Ebix Insurance No. S200002136
AMENDMENT NO. 1
TO THE AGREEMENT FOR SERVICES
BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE MEDICAL GROUP, INC.
PREAMBLE
This agreement ("Amendment No. 1 ") is entered into between the City of Santa Clara, California, a chartered California municipal corporation (City) and The Permanente Medical Group, Inc., a California corporation, (Contractor). City and Contractor may be referred to individually as a "Party" or collectively as the "Parties" or the "Parties to this Agreement." •
RECITALS
A The Parties previously entered into an agreement entitled "Agreement for the Performance of Services by and Between the City of Santa Cla·ra, California and the Permanente Medical Group, Inc.", dated September 14, 2017 (the "Original Agreement"); and
B. The Parties entered .into the Original Agreement for the purpose of having Contractor provide professional medical services for public safety employees, and the Parties now wish to amend the Original Agreement to replace Exhibit B "Fee Schedule," to reflect alteration to PPD testing, addition of physician consultation time, and addition of QuantiFERON testing.
The Parties agree as follows:
AGREEMENT TERMS AND CONDITIONS
1. AMENDMENT TERMS AND CONDITIONS
· Exhibit B "Fee Schedule" of the Qriginal Agreement, is hereby deleted in its • entirety and replaced with a new Exhibit B in the form attached hereto as "Exhibit B First Amended Fee Schedule."
2. TERMS
All other terms of the Original Agreement which are not in conflict with the provisions of this Amendment No. 1 shall remain unchanged in full force and effect. In case of a conflict in the terms of the Original Agreement and this Amendment No. 1, the provisions of this Amendment No. 1 shall control.
Amendment No. 1 to Agreement/The Permanente Medical Group, Inc.
Rev. 09/13/2019
3. COUNTERPARTS
- This Agreement may be executed in counterparts, each of which shall be deemed to be an original, but both of which shall constitute one and the same instrument.
The Parties acknowledge and accept the terms and conditions of this Amendment No. 1 as eviden _ced by the following signatu'res of their duly authorized representatives.
CITY OF SANTA CLARA, CALIFORNIA
a chartered California municipal corporation
APPROVED AS TO -FORM:
Dated: I I ~ l'i , l't
"CITY"
lf:lj/2. r sANT ANA
City Manager
1500 Warburton Avenue
Santa Clara, CA 95050
Telephone: (408) 615-2210
Fax: (408) 241-6771
THE PERMANENTE MEDICAL GROUP, INC.
a California corporation
Dated: I o / 3 1 l ;:u, L 1 •
By (Signature): ~""'-~a- h,..,:..,Q_ ~ ~
Name: Lavanya Kai r, MD, MPH ~-
Title:
Principal Place of
Business Address:
Medical Director, KPOJ Occupational Heqlth and Safety
Services - NCAL ------------------
Occupational Health Sales and Account
Management
1800 Harrison Street, 9th Floor
Oakland, CA 94612
Attention: Sales Manager
"CONTRACTOR"
Amendment No. 1 to Agreement/The Permanente Medical Group, Inc.
Rev. 09/13/2019
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE GROUP, INC.
EXHIBITB
FIRST AMENDED FEE SCHEDULE
Consultant shall provide a schedule of rates and fees which includes all billing amounts and costs as follows (if applicable), such as:
OCCUPATIONAL HEALTH AND SAFETY SERVICES TO BE PROVIDED TO THE CITY OF SANTA CLARA FIRE DEPARTMENT.
FIREFIGHTER PREPLACEMENT EXAM (FFPP)
300398 Firefighter Physical Exam $95.00
92552 Audiogram, screening $30.00
94010 Spirometry $35.00
300422 PPD, 2 step, 2 placements and readings (no charge to $30.00 current KP HP members)
-OR-
86480 QuantiFERON $127.00
71045 Chest X-Ray, 2 views (baseline) $65.00
85025 CBC with automated differential $15.00
80053 Chem Comprehensive Panel $35.00
86704 Titer: Hepatitis B Core Antibody, HBcAb $31.00
86803 Titer: Hepatitis C $45.00
86708 Hepatitis A lgG Antibody, HAAb (titer) $40.00
86706 Hepatitis B Surface antibody, HBSAb $31.00
-
36415 Venipuncture $15.00
Amendment No. 1 to Agreement/The Permanente Medical Group, Inc.
Rev. 09/13/2019 •
93000 EKG, resting -and- $50.00
93015 Cardiac Stress Test with Treadmill $230.00
300420 Drug Screen Preferred Alliance "Quick Test" Billed by Preferred Alliance
300413 Form completion (2 or more pages for DMV /DOT $25.00 Exam)
As Clinically Indicated:
90746 Vaccine: Hepatitis B (series of 3 injections) (no charge $94.00/injection to current KP HP members)
90632 Vaccine: Hepatitis A (series of 2 injections) $96.00/injection 90707 Vaccine: MMR injection (series of 2 injections, if $76.00/injection indicated)
90716 Vaccine: Varivax (chickenpox)(series of2 injections if $132.00/injection indicated)
90715 Vaccine: Tdap (tetanus, diphtheria, pertussis) $63.00 90713 Vaccine: Polio ( eiPV) if no prior vaccination $40.00 90658 Vaccine: Influenza (when seasonally available) $20.00 86580 PPD, one placement and one reading (no charge to $20.00 current KP HP members) .
71045 Chest X-Ray for positive PPD (1 view) $55.00
81001 Urinalysis with microscopic (if abnormal UA dipstick) $15.00 86735 Titer: Mumps antibody screen $35.00
86762 Titer: Rubella antibody screen $35.00
86765 Titer: Rubeola antibody screen $35.00
86787 Titer: Varicella antibody screen $35.00
300408 Physician Consultation; each additional 15 minutes $60.00 Amendment No. 1 to Agreement/The Permanente Medical Group, Inc.
Rev. 09/13/2019
FIREFIGHTER-ANNUAL OR PERIODIC (FFANN)
300398 Firefighter Physical Exam $95.00
92552 Audiogram, screening $30.00
94010 Spirometry $35.00
86480 QuantiFERON Testing $127.00
85025 CBC with automated differential $15.00
80053 Chem. Comprehensive Panel $35.00
36415 Venipuncture $15.00
93000 EKG Resting -AND- $50.00
93015 Cardiac Stress Test with Treadmill (males 45+ or $230.00 females 55+ with 2 or more NFPA risk factors) -NFPA
and Wellness
300413 Form completion (2 or more pages for DMV /DOT $25.00 Exam)
As Clinically Indicated:
71045 Chest X-Ray for positive PPD (I view) $55.00
71046 Chest X-Ray for positive PPD + symptoms (2 views) (or $65.00 baseline · and (c4 every 5 years)
81001 Urinalysis with microscopic (if abnormal UA dipstick) $15.00 82274 Fecal Immunochemical Test ( 40+ or as clinically $30.00 indicated- can be done by personal physician) -NFPA
and Wellness
84152 PSA for males; prostate specific antigen $53.00
86580 PPD, one placement and one reading (no charge to $20.00 • current KP HP members)
90746 Vaccine: Hepatitis B (series of 3 injections, if indicated $94.00/injection or declination) (no char5-;e to current KP HP members)
90632 Vaccine: Hepatitis A (series of 2 injections) $96.00/iniection Amendment No. 1 to Agreement/The Permanente Medical Group, Inc.
Rev. 09/13/2019
90713 Vaccine: Polio ( eiPV) if no prior vaccination $40.00 90715 Vaccine: Tdap (tetanus, diphtheria, pertussis) $63.00 90707 Vaccine: MMR injection (series of2 injections, if $76.00/injection indicated)
90716 Vaccine: Varivax (chickenpox)(series of2 injections if $132.00/injection indicated)
86735 Titer: Mumps antibody screen $35.00
86762 Titer: Rubella antibody screen $35.00
86765 Titer: Rubeola antibody screen $35.00
86787 Titer: Varicella antibody screen $35.00
300408 Physician Consultation; each additional 15 · minutes $60.00
FITNESS FOR DUTY /RETURN TO WORK (FFD/RTW)
300397 Fitness for Duty Physical Exam, initial $95.00
As Clinically Indicated:
300408 Physician Consultation; each additional 15 minutes $60.00
VACCINATION ONLY (VAX)
90707 Vaccine: MMR injection (if indicated) $76.00/iniection • 90716 Vaccine: Varivax ( chickenpox)(if indicated) $132.00/injection 90746 Vaccine: Hepatitis B (series of 3 injections) (no charge $94.00/injection to current KP HP members)
90658 Influenza vaccine injection, as vaccine is available, (no $20.00 charKe to current KP HP members)
90715 Vaccine: Tdap $63.00
90713 Polio vaccine injection $40.00
90632 Hepatitis A vaccine (Havarix), per injection (series of 2) $96.00 Amendment No. 1 to Agreement/The Permanente Medical Group, Inc.
Rev. 09/13/2019
RESPIRATOR l\1EDICAL EVALUATION- BASELINE/ ANNUAL (RESP) 300415 Review of Respirator Questionnaire by MD/NP /RN $35.00 As Clinically Indicated:
71020 Chest X-Ray (2 views) $65.00
300391 Respirator Physical Exam $60.00
93000 EKG Resting $50.00
93015 Cardiac Stress Test with Treadmill $230.00
94010 Spirometry $35.00
300408 Physician Consultation; each 15 minutes $60.00
-
DMV/DOT EXAM (DMV)
300390 DMV /DOT Physical Exam $115.00
In no event shall the amount billed to City by Contractor for services under this Agreement exceed three hundred thirty-four thousand dollars ($334,000) for the term of this Agreement, subject to budget appropriations.
Amendment No. 1 to Agreement/The Permanente Medical Group , Inc.
Rev. 09/13/2019