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Home My WebLink AboutRESPONSE - FAX QUOTE - 8648 DRUG & ALCOHOL TESTINGWorkwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 1 of 23 City of Fort Collins Quote No. 8648 Drug and Alcohol Screening Services 2017 Financial Services, Purchasing Division 215 North Mason Street, 2nd Floor PO Box 580 Fort Collins, CO 80522 970.221.6775 fcgov.com/purchasing DUE DATE AND TIME: Prior to 3 PM on Dec 20, 2017 Workwell Occupational Medicine, LLC Stephen Pottenger, CEO steve.pottenger@workwellworks.com www.workwellworks.com 164 Primrose Ct. Longmont, CO 80501 303.827.3158 1600 Specht Pt Rd., Ste. 115 3350 Peoria St., Ste. 190 2550 S. Parker Rd., Ste. 150 Fort Collins, CO 80525 Aurora, CO 80010 Aurora, CO 80014 970.672.5100 303.365.4646 720.512.4408 970.672.5105 fax 303.365.4644 fax 720.512.5978 fax 205 S. Main St., Ste. C 1608 Topaz Dr. 1275 58th Ave., Ste. 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 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 2 of 23 December 20, 2017 Gerry S. Paul Director of Purchasing City of Fort Collins 215 North Mason Street, 2nd Floor Fort Collins, CO 80522 Dear Gerry and City of Fort Collins: Thank you for the opportunity to respond to your invitation to bid for Drug and Alcohol Testing for City of Fort Collins. We are Workwell Occupational Medicine, LLC (“Workwell”), a locally owned and operated group of workers’ compensation and Occupational Medicine specialists. We deliver services to companies in every industry, of every size, in a professional manner, providing exceptional customer service and superior medical care for businesses and their employees throughout Boulder, Larimer, Denver, Arapahoe, Broomfield and Weld counties. We ONLY focus on Occupational Medicine so we can manage schedules efficiently and communicate with clients timely! Our full facility clinics treat on-the-job injuries and perform drug and alcohol screenings, physical exams, pre- and post-employment functional testing. In addition, we offer employers customized options such as ergonomic evaluations, safety trainings, and health and wellness services. As a leader in Occupational Medicine, we understand the importance of reliability with you, the employer, when it comes to establishing a drug and alcohol testing facility. We train our staff regularly and support them to ensure results are timely, specimens are carefully handled, your employees are treated with professionalism and wait times are minimized. All of our Chain of Custody forms are electronically maintained and patient confidentiality is strictly adhered to. Results are reported through a secure portal and archived for up to two years to establish a worry-free process for both you and your employees. Currently, we provide services for a number of municipalities similar to the City of Fort Collins and, as experts within our field, we feel uniquely qualified to provide the services you have outlined in your request. We hope you feel the same when considering our proposal and trust that you will find our response more than adequate. It is our desire to not only address your requirements, but also answer any questions that may arise after your 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 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 3 of 23 TABLE OF CONTENTS SECTION I: COVER LETTER PAGE 2 A. Objective B. Background SECTION II: SCOPE OF WORK PAGE 4 A. Services to Be Provided B. Certification and Documentation C. Records Retention D. Deliverables SECTION III: QUOTE SUBMITTAL PAGE 7 A. eScreen Preferred Provider Documentation B. Qualifications of Firm and Staff C. References D. Fee Schedule E. Description of Facilities F. Signed Vendor Statement ATTACHMENTS W-9 Attachment A Insurance Certificate Attachment B Drug and Alcohol Policy and Procedures Attachment C HIPAA/Uses and Disclosures of PHI Attachment D Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 4 of 23 SECTION II: SCOPE OF WORK Workwell Occupational Medicine, LLC is a full testing and collection facility for all drug and alcohol services. We are contracted, and certified, to provide testing in all our locations for every lab in the regional and nationwide substance abuse testing market. Every year, across the organization, Workwell provides approximately 15,000 rapid, DOT, and non-DOT drug and alcohol tests, to include post-accident, pre-employment, reasonable suspicion, random, and return-to-duty. We have the experience, results, and service your organization deserves. Our facility is a member of the eScreen Drug Screening Network (www.escreen.com). eScreen provides affordable, rapid, compliant and efficient employee drug testing services for companies seeking faster hiring transactions and paperless solutions, step-by-step protocols ensure consistency and total electronic forms completion, optical e-Reader 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 and are available to authorized staff 24 hours a day, usually within 1 hour of test collection. The eScreen Drugs of Abuse Screening system is intended for use by professionals in prescription workplace settings for the rapid, qualitative detection of target drugs and/or metabolites including cocaine, cannabinoids, methamphetamine, opiates, and phencyclidine in urine. The eScreen system is a ‘screen only’ device. All inconclusive samples are sent to SAMHSA certified laboratories for further testing. Workwell also provides the benefit of having multiple locations all along the front range to provide your organization and your employees the flexibility of obtaining services wherever the need may be. Our facilities are fully HIPAA compliant, secure, and provide a private area for all collection services. Your organization has the ability to tour any of these sites at your convenience to ensure that Workwell complies with your organization’s commitment to privacy and security. Workwell is fully compliant with all DOT regulations and SAMHSA guidelines in the collection, storage, and transport of urine specimens. This includes all necessary materials, equipment and facilities that are necessary for compliant DOT and NON DOT collections including refrigerated storage of specimens. All DOT specimens are sent directly to the lab for processing and reported per DOT guidelines. eScreen’s eCup is a patented urine collection device designed to allow for Non-DOT rapid, under-seal screening. A major advantage to the “smart” cup is that it doesn’t require human intervention or interpretation—which means no chance of human error. The normal processing time to complete urine screening is approximately 6 minutes. Negative results typically reported within 15 minutes via fax or email to the designated employer contacts. How does the eCup work? Once the donor’s urine specimen is placed into the plastic cup, the lid is attached and sealed. This creates a completely self-contained unit that does not require Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 5 of 23 the clinician to pour, transfer or pipette the specimen into any other container. Instead, the cup—in combination with the patented eReader appliance—does all the work. The eCup’s lid contains several embedded reagent test strips that are sensitive to the five-test SAMHSA (Substance Abuse and Mental Health Services Administration) profile cutoff levels. The lid’s test strips also detect and provide adulteration panels for pH, creatinine and nitrates. These are performed on each test. When the eCup is placed into the eReader device, its test strips are digitally screened for the presence or absence of drugs of abuse. All specimens sent for laboratory confirmation are sent via next-day air services using Fed-Ex. All specimens are collected, stored, and transported using DOT compliant procedures. All transportation, courier fees, confirmatory testing and analysis, and MRO fees are included in the price of the drug screen. The two test strips, located inside the eCup lid, utilize qualitative competitive inhibition immunoassay strip technology for the qualitative determination of the presence of the following classes of drugs and their metabolites at the following cutoff concentrations: Cocaine - 300 ng/ml Phencyclidine - 25 ng/ml Cannabinoids - 50 ng/ml Methamphetamine - 1000 ng/ml Morphine - 2000 ng/ml Workwell employs personnel who are certified Breath Alcohol Technicians and we have the instrumentation to conduct breath alcohol tests. Our trained and certified staff follow the procedures established by the Department of Transportation for both Non-DOT and DOT drug screens. This ensures proper procedures are trained and followed consistently every time. Our Electronic Medical Records System also allows each clients’ protocol to be customized and followed thoroughly between all of our clinic locations. Training and compliance is persistently monitored by our Director of Operations. Test results are only available through a secure portal via myescreen.com that is only accessible to the individuals that have been given the User ID and Password that is established by the Human Resources Department at the City of Fort Collins. Workwell can coordinate and facilitate processes with other collection and laboratory facilities when an employee requests additional testing at another location. The City’s Designated Employer Representative (DER) has access to the status of a pending test specimen within 15 minutes of Workwell collecting the specimen via their secure portal via www.myescreen.com. It will notify the DER in real time if the specimen has been sent to lab, is under MRO review or a test result has been confirmed positive or negative. Once a result is posted, the DER can also click on the donor name and a full printable report is available. Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 6 of 23 City of Fort Collins staff can conduct inspections or request a tour of the collection facility at any time without notice by contacting their dedicated Clinic Manager, who can assist with any additional needs: JOLYNN DIESING joylnn.diesing@workwellworks.com 970.672.5100 AURORA SOUTHEAST: Ian Zinth / ian.zinth@workwellworks.com / 720.512.4408 DENVER NORTHEAST: Becca Meyer-Grittner / becca.meyergrittner@workwellworks.com / 970.672.5100 GREELEY: Jeri Coyle / jeri.coyle@workwellworks.com / 970.356.9800 LONGMONT: Kaitlyn Caudill / kaitlyn.caudill@workwellworks.com / 303.702.1612 LOVELAND: Dawn Kramer / dawn.kramer@workwellworks.com / 970.775.2081 Our Director of Operations is also available when needed: JUDY PEINADO judy.peinado@workwellworks.com 303.827.3158 and 303.775.4117 Workwell can provide monthly billing statements summarizing the number of tests processed, including the reason for testing (e.g. pre-employment, random, post-accident). Once a result is posted via the MyeScreen secure portal, the DER can click on the donor name and a full printable report is available. The City’s results will be archived online for up to two years. Results reports are available within 15 minutes of collection for Non-DOT negative results and within 72-96 hours for DOT or non-negative results. The utmost consideration is taken into account when obtaining specimens that will allow for individual privacy during the collection procedure. All reporting procedures are secure and online, only available to the DER with the User ID and Password. Workwell has provisions in place to ensure that the collection site will be secure at all times and that no unauthorized personnel may be permitted in any part of the collection site where specimens or records are obtained and stored. All of our eScreen documentation is electronically managed. Workwell adheres to all City and Federal guidelines for collecting proper donor identification and completing forms accurately: • We require a photo ID from all donors before proceeding with any collection. • We require a release be signed by a legal guardian if a donor is under the age of 18. • We require all Chain of Custody forms be accurately completed during the collection process. Staff is regularly tested and trained on completing forms accurately. Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 7 of 23 SECTION III: QUOTE SUBMITTAL A. Workwell is an eScreen Preferred Vendor. This can be verified through contacting: CHRISTINA HILL Regional Manager Midwest eScreen, Inc. christina.hill@escreen.com 913.912.0794 B. Qualifications of Our Firm & Staff • Serving Colorado Businesses Since 1996, fully licensed and insured • Focusing On Prompt Recovery and Appropriate Return-To-Work Programs • Dedicated to 100% Professional Occupational Medicine • Convenient Walk-In Appointments & Efficient Urgent Care Facilities • Experienced Level II Medical Providers • Electronic Medical Record and On-line Access for Employers and Insurance Providers • Onsite Physical Therapy and Pharmacy • Se Habla Español – Spanish Speaking Providers and Staff in most facilities • Complete Offering of Corporate Care Services Compliance: Medical Director Services, Compliance Management, Medical Surveillance, IME Pre-Employment: Drug/Alcohol Screens, Baseline Physicals, Essential Job Function Testing Health & Wellness: Health Risk Assessments, select mobile on-site services Support: Health Fairs, Educational Seminars, Workers’ Compensation Conferences, e-Newsletters and more Personnel providing services to City of Fort Collins and their experience: Name: Jolynn Diesing – Clinic Manager Years of employment with our organization: 6 years Years of experience in industry: 6 years Years of experience performing work relevant to service proposed: 6 years Licenses, professional designations, and/or degrees earned: Bachelors of Science in Healthcare Management, Associates of Applied Science in Medical Assisting, Certified DOT Collector, Certified Breath Alcohol Technician, Certified Hair Collector, Certified eScreen Trainer Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 8 of 23 Name: Kayla Davila – Front Office Specialist Years of employment with our organization: 3 years Years of experience in industry: 5 years Years of experience performing work relevant to service proposed: 5 years Licenses, professional designations, and/or degrees earned: Bachelors of Science in Human Development Family Studies – Health Professions and Sports Medicine, Certified Nurse Aide Name: Denisee Gonzalez – Medical Assistant Years of employment with our organization: > 1 year Years of experience in industry: 1 year Years of experience performing work relevant to service proposed: >1 year Licenses, professional designations, and/or degrees earned: Registered Medical Assistant, Certified DOT Collector, Certified Breath Alcohol Technician, Certified Hair Collector Name: Doria Mey – Radiologist Technician Years of employment with our organization: < 1 year Years of experience in industry: 12 years Years of experience performing work relevant to service proposed: 12 Years Licenses, professional designations, and/or degrees earned: Associates of Applied Sciences in Radiology, Certified DOT Collector, Certified Breath Alcohol Technician, Certified Hair Collector, Certified Nurse Aide, Certified Phlebotomist MRO Name: Stephen Kracht, MD Professional Qualifications: MD, nationally recognized MRO Experience: 12+ years After-Hours Collections Accu-Test of Northern Colorado / Alan Hayashi and Matt Berwick 2529 N. Lincoln Ave., Ste. C, Loveland, CO 80538 Phone: 970-227-9583 or 970-663-3674 Fax 970-278-1225 Workwell has been in the eScreen network since 2006 and collects more than 20,000 drug screens per year. Laboratory/Facility Background: Workwell utilizes the eScreen testing system and Abbott labs in all our locations. Founded in 1998 by Dr. Murray Lappe and the nation’s largest MRO corporation, eScreen is SAMHSA certified and has provided drugs-of-abuse screening and automated hiring program solutions for some of the nation’s largest hiring programs. Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 9 of 23 Workwell Occupational Medicine, LLC is able to meet all of the outlined requirements contained in the City of Fort Collins RFQ / Quote 8648. Workwell is a privately owned and locally operated limited liability corporation serving Colorado businesses since 1996. Our organization employs 50+ people including 11 physicians, 3 physician extenders and 6 Physical Therapists. We offer a complete array of Occupational Medicine and corporate care services and are the largest specialist provider of our kind in Colorado. 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. We are the clear choice if you need a professional, dedicated, comprehensive, quality, cost effective and service oriented occupational health provider in Colorado. As a local organization, Workwell has the unique ability to be nimble and reactive to our client needs and market demands. Our schedules are watched closely, and staffing levels and processes are constantly evaluated to ensure our clinics are working efficiently and at top notch care levels. We take pride in recruiting highly qualified medical staff and strive to be the premiere resource in Colorado for all types of industry. Workwell understands the need to keep wait times low and get employees back to work quickly and safely, especially during drug and alcohol screening. Workwell Occupational Medicine, LLC is willing and able to provide all the previously listed services to City of Fort Collins employees. Our organization fully understands, and accepts, all requirements of City of Fort Collins to participate in this RFQ and to provide these services in the future to you and your employees. Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 10 of 23 C. REFERENCES 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 Thompson School District R2J Denise Absalom, Risk Manager 535 North Douglas Avenue 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 Kim Brunson, Risk Manager 350 Kimbark Street Longmont, CO 80501 303.651.8724 kim.brunson@longmontcolorado.gov PROJECT SCOPE: workers’ compensation injury care, physical therapy, case management, drug and alcohol screening, pre-employment and DOT physicals STATUS: Active Larimer County Jeffrey Green, Director of Risk Management 200 West Oak Street Fort Collins, CO 80522 970.498.5962 jlgreen@larimer.org PROJECT SCOPE: workers’ compensation injury care, physical therapy, case management, drug and alcohol screening, pre-employment and DOT physicals STATUS: Active Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 11 of 23 D. FEE SCHEDULE Drug and Alcohol Testing Cost per Test (DOT) Cost per Test (Non-DOT) Drug Sample Collection $25 $25 Alcohol Sample Collection $25 $25 Rapid Test N/A $30 Breath Alcohol Test $20 $20 DOT Drug Screen** $35 N/A Non-DOT Drug Screen (eScreen 5 Panel) N/A $25 MRO Services for Drug Testing $0* $0* After-hour drug and/or alcohol sample collection N/A N/A Additional administrative fee(s) – please explain None None Optional services provided N/A N/A 1. *MRO Services – the cost of confirmation laboratory analysis and any MRO associated fees and/or administrative fees are included in the price of the DOT and Non-DOT laboratory tests. 2. Expert Testimony -- $450/hr 3. On-site Mobile Services – Workwell provides on-site mobile screening services at your location with a guaranteed minimum of 25 tests. Fees are $55/hr on-site time for each Workwell staff member + the listed cost of the tests performed. 4. Random Pool List Generator -- $100/hr ** Effective January 1, 2018, The Federal Department of Transportation (DOT) revised its drug testing program regulation to include detection for four semi-synthetic opioids: hydrocodone, hydromorphone, oxycodone, and oxymorphone. In addition, methylenedioxyamphetamine (MDA) has been added as an initial test analyte, and methylenedioxyethylamphetamine (MDEA) has been removed as a confirmatory test analyte. Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 12 of 23 E. GENERAL DESCRIPTION OF FACILITIES WORKWELL Occupational Medicine - FTC 1600 Specht Point Road, Ste 115 Fort Collins, CO 80525 Phone: 970.672.5100 Fax: 970.672.5105 Hours: 8am-5pm Monday-Friday WORKWELL Occupational Medicine - ASE 2550 S. Parker Rd. Ste. 150 Aurora, CO 80014 Phone: 720.512.4408 Fax: 720.512.5978 Hours: 8am-5pm Monday-Friday WORKWELL Occupational Medicine - DNE 3350 Peoria Ave. Ste. 190 Aurora, CO 80011 Phone: 303.365.4646 Fax: 303.365.4644 Hours: 8am-5pm Monday-Friday WORKWELL Occupational Medicine - GRE 2528 West 16th Street Greeley, CO 80634 Phone: 970.356.9800 Fax: 970.353.3182 Hours: 8am-5pm Monday-Friday WORKWELL Occupational Medicine - LMT 205 S. Main Street, Ste C Longmont, CO 80501 Phone: 303.702.1612 Fax: 303.774.7899 Hours: 8am-5pm M, W, F; 7am-5pm T, Th WORKWELL Occupational Medicine - LVD 1608 Topaz Drive Loveland, CO 80537 Phone: 970.593.0125 Fax: 970.593.0127 Hours: 8am-5pm Monday-Friday Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 13 of 23 F. 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 0 addenda. Firm Name: Workwell Occupational Medicine, LLC Physical Address: 1600 Specht Point Road, Suite 150, Fort Collins, CO 80525 Remit-to Address: 164 Primrose Ct, Longmont, CO 80501 Phone: 303.827.3158 Authorized Agent of Firm Name: Stephen Pottenger Signature of Authorized Agent: Primary Contact for Project: Nathan Johnson Title: Director of Business Development Email Address: nate.johnson@workwellworks.com Phone: 303.827.3158 Cell Phone: 720.526.7539 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 14 of 23 ATTACHMENT A Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 15 of 23 ATTACHMENT B Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 16 of 23 ATTACHMENT C Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 17 of 23 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 18 of 23 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 19 of 23 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 20 of 23 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 21 of 23 ATTACHMENT D WORKWELL OCCUPATIONAL MEDICINE 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 Occupational Medicine, 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); Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 22 of 23 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; 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 Workwell Occupational Medicine, LLC 2017 City of Fort Collins RFQ 8648 - Drug and Alcohol Testing Page 23 of 23 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. Privacy Official Contact Information: Privacy Official WORKWELL Occupational Medicine 164 Primrose Court Longmont, CO 80501 (303) 827-3158 Approved: Dec. 2015 By: JP/BM