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HomeMy WebLinkAboutRESPONSE - FAX QUOTE - 8648 DRUG & ALCOHOL TESTINGHeidi Collins Account Executive 7401 Church Ranch Road Blvd., Suite 202 Westminster, Colorado 80021 Phone: 303.388.3627 Email: hecampbell@concentra.com City of Fort Collins DUE: December 20, 2017 3:00 p.m. MST PRESENTED TO Request for Quote: Drug & Alcohol Screening Services 2017 No. 8648 PRESENTED BY concentra.com ● 5080 Spectrum Drive, 1200 West Tower, Addison, Texas 75001 ● Phone 800.232.3550 ● Fax 972.725.6439 December 20, 2017 Beth Diven Buyer City of Fort Collins purchasing@fcgov.com Reference: Drug and Alcohol Screening Services 2017 (8648) Dear Ms. Diven: In response to the Request for Quote (RFQ) No. 8648, Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers (Concentra), submits our response to provide drug and alcohol testing and other screening services as needed to the City of Fort Collins (City). Concentra is highly qualified and well positioned to perform the services the City is seeking. The strength of our local employer relationships, expertise in the medical industry, and commitment to service excellence, creates distinct advantages and differentiates Concentra from our competitors. Concentra is confident in our ability to perform the scope of work successfully and professionally. Concentra would value our role as the City’s occupational health partner for the services requested. Concentra’s leadership and staff will remain committed to treating the City’s employees to a welcoming and respectful patient experience. Our objective is to deliver a quality program that meets immediate health care needs, exceeds program expectations, and remains in compliance with the most recent medical standards and guidelines relevant to the scope of work. For the City’s program, Concentra assigns Heidi Campbell, account executive, to serve as the initial contact and liaison between Concentra and the City. She will work proactively with the center leadership team to ensure that the services rendered remain consistent, professional, and in full compliance with all local, state, and federal guidelines, as well as the City’s specifications. Should the City have questions concerning our response, please contact Ms. Campbell via phone: 303.388.3627 or email: hecampbell@concentra.com. Concentra’s proposal includes our response to the City’s specifications, as well as relevant attachments. Concentra affirms that:  All information contained herein is current, complete, accurate, and remains valid for 90 days following the due date, November 20, 2017.  The City anticipates a contract term of one year which can be renewed for up to an additional four (4) one-year terms. We look forward to the opportunity to serve as the preferred partner for drug and alcohol testing and other screening services as needed to the City of Fort Collins and its employees. Respectfully submitted, Robert G. Hassett, DO, MPH President, Director, Secretary, and Treasurer Occupational Health Centers of the Southwest P.A. d/b/a Concentra Medical Centers DocuSign Envelope ID: ACCC24D6-29B8-4F51-8D72-D58AE660C726 City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 15, 2017 Table of Contents © 2017 Concentra Operating Corporation. All rights reserved. Table of Contents A. Proposal Response .................................................................................................... 2 B. Experience ............................................................................................................... 10 C. Facilities and Locations ............................................................................................ 13 D. References .............................................................................................................. 14 E. Fee Schedule ........................................................................................................... 15 F. Signed Vendor Statement ........................................................................................ 16 G. Sustainability ............................................................................................................ 17 H. Attachments ............................................................................................................. 18 City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 2 A. Proposal Response Scope of Services to be Provided Concentra understands that the City is seeking a vendor that can offer services to collect urine and breath samples for screening applicants and employees for the presence of inappropriate prescriptions or illegal drugs and/or alcohol in their system. Concentra understands that all tests must follow Department of Transportation (DOT) protocol. Concentra affirms that we are an eScreen preferred provider. Concentra realizes that the drug and alcohol testing services will include Non-DOT and DOT (FMCSA and FTA) tests such as pre-employment, random, reasonable suspicion, post-accident, return-to-duty, and f ollow-up. All samples will be tested by a SAMSHA approved and regulated laboratory and picked up daily (Monday through Friday). Drug, Alcohol Testing Urine Drug Screens DOT regulation 49 CFR Part 40 outlines “Procedures for Transportation Workplace Drug and Alcohol Testing Programs,” providing guidelines and standards for drug and alcohol testing. For more than two decades, these procedures have been considered the gold standard. Therefore, Concentra conducts all drug testing (DOT and non-DOT) in full compliance with 49 CFR Part 40 and adheres to all Substance Abuse and Mental Health Services Administration (SAMHSA) policies and procedures. By following these procedures in federal and non-federal testing Concentra streamlines the collection process, offers defensible procedures for our collectors and clients, and ensures donor confidentiality. Our typical process includes:  Certified staff to perform DOT collections  Collection via a split sample method as required by DOT  Use of the proper chain of custody form (CCF) for regulated and non-regulated testing  Proper specimen containment  Shipment of specimen to a certified laboratory for analysis within 24 hours or the next business day  Laboratory analysis performed by an appropriately licensed and certified laboratory  Medical review officer (MRO) review as appropriate Collection Procedures Collector Manual Concentra maintains clear and well-documented procedures in our Drug Screen Collection Manual. Our manual outlines procedures specific to every segment of specimen collection, including, but not limited to the following:  Preparation for collections  Collection process  Unusual circumstances  Forms  Additional guidelines and procedures We also include detailed instructions on specimen shipment and our laboratory vendor maintains guidelines specific to the testing process. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 3 Collection Supplies Concentra maintains all supplies necessary for specimen collection and transport to our laboratory vendor. Supplies include, but may not be limited to, the following:  DHHS/SAMHSA approved collection kits  Custody and control forms  Shipping materials  Specimen bags  Tamper-evident seals to preserve specimen integrity Donor Identification Our front desk personnel will verify the employee’s identification by requesting a picture ID. The collector then confirms the employee’s identity in the collection area and proceeds with the collection process. Concentra Collectors Concentra’s certification course meets and exceeds the DOT training model. To help ensure consistency among all Concentra markets in adhering to DOT regulations, we developed a three-phase Collector Certification Program. Our policy is that all collectors (new hires and existing) successfully complete each phase of the program prior to Concentra certifying the individual to perform drug screen collections. Concentra’s intention is to maintain high standards and quality throughout the collection process. To that end, although DOT regulations require refresher training to occur within five years, Concentra requires refresher training for all collectors every 2.5 years. If the collector does not complete refresher training within the designated timeframe, we will not allow him/her to perform DOT collections. We summarize each phase of our Collector Certification Program in the following table. Collector Certification Program Phase One: Study Guide and Quiz Intranet study guide and quiz (required prior to attending phase two) Phase Two: Classroom Instruction  Interactive instruction  Hands-on collection training  Written examination (85% pass rate required for certification)  Completion of Collector Acknowledgement Form Phase Three: Proficiency Examination  Five consecutive, error-free mock collections  Two uneventful collection scenarios  One “insufficient quantity of urine” scenario  One “temperature out-of-range” scenario  One scenario in which the donor refuses to sign the CCF and initial the specimen bottle’s tamper-evident seal Collection Area Security and Measures to Ensure Valid Samples Concentra takes measures to secure the collection area, prevent unauthorized access, and ensure the collection of valid specimen samples. Examples of these measures include, but are not limited to, the following:  We confirm the donor’s identity twice (once by the front desk personnel, then by the collector) City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 4  Once in the designated area, the collector is limited to conducting one collection at a time to avoid possible distractions that could compromise security and the integrity of the sample  As required, we perform observed collections in accordance with all state and federal regulations  Items in the collection area (i.e., trash receptacles, paper towel holders, under-sink areas, etc.) are secure to avoid the concealment of contaminants  Concentra facilities are equipped with a single-toilet room that has a full-length privacy door within which urination can occur  Water sources are unavailable to applicants/employees – the water is turned off at the sink, the handles are taped to prevent opening faucets, and the toilet tank cover is taped so that there is no access to water  Water in the toilet is blue and there is no access to soap, disinfectants, cleaning agents, or other possible adulterants  Prior to the collection, the collection site is inspected to ensure no foreign or unauthorized substances are present Collection Process Concentra administers drug tests are using the DOT-required split sample method. All samples are tested for substances outlined in the most recent regulations. The certified collector and appropriate laboratory adhere to the following guidelines:  Collects a minimum of 45 milliliters (ml.) of urine  Divides the specimen into two bottles, 30 ml. in one and 15 ml. into a second bottle  Seals the specimen appropriately  Sends each specimen to the laboratory, ensuring shipment occurs within 24 hours or during the next business day  Once received, the lab analyzes the primary 30 ml. bottle while the second bottle is held pending a request from the employee for a second test in the event of a verified positive of the primary test Observed Collections We acknowledge that in certain instances, direct observation may be requested and Concentra can meet this requirement. The following summarizes Concentra’s approach to direct observation of collections. Our procedures are in accordance with the DOT guidelines. Per DOT’s 49 CFR Part 40, directly observed collections are authorized and required only when:  The employee attempts to tamper with his/her specimen at the collection site  The specimen temperature is outside the acceptable range  The specimen shows signs of tampering ~ unusual color / odor / characteristic  The collector finds an item in the employee’s pockets or wallet which appears to be brought into the site to contaminate a specimen; or the collector notes conduct suggesting tampering  The Medical Review Officer (MRO) orders the direct observation because  The employee has no legitimate medical reason for certain atypical laboratory results  The employee’s positive or refusal (adulterated/substituted) test result had to be canceled because the split specimen test could not be performed (for example, the split was not collected)  The employer orders direct observation for a Follow-Up test or a Return-to-Duty test  The observer must be the same gender as the employee  If the collector is not the observer, the collector must instruct the observer about the procedures for checking the employee for prosthetic or other devices designed to carry “clean” urine and urine substitutes AND for watching the employee urinate into the collection container City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 5  The observer requests the employee to raise his or her shirt, blouse or dress / skirt, as appropriate, above the waist, just above the navel; and lower clothing and underpants to mid-thigh and show the observer, by turning around, that the employee does not have such a device  If the employee has a device, the observer immediately notifies the collector; the collector stops the collection; and the collector thoroughly documents the circumstances surrounding the event in the remarks section of CCF  The collector notifies the DER  This is a refusal to test  If he employee does not have a device, the employee is permitted to return clothing to its proper position for the observed collection  The observer must watch the urine go from the employee’s body into the collection container  The observer must watch as the employee takes the specimen to the collector  The collector then completes the collection process  Failure of the employee to permit any part of the direct observation procedure is a refusal to test Chain of Custody When collecting urine specimens, Concentra adheres to all SAMHSA policies and procedures to ensure appropriate chain of custody to document the integrity and security of the specimen from the time of collection until receipt by the laboratory. For DOT collections, we use the federal CCF; for non- regulated drug screens, we use the non-federal CCF. Specific to DOT testing, Concentra completes the federal CCF in accordance with SAMHSA guidelines as we outline below:  Collector ensures that the name and address of the drug testing laboratory appears on the top of the CCF and the specimen ID number on the top of the CCF matches the specimen ID number on the labels/seals  Collector provides the required information in step 1 on the CCF and provides a remark in step 2 if the donor refuses to provide his/her Social Security or employee ID number  Collector gives a collection container to the donor to provide specimen  After the donor gives the specimen to the collector, the collector checks the temperature of the specimen within four minutes, marks the appropriate temperature box in step 2 on the CCF, and provides a remark if the temperature is outside the acceptable range  Collector checks the split or single specimen collection box:  If no specimen is collected, the collector checks that box, provides a remark, discards Copy 1, and distributes the remaining copies as required  If it is an observed collection, the collector checks that box and provides a remark  Donor watches as the collector pours the specimen from the collection container into the specimen bottle(s), places the cap(s) on the specimen bottle(s), and affixes the label(s)/seal(s) on the specimen bottle(s)  After affixing the labels/seals, the collector dates the specimen bottle label(s)  Donor initials affixed and dated specimen bottle label(s)  Collector turns to Copy 2 (MRO Copy) and instructs the donor to (1) read the certification statement in step 5 and (2) sign, print name, date, provide phone numbers, and date of birth; if the donor refuses to sign the certification statement, the collector provides a remark in step 2 on Copy 1  Collector completes step 4 (i.e., provides signature, printed name, date, time of collection, and name of delivery service), immediately places the sealed specimen bottle(s) and Copy 1 of the CCF in a leak-proof plastic bag, releases specimen package to the delivery service, and distributes the other copies as required City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 6 Specimen Transport Once the specimen is sealed, a courier picks up the specimen from the collection site via automobile. The collector or collection site must ensure that each specimen collected is shipped to a laboratory as quickly as possible, but in any case, within 24 hours or during the next business day. Specimens are picked up one to two times per day depending on the volume of the center location. Breath Alcohol Testing Concentra conducts breath alcohol testing using an evidential breath testing (EBT) device approved on the National Highway Traffic Safety Administration’s (NHTSA) Conforming Products List for both screening and confirmation testing. To ensure quality results, we calibrate each EBT device daily, as well as after every positive result, without exception. Records of the calibration are placed on file with a retention period of five years. In addition, personnel performing breath alcohol testing are trained and certified as breath alcohol technicians (BAT) in accordance with DOT guidelines. Initial Test Typically, breath alcohol tests that register less than 0.02 g/210 L are reported as negative (for the purposes of DOT) and no additional testing is required. Breath alcohol tests that register 0.02 g/210 L or greater require a second confirmatory test. Confirmation Test If the confirmatory test is less than 0.02 g/210 L, the results are reported as negative. Breath alcohol results that register 0.04 g/210 L or greater on the confirmation test are immediately reported to the client. A 0.04 g/210 L is considered a DOT positive result. Concentra also offers blood, hair and saliva testing if requested by the City. Post-Accident Testing Concentra acknowledges that the City desires the successful proposer to provide post-accident drug and alcohol testing to its employees. All post-accident drug and alcohol testing outside of normal business hours will be available upon request. Random Testing Concentra offers random drug and alcohol testing at our Fort Collins medical facility. Concentra utilizes an unbiased random selection methodology using a computer-generated process, designs its program to eliminate any manipulation, and adheres to DOT regulations. Concentra uses the most recent percentages (drug/alcohol) as delivered by the DOT and will update pools monthly or as the City dictates. We outline the random selection process below:  The City and Concentra discuss the available “testing cycle” options (frequency of random selections, i.e., quarterly, monthly, bi-monthly, etc.) and determine an appropriate testing cycle for the City’s program. The testing cycle will meet the DOT standards and frequency.  The City updates its employee list prior to each testing cycle and submits the updated list using a mutually agreed upon method (i.e., mail, email, fax, etc.).  At the beginning of each testing cycle, Concentra transmits the identification of all employees selected for testing during that cycle to the City’s designated employer representative (DER).  The City determines the schedule of testing for each employee requiring testing and assures that each employee selected is tested prior to the end of the testing cycle.  When the City notifies the employee, the individual must proceed immediately to the Concentra collection site. Concentra tracks the arrival/departure time of the employee.  At the conclusion of the testing cycle, Concentra notes all employees who were selected for testing, those not tested, and individuals whose absence was not explained by the City. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 7  Concentra sends a written notice of the “failure to test” to the City’s DER. Reasonable Suspicion Testing Concentra acknowledges the City requires the proposer to provide reasonable suspicion drug and alcohol testing. All reasonable suspicion drug and alcohol testing will be available upon request, outside of normal business hours. Return-to-Duty Tests Concentra acknowledges the City requires the proposer to provide to be screened for return to duty drug and alcohol testing. All return-to-duty drug and alcohol testing will be available upon request, during normal business hours. Positive Follow-Up Testing Concentra understands that the City requests that the proposer provides positive follow-up drug and alcohol testing on the City’s employees. Drug and Alcohol Results Concentra’s average turnaround time for a negative drug screen result is 24-48 hours upon receipt at the lab. However, a positive result turnaround timeframe, including MRO review, varies for non-DOT and DOT tests, and may take 48 to 72 hours depending on the MRO verifications. We provide results reporting electronically via our Employer Portal.  Non-DOT Positives – For a non-DOT positive drug test, MRO review is at the employer’s discretion and results can take 48 to 72 hours upon receipt at the lab.  DOT Positives – MRO review is required for all DOT positive drug tests. While we can report a confirmed positive result to the MRO within 48 hours, the average turnaround time for a positive DOT drug screen review by the MRO varies due to the responsiveness of the donor to the MRO in accordance with DOT regulations. The donor has up to five days to make contact with the MRO per DOT guidelines before the MRO reports a result. Unless otherwise noted, the MRO will conduct the MRO investigation in accordance with the DOT guidelines. Concentra acknowledges and affirms that negative results will be provided through eScreen. Positive results require review by eScreen’s designated Medical Review Officer (MRO) with the City’s Designated Employer Representative (DER). Patient Confidentiality Records Management Concentra understands the importance of ensuring confidentiality of personal health information (PHI) and we maintain medical charts in accordance with the state practice acts governing their licensure. We house all charts on site and in a secure location, and provide all candidates and employees with HIPAA consent forms and Notice of Privacy statements. Per state and federal laws, the client’s management personnel can only access these records on a “need to know” basis. We thoroughly train all Concentra employees designated to provide services on the HIPAA regulations that cover the release of medical records, authorization forms, and personal health information. Specifically, we instruct our staff not to disclose PHI either verbally or in writing to any other individual without the express written permission of the employee. We created more than 70 HIPAA-related policies and procedures company-wide. The following are examples of processes, procedures, and guidelines we have in place to support compliance with HIPAA legislation: City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 8  Include a Business Associate HIPAA agreement in all client and vendor contracts between Concentra and the party with whom we are contracting; agreement is reflective of the current HIPAA legislation and has been affirmed by legal counsel (who specializes in this area)  Own and hold secure internal documentation systems and an on-site server, all of which are firewall and virus protected and monitored daily  Have a secured intranet for all internal documents and employ a secured virtual private network (VPN) system for remote access  Maintain a HIPAA-specific internal policy manual outlining the required privacy and security requirements for handling, maintaining, and disposing of PHI  Contract with a bonded, HIPAA-compliant vendor to manage the shredding and recycling of paper documents located internally in locked cabinets within our internal office space (as per HIPAA guidelines)  Bonded, HIPAA-compliant vendor picks up and removes all materials from our offices; we require identification and signature by bonded workers  Password protect all sensitive client files and only allow access to those staff members who require this to support direct client services  Communicate acknowledgement of our compliance to HIPAA legislation to all employees during the program rollout process  Never share individual PHI with any party i.e., client (employer), insurance company, or other provider(s) without prior consent from the individual (as per HIPAA regulations) Records Retention Below we affirm the following record retention stipulations will be followed as required by the City:  Retention of records for five years as stipulated in 49CFR 382.401 and 655.71.  Records of driver alcohol test results indication and alcohol concentration of 0.00 or greater;  Records of driver verified positive controlled substance test results;  Documentation of refusals to take required alcohol and/or controlled substances tests.  Maintain records concerning the collection process and test results for at least 5 years for a positive test and at least one year for a negative test.  Maintain records for a minimum of one year for negative and canceled controlled substance test results.  Assure that all non-negative urine specimens are retained by the drug testing laboratory for a minimum of one year.  Assure all test results are forwarded directly to the MRO for disposition to the City of Fort Collins DER.  Submit monthly invoices to eScreen and the City DER reflecting fees for drug and alcohol tests including the testing date, name of employee, type of test given, phone number and email address of billing contact and keep the City updated if this information changes  All test results will be reported to City DER through the eScreen website. Laboratory Services Drug Panels For laboratory services, we propose to utilize our preferred vendor, Quest. Each of Quest’s Forensic Toxicology laboratories is certified by the Department of Health and Human Services (HHS)/SAMHSA to perform urine drug testing under the federal program. The four SAMHSA certified laboratories are compliant with SAMHSA guidelines as detailed in the Federal Register and DOT’s 49 CFR Part 40 rules, detailed in Federal Register 65 (244): 79462-79579 (12-19-2000), and any subsequent revisions. The DOT, Nuclear Regulatory Commission (NRC), Federal Railroad Administration (FRA), Pipeline and Hazardous Materials Safety Administration (PHMSA), and the FMCSA all require this certification. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 9 Each laboratory is accredited by the College of American Pathologists Forensic Drug Testing (CAP- FDT) program and licensed by the state where the laboratory is located. Quest’s drug testing procedures and laboratories are also fully certified and accredited by federal government agencies, and professional organizations such as the Agency for Health Care Administration (AHCA) Florida and Clinical Laboratory Improvement Amendments (CLIA). MRO Services Utilizing an MRO decreases the risk of a non-negative result due to donor’s ingestion of a lawfully prescribed substance. The MRO can ask medically related questions (which the City cannot under the ADA) and definitely ascertain a positive or negative result. For our engagement with the City, Concentra proposes to continue providing the City with MRO services through eScreen, Inc. (eScreen), for which Concentra is an eScreen preferred provider. eScreen MRO services are provided through Stephen Kracht, DO, of eScreen. Dr. Kracht is certified by the American Association of Medical Review Officers (AAMRO), the Medical Review Officer Certification Council (MROCC), and American Board of Independent Medical Examiners (ABIME). He possesses more than 20 years of expertise as a certified MRO. MRO Responsibilities The MRO service reviews and interprets non-negative test results obtained through the City’s program to assure a scientifically valid result and then determines whether a legitimate medical explanation could account for a laboratory-confirmed positive result. Specifically, the MRO typically makes three or more attempts during a 24-hour period to reach the donor, barring unforeseen circumstances (such as donor’s phone disconnected). During the interview, the MRO does not typically analyze the collection process with the donor, but rather focuses on alternative, legitimate medical explanations for test results. The MRO always reviews the MRO copy of the Chain of Custody form for non-negative tests. If not transmitted prior to the lab results, the MRO assistant calls the collection site to request timely transmission of the MRO copy. If the Lab copy is not transmitted with the lab results, the MRO assistant calls the lab to request timely transmission of the Lab copy as well. The MRO will not initiate a donor interview until receiving the MRO copy of the Chain of Custody form, and will not transmit verified results until receiving the Lab copy. If the MRO is unable to obtain either copy, the MRO will notify the City of a “canceled” test. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 10 B. Experience Drug and Alcohol Testing Experience Concentra has been conducting drug and alcohol testing since our inception more than three decades ago. We maintain written guidelines on all relevant regulatory standards and create client-specific service packages tailored to meet the unique needs of each client’s program requirements. Furthermore, we assure that only qualified individuals will perform the requested services in accordance with all local, state, and federal guidelines. Concentra’s acquired experience uniquely positions us to deliver a complete solution that exceeds our clients’ expectations. Our proposed program incorporates extensive expertise in the areas of examinations and other occupational health care services, and maintaining compliance with various regulatory agencies. As appropriate, we are happy to discuss our additional capabilities with the City. Colorado Experience For years, Colorado employers have trusted Concentra to manage multiple facets of their employees’ occupational health care needs. Our experience in the state runs the gamut of all clinic-related services, including drug and alcohol screening services, requested by the City's RFQ. In addition, we have direct experience performing these screening services for the City. We are knowledgeable of Colorado guidelines and we adhere to the state’s regulatory requirements pertaining to the provision of health care services. Staff Qualifications Concentra carefully considers each project and its unique goals when assigning an account management team. We take a collaborative approach that combines local operational and clinical support to ensure quality and service excellence. The individuals we select will bring valuable, relevant experience to the program and provide ongoing support within their respective areas of expertise. We include their resumes as Attachment A – Staff Qualifications. Initial Contact Heidi Campbell, account executive, will serve as the City’s initial point of contact throughout the procurement and contracting phases. She will be responsible for ensuring Concentra colleagues know and understand the City’s program requirements and be available to answer any questions you may have throughout this initial phase of engagement. Operational Oversight Sandy Banda Baquera, MA, center operations director (COD) serves as the day-to-day contact for program operations. Ms. Banda Baquera regularly monitors processes and procedures to ensure ongoing compliance with applicable regulations and guidelines, as well as the City’s specific program specifications. She will be invaluable to the success of the program and is available to answer questions, address issues, and ensure the program continues to operate efficiently. Account Executive Heidi Campbell 18 years with Concentra Center Operations Directors Sandy Banda Baquera 6.5+ years with Concentra Concentra employs highly trained and certified staff to perform testing to include:  2,568 Drug Specimen Collectors  2,273 Breath Alcohol Technicians City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 11 Ms. Banda Baquera’s responsibilities include:  Serves as the liaison between Concentra and the City  Oversees day-to-day center operations  Implements and ensures ongoing compliance with operational policies, procedures, and training programs within the center  Manages patient care issues and other center issues requiring resolutions  Ensures a clear understanding of contract objectives and deliverables to ensure successful execution of programs and projects  Collaborates with center, area, and regional leadership teams to ensure we effectively deliver the agreed upon scope of work, monitor program outcomes, and maintain the City’s account Clinical Oversight Rosalinda Pineiro, MD, FAAFP, center medical director (CMD) provides primary oversight for clinical practices, ensuring continued compliance. Dr. Pineiro ensures that the medical interpretations and associated clearances comply with the most recent medical standards and guidelines, and adhere to applicable regulations. Her expertise relevant to the desired scope of work will be instrumental in the provision of services. Dr. Pineiro’s responsibilities include:  Reviewing all medical history and performing medical physical examinations  Understanding all medical surveillance requirements of DOT, the Occupational Safety and Health Administration (OSHA), the American with Disabilities Act (ADA), and other regulated examinations  Reporting the results of the medical evaluation to the employee, including any medical condition(s) identified during the evaluation  Providing the recommendation as to whether the employee is medically certified to safely perform the essential job tasks  Forwarding copies of any abnormal results, along with patient instructions regarding primary care follow-up, to individuals who were instructed to seek medical follow-up to address any medical conditions or abnormal laboratory results identified during the evaluation  Providing or arranging for a prescriptive rehabilitation and/or fitness program when indicated to aid in the employee’s recovery from illness or injury and enhance his/her ability to safely perform essential job tasks  Reviewing medical evaluations conducted by other clinicians  Reviewing individual medical evaluations and aggregate data to detect evidence of occupational exposure(s) or clusters of occupational disease Clinic Staff Concentra employs skilled and experienced health care professionals to deliver services relevant to our offering. Our staff includes any combination of physicians, mid-levels, nurses, physical therapists, radiology technicians, and medical assistants. Clinical Professionals Concentra will only utilize qualified and appropriately licensed and credentialed clinical professionals to serve the occupational health needs of the City’s workforce. These professionals are skilled in their respective area of expertise and undergo extensive annual training in addition to continuing education classes. Furthermore, our clinical professionals are vigilant in applying their knowledge to recognize and diagnose potential exposures and resulting health issues. They regularly monitor OSHA, DOT, Center Medical Director Rosalinda Pineiro, MD, FAAFP 22 years with Concentra City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 12 ADA, and other applicable federal and state regulations to ensure all associated services remain in compliance and adhere to best practice guidelines. Certification and Documentation Concentra Medical Centers employ qualified support personnel whom we train and fully certify to perform their associated tasks. Specifically, our staff includes drug specimen collectors certified to perform DOT collections, certified breath alcohol technicians, National Institute for Occupational Safety and Health (NIOSH)-certified pulmonary function testers, Council for Accreditation in Occupational Hearing Conservation (CAOHC)-certified personnel to perform audiometric testing, certified radiologic technologists, certified medical assistants, and certified phlebotomists. We include their BAT/UDS certifications as Attachment A – Staff Qualifications. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 13 C. Facilities and Locations Primary Facility Location Within the hundreds of clinics in operation nationwide, 18 are in Colorado and one is in the Fort Collins market. Concentra proposes our Fort Collins center to serve as the primary site for the City. This facility maintains the necessary equipment and staffing resources and employs clinicians who are thoroughly knowledgeable of all applicable state and federal regulations. We provide location and contact information for the Fort Collins center below. Concentra Medical Centers – Fort Collins Address 620 South Lemay Avenue Fort Collins, Colorado 80524 Contact Information Phone: 970.221.5811 Fax: 970.221.5817 Hours of Operation Monday – Friday, 7:00 a.m. – 7:00 p.m. Saturday, 9:00 a.m. – 1:00 p.m. For the City’s after hours drug and alcohol screening services, Concentra offers the Fort Collins center to perform the tests within the Monday through Friday from 7:00 a.m. to 7:00 p.m. and Saturday from 9:00 a.m. to 1:00 p.m. operating hours. The fees for the screening services is presented on page 15 of this proposal. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 14 D. References Concentra offers the following current client references for the City’s review. We encourage the City to contact these entities as they can attest to our ability to perform drug and alcohol testing and other screening services like those requested in the City’s RFQ. We perform these listed services per each client’s specifications and in full compliance with all regulatory guidelines. Client References Entity Contact Name, Phone, Email Information Services Performed Benchmark Electrical Kim Page, 970.229.1885 kim@besemail.com DOT physicals with drug screens, injury care, pre-placement physicals with human performance evaluations Piersons Concrete Natalie Pierson 970.221.1509 natalie@piersonconcrete.com DOT physicals with regulated drug screens, injury care, return- to-work physicals Northern Colorado Yellow Cab Megan Kaliczak 970-988-3437 Megan.kaliczak@transdev.com DOT physicals, rapid 5pnl,BAT,regulated UDS collect, non regulated UDS collect City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 15 E. Fee Schedule Concentra appreciates the opportunity to present our proposed fee schedule for City’s drug and alcohol screening services program. In the table, below, we provide our fee schedule. We affirm all information contained herein is current, complete, accurate, and remains valid for 90 days following the due date, December 20, 2017. Fee Schedule – Drug & Alcohol Screening Services Services Price eScreen UDS Collect $20 BAT collection $29 City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 16 F. Signed Vendor Statement We include the City’s signed vendor statement as Attachment B – Signed Vendor Statement. City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 17 G. Sustainability Concentra appreciates the City’s commitment to providing a sustainable environment for its employees. Concentra affirms that if selected, we will put forth our best efforts to meet the City’s sustainability requirements as they pertain to our business operations. Our staff will support the City’s existing sustainability programs. Internally, Concentra maintains policies and procedures that support organizational sustainability goals and objectives. In the following table, we highlight our strategies for practicing environmental responsibility throughout our organization. Concentra’s Green Initiatives Recycling: Iron Mountain bins recycled by vendors regularly ♦ Office trash is separated by “wet trash” and “dry trash” at Concentra’s corporate office, and is recycled by the building's janitorial service/vendor (plastic, cans and paper are recycled) Energy Efficiency: Colleagues are instructed to power down computers at night in administrative office locations (unless specifically requested otherwise by IT for system maintenance, etc.) ♦ Lights in the corporate building are automatically shut off at 10:00 pm (except those required for emergency) if not shut off by an individual ♦ Energy efficient light bulbs are used (or are currently being placed) in offices and centers ♦ Purchase and use copiers with the capability of two-sided printing and energy- saving features Other Practices: A meeting “paper/presentation” policy has been created including guidelines on the reduction in copying, two-sided paper usage, etc. for meetings and presentations ♦ “Green” notice placed on emails: “Before printing, please consider the environment” ♦ Old equipment and furniture is donated to resale stores or otherwise reused/recycled ♦ Request janitorial vendors and service providers use environmentally friendly products City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Page 18 H. Attachments In this section, Concentra includes the following information for the City’s review:  Attachment A – Staff Qualifications  Attachment B – Signed Vendor Statement  Attachment C – Legal and Risk Documents City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Attachments Attachment A Staff Qualifications Heidi E. Campbell 3800 Pike Rd. 26-202 Longmont CO 80503 HECampbell@concentra.com Cell 303-918-5013 August 2017-Present Account Executive Concentra Fort Collins, Boulder, Thornton Work for each clinic to sell Concentra services to employers in the surrounding areas. Hit monthly sales goals set for me. Communicate with each clinic on employers expectations of the center. Build relationships with employers by excellent communication and following up with employers starting the communication between them and the center operations director. September 2014-August Physical Therapy Operations/Front Office Specialist Concentra Boulder CO Work to organize, schedule and maintain a busy Physical Therapy and Front Office clinic through communication, follow up and problem solving. Build relationships with employer by providing communication on injured workers status, setting up new service packages and helping solve conflict appropriately. January 2013- July 2014/June 2008-November 2012 Personal Trainer 24 Hour Fitness/ Holy Family Memorial Wellness Center Denver CO /Manitowoc WI While at both jobs I introduced new programs to the centers that helped increase revenue for the clinic and my personal training business while building lasting relationships with prominent people in the community. Increased Personal Training revenue at the Wellness Center for the first time since opened and continued to pull new business in through referrals and different incentives that I created. September 2006-January 2008 Fitness Coordinator/Manager Two Rivers LIFE Fitness Center Two Rivers, WI Served on a corporate wellness committee to bring programs/wellness knowledge to company employees and the community. Helped increase club usage and revenue by creating new programs, monthly newsletters and working on a marketing strategy with the club owner. Ensured the daily operations of the fitness center went smoothly. Education: Bachelor of Science Exercise Science/Health Promotion UW Oshkosh Graduated May 2006 Current Professional Certifications FST Fascial Stretch Therapist since 2011 Stretch To Win Institute Tempe AZ Current CPR & AED Professional References available upon request SANDRA BANDA BAQUERA OBJECTIVE To obtain a full time position with opportunities for advancement, encourage my professional growth, and further my education within the field of Health Care Administration. SKILLS & ABILITIES Bilingual- English/Spanish, experience with Microsoft Office, reliable, accountable, excellent attendance, multitasker, client relations and communication, operations management, time card management, account maintenance/management, leadership and colleague management skills, Efficient time management, organized. Clinical Skills: EMR experience, phlebotomy skills, vaccine administration, acquiring patient vital signs, PFT/spirometry, EKGs, peak flows, and Audiograms. Certifications: CPR Certified, Certified Drug & Alcohol technician, CAOHC certified technician, Preceptor and trainer for new/current staff. Receptionist experience- Answering phones, scheduling, Checking patients in/out, experience with referrals, management of physician schedules. EXPERIENCE CENTER OPERATIONS DIRECTOR/MEDICAL ASSISTANT CONCENTRA NOVEMBER 2011- CURRENT Concentra has allowed me to progress within my professional career aspirations. I started as a Medical Assistant and within a year was promoted to a Back Office Lead position/ extended hours manager. My clinical skills were assessed yearly, and I was responsible for managing the other Medical Assistants. After 6 years with the company I received two additional promotions from Assistant Operations Director to now the Center Operations Director. My responsibilities include but are not limited to, operations management, patient facilitation, implementation of policies and procedures, Relationship building with clients, employers and patients. I manage most of our employer accounts through consistent communication, and maintenance any accounts as needed. MEDICAL ASSISTANT HERITAGE FAMILY MEDICINE APRIL 2015-OCTOBER 2015 Medical Assistant, also remained prn with Concentra during this time. Gained eMD’s EMR system skills. Clinical skills were exercised daily, performed in house lab tests, electronic prescription refills. The clinic was privately owned, and started going out of business which resulted in my short stay with the company. MEDICAL ASSISTANT GENERAL CARE MEDICAL CLINIC JANUARY 2011- NOVEMBER 2011 Gained clinical skills, obtained patient medical history and vital signs. Performed any available in-house testing requested by the physicians i.e. Spirometry, Respirator Fit Testing, EKG’s, phlebotomy, and vaccine administration. Became a certified drug and alcohol technician. Managed the schedule for the back office staff. MEDICAL ASSISTANT ALPINE FAMILY PRACTICE MAY 2010- JULY 2010 Externship for school was completed at this facility. Worked mostly on the OBGYN side of the facility, assisted with basic patient vitals, phlebotomy and vaccine administration. Assisted in numerous pelvic exams, and placements of IUD’s. SALES ASSOCIATE MACYS JULY 2008- MAY 2010 Worked as a sales associate, and department specialist. Gained customer services skills, as well as cash register experience. Managed inventory, and daily cash fund. PAGE 2 SALES ASSOCIATE ROCKY MOUNTAIN CHOCOLATE FACTORY OCTOBER 2006- JULY 2008/ JULY 2010-JULY 2013 Worked as a sales associate, and was promoted to a manager position. Was responsible for inventory management, employee schedules, hiring and termination of employees as well - as daily deposits. EDUCATION COLORADO CHRISTIAN UNIVERSITY, LOVELAND, CO PURSUING A BACHELORS DEGREE IN HEALTH CARE ADMINISTRATION I will be receiving a Bachelors Degree in Health Care Administration Summer of 2018. I will also plan on retaining a degree as RN-BSN in the future as well. ANTHEM COLLEGE, AURORA, CO MEDICAL ASSISTINT DIPLOMA Seven months of accelerated courses towards my Medical Assisting Diploma with a month and half of full time externship worked. Graduated with honors in excellent grades as well as attendance. Was also able to participate in the Channel 9 News health fair for phlebotomy experience. FORT COLLINS HIGH SCHOOL, FORT COLLINS, CO HIGH SCHOOL DIPLOMA DIPLOMA General education, completed all years of high school. REFERENCES JEFF WINKLER, PHYSICIAN ASSISTANT CONCENTRA MEDICAL CENTER 970-430-1917 LEANNE CHACON, OFFICE MANAGER GENERAL CARE MEDICAL CENTER 970-213-2235 JULIE BALDERSON, PHYSICIAN ASSISTANT CONCENTRA MEDICAL CENTER 970-290-4329 CHARLES RAEL OPERATIONS DIRECTOR CONCENTRA MEDICAL CENTER 970-286-9633 ROSALINDA PINEIRO, MD MEDICAL DIRECTOR CONCENTRA MEDICAL CENTER 970-221-5811 To become Board Certified, a physician must achieve expertise in a medical specialty or subspecialty that meets the profession-driven standards and requirements of one (or more) of the 24 ABMS certifying boards. To maintain Board Certification, the certifying boards may require physicians, depending on their date of initial certification, to participate in on-going programs of continuing learning and assessment (Maintenance of Certification) designed to help them remain current in an increasingly complex practice environment. Rosalinda Pineiromora ( ABMSUID - 345165 ) Viewed:10/3/2017 5:15:30 PM CST DOB: Private Education: 1982 MD (Doctor of Medicine) Address: Private Fort Collins, CO 80524-3543 (United States) Individual NPI : 1528183050 Certification: 1 NPI: Not for Primary Source Verification (PSV). 2 State of Licensure provided by Federation of State Medical Boards (FSMB): Not for Primary Source Verification (PSV). ABMS ® Board Certification Credentials Profile A service provided by the American Board of Medical Specialties New Search | Search Results | Email For Feedback | Save Physician | Print Profile Show Active Medical License(s) : American Board of Family Medicine Family Medicine - General Status: Certified Status Duration Occurrence Start Date - End Date Reverification Date Participating in MOC Active MOC Recertification 11/17/2016 - 02/15/2018 Yes Expired Time-Limited Recertification 12/03/2005 - 12/31/2015 Expired Time-Limited Recertification 07/10/1998 - 12/31/2005 Expired Time-Limited Initial Certification 07/10/1992 - 12/31/1999 Learn more about Family Medicine MOC program Notice: It is up to the user to determine if the physician record obtained from this service is that of the physician being sought. With the exception of our Medical Specialists Online (MSO) product, all information as presented by ABMS Solutions products are approved for business use and are considered Primary Source Verified (PSV) and meet the primary source verification requirements as set by The Joint Commission, NCQA, URAC and other key accrediting agencies. The ABMS physician specialty certification data provided by ABMS Solutions/CertiFACTS Online is proprietary and copyrighted by the American Board of Medical Specialties (ABMS ® ) and subject to the intellectual property laws of the United States. © 2017, ABMS Solutions, LLC, All Rights Reserved. Product names and logos are all marks of the American Board of Medical Specialties. 1 2 ABMS Board Certification Credentials Profile Page 1 of 1 https://certifacts.abms.org/DCReport.aspx?singleresult=true&abmsuid=345165 10/3/2017 Lookup Detail View Licensee Information This serves as primary source verification* of the license. *Primary source verification: License information provided by the Colorado Division of Professions and Occupations, established by 24-34-102 C.R.S. Name Public Address Rosalinda Pineiro 620 S Lemay Ave Fort Collins, CO 80524-3543 Credential Information License Number License Method License Type License Status Original Issue Date Effective Date Expiration Date DR.0033954 Original Physician Active 08/19/1994 05/01/2017 04/30/2019 Supervision Relationship Supervisor/Supervisee License Start Date Relationship Type Supervises Amber R Payne PA.0002011 06/25/2013 Supervisor Supervises Joel Willis Schwartzkopf PA.0002917 11/13/2014 Supervisor Supervises Julia Lynn Balderson PA.0000933 12/20/2013 Supervisor Board/Program Actions Discipline There is no Discipline or Board Actions on file for this credential. Generated on: 11/18/2017 7:56:58 AM Print Lookup Details Page 1 of 1 https://apps.colorado.gov/dora/licensing/Lookup/PrintLicenseDetails.aspx?cred=413224... 11/18/2017 City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Attachments Attachment B Signed Vendor Statement RFQ – DOT Medical Exams 2017 Page 5 of 15 IV. VENDOR STATEMENT Vendor hereby acknowledges receipt of the City of Fort Collins Request for Quote and acknowledges that it has read and agrees to be fully bound by all of the terms, conditions and other provisions set forth in the RFQ. Additionally, Vendor hereby makes the following representations to City: a. All of the statements and representations made in this submittal are true to the best of the Vendor’s knowledge and belief. b. Vendor commits that it is able to meet the terms provided in this quote. c. This quote is a firm and binding offer, for a period of 90 days from the date hereof. d. Vendor further agrees that the method of award is acceptable. e. Vendor also agrees to complete the proposed Agreement with the City of Fort Collins within 30 days of notice of award. f. If contract is not completed and signed within 30 days, City reserves the right to cancel and award to the next lowest quote. g. Vendor acknowledge receipt of addenda. Firm Name: Physical Address: Remit to Address: Phone: Authorized Agent of Firm Name: Signature of Authorized Agent: Primary Contact for Project: Title: Email Address: Phone: Cell Phone: NOTE: VENDOR STATEMENT IS TO BE SIGNED & RETURNED WITH YOUR QUOTE. Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers 5080 Spectrum Drive, Suite1200W, Addison, Texas 75001 P.O. Box 9008, Broomfield, Colorado 80021 800.232.3550 Robert G. Hassett, DO, MPH, Director, President, Treasurer, Secretary Heidi Campbell Account Executive hecampbell@concentra.com 303.388.3627 303.918.5018 DocuSign Envelope ID: 32C181DC-5215-481C-AFC7-657AAC21701E City of Fort Collins ♦ No. 8648 Drug and Alcohol Screening Services December 20, 2017 Attachments Attachment C Legal and Risk Documents Official Purchasing Document Last updated 10/2017 RFQ – DOT Medical Exams 2017 Page 6 of 15 V. SAMPLE SERVICES AGREEMENT – FOR REFERENCE ONLY – DO NOT SIGN SERVICES AGREEMENT THIS AGREEMENT made and entered into the day and year set forth below by and between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter referred to as the "City" and , hereinafter referred to as "Service Provider". WITNESSETH: In consideration of the mutual covenants and obligations herein expressed, it is agreed by and between the parties hereto as follows: 1. Scope of Services. The Service Provider agrees to provide services in accordance with the scope of services attached hereto as Exhibit A, consisting of ( ) page(s) and incorporated herein by this reference. Irrespective of references in Exhibit A to certain named third parties, Service Provider shall be solely responsible for performance of all duties hereunder. 2. The Work Schedule. [Optional] The services to be performed pursuant to this Agreement shall be performed in accordance with the Work Schedule attached hereto as Exhibit , consisting of ( ) page(s), and incorporated herein by this reference. 3. Time of Commencement and Completion of Services. The services to be performed pursuant to this Agreement shall be initiated within ( ) days following execution of this Agreement. Services shall be completed no later than . Time is of the essence. Any extensions of the time limit set forth above must be agreed upon in a writing signed by the parties. 4. Contract Period. This Agreement shall commence , 20 , and shall continue in full force and effect until , 20 , unless sooner terminated as herein provided. In addition, at the option of the City, the Agreement may be extended for additional one year periods not to exceed ( ) additional one year periods. Renewals and pricing changes shall be negotiated by and agreed to by both parties. Written notice of renewal shall be provided to the Service Provider and mailed no later than thirty (30) days prior to contract end. 5. Delay. If either party is prevented in whole or in part from performing its obligations by unforeseeable causes beyond its reasonable control and without its fault or negligence, then the party so prevented shall be excused from whatever performance is prevented by such cause. To the extent that the performance is actually prevented, the Service Provider must provide written notice to the City of such condition within fifteen (15) days from the onset of such condition. 6. Early Termination by City/Notice. Notwithstanding the time periods contained herein, the City may terminate this Agreement at any time without cause by providing written notice of Official Purchasing Document Last updated 10/2017 RFQ – DOT Medical Exams 2017 Page 7 of 15 termination to the Service Provider. Such notice shall be delivered at least fifteen (15) days prior to the termination date contained in said notice unless otherwise agreed in writing by the parties. All notices provided under this Agreement shall be effective when mailed, postage prepaid and sent to the following addresses: Service Provider: City: Copy to: Attn: City of Fort Collins Attn: PO Box 580 Fort Collins, CO 80522 City of Fort Collins Attn: Purchasing Dept. PO Box 580 Fort Collins, CO 80522 In the event of early termination by the City, the Service Provider shall be paid for services rendered to the date of termination, subject only to the satisfactory performance of the Service Provider's obligations under this Agreement. Such payment shall be the Service Provider's sole right and remedy for such termination. 7. Contract Sum. The City shall pay the Service Provider for the performance of this Contract, subject to additions and deletions provided herein, ($ ) as per the attached Exhibit " ", consisting of page(s), and incorporated herein by this reference. 8. City Representative. The City will designate, prior to commencement of the work, its representative who shall make, within the scope of his or her authority, all necessary and proper decisions with reference to the services provided under this agreement. All requests concerning this agreement shall be directed to the City Representative. 9. Independent Service provider. The services to be performed by Service Provider are those of an independent service provider and not of an employee of the City of Fort Collins. The City shall not be responsible for withholding any portion of Service Provider's compensation hereunder for the payment of FICA, Workmen's Compensation or other taxes or benefits or for any other purpose. 10. Subcontractors. Service Provider may not subcontract any of the Work set forth in the Exhibit A, Statement of Work without the prior written consent of the city, which shall not be unreasonably withheld. If any of the Work is subcontracted hereunder (with the consent of the City), then the following provisions shall apply: (a) the subcontractor must be a reputable, qualified firm with an established record of successful performance in its respective trade performing identical or substantially similar work, (b) the subcontractor will be required to comply with all applicable terms of this Agreement, (c) the subcontract will not create any contractual relationship between any such subcontractor and the City, nor will it obligate the City to pay or see to the payment of any subcontractor, and (d) the work of the subcontractor will be subject to inspection by the City to the same extent as the work of the Service Provider. 11. Personal Services. It is understood that the City enters into the Agreement based on the special abilities of the Service Provider and that this Agreement shall be considered as an agreement for personal services. Accordingly, the Service Provider shall neither assign any Official Purchasing Document Last updated 10/2017 RFQ – DOT Medical Exams 2017 Page 8 of 15 responsibilities nor delegate any duties arising under the Agreement without the prior written consent of the City. 12. Acceptance Not Waiver. The City's approval or acceptance of, or payment for any of the services shall not be construed to operate as a waiver of any rights or benefits provided to the City under this Agreement or cause of action arising out of performance of this Agreement. 13. Warranty. a. Service Provider warrants that all work performed hereunder shall be performed with the highest degree of competence and care in accordance with accepted standards for work of a similar nature. b. Unless otherwise provided in the Agreement, all materials and equipment incorporated into any work shall be new and, where not specified, of the most suitable grade of their respective kinds for their intended use, and all workmanship shall be acceptable to City. c. Service Provider warrants all equipment, materials, labor and other work, provided under this Agreement, except City-furnished materials, equipment and labor, against defects and nonconformances in design, materials and workmanship/workwomanship for a period beginning with the start of the work and ending twelve (12) months from and after final acceptance under the Agreement, regardless whether the same were furnished or performed by Service Provider or by any of its subcontractors of any tier. Upon receipt of written notice from City of any such defect or nonconformances, the affected item or part thereof shall be redesigned, repaired or replaced by Service Provider in a manner and at a time acceptable to City. 14. Default. Each and every term and condition hereof shall be deemed to be a material element of this Agreement. In the event either party should fail or refuse to perform according to the terms of this agreement, such party may be declared in default thereof. 15. Remedies. In the event a party has been declared in default, such defaulting party shall be allowed a period of ten (10) days within which to cure said default. In the event the default remains uncorrected, the party declaring default may elect to (a) terminate the Agreement and seek damages; (b) treat the Agreement as continuing and require specific performance; or (c) avail himself of any other remedy at law or equity. If the non-defaulting party commences legal or equitable actions against the defaulting party, the defaulting party shall be liable to the non-defaulting party for the non-defaulting party's reasonable attorney fees and costs incurred because of the default. 16. Binding Effect. This writing, together with the exhibits hereto, constitutes the entire agreement between the parties and shall be binding upon said parties, their officers, employees, agents and assigns and shall inure to the benefit of the respective survivors, heirs, personal representatives, successors and assigns of said parties. 17. Indemnity/Insurance. Official Purchasing Document Last updated 10/2017 RFQ – DOT Medical Exams 2017 Page 9 of 15 a. The Service Provider agrees to indemnify and save harmless the City, its officers, agents and employees against and from any and all actions, suits, claims, demands or liability of any character whatsoever brought or asserted for injuries to or death of any person or persons, or damages to property arising out of, result from or occurring in connection with the performance of any service hereunder. b. The Service Provider shall take all necessary precautions in performing the work hereunder to prevent injury to persons and property. c. Without limiting any of the Service Provider's obligations hereunder, the Service Provider shall provide and maintain insurance coverage naming the City as an additional insured under this Agreement of the type and with the limits specified within Exhibit , consisting of one (1) page, attached hereto and incorporated herein by this reference. The Service Provider before commencing services hereunder, shall deliver to the City's Purchasing Director, P. O. Box 580, Fort Collins, Colorado 80522, one copy of a certificate evidencing the insurance coverage required from an insurance company acceptable to the City. 18. Entire Agreement. This Agreement, along with all Exhibits and other documents incorporated herein, shall constitute the entire Agreement of the parties. Covenants or representations not contained in this Agreement shall not be binding on the parties. 19. Law/Severability. The laws of the State of Colorado shall govern the construction interpretation, execution and enforcement of this Agreement. In the event any provision of this Agreement shall be held invalid or unenforceable by any court of competent jurisdiction, such holding shall not invalidate or render unenforceable any other provision of this Agreement. 20. Prohibition Against Employing Illegal Aliens. Pursuant to Section 8-17.5-101, C.R.S., et. seq., Service Provider represents and agrees that: a. As of the date of this Agreement: 1. Service Provider does not knowingly employ or contract with an illegal alien who will perform work under this Agreement; and 2. Service Provider will participate in either the e-Verify program created in Public Law 208, 104th Congress, as amended, and expanded in Public Law 156, 108th Congress, as amended, administered by the United States Department of Homeland Security (the “e-Verify Program”) or the Department Program (the “Department Program”), an employment verification program established pursuant to Section 8- 17.5-102(5)(c) C.R.S. in order to confirm the employment eligibility of all newly hired employees to perform work under this Agreement. b. Service Provider shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or knowingly enter into a contract with a subcontractor that knowingly employs or contracts with an illegal alien to perform work under this Agreement. Official Purchasing Document Last updated 10/2017 RFQ – DOT Medical Exams 2017 Page 10 of 15 c. Service Provider is prohibited from using the e-Verify Program or Department Program procedures to undertake pre-employment screening of job applicants while this Agreement is being performed. d. If Service Provider obtains actual knowledge that a subcontractor performing work under this Agreement knowingly employs or contracts with an illegal alien, Service Provider shall: 1. Notify such subcontractor and the City within three days that Service Provider has actual knowledge that the subcontractor is employing or contracting with an illegal alien; and 2. Terminate the subcontract with the subcontractor if within three days of receiving the notice required pursuant to this section the subcontractor does not cease employing or contracting with the illegal alien; except that Service Provider shall not terminate the contract with the subcontractor if during such three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. e. Service Provider shall comply with any reasonable request by the Colorado Department of Labor and Employment (the “Department”) made in the course of an investigation that the Department undertakes or is undertaking pursuant to the authority established in Subsection 8-17.5-102 (5), C.R.S. f. If Service Provider violates any provision of this Agreement pertaining to the duties imposed by Subsection 8-17.5-102, C.R.S. the City may terminate this Agreement. If this Agreement is so terminated, Service Provider shall be liable for actual and consequential damages to the City arising out of Service Provider’s violation of Subsection 8-17.5-102, C.R.S. g. The City will notify the Office of the Secretary of State if Service Provider violates this provision of this Agreement and the City terminates the Agreement for such breach. 21. Special Provisions. Special provisions or conditions relating to the services to be performed pursuant to this Agreement are set forth in Exhibit - Confidentiality, consisting of one (1) page, attached hereto and incorporated herein by this reference. Official Purchasing Document Last updated 10/2017 RFQ – DOT Medical Exams 2017 Page 11 of 15 THE CITY OF FORT COLLINS, COLORADO By: Gerry Paul Purchasing Director DATE: ATTEST: APPROVED AS TO FORM: SERVICE PROVIDER'S NAME By: Printed: Title: CORPORATE PRESIDENT OR VICE PRESIDENT Date: The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC POLICY PRO- GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS PER STATUTE OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: CONCGRO-01 1 1 The Graham Company Occupational Health Centers of The Southwest PA c/o Select Medical Corporation 4716 Old Gettysburg Rd. Mechanicsburg PA 17055 25 CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-2; Effective 6/1/2017-2018 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-2; Effective 6/1/2017-2018 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-2; Effective 6/1/2017-2018 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-2; Effective 6/1/2017-2018 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-2; Effective 6/1/2017-2018 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Policy #WA7-63D-510199-047; Effective: 6/1/2017-2018 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Policy #WA7-63D-510199-057 and WC7-631-510199-067; Effective: 6/1/2017-2018 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas – Policy #WC7-631-510199-077; Effective: 6/1/2017-2018 OHC of Southwest (AZ/UT) – Policy #WC2-631-510199-117; Effective: 6/1/2017-2018 OHC of Delaware – Policy #WC2-631-510199-107; Effective: 6/1/2017-2018 OHC of Georgia/Hawaii – Policy #WC2-631-510199-177; Effective: 6/1/2017-2018 OHC of Illinois – Policy #WC2-631-510199-197; Effective: 6/1/2017-2018 OHC of Louisiana – Policy #WC2-631-510199-097; Effective: 6/1/2017-2018 OHC of Michigan – Policy #WC2-631-510199-187; Effective: 6/1/2017-2018 OHC of Nebraska – Policy #WC2-631-510199-147; Effective: 6/1/2017-2018 OHC of New Jersey – Policy #WC2-631-510199-137; Effective: 6/1/2017-2018 OHC of North Carolina – Policy #WC7-631-510199-087; Effective: 6/1/2017-2018 OHC of Southwest (KS) – Policy #WC2-631-510199-127; Effective: 6/1/2017-2018 Therapy Centers of Southwest I, PA (OR) - Policy #WC2-631-510199-167; Effective: 6/1/2017-2018 Therapy Centers of South Carolina, PA - Policy #WC2-631-510199-157; Effective: 6/1/2017-2018 CYBER LIABILITY - National Union Fire Insurance Company of Pittsburgh, PA - Policy #01-863-48-21; Effective 9/25/2016-2017 - Limit: $10,000,000 Security and Privacy Coverage is provided for all medical professionals employed or contracted by the above Named Insured, only while working for or on behalf of the above Named Insured. RE: OHC-SWPA/CMC IS BIDDING ON AN RFP UNDER # 8637 DOT MEDICAL EXAMS CITY OF FORT COLLINS IS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY, AUTOMOBILE LIABILITY AND EXCESS LIABILITY COVERAGES IF REQUIRED BY WRITTEN CONTRACT. PROPERTY DAMAGE $ $ $ $ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12/11/2017 The Graham Company The Graham Building 1 Penn Square West Philadelphia PA 19102- SelectMed Unit 215-567-6300 215-525-0243 SELECTMED_UNIT@grahamco.com Columbia Casualty Company 31127 CONCGRO-01 American Guarantee & Liability 26247 Occupational Health Centers of The Southwest PA c/o Select Medical Corporation 4716 Old Gettysburg Rd. Mechanicsburg PA 17055 Liberty Mutual Fire Insurance Company 23035 Allied World Assurance Company, Ltd. (DOMICILED Liberty Insurance Corporation 42404 780994633 A X 1,000,000 X 500,000 X Professional Lia 10,000 X $1M Claim/$3M Ag 1,000,000 3,000,000 X Y HAZ 4032244581-2 6/1/2017 6/1/2018 3,000,000 C 2,000,000 X Y AS2-631-510199-037 6/1/2017 6/1/2018 A X X 10,000,000 2,000,000 Y HMC 4032235752-2 X 10,000,000 6/1/2017 6/1/2018 E E N WA7-63D-510199-017 WC7-631-510199-027 6/1/2017 6/1/2017 6/1/2018 6/1/2018 X 1,000,000 1,000,000 1,000,000 B D Property Excess Liability ZMD0119116-02 C023701-003 6/1/2017 6/1/2017 6/1/2018 6/1/2018 SEE BELOW $10M Each Occurrence $10M Aggregate UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $2,000,000 Self-Insured Retention each Occurrence/Claim subject to a $10,000,000 Aggregate. PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-2; Effective 6/1/2017-2018 - $250,000 Each Medical Incident/$750,000 Aggregate Per Insured or Surgeon See Attached... CITY OF FORT COLLINS PO BOX 580 ATTN: PURCHASING DIRECTOR FORT COLLINS CO 80522