HomeMy WebLinkAboutRESPONSE - RFP - 7438 MEDICAL PROVIDER - WORKERS COMPENSATION & DOT MEDICAL EXAMS (2)Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 1 of 22
City of Fort Collins
Financial Services
Purchasing Division
215 N. Mason St. 2nd Floor
PO Box 580
Fort Collins, CO 80522
970.221.6775
fcgov.com/purchasing
Response to Proposal No. 7438
DUE DATE AND TIME: 10/26/2012, 3:00PM
Medical Provider
Workers’ Compensation and DOT Medical
Exam Services for the Employees of the City of
Fort Collins Risk Management
Workwell Occupational Medicine, LLC
Stephen Pottenger, CEO
steve.pottenger@workwellworks.com
www.workwellworks.com
205 S. Main Street, #G
Longmont, CO 80501
303.827.3158
205 S. Main Street, #C 1608 Topaz Dr. 1275 58th Ave, #C
Longmont, CO 80501 Loveland, CO 80537 Greeley, CO 80634
303.702.1612 970.593.0125 970.356.9800
303.774.7899 fax 970.593.0127 fax 970.353.3182 fax
1600 Specht Point Rd, 115 3434 47th St., #100
Fort Collins, CO 80525 Boulder, CO 80301
970.672.5100 303.219.5022
970.672.5105 fax 303.219.5023 fax
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 2 of 22
October 26, 2012
Jim O’Neill, CPPO, FNIGP, Buyer
City of Fort Collins
Financial Services
Purchasing Division
215 N. Mason St. 2nd Floor
PO Box 580
Fort Collins, CO 80522
970.221.6779
joneill@fcgov.com
Lance Murray, Project Manager
City of Fort Collins
970.221.6807
lmurray@fcgov.com
Dear Mr. O’Neill, Mr. Murray and the City of Fort Collins,
Thank you for the opportunity to respond to your RFP for Designated Medical Provider services and DOT
Medical Exam services. We are Workwell Occupational Medicine, LLC (“Workwell”) a locally owned and
operated, group of workers’ compensation specialists. We have locations in Fort Collins, Longmont, Loveland,
Greeley and Boulder and serve businesses and their employees throughout Boulder, Larimer, and Weld
counties. We serve companies in every industry, of every size in a professional manner, providing exceptional
customer service and superior medical care. We ONLY focus on Occupational Medicine so we can manage
cases efficiently and get your employees back to work timely!
Workwell is a full facility clinic that not only treats on-the-job injuries, but also performs drug and alcohol
screening, physical exams, pre and post-employment functional testing and offers employers customized options
such as ergonomic evaluations, safety trainings, and health and wellness services.
As an Occupational Medical leader, we understand the importance of communication with you, the employer.
We communicate with you throughout the case, including provider phone calls following initial visits, and typed
emailed reports for the duration of the claim. All of our medical records are electronically maintained and
patient confidentiality is strictly adhered to. Our Level II accredited physicians and providers establish a working
trust with your employees to ensure a positive outcome for the patient and you, the employer.
As a current provider of services to other municipalities in Northern Colorado and experts within our field, we
feel uniquely qualified to provide the services you have outlined in your request and we hope you feel the same
when considering our proposal. We trust that you will find our response to your RFP adequate, and that we
have written it in such a way to not only address your requirements, but also to answer any questions that may
arise after review. Thank you, again, for the opportunity to respond and we look forward to retaining your trust
and your business.
Sincerely,
Stephen Pottenger
Chief Executive Officer
Workwell Occupational Medicine, LLC
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 3 of 22
TABLE OF CONTENTS
COVER LETTER PAGE 2
RESPONSIBILITY INFORMATION
1. General Offeror Information PAGE 4
2. Responsibility Information PAGE 5
References
MANDATORY GUIDELINES PAGE 6
SCOPE OF WORK PAGE 8
1. Experience/Qualifications of the Firm
2. Services/Office Standards
3. Billing
ATTACHMENTS
W-9 Attachment A
CLINIC FORMS Attachment B
BLOODBORNE PATHOGENS EXPOSURE CONTROL Attachment C
DRUG AND ALCOHOL POLICY AND PROCEDURE Attachment D
MEDICAL CASE MANAGEMENT & UTILIZATION REVIEW Attachment E
HIPAA & RELATED MATTERS Attachment F
PRIVACY POLICY Attachment G
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 4 of 22
GENERAL OFFORER’S INFORMATION
Workwell Occupational Medicine, LLC
Stephen Pottenger
205 S. Main Street, #G
Longmont, CO 80501
(303) 827-3158
(303) 774-7899 fax
steve.pottenger@workwellworks.com
www.workwellworks.com
1. Serving Colorado Businesses Since 1996
2. Focusing On Prompt Recovery And Appropriate Return-To-Work Programs
3. Dedicated to 100% Professional Occupational Medicine
4. Convenient Walk-In Appointments & Efficient Urgent Care Facilities
5. Experienced Level II Medical Providers
6. Electronic Medical Record and On-line Access for Employers and Insurance Providers
7. Onsite Physical Therapy and Pharmacy
8. Se Habla Espanol – Spanish Speaking Providers and Staff in most facilities
9. Complete Offering of Corporate Care Services
Compliance – Medical Director Services, Compliance Management, Medical Surveillance, IME
Pre-Employment – Drug/Alcohol Testing, Baseline Examinations, Physicals and Function Testing
Safety – Safety Training Classes, Training Videos
Health & Wellness – Ergonomics, On-Site Flu Shots, Health Risk Assessments, select mobile on-site
services
Support – Health Fairs, Educational Seminars, Workers’ Compensation Conferences, e-Newsletters
and more
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 5 of 22
REFERENCES
Poudre Valley School District
Kristin Bennett, Risk Management
2407 Laporte Ave
Fort Collins, CO 80521-2211
(970) 490-3627
kbennett@psdschools.org
Project Scope: workers’ compensation injury care, physical therapy, case management
Status: Active
Colorado State University
Kenda Weigang, Associate Director of Risk Management
141c General Services Bldg
Fort Collins, CO 80523
(970) 491-4832
Kenda.weigang@colostate.edu
Project Scope: workers’ compensation injury care, physical therapy, case management
Status: Active
St. Vrain Valley School District
Heather Keith, Risk Manager
395 S. Pratt Parkway
Longmont, CO 80501
(303) 682-7428
Keith.heather@stvrain.k12.co.us
Project Scope: workers’ compensation injury care, physical therapy, case management
Status: Active
Boulder County
Andrea Bell, Risk Manager
2025 14th Street
Boulder, CO 80306
(303) 441-3872
(303) 441-3568 fax
abell@co.boulder.co.us
Project Scope: workers’ compensation injury care, physical therapy, case management
Status: Active
Thompson School District R2J
Barb Swanson, Risk Manager
535 N. Douglas Ave
Loveland, CO 80537
(970) 613-5006
swansonb@thompson.k12.co.us
Project Scope: workers’ compensation injury care, physical therapy, case management, pre-employment and
DOT physicals
Status: Active
City of Longmont
Deb Carson, Risk Manager
350 Kimbark Street
Longmont, CO 80501
(303) 651-8720
Deb.carson@ci.longmont.co.us
Project Scope: workers’ compensation injury care, physical therapy, case management, drug & alcohol screening,
pre-employment and DOT physicals
Status: Active
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 6 of 22
MANDATORY GUIDELINES
Workwell providers specialize in Occupational Medicine services and possess the following credentials:
a) Workwell physicians have many different areas of training and have internal and external resources that
are Board Certified in Occupational Medicine, at American Board of Preventative Medicine.
b) All Workwell MD/DO’s are Board Certified/eligible in the area of primary care such as family practice
or internal medicine.
c) All Workwell physicians have a minimum of three years in active practice in Occupational Medicine with
the vast majority of that time being spent in direct patient care.
d) We have considerable talent and experience in the management of treatment of musculoskeletal
disorders, cumulative trauma disorders, and other work-related conditions.
e) Our staff has an excellent understanding of the ergonomic and integrated disability management
programs in workers’ compensation.
f) Our providers and legal team have extensive experience in medical-legal aspects of occupational
medicine.
g) All of our physicians are current with Level II accreditation by the State of Colorado and continuing
education at all times to update knowledge of current workers’ compensation laws in the State of
Colorado.
Workwell is a privately owned and locally operated limited liability corporation serving Colorado businesses
since 1996. Workwell serves thousands of clients, in five distinct markets in Northern Colorado (Loveland,
Longmont, Greeley, Boulder and Fort Collins). Our organization employs 40+ people including 6 physicians
and 3 physician extenders. We offer a complete array of occupational medicine and corporate care services
and are the only specialist provider of our kind in Northern Colorado. We are the largest privately held
Occupational Medicine provider in Colorado and we serve as a resource to businesses and insurance
companies as experts in our field, regularly lecturing and presenting on a variety of topics and interests.
Workwell is the only provider of 100% Occupational Medicine in Northern Colorado which means that we are
dedicated to you, the employer, and the care of your employees. The area’s largest worker’s compensation
insurance company states that Workwell is 26% less expensive in total medical dollars/case and returns
employees to work 23% sooner, on average, than other physicians on the front range. We are the clear
choice if you need a Professional, Dedicated, Comprehensive, Quality, Cost Effective and Service Oriented
Occupational Health Provider in Northern Colorado.
Workwell has 9 providers total at all 5 of our clinic locations:
J. Peter Mars, MD (Boulder, CO)
William Ford, C-ANP (Longmont, CO)
Lloyd Thurston, MD DO CIME (Loveland, CO)
Hope Edmonds, MD (Fort Collins, CO)
Marc-Andre Chimonas, MD (Longmont, Greeley CO)
Kerry Kamer, MD (Greeley, CO)
Don Downs, PA (Longmont, Fort Collins, Greeley, CO)
Fred Scherr, MD (Fort Collins, CO)
Ryan Otten, MD (Longmont, Boulder, CO)
Our business model is different for a reason. As the experts, we are an important and significant resource for our
clients as we understand all aspects of the workers’ compensation industry and we provide a comprehensive
corporate model of care. Our medical model is different for a reason. As the qualified provider, we schedule 30
minutes per initial injury visit allowing time for our providers to gain trust and understanding of the employee’s
injury and concerns. This in turn statistically shows our claims closing more consistently without reopens and
lower rates of Attorney involvement. We are like no other as we only provide professional medicine services to
you the employer, and are a partner in the care of your business and your employees managing the claim from start
to finish.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 7 of 22
Workwell fees for Workers’ Compensation Medical Cases follow the Colorado State Division of Workers’
Compensation Fee Schedule. The rates can change depending on the State Fee Schedule. The hourly fee for Expert
testimony is $450/hour. Workwell does not discount bills for prompt payment.
Our physicians and providers are the case managers. In order to provide quality medical care and excellent
customer service, they are limited to a maximum of 2-4 patients/hour and a maximum of 24 patients a day so
that each provider has time to fulfill necessary tasks associated with the case management requirements of
Workwell. Our providers are given the opportunity to provide customer service throughout the day and take
as many calls as they can around patient care. For those not immediately returned, phone calls are returned
the same day for medical communication and all other calls are returned within 24 hours.
Our office staff coordinates appointments with physical therapists, specialists’ referrals, and medical providers
to assure prompt care and effective follow up treatment. We have physical therapy gyms in each clinic to
minimize travel time and schedule visits conveniently and efficiently for our patients. All primary care medical
services and physical therapy services are provided on-site.
Our company provides basic laboratory services such as general screenings (TB, drug & alcohol, cholesterol,
etc.) and utilizes Quest Laboratories for all other services. Our facilities are also regional collection sites for
many other laboratories across the country.
X-ray, CT, and MRI imaging is provided by local imaging groups. All Subcontractors are separately owned
organizations. Imaging reviews films read by the physician and they are Board Certified radiologists. Workwell
is continuously evaluating opportunities to expand services in-house and will do so if and when needed.
Workwell has Pharmacy services available on-site, as well as quantitative Audio Booth testing and Pulmonary
Function testing at most clinic locations.
Workwell physicians follow the Colorado State Division of Workers’ Compensation Guidelines when treating
an employee who claims mental disability as a result of a physical injury.
Workwell physicians are the case managers and they oversee all aspects of treatment from consult evaluations to
specialist and physical therapy referrals. The physician’s primary goals are to provide personal and attentive medical
care, and to keep patients working while their injuries are being resolved as expeditiously and cost effectively as
possible. As the result of consistently returning employees back to full duty, Workwell has experienced less than
4% loss time cases. Our employer clients appreciate our provider’s prompt communication and availability to
discuss any issue regarding the employee’s work-related case.
An injured worker is rarely taken off work completely and appropriate restrictions are given in an effort to
allow the injury to heal. Modified work duty is always the first consideration, and even preferred, as this is
much more conducive to rapid recovery. Good communication between the physician and employer
representative is key to establishing and instituting an appropriate modified duty program.
Workwell only utilizes referral sources and/or diagnostic testing services that schedule and service patients within
0-72 hours, have direct service providers coordinate care with our physicians directly, provide any and all
paperwork in a timely and legible format, and with a complete understanding of the worker’s compensation system
at hand. This is important because they then understand the financial impact it has on our employer clients.
Workwell utilizes the most current, technologically advanced, occupational health specific Electronic Medical
Record available today. All WC-164’s and physician notes are currently available from our offices via email.
WWindow™ also allows an employer or their insurance carrier to access all reports, clinic information, visit
notes, etc. via an encrypted and HIPAA compliant electronic portal.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 8 of 22
SCOPE OF WORK
QUALIFICATIONS & EXPERIENCE
Our offices are open 8-5, Monday thru Friday with walk-in appointments available any time. Typically, we ask
that appointments be made in advance so that we can accommodate urgent injury care and so that we can
maintain wait times under 10 minutes. Walk-in availability is necessary for our clients and this concept is built
into our service model. Authorization is required for all patients; however, there are instances when this
procedure must be circumvented to provide immediate medical care. Our office staff coordinates activities with
nurses, medical assistants, and medical providers to assure prompt care. The front office staff then diligently
works to contact the employer, supervisors, insurance carriers, and/or specialists to coordinate any and all
documentation and authorization. Therefore, our offices will accommodate any and all walk-in appointments
with proper authorization.
Our organization has implemented a new Electronic Medical Records system (EMR) which integrates case
management for our physicians & staff. The system is configured to track certain types of appointments, referrals,
and orders and is managed by each staff member and medical provider to ensure that all documentation and visits
are completed. These are numbered; color coded and managed internally to help keep the case on track. Finally, for
many large employers, our staff conducts regular meetings to discuss cases and ensure that our team approach is
appropriate. We also have on-line reporting available for our employers via our WWindow™ system on our
website. This allows access to secure reports to help keep employers informed of patient visit information.
As the areas only 100% Occupational Medicine Specialists, our physicians are Level II Accredited per the Colorado
State Division of Worker’s Compensation. This allows our providers to treat patients to case closure, without
having to refer them out to another physician for disability rating/impairment ratings, if needed. With this Level II
knowledge and expertise, we understand how the treating and processing of on-the-job injuries affect employees and
your overall cost containment strategies.
Our entire delivery of care and service model is structured to not only allow the employee to feel comfortable with
the provider and our clinic, but it also gives the physician the opportunity to develop the most appropriate and
effective treatment plan. Workwell is a staunch advocate of education and communication with our employees and
their employers. Our clients find this to be extremely helpful and Workwell significantly reduces the ‘hassle-factor’
for employer representatives.
Workwell has 5 clinic locations in Northern Colorado (Longmont, Loveland, Greeley Boulder and Fort Collins)
and our computer system is seamless so your employees can use the location that is most convenient for them.
Workwell employees are treated in the same manner as that of our clients and vice versa. All individuals are
thoroughly tested, counseled, and followed-up with according to nationally recognized protocols. Our
“Exposure Control Plan” fully documents any and all bloodborne pathogens protocols and includes procedures,
protocols, checklists, records, etc.
Please Reference Attachment C for Bloodborne Pathogens Exposure Control Plan
On occasion, providers from our other locations may fill in for employees utilizing sick days or vacation. We
have dedicated ‘float’ providers internally that can be called upon if needed.
SERVICE/OFFICE STANDARDS
Workwell has an excellent relationship with our service contractors and referral specialists. We extend both
our customer service and expedited care models to any established business vendor and require professional,
appropriate, and time sensitive expectations. All vendors and/or referral sources services that utilize Workwell
services are agreed to respond either same day or within 24 hours. All medical referrals for testing or specialty
care are requested to be performed within 48 hours.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 9 of 22
All referrals are pre-authorized by either Workwell by the provider receiving the referral. Once authorization is
obtained, appointments are made by Workwell staff and all pertinent information sent to the referred office.
Also, any company or insurer specifically requiring specific documentation is then copied at this time.
Referral appointments are directed to local specialists can be customized to each client should they have a
preference. These appointments are made and tracked thru our computer system so that we are able make
sure that reports and notes are attached to the medical record. Appointments with the physician, following a
referral, are made at the time the referral appointment is made. Referrals appointments not completed within
72 are notified by our office. Furthermore, all no-show appointments are followed up by our staff and
documented to the employer and insurance company.
Missed appointments, cancellations, and other important information are independently tracked through our
system and can be communicated in part or in whole by our offices. There are no fees for missed appointments.
However, if a patient misses a second appointment, per the Colorado Workers’ Compensation Act, a third
“demand” appointment may be made by insurance carrier.
Workwell strives to keep communication open between our staff and our client. The physician provider (for
medical related issues) is the case manager and directly accessible by the employer and/or insurer. Each clinic
has a designated Director of Client Services (for account related issues) that provides account management
activities to clients. Finally, each clinic has a designated administrative supervisor (for administrative issues) that
can assist when needed. Also, our CEO and CMO are available for any client and any issue.
Workwell uses the Colorado WC-164 form. All Workwell forms are computer generated and either emailed
or faxed to the company contact. Furthermore, employers that designate Workwell have access to
WWindow™, a 128-bit encrypted HIPAA compliant online system to retrieve reports, notes, appointment
information, etc, all through a secure username and password.
Please Reference Attachment B for Clinic Forms
Workwell has the ability to customize processes for each client including the documentation provided, method
of transfer (fax, mail, email) and other specific processes. This information, including the provider phone call, is
usually transmitted same day, and in many cases, within 1 hour of service. Our normal method of notifying the
employer and adjustor on new injuries involve documentation (CO-164 or medical provider notes) sent via
email to the company contact or adjustor. The medical provider who rendered treatment will contact the
employer via phone to discuss the case. Physician calls on each new injury, red flags and special diagnostic
procedures. This is a routine system that is currently in place for all Workwell injuries, for all of our clients.
Our providers work hand in hand with employers to facilitate effective and appropriate return to work
programs. Communication is done via phone, fax, and email and customized on the preference of the company
contact.
Workwell can offer our clients at least one staffing a quarter without charge. Workwell providers written
medical treatment plan within 48 hours when requested. Our staff can also conduct return to work or fitness
for duty examinations as requested and provide appropriate feedback to staff regarding employees work
restrictions and the employees job duties.
Since Workwell, is 100% Occupational Medicine our providers constantly assess work relatedness and take the
time during the initial visit to diminish the possibility of fraudulent claims to the best of their ability.
Workwell’s front office staff pre-authorizes any and all work-related injury care services. Furthermore, after
pre-authorization, our staff will schedule the appointment for the patient and notify the employer for approval
prior to referral of the patient to another physician or outside facility. The patient is provided a written status
report following all visits.
Our company policy is to provide written results to employer and employee within 24 hours or sooner of DOT
Medical Exam. This can include a copy of DOT Card and Long form.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 10 of 22
Workwell provides occupational health related services that include physicals such as DOT, HAZMAT,
Respirator, pre and post-placement physicals, periodic/annual examinations, hearing, pulmonary, and/or
monitoring services, Impairment Ratings, essential job function testing and more. Due to the complex nature of
today’s employer, all our examination and monitoring services are customized to their specific need, their
specific job or department, and location. We can customize a procedure in a variety of ways to provide you the
service that you need. We can also make these jobs specific, outlined and documented for future reference.
Our facility is also a member of the eScreen Drug Screening Network (www.escreen.com). eScreen provides
affordable, rapid, compliant and efficient employee drug testing and background check services for companies
seeking faster hiring transactions and paperless solutions. Step-by-step protocols ensure consistency and total
electronic forms completion. Optical eReader technology determines test results under seal, leaving no room
for human or procedural errors. Results are immediately reported to the employer’s secure MyeScreen.com
account.
Please Reference Attachment D for Drug and Alcohol Policy and Procedures
Workwell is ADA Compliant at all locations.
Ergonomic services and Back Schools are billed at $120/hr. These are customized to your specific needs and can
be on-site at your location. Trainings, depending on the type, duration, and frequency, may or may not have
charges associated. We also provide a complete line of educational, training, and safety videos for $25/each.
Examples include:
First Aid/CPR/AED
Bloodborne Pathogens
Personal Protective Equipment
Hazard Communication
Back Injury/Hearing Protection
Emergency Preparedness
Slips/Trips/Falls Protection
Our website, www.workwellworks.com also provides information, updated monthly, to include safety tips and
topics, industry news, and more.
Please Reference Attachment E for Medical Case Management and Case Review
Please Reference Attachment F for HIPAA & Related Matters
BILLING (ALL BILLS WILL BE SENT TO THE OFFICE OF FINANCIAL SERVICES; CITY OF FORT COLLINS)
Workwell utilizes an electronic format and electronic clearinghouse to submit all workers’ compensation injury
claims and any electronic documentation that is provided to the City of Fort Collins will be in Adobe format
(.pdf). If the City of Fort Collins is unable to interface with the clearinghouse, we can submit all invoices either
via paper, email, or FTP. Workwll will use the HCFA 1500 billing form and the medical report will be attached
to the bill. Bills can be emailed.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 11 of 22
Attachment A
W-9
The W-9 is provided on the following page for your reference.
Form W-9 (Rev. 10-2007) Page 2
Sole proprietor. Enter your individual name as shown on your
income tax return on the “Name” line. You may enter your
business, trade, or “doing business as (DBA)” name on the
“Business name” line.
Other entities. Enter your business name as shown on required
federal tax documents on the “Name” line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
name on the “Business name” line.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Specific Instructions
Name
Exempt Payee
5. You do not certify to the requester that you are not subject
to backup withholding under 4 above (for reportable interest and
dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not to
willful neglect.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil and
criminal penalties.
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the “Exempt payee” box in the line following the
business name, sign and date the form.
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
3. The IRS tells the requester that you furnished an incorrect
TIN,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your tax return.
1. You do not furnish your TIN to the requester,
Form W-9 (Rev. 10-2007) Page 3
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.ssa.gov. You
may also get this form by calling 1-800-772-1213. Use Form
W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can
apply for an EIN online by accessing the IRS website at
www.irs.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W-7
and SS-4 from the IRS by visiting www.irs.gov or by calling
1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN,
write “Applied For” in the space for the TIN, sign and date the
form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily
tradable instruments, generally you will have 60 days to get a
TIN and give it to the requester before you are subject to backup
withholding on payments. The 60-day rule does not apply to
other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to
the requester.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are a single-member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter the owner’s SSN (or EIN, if the owner
has one). Do not enter the disregarded entity’s EIN. If the LLC is
classified as a corporation or partnership, enter the entity’s EIN.
Note. See the chart on page 4 for further clarification of name
and TIN combinations.
Note. Entering “Applied For” means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner
must use the appropriate Form W-8.
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
THEN the payment is exempt
for . . .
IF the payment is for . . .
Form W-9 (Rev. 10-2007) Page 4
Give name and EIN of:
For this type of account:
3. Real estate transactions. You must sign the certification.
You may cross out item 2 of the certification.
A valid trust, estate, or pension trust
6.
Legal entity 4
4. Other payments. You must give your correct TIN, but you
do not have to sign the certification unless you have been
notified that you have previously given an incorrect TIN. “Other
payments” include payments made in the course of the
requester’s trade or business for rents, royalties, goods (other
than bills for merchandise), medical and health care services
(including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
The corporation
Corporate or LLC electing
corporate status on Form 8832
7.
The organization
Association, club, religious,
charitable, educational, or other
tax-exempt organization
8.
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,
Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your
correct TIN, but you do not have to sign the certification.
The partnership
Partnership or multi-member LLC
9.
The broker or nominee
A broker or registered nominee
10.
The public entity
Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
11.
Privacy Act Notice
List first and circle the name of the person whose number you furnish. If only one person
on a joint account has an SSN, that person’s number must be furnished.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business or “DBA”
name on the second name line. You may use either your SSN or EIN (if you have one),
but the IRS encourages you to use your SSN.
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN
of the personal representative or trustee unless the legal entity itself is not designated in
the account title.) Also see Special rules for partnerships on page 1.
Note. If no name is circled when more than one name is listed,
the number will be considered to be that of the first name listed.
Disregarded entity not owned by an
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 12 of 22
Attachment B
CLINIC FORMS
Clinic Forms are provided on the following page for your reference:
1. Consent to Treatment
2. Consent to Treatment – Drug & Alcohol Screening
3. Consent to Treatment – Immunizations
4. CO-164
5. Notice of Missed or Cancelled Appointment
6. Physical Results Report
7. POET Exam Results Report
8. Drug & Alcohol Report
*The forms included in this proposal are copies of .PDF forms and may not be an accurate reflection of the true image quality.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 13 of 22
Attachment C
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
The Bloodborne Pathogens Exposure Control Plan is provided on the following pages for your reference.
WORKWELL Occupational Medicine
Colorado Center for Rehabilitation
BLOODBORNE PATHOGENS
EXPOSURE CONTROL PLAN
(Revised January 15, 2007)
revised 1/15/07 2
BLOODBORNE PATHOGENS
EXPOSURE CONTROL PLAN
TABLE OF CONTENTS
A. Purpose.............................................................................................................................. 3
B. Authority and Reference.................................................................................................. 3
C. Application......................................................................................................................... 3
D. Responsibility for Compliance......................................................................................... 3
E. Exposure Determination.................................................................................................... 4
F. Methods for Compliance.................................................................................................... 5
G. Hepatitis B Vaccination..................................................................................................... 10
H. Post Exposure Evaluation and Follow -up....................................................................... 12
I. Communication about Hazards to Employees................................................................. 14
J. RecordKeeping..................................................................................................................... 15
K. Evaluation and Review....................................................................................................... 16
Appendix A............. ................................................................................................................. 17
Appendix B............................................................................................................................... 21
Appendix C............................................................................................................................... 22
Appendix D............................................................................................................................... 23
Appendix E............................................................................................................................... 24
Appendix F................................................................................................................................ 25
Appendix G............................................................................................................................... 26
Appendix H............................................................................................................................... 27
Appendix I................................................................................................................................. 28
Appendix J................................................................................................................................. 29
revised 1/15/07 3
WORKWELL Occupational Medicine
Date of Preparation ____________________________
A. PURPOSE
The purpose of this Bloodborne Pathogens Exposure Control Plan is to protect the
health and safety of all employees who can be reasonably expected, as the result of
performing their job duties, to be exposed to blood or potentially infectious
materials and comply with the COMM/OSHA Standard 29 CFR 1910.1030
Bloodborne Pathogens Exposure Control. Definitions of terms relating to this
exposure control plan are found in Appendix A.
B. AUTHORITY & REFERENCE
Occupational Safety and Health Administration (OSHA) CFR 29 1910.1030
Dept. of Commerce (Chapter 32)
C. APPLICATION
This plan applies to all employees who are engaged in activities that involve
exposures to blood or other body fluids.
D. RESPONSIBILITY FOR COMPLIANCE
The development and administration of this Bloodborne Pathogens Exposure
Control Plan will be the responsibility of the on-site medical provider. These
responsibilities will include
1. Establishing a written exposure control plan and developing a schedule for
implementing other provisions of the standard.
2. Developing written procedures for cleaning and handling contaminated
materials, and for disposing of hazardous waste generated within all
buildings and facilities.
3. Providing appropriate personal protective equipment that is readily
accessible to identified employees.
4. Providing hepatitis B vaccines under specific circumstances as defined by
an exposure determination and/or medical follow-up for exposure incidents.
5. Providing warning labels or color-coded containers for use with hazardous
waste.
6. Providing training to current employees within 90 days of the effective date,
of the plan and initially to new employees and thereafter, annually.
7. Developing written procedures for meeting the requirements for medical
record keeping.
revised 1/15/07 4
8. Providing for retention of medical records for the duration of employment,
plus 30 years.
9. Conducting an annual review of the effectiveness of this exposure control
plan and updating the plan as needed.
E. EXPOSURE DETERMINATION
This Company will determine which employees can reasonably be expected to be
exposed to blood or other body fluids containing blood in the course of their work.
These employees, for the purposes of compliance with this standard, may include
1) designated first aid providers, i.e. those employees whose primary job
assignment would include rendering first aid; and 2) those employees who might
render first aid only as a collateral duty. Note: These exposure determinations may
be performed by a qualified person (i.e. occupational, public health or infection
control nurse, industrial hygienist or safety professional) or a committee consisting
of qualified persons with appropriate education, experience and/or training. The
committee should include one or more representatives from management and from
employees.
All decisions relating to Bloodborne exposure by job classification will be
documented using the form found in Appendix B.
A. Job Classifications
The Chief Medical Officer (CMO) has identified the following job
classifications as those in which employees could be exposed to Bloodborne
pathogens in the course of fulfilling their job requirements:
Job Classifications:
1. Medical Provider (Physician, Nurse Practitioner, Physicians Assistant)
2. Medical Assistant
3. Front Office Personnel
4. Physical Therapist
B. Tasks and Procedures
This Company will determine a list of tasks performed by employees in the above
job classifications in which exposure to Bloodborne pathogens may occur (without
regard to the use of personal protective equipment) and the safety precautions and
personal protective equipment that must be observed and used to prevent contact
with Bloodborne pathogens (See Appendix C)
Note: These tasks/procedures may include, but not be limited to, the following
examples:
1. Care of minor injuries, i.e., bloody nose, scrape, minor cuts;
2. Initial care of injuries that require medical or dental assistance, i.e.,
damaged teeth, broken bone protruding through the skin, severe
laceration;
revised 1/15/07 5
3. Care of patients with medical needs, i.e., tracheotomy, colostomy,
injections;
4. Care of patients who need assistance in daily living skills, i.e.,
toileting, dressing, hand washing, feeding and menstrual needs;
5. Care of patients who exhibit behaviors that may injure themselves or
others, i.e., biting, hitting, scratching;
6. Care of an injured person in laboratory setting, vocational education
setting, etc;
7. Care of injured person during a therapeutic or rehabilitative activity;
8. Cleaning tasks associated with body fluid spills.
F METHOD OF COMPLIANCE
The following methods of compliance, as mandated by the COMM/OSHA
standard, will be incorporated into this exposure control plan. This Company will
determine appropriate specific guidelines for cleaning, decontamination and waste
disposal procedures. Note: Once these guidelines are written, they should be
distributed to the affected employees and/or posted in appropriate locations and the
contents included in the training program.
A. Universal Precautions
Universal precautions will be used in order to prevent contact with blood or
other potentially infectious materials (OPIM). All blood or other potentially
contaminated body fluids will be considered to be infectious. Under
circumstances in which differentiation among body fluid types is difficult or
impossible, all body fluids will be considered potentially infectious
materials.
B. Engineering and Work Practice Controls
Engineering and work practice controls are designed to eliminate or minimize
employee exposure. Where occupational exposure remains after institution of these
controls, personal protective equipment shall also be used.
C. Exposure Incident Investigation
An exposure incident is defined as contact with blood or other potentially
infectious materials on an employee's non-intact skin, eye, mouth, other
mucous membrane or by piercing the skin or mucous membrane through
such events as needle sticks.
An exposure incident investigation form will be completed each time an
exposure incident occurs (See Appendix D).
D. Handwashing
revised 1/15/07 6
1. This Company will provide handwashing facilities which are readily
accessible to employees, or when provision for handwashing
facilities is not feasible, this Company will provide either an
appropriate antiseptic hand cleanser in conjunction with clean
cloth/paper towels or antiseptic towelettes.
2. Employees will wash hands or any other skin with soap and water,
or flush mucous membranes with water immediately or as soon as
feasible following contact of such body areas with blood or other
potentially infectious materials.
3. Employees will wash their hands immediately or as soon as feasible
after removal of gloves or other personal protective equipment.
When antiseptic hand cleaners or towelettes are used, hands will be
washed with soap and running water as soon as feasible. Do not
reuse gloves.
E. Housekeeping and Waste Procedures
a. This Company will ensure that the worksite is maintained in a clean
and sanitary condition. This Company will also determine and
implement an appropriate written schedule for cleaning and method
of decontamination based upon the location within the facility, type
of surface to be cleaned, type of soil present and the tasks or
procedures being performed.
2. All equipment, materials, environmental and working surfaces will
be cleaned and decontaminated after contact with blood or other
potentially infectious materials.
a. Contaminated work surfaces will be decontaminated
with an appropriate disinfectant immediately after
completion of procedures/task/therapy, or as soon as
feasible, when surfaces are overtly contaminated or
after any spill of blood or other potentially infectious
materials, and at the end of the work day if the
surface may have become contaminated since the last
cleaning.
b. Protective coverings, such as plastic wrap, aluminum
foil, or imperiously-backed absorbent paper used to
cover equipment and environmental surfaces, will be
removed and replaced as soon as feasible when they
become contaminated with blood or OPIM, or at the
end of the school day if they have become
contaminated since the last cleaning.
3. All bins, pails, cans, and similar receptacles intended for reuse
which have a reasonable likelihood for becoming contaminated with
blood or other potentially infectious materials will be inspected and
decontaminated on a regularly scheduled basis and cleaned and
decontaminated immediately or as soon as feasible upon visible
contamination.
revised 1/15/07 7
4. Materials, such as paper towels, gauze squares or clothing, used in
the treatment of blood or OPIM spills that are blood-soaked or caked
with blood will be bagged, tied and designated as a biohazard. The
bag will then be removed from the site as soon as feasible and
replaced with a clean bag. Bags designated as biohazard (containing
blood or OPIM contaminated materials) bags will be red in color or
affixed with a biohazard label and will available at the following
locations:
Locations:
1. Medical Procedure Room at each location
Note: According to the Department of Health and Social
Services, biohazardous waste for this standard's purposes
will only include items that are blood-soaked, caked with
blood or contain liquid blood that could be wrung out of the
item. This would also include items such as sharps, broken
glass or plastic on which there is fresh blood.
5. A custodian will respond immediately to any major blood or OPIM
incident so that the area can be cleaned, decontaminated, and the
material removed immediately.
Note: A major blood or OPIM incident is one in which there will be
biohazardous material for disposal.
6. * A marked biohazard container will be available in the medical
procedure area for the containment of biohazards designated bags.
7. In the event that regulated waste leaks from a bag or container, the
waste will be placed in a second container and the area will be
cleaned and decontaminated.
8. Broken glass contaminated with blood or OPIM will not be picked
up directly with the hands. The glass will be cleaned up using
mechanical means, such as a brush and dustpan, tongs, or forceps.
All broken glass will be containerized.
9. Contaminated sharps, broken glass, plastic or other sharp objects
will be placed into appropriate sharps containers. The sharps
containers will be closeable, puncture resistant, labeled with a
biohazard label, and leak proof. Containers will be maintained in an
upright position. Containers will be easily accessible to staff and
located as close as feasible to the immediate area where sharps are
used or can be reasonably anticipated to be found. If an incident
occurs where there is contaminated material that is too large for a
sharps container, the custodian will be contacted immediately to
obtain an appropriate biohazard container for this material.
Reusable sharps that are contaminated with blood or other
potentially infectious materials will not be stored or
processed in a manner that requires employees to reach by
revised 1/15/07 8
hand into the containers where these sharps have been
placed.
* Employees will notify clinic administrator when sharp
containers become 3/4 full so that the containers can be
disposed of properly. Note: Our company utilizes a third
party vendor for disposal of medical and contagious waste.
Contaminated needles will not be bent, recapped, removed,
sheared or purposely broken.
10. Disposal of all regulated waste will be in accordance with applicable
regulations of the United States, the Department of Commerce and
the Department of Natural Resources.
11. Food and drink will not be kept in refrigerators, freezers, cabinets,
or on shelves, counter-tops or bench tops where blood or other
potentially infectious materials are present.
12. All procedures involving blood or other potentially infectious
materials will be performed in such a manner as to minimize
splashing, spraying, splattering, and generating droplets of these
substances. Mouth pipetting/ suctioning of blood or OPIM is
prohibited; e.g., sucking out snakebites.
13. Specimens of blood or other potentially infectious materials will be
placed in containers which prevent leaking during collection,
handling, processing, storage, transport, or shipping. These
containers will be labeled with a biohazard symbol or be colored
red.
14. Equipment which may become contaminated with blood or other
potentially infectious material is to be examined prior to servicing
and shipping and is to be decontaminated, if feasible. If not feasible,
a readily observable biohazard label stating which portions are
contaminated is to be affixed to the equipment. This information is
to be conveyed to all affected employees, the service representative,
and/or manufacturer, as appropriate, prior to handling, servicing or
shipping. Equipment to consider may include communication
devices, and vocational equipment needing repair after an exposure
incident.
15. Contaminated laundry will be handled as little as possible. Gloves must be
worn when handling contaminated laundry. Contaminated laundry will be
bagged or containerized at the location where it was used and will not be
sorted or rinsed in the location of use. Containers must be leak-proof if there
is reasonable likelihood of soak-through or leakage. All contaminated
laundry will be placed and transported in bags or containers that are
biohazard-labeled or colored red.
16. Equipment which may become contaminated with blood or other potentially
infectious materials shall be examined prior to servicing or shipping and
shall be decontaminated as necessary, unless the employer can demonstrate
that decontamination of such equipment or portions of such equipment is
not feasible.
revised 1/15/07 9
17. The employer shall ensure that this information is conveyed to all affected
employees, the servicing representative, and/or the manufacturer, as
appropriate, prior to handling, servicing, or shipping so that appropriate
precautions will be taken.
F. Personal Protective Equipment
1. Where the potential of occupational exposure remains after institution of
engineering and work controls, personal protective equipment will be used.
Personal protective equipment will be considered "appropriate" only if it
does not permit blood or other potentially infectious materials to pass
through to or reach the employee's work clothes, street clothes,
undergarments, skin, eyes, mouth, or other mucous membranes under
normal conditions of use and for the duration of time which the protective
equipment will be used. The employer shall clean, launder, repair and
replace, and dispose of personal protective equipment at no cost to the
employee. The types of personal protection equipment (PPE) available
employees include:
Types of Personal Protective Equipment
1. Face Shields
2. Disposable Gloves – Latex and Latex-Free
3. Disposable Aprons
a. Gloves will be worn when it can be reasonably anticipated that the
employee may have hand contact with blood, other potentially
infectious materials, mucous membranes, and non-intact skin; and
when handling or touching contaminated items or surfaces.
b. Disposable gloves will be replaced as soon as practical when
contaminated or as soon as feasible if they are torn, punctured, or
when the ability to function as a barrier is compromised. Disposable
gloves will not be washed or decontaminated for re-use
(contaminated disposable gloves do not meet the DNR definition of
infectious waste and do not need to be disposed of in red or specially
labeled bags).
c. Hypoallergenic gloves, glove liners, powderless gloves, or other
similar alternatives will be readily accessible to those employees
who are allergic to the gloves nominally provided.
d. Masks, in combination with eye protection devices, such as goggles
or glasses with solid side shields, or chin-length face shields, will be
worn whenever splashes, spray, spatter, or droplets of blood or other
potentially infectious materials may be generated and eye, nose, or
mouth contamination can be reasonably anticipated, i.e., custodian
cleaning a clogged toilet, nurses or aides who are performing
suctioning.
e. Appropriate protective clothing will be worn in occupational
exposure situations. The type and characteristics will depend upon
the task, location, and degree of exposure anticipated.
revised 1/15/07 10
2. This Company will ensure that appropriate personal protective
equipment is readily accessible at the worksite. Personal protective
equipment will be available in the following locations:
Locations:
1. Medical Procedure Room at each location
a. The Employer will clean, launder and dispose of personal protective
equipment, at no cost to the employee.
b. The Employer will repair or replace personal protective equipment
as needed to maintain its effectiveness, at no cost to the employee.
3. All personal protective equipment will be removed prior to leaving
the work area. When personal protective equipment/supplies are
removed, the equipment will be placed in an appropriately
designated area or container for storage, washing, decontamination
or disposal.
4. If a garment(s) is penetrated by blood or other potentially infectious
materials, the garment(s) will be removed immediately, or as soon
as feasible.
5. Supervisors will ensure that their employees use the appropriate
personal protective equipment. If an employee temporarily and/or
briefly declines to use personal protective equipment because the
equipment is in his/her judgment that in that particular instance it
would have posed an increased hazard to the employee or others, in
that particular instance, the Company will investigate and document
the circumstances in order to determine whether changes can be
instituted to prevent such occurrences in the future.
G. HEPATITIS B VACCINATION
A. The hepatitis B vaccine will be available for employees whose designated
job assignment includes the rendering of first aid treatment, or who have
occupational exposure to blood or OPIM.
1. This Company will make the hepatitis B vaccination series available
to all employees who have occupational exposure after the
employee(s) have been given information on the hepatitis B vaccine,
including information on its efficacy, safety, method of
administration and the benefits of being vaccinated. The
vaccinations will be offered at not cost to the employee and at
reasonable times.
2. The Clinic Adminstrator will make the hepatitis B vaccination series
available after the training and within 10 working days of initial
assignment to all employees who have occupational exposure.
3. The hepatitis B vaccination series will be made available to the
employee at a reasonable time and place, and performed by or under
the supervision of a licensed physician according to the most current
recommendations of the U.S. Public Health Service. This Company
revised 1/15/07 11
will assure that the laboratory tests are then conducted by an
accredited laboratory.
4. This Company will not make participation in a pre-employment
screening program a prerequisite for receiving the hepatitis B
vaccine.
5. If an employee initially declines the hepatitis B vaccination series,
but at a later date while still covered under the standard decides to
accept the vaccination, this Company will make available the
hepatitis B vaccine at that time.
6. The Clinic Administrator will assure that employees who decline to
accept the hepatitis B vaccine offered by this Company will sign the
declination statement established under the standard. (Appendix E).
7. If a routine booster dose(s) of hepatitis B vaccine is recommended
by the U.S. Public Health Service or other health care provided at a
future date, the booster dose(s) will be made available at no charge
to the employee.
8. Records regarding HBV vaccinations or declinations will be
maintained by the Clinic Administrator.
9. The Clinic Administrator will ensure that the health care
professional responsible for employee's hepatitis B vaccination is
provided with a copy of this regulation.
B. Hepatitis B vaccines will be available for employees who render first aid
only as a collateral duty responding solely to injuries resulting from
workplace incidents, generally at the location where the incident occurred.
1. The Clinic Administrator will provide the hepatitis B vaccine or
vaccination series to those unvaccinated employees whose primary
job assignment is not the rendering of first aid only in the event that
they render assistance in any situation involving the presence of
blood or OPIM as identified in Appendix B.
2. All first aid incidents involving the presence of blood or OPIM will
be reported to this Company's Clinic Administrator by the end of the
work day on which the incident occurred.
3. The Company's exposure incident investigation form (See Appendix
D) will be used to report first aid incidents involving blood or
OPIM. The incident description must include a determination of
whether or not, in addition to the presence of blood or other
potentially infected materials, an "exposure incident," as defined by
the standard, occurred.
4. This determination is necessary in order to ensure that the proper
post-exposure evaluation, prophylaxis and follow-up procedures are
made available immediately if there has been an exposure incident
as defined by the standard.
revised 1/15/07 12
5. The full hepatitis B vaccination series will be made available as
soon as possible, but in no event later than 24 hours, to all
unvaccinated first aid providers who have rendered assistance in any
situation involving the presence of blood or other potentially
infectious materials regardless of whether or not a specific
"exposure incident," as defined by the standard, has occurred.
6. The hepatitis B vaccination record or declination statement will be
completed for each exposed employee (See Appendix E or F). All
other pertinent conditions will also be followed for those persons
who receive the pre-exposure hepatitis B vaccine.
7. This incident investigation form will be recorded on a list of
recorded first aid incidents and will be readily available to
employees.
8. This reporting procedure will be included in the training program.
H. POST-EXPOSURE EVALUATION AND FOLLOW-UP
A. Following a report of an exposure incident, this Company will-make
immediately available to the exposed employee a confidential medical
examination and follow-up, including at least the following elements (See
Appendix G):
1. Documentation of the route(s) of exposure, and the circumstances
under which the exposure incident occurred;
2. Identification and documentation of the source individual, if
possible, or unless this Company can establish that identification is
infeasible or prohibited by state or local law;
a. The source individual's blood will be tested as soon as
feasible and after consent is obtained in order to determine
HBV and HIV infectivity. If consent is not obtained, this
Company will establish that legally required consent cannot
be obtained. When the source individual's consent is not
required by law, the source individual's blood, if available,
shall be tested and the results documented.
b. Results of the source individual's testing will be made
available to the exposed employee only after consent is
obtained, and the employee will be informed of applicable
laws and regulations concerning disclosure of the identity
and infectious status of the source individual.
3. The exposed employee's blood will be collected as soon as feasible
and tested after consent is obtained. If the employee consents to
baseline blood collection, but does not consent at that time for HIV
serological testing, the sample will be preserved for at least 90 days.
If, within 90 days of the exposure incident, the employee elects to
have the baseline sample tested, such testing will be done as soon as
feasible.
revised 1/15/07 13
4. For post-exposure prophylaxis, this Company will follow
recommendations established by the U.S. Public Health Service:
a. Retesting for HIV at 6 weeks, 3 months, and 6 months post exposure.
b. Retesting for Hepatitis C and liver function screening (ALT) at 6 months.
c. Complete Hepatitis B vaccination series (1 month, 2 month, 6 months)
d. Complete tetanus immunization at incident, 1 month and 6 months.
5. Counseling will be made available at no cost to employees and their
families on the implications of testing and post-exposure
prophylaxis;
a. Until results are know, it is recommended that exposed individuals should
practice “safe sex” (latex condom and HIV virucidal contraceptive material)
or abstinence for 6 months. Also, refrain from donating blood until re-tested
and prevent exposure (Hepatitis) by refraining to share toothbrushes or razors.
The risk of transmission perinatally or by breastfeeding is unknown.
6. An evaluation of any reported illnesses will be conducted.
7. Follow-up procedures for Post Exposure (reference Follow-Up
Protocol in Policy & Procedures Manual), to include HIV:
a. Schedule follow-up appointment at appropriate interval (Sec. H.4)
b. Have patient pre-address reminder card and return to scheduler
c. Mail out reminder postcard 7-10 calendar days before scheduled appt.
d. If patient “no-shows” for appointment, call patient and employer to
reschedule.
e. Call patient daily until new appointment set. If unable to contact after
(3) attempts, contact employer again.
f. After (10) days of no response, send patient a certified letter with
return receipt and signature required, advising to call and schedule appt.
B. This Company will ensure that all medical evaluations and procedures,
including prophylaxis, are made available at no cost and at a reasonable
time and place to the employee. All medical evaluations and procedures
will be conducted by or under the supervision of a licensed physician and
laboratory tests will be conducted in accredited laboratories.
C. Information provided to the health care professional who evaluates the
employee will include (See Appendix G):
1. A description of the employee's duties as they relate to the exposure
incident;
2. Documentation of the route of exposure and the circumstances under
which the exposure occurred;
3. Results of the source individual's blood testing, if consent was given
and the results are available;
revised 1/15/07 14
4. All medical records relevant to the appropriate treatment of the
employee, including vaccination status are this Company’s
responsibility to maintain.
D. This Company will obtain and provide the employee with a copy of the
evaluating health care professional's written opinion within 15 days of the
completion of the evaluation.
1. The health care professional's written opinion for hepatitis B
vaccination will be limited to whether hepatitis B vaccination is
indicated for an employee, and if the employee has received such
vaccination.
2. The health care professional's written opinion for post-exposure
evaluation and follow-up shall be limited to the following
information:
a. This employee has been informed of the results of the
evaluation; and
b. This employee has been told about any medical conditions
resulting from exposure to blood or other potentially
infectious materials which require further evaluation and or
treatment.
3. All other findings or diagnoses will remain confidential and will not
be included in the written report.
I. COMMUNICATION ABOUT HAZARDS TO EMPLOYEES
A. Warning labels will be affixed to containers of regulated waste,
refrigerators, and freezers containing blood or other potentially infectious
material; and other containers used to store, transport or ship blood or other
potentially infectious materials. Exception: Red bags or red containers may
be substituted for labels.
1. These labels will be fluorescent orange or orange-red or
predominantly so, with lettering or symbols in a contrasting color.
2. These labels will be an integral part of the container or will be
affixed as close as feasible to the container by string, wire, adhesive,
or other methods that prevent their loss or unintentional removal.
3. Labels for contaminated equipment must follow the same labeling
requirements. In addition, the labels will also state which portions of
the equipment remain contaminated.
B. Information and Training
revised 1/15/07 15
1. This Company will ensure that all current and new employees with
potential for occupational exposure participate in an initial and
annual training program at no cost to employees.
2. Training will be provided at the time of initial assignment to tasks
when occupational exposure may take place and at least annually
thereafter.
Note: For employees who have received training on Bloodborne in
pathogens that preceded the effective date of this standard,
only training with respect to the provisions of the standard
which were not included need to be provided.
3. This Company will provide additional training when changes, such
as modifications of tasks or procedures, affect employee potential
for occupational exposure. The additional training may be limited to
addressing the new exposures created.
4. Only material appropriate in content and vocabulary to the
educational level, literacy and language of employees will be used in
the training. Appendix H contains the required content for training.
5. The person conducting the training will be knowledgeable in the
subject matter covered by the elements contained in the training
program, as it relates to this Company workplace.
J. RECORDKEEPING
A Medical Records (See Appendix G):
1. This Company will establish and maintain an accurate medical
record for each employee with an occupational exposure. This
record will include:
a. The name and social security number of employee;
b. A copy of employee's hepatitis B vaccination record or
declination form and any additional medical records relative
to hepatitis B;
c. If exposure incident(s) have occurred, a copy of all results of
examinations, medical testing and follow-up procedures;
d. If exposure incident(s) have occurred, a copy of the health
care professional's written opinion;
e. If exposure incident(s) have occurred, a copy of the
information provided to the health care professional: i.e.,
exposure incident investigation form and the results of the
source individual's blood testing, if available and if consent
has been obtained for release.
revised 1/15/07 16
2. This Company will insure that the employee's medical records are
kept confidential and are not disclosed or reported without the
employee's expressed written consent to any person within or
outside of this Company, except as required by law. These medical
records will be kept separate from other personnel records.
3. These medical records will be maintained for the duration of
employment plus 30 years.
B. Training Records (See Appendix H)
1. Training records will include:
a. The date(s) of the training session
b. The contents or a summary of the training sessions
c. The name(s) and qualifications of person(s) conducting the
training
d. The name and job titles of all persons attending the training
session
2. Training records will be maintained for 10 years from the date the
training occurred.
C. Availability of Records
This Company will insure:
1. All records required to be maintained by this standard will be made
available upon request to the Department of Commerce upon request
for examination and copying.
2. Employee training records required by this standard will be provided
upon request for examination and copying to employees, to
employee representatives, and to the Department of Commerce.
3. Employee medical records required by this standard will be
provided upon request for examination and copying to the subject
employee and to anyone having written consent of the affected
employee and to the Department Commerce.
4. This Company will comply with the requirements involving the
transfer of records set forth in this standard.
K. EVALUATION AND REVIEW
A. The CMO will conduct an annual evaluation and review of
the effectiveness of this exposure control plan and will coordinate corrective
action and update the plan as needed.
NOTE: When there is an asterisk (*) placed in front of a guideline, then this
plan is not required by the Bloodborne Pathogens Exposure Control standard. This
written exposure control plan was developed by the Wisconsin Department of Public Instruction,the Bureau
of State Risk Management, and adapted by WORKWELL Occupational Medicine. This plan is available on
computer disk. (File name exposure control plan.doc).
revised 1/15/07 17
Appendix A
DEFINITIONS FOR THE PURPOSES OF THIS
EXPOSURE CONTROL PLAN
Antibody a substance produced in the blood of an individual which is capable
of producing a specific immunity to a specific germ or virus.
Amniotic Fluid the fluid surrounding the embryo in the mother's womb.
Antigen any substance which stimulates the formation of an antibody
Assistant Secretary the Assistant Secretary of Labor for Occupational Safety and Health,
or designated representative.
Biohazard Label a label affixed to containers of regulated waste, refrigerators/freezers
and other containers used to store, transport or ship blood and other
potentially infectious materials. The label must be fluorescent
orange-red in color with the biohazard symbol and the word
biohazard on the lower part of the label.
Blood human blood, human blood components, and products made from
human blood.
Bloodborne Pathogens pathogenic (disease producing) microorganisms that are present in
human blood and can cause disease in humans. These pathogens
include, but are not limited to, hepatitis B virus (HBV) and human
immunodeficiency virus (HIV)
Cerebrospinal Fluid a clear, colorless fluid surrounding the brain and spinal cord. It can
be withdrawn by performing a spinal puncture.
Clinical Laboratory a workplace where diagnostic or other screening procedures are
performed on blood or other potentially infectious materials.
Contaminated the presence or the reasonably anticipated presence of blood or other
potentially infectious materials on an item or surface.
Contaminated Laundry laundry which has been soiled with blood or other potentially
infectious materials or may contain sharps.
Contaminated Sharp any contaminated object that can penetrate the skin including, but
not limited to needles, scalpels, broken glass, capillary tubes, and
the exposed ends of dental wires.
Decontamination the use of physical or chemical means to remove, inactivate, or
destroy Bloodborne pathogens on a surface or item to the point
where they are no longer capable of transmitting infectious particles
and the surface or item is rendered safe for handling, use or disposal.
COMM Industry, Labor and Human Relations
revised 1/15/07 18
Engineering Controls controls (i.e., sharps disposal containers, self-sheathing needles) that
isolate or remove the Bloodborne pathogens hazard from the
workplace.
Exposure Control Plan a written program developed and implemented by the employer
which sets forth procedures, engineering controls, personal
protective equipment, work practices and other methods that are
capable of protecting employees from exposures to Bloodborne
pathogens, and meets the requirements spelled out by the OSHA
Bloodborne Pathogens Standard.
Exposure Determination how and when occupational exposure occurs and which job
classifications and/or individuals are at risk of exposure without
regard to the use of personal protective equipment.
Exposure Incident a specific eye, mouth, other mucous membrane, non-intact skin, or
parenteral contact with blood or other potentially infectious
materials that results from the performance of an employee's duties.
Handwashing Facilities a facility providing an adequate supply of running potable water,
soap and single use towels, medicated towelettes or hot air drying
machines.
HBV Hepatitis B Virus.
HIV Human Immunodeficiency Virus.
Licensed Health care
Professional a person whose legally permitted scope and practice allows him or
her to independently perform the activities required by paragraph (f)
of the standard: hepatitis B vaccination and post exposure evaluation
and follow-up. (In Wisconsin onlya licensed physician meets
definition).
Medical Consultation a consultation which takes place between an employee and a
licensed healthcare professional for the purpose of determining the
employee's medical condition resulting from exposure to blood or
other potentially infectious materials, as well as any further
evaluation or treatment that is required.
Mucus a thick liquid secreted by glands, such as those lining the nasal
passages, the stomach and intestines, the vagina, etc.
Mucous Membranes a surface membrane composed of cells which secrete various forms
of mucus, as in the lining of the respiratory tract and the
gastrointestinal tract, etc.
Occupational Exposure a reasonably anticipated skin, eye, mucous membrane, or parenteral
contact with blood or other potentially infectious materials that may
result from the performance of an employee's duties.
OSHA the Occupational Safety and Health Administration of the U.S.
Department of Labor; the Federal agency with safety and health
revised 1/15/07 19
regulatory and enforcement authorities for most U.S. industry and
business.
Other Potentially (1) the following human body fluids: semen, vaginal secretions,
Infectious Materials menstrual blood, vomit, cerebrospinal fluid, synovial fluid,
(0PIM) pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva
in dental procedures, any body fluid that is visibly contaminated
with blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids; (2) any unfixed
tissue or organ (other than intact skin) from a human (living or
dead); and (3) HIV-containing cell or tissue cultures, organ cultures,
and HIV- or HBV-containing culture medium or other solutions; and
blood, organs, or other tissues from experimental animals infected
with HIV or HBV.
Parenteral piercing mucous membranes or the skin barrier through such events
as needlesticks, human bites, cuts, and abrasions.
Pathogen a bacteria or virus capable of causing infection or disease.
Pericardial Fluid fluid from around the heart.
Pericardium the sheath of tissue encasing the heart.
Peritoneal Fluid the clear straw-colored serous fluid secreted by the cells of the
peritoneum.
Peritoneum the lining membrane of the abdominal (peritoneal) cavity. It is
composed of a thin layer of cells.
Personal Protective
Equipment specialized clothing or equipment worn by an employee for
protection against a hazard. General work clothes (i.e., uniforms,
pants, shirts or blouses) not intended to function as protection
against a hazard are not considered to be personal protective
equipment. Personal protective equipment may include, but is not
limited to, gloves, gowns, laboratory coats, face shields or masks
and eye protection equipment, and mouthpieces, resuscitation bags,
pocket masks, or other ventilation devices. Personal protective
equipment will be considered "appropriate" only if it does not permit
blood or other potentially infectious materials to pass through to or
reach the employee's work clothes, street clothes, undergarments,
skin, eyes, mouth, or other mucous membrane under nominal
conditions of use and for the duration of time which the protective
equipment is used.
Pleural the membrane lining the chest cavity and covering the lungs. It is
made up of a thin sheet of cells.
Pleural Fluid fluid from the pleural cavity.
Production Facility a facility engaged in industrial-scale, large-volume or high
concentration production of HIV or HBV.
revised 1/15/07 20
Prophylaxis the measures carried out to prevent diseases.
Regulated Waste liquid or semi-liquid blood or other potentially infectious materials
in a liquid or semi-liquid state if compressed; items that are caked
with dried blood or other potentially infectious materials and are
capable of releasing these materials during handling; contaminated
sharps; and pathological and microbiological wastes containing
blood or other potentially infectious materials.
Research Laboratory a laboratory producing or using research-laboratory-scale amounts
of HIV or HBV. Research laboratories may produce high
concentrations of HIV or HBV but not in the volume found in
production facilities.
Serous Fluids liquids of the body, similar to blood serum, which are in part
secreted by serous membranes.
Source Individual any individual, living or dead, whose blood or other potentially
infectious materials may be a source of occupational exposure to the
employee. Examples include, but are not limited to, hospital and
clinic patients; clients in institutions for the developmentally
disabled; trauma victims; clients of drug and alcohol treatment
facilities; residents of hospices and nursing homes; human remains;
and individuals who donate or sell blood or blood components.
Sterilize the use of a physical or chemical procedure to destroy all microbial
life including highly resistant bacterial endospores.
Synovial Fluid the clear amber fluid usually present in small quantities in a joint of
the body (i.e., knee, elbow).
Universal Precautions an approach to infection control. According to the concept of
Universal Precautions, all human blood and certain human body
fluids are treated as if known to be infectious for HIV, HBV, and
other Bloodborne pathogens.
Vascular pertaining to or composed of blood vessels
Work Practice Controls controls that reduce the likelihood of exposure by altering the
manner in which the task is performed.
revised 1/15/07 21
Appendix B
EXPOSURE DETERMINATION FORM
Facility: ___________________________ Location: _______________________
Job Classification
All Employees
Have Exposure
Some Employees
Have Exposure
(List Job Title)
None Have
Exposure
revised 1/15/07 22
Appendix C
TASK AND PROCEDURES RECORD
Facility: ______________________________________________ Location: ____________________________________________
Type of Bodily Fluid/Substance to Which Exposure is likely:
1. Blood 6. Unfixed human tissues or organs 11. HIV-containing cell or tissue cultures
2. Semen 7. Amniotic Fluids 12. Organ cultures
3. Vaginal Secretions 8. Synovial Fluids 13. HIV-or HBV-containing culture media
4. CerebrospinalFluids 9. Saliva in dental procedures or solutions
5. Percardial Fluids 10. Peritoneal Fluids 14. Body Fluids visibly contaminated with blood
Job Classification Task/Procedure Type(s) of
Exposure
(See Code)
Protective Procedure(s) Protective Barrier(s)
(Gloves, Gown, Apron,
Mask, Eyewear etc.)
1.
2.
3.
4.
5.
6.
7.
8.
9.
revised 1/15/07 23
Appendix D
EXPOSURE INCIDENT INVESTIGATION FORM
Date of Incident: Time of Incident: ___________________
Location:_______________________________________________________________
Person(s) Involved: ______________________________________________________
Potentially Infectious Materials Involved:
Type: ________________________ Source: ____________________________
Circumstances (what was occurring at the time of the incident): ________________
_______________________________________________________________________
_______________________________________________________________________
How was the incident caused: (accident, equipment malfunction, etc.) List any tool,
machine, or equipment involved:___________________________________________
_______________________________________________________________________
Personal protective equipment being used at the time of the incident:
_______________________________________________________________________
_______________________________________________________________________
Actions taken (decontamination, clean-up, reporting, etc.) _____________________
_______________________________________________________________________
_______________________________________________________________________
Recommendations for avoiding repetition of incident: _________________________
_______________________________________________________________________
_______________________________________________________________________
revised 1/15/07 24
Appendix E
HEPATITIS B VACCINE DECLINATION
I understand that due to my occupational exposure to blood or other potentially infectious
materials I may be at risk of acquiring hepatitis B virus (HIV) infection. I have been given
the opportunity to be vaccinated with hepatitis B vaccine at no charge to myself.
However, I decline hepatitis B vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring hepatitis B which is a serious disease. If in the
future I continue to have occupational exposure to blood or other potentially infectious
materials and I want to be vaccinated with hepatitis B vaccine, I understand that I can
receive the vaccination series at no charge to me.
Employee Name (Please Print): ____________________________________________
Employee Signature: _____________________________________________________
Date: __________________
revised 1/15/07 25
Appendix F
Informed Consent for Receiving Hepatitis B Vaccine
I have read the attached information concerning Hepatitis B and I understand the risks and benefits of receiving this vaccine.
I request that Hepatitis B be given to me. I understand that I will be notified using the information listed below by WORKWELL
Occupational Medicine for my second and third injections. I understand that it is my responsibility to return on the designated
date(s) as indicated on this form below.
Signature____________________________________________________ Date ____________________
Printed Name__________________________________________________________________________
Home Address _________________________________________________________________________
City, State, Zip _________________________________________________________________________
Home Phone # ___________________________Date of Birth ___________ SS # ___________________
Witness_______________________________________________________________________________
Employer (if applicable) __________________________________________________________________
First Injection
Injection Date ___/___/200__ Dose _______ Site ____________ Lot# ___________ Exp___/___/200__
_____________________________________________
Signature of person administering injection
Second Injection
(One month after first injection, __/__/200__)
Injection Date ___/___/200__ Dose _______ Site ____________ Lot# ___________ Exp___/___/200__
_____________________________________________
Signature of person administering injection
Third Injection
(Four months after the second injection, __/__/200__)
Injection Date ___/___/200__ Dose _______ Site ____________ Lot# ___________ Exp___/___/200__
_____________________________________________
Signature of person administering injection
revised 1/15/07 26
Appendix G
EMPLOYEE MEDICAL RECORD CHECKLIST
NAME: ________________________________________________________________
SOCIAL SECURITY NUMBER: __________________________________________
LOCATION: ___________________________________________________________
JOB CLASSIFICATION: ________________________________________________
Attach a copy of the employee's hepatitis B vaccination record or declination form. Attach
any additional medical records relative to hepatitis B.
---------------------------------------------------------------------------------------------------------
Brief Description of Exposure Incident: ______________________________________
_______________________________________________________________________
Log and attach copy of: (Check all that apply)
The information provided to the health care professional
The Exposure Incident Investigation Report
The results of the source individual's blood testing, if consent for release has
been obtained and results are available
The health care professional's written opinion
-------------------------------------------------------------------------------------------------------------
Brief Description of Exposure Incident: ______________________________________
_______________________________________________________________________
Log and attach a copy of: (Check all that apply)
The information provided to the health care professional
The Exposure Incident Investigation Report
The results of the source individual's blood testing, if consent for release has
been obtained and results are available
The health care professional's written opinion
revised 1/15/07 27
Appendix H
INFORMATION AND TRAINING RECORD FOR
EMPLOYEES WITH POTENTIAL EXPOSURE
TO BLOODBORNE PATHOGENS
Date(s) of training:
Trainer(s) name and qualifications:
Names and Job Titles of all employees attending this training: (See Attached)
Agenda and/or materials presented to participants included:
• An accessible copy of the text of the COMM/OSHA Standard.
• A general explanation of the epidemiology and symptoms of Bloodborne diseases.
• An explanation of the modes of transmission of Bloodborne pathogens.
• An explanation of the exposure control plan and the means by which employees can
obtain a copy of the written plan.
• An explanation of the appropriate methods for recognizing tasks/activities that may
involve exposure to blood and other potentially infectious materials.
• An explanation of the use and limitations of methods that will prevent or reduce
exposure: i.e., engineering controls, work practices, and personal protective equipment.
• Information on the types, proper use, location, removal, handling, decontamination, and
disposal of personal protective equipment or other contaminated items.
• An explanation of the basis for selection of personal protective equipment.
• Information on the HBV vaccine, its efficacy, safety, method of administration, benefits
of vaccination, and provision at no cost to the employee.
• Information on the appropriate actions to take and persons to contact in an emergency
involving blood and other potentially infectious materials.
• An explanation of the procedure to follow if an exposure incident occurs, the method
of reporting, and the medical follow-up that is available.
• Information on the post-exposure evaluation and follow-up that is provided.
• An explanation of the signs, symbols, and color-coding of biohazards.
• A question and answer session between the trainer(s) and employee(s).
• List of contacts within the health community that can be resources to the employees if
they have questions after training.
Signature of Training Coordinator: ________________________________________
revised 1/15/07 28
Appendix I
NEEDLESTICKS/SHARPS EXPOSURE LOG
Instructions:
1. Complete a log for each employee exposure incident involving a sharp
2. Make a photocopy for your own record; and
3. Ensure that the form is received by your department’s Worker’s Compensation Department.
Employee exposed:
Social Security Number: Phone number/ E-mail:
Department:
Supervisor: Phone number/ E-mail:
Date and Time of Stick or contact
with Sharp:
Location of Incident: Job classification of employee:
Nature of exposure:
Body part stuck: Procedure being performed at time of exposure:
Describe how the incident occurred:
r Patient agitated/ hostile r Emptying on handling sharps container
r During disposal r Other
____________________________________________________
r Re-sheathing
Sharps information if known (Type, Brand, Model) e.g. 18g needle/ABC Medical/ “no stick” syringe:
a. Was the sharp/ needle contaminated? _____________________________
b. If yes, what was the contaminant? _________________________________
c. Did the device used have a retractable or self-sheathing needle? _____________________
d. If yes, was training provided on its proper use? _____________________
For the employee: What do you think could have been done to prevent this injury?
For the employer: What do you think could have been done to prevent this injury?
Employee’s Signature:
Date:
revised 1/15/07 29
Appendix J
revised 1/15/07 30
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 14 of 22
Attachment D
DRUG AND ALCOHOL POLICIES &
PROCEDURES
Workwell Occupational Medicine, LLC 2012
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Workwell Occupational Medicine, LLC 2012
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Workwell Occupational Medicine, LLC 2012
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Workwell Occupational Medicine, LLC 2012
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Attachment E
MEDICAL CASE MANAGEMENT PROGRAM
Workwell’s Medical Case Management Program assures that injured workers receive appropriate, timely and
cost-effective care. The physician provider is the medical case manager from the start of the case through case
closure. Our experienced providers, our ancillary medical staff, and our software system assure that
communication is timely, referrals are scheduled promptly and return to work is addressed in all instances.
All components of the medical management program are provided in accordance with the Colorado Division of
Worker’s Compensation Treatment Guidelines and other rules and regulations governing the management of an
injured worker. Workwell, also, utilizes the comprehensive guidelines set forth by Pinnacol Assurance and the
Occupational Medicine Practice Guidelines, 2nd Edition, American College of Occupational and Environmental
Medicine.
The providers personally oversee all aspects of the patient’s care including the following:
• Assesses causality: The provider will determine whether or not an occupational injury or exposure took
place and that it is medically probable that the on-the-job event or exposure did cause the injury.
• Manages return to work: The provider whole-heartedly believes that when a patient returns to work after
an injury, they recover more quickly and sustain less permanent physical impairment than a worker who does
not return to work.
• Educates the injured worker: The provider provides the injured worker with information regarding their
treatment plan, their course of recovery, and return to work expectations.
• Communicates to all parties on a timely basis: The provider communicates to the employer all
information by phone, written reports (WC-164) and dictation the injured worker’s treatment plan, return to
work status, anticipated impairment and permanent restrictions after each patient visit.
• Manages referrals: The provider schedules appointments with specialists within 2 business days when at all
possible and expects communication from the specialist within 24 hours of the patient visit along with a more
extensive dictation to follow. The provider maintains management of the patient’s treatment plan and expects
the specialist to communicate any other needs for referrals or diagnostic exams to them. The primary care
provider, also, manages referrals to therapy or diagnostics.
• Provides for the comprehensive medical management: The provider uses the Occupational Medicine
Practice Guidelines, 2nd Edition, Colorado Division of Worker’s Compensation Treatment Guidelines and other
Division Rules and Regulations as a guide to medically manage a patient’s injuries.
• Determines MMI: The provider determines when a patient has arrived at Maximum Medical Improvement
and documents this on the M164 and in their dictation.
• Determines permanent impairment: The provider determines if a patient has permanent impairment and
will provide the impairment rating when appropriate.
• Discharges the injured worker when appropriate: The provider will discharge the patient when
appropriate. If the provider recommends maintenance treatment for after discharge, those recommendations
will be written in accordance with the Colorado Division of Workers’ Compensation.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 19 of 22
UTILIZATION REVIEW/QUALITY IMPROVEMENT
The following lists the various components of the Workwell
Program’s Quality Assurance Program.
Credentialing: Prior to being hired, Workwell providers go through a thorough credentialing process that
confirms they have the professional training, licensure, certifications and clinical experience to deliver quality
medical care. They must be Level II certified within one year of being hired.
Patient Satisfaction Surveys: Patient satisfaction is extremely important to us. We are 100% committed to
providing outstanding patient care. We believe that the best way to maintain a quality program is to survey our
patients. Patient Satisfaction Surveys are provided to a designated number of patients who were treated in the
Workwell Clinics each month. Quarterly summaries of the surveys are compiled and then, reviewed by the
Clinic Management team. It is expected that the clinics maintain a 90% or higher satisfaction score. Action Plans
are created when necessary and reviewed by the Risk Management team.
Employer Satisfaction Survey: As with the patient satisfaction survey, it is important to us to know what
employers are experiencing at Workwell. Annual periodic employer satisfaction surveys are distributed to
employers either by mail, telephone or at an employer event. The surveys are summarized, reviewed and action
plans are created when necessary.
Medical Director Peer Review: Peter Mars, MD, CMO and Fred Scherr, MD, CMP perform quarterly case
reviews on all of our providers. Each quarter they address a specific topic for our providers to train, provide
special case review, and address specific areas of concern if needed. Providers, payers or employers may request
that Dr. Mars and or Dr. Scherr review a chart at any time.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 20 of 22
Attachment F
HIPAA & RELATED MATTERS:
1. Are you (the Provider) a “covered entity” under the “Administrative Simplification” provisions of the federal
Health Insurance Portability and Accountability Act of 1996 (HIPAA)? If you are a HIPAA covered entity,
provide a copy of the Notice of Privacy Practices you provide to all of your patients.
Yes. Please reference Appendix H
2. What portion of the providers in your referral network are covered providers under HIPAA?
100% for any workers’ compensation matter
3. Identify and describe any practical or procedural operational impacts of HIPAA on your provision of
services under the proposed contract. Include any anticipated impact on communication of information
regarding treatment of individual claimants between providers in your network and URM and its designees,
and the provision of general utilization or other data requested by URM under the proposed contract.
We have been able to accommodate all the necessary provisions without any operational issues. We
do not foresee any future problems complying with HIPAA or electronic conveyance method in the
future. All patients are required to sign consent forms which allows us to communicate with employers
and insurance companies.
4. Will you require URM to take any specific action (e.g. secure claimant/employee authorization) to facilitate
the exchange of claims-related information and other data between network providers and the University,
as contemplated under the proposed contract? If so, please describe these requirements.
A “Medical Record Release Authorization” is requested at the beginning of each injury to facilitate any
future data exchange among workers’ compensation providers.
5. Do you routinely secure a signed authorization for workers’ compensation patients to disclose medical and
other individually identifiable health-related information to insurance carriers, employees or others, as
necessary or appropriate for claim administration and related purposes? Please provide a copy of the
form(s) you will use, if any, to secure patient authorization for the use and/or disclosure of medical and
other information to URM. Please see HIPAA Attachment.
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 21 of 22
Attachment G
PRIVACY POLICY
WORKWELL OCCUPATIONAL MEDICINE, LLC NOTICE OF PRIVACY PRACTICES GUARDING
PROTECTED HEALTH INFORMATION
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.
Workwell, through its subsidiaries and affiliates, provides injury care services and related services. These subsidiaries
and affiliates providing such services are hereinafter referred to as "Workwell," "we," "our," or "us." Due to the
nature of these services, we are required by law to maintain the privacy of certain confidential health care
information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and
privacy practices with respect to your PHI. We are also required to abide by the terms of the version of this Notice
currently in effect.
Uses and Disclosures of PHI: We may use PHI for the purposes of treatment, payment and health care
operations, in most cases without your written permission. Examples of our use of your PHI:
For Treatment. This includes such things as obtaining verbal and written information about your medical
condition and treatment from you as well as from others, such as doctors and nurses who give orders to allow
us to provide treatment to you. We may give your PHI to other health care providers involved in your
treatment, and may transfer your PHI via fax or telephone to the hospital or other provider specialists.
For Payment. This includes any activities we must undertake in order to get reimbursed for the services we
provide to you, including such things as submitting bills to insurance companies, making medical necessity
determinations and collecting outstanding accounts.
For Health Care Operations. This includes quality assurance activities, licensing and training programs to ensure
that our personnel meet our standards of care and follow established policies and procedures, as well as certain
other management functions.
Reminders for Scheduled Appointments and Information on Other Services. We may also contact you with a
reminder of any scheduled appointments for non-emergency service, or to inform you about other services we
provide.
Use and Disclosure of PHI Without Your Authorization. We are permitted to use PHI without your written
authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state law,
including:
For the treatment, payment or health care operations activities of another health care provider who treats you;
For health care and legal compliance activities;
To a family member, other relative, or close personal friend or other individual involved in your care if we
obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you
do not raise an objection, and in certain other circumstances where we are unable to obtain your agreement
and believe the disclosure is in your best interests;
To a public health authority in certain situations as required by law (such as to report abuse, neglect or domestic
violence);
For health oversight activities including audits or government investigations, inspections, disciplinary proceedings,
and other administrative or judicial actions undertaken by the government (or their contractors) by law to
oversee the health care system;
For judicial and administrative proceedings as required by a court or administrative order, or in some cases in
response to a subpoena or other legal process;
For law enforcement activities in limited situations, such as when responding to a warrant;
For military, national defense and security and other special government functions;
To avert a serious threat to the health and safety of a person or the public at large;
Workwell Occupational Medicine, LLC 2012
RFP 7438 Medical Provider – Workers Compensation & DOT Medical Exams Page 22 of 22
For workers’ compensation purposes, and in compliance with workers’ compensation laws;
To coroners, medical examiners, and funeral directors for identifying a deceased person, determining cause of
death, or carrying on their duties as authorized by law;
If you are an organ donor, we may release health information to organizations that handle organ procurement
or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ donation
and transplantation;
For research projects, but this will be subject to strict oversight and approvals;
Use or disclose health information about you in a way that does not personally identify you or reveal who you
are.
Any other use or disclosure of PHI, other than those listed above will only be made with your written authorization.
You may revoke your authorization at any time, in writing, except to the extent that we have already used or
disclosed medical information in reliance on that authorization.
Patient Rights: As a patient, you have a number of rights with respect to your PHI, including:
The right to access, copy or inspect your PHI. This means you may inspect and copy most of the medical
information about you that we maintain. We will normally provide you with access to this information within 30
days of your request. We may also charge you a reasonable fee, as state law permits, to provide a copy of any
medical information you have the right to access. In limited circumstances, we may deny you access to your
medical information, and you may appeal certain types of denials. We have forms available to request access to
your PHI and we will provide a written response if we deny you access and let you know your appeal rights. You
also have the right to receive confidential communications of your PHI. If you wish to inspect or obtain a copy of
your medical information, you should contact our local privacy representative.
The Right to Amend Your PHI. You have the right to ask us to amend written medical information we may have
about you. We will generally amend your information within 60 days of your request and will notify you when
we have amended the information. We are permitted by law to deny your request to amend your medical
information only in certain circumstances, like when we believe the information you have asked us to amend is
correct. If you wish to request an amendment of the medical information we have about you, please contact our
local privacy representative to obtain an amendment request form.
The Right to Request an Accounting. You may request an accounting from us of certain disclosures of your
medical information we have made in the six years prior to the date of your request. However, your requests
for an accounting of disclosures cannot precede the implementation date of HIPAA April 14, 2003. We are not
required to give you an accounting of information we have used or disclosed for purposes of treatment, payment
or health care operations, or when we share your health information with our business associates, such as our
billing company or a medical facility from/to which we have transported you. We are also not required to give
you an accounting of our uses of PHI for which you have already given us written authorization
The Right to Request That We Restrict the Uses and Disclosures of Your PHI. You have the right to request
that we restrict how we use and disclose your medical information we have about you. We are not required to
agree to any restrictions you request, but any restrictions agreed to by us in writing are binding on us.
Internet and the Right to Obtain a Paper Copy of the Notice on Request. If you would like a paper copy of this
Notice, you may print this off your computer by choosing that option, or you may contact us at the address
listed below and we will provide you a paper copy of the Notice upon request.
Revisions to the Notice: We reserve the right to change the terms of this Notice at any time, and the changes will
be effective immediately and will apply to all PHI we maintain. Any material changes to the Notice will be promptly
posted in our facilities and posted to our web site, if we maintain one. You can get a copy of the latest version of this
Notice by contacting our offices.
Your Legal Rights and Complaints: You also have the right to complain to us, or to the Secretary of the United
States Department of Health and Human Services if you believe your privacy rights have been violated. You will not
be retaliated against in any way for filing a complaint with us or to the government. Should you have any questions,
comments or complaints you may direct all inquiries to our offices.
Effective Date of the Notice: April 14, 2003
individual
The owner
12.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
1
2
3
4
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
a job or may file a tax return using your SSN to receive a refund.
What Name and Number To Give the Requester
Give name and SSN of:
For this type of account:
The individual
1.
Individual
The actual owner of the account or,
if combined funds, the first
individual on the account
2.
Two or more individuals (joint
account)
The minor 2
3.
Custodian account of a minor
(Uniform Gift to Minors Act)
The grantor-trustee 1
4.
a. The usual revocable savings
trust (grantor is also trustee)
The actual owner 1
b. So-called trust account that is
not a legal or valid trust under
state law
The owner 3
5.
Sole proprietorship or disregarded
entity owned by an individual
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
1
To reduce your risk:
● Protect your SSN,
● Ensure your employer is protecting your SSN, and
● Be careful when choosing a tax preparer.
Victims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving tax
problems that have not been resolved through normal channels,
may be eligible for Taxpayer Advocate Service (TAS) assistance.
You can reach TAS by calling the TAS toll-free case intake line
at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt to scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1-800-366-4484. You can forward suspicious emails to the
Federal Trade Commission at: spam@uce.gov or contact them at
www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).
Visit the IRS website at www.irs.gov to learn more about
identity theft and how to reduce your risk.
All exempt payees except
for 9
Interest and dividend payments
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Broker transactions
Exempt payees 1 through 5
Barter exchange transactions
and patronage dividends
Generally, exempt payees
1 through 7
Payments over $600 required
to be reported and direct
sales over $5,000
See Form 1099-MISC, Miscellaneous Income, and its instructions.
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys’ fees, and
payments for services paid by a federal executive agency.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
1
2
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
2
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account
satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
1
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
during 1983. You must give your correct TIN, but you do not
have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts considered
inactive during 1983. You must sign the certification or backup
withholding will apply. If you are subject to backup withholding
and you are merely providing your correct TIN to the requester,
you must cross out item 2 in the certification before signing the
form.
Part II. Certification
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
To establish to the withholding agent that you are a U.S. person,
or resident alien, sign Form W-9. You may be requested to sign
by the withholding agent even if items 1, 4, and 5 below indicate
otherwise.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28% of such payments. This is called “backup withholding.”
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
Payments you receive will be subject to backup
withholding if:
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the Chinese student
becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of
the first protocol) and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
Note. You are requested to check the appropriate box for your
status (individual/sole proprietor, corporation, etc.).
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.
However, most tax treaties contain a provision known as a
“saving clause.” Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
Also see Special rules for partnerships on page 1.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
● The U.S. grantor or other owner of a grantor trust and not the
trust, and
● The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Limited liability company (LLC). Check the “Limited liability
company” box only and enter the appropriate code for the tax
classification (“D” for disregarded entity, “C” for corporation, “P”
for partnership) in the space provided.
For a single-member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 301.7701-3, enter the
owner’s name on the “Name” line. Enter the LLC’s name on the
“Business name” line.
For an LLC classified as a partnership or a corporation, enter
the LLC’s name on the “Name” line and any business, trade, or
DBA name on the “Business name” line.