City of
Santa Clara
The Center of What's Possible
Date:
To:
From:
September 12, 2017
City Manager for Council Action
Fire Chief
AGENDA ITEM #: l d-. 8j
AGENDA REPORT
Subject: Approval of Agreement for Performance of Services with The Permanente Medical Group, Inc.
EXECUTIVE SUMMARY
Since 1999 the Santa Clara Fire Department has had an agreement with The Permanente Medical Group, Inc. for professional medical services for public safety employees. The Occupational Health and Safety Services Division of The Permanente Medical Group , Inc. has extensive experience and knowledge of the Occupational Safety and Health Administration (OSHA) Standard 190.156 - Fire Brigades, OSHA Standard 1910.134 - Respiratory Protection and the National Fire Protection Agency (NFPA) Standard on Comprehensive Occupational Medical Program for Fire Departments (NFPA 1582). These guidelines and standards outline the required medical services for public safety employees. The Permanente Medical Group, Inc. has been selected to continue providing these services, which include approximately 150 annual or periodic exams, evaluations or vaccinations for sworn Fire Department employees and approximately 40 members of the Volunteer Reserve Division. The Permanente Medical Group , Inc. also provides new hire physical clearances for firefighter candidates, as well as respirator evaluations for Santa Clara Police Officers mandated under OSHA Standard 1910.134. The services provided to the City each year can vary greatly based on the number and the extent of on-duty injuries, staffing and clinical indications; therefore the not to exceed amount included in the agreement is based on an average of expenditures in recent fiscal years plus an allowance for additional procedures that are frequently added due to State and Federal regulatory requirements.
ADVANTAGES AND DISADVANTAGES OF ISSUE
Approval of the Agreement will allow continued OSHA required medical services for public safety employees, which are critical to their health and safety and that of the citizens they serve . No disadvantages were identified.
ECONOMIC/FISCAL IMPACT
The estimated annual cost for public safety medical services is $111,333 and the total cost for the three-year contract shall not exceed $334,000. Funding is available in the Fire Department Contractual Services account (001-7822-87870).
RECOMMENDATION
That the Council approve and authorize the City Manager to execute a three-year Agreement for Professional Services with The Permanente Medical Group , Inc. for required public safety medical Subject: Approval of Agreement for Performance of Services with The Permanente Medical Group, Inc.
services , in an amount not to exceed $111,333 per fiscal year for FY 17 /18, FY 18/19 and FY 19/20, and a total amount not to exceed $334,000 subject to budget appropriations.
Fire Chief
~ RQVED: /).._ ,. _
~UAJ r~nr
Rajeev Batra
City Manager
Documents Related to this Report:
Certified as to Availabilit of Funds: ~
001- 22-87870 $111 ,333
1) Agreement for the Performance of Services By and Between the City of Santa Clara, California, and The Permanente Medical Group, Inc.
EBIX Insurance No. S200002136
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE MEDICAL GROUP, INC
PREAMBLE
This agreement for the performance of services ("Agreement") is by and between The Permanente Medical Group, Inc., a California corporation, with its principal place of business located at 1950 Franklin Street, Oakland, CA 94612 ("Contractor"), and the City of Santa Clara, California, a chartered California municipal corporation with its primary business address at 1500 Warburton Avenue, Santa Clara, California 95050 ("City"). City and Contractor may be referred to individually as a "Party" or collectively as the "Parties" or the "Parties to this Agreement."
RECITALS
A. City desires to secure professional services more fully described in this Agreement, at Exhibit A, entitled "Scope of Services"; and
B. Contractor represents that it, and its subcontractors , if any, have the professional qualifications, expertise, necessary licenses and desire to provide certain goods and/or required services of the quality and type which meet objectives and requirements of City; and,
C. The Parties have specified herein the terms and conditions under which such services will be provided and paid for.
The Parties agree as follows:
AGREEMENT PROVISIONS
1. RETENTION OF CONTRACTOR.
City hereby contracts with Contractor to perform services set forth in this Agreement. To accomplish that end, City may assign a Project Manager to personally direct the Services to be provided by Contractor and will notify Contractor in writing of City's choice . City shall pay for all such materials and services provided which are consistent with the terms of this Agreement.
2. SERVICES TO BE PROVIDED.
Except as specified in this Agreement, Contractor shall furnish all technical and professional services, including labor, material, equipment, transportation, supervision · and expertise ( collectively referred to as "Services") to satisfactorily complete the work required by City at his/her own risk and expense. Services to be provided to City are Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
more fully described in Exhibit A entitled "SCOPE OF SERVICES." All of the exhibits referenced in this Agreement are attached and are incorporated by this reference.
3. COMMENCEMENT AND COMPLETION OF SERVICES.
A. Contractor shall begin providing the services under the requirements of this Agreement upon receipt of written Notice to Proceed from City. Such notice shall be deemed to have occurred three (3) calendar days after it has been deposited in the regular United States mail. Contractor shall complete the Services within the time limits set forth in the Scope of Services or as mutually determined in writing by the Parties .
B. When City determines that Contractor has satisfactorily completed the Services, City shall give Contractor written Notice of Final Acceptance. Upon receipt of such notice , Contractor shall not incur any further costs under this Agreement.
Contractor may request this determination of completion be made when, in its opinion, the Services have been satisfactorily completed. If so requested by the contractor, City shall make this determination within fourteen ( 14) days of its receipt of such request.
4. QUALIFICATIONS OF CONTRACTOR - STANDARD OF WORKMANSIDP.
Contractor represents and maintains that it has the necessary expertise in the professional calling necessary to perform services , and its duties and obligations , expressed and implied, contained herein , and City expressly relies upon Contractor's representations regarding its skills and knowledge . Contractor shall perform such services and duties in conformance to and consistent with the professional standards of a specialist in the same discipline in the State of California .
The plans, designs, specifications, estimates , calculations, reports and other documents furnished under Exhibit A shall be of a quality reasonably acceptable to City. The criteria for acceptance of the work provided under this Agreement shall be a product of neat appearance , well organized, that is technically and grammatically correct , checked and having the maker and checker identified . The minimum standard of appearance, organization and content of the drawings shall be that used by City for similar projects.
5. TERM OF AGREEMENT.
Unless otherwise set forth in this Agreement or unless this paragraph is subsequently modified by a written amendment to this Agreement , the term of this Agreement shall begin on the Effective Date of this Agreement and terminate on August 31, 2020.
6. MONITORING OF SERVICES.
City may monitor the Services performed under this Agreement to determine whether Contractor ' s operation conforms to City policy and to the terms of this Agreement. City may also monitor the Services to be performed to determine whether financial operations are conducted in accord with applicable City, county, state, and federal requirements. If Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
any action of Contractor constitutes a breach, City may terminate this Agreement pursuant to the provisions described herein.
7. WARRANTY.
Contractor expressly warrants that all materials and services covered by this Agreement shall be fit for the purpose intended, shall be free from defect, and shall conform to the specifications, requirements, and instructions upon which this Agreement is based .
Contractor agrees to promptly replace or correct any incomplete, inaccurate , or defective Services at no further cost to City when defects are due to the negligence, errors or omissions of Contractor. If Contractor fails to promptly correct or replace materials or services , City may make corrections or replace materials or services and charge Contractor for the cost incurred by City.
8. PERFORMANCE OF SERVICES.
Contractor shall perform all requested services in an efficient and expeditious manner and shall work closely with and be guided by City. Contractor shall be as fully responsible to City for the acts and omissions of its subcontractors, and of persons either directly or indirectly employed by them, as Contractor is for the acts and omissions of persons directly employed by it. Contractor will perform all Services in a safe manner and in accordance with all federal, state and local operation and safety regulations .
9. BUSINESS TAX LICENSE REQUIRED.
Contractor must comply with Santa Clara City Code section 3.40.060, as that section may be amended from time to time or renumbered, which requires that any person who transacts or carries on any business in the City of Santa Clara pay business license tax to the City. A business tax certificate may be obtained by completing the Business Tax Affidavit Form and paying the applicable fee at the Santa Clara City Hall Municipal Services Division .
10. RESPONSIBILITY OF CONTRACTOR.
Contractor shall be responsible for the professional quality, technical accuracy and coordination of the Services furnished by it under this Agreement. Neither City 's review , acceptance, nor payments for any of the Services required under this Agreement shall be construed to operate as a waiver of any rights under this Agreement or of any cause of action arising out of the performance of this Agreement and Contractor shall be and remain liable to City in accordance with applicable law for all damages to City caused by Contractor negligent performance of any of the Services furnished under this Agreement.
Any acceptance by City of plans, specifications, construction contract docum ents, reports , diagrams, maps and other material prepared by Contractor shall not in any respect absolve Contractor from the responsibility Contractor has in accordance with customary standards of good professional practice in compliance with applicable federal , state , county, and/or municipal laws, ordinances, regulations, rules and orders.
Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
11. COMPENSATION AND PAYMENT.
In consideration for Contractor's complete performance of Services, City shall pay Contractor for all materials provided and services rendered by Contractor at the rate per hour for labor and cost per unit for materials as outlined in Exhibit B, entitled "SCHEDULE OF FEES."
Contractor will bill City on a monthly basis for Services provided by Contractor during the preceding month, subject to verification by City. City will pay Contractor within thirty (3 0) days of City's receipt of invoice.
12. TERMINATION OF AGREEMENT.
Either Party may terminate this Agreement without cause by giving the other Party written notice ("Notice of Termination") which clearly expresses that Party's intent to terminate the Agreement. Notice of Termination shall become effective no less than thirty (30) calendar days after a Party receives such notice. After either Party terminates the Agreement, Contractor shall discontinue further services as of the effective date of termination, and City shall pay Contractor for all Services satisfactorily performed up to such date.
13. NO ASSIGNMENT OR SUBCONTRACTING OF AGREEMENT.
City and Contractor bind themselves , their successors and assigns to all covenants of this Agreement. This Agreement shall not be assigned or transferred without the prior written approval of City. Contractor shall not hire subcontractors without express written permission from City.
14. NO THIRD PARTY BENEFICIARY.
This Agreement shall not be construed to be an agreement for the benefit of any third party or parties and no third party or parties shall have any claim or right of action under this Agreement for any cause whatsoever .
15. INDEPENDENT CONTRACTOR.
Contractor and all person(s) employed by or contracted with Contractor to furnish labor and/or materials under this Agreement are independent contractors and do not aqt as agent(s) or employee(s) of City. Contractor has full rights, however, to manage its employees in their performance of Services under this Agreement. Contractor is not authorized to bind City to any contracts or other obligations.
16. NO PLEDGING OF CITY'S CREDIT.
Under no circumstances shall Contractor have the authority or power to pledge the credit of City or incur any obligation in the name of City. Contractor shall save and hold harmless the City, its City Council, its officers, employees, boards and commissions for expenses arising out of any unauthorized pledges of City' s credit by Contractor under this Agreement.
Agreement for the Performance of Services/The Permanente Medical Group Rev . 06/22/17
17. CONFIDENTIALITY OF MATERIAL.
All ideas, memoranda, specifications , plans, manufacturing procedures, data, drawings, descriptions, documents, discussions or other information developed or received by or for Contractor and all other written information submitted to Contractor in connection with · the performance of this Agreement shall be held confidential by Contractor and shall not, without the prior written consent of City, be used for any purposes other than the performance of the Services nor be disclosed to an entity not connected with performance of the Services. Nothing furnished to Contractor which is otherwise known to Contractor or becomes generally known to the related industry shall be deemed confidential.
Notwithstanding the foregoing , this Paragraph 17 shall not apply to medical records, Contractor shall retain all rights and title to such medical records, and Contractor may use any medical record created or modified by Consultant in connection with its provision of Services hereunder in any manner it desires subject to applicable law, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
18. USE OF CITY NAME OR EMBLEM.
Contractor shall not use City's name, insignia, or emblem, or distribute any information related to services under this Agreement in any magazine, trade paper, newspaper or other medium without express written consent of City.
19. OWNERSHIP OF MATERIAL.
All material, including information developed on computer(s) , which shall include , but not be limited to, data, sketches, tracings, drawings, plans, diagrams, quantities, estimates, specifications, proposals,'tests, maps , calculations, photographs , reports and other material developed, collected , prepared or caused to be prepared under this Agreement shall be the property of City but Contractor may retain and use copies thereof.
City shall not be limited in any way or at any time in its use of said material. However , Contractor shall not be responsible for damages resulting from the use of said material for work other than Project, including, but not limited to, the release of this material to third parties. Notwithstanding the foregoing, this Paragraph 19 shall not apply to medical records and any medical record created or modified by Contractor in connection with its provision of Services hereunder shall not be considered work product developed, collected, prepared or caused to be prepared by Contractor in the performance of this Agreement. Contractor shall retain all rights and title to such medical records, subject to applicable law, including but not limited to HIPPA.
20. RIGHT OF CITY TO INSPECT RECORDS OF CONTRACTOR.
City, through its authorized employees , representatives or agents shall have the right during the term of this Agreement and for three (3) years from the date of final payment for goods or services provided under this Agreement, to audit the books and records of Contractor for the purpose of verifying any and all charges made by Contractor in connection with Contractor compensation under this Agreement, including termination of Contractor . Contractor agrees to maintain sufficient books and records in accordance with generally accepted accounting principles to establish the correctness of all charges submitted to City. Any expenses not so recorded shall be disallowed by City .
Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
Contractor shall submit to City any and all reports concerning its performance under this Agreement that may be requested by City in writing. Contractor agrees to assist City in meeting City's reporting requirements to the State and other agencies with respect to Contractor's Services hereunder.
21. CORRECTION OF SERVICES.
Contractor agrees to correct any incomplete, inaccurate or defective Services at no further costs to City, when such defects are due to the negligence, errors or omissions of Contractor.
22. FAIR EMPLOYMENT.
Contractor shall not discriminate against any employee or applicant for employment because ofrace, color, creed, national origin, gender, sexual orientation, age, disability, religion, ethnic background, or marital status, in violation of state or federal law.
23. HOLD HARMLESS/INDEMNIFICATION.
To the extent permitted by law, Contractor agrees to protect, defend, hold harmless and indemnify City, its City Council, commissions, officers, employees , volunteers and agents from and against any claim, injury, liability, loss, cost , and/or expense or damage, including all costs and reasonable attorney's fees in providing a defense to any claim arising therefrom, for which City shall become liable arising from Contractor ' s negligent acts or willful misconduct with respect to or in any way connected with the Services performed by Contractor pursuant to this Agreement , but excluding: (1) liabilities due to the sole negligence or willful misconduct of City, its City Council, commissions, officers , employees , volunteers and agents, and (2) any liability arising as a result of an employment-related dispute (including but not limited to a lawsuit by an employee of City for employment discrimination based on results of Contractor's Services, a lawsuit by an employee of City alleging breach of an employment statute or regulation , etc.).
24. INSURANCE REQUIREMENTS.
'
During the term of this Agreement , and for any time period set forth in Exhibit C, Contractor shall provide and maintain in full force and effect, at no cost to City insurance policies with respect to employees and vehicles assigned to the Performance of Services under this Agreement with coverage amounts, required endorsements, certificates of insurance, and coverage verifications as defined in Exhibit C. Notwithstanding any other provision of this Agreement, including but not limited to those contained in this section and Exhibit C, Contractor, in lieu of any insurance requirements contained herein, may fulfill such insurance obligations through its alternative risk management programs , including self insurance, and City consents to such self insurance and agrees that, in such case, Contractor cannot provide endorsements or report deductibles , or self-insured retentions, or other requirements that are inconsistent with a program of self insurance.
Contractor's fulfillment of the insurance requirements through alternate risk management programs shall not constitute a breach of this Agreement.
Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
25. AMENDMENTS.
This Agreement may be amended only with the written consent of both Parties.
26. INTEGRATED DOCUMENT.
This Agreement represents the entire agreement between City and Contractor. No other understanding, agreements, conversations, or otherwise, with any representative of City prior to execution of this Agreement shall affect or modify any of the terms or obligations of this Agreement. Any verbal agreement shall be considered unofficial information and is not binding upon City.
27. SEVERABILITY CLAUSE.
In case any one or more of the provisions in this Agreement shall, for any reason, be held invalid, illegal or unenforceable in any respect, it shall not affect the validity of the other provisions , which shall remain in full force and effect.
28. WAIVER.
Contractor agrees that waiver by City of any one or more of the conditions of performance under this Agreement shall not be construed as waiver(s) of any other condition of performance under this Agreement.
29. NOTICES.
All notices to the Parties shall, unless otherwise requested in writing, be sent to City addressed as follows:
City of Santa Clara
Attention: Fire Department
1500 Warburton Avenue
Santa Clara, California 95050
or by facsimile at ( 408) 246-8652
And to Contractor addressed as follows:
Attention: Sales Manager
Kaiser Permanente
Occupational Health Sales and Account Management
1800 Harrison Street, 9th Floor
Oakland, CA 94612
or by facsimile at (510) 625-3656
If notice is sent via facsimile, a signed, hard copy of the material shall also be mailed.
The workday the facsimile was sent shall control the date notice was deemed given if there is a facsimile machine generated document on the date of transmission. A facsimile transmitted after 1 :00 p.m. on a Friday shall be deemed to have been transmitted on the following Monday.
Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
30. CAPTIONS.
The captions of the various sections, paragraphs and subparagraphs of this Agreement are for convenience only and shall not be considered or referred to in resolving questions of interpretation.
31. LAW GOVERNING CONTRACT AND VENUE.
This Agreement shall be governed and construed in accordance with the statutes and laws of the State of California. The venue of any suit filed by either Party shall be vested in the state courts of the County of Santa Clara, or if appropriate, inthe United States District Court, Northern District of California, San Jose, California.
32. DISPUTE RESOLUTION.
A. Unless otherwise mutually agreed to by the Parties, any controversies between Contractor and City regarding the construction or application of this Agreement, and claims arising out of this Agreement or its breach, shall be submitted to mediation within thirty (3 0) days of the written request of one Party after the service of that request on the other Party.
B. The Parties may agree on one mediator . If they cannot agree on one mediator, the Party demanding mediation shall request the Superior Court of Santa Clara County to appoint a mediator. The mediation meeting shall not exceed one day (eight (8) hours). The Parties may agree to extend the time allowed for mediation under this Agreement.
C. The costs of mediation shall be borne by the Parties equally.
D. For any contract dispute, mediation under this section is a condition precedent to filing an action in any court. In the event of mediation which arises out of any dispute related to this Agreement, the Parties shall each pay their respective attorney's fees, expert witness costs and cost of suit through mediation only. If mediation does not resolve the dispute, the Parties agree that the matter shall be litigated in a court oflaw, and not subject to the arbitration provisions of the Public Contracts Code.
33. COMPLIANCE WITH ETHICAL STANDARDS.
Contractor shall:
A. Read Exhibit D, entitled "ETHICAL STANDARDS FOR CONTRACTORS
SEEKING TO ENTER INTO AN AGREEMENT WITH THE CITY OF SANTA CLARA, CALIFORNIA"; and,
B. Execute Exhibit E, entitled "AFFIDAVIT OF COMPLIANCE WITH ETHICAL STANDARDS."
Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
34. AFFORDABLE CARE ACT OBLIGATIONS
To the extent Contractor is obligated to provide health insurance coverage to its employees pursuant to the Affordable Care Act ("Act") and/or any other similar federal or state law, Contractor warrants that it is meeting its obligations under the Act and will fully indemnify and hold harmless City for any penalties, fmes, adverse rulings, or tax payments associated with Contractor's responsibilities under the Act.
35. CONFLICT OF INTERESTS.
This Agreement does_not preyent either Party from entering into similar agreement_s with other parties. To prevent a conflict of interest, Contractor certifies that to the best of its knowledge, no City officer , employee or authorized representative has any financial interest in the business of Contractor and that no person associated with Contractor has any interest , direct or indirect , which could conflict with the faithful performance of this Agreement. Contractor is familiar "Yith the provisions of California Government Code Section 87100 and following, and certifies that it does not know of any facts which would violate these code provisions. Contractor will advise City if a conflict arises .
Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22 /17
CITY OF SANTA CLARA, CALIFORNIA
a chartered California municipal corporation
APPROVED AS TO FORM:
~~ ATfEST'fv:
ROD DIRIDON, JR.
City Clerk
"CITY"
Dated: q · f L} · I I
~~
City Manager
1500 Warburton Avenue
Santa Clara, CA 95050
Telephone: (408) 615-2210
Fax: (408) 241-6771
THE PERMANENTE MEDICAL GROUP, INC.
*choose one: corporation/partnership/individual
Dated: C, /1, / f7
- - -----'-------
By:
(Signature of Person executing the Agreement on behalf of Contractor) Name: Constance C. Chiulli on behalf of Roman Kownacki, MD, MPH ____ _______ ____: __ __...::.::.....:...:c..:..______:........:____:---'-..::....:...---'-------- - --- T it le: Constance C. Chiulli: Regional Director, Occupational Health Service Line Roman Kownacki, MD, MPH: Medical Director, Regional Occupational Health - N orthem California
Local Address: 1800 Harrison St. 21st Floor, Oakland, CA 94612 Email [email protected]
Address: [email protected]
Telephone: (510) 625-3306- Constance C. Chiulli
(510) 625-7175 - RomanKownacki, MD, MPH
Fax: (510) 625-3037
"CONTRACTOR"
S:\Attomey\AGREEMENTS\Service\OVER $SOK SERVICE AGREEMENT FORM.doc Agreement for the Performance of Services/The Permanente Medical Group Rev. 06/22/17
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE MEDICAL GROUP, INC
EXHIBIT A
SCOPE OF SERVICES
The Services to be performed for the City by the Contractor under this Agreement and shall be provided according to the following terms:
If City is requesting a health screening/physical examination of a job applicant or employee, the City will provide to the Contractor detailed information concerning the physical requirements for performing the job at issue . This information should include a written job description, including physical and mental requirements and environmental conditions . The examination and any medical conclusions will be based on the information furnished by the City and the physician's general understanding of the requirements of the jobs of similar nature. Contractor conducts such examinations with the city's assurances that the examination and city's medical inquiries are job related and consistent with the business needs of the City, and otherwise comply with all applicable legal obligations.
Based on its health screening/physical examination of a job applicant/employee, Contractor will advise City of the following:
a)the applicant/employee's physical limitations, if any, and the specific job tasks that cannot be performed and/ or environmental conditions, if any, that are related to any risk to heal and safety , and, b) changes that may be made to permit the job tasks to be performed and/or eliminate /reduce the risk. Contractor will make no determination of whether job tasks are essential to the position in question. Any changes that are recommended are advisory only, based on the physician's general understanding of the job and environment in question, and are not intended to supplant the right of the City to determine what modifications are available and reasonable.
To the extent that other conditions are identified, Contractor will also: a) notify the employee/applicant of any medical condition, identified during the limited medical evaluation that the City request, that the Contractor believes requires further attention, and recommend that the employee/applicant seek care from his or her personal provider, therefore encouraging health and wellness, leading to a more productive workforce, and b) upon authorization of the employee/applicant, Contractor will inform his or his personal medical provider by transmitting copies ofthe medical records created during the visit.
Contractor will maintain a medical records for each individual that will contain records of employer requested services , in addition to past, present and future services requested by the employee/applicant.
Agreement with The Permanente Medical Group, Inc./Scope of Services/Exhibit A Rev. 06/22/17
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE GROUP, INC.
EXHIBITB
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
92552 Audiogram , screening
94010 Spirometry
300422 PPD, 2 step, 2 placements and readings (no charge to current KP HP members)
71020 Chest X-Ray, 2 views (baseline)
85025 CBC with automated differential
80053 Chem Comprehensive Panel
86704 Titer: Hepatitis B Core Antibody , HBcAb
86803 Titer : Hepatitis C
86708 Hepatitis A IgG Antibody , HAAb (titer)
86706 Hepatitis B Surface antibody, HBSAb
Agreement with The Perman ente Medical Group, Inc./Fee Schedule /Exhibit B Rev. 06/22/1 7
$95.00
$30.00
$35.00
$30.00
$65.00
$15.00
$35.00
$31.00
$45.00
$40.00
$31.00
36415 Venipuncture
93000 EKG, resting -and-
93015 Cardiac Stress Test with Treadmill
300420 Drug Screen Preferred Alliance "Quick Test"
300413 Form completion (2 or more pages for DMV/DOT
Exam)
As Clinically Indicated:
90746 Vaccine: Hepatitis B (series of 3 injections) (no charge to current KP HP members)
90632 Vaccine: Hepatitis A (series of 2 injections)
90707 Vaccine: MMR injection (series of 2 injections, if indicated)
90716 Vaccine: Varivax (chickenpox)(series of 2 injections if indicated)
90715 Vaccine : Tdap (tetanus , diphtheria , pertussis) 90713 Vaccine : Polio ( eiPV) if no prior vaccination
90658 Vaccine : Influenza (when seasonally available)
86580 PPD, one placem ent and one reading (no charge to current KP HP members)
71010 Chest X-Ray for positive PPD (1 view)
81001 Urinalysis with microscopic (if abnormal UA dipstick) 86735 Titer: Mumps antibody screen
86762 Titer: Rubella antibody screen
86765 Titer: Rubeola antibody screen
86787 Titer: V aricella antibody screen
Agreement with The Permanente Medical Group, Inc./Fee Schedule /Exhibit B Rev. 06/22/ 17
$15.00
$50.00
$230.00
Billed by
Preferred
Alliance
$25.00
$94.00/injection
$96.00/injection
$76.00/injection
$ 132.00/injection
$63.00
$40.00
$20.00
$20.00
$55.00
$15.00
$35.00
$35.00
$35.00
$35.00
FIREFIGHTER-ANNUAL OR PERIODIC (FFANN)
300398 Firefighter Physical Exam
-
92552 Audiogram, screening
94010 Spirometry
86580 PPD, PLACEMENT AND READING (no charge to
current KP HP members)
85025 CBC with automated differential
80053 ' Chem. Comprehensive Panel
36415 Venipuncture
93000 EKG Resting -AND-
93015 Cardiac Stress Test with Treadmill (males 45+ or
females 5 5+ with 2 or more NFP A risk factors) -NF PA
and Wellness
300413 Form completion (2 or more pages for DMV /DOT
Exam)
As Clinicallv Indicated:
71010 Chest X-Ray for positive PPD (1 view)
71020 Chest X-Ray for positive PPD + symptoms (2 views) (or baseline and (@ every 5 years)
81001 Urinalysis with microscopic (if abnormal UA dipstick) 82274 Fecal Immunochemical Test (40+ or as clinically
indicated- can be done by personal physician) -NFPA
and Wellness
84152 PSA for males; prostate specific antigen
Agreement with The Permanente Medical Group, lnc./Fee Schedule/Exhibit B Rev. 06/22/17
$95.00
$30.00
$35.00
$20.00
$15.00
$35.00
$15.00
$50.00
$230.00
$25.00
$55.00
$65.00
$15.00
$30.00
$53.00
90746 Vaccine : Hepatitis B (series of 3 injections, if indicated or declination) (no charf!e to current KP HP members)
90632 Vaccine: Hepatitis A (series of 2 injections)
90713 Vaccine: Polio (eiPV) if no orior vaccination
90715 Vaccine: Tdap (tetanus, diphtheria , oertussis)
90707 Vaccine: MMR injection (series of 2 injections, if indicated)
90716 Vaccine: Varivax (chickenpox)(series of 2 injections if indicated)
86735 Titer: Mumps antibody screen
86762 Titer: Rubella antibody screen
86765 Titer: Rubeola antibody screen
86787 Titer: V aricella antibody screen
FITNESS FOR DUTY/RETURN TO WORK (FFD/RTW)
300397 I Fitness for Duty Physical Exam, initial
As Clinicallv Indicated:
300408 I Physician Consultation; each additional 15 minutes Agreement with The Permanent e Medical Group, Inc./Fee Schedule/Exhibit B Rev. 06/22/1 7
$94.00/injection
$96.00/iniection
$40.00
$63.00
$76.00/injection
$132.00/injection
$35.00
$35.00
$35.00
$35.00
I $95.oo
I $60.00
VACCINATION ONLY (VAX)
90707 Vaccine: MMR injection (if indicated) $76.00/injection ~90716~ ,r-accine: V arivroc ( chickenpox )(if indicated) $1-32.00/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 char~e 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
RESPIRATOR MEDICAL EVALUATION- BASELINE/ ANNUAL (RESP)
I
300415 Review of Respirator Questionnaire by MD/NP/RN
As Clinically Indicated:
71020 Chest X-Rav (2 views)
300391 Respirator Physical Exam
93000 EKG Resting
93015 Cardiac Stress Test with Treadmill
94010 Spirometry
300408 Physician Consultation; each 15 minutes
Agreement with The Permanente Medical Group, Inc./ Fee Schedule /Exhibit B Rev. 06/22/17
$35.00
$65.00
$60.00
$50.00
$230.00
$35.00
$60.00
DMV/DOT EXAM (DMV)
300390 \ DMV /DOT Physical Exam I $115.oo
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.
Agreement with The Permanente Medical Group, Inc./Fee Schedule/Exhibit B Rev. 06/22/17
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE .
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE MEDICAL GROUP, INC.
EXHIBITC
INSURANCE REQUIREMENTS
INSURANCE COVERAGE REQUIREMENTS
Without limiting the Contractor's indemnification of the City, and prior to commencing any of the Services required under this Agreement, the Contractor shall provide and maintain in full force and effect, at its sole cost and expense, the following insurance policies with at least the indicated coverages, provisions and endorsements:
COMMERCIAL GENERAL LIABILITY INSURANCE
Commercial General Liability Insurance policy which provides coverage at least as broad as Insurance Services Office form CG 00 01. Policy limits are subject to review, but shall in no event be less than, the following:
$1,000,000 Each Occurrence
$2,000,000 General Aggregate
$2,000,000 Products/Completed Operations Aggregate
$1,000,000 Personal lnjucy
Exact structure and layering of the coverage shall be left to the discretion of Contractor; however, any excess or umbrella policies used to meet the required limits shall be at least as broad as the underlying coverage and shall otherwise follow form.
The following provisions shall apply to the Commercial Liability policy as well as any umbrella policy maintained by the Contractor to comply with the insurance requirements of this Agreement:
Coverage shall be on a "pay on behalf' basis with defense costs payable in addition to policy limits;
There shall be no cross liability exclusion which precludes coverage for claims or suits by one insured against another; and
Coverage shall apply separately to each insured against whom a claim is made or a suit is brought , except with respect to the limits of liability.
Agreement with The Permanente Medical Group, Inc./Insurance Requirements/Exhibit C Rev. 06/22/17
BUSINESS AUTOMOBILE LIABILITY INSURANCE
Business automobile liability insurance policy which provides coverage at least as broad as ISO form CA 00 01 with policy limits a minimum limit of not less than one million dollars ($1,000,000) each accident using, or providing coverage at least as broad as, Insurance Services Office form CA 00 01. Liability coverage shall apply to all owned, non-owned and hired autos.
In the event that the Work being performed under this Agreement involves transporting of hazardous or regulated substances, hazardous or regulatea wastes and/or liazaroous or regulated materials, Contractor and/or its subcontractors involved in such activities shall provide coverage with a limit of two million dollars ($2,000,000) per accident covering transportation of such materials by the addition to the Business Auto Coverage Policy of Environmental Impairment Endorsement MCS90 or Insurance Services Office endorsement form CA 99 48, which amends the pollution exclusion in the standard Business Automobile Policy to cover pollutants that are in or upon, being transported or towed by, being loaded onto, or being unloaded from a covered auto.
WORKERS' COMPENSATION
Workers' Compensation Insurance Policy as required by statute and employer's liability with limits of at least one million dollars ($1,000,000) policy limit Bodily Injury by disease , one million dollars ($1,000,000) each accident/Bodily Injury and one million dollars ($1,000,000) each employee Bodily Injury by disease.
The indemnification and hold harmless obligations of Contractor included in this Agreement shall not be limited in any way by any limitation on the amount or type of damage, compensation or benefit payable by or for Contractor or any subcontractor under any Workers' Compensation Act(s), Disability Benefits Act(s) or other employee benefits act(s).
This policy must include a Waiver of Subrogation in favor of the City of Santa Clara, its City Council, commissions, officers, employees , volunteers and agents.
COMPLIANCE WITH REQUIREMENTS
All of the following clauses and/or endorsements, or similar provisions, must be part of each commercial general liability policy , and each umbrella or excess policy.
Additional Insureds . City of Santa Clara, its City Council, commissions, officers, employees, volunteers and agents are hereby added as additional insureds in respect to liability arising out of Contractor ' s work for City, using Insurance Services Office (ISO) Endorsement CG 20 10 11 85 or the combination of CG 20 10 03 97 and CG 20 37 10 01, or its equivalent.
Primary and non-contributing. Each insurance policy provided by Contractor shall contain language or be endorsed to contain wording making it primary insurance as respects to, and not requiring contribution from, any other insurance which the Agreement with The Permanente Medical Group, Inc./Insurance Requir ements/Exhibit C Rev. 06/22/17
Indemnities may possess, including any self-insurance or self-insured retention they may have. Any other insurance Indemnities may possess shall be considered excess insurance only and shall not be called upon to contribute with Contractor's insurance.
Cancellation .
Each insurance policy shall contain language or be endorsed to reflect that no cancellation or modification of the coverage provided due to non-payment of premiums shairbe effective until written notice has been given to City at least ten (10) days prior to the effective date of such modification or cancellation . In the event of non-renewal , written notice shall be given at least ten (10) days prior to the effective date of non-renewal.
Each insurance policy shall contain language or be endorsed to reflect that no cancellation or modification of the coverage provided for any cause save and except non-payment of premiums shall be effective until written notice has been given to City at least thirty (30) days prior to the effective date of such modification or cancellation. In the event of non-renewal , written notice shall be given at least thirty (30) days prior to the effective date of non-renewal.
Other Endorsements. Other endorsements may be required for policies other than the commercial general liability policy if specified in the description of required insurance set forth in Sections A through D of this Exhibit C, above.
ADDITIONAL INSURANCE RELATED PROVISIONS
Contractor and City agree as follows:
Contractor agrees to ensure that subcontractors , and any other party involved with the Services who is brought onto or involved in the performance of the Services by Contractor, provide the same minimum insurance coverage required of Contractor, except as with respect to limits. Contractor agrees to monitor and review all such coverage and assumes all responsibility for ensuring that such coverage is provided in conformity with the requirements of this Agreement.
Contractor agrees that upon request by City, all agreements with, and insurance compliance documents provided by, such subcontractors and others engaged in the project will be submitted to City for review .
Contractor agrees to be responsible for ensuring that no contract used by any party involved in any way with the project reserves the right to charge City or Contractor for the cost of additional insurance coverage required by this Agreement. Any such provisions are to be deleted with reference to City. It is not the intent of City to reimburse any third party for the cost of complying with these requirements. There shall be no recourse against City for payment of premiums or other amounts with respect thereto .
Agreement with The Permanente Medical Group, Inc./Insurance Requirem ents/Exhibit C Rev. 06/22/1 7
The City reserves the right to withhold payments from the Contractor in the event of material noncompliance with the insurance requirements set forth in _this Agreement.
EVIDENCE OF COVERAGE
Prior to commencement of any Services under this Agreement, Contractor, and each and every subcontractor (of every tier) shall, at its sole cost and expense, provide and maintain not less than the minimum insurance coverage with the endorsements and deductibles indicated in this Agreement. Such insurance coverage shall be maintained with insurers, and under forms of policies, satisfactory to City and as described in this Agreement. Contractor shall file with the City all certificates and endorsements for the required insurance policies for City's approval as to adequacy of the insurance protection.
EVIDENCE OF COMPLIANCE
Contractor or its insurance broker shall provide the required proof of insurance compliance, consisting oflnsurance Services Office (ISO) endorsement forms or their equivalent and the ACORD form 25-S certificate of insurance ( or its equivalent), evidencing all required coverage shall be delivered to City, or its representative as set forth below, at or prior to execution of this Agreement . Upon City' s request, Contractor shall submit to City copies of the actual insurance policies or renewals or replacements .
Unless otherwise required by the terms of this Agreement , all certificates, endorsements, coverage verifications and other items required to be delivered to City pursuant to this Agreement shall be mailed to:
EBIX Inc.
City of Santa Clara [*insert City department name here] P.O. Box 100085- S2 or 1 Ebix Way
Duluth, GA 30096 John's Creek, GA 30097
Telephone number:
Fax number:
Email address:
QUALIFYING INSURERS
951-766-2280
770-325-0409
[email protected]
All of the insurance companies providing insurance for Contractor shall have, and provide written proof of, an A. M. Best rating of at least A minus 6 (A- VI) or shall be an insurance company ·of equal financial stability that is approved by the City or its insurance compliance representatives.
S:\Attomey\lNSURANCE\CITY\EXHIBIT C-02 Contract over $50,000 limited exposure.doc Agreement with The Permanente Medical Group, Inc./Insurance Requirements/Exhibit C Rev. 06/22/17
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE MEDICAL GROUP, INC.
EXIDBITD
ETHICAL STANDARDS FOR CONTRACTORS SEEKING TO ENTER INTO AN
AGREEMENT WITH THE CITY OF SANTA CLARA, CALIFORNIA
Termination of Agreement for Certain Acts.
A. The City may, at its sole discretion, terminate this Agreement in the event any one or more of the following occurs:
1. If a Contractor 1 does any of the following:
a. Is convicted2 of operating a business in violation of any Federal, State or local law or regulation;
b. Is convicted of a crime punishable as a felony involving dishonesty3; c. Is convicted of an offense involving dishonesty or is convicted of fraud or a criminal offense in connection with: (1) obtaining; (2) attempting to obtain; or, (3) performing a public contract or subcontract; d. Is convicted of any offense which indicates a lack of business integrity or business honesty which seriously and directly affects the present responsibility of a City contractor or subcontractor; and/or, e. Made (or makes) any false statement(s) or representation(s) with respect to this Agreement.
For purposes of this Agreement, the word "Consultant " (whether a person or a legal entity) also refers to "Contractor" and means any of the following: an owner or co-owner of a sole proprietorship; a person who controls or who has the power to control a business entity; a general partner of a partnership; a principal in a joint venture; or a primary corporate stockholder [i.e., a person who owns more than ten percent ( 10%) of the outstanding stock of a corporation] and who is active in the day to day operations of that corporation. 2 For purposes of this Agreement, the words "convicted " or "conviction" mean a judgment or conviction ofa criminal offense by any court of competent jurisdiction, whether entered upon a verdict or a plea, and includes a conviction entered upon a plea ofnolo contendere within the past five (5) years.
As used herein , "dishonesty" includes, but is not limited to, embezzlement, theft, forgery , bribery, falsification or destruction of records, making false statements, failure to pay tax obligations , receiving stolen property, collusion or conspiracy.
Agreement with The Permanente Medical Group , Inc./Ethical Standards for Contractors/ Exhibit D Rev. 06/22/17
2. If fraudulent, criminal or other seriously improper conduct of any officer, director, shareholder, partner, employee or other individual associated with the Contractor can be imputed to the Contractor when the conduct occurred in connection with the individual's performance of duties for or on behalf of the Contractor, with the Contractor's knowledge, approval or acquiescence, the Contractor's acceptance of the benefits derived from the conduct shall be evidence of such knowledge, approval or acquiescence .
B. The City may also terminate this Agreement in the event any one or more of the following occurs:
1. The City determines that Contractor no longer has the financial capability 4 or business experience 5 to perform the terms of, or operate under, this Agreement; or,
2. If City determines that the Contractor fails to submit information , or submits false information ·, which is required to perform or be awarded a contract with City, including, but not limited to, Contrac_tor's failure to maintain a required State issued license, failure to obtain a City business license (if applicable) or failure to provide and maintain bonds and/or insurance policies required under this Agreement.
C. In the event a prospective Contractor (or bidder) is ruled ineligible (debarred) to participate in a contract award process or a contract is terminated pursuant to these provisions, Contractor may appeal the City's action to the City Council by filing a written request with the City Clerk within ten (10) days of the notice given by City to have the matter heard . The matter will be heard within thirty (30) days of the filing of the appeal request with the City Clerk. The Contractor will have the burden of proof on the appeal.
The Contractor shall have the opportunity to present evidence, both oral and documentary, and argument.
4 Contractor becomes insolvent, transfers assets in fraud of creditors , makes an assignment for the benefit of creditors, files a petition under any section or chapter of the federal Bankruptcy Code (11 U.S.C.), as amended, or under any similar law or statute of the United States or any state thereof , is adjudged bankrupt or insolvent in proceedings under such laws, or a receiver or trustee is appointed for all or substantially all of the assets of Contractor.
5 Loss of personnel deemed essential by the City for the successful performance of the obligations of the Contractor to the City.
Agreement with The Permanente Medical Group, lnc./Ethical Standards for Contractors/Exhibit D Rev. 06/22/17
AGREEMENT FOR THE PERFORMANCE OF SERVICES
BY AND BETWEEN THE
CITY OF SANTA CLARA, CALIFORNIA,
AND
THE PERMANENTE MEDICAL GROUP, INC.
EXHIBITE
AFFIDAVIT OF COMPLIANCE WITH ETffiCAL STANDARDS
I hereby state that I have read and understand the language , entitled "Ethical Standards" set forth in Exhibit D. I have the authority to make these representations on my own behalf or on behalf of the legal entity identified herein. I have examined appropriate business records, and I have made appropriate inquiry of those individuals potentially included within the definition of "Contractor" contained in Ethical Standards at footnote 1.
Based on my review of the appropriate documents and my good-faith review of the necessary inquiry responses, I hereby state that neither the business entity nor any individual(s) belonging to said "Contractor" category [i.e., owner or co-owner of a sole proprietorship , general partner, person who contro ls or has power to control a business entity , etc.] has been convicted of any one or more of the crimes identified in the Ethical Standards within the past five (5) years.
The above assertions are true and correct and are made under penalty of perjury under the laws of the State of California.
THE PERMANENTE MEDICAL GROUP, INC
Corporation
By: - ~- - - __ t_,-=U~u=~=:.=----- - ---
Signature of Authorized Person or Representative
Name: Constance C. Chiulli on behalf of Roman Kownacki, MD, MPH Title: Constance C. Chiulli: Regional Director, Occupational Health Service Line Dr. Roman Kownacki: Medical Director , Regional Occupational Health - Northern California
NOTARY'S ACKNOWLEDGMENT TO BE ATTACHED
Please execute the affidavit and attach a notary public's acknowledgment of execution of the affidavit by the signatory. If the affidavit is on behalf of a corporation, partnership , or other legal entity, the entity's complete legal name and the title of the person signing on behalf of the legal entity shall appear above. Written evidence of the authority of the person executing this affidavit on behalf of a corporation, partnership, joint venture , or any other legal entity, other than a sole proprietorship, shall be attached.
Agreement with The Permanente Medical Group, Jnc./Ethical Standards for Contractors/Exhibit E Rev . 06/22/17
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMEN T CIVIL CODE§ 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that docu_ment. &~eciC~~m~ )
County of -A-larneduL )
On 3o,n t. ~ /1.0{1- before me, &Ileen Thvile,, ~0{'4 I N~n/ P/)_b) ,c, I Date He~ {nsert ~F'!1iJ~d Title of
1 the Officer
personal ly appeared _ _ ___._C.,_,,,D~ t'-'fl-=?ifl~,_,_Vl_..,,{£""". "--"_'---'()~....,,Le..::.~.LV\.L...!..l\ U-=-\ _,_\ _1 _ _ _____ _ _ _ Name(:j{ of Signer.(s)
who proved to me on the basis of satisfactory evidence to be the person(,ef whose name~r isl.a~ subscribed to the within instrument and acknowledged to me that J;i~she/tt-rey executed the same in t-#/her/t~r authorized capacityµe~. and that by ~her/~r signature~ on the instrument the person_{s}, or the entity upon behalf of which the person(s) acted, executed the instrument.
I .COLLEEN DA~LE-HONG I
i; , Comml11ion No. 2207061 z
If •. NOTARY PUBLIC-CALIFORNIA H
I · ALAMEDA COUNTY J Mw Comm. EMpilet AUGUST 22, 2021
• II FJ I } I t
Place Notary Seal Above
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature _1~~1'.L~L/4'J.JUCIL.LU.~~.::::::::1=1t7- _L~._ ---------------OPTIONAL---------------
Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document.
Descript ion of Attached Doc~ ent l Nmfl-6/rl~Md )e -~ J)_ Title or Type of Document: . e .{JA... Document Date: __ __._..~- ---- Number of Pages: ___ Si~ r( Other Than Named Above : _____ ____ _ _ _ _ Capacity( ies) Claimed by Signer(s)
Signer's Name: _____ _ _ _ _ _ _ _
D Corporate Officer - Title(s): _ _____ _
D Partner - D Limited D General
Signer's Name: _ _ ___ _ _____ _
D Corporate Officer - Title(s): _ _ ____ _
D Partner - D Limited D General
D Individual D Attorney in Fact D Individual D Attorney in Fact D Trustee D Guardian or Conservator D Trustee D Guardian or Conservat or D Other: ____ _ _ _ _ _ _ _ ___ _ D Other: ___ ___ _ ______ _ Signer Is Representing: _ _ ____ __ _ Signer Is Representing: ___ _____ _ ©20 14 National Notary Association• www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907