Permanente Medical Group, Inc Page 1 of 8
THIRD AMENDMENT TO SERVICE CONSULTANT AGREEMENT
This Third Amendment to Service Consultant Agreement (“Third Amendment”) is entered into this ____ day of April 2022 (“Effective Date”), by and between the CITY OF ALAMEDA, a municipal corporation (the “ City”), and The Permanente Medical Group, Inc., a California corporation, whose address is 1800 Harrison Street, 9 th Floor, Oakland, CA, 94612 (“Consultant”), in reference to the following facts and circumstances:
RECITALS
A. On September 1, 2015, an agreement was entered into by and between the City and Consultant (hereinafter “Agreement”) with compensation not to exceed $200,000.
B. On September 1, 2018, the o riginal agreement was amended between the City and Consultant (hereinafter “First Amendment”) with additional compensation not to exceed $230,000 for services rendered during the added contractual term between September 1, 2018 and August 31, 2021, and with a total aggregate not to exceed amount of $430,000.
C. On July 20, 2021, the First Amendment was amended between the City and Consultant (hereinafter “Second Amendment”) with additional compensation not to exceed $260,000 for services rendered during the added contractual term between September 1, 2021 and August 31, 2024, and with a total aggregate not to exceed amount of $690,000.
NOW, THEREFORE, it is mutually agreed by and between the undersigned parties as follows:
1. Exhibit A to the Agreement is deleted in its entirety and replaced with Exhibit A-1 in the form attached hereto.
2. Except as expressly modified herein, all other terms and covenants set forth in the Agreement shall remain the same and shall be in full force and effect.
[Signature Page follows]
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D
Permanente Medical Group, Inc Page 2 of 8
IN WITNESS WHEREOF, the par ties have each caused this Agreement to be duly executed on its behalf as of the Effective Date.
The Permanente Medical CITY OF ALAMEDA
Group, Inc., a California corporation a municipal corporation Richard S. Isaacs, MD FACS Eric J. Levitt
CEO and Executive Director City Manager
Patricia T. West
VP, VP, TPMG Financial Services
CFO
RECOMMENDED FOR APPROVAL
Nancy Bronstein
Human Resources Director
APPROVED AS TO FORM: City
Attorney
Alan M. Cohen
Assistant City Attorney
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D 4/6/2022
4/6/2022
Permanente Medical Group, Inc Page 3 of 8
City of Alameda
Exhibit A-1
Billing Code Description of Services Cost of
Services
PREPLACEMENT EXAM (PP1)
300388 Preplacement Physical Exam $65.00
As Employer Requested:
86580 PPD, 1 step, placement and reading $20.00
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Clinically Indicated:
71045 Chest X-Ray, 1 view $55.00
71046 Chest X-Ray, 2 views $75.00
PREPLACEMENT EXAM (PP3)
300388 Preplacement Physical Exam $65.00
As Employer Requested:
300415 Review of Respirator Questionnaire by MD/NP/RN $35.00 86580 PPD, 1 step, placement and reading $20.00
92552 Audiogram, screening $54.00
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Clinically Indicated:
94010 Spirometry $60.00
93000 EKG, resting $50.00
93015 Cardiac Stress Test with Treadmill $230.00
71045 Chest X-Ray, 1 view $55.00
71046 Chest X-Ray, 2 views $75.00
90746 Vaccine: Hepatitis B, may need series of 3 injections $130.00/injection 90632 Vaccine: Hepatitis A, may need series of 2 injections $114.00/injection 90636 Vaccine: Twinrix (Hep B and Hep A combo), series of 3 injections
$191.00/injection
86706 Titer: Hepatitis B Surface Antibody (HBsAb) $35.00 86708 Titer: Hepatitis A IgG Antibody (HAAb) $40.00
300408 Physician Consultation, each 15 minutes $64.00/15 mins PREPLACEMENT EXAM (PP5)
300388 Preplacement Physical Exam $65.00
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D
Permanente Medical Group, Inc Page 4 of 8
300422 PPD, 2 step, 2 placements and readings $30.00
As Employer Requested:
92552 Audiogram, screening $54.00
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Clinically Indicated:
36415 Venipuncture $15.00
71045 Chest X-Ray, 1 view $55.00
71046 Chest X-Ray, 2 views $75.00
86580 PPD, 1 step, placement and reading $20.00
86317 Titer: Rabies Antibody Testing $43.00
90675 Rabies Vaccine, series of 3 injections $579.00/injection 300408 Physician Consultation, each 15 minutes $64.00/15 mins
POLICE/SHERIFF PREPLACEMENT EXAM (POSTPP)
300399 POST Physical Exam $127.00
92552 Audiogram, screening $54.00
94010 Spirometry $60.00
93000 EKG, resting $50.00
93015 Cardiac Stress Test with Treadmill $230.00
86580 PPD, 1 step, placement and reading
-OR-
$20.00
86480 QuantiFERON $145.00
85025 CBC with automated differential $20.00
80053 Chem Comprehensive Panel $41.00
86706 Titer: Hepatitis B Surface Antibody (HBsAb) $35.00 86704 Titer: Hepatitis B Core Antibody (HBcAb) $31.00
86803 Titer: Hepatitis C Antibody Screen $56.00
86708 Titer: Hepatitis A IgG Antibody (HAAb) $40.00
36415 Venipuncture $15.00
As Employer Requested:
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Clinically Indicated:
90746 Vaccine: Hepatitis B, may need series of 3 injections $130.00/injection 90632 Vaccine: Hepatitis A, may need series of 2 injections $114.00/injection 90636 Vaccine: Twinrix (Hep B and Hep A combo), series of 3 injections
$191.00/injection
90707 Vaccine: Measles Mumps Rubella (MMR), may need series of 2 injections
$103.00/injection
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D
Permanente Medical Group, Inc Page 5 of 8
90716 Vaccine: Varivax (Varicella or Chickenpox), may need series of 2 injections
$152.00/injection
90715 Vaccine: Tdap
–OR–
$63.00
90714 Vaccine: Td $34.00
90658 Vaccine: Influenza (when seasonally available) $20.00 86735 Titer: Mumps Antibody Screen $35.00
86762 Titer: Rubella Antibody Screen (German Measles) $35.00 86765 Titer: Rubeola Antibody Screen (Measles) $35.00
86787 Titer: Varicella (Varicella or Chickenpox) Antibody Screen $35.00 81001 Urinalysis with microscopy $16.00
71045 Chest X-Ray, 1 view $55.00
71046 Chest X-Ray, 2 views $75.00
75571 Cardiac calcium scoring CT scan $265.00
300408 Physician Consultation, each 15 minutes $64.00/15 mins
PUBLIC SAFETY DISPATCHER PREPLACEMENT EXAM (DISPATCH)
300388 Preplacement Physical Exam $65.00
92552 Audiogram, screening $54.00
As Employer Requested:
86580 PPD, 1 step, placement and reading $20.00
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Clinically Indicated:
71045 Chest X-Ray, 1 view $55.00
71046 Chest X-Ray, 2 views $75.00
FIREFIGHTER PREPLACEMENT EXAM (FFPP)
300398 Firefighter Physical Exam $127.00
92552 Audiogram, screening $54.00
94010 Spirometry $60.00
85025 CBC with automated differential $20.00
80053 Chem Comprehensive Panel $41.00
36415 Venipuncture $15.00
71046 Chest X-Rays (2 views, PA & Lateral) $75.00
300422 PPD, 2 step, 2 placements and readings
-OR-
$30.00
86480 QuantiFERON $145.00
93000 EKG, resting $50.00
93015 Cardiac Stress Test with Treadmill $230.00
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D
Permanente Medical Group, Inc Page 6 of 8
86706 Titer: Hepatitis B Surface Antibody (HBsAb) $35.00 86704 Titer: Hepatitis B Core Antibody (HBcAb) $31.00
86803 Titer: Hepatitis C Antibody Screen $56.00
86708 Titer: Hepatitis A IgG Antibody (HAAb) $40.00
As Employer Requested:
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Clinically Indicated:
90746 Vaccine: Hepatitis B, may need series of 3 injections $130.00/injection 90632 Vaccine: Hepatitis A, may need series of 2 injections $114.00/injection 90636 Vaccine: Twinrix (Hep B and Hep A combo), series of 3 injections
$191.00/injection
90707 Vaccine: Measles Mumps Rubella (MMR), may need series of 2 injections
$103.00/injection
90716 Vaccine: Varivax (Varicella or Chickenpox), may need series of 2 injections
$152.00/injection
90715 Vaccine: Tdap
–OR–
$63.00
90714 Vaccine: Td $34.00
90658 Vaccine: Influenza (when seasonally available) $20.00 86735 Titer: Mumps Antibody Screen $35.00
86762 Titer: Rubella Antibody Screen (German Measles) $35.00 86765 Titer: Rubeola Antibody Screen (Measles) $35.00
86787 Titer: Varicella (Varicella or Chickenpox) Antibody Screen $35.00 81001 Urinalysis with microscopy $16.00
71045 Chest X-Ray, 1 view $55.00
300408 Physician Consultation, each 15 minutes $64.00/15 mins
RESPIRATOR BASELINE/PERIODIC (RESP)
300415 Review of OSHA Respirator Questionnaire by MD/NP/RN $35.00 As Employer Requested:
300410 Respirator Fit Test, qualitative $41.00
As Clinically Indicated:
300391 Respirator Clearance Physical Exam $64.00
94010 Spirometry $60.00
71046 Chest X-Ray (2 views) $75.00
93000 EKG, resting $50.00
93015 Cardiac Stress Test with Treadmill $230.00
300408 Physician Consultation, each 15 minutes $64.00/15 mins
AUDIOGRAM (AUDIO)
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D
Permanente Medical Group, Inc Page 7 of 8
92552 Audiogram, screening $54.00
As Clinically Indicated:
300408 Physician Consultation, each 15 minutes $64.00/15 mins
DMV/DOT EXAM (DMV/DOT)
300390 DMV/DOT Physical Exam $115.00
URINE DRUG AND BREATH ALCOHOL TESTING (DRUG)
300411 Collection for Drug Screen-Preferred Alliance Billed by Preferred Alliance
As Indicated:
82075 Breath Alcohol Testing (BAT) – Preferred Alliance Billed by Preferred Alliance
300421 Breath Alcohol Testing (BAT), Confirmatory – Preferred Alliance
Billed by Preferred
Alliance
VACCINATION ONLY (VAX)
300406 History/Review of Tests/Brief Screen - No Physical Exam $42.00 As Clinically Indicated:
90746 Vaccine: Hepatitis B, may need series of 3 injections $130.00/injection 90632 Vaccine: Hepatitis A, may need series of 2 injections $114.00/injection 90636 Vaccine: Twinrix (Hep B and Hep A combo), series of 3 injections
$191.00/injection
90707 Vaccine: Measles Mumps Rubella (MMR), may need series of 2 injections
$103.00/injection
90716 Vaccine: Varivax (Varicella or Chickenpox), may need series of 2 injections
$152.00/injection
90715 Vaccine: Tdap
–OR–
$63.00
90714 Vaccine: Td $34.00
90658 Vaccine: Influenza (when seasonally available) $20.00 90675 Rabies Vaccine, series of 3 injections $579.00/injection
LABORATORY ONLY (LAB)
300406 History/Review of Tests/Brief Screen - No Physical Exam $42.00 36415 Venipuncture $15.00
As Clinically Indicated:
86706 Titer: Hepatitis B Surface Antibody (HBsAb) $35.00 86708 Titer: Hepatitis A IgG Antibody (HAAb) $40.00
86735 Titer: Mumps Antibody Screen $35.00
86762 Titer: Rubella Antibody Screen (German Measles) $35.00 86765 Titer: Rubeola Antibody Screen (Measles) $35.00
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D
Permanente Medical Group, Inc Page 8 of 8
86787 Titer: Varicella (Varicella or Chickenpox) Antibody Screen $35.00 86317 Titer: Rabies Antibody Testing $43.00
TB CLEARANCE PPD – INTRADERMAL SKIN TEST (PPD/TB CLEARANCE) 86580 PPD, 1 step, 1 placement and reading
-OR-
$20.00
86480 QuantiFERON $145.00
As Clinically Indicated:
36415 Venipuncture $15.00
300422 PPD, 2 step, 2 placements and readings $30.00
71045 Chest X-Ray, 1 view $55.00
71046 Chest X-Ray, 2 views $75.00
99211 Brief encounter with non-MD Consultant (PPD-Review of Symptoms Form)
$25.00
DocuSign Envelope ID: 39388BF4-1990-4A49-A48C-0C8AC2C7727D