted client's mjuied workers is available at Harmony Urgent Care Center, Medical Center of the Rockies and Poudre Valley Hospital Should you have any questions, please do not hetiitate to contact me at (970) 495-8457 Sincerely, L,-). Practice Manageh( OLcupational Health A Magnet Hospital for Nursing Excellence 1330 Oakndge Drive • Fort Collins, Colorado 80525 • (970) 495-8450 • Fax (970) 495-7664 • vvvvvv pvhs org Office Hours and Appointments Our three OHS Clinics are open Monday through Friday We sched- ule appointments to give you better service if you are unable to keep an appointment, kindly notify us 24 hours in advance If you need care when the OHS Clinics are closed, you may go to • Poudre Valley Hospital Emergency Department, 1024 S Lemay Avenue, Fort Collins (open 24 hours a day) • Harmony Urgent Care Center, 2127 E Harmony Road, Fort Collins (open 9 am to 9 pm, call for holiday hours) • Medical Center of the Rockies Emergency Department, 2500 Rocky Mountain Avenue, Loveland (open 24 hours) For more information about your rights under workers' compensa- tion laws, contact your employer, your workers' compensation insur- ance company, or the state Department of Labor (1-888-390-7936) Prescription refill line- 970/495-8464 Allow 48 hours for prescription refill prior to picking up your prescription 0 OCCUPATIONAL HEALTH SERVICES A SERVICE OF POuDRE VALLEY HOSPITAL South Fort Collins Clinic 1330 Oakridge Drive Fort Collins, CO 80525 970-495-8450 North Fort Collins Clinic 1025 Pennock Place, Suite 121 Fort Collins, CO 80524 970-495-8450 Loveland Clinic Medical Office Budding at Medical Center of the Rockies 2500 Rocky Mountain Avenue, Suite 330 Loveland, CO 80538 970-495-8450 OccupatRonal Health PATIENT INFORMATION OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs org Occupational Health Services (OHS) Is dedicated to the treatment and prevention of work -related Injuries and illnesses, pre -employment drug screening, and pre -placement physicals. Our goals are to provide you, our patient, with the highest quality of care, to help you recover and return to your pre -Injury work status as soon as possible Our Staff The OHS Staff includes doctors, nurses, and nurse practitioners with years of experience in occupational medicine, and a knowledgeable, caring support staff who can answer your questions and help you with your work -related injury or illness In addition, physical and occupational therapists who specialize in work -related injuries can see you when you need rehabilitation treatments Designated Medical Provider As the designated medical provider for your employer, it is OHS' responsibility to communicate with your employer about your injury and your ability to work We remain neutral about the details of your claim Our role as the designated provider should not be con- fused with the "company doc " OHS must authorize referrals to other doctors for you, please note that workers' compensation insurance may not cover unauthorized visits or services (such as testing, specialist visits) if you do not have a referral OHS will continue to coordinate your care until our physician deter- mines that your injury(ies) has reached "maximum medical improve- ment" (MMI) Maximum medical improvement means that the injury or condition causing your disability has become stable and no further medical treatment will improve the condition Work Status Report At the end of every visit, you will receive a Work Status Report This indicates any physical limitations which you should consider on the job and at home You will receive two copies of the report - one for you and one for your employer It is your responsibility to discuss these limitations with your employer Based on this information, your employer will decide if work within these limitations is available It is with your welfare in mind that we return you to your work- place and recommend modified duty, as soon as medically possible Long absences from work can decrease physical conditioning and self-esteem, and increase social and family problems Your Responsibilities a Keep all appointments • Ask us if you don't understand your diagnosis, treatment plan, etc • Immediately after each OHS visit, provide your employer with a copy of your work status report • Contact your claims adjuster about any questions regarding your workers' compensation benefits • Wear comfortable clothing when you have any therapy (rehab) appointments In consideration of others, please do not wear perfume, colognes, lotions, they may trigger allergies or respiratory conditions in other patients or staff Our goal: to return you to your pre -injury work status as soon as possible. ��� OCCUPATIONAL H � ALTH S � IZVIC : S A SERVICE OF POUDRE VALLEY HOSPITAL OCCUPATIONAL HEALTH SERVICES South Fort Collins Clinic Open 8 00 am — 5 00 pm Mon -Fri Walk-in Patients Welcome North Fort Collins Clinic Open 8 00 am — 5 00 pm Mon -Fri Walk-in Patients Welcome Loveland Clinic Open 8 00 am — 5 00 pm Mon -Fri Walk-in Patients Welcome • Work Injury Medical Care • Walk-in Clinic for Work Injuries (see hours above) • Diagnostic Services • Physical Exams • Injury Prevention Services • Vaccinations • Physical Therapy • Occupational Therapy • Drug & Alcohol Testing • Services Provided to Contracted Employers and Their Employees • Employment Testing For after-hours care and on weekends, please use HARMONY URGENT CARE CENTER Open for OHS patients 5 00 pm — 9 00 pm M—F and weekends 9 00 am — 9 00 pm (call for holiday hours) • Diagnosis & Treatment of Minor Injuries • Sprains, Strains, Aches, Minor Fractures • Staffed by Physicians & Nurse Practitioners • Walk-in Clinic, No Appointment Necessary P®U®RE VALLEY HOSPITAL EMERGENCY DEPARTMENT 1024 S Lemay Avenue, Fort Collins Open 24 hours • Diagnosis & Treatment of Major & Minor Injuries • Staffed by Physicians & Nurse Practitioners MEDICAL CENTER OF THE ROCKIES EMERGENCY DEPARTMENT 2500 Rocky Mountain Avenue, Loveland Open 24 hours • Diagnosis & Treatment of Major & Minor Injuries • Staffed by Physicians & Nurse Practitioners r ({/(\�'��� 11�r`JG/t I1� ��{jJ—J�t�e • j-1I I1�^j. • (\(\}�/�/��'II�I��\\'G'1I'II� �II^'I/ ^ ��jL�'J.j��� • .),�ju�SIII n`/���,) ����/J\� �\\j\Y/�//J a ��1/ry�ja `�/'ti]�) + Y a r -PCC �J .CJ w�G.=�V(J V`�U C]C� ���VLi V�F�va V ��LJV iti♦r �'�' . • •.`�..��a�uQ¢r�� ap�'i�o��a� ea��aga �u��o�ad � � � � � .- .,, ..G, E Elizabeth St. Garfield St. ER ai ai Q rn Q T Oakridge cc c O c m U E y E t\ I F— I (map not to scale) ® OHS North 1025 Pennock Place (970)495-8450 Fax (970) 495-7620 In FMC building, 2 blocks north of PVH At NORTH Drake Rd. Mulberry / CO 14 Prospect Rd. Horsetooth Rd. Harmony Rd. r, -d D: � U rn a N OHS South 1330 Oakridge Drive (970)495-8450 Fax (970) 495-7620 2 blocks east of Harmony & Lemay Exit 269 Crossroads Blvd. XX ai a ER c O Q@ N g WiaOd Y V ~ O r 34 °C 5 Exit 265 ❑ Harmony Urgent Care Center 2127 E Harmony Road (970)297-6250 Harmony & Timberline Follow Urgent Care signs, use Ambulatory Care entrance (east side) p Loveland Clinic Medical Office Building at Medical Center of the Rockies 2500 Rocky Mountain Avenue (970)495-8450 Fax (970) 495-7620 C 04/0 E 3004 R aOHS Support Staff: Q The key to our provision of excellent customer service is our outstanding support and clinic staff We have found that we are better able to meet the needs of our clients and patients when we cross train our staff to do a number of tasks to assure service delivery in the event of unexpected staffing problems or patient volume In addition to their skills in patient Intake and triage, OHS clinic staff is certified in conducting drug and alcohol testing, administering Immunizations, vaccines, and assisting with procedures as Qrequested 3. Copy of Fee schedule (Attachment G and H) OHS fees for injury management, testimony, Impairment, etc are billed at the rate outlined in Rule 18 of the Workers' Compensation Rules of Procedure Included in (Attachment G) are the current 2007 fees for Injury treatment as billing by OHS, and copies of letters outlining fees and payment requirements for deposition, testimony and DIMES In January 2008, there will bean Increase in the fee schedule as determined by the Colorado Legislature, this Increase is expected to be two percent (2% ) A revised fee schedule will be forwarded at that time for Inclusion in the provider agreement if OHS is awarded the proposal bid Fees not covered under the fee schedule for non Injury service such as post offer testing, Fit for Duty testing, DOT physicals, etc are included in Q (Attachment H) and are listed at 2008 rates A two percent (2%) prompt payment discount will be given for payment received within two weeks of billing 4. Description of Facilities aLoveland OHS Clinic: Monday -Friday 8.00AM-5:OOPM ` Located in the Medical Center of the Rockies campus, at 2500 Rocky Mountain Ave, Suite 330 this new facility offers a comprehensive array of state of the art diagnostic and treatment services including all radiology, imaging and laboratory services Physical therapy is offered onsite within the OHS clinic Drug Collection and Breath Alcohol Testing certified staff is on site Oakndge OHS Clinic: Monday -Friday 7.00AM-6:OOPM Located at 1330 Oakridge Drive in Fort Collins Physical, Occupational and Massage therapy are provided on site by OHS staff Post offer testing, Fit for Duty testing and Functional Capacity Evaluations provided on site Patients are referred to the Harmony Campus for radiology, laboratory and other diagnostic services Drug Collection and Breath Alcohol Testing certified staff is on site Pennock OHS Clinic. Monday -Friday 8.00AM-5:OOPM Located just north of PVH at 1025 Pennock Place, this clinic has its own Physical therapy services on site as well as x-ray within the same building Additional imaging and laboratory services are available PVH Drug Collection and Breath Alcohol Testing certified staff is on site Our clinics are each set up to address urgent care situations in our procedure rooms such as, laceration repairs, eye injuries requiring irrigation and Slit Lamp examination, and exposure to blood or body fluid requiring an immediate blood draw from source Occupational Health Services t Poudre Valley Health System OCCUPATIONAL HEALTH SERVICES A Service of Poudre Valley Hospital Fort Collins Colorado www pvhe org On behalf of our entire staff, we would like to extend to you a warm welcome We are at your service and are committed to helping you make a full recovery The following Information will be useful to help manage your care at Occupational Health Seances Your Provider today Your Medical Assistant/RN today Cese Manager Refill line for prescriptions — 970-495-8464 (please allow 48 hours for prescoprons to be filled) Should you need to cancel or change ar oointments or have any questions or concerns please call us at 970-495-8450 We are open from 8 - 5 Monday through Friday If you have emergency needs during non -business hours, please use Harmony Urgent Care Center or PVH Emergency Department and we will follow up with your care the following business day We appreciate the opportunity to serve you please do not hesitate to call if you have questions 12-05 6-320 Page is too large to OCR. ''e DRE VALLE ALTH SYSTE Occupational Health Services PATIENT INFORMATION Name Social Security Number Primary Care Physician Marital Status S/M/D/W (Please Print) Number of Children OCCUPATIONAL HISTORY. Employer Job Title Please describe the physical demands of your lob How long have you been with this employer? Do you have a second lob? ❑Yes ❑ No If yes, Please describe Date of Birth Date of Injury Height __ & Weight List all prescriptions and non-prescription medicines, herbals, vitamins and dietary supplements you take Include dose and how often you take the dose Name Dose (number of mg) How often Do you have any allergies or reactions to medications? ❑Yes ❑No If Yes, please describe below Medication Reaction Other allergies Please Specify (i a latex, metals, wheat, yeast and egg whites) REVIEW OF SYSTEMS: Please check any symptoms you have had recently ❑ None ❑ Poor sleep ❑ Nausea ❑ Hearing Loss ❑ Ringing in Ears ❑ Difficulty breathing ❑ Chest pain ❑ Abdominal pain ❑ Persistent cough - For how long? _ ❑ Loss of bowel control ❑ Weakness ❑ Unexplained fever —Temp ❑ Anxiety/Depression ❑ ,Arthritis ❑ Unexplained weight change - Please describe ❑ Bloody, black, or tarry stools ❑ Other Females only Is there a possibility you could be pregnant? ❑Yes ❑ No Are you currently breast feeding? ❑Yes ❑ No PAST MEDICAL HISTORY: Please list any general medical problems which you have had ❑ None ❑ Heart disease ❑ Diabetes ❑ High blood pressure ❑ Clotting problems ❑ Glaucoma ❑ Ulcers/Gerd ❑ Cancer ❑ Asthma ❑ Other ❑ Kidney problems Have you experienced any physical problems in the past involving the same area of the body as this injury? ❑Yes ❑ No If yes, please describe Have you ever had any prior on the job injuries with any employer in the past? ❑Yes ❑ No If yes, please, describe the injury, list the doctor, date, and duration of time off of work Injury Doctor Date Time loss Patient Identification Please complete other :side. OCCUPATIONAL HEALTH SERVICES an 7/2007 SHARED H/HMC/ADMIN/OCCUPATIONAL HEALTHIOHSlOHS FORMSIINJURY HISTORY #306 PATIENT INJURY HISTORY Please list all surgeries you have had in the past ❑ None SOCIAL HISTORY: What are your leisure/recreational activities? Do you smoke? ❑ Never ❑Yes ❑ No If yes, Quantity per day Do you drink alcohol? ❑ Never ❑Yes ❑ No If yes, How many drinks per week Do you use non prescription/recreational drugs ❑ Never❑Yes ❑ No Kind FAMILY MEDICAL HISTORY: Please list any significant medical conditions that run in your family ACTIVITIES OF DAILY LIVING: Are there any non -work activities that you are unable to do now? (e g (Please explain) How long years eating, walking, grooming, riding in a car, etc ) EDUCATION ASSESSMENT KEY: USE THIS "KEY", PLEASE MARK THE LOCATION OF Education Needs Do you or your family need YOUR PAIN information on the following? ❑ None /ll Stabbing XXX Burning 000 Pins/Needles ❑ Current illness ❑ Medications =_= Numbness «< Aching ❑ Diet/Nutrition El Equipment ❑ Home Care ❑ Rehab techniques ❑ Treatments/Procedures ❑ Personal hygiene F=ont Back ❑ Community Resources ❑ Other ft LeLeR ❑ Access to Follow-up care Right Right Preferred Learning Method. ❑ None ❑ Reading ❑ Listening ❑ Demonstration ❑Video Barriers/Limitations: Check all that apply ❑ ❑ Language ❑ Culture ❑ Cognitive ❑ Vision ❑ Physical ❑ Religion ❑ Emotional ❑ Read/write ❑ Financial ❑ Hearing ❑ Desire/Motivation ❑ Other None Do you have religious beliefs/rituals, cultural values/ practices we need to know about that would aid in your care? ❑ None ❑Yes ,Please explain f Patient Signature Date: I' Provider Review Date OCCUPATIONAL HEALTH SERVICES PATIENT INJURY HISTORY Dominant Hand ❑ Right ❑ Left ❑ Sudden onset of pain ❑ Gradual or delayed onset of pain Today's Pain Rating: No Severe Pain 1 i 3 I 4 i 6 7 i 9 Pain PLEASE RANK YOUR PAIN ON THE SCALE Patient Name: Unit #: 12/13/2006 SHARED H/HMC/ADMIN/OrrUPATIONAL HEALTH/OHS/OHS PoRMSIINJURY HISTORY#306 D POUDRE VALLEY HEALTH SYSTEM iVOO TICS= OO F IME31i; " PRfi,CTICES (Version 02022007.2) This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information. Please Review It Carefully to Protect Your Rights. Your health information is personal, and Poudre Valley Health System (PVHS) is committed to protecting it Maintaining accurate and confidential health information is critical to our ability to provide you with quality care and to comply with certain laws. This notice will describe the ways in which your health information may be used and disclosed, and also describes your rights and obligations regarding your health information Poudre Valley Hospital (PVH) and Medical Center of the Rockies (MCR) are part of PVHS Together they have joined with PVHS and other health professionals to provide and manage your care and information about your care, as allowed by regulation PVH and MCR have formed an organized health care arrangement with the members of their medical staffs and other independent professionals for the purpose of health care delivery within PVHS PVHS has ownership relationships with other types of providers, as well, and these other providers are termed "Affiliated Covered Entities." This means that your health information may be shared by PVHS, the Organized Health Care Arrangement, and PVHS' Affiliated Covered Entities, in connection with providing your services and treatment (and payment for services), as well as other operational activities of these providers In this Notice, the terms "we" and "our" refer jointly to PVHS, PVH and MCR, members of the PVHS Organized Health Care Arrangement, and PVHS Affiliated Covered Entities 1. We Are Legally Required to Safeguard Your Protected Health Information by: A. Maintaining the privacy of your health information, also known as "protected health information" or "PHI;" B. Providing you with this Notice, and C. Complying with this Notice. II. Future Changes to our Practices and This Notice. We reserve the right to change our privacy practices If a change in our practices is important, we will revise this Notice You may obtain a copy of any revised Notice by contacting the PVH main line at 970495- 7000 and asking for the Privacy Office; contacting the MCR main line at 970-624-2500 and asking for the Privacy Office, picking one up in an admitting area within PVHS; or from our web site, www pvhs org Ill. How We May Use and Disclose Your Protected Health Information. The law requires us to have your written authorization for some uses and disclosures. In other circumstances, the law allows us to use or disclose PHI without your written authorization Some types of PHI, such as drug and alcohol abuse patient treatment information, HIV test results, mental health information, and genetic testing results, may be subject to greater protection of your privacy. In general, we disclose a minor patient's PHI to a parent or guardian 65-011" PSHP #694 1 W06 A 1 o-060 A. Uses and Disclosures for Treatment, Payment and Health Care Operations. PHI may be used or disclosed in the following situations: • To provide treatment to you, we may use or disclose your PHI to physicians, nurses, and other health care personnel who are involved in your care • To contact you as a reminder that you have an appointment for treatment, to tell you about or recommend possible treatment options or alternatives, or about health -related benefits or services that may interest you, we may use and disclose your PHI o To get paid for treatment provided to you we may use or disclose your PHI to your insurance earner We may also use or disclose your PHI to our business associates who perform billing and claims processing services G To operate PVHS we may use or disclose your PHI to evaluate the quality of care you received, to evaluate the performance of those involved with your care or to evaluate other business functions We may also provide your contact information (such as name, address and phone number) and the dates you received services from us, to the PVH Foundation, which handles hospital (system) fund-raising efforts B. Uses and Disclosures That Require Us to Give You the Opportunity to Object. If you do not object, we may include your name, location in our facility and general condition in: o A patient directory used for requests by those who ask for you by name If you do not object, we also disclose information from the directory and your religious affiliation to clergy who visit the PVHS facilities o We may provide relevant portions of your PHI to a family member, friend or other person you indicate is involved in your health care or in helping you get payment for your health care In an emergency or when you are not capable of agreeing or objecting to these disclosures, we will disclose PHI as we determine is in your best interest, but will tell you about it after the emergency, and give you the opportunity to object to future disclosures to family and friends 6 We may also disclose your PHI to persons performing disaster relief notification activities C. The law also allows us to disclose PHI without your written authorization in the following situations: ® When Required or Authorized by Law. We disclose PHI when we are required to do so by federal, state or local law Tlus may include the release of PHI to a law enforcement official o For Public Health Activities. We disclose PHI when we report the occurrence of certain injuries, diseases, or adverse reactions to a drug or medical device • For Reports About Victims of Abuse, Neglect or Domestic Violence. We disclose your PHI in these reports if we are required or authorized by law to do so, or if you otherwise agree e To Health Oversight Agencies. We provide PHI as requested to government agencies who have authority to audit or investigate our operations G For Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we disclose your PHI in response to a subpoena or other lawful request, but only if efforts have been made to tell you about the request or to obtain a court order that will protect the PHI requested o To Coroners, Medical Examiners and Funeral Directors. We disclose PHI to facilitate the duties of these individuals o To Organ Procurement Organizations. We disclose PHI to facilitate organ donation and transplantation o For Medical Research. We may disclose your PHI, without your written authorization, to medical researchers who request it for approved medical research projects Such disclosures must be cleared through a special approval process Researchers, are required to safeguard any PHI they receive o To Avert a Serious Threat to Health or Safety. We disclose your PHI to someone who can help prevent a serious threat to your health and safety or the health and safety of another person or the public o For Special Government Functions. We disclose your PHI, for example, to federal officials for intelligence and national security activities that are authorized by law, or so that they may provide protective services to the President or foreign heads of state or conduct special investigations authorized by law (Version 02022007 2) • To Workers' Compensation or Similar Programs. We provide your PHI to these programs in order for you to obtain benefits for work -related injuries or illness IV. Other Uses and Disclosures of Your Protected Health Information. Other uses and disclosures of your PHI that are not covered by this Notice or the laws that apply to us will be made only with your written permission You may revoke that permission, in writing, at any time V. Your Rights Related to Your Protected Health Information: A. The Right to Request Limits on Uses and Disclosures of Your PHI. You may ask us to limit how we use and disclose your PHI, as long as you are not asking us to limit uses and disclosures that we are required or authorized to make. Requests must be submitted in writing to our Medical Records Department We are not required to agree to your request, but if we do, we will put it in writing and will abide by the agreement except when you require emergency treatment B. The Right to Choose How We Communicate With You. You may ask that we send information to you at a specific address (for example, at work rather than at home) or in a specific manner (for example, by e-mail rather than by regular mail, or never by telephone). We may agree to your request as long as we believe it is reasonable and we determine that it would riot be disruptive to our procedures. You must make any such request in writing to our Medical Records Department. C. The Right to See and Copy Your PHI. Except for limited circumstances, you may look at and copy your PHI if you ask in writing. Any such request must be subrrutted to the Medical Records Department where you received your services. They will respond to your request within 30 days, if available on site or 60 days if the PHI is kept offsite If extra time is needed we may extend the response time by an additional 30 days In certain situations we may deny your request, but if we do, we will tell you in writing of the reasons for the demal and explain your right to have the denial reviewed. If you ask us to copy your PHI, a fee may be charged for the costs of copying, mailing or other supplies associated with your request. Alternatively, we may provide you with a summary or explanation of your PHI, as long as you agree to that and to the cost of providing the summary in advance. D. The Right to Correct or Update Your PHI. If you believe that the PHI we have about you is incomplete or incorrect, you may ask us to amend it Requests must be submitted in writing to the Medical Records Department where you received your services, and tell us why you think the amendment is appropriate We will act on your request witlun 60 days (or 90 days if extra time is needed), and will inform you in writing whether we agree to amend or not. We may deny your request if you ask us to amend information that • was not created by us; • is not part of the Pb1I we keep about you; • is not part of the PHI that you would be allowed to see or copy; or • is determined by us to be accurate and complete. If we deny your request, we will tell you in writing how to submit a statement of disagreement or complaint, or to request inclusion of your original amendment request in your PHI E. The Right to Get a List of Your PHI Disclosures We Have Made. The list will not include disclosures made for our treatment, payment and health care operations purposes, those made directly to you, your family or friends or through our facility directory, or for disaster notification purposes The list will not mclude disclosures made with your written (Vernon 02022007.2) authorization, for national security purposes, to E law enforcement personnel, disclosure of limited data set, or disclosures made before April 14, 2003. Your request for a list of disclosures must be made in writing and be submitted to the Medical Records Department where you received your services We will respond to your request within 60 days (or 90 days if the extra time is needed) The list we provide will include disclosures made within the last six years unless you specify a shorter period The first list you request within a 12-month period will be free You will be charged a fee for any additional lists POUDRE VALLEY HOSPITAL POUDRE VALLEY HEALTH SYSTEM The Right to Get a Paper Copy of This Notice. Even if you have agreed to receive this Notice by e-mail, you have the right to request and obtain a paper copy by calling the PVHS main phone number 970-495-7000 or the MCR main phone number 970-624-2500. Any revised notice will be available in PVHS admitting areas and on our web site, www pvhs org. Complaints. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the federal Department of Health and Human Services To file a complaint with us, put your complaint in writing and address it to our Privacy Office We will not retaliate against you for filing a complaint. You may also contact our Privacy Office if you have questions or comments about our privacy practices MEDICAL CENTER OF THE ROCKIES POUDRE VALLEY HEALTH SYSTEM 1024 South Lemay Avenue 2500 Rocky Mountain Avenue Fort Collins, Colorado 80524-3998 Loveland, Colorado 80538 (970) 495-7000 (970) 624-2500 vvvvvv pvhs org vvvvvv pvhs org 1*7 POUDRE VALLEY HEALTH SYSTEM Fort Collins, Colorado 80528-3144 (970) 297-6700 • vvvvvv pvhs org (Version 02022007.2) Patient Name Working --Yes _Ni Summary Sheet Reviewed Changes Time/Nursing Assessment Z Occupational alth Services 00 A Service of Poudre Valley Hospital Poudre Vallee Health System Date of Service Date of Injury Yes No Updated Date Pulse Temp (if applicable) ®gym Time/Physician Assessment Prescripuom Impressions DICTATED Time Out MD SIGNATURE Date. OCCUPATIONAL HEALTH ASSESSMENT SHEET Inmals NEW MEDS AND PROCEDURES PHYSICIAN ORDERS X-Rav Lab Rehab Referral CALL / VOICL .MAIL / LEFT MFSSAGE / FAX / MAIL To From By \Whom Voice Mail, Message, Buse, Out of Service Nuent l&nnficanon E-201 061/99 Occupational th Services A Service of Poudre Valley Hospital Poudre Valley Health System Name DOI SSN# Pt Phone, Company. _ _ Phone DOB Contact Person Identified Learning Barriers, Insurance Carrier. Contact Person Phone Fax Claim #• Measures taken to address them ACTIVE PROBLEM LIST GUKKLNI MCU1L.A11VPIJ - 1nc1U4e La Ken over'Cne Iasi 3U F — DRUG ALLERGIES AND/OR ADVE RSE REACTIONS MEDICATION REACTION MEDICATION REACTION Key A - Anaphylactic IU - Urticana, R - Rash Other significant allergies (such as latex, foods, other allergens) Form Completed by Date OHS SUMMARY SHEET I - Intolerance O - Other/Unknown Identifcation Patient E 301 o3/m a V I a I I I 1II 1 N patient and injured employee Each clinic is equipped with an Audiology testing booth, Spirometry for Pulmonary Function testing, EKG, and Titmus Vision screener to evaluate the occupational vision testing requirements for DOT and other medical surveillance tests Each clinic is a collection site for Drug and Breath Alcohol testing Pharmacy services are not provides by OHS, we work with the client company to assure employees are directed to the insurers selected pharmacy or OHS provides of list of local pharmacies who accept workers' compensation billing All OHS clinics are able to do immunizations, such as Hepatitis A and B, Rabies, MMR, and PPD testing An essential element of our ability to provide rapid, coordinated and comprehensive services is the fact that we are able to view electronically, on line, any report, physician dictation or study completed within PVHS This connectivity assures ready access to all aspects of a patient's care Conversely, should an OHS patient require emergency treatment or hospitalization the OHS medical record is readily available 5 Scope of Work At OHS we feel World Class Healthcare is the right of each of our patients In the treatment of the injured worker this means early and ongoing aggressive management of the injury or illness with a determined focus on returning the worker to the job in a productive capacity as soon as possible Our Medical Director, Dr Holthouser routinely describes our care of the injured worker as "managed care on steroids," indicating the focused and intense way we manage care of the injured worker All clinics are available for walk-in new injury visits from 8 OOAM-5 OOPM, Monday - Friday Recheck appointments are scheduled per the physician and vary from 20 minutes to 40 minutes As a walk-in clinic we are well aware of the potential wait that an unexpected, but urgent walk-in patient may have on the existing patients scheduled for an appointment We do a number of things to address this potential impact We ask our employers to notify us immediately of incoming injuries so that we can review the severity and make necessary staffing changes or shift appointments as able We also ask the employer to assist us in letting the injured worker know the importance of being on time for appointments, and when a cancellation is necessary, that they do so at least twenty four hours prior to the appointment With these strategies, we are able to keep our patient satisfaction with wait time in the ninetieth percentile on our Avatar patient satisfaction survey tool Our job begins with the most complete history possible, a thorough understanding of the mechanism of injury, the job requirements and diagnostic testing to obtain the information needed to determine work relatedness, diagnosis, and treatment plan We value the information we glean from the patient, the employer and the carrier in assuring complete and accurate data is available in the management of the case Adherence to the Division Guidelines for injuries provides a structure for decision making The patient is the focus of our care We encourage an active role in the treatment plan and require individual responsibility for follow in adherence to the treatment plan, home program, and modified duty recommendations in all aspects of the individual's activities We stamp our M-164 forms with a notice stating, "These work restrictions apply to work, home, sports, and leisure activities " Work restrictions are reviewed with the patient by the provider, and then again by the MA during our check-out process We feel this offers Occupational Health Services Poudre Valley Health System E 3 POUDRE VALLEY HEALTH SYSTEM Occupational Health Services Patient Follow Up Visit PATIENT INFORMATION (Please Print) Name Social Security Number Since your last visit, are you feeling ❑ Same ❑ Better Specific issues you would like to address today Please list any medications you have started or discontinued since your last visit to OHS Medication Started Stopped ❑ ❑ ❑ ❑ ❑ ❑ Problems with your current medications? ❑ Yes ❑ No If yes, Please explain Are you having any stomach pain? ❑ Yes ❑ No Are you having problems sleeping? ❑ Yes ❑ No How often are you doing your home exercise program? Any problems with your home exercise program? Work Status ❑ Working Hull duty ❑ Working restricted duty ❑ Off work (restricted duty not available) ❑ Off work (other reason) Date of Birth Date of Injury ❑ Worse KEY USE THIS "KEY", PLEASE MARK THE LOCATION OF YOUR PAIN 111 Stabbin )I;XX Burning 000 Pins/Needles Numbness <<Aching Rtgl Today's Pain Rating ht No Severe Are you having any problems with following or maintaining your Pain 1 2 3 a 5 6 7 6 9 Pain work restrictions? ❑ Yes ❑ No ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ PLEASE RANK YOUR PAIN ON THE SCALE Patient Identification Patient Signature Date MD Review Date PSHP 9 ivoo Shared HIHMCIADMIN/OCCUPATIONAL HEALTHIOHSIOHS FORMS Occupationa Hea th The Occupational Health program is designed to assist you with the prevention, treatment, and management of work -related injuries / d <1 Our goals are to: • Deliver prompt, quality care to injured workers • Communicate with the client company at each stage of treatment • Return injured employees as quickly as possible to their pre -injury work status • Provide area employers with additional assistance in the areas of prevention and pre -placement services Occupational Injury Management • Walk-in/urgent care • Minor injury (trauma) treatment • Treatment of work -related injuries & illnesses • Comprehensive, in-house nurse case management • Expertise in toxic exposures, epidemiology, indoor air quality • Delayed recovery treatment • Physical, occupational, and massage therapies on -site Diagnostic Services • Pulmonary function testing • Comprehensive blood testing . EKG (electrocardiogram) • Nerve Conduction Tests • EMG Tests (electromyogram, for muscles' electrical activity) • Pain Management & Injections • Audiogram (booth) 01 m;;;;;; Health (continued) Occupational Physical Exams • Pre -employment history & exam • DOT (for commercial drivers) • Respirator fitness evaluation • Fit for Duty • Impairment ratings to set disability • MMI evaluations for case closure • IME (Independent medical evaluation) • Employment physicals Preventive Services • Job -specific ergonomic analysis • Functional capacity evaluations • TB skin testing evaluation • Flu & hepatitis Immunizations • Medical surveillance • Post -offer employment testing Drug & Alcohol Screening • Specimen collection (Federal guidelines) • NIDA and NIDA-like collection/reporting • Instant/on-site drug testing • Evidential breath alcohol testing (BAT) • Medical review officer (MRO) For information, call (970) 495-8450 www.pvhs.org OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs org *South Fort Collins Clinic O North Fort Collins Clinic C Loveland Clinic 1330 Oakridge Drive 1025 Pennock Place, Suite 121 Medical Office Building at Medical Center of the Rockies Fort Collins, CO 80525 Fort Collins, CO 80524 2500 Rocky Mountain Avenue, Suite 330 (970) 49S-8450 (970) 495-8450 Loveland, CO 80538 (970) 495-8450 C 04107 E-3004 E 17 mployment Testong Occupational Health Services, a service of Poudre Valley Hospital, is committed to helping employers prevent vvork-related Injuries and maintain a healthy work force Our continuum of services includes treatment, rehabilitation, case management, screening/testing, health promotion and education Job Site Analysis Consists of a visit to the job site to analyze job -specific activities, identify risk factors, and evaluate physical requirements of the job Includes photographing body positions/equipment used to perform job tasks, and measuring/weighing objects to determine the essential job functions Recommendations are given concerning adaptations and corrective actions that could alleviate cumulative trauma and prevent injuries at the job site Cost $75 00/hour WorkSTEPS Post -Offer Employment Testing Tests are administered post -offer, with employment being contingent upon passing the essential job functions and/or medical risk criteria for the position Comprehensive Test 2-hour post -offer test which gathers data on more than 30 measures to determine a candidate's ability to safely perform job -specific activities Gives a "capable" or "not capable" recommendation based upon ability to meet lob -specific requirements, or medical risk criteria The musculoskele- tal information can be used by medical providers to establish pre -injury status to avoid paying for rehabilitation services that are fraudulent or not based upon achievable functional goals Cost $110 00 Basic Back Evaluation 30-45 minute post -offer evaluation to assess current cardiovascular fitness, safe lifting capacity, and job specific activities Does not include musculoskeletal evaluation Cost $50 00 WorkSTEPS Employment Testing (map not wn .) (continued) t< J k - c SE; NORTH c f Nwv 34 5� WorkSTEPS Comprehensive Post Employment / Fit For Duty Testing 2-hour post -employment test which gathers extensive data to determine a worker's ability to safely perform physical job requirements This test can be used to clas- sify employees according to risk, and then Implement prevention strategies to lower susceptibility to injury Work conditioning, accommodation and other options are made available to the employer based upon results Cost $1 10 00 WorkSTEPS Carpal Tunnel Screening Evaluates highly repetitive, high -paced positions involving upper extremities Purpose is to identify individuals with high risk for development of upper extremity cumulative trauma disorders Cost $110 00 Cost including Comprehensive Test $150 00 Functional Capacity Evaluations The FCE measures an employee's function after an injury The WorkSTEPS FCE is designed to follow the same pre -injury test protocols of the employment tests to compare the results, document existing impairment, prove consistency, and create realistic, objective treatment goals and return to work recommendations The WorkSTEPS FCE is automated and includes criteria to evaluate symptom magnification, inappropriate illness behavior, and validity of performance Cost $180 00/hour (per workers' comp fee schedule) OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs org *South Fort Collins Clinic © North Fort Collins Clinic U Loveland Clinic 1330 Oakridge Drive 1025 Pennock Place, Suite 121 Medical Office Building at Medical Center of the Rockies Fort Collins, CO 80525 Fort Collins, CO 80524 2500 Rocky Mountain Avenue, Suite 330 (970) 495-8450 (970) 495-8450 Loveland, CO 80538 (970) 495-8450 C D4/09 E-3004 Drug Screen INT611140416111 0���11 When you choose Occupational Health Services to perform drug/alcohol testing, you are assured that stringent chain -of -custody steps are carefully followed These Include DOT, and non -DOT collections, as well as MRO services upon request For more Information, call 970-495-8450. 7 Conventional Lab Testing • Requested by employers requiring a complete drug screen, using lab analysis and MRO services as required • DOT testing procedures are followed on all collections • Typically used for pre -employment, post -accident, random, and reasonable suspicion situations • OHS uses Quest/SmithKline Beecham as its SAMHSA-certified laboratory • Results are available online with employer -specific passwords within 24 - 48 hours • OHS can also collect and send specimens to an employer's designated lab when kits, chain of custody forms, and mailing supplies are provided at the time of collection On -Site Drug Screening • Requested by employers requiring immediate results for non -DOT pre -employment or post -accident screening • RESULTS ARE AVAILABLE WITHIN 15 — 30 MINUTES • Non -negative results are sent to SAMHSA-certified lab to confirm analysis • Offers the benefit of immediate finding that job applicants and/or employees are drug -free n., Breath -Alcohol Testing • DOT -approved screening to measure concentration of alcohol in the body • Nearly 100% accurate, all positive tests are repeated after 15 minutes to confirm results • Results are available immediately for the employer's designated contact C Lu ��`1��•,�•'ll 1 11 t���f"111�•l t 1���11 (continued) 14 11 En6 q Prospect Rd I s Oakrltl9e m ®sus � $, n m c o _ 11 F � ' (map nut to scale) Uossroads Blvdi i j Q ER RO0.TM c v� I a C Hwy 3d j Hair Testing 0 Hair testing detects drugs abused during the past 90 days as Requested by employers who desire not only a current measure of drug use, but also information on historic pattern of use (including quantity) • Collection is easier and less embarrassing than a urine sample • Results are available within 24 - 48 hours Important Information • All drug and alcohol tests and collections are conducted from 8 a m to 5 p m weekdays • Off -hour and weekend drug testing is done in the Emergency Departments at Poudre Valley Hospital and Medical Center of the Rockies, or Harmony Urgent Care Center (fees are significantly higher) • Employees must have a photo ID with them at the time of collection OHS is able to conduct multiple collections within a given time frame with advance notice at an employer's worksite Fees for Services at the OHS Clinics Conventional Lab Testing $40/test e Includes collection, laboratory analysis, adulterant testing, and MRO analysis On -Site Drug Screen $30/test o Includes collection, adulterant testing, and lab confirmation/MRO services for non -negative results Breath -Alcohol Testing $30/test Retest confirmation $25 Hair Testing* $25/test * Collection only Fees for laboratory analysis and mailing of specimen are belled directly to the employer by Psychemedics Corporation OCCUPATIONAL HEALTH SERVICES A SERVICE OF POUDRE VALLEY HOSPITAL www pvhs org +South Fort Collins Clinic 0 North Fort Collins Clinic o Loveland Clinic 1330 Oakridge Drive 1025 Pennock Place, Suite 121 Medical Office Building at Medical Center of the Rockies Fort Collins, CO 80525 Fort Collins, CO 80524 2500 Rocky Mountain Avenue, Suite 330 (970) 495-8450 (970) 495-8450 Loveland, CO 80538 (970)495-8450 C 04/07 E-3004