HomeMy WebLinkAbout461367 WORKWELL 499991 COLORADO HEALTH MEDICAL GRP - CONTRACT - RFP - 7438 MEDICAL PROVIDER - WORKERS COMPENSATION & DOTSERVICES AGREEMENT
THIS AGREEMENT made and entered into the day and year set forth below by and
between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter
referred to as the "City" and Colorado Health Medical Group hereinafter referred to as "Service
Provider".
WITNESSETH:
In consideration of the mutual covenants and obligations herein expressed, it is agreed
by and between the parties hereto as follows:
1. Scope of Services. The Service Provider agrees to provide services in
accordance with the scope of services attached hereto as Exhibit "A", consisting of two (2)
pages and incorporated herein by this reference.
2. Contract Period. This Agreement shall commence February 1, 2013, and shall
continue in full force and effect until January 31, 2014, unless sooner terminated as herein
provided. In addition, at the option of the City, the Agreement may be extended for additional
one year periods not to exceed four (4) additional one year periods. Renewals and pricing
changes shall be negotiated by and agreed to by both parties. The Denver Boulder Greeley
CPIU published by the Colorado State Planning and Budget Office will be used as a guide.
Written notice of renewal shall be provided to the Service Provider and mailed no later than
ninety (90) days prior to contract end.
3. Delay. If either party is prevented in whole or in part from performing its
obligations by unforeseeable causes beyond its reasonable control and without its fault or
negligence, then the party so prevented shall be excused from whatever performance is
prevented by such cause. To the extent that the performance is actually prevented, the Service
Provider must provide written notice to the City of such condition within fifteen (15) days from
the onset of such condition.
4. Early Termination by City/Notice. Notwithstanding the time periods contained
Services Agreement
RFP 7438 Medical Provider — Workers Compensation & DOT Medical Exams Page 1 of 12
EXHIBIT
COMPENSATION
COLORADO HEALTH MEDICAL GROUP
OCCUPATIONAL HEALTH
2012 Client Services Fee Schedule
REV|SEDUX2O1%
PHVSICAXS�;
_"FtE,.:<
DRUG SCREENS
FEE
I leighl WeigH Vital Signs (indk)ded)
On-stle Drug Screen (rap�d test)
$40.00
Whisper Test (inclujed)
Hair testing collection
$40..00
$68.00�
Confirmation of positive BAT
M.00
History and Physical
Height Weight Vital Signs (included)
Snatch Eye Chart (iricluderl)
IrthhunLzatforts
Recheck for card restrictions or for addition
To a corporate phisical
S35.00
Hepatitis B per Injection (series of 3)
$70.50
Comprehensive History& Physical
DiphtheripJ Pertusisl Tetanus (ADAPT)
$67.00
Hdght, VicigN, Vital Signs (included)
Admirilstreticin fee for all Injections (excluding
TB Skin test) ' Effective Jan 2013
$25.00
Includes: Basic Exam written opinion
EKG
$100.00
Base line
Annualtiseriodic
S15.00
EKG with inerp at OHS site
$15U0
Other ff indicated,
EKG and Interpretation QvICR
$150.00
Pulmoriary Function Test
S40.00
Chest X-Ray (PA & Let) (w interp)
$105.00
Chest X-ray (PA & Lot) with interp
$105.00
Chest X-ray (PA one view only) (w interp)
$105.00
Occupational Exposure History Review
$30.00
Services Agreement
RFP74J8Medical Provider — Workers Compensation & DOT Medical Exams Page 1Oo|12
-475.00,
Work t.%, J,
Includes basic Exam + written opm on
Set up and program education NIC
Other it indicated:
Post Offer Comprehensive Testing
$130.00
Lead/ZZP Panel (OCH-lPanel) per
Per PVH
Car pal I ur ii rel Testing (only)
$120.00
Per PVHS Lab
quote
Post Offer Basic & Carpal Tunnel'T+ io ling
$150.00
required
ftm lab
UA Microscopic per PVHS Lab
quote
Job Site analysis (per hour)
$15C.W
required
horn lab
Range of fil'(-�Illoul ,-I
$76.00
Ergonomic Training (par hour)
$150.00
Back Solely Training (per hour)
$75.001
Resptrstcry P
$55.00
Job Site Analys s (per hour)
$150.00
Includes, OSHA Questionnaire with
Dynamic Ulf Test 2,504-DI-T
$50.00
Medical Exam
Workcare back lost and form
$35.00
Other if Indicated:
Professional supervision of Audiometric
$150.001hr
Program (included annual revroiii of overall
re--ulls of testing, annual program review and
recommendations: typically 1.3 houm"r)
Pulmonary Function lest (additional)
$40.00
Fit for Duty Exam (non work related, includes:
$230.00
Medical Record rgrvi(� and e)cand tip to"
(each
hour, as well as CvYipletion of ADA cr FlYlLA
awl] %
documentation and recommendation for duty.)
hour
$115.00)
Physician on site education (per hour)
$150.00
Respiratory Clearance
Physician Ill Review 10vevslle (per hour)
$200.00
OSHA Questionnaire, no physical exam
$25.00
Administrative Review 99900.01
$25.00
Cwrdjmation of Blood borne Pathogen
$69.391
exposures: 11 -20 minutes S46.26 21-30 min'
ALL BLOOD DRAW iiita COLLECTIONS W 15.,edca d and rilb.fdiionbi.hor.. nwAr. "hill fiitio. a 364.00.
All work cmm bilk,, is per the Stria of Co N. ."h.d.re and L' .'c6s,d by the 3w, anrwNly efrective Jrn 1 of ..h yav
Lo.M.w
kram 11n. 970455.8450
Sch4d,An0 fa phyi,;cW. 970-297.6$66
Fvri COMM, CO 4674 Snow &I.,, D, STE 200
Lclvit1wW, 00 2500 Rocky Min Avo. SoUth M.d,fl 016CP Bldg, STE lud)
QOWW, CO 1900I &-' St. Greeley lvedc,itj Cortt.r. STE 300
lch"me,WY Cheyenne M66cM Sre,w.,d. SV4 Rvisid
Services Agreement
RFP 7438 Medical Provider — Workers Compensation & DOT Medical Exams Page 11 of 12
EXHIBIT C
INSURANCE REQUIREMENTS
1. The Service Provider will provide, from insurance companies acceptable to the City, the
insurance coverage designated hereinafter and pay all costs. Before commencing work under
this bid, the Service Provider shall furnish the City with certificates of insurance showing the
type, amount, class of operations covered, effective dates and date of expiration of policies, and
containing substantially the following statement:
"The insurance evidenced by this Certificate will not be cancelled or materially altered,
except after ten (10) days written notice has been received by the City of Fort Collins."
In case of the breach of any provision of the Insurance Requirements, the City, at its option,
may take out and maintain, at the expense of the Service Provider, such insurance as the City
may deem proper and may deduct the cost of such insurance from any monies which may be
due or become due the Service Provider under this Agreement. The City, its officers, agents
and employees shall be named as additional insureds on the Service Provider's general liability
and automobile liability insurance policies for any claims arising out of work performed under
this Agreement.
Insurance coverages shall be as follows:
A. Workers' Compensation & Employer's Liability. The Service Provider shall
maintain during the life of this Agreement for all of the Service Provider's employees
engaged in work performed under this agreement:
Workers' Compensation insurance with statutory limits as required by
Colorado law.
2. Employer's Liability insurance with limits of $100,000 per accident,
$500,000 disease aggregate, and $100,000 disease each employee.
B. Commercial General & Vehicle Liability. The Service Provider shall maintain
during the life of this Agreement such commercial general liability and automobile liability
insurance as will provide coverage for damage claims of personal injury, including
accidental death, as well as for claims for property damage, which may arise directly or
indirectly from the performance of work under this Agreement. Coverage for property
damage shall be on a "broad form" basis. The amount of insurance for each coverage,
Commercial General and Vehicle, shall not be less than $500,000 combined single limits
for bodily injury and property damage:
In the event any work is performed by a subcontractor, the Service Provider shall be
responsible for any liability directly or indirectly arising out of the work performed under
this Agreement by a subcontractor, which liability is not covered by the subcontractor's
insurance.
Services Agreement
RFP 7438 Medical Provider— Workers Compensation & DOT Medical Exams Page 12 of 12
PVHEA
Client#: 12582
ACORD,, CERTIFICATE OF LIABILITY INSURANCE
DATE""""'
11120/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Flood & Peterson Ins., Inc.
P. O. Box 578
Greeley, CO 80632
970356-0123
CONTACT NAME: Nikki Mosbrucker
NAME,
970 266-7123 FAX 970 506.6823
A/C No Ezt : AIC, No
EMAIL ADDRESS: t% nikki.mosbrucker@/�'�floodandP eterson.com
PKUDULLK
CUSTOMER ID#:
INSURER(S) AFFORDING COVERAGE
NAIC#
INSURED
Poudre Valley Hospital
Poudre Valley Health Care, Inc.
2315 E Harmony Road, Suite 200
Fort Collins, CO 80528-8620
INSURER A: Copic Companies
INSURER B Safety National Casualty Com an
INSURER CChartis Insurance
INSURER D : '
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
T
TYPE OF INSURANCE
DDL
NSR
UBR
D
POLICY NUMBER
POLICY EFF
MMIODIYYYY
POLICY EXP LIMITS
MMIDDIYYYY
A
GENERAL LIABILITY
X COMMERCIAL GENERALLIADILITY
X CLAIMS -MADE FXIOCCUR
X Malpractice
HCC0008522
4101/201204/0112013EACHOCCURRENCE
$1000000
PREMISES EaEoccu ence1
s500,000
MEDEXP(Anymeperson)
$5,000
PERSONAL B ADV INJURY
$1,000,000
Liability
GENERAL AGGREGATE
$3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
17 POLICY r7 PRO X LOCI
JECT
PRODUCTS - COMP/OP AGO
$1,000,000
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT
Ca accident)
$
BODILY I NJURY(Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
A
X
UMBRELLA LIMB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
UCC0009293
4/01/2012
04/0112013
EACHOCCURRENCE
$15,000000
X
AGGREGATE
$15 OOO OOO
DEDUCTIBLE
RETENTION S
$
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITYER
ANY PROPRIETOWPARTNEWEXECUIRVEYIN
(Mandatory in NH, E%CLUDED9
If yee, descnbe under
DE SCRIPTION OF OPERATIONS below
NIA
SP4045997
4/01/2012
04/01/2013
X WC RSTAT
YLIMU- OTH-
EOFFICEWME.L. EACH ACCIDENT
$1,000,000
E.L. DI SEASE - EA EMPLOYEE
$1,000,000
E.L. DISEASE -POLICY LIMIT
$1,000,000
C
Directors &
Officers Liab
17013164
4/01/2012
04/01/201
$11,000,000 Limit
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
'For Information Only' I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S747734/M688594 NIK
herein, the City may terminate this Agreement at any time without cause by providing written
notice of termination to the Service Provider. Such notice shall be delivered at least fifteen (15)
days prior to the termination date contained in said notice unless otherwise agreed in writing by
the parties. All notices provided under this Agreement shall be effective when mailed, postage
prepaid and sent to the following addresses:
City: Copy to: Service Provider:
City of Fort Collins City of Fort Collins Colorado Health Medical Group
Attn: Purchasing Attn: Lance Murray Attn: Jill Fitzgerald
PO Box 580 PO Box 580 4674 Snow Mesa Drive, Suite 200
Fort Collins, CO 80522 Fort Collins. CO 80522 Fort Collins, CO 80528
In the event of early termination by the City, the Service Provider shall be paid for services
rendered to the date of termination, subject only to the satisfactory performance of the Service
Provider's obligations under this Agreement. Such payment shall be the Service Provider's sole
right and remedy for such termination.
5. Contract Sum. The City shall pay the Service provider for the performance of this
Contract, subject to additions and deletions provided herein, per the attached Exhibit "B",
consisting of two (2) pages, and incorporated herein by this reference.
6. City Representative. The City will designate, prior to commencement of the
work, its representative who shall make, within the scope of his or her authority, all necessary
and proper decisions with reference to the services provided under this agreement. All requests
concerning this agreement shall be directed to the City Representative.
7. Independent Service provider. The services to be performed by Service Provider
are those of an independent service provider and not of an employee of the City of Fort Collins.
The City shall not be responsible for withholding any portion of Service Provider's compensation
hereunder for the payment of FICA, Workmen's Compensation or other taxes or benefits or for
any other purpose.
8. Personal Services. It is understood that the City enters into the Agreement
based on the special abilities of the Service Provider and that this Agreement shall be
Services Agreement
RFP 7438 Medical Provider— Workers Compensation 3 DOT Medical Exams Page 2 of 12
considered as an agreement for personal services. Accordingly, the Service Provider shall
neither assign any responsibilities nor delegate any duties arising under the Agreement without
the prior written consent of the City.
9. Acceptance Not Waiver. The City's approval or acceptance of, or payment for
any of the services shall not be construed to operate as a waiver of any rights or benefits
provided to the City under this Agreement or cause of action arising out of performance of this
Agreement.
M Warranty.
a. Service Provider warrants that all work performed hereunder shall be
performed with the highest degree of competence and care in accordance with accepted
standards for work of a similar nature.
b. Unless otherwise provided in the Agreement, all materials and equipment
incorporated into any work shall be new and, where not specified, of the most suitable grade of
their respective kinds for their intended use, and all workmanship shall be acceptable to City.
C. Service Provider warrants all equipment, materials, labor and other work,
provided under this Agreement, except City -furnished materials, equipment and labor, against
defects and nonconformances in design, materials and workmanshiplworkwomanship for a
period beginning with the start of the work and ending twelve (12) months from and after final
acceptance under the Agreement, regardless whether the same were furnished or performed by
Service Provider or by any of its subcontractors of any tier. Upon receipt of written notice from
City of any such defect or nonconformances, the affected item or part thereof shall be
redesigned, repaired or replaced by Service Provider in a manner and at a time acceptable to
City.
11. Default. Each and every term and condition hereof shall be deemed to be a
material element of this Agreement. In the event either party should fail or refuse to perform
according to the terms of this agreement, such party may be declared in default thereof.
Services Agreement
RFP 7438 Medical Provider — Workers Compensation & DOT Medical Exams Page 3 of 12
12. Remedies. In the event a party has been declared in default, such defaulting
party shall be allowed a period of ten (10) days within which to cure said default. In the event
the default remains uncorrected, the party declaring default may elect to (a) terminate the
Agreement and seek damages; (b) treat the Agreement as continuing and require specific
performance; or (c) avail himself of any other remedy at law or equity. If the non -defaulting party
commences legal or equitable actions against the defaulting party, the defaulting party shall be
liable to the non -defaulting party for the non -defaulting party's reasonable attorney fees and
costs incurred because of the default.
13. Binding Effect. This writing, together with the exhibits hereto, constitutes the
entire agreement between the parties and shall be binding upon said parties, their officers,
employees, agents and assigns and shall inure to the benefit of the respective survivors, heirs,
personal representatives, successors and assigns of said parties.
14. Indemnity/] nsurance.
a. The Service Provider agrees to indemnify and save harmless the City, its
officers, agents and employees against and from any and all actions, suits, claims, demands or
liability of any character whatsoever brought or asserted for injuries to or death of any person or
persons, or damages to property arising out of, result from or occurring in connection with the
performance of any service hereunder.
b. The Service Provider shall take all necessary precautions in performing the
work hereunder to prevent injury to persons and property.
c. Without limiting any of the Service Provider's obligations hereunder, the
Service Provider shall provide and maintain insurance coverage naming the City as an
additional insured under this Agreement of the type and with the limits specified within Exhibit C,
consisting of one (1) page, attached hereto and incorporated herein by this reference. The
Service Provider before commencing services hereunder, shall deliver to the City's Director of
Purchasing and Risk Management, P. O. Box 580 Fort Collins, Colorado 80522 one copy of a
Services Agreement
RFP 7438 Medical Provider - Workers Compensation & DOT Medical Exams Page 4 of 12
certificate evidencing the insurance coverage required from an insurance company acceptable
to the City.
15. Entire Agreement, This Agreement, along with all Exhibits and other documents
incorporated herein, shall constitute the entire Agreement of the parties. Covenants or
representations not contained in this Agreement shall not be binding on the parties.
16. Law/Severability. The laws of the State of Colorado shall govern the construction
interpretation, execution and enforcement of this Agreement. In the event any provision of this
Agreement shall be held invalid or unenforceable by any court of competent jurisdiction, such
holding shall not invalidate or render unenforceable any other provision of this Agreement.
17. Prohibition Against Employing Illegal Aliens. Pursuant to Section 8-17.5-101,
C.R.S., et. seq., Service Provider represents and agrees that:
a. As of the date of this Agreement:
1. Service Provider does not knowingly employ or contract with an illegal
alien who will perform work under this Agreement; and
2. Service Provider will participate in either the e-Verify program created
in Public Law 208, 104th Congress, as amended, and expanded in Public Law 156, 108th
Congress, as amended, administered by the United States Department of Homeland Security
(the "e-Verify Program") or the Department Program (the "Department Program"), an
employment verification program established pursuant to Section 8-17.5-102(5)(c) C.R.S. in
order to confirm the employment eligibility of all newly hired employees to perform work under
this Agreement.
b. Service Provider shall not knowingly employ or contract with an illegal alien to
perform work under this Agreement or knowingly enter into a contract with a subcontractor that
knowingly employs or contracts with an illegal alien to perform work under this Agreement.
Services Agreement
RFP 7438 Medical Provider — Workers Compensation & DOT Medical Exams Page 5 of 12
c. Service Provider is prohibited from using the e-Verify Program or Department
Program procedures to undertake pre -employment screening of job applicants while this
Agreement is being performed.
d. If Service Provider obtains actual knowledge that a subcontractor performing
work under this Agreement knowingly employs or contracts with an illegal alien, Service
Provider shall:
1. Notify such subcontractor and the City within three days that Service Provider
has actual knowledge that the subcontractor is employing or contracting with an illegal alien;
and
2. Terminate the subcontract with the subcontractor if within three days of
receiving the notice required pursuant to this section the subcontractor does not cease
employing or contracting with the illegal alien; except that Service Provider shall not terminate
the contract with the subcontractor if during such three days the subcontractor provides
information to establish that the subcontractor has not knowingly employed or contracted with
an illegal alien.
e. Service Provider shall comply with any reasonable request by the Colorado
Department of Labor and Employment (the "Department') made in the course of an
investigation that the Department undertakes or is undertaking pursuant to the authority
established in Subsection 8-17.5-102 (5), C.R.S.
f. If Service Provider violates any provision of this Agreement pertaining to the
duties imposed by Subsection 8-17.5-102, C.R.S. the City may terminate this Agreement. If this
Agreement is so terminated, Service Provider shall be liable for actual and consequential
damages to the City arising out of Service Provider's violation of Subsection 8-17.5-102, C.R.S.
g. The City will notify the Office of the Secretary of State if Service Provider
violates this provision of this Agreement and the City terminates the Agreement for such breach.
Services Agreement
RFP 7438 Medical Provider —Workers Compensation & DOT Medical Exams Page 6 of 12
CITY OF FORT COLLINS, COLORADO
a municcorporation
By:
f-OK James B. 'Neill ll, CPPO, FNIGP
sx,,-Director of Purchasing and Risk Management
Date: ��/ / / 5
ATTEST:
S2rEA
ORTCity Clerk
APPR V AST FORM:
Assistant
COLORADO HEALTH MEDICAL GROUP
CORPORATE PRESIDENT OR VICE PRESIDENT
Date:
ATTEST: (C rporate Seal)
CORPORATE SECRETARY
Services Agreement
RFP 7438 Medical Provider - Workers Compensation & DOT Medical Exams Page 7 of 12
EXHIBIT A
SCOPE OF WORK
1. Provide appropriate medical care and case management at a minimum of five (5) days a
week from 8:00 a.m. to 5:00 p.m., for City of Fort Collins employees that have injuries or
illnesses alleged to have occurred as a result of their employment.
2. Maintain accurate medical records for every City employee receiving medical care.
Individual patient records and reporting systems necessary to carry out program
administrative, planning, and legal requirements will be established and maintained.
3. Notify Risk Management after medical treatment is rendered. Notification includes a phone
call after initial treatment detailing treatment rendered, any work modifications or time lost,
treatment plan forward as well as prompt access to the M 164 or equivalent documentation
detailing, injury/exposure, work restrictions, work relatedness and anticipated MMI timeline.
This information should be transmitted to the city's electronic mail system. ,
4. Notify Risk Management for approval prior to referral of employee from your facility to
another physician, or upon admission to a hospital or other facility. All information for on-
going treatment shall be sent promptly to the receiving physician, hospital or other facility.
5. Provide employee with written "status" report (M164) outlining work restrictions, if any, for
every visit.
6. Provide a written report within TWO (2) days of initial treatment to claim administrator.
7. Provide DOT medical exam results within 24 hours of service to the employer (Risk
Management) and Department of Revenue.
8. Provide Risk Management and city employees with access to or copies of all written
communications regarding medical treatment and DOT medical exams.
9. Provide specialty services as requested such as physical examinations, audiograrns, x-rays,
EKG's, immunizations, physical therapy, drug and alcohol testing. DOT physicals, pre-
employment physicals and other medical services as may be deemed beneficial to City
employees and the employer.
10. Be familiar with Workers' Compensation laws and provide hearing testimony when needed.
11. City employees shall initially be treated only by Level II accredited physicians for treatment
of injury. Impairment ratings may only be completed by Level 11 accredited physicians. DOT
medical exams must be completed by a medical examiner licensed, certified and/or
registered in accordance with applicable State and or Federal laws and regulations.
12. Cooperate with the City's claim administrator and risk management staff in submitting
information at their request as needed in a timely manner.
13. Participate in consultations with employer and claim administrator as requested to discuss
specific cases and procedures.
14. Provide a written medical treatment plan when requested.
Services Agreement
RFP 7438 Medical Provider — Workers Compensation 8 DOT Medical Exams Page 8 of 12
15. Conduct return to work or fitness for duty examinations as requested by the City's Risk
Management or Human Resources department, and provide appropriate feedback to staff
regarding employees' work restrictions vis-a-vis the employees' job duties.
16. Assess work relatedness upon initial employee visit to diminish the possibility of fraudulent
claims.
17. Rely upon the most up to date Medical Treatment Guidelines adopted by the Colorado
Division of Workers' Compensation when treating patients and when determining work
relatedness. Communicate a diagnosis -based treatment plan that includes specific
treatment goals with expected time frames for completion in all cases where treatment
falling within the purview of the medical treatment guidelines continues beyond 6 weeks.
Within 14 days of request by any party, the provider shall supply a copy of the treatment
plan both to the patient and to the payer. Should the patient otherwise require care that
deviates from the medical treatment guidelines, the provider shall supply the patient and the
employer with a written explanation of the medical necessity for such care.
18. Employees may be given a "Patient Satisfaction Survey" upon completion of medical
services or when they reach MMI.
Services Agreement
RFP 7438 Medical Provider — Workers Compensation & DOT Medical Exams Page 9 of 12