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HomeMy WebLinkAboutContract 46329-A1 CITY SECRETARY CONTRACT NO. 47 // PROFESSIONAL SERVICES AGREEMENT AMENDMENT NO. 1 G�� T his PROFESSIONAL SERVICES AGREEMENT AMENDMENT NO. 1 ("Agreement") is made and entered into by and between the CITY OF FORT WORTH (the"CITY"), a home rule municipal corporation of the State of Texas, acting by and through Susan Alanis, its duly authorized Assistant City Manager and Occupational Health Centers of the Southwest, P.A.,dba Concentra Medical Centers ("PROVIDER"), acting by and through Robert G. Hassett, D.O., MPH, its duly authorized President. RECITALS WHEREAS, the parties have previously entered into City of Fort Worth City Secretary Contract No. 46329 (the "Contract"), which was executed on December 16, 2014; and WHEREAS, the Contract involved injury-related occupational health and worker's compensation services; and WHEREAS, the original term of the Contract began on January 1 2015 and expired on December 31 2017: and WHEREAS,the City and PROVIDER now wish to amend the original Contract to strike references to injury- related occupational health and workers compensation services; and WHEREAS, the City and PROVIDER desire to continue the services for occupational health care services that do not relate to an on-the-job injury. NOW, THEREFORE, City and PROVIDER, acting herein by and through their duly authorized representatives, enter into the following Agreement to amend the Contract entirely as follows: 1 The Agreement is amended by deleting Section 2 of the Agreement and replacing it with the following: 662. GENERAL 2.1 PROVIDER hereby agrees to provide the CITY, in accordance with medically necessary or appropriate professional standards, a full range of occupational health care services, as outlined in Exhibits"A" through "C," including any attachments thereto, all of which are hereby made part of this Agreement for all purposes. Exhibit"C"constitutes, at least in part, a proposal presented by PROVIDER to the CITY prior to the Effective Date of this Agreement,as hereafter defined. Therefore, in the event there is any conflict between the provisions and conditions of the proposal and the provisions and conditions set forth in the body of this Agreement, the provisions and conditions set forth in the body of the Agreement shall control. 2.2 CITY and PROVIDER both recognize and acknowledge the professional nature of this Agreement. Being cognizant that issues of interpretation and performance will inevitably arise, both parties agree to consult with each other and covenant to negotiate in the utmost good faith in order to ensure performance of this Agreement without hindrance. 2.3 Services under this Agreement will be provided at PROVIDER's current facilities, at a subcontractor's facilities (if the subcontractor and the facilities are approved in writing by the CITY prior to such services being provided), and at such CITY facilities and other locations as may be mutually agreed to in writing by PROVIDER and CITY. 2.4 To the extent that the services to be performed under this Agreement constitute non-injury related occupational health care services performed by persons other than PROVIDER and covered by the "Police and Fire Physical Assessment Contracts" (hereafter defined), both G o�tt5w ZF1 parties recognize the non-exclusive nature of this Agreement. The "Police and Fire Physical crC'(sGC�� Professional Services Agreement Occupational Health—Concentra O"SCIAL RECORD Page 1 of 11 ClITY SECRETARY eer wnc ru Iry Assessment Contracts" are defined as(a)those certain contracts entered into by the CITY for the performance of: (i) post-offer physicals for persons offered jobs by the CITY's Police and Fire Departments; (ii)routine physical fitness assessments for persons employed by the CITY's Police and Fire Departments; and (iii) such other matters as are contained in such contracts, and (b) any renewals thereof." 2. The Agreement is amended by deleting Section 4 of the Agreement and replacing it with the following: 464. INVOICING AND COMPENSATION 4.1 The Parties agree the Schedule for Compensation as shown in the attached Exhibit "B" is acceptable as the compensation to be paid to PROVIDER for occupational health care services provided to current and prospective CITY employees during the initial contract period and the subsequent option periods, if exercised by the CITY. The parties acknowledge that additional services provided by PROVIDER to the CITY may become desirable and agree to conduct negotiations on such additional services in good faith to arrive at mutually agreeable terms for such additional services with respect to performance and compensation. Any additional services will be reflected by a separate agreement or by a written amendment to this Agreement signed by the parties. 4.2 For occupational health care services that do not relate to an on-the-job injury, PROVIDER shall issue monthly invoices to the CITY and will provide the CITY sufficient documentation to reasonably substantiate the invoices. The invoice shall be broken down by CITY department and shall list the name, CITY employee identification number dates of service, and service provided. The invoice shall be provided to the CITY on or before the 101h day of the month following the end of the month in which services were provided. CITY shall pay such invoices in accordance with CITY Financial Management Services procedures and requirements. Invoices are due and payable within thirty(30)days from the date the invoices are received by the CITY. 4.3 For occupational health care services that do not relate to an on-the-job injury, billing issues shall be handled in accordance with the terms of this Agreement. In the event of a disputed or contested billing, only the portion so contested will be withheld from payment, and the undisputed portion will be paid. The CITY will exercise reasonableness in contesting any bill or portion thereof. No interest will accrue on any contested portion of the billing; provided, however, that CITY shall make payment in full to PROVIDER within sixty(60)days of the date the contested matter is resolved." The Agreement is amended by deleting Section 17 of the Agreement and replacing it with the following: 1117. NOTICES Notices required pursuant to the provisions of this Agreement shall be conclusively determined to have been delivered when (i) hand-delivered to the other party, its agents, employees, servants or representatives; (ii) delivered by facsimile with electronic confirmation of the transmission; or (iii) received by the other party by United States Mail, registered, return receipt requested, addressed as follows: To CITY: To PROVIDER City of Fort Worth Occupational Health Centers of the Southwest Attn: Mark Barta P.A., dba Concentra Medical Centers 1000 Throckmorton Attn: Legal -Contracting Fort Worth TX 76102-6311 Address: 5080 Spectrum Drive, Suite 120OW Facsimile: (817) 392-7790 Addison, TX 75001 Professional Services Agreement Occupational Health—Concentra Page 2 of 11 E-mail: Mark.Barta(pD_fortworthtexas.gov Facsimile: (972) 720-7770 Email: legal—contracts@concentra.com With copy to City Attorney's Office at same address." 4. The Agreement is amended by deleting Exhibit A, Exhibit B, Exhibit C, and Exhibit D of the Agreement and replacing it with Exhibit A, Exhibit B, Exhibit C, and Exhibit D attached, and incorporated by reference. 5. All other provisions of the Contract which are not expressly amended herein shall remain in full force and effect. IN WITNESS, WHEREOF, the parties hereto have executed this Agreement in multiples this 6th day of June, 201 CITY OF FORT WORTH: OCCUPATIONAL HEALTH CENTERS OF THE SOUTHWEST, P.A., DBA CONCENTRA MEDICAL CENTERS By: By: Susa Al is, Assistant City Manager Robert G. Hassett, D.O., MPH, President, Date: � Treasurer and Corporate Secretary � a'' l � � �� -- Date: June when ATTEST: ST: Mary ayse , t e a APPROVED AS TO FOR Lt —1) g . Y. G Is C Mcew� Assistant City t ey CONTRACT AUTHORIZATION: M&C: C-27056 Date Approved: 10/28/2014 O"IC"RECORD CITY S9ICRETARY r"L WOR'TI 9 TX Professional Services Agreement Occupational Health—Concentra Page 3 of 11 EXHIBIT A - SCOPE OF SERVICES A.I. PROVIDER FACILITIES A.1.1 PROVIDER's facilities shall be of adequate size and capability to provide all necessary health care for injured employees, as well as provide other occupational health or other related services as outlined in this Agreement and its exhibits. These facilities must be operated and maintained to ensure a healthful and safe environment for CITY employees. A.1.2 Clinic Locations A.1.2.1 PROVIDER must operate sufficient clinic locations in the Fort Worth/Dallas area to provide convenient occupational health care services to CITY employees. The CITY will primarily utilize facilities located in Fort Worth. However current and prospective CITY employees may access any other Concentra Medical Centers located in the Fort Worth/Dallas metroplex, or any other Concentra Medical Center locations in Texas and the United States as necessary. A.1.2.2 PROVIDER operates sixteen (16) clinic locations in the Fort Worth/Dallas area and hundreds of other locations around the United States. The CITY will primarily utilize PROVIDER's Fort Worth locations as detailed in PROVIDER's Response to City RFP No. 14-0225, a copy of which proposal is attached as Exhibit "D" to the Agreement. However, CITY-associated personnel can access any other PROVIDER location as necessary. A.1.3 Primary Clinic Location The facility listed below shall be designated as the primary facility for use of CITY Employees. Hours of operation of the primary facility shall at a minimum be 7:00 a.m. to 7:00 p.m. Monday through Friday. However, it is desirable that PROVIDER provide extended hours during weekdays and on weekends and holidays at the designated primary facility and/or other facilities as a means to better accommodate CITY employees who work evening, night, weekend and/or holiday shifts. The designated clinic facility that shall serve as CITY's primary clinic facility is: Concentra Medical Center Forest Park 2500 West Freeway(130), Suite 100 Fort Worth, TX 76102 Phone: 817.882.8700 Fax: 817.882.8707 Hours of Operation 8:00 a.m. —8:00 p.m. (M-F) 8:00 a.m. —5:00 p.m. Sat. A.1.4 Convenience of Employees The designated primary facility shall have at a minimum: a dedicated telephone and fax numbers for CITY employees; a CITY check-in desk; a private waiting room; a minimum of two (2) exam rooms dedicated to CITY employees;and a sufficient number qualified medical doctors dedicated to the examination and treatment of CITY employees. A.1.5 Wait Times Professional Services Agreement Occupational Health—Concentra Page 14 of 11 Maximum wait times for CITY employees to wait for medical treatment and/or other occupational health care services shall not exceed fifteen (15) minutes. A.1.6 Hours of Operation PROVIDER must make contracted services available weekdays, Monday through Friday from 7:00 a.m. to 7:00 p.m. The CITY considers these hours of operation as a minimum requirement and would provide favorable consideration to providing medical services at additional times. A.1.7 Accreditation If PROVIDER currently is not accredited by the Urgent Care Center Accreditation (UCCA) Program and/or the Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission), PROVIDER agrees to consider seeking such accreditation. A.2 CLINIC PERSONNEL A.2.1 PROVIDER's health care practitioners must be credentialed, experienced in occupational medicine, and possess documented expertise in the evaluation, treatment, oversight, and recovery of employees injured on the job. This expertise must also encompass an effective system of communication with the CITY and their agents to ensure prompt delivery of necessary services and overall coordination of the CITY's programs. A.2.2 PROVIDER must utilize Texas licensed medical doctors and other licensed health care practitioners and administrative staff sufficient to perform all necessary health care and other required services. PROVIDER must exercise due diligence to ensure health care practitioners are properly credentialed in their respective and specific areas of medical practice. A.2.3 PROVIDER's medical doctors and health care practitioners must be familiar with and utilize evidenced-based medicine in the evaluation, treatment, oversight, and recovery of employees injured on the job as required by the Texas Labor Code and related Rules. A.2.4 Health care practitioners and facilities must be capable of providing the full range of occupational health care services required by the CITY and its employees(refer to the non-injury occupational health care services list in Exhibit"C". A.7 NON-INJURY OCCUPATIONAL HEALTH CARE SERVICES A.7.1 Post-Offer Employment / Promotional / Return-to-Work Physical Exams or Fitness for Duty and other Assessments PROVIDER will perform CITY Pre-Placement Physical Examinations, DOT Physical Examinations, Fitness for Duty Examinations, Physical Demand Job Assessments, Physical Ability Testing, Physical Fitness Assessments, Medical Surveillance and Screening Examinations, Medical and Work History Questionnaires, Clinical Testing Services, Immunization and Infectious Disease Screening, and Respirator Clearance andFit Testing for Post-Offer Physicals and annual compliance. A.7.2 Drug Screening and Alcohol Testing A.7.2.1 PROVIDER shall provide drug and/or alcohol testing in accordance with 49 CFR part 40 Department of Transportation ("DOT") regulations for collection, handling, testing, and reporting of results. The CITY will have the opportunity to identify a specific person(s) who will be authorized to receive or access all drug and alcohol testing results. The CITY will also Professional Services Agreement Occupational Health—Concentra Page 15 of 11 have the opportunity to authorize one or more specific persons who will have authorization and access to all positive post-accident drug screen results. A.7.2.2 PROVIDER will utilize Quest Diagnostics for all laboratory testing. PROVIDER at its sole cost and expense will provide the necessary software to allow access to test results from Quest. A.7.2.3 A Medical Review Officer ("MRO") must be dedicated to the CITY's account for the purposes of PROVIDER's participation in the CITY's Commercial Driver's License ("CDL") program. A.7.2.4 PROVIDER will subcontract its Medical Review Officer("MRO") services, and the CITY consents to such subcontracting. The MRO services include the random selection task. A.7.2.5 In the event a CITY employee requests testing of the"B"vial,the employee will be responsible for the cost associated with the testing before the process will be initiated. CITY shall not be responsible for any cost or fees associated with this service. A.7.2.6 Two copies of PROVIDER's "Drug/Alcohol Testing Manual" will be provided to the CITY and delivered to the individual identified by the CITY prior to the Effective Date of this Agreement. A.7.2.7 Infrequent on-site drug testing (less than 4 per month) may be conducted with no on-site service charge to the CITY. However if a permanent need exists, an amendment to this Agreement will be negotiated and executed in writing by the Parties. A.7.3 Clinical Testing PROVIDER agrees to offer the CITY clinical testing, including but not limited to pulmonary function, audiometric, EKG, chest x-rays, and lumbar x-rays. PROVIDER warrants that all equipment being utilized for clinical testing services is calibrated prior to testing and in working order. All chest and lumbar x-rays are performed by registered technicians. All audiometric testing will be performed by trained technicians. A.7.4 Exposure Control Program A.7.4.1 PROVIDER may be required to administer any existing preventative immunizations or treatments to employees, and their immediate family members, to a disease that they may be exposed in performing official duties in accordance with requirements under the Texas Government Code, Chapter 607. Such immunizations may be required to be administered on-site and after standard work hours at City designated facilities. A.7.4.3 PROVIDER will administer influenza vaccines to CITY employees at designated on-site CITY locations. PROVIDER will be required to provide information to each employee regarding the vaccine to be administered, prior to the vaccination(s). Some on-site vaccination events may occur after standard work hours. Professional Services Agreement Occupational Health—Concentra Page 16 of 11 A.7.4.4 PROVIDER will test CITY employees exposed to communicable diseases, lead, hazardous chemicals, or other potential hazards in the performance of their duties, and to provide medical surveillance services in accordance with the CITY's CDL Program. Lead Medical Surveillance and other Hazardous chemicals will follow OSHA regulations. Results will be relayed by a Written Medical Opinion for the regulated hazard. A.7.4.5 PROVIDER will provide any necessary counseling services relevant to urinary drug screening, human immunodeficiency virus (HIV) testing and other health and safety related issues. A.7.5 Medical Surveillance PROVIDER will test and monitor CITY employees exposed to, lead, asbestos, hazardous chemicals or other potential hazards associated with the performance of their duties. Lead and Asbestos Medical Surveillance or other Hazardous Exposures will follow OSHA regulations as appropriate. Results will be relayed by a Written Medical Opinion for the regulated hazard. A.7.6 Commercial Driver's License (CDL) Program .7 6.1 PROVIDER will actively participate in the CITY's CDL Program. Participation will include provision of physical examinations that meet US Department of Labor requirements, determinations and reporting to CITY of the condition of CITY employees to operate a commercial vehicle, issuance of medical certification cards, and participation on the CITY's Medical Review Board for these purposes. A.7.6.2 PROVIDER must dedicate a Medical Review Officer("MRO")to the CITY for purposes of PROVIDER's participation in the CITY's CDL Program. A.7.7 Reports and Validation Studies A.7.7.1 PROVIDER will provide reports to CITY designated individuals in a timely manner. Specific reports may include, but are not limited to the"Utilization Management Report","Activity Status Report","Non-Injury Status Report", "Patient Referral Report", "Patient Visit Information", and the OCCU 300 Report". Reports will be generated at no additional cost to the CITY. A.7 7.2 The CITY and PROVIDER will share workers' compensation data for an annual Validation Study of work related injury outcomes. A.7.8 Additional Services PROVIDER may provide additional services relating to occupational health care or other related services for consideration by the CITY. Professional Services Agreement Occupational Health—Concentra Page 17 of 11 EXHIBIT B - NON-INJURY OCCUPATIONAL HEALTH CARE SERVICES SCHEDULE OF COMPENSATION B.1 Breath .Alcohol Tests Service Fee Service Fee Service Fee Service Fee Option Service Fee Service Description Contract Contract Contract Option Contract Year 1 Year 2 Year 3 Contract Year 5 Year 4 Breath Alcohol Test Post-Job Offer $18.00 $18.00 $18.00 $18.00 $18.00 Breath Alcohol Test Random $18.00 $18.00 $18.00 $18.00 $18.00 Breath Alcohol Test Post Accident $18.00 S18.00 $18.00 $18.00 $18.00 Breath Alcohol Test Follow-up $18.00 518.00 $18.00 $18.00 $18.00 Breath Alcohol Test Reasonable Suspicion $18.00 '.,,,'8.00 $18.00 $18.00 $18.00 After hours Breath Alcohol Test $18.00 S 8.00 $18.00 $18.00 $18.00 13.2 Urinary I)rut<Screens ((!I)5) Service Fee Service Fee Service Fee Service Fee Option Service Fee Service Description Contract Contract Contract Option Contract Year 1 Year 2 Year 3 Contract Year 5 Year 4 UDS-Non Regulated Pre- $40.00 $40.00 $40.00 $40.00 $40.00 Placement UDS-Non 1Ze=ulated Random $40.00 $40.00 $40.00 $40.00 $40.00 UDS Non Regulated Post $40.00 $40.00 $40.00 $40.00 $40.00 Accident UDS Non Reg Follow U $40.00 $40.00 $40.00 $40.0Q $40.00 UDS-Non Regulated Reasonable $40.00 $40.00 $40.00 S11(_).00 $40.00 Suspicion UDS-1ZeQulated Pre-Placement $40.00 540.00 $40.00 540.00 $40.00 UDS Regulated Random $40.00 S-10.00 $40.00 $40.0() S-40,00 UDS-Rcaulated Post Accident $40.00 540.00 $40.00 $40.00 $40.00 UDS ILegulated Follow U $40.00 S40.00 $40.00 540,00 $40.00 UDS-Regulated Reasonable $40.00 $40.00 $40.00 40.00 $40.00 Sw,picion B.3 Physical Examinations/Assessments Service Service Service Service Fee Fee Service Fee Service Description Contract Contract Contract Option Option Year 1 Year 2 Year 3 Contract Contract Year 5 Year 4 Physical Examination Post Offer $40.00 $40.00 $42.00 $44.00 $46.00 Placement PhysicalExamination-Other $40.00 $40.00 $42.00 $44.00 $46.00 DOT Ph`sical Examination-Post- $40.00 $40.00 $42.00 $44.00 $46.00 3'n Offer Placement [SOT I'h.sical Recertification $40.00 $40.00 $42.00 $44.00 $46.00 Re pwatoi Physical Exams ition $35.00 $35.00 $37.00 $39.00 $41.00 Physical Demand Job $350.00 $350.00 $350.00 $350.00 $350.00 Assessments Physical Fitness for Duty Testing $38.00 $38.00 $40.00 $42.00 $44.00 Level 1 Physical Fitness for Duty Testing $40.00 $40.00 $42.00 $44.00 $46.00 Level 2 Professional Services Agreement Occupational Health-Concentra Page 18 of 11 Physical Fitness for Duty Testing $42.00 $42.00 $44.00 $46.00 $48.00 Level 3 Physical Fitness for Duty Testing $45.00 $45.00 $47.00 $49.00 $51.00 Level 4 Medical Surveillance Physical $100.00 $100.00 $100.00 $100.00 $100.00 Exam Physical Return to Work $40.00 $40.00 $42.00 $44.00 $46.00 HPE Level 4 $7 .00 575.00 $79.00 $83.00 $87.00 HPE Level 5 51 m S 00 $131.00 $137.00 $143.00 HPE Development 5350.00 `5350.00 $350.00 $350.00 $350.00 HPE Admin Fee $100.00 100.00 $100.00 $100.00 $100.00 B.4 Laboratory Testing Service Service Service Fee Fee Service Fee Fee Service Fee Service Description Contract Contract Contract Option Option Year 1 Year 2 Year 3 Contract Contract Year 5 Year 4 Blood Collection Medical $235.00 $235.00 $235.00 $235.00 $235.00 Surveillance Exam Drug Screen-Blood $165.00 $165.00 $165.00 $165.00 $165.00 Drug Screen-Re-Test(Split $175.00 $175.00 $175.00 $175.00 $175.00 Specimen) Hemoccult(in Center) $8.00 $8.00 $8.00 58.00 S8.00 Glucose Finger Stick $13.00 $13.00 $13.00 5 sl Complete Blood Count(CBC) $15.00 $15.00 $15.00 S'5.00 S15.00 Blood Chemistry 20/23 $38.00 $38.00 $38.00 $38.00 535.00 Hemoglobin AIC $58.00 $58.00 $58.00 $58.00 $58.00 Hydrocar/Oxyg Volatiles - $75.00 $75.00 $75.00 $75.00 $75.00 Blood/Urine U/A Manual Microscopic $33.00 533.00S 3 .00 $33.00 $33.00 Blood-Lead $70.00 570.00 570.00 $70.00 $70-00 Blood-Chloroform $127.00 S,/_5.00 $127.00 $127.00 $12 1.00 Blood-Formaldehyde Screen $100.00 S 00.00 $100.00 $100.00 $100.00 Blood-PCB $130.00 5130,00 $130.00 $130.00 S170.,A Blood-Hepatitis A Surface $65.00 $65.00 $65.00 $65.00 DV..V V Antibody Blood-Hepatitis B Surface $90.00 $90.00 $90.00 $90.00 $90.00 Antibody Blood Hepatitis B Surface $40.00 $40.00 $40.00 $40.00 $40.00 Antigen Blooki t Iepatitk ' Antibody $97.35 $97.35 $97.35 $97.35 $97.35 Blood Illi" Screen $47.00 $47.00 $47.00 $47.00 $47.00 Blood HIS' confirmation $65.00 $65.00 $65.00 $65.00 $65.00 t 'etitCcn Blot) l INIP Titer S147.00 $147.00 $147.00 $147.00 $147.00 Rabies Titer 595.00 595,00 S9�;.00 $95.00 $95.00 Hepatitis A Titer 565.00 so .00 S6;.00 $65.00 $65.00 I le atitis B Titer $55.00 555.00 SS r.00 $55.00 $55.00 B.5 Immunizations/Vaccines Service Service Service Fee Service Service Fee Service Description Fee Fee Contract Fee Option Year 3 Option Contract Year 5 Professional Services Agreement Occupational Health-Concentra Page 19 of 11 Contract Contract Contract Year 1 Year 2 Year 4 Rabies Vaccines/Ist Injection $390.00 $390.00 $390.00 $390.00 5390.00 Rabies Vaccines/2nd Injection $390.00 $390.00 $390.00 $390.00 5390.00 Rabies Vaccines/3rd Injection $390.00 $390.00 5390.00 g 90.00 5390.00 Tetanus Toxoid $20.00 $20.00 520.00 520.00 $20.00 PPD(Mantoux) $15.00 $15.00 $15.00 S 5.00 $15.00 TB Skin Test $15.00 $15.00 $15.00 $15.00 $15.00 Influenza(Flr N/A $25.00 $25.00 $25.00 $25.00 Quadra�;Ilcnt 4saurr7 Hepatitis A Vaccine/1st Injection $65.00 $65.00 $65.00 $65.00 565.00 Hepatitis B Vaccine/1st Injection $55.00 $55.00 $55.00 $55.00 555.00 Hepatitis B Vaccine/2nd Injection $55.00 $55.00 $5 .00 $55.00 555.00 Hepatitis B Vaccine/3rd Injection $55.00 $55.00 53 .[)0 $55.00 555,00 Hepatitis B Surface Antibody $90.00 $90,00 59o.00 $90.00 Sa)().00 Hepatitis A&B Vaccine/1 st $120.00 $120.00 ` 120.00 $120.00 $120.00 Injection Varicilla Titer $82.00 582.00 5h-1.00 $82.00 S8200 Tda (pertussis/whooping cough) $70.00 510.0() 570.00 $70.00 $70.00 MMR Vaccine $80.00 $80.00 $80: 00 $80.00 Sv.J Varicilla Vaccine $125.00 $125 0(1 $125.00 $125.00 $125.00 B.6 taller Procedures/Services Service Service Service Fee Flee Service Fee Fee Service Fee Service Description Contract Contract Contract Option Option Year 1 Year 2 Year 3 Contract Contract Year 5 Year 4 Audiw,rrnr 520.00 $20.00 $20.00 $20.00 $20.00 4 It.n 552.00 ti52.00 $52.00 $52.00 $52.00 S34.50 531.50 $34.50 $34.50 $34.50 1'ultrwtrar. est $2100 42`.00 $21.00 $21.00 $21.00 IZ tii,,_ $65.00 465.0[t 565.00 $65.00 $65.00 Functi, ,tmg * $35.66 4-;x.66 5.66 $35.66 $35.66 OSHA respirator 1,} w'liunnaire $25.00 M S2^.()0 $25.00 $25.00 ()uahtati%e Ede,3ir,itur rrt Test $38.00 38.t`)11� --T-1 8-0 438110 $38.00 $38.00 �f oration $15.00 S 1-� 0�, S I fl.00 $15.00 $15.00 Job �,r Physical Demands Assessment(per Job N/A $o: .itC ).7 00 $95.00 $95.00 Title) * For 15 Minutes Professional Services Agreement Occupational Health-Concentra Page 20 of 11 EXHIBIT C - PROVIDER'S RESPONSE TO CITY RFP Professional Services Agreement Occupational Health—Concentra Page 21 of 11 Medical Provider of Occupational Health Care Services AL RFP No. 14-0225 9,r PRESENTED TO ®UE: City of Fort Worth, TX September 11,2014 1:30 p.m.Central PRESENTED BY C®ncen traj .ferry Francis Sales Manager 2500 West Freeway,Suite 100 Fort Worth,TX 76102 Phone: 817.882.8700 Fax: 817.882.8707 Mobile: 214.649.1213 Email:jerry_francis@concentra.com ACity of Fort Worth,1 X+RFP No.14-0225 ncen fir® Medical Provider of Occupational Health Care Services Table of Contents 1. Executive Summary................................................................................................................................2 2. Conflict of Interest Questionnaire........................................................................................................21 3. Qualifications Questionnaire................................................................................................................21 4. Fees and Charges Schedule..................................................................................................................21 S. MBE Utilization Plan.............................................................................................................................22 6. Financial Information............................................................................................................................22 7. Organizational Information..................................................................................................................22 8. Location Map........................................................................................................................................24 9. Organizational Chart....................................................................................................... ..24 .................... 10. Sample Reports.... .............................................................................................................................25 11. References............................................................................................................................................25 Attachments A—City-required Documents B—Legal/Risk Documents C—Personnel Qualifications D—Fees and Charges Schedule E—Financial Information F—Sample Reports ©2014 Concentra Operating Corporation.All rights reserved. ^�^ Table of Contents Concen r City of Fort Worth,-TX t RFP No.14-0225 ra, Medical Provider of Occupational Health Care Services t September 11,2014 Doris Brent,Contract Compliance Specialist City of Fort Worth,Purchasing Division 1000 Throckmorton Street,Lower Level Fort Worth,TX 76102 RE: Medical Provider of Occupational Health Care Services,RFP No.14-0225 Dear Ms.Brent: Concentra is pleased to present our capabilities to the City of Fort Worth(the City).In issuing Request for Proposal(RFP)No.14-0225,we understand that the City seeks a qualified vendor to provide occupational healthcare services.Concentra is highly qualified and well positioned to perform the services the City is seeking.Concentra values our role as the City's current provider of the services requested in the RFP and if selected,we will remain committed to assisting the City reach its healthcare goals. To best serve our clients' needs,Concentra draws from a pool of experienced professionals to provide local program oversight and support. For the City's program,Concentra assigns Mr,Jerry Francis,Sales Manager, to serve as the initial contact and customer liaison between Concentra and the City.Should the City have questions concerning our response,please contact Mr. Francis via phone:214..649.1213, or 1 by email:jerry_francis@concentra.com. This document contains Concentra's response to the services outlined in the City's specifications,pricing information,and relevant attachments.Concentra affirms that all information contained herein is current,complete,accurate,and remains valid for 180 days following the due date,September 11,2014. Furthermore,we include all required forms and business credentials as Attachment A—City-required Documents. Our Legal and Risk Departments reviewed the terms,conditions,and insurance requirements and made minor modifications to the language.We include these suggested revisions as Attachment B—Legal/Risk Documents.Additionally,Concentra does not agree to enter into a cooperative purchasing agreement at this time. If Concentra is the successful bidder,we desire to engage in open dialogue with the City, review the proposed modifications,and ultimately create an agreement that not only outlines the schedule of services,but also protects the business interests of both the City and Concentra. i Concentra values the City's consideration of our response.We are confident that when the City takes into account our experience,capabilities,technology,infrastructure,project management,and price, Concentra will emerge as the clear choice to perform the occupational healthcare services the City of Fort Worth desires. Resp•c u ly submit d, Y Arlene G. King Authorized Representative 444 D.-1 City of Fort Worth,TX 9 RFP No.14-0225 Concen[Lr® Medical Provider of Occupational Health Care Services 1. Executive Summary Program Overview Concentra acknowledges that the City seeks a qualified vendor to provide occupational healthcare services. For the purposes of this RFP,the City specifically requires: Injury care/treatment • Exposure control program • Physical examinations • Medical surveillance Drug and alcohol testing . Commercial Driver's License(CDL)program • Clinical testing Concentra Solution Concentra has direct experience serving as the City's preferred vendor for the specific services requested in the bid specifications.We are confident that our involvement in the current program, expertise,and best practices approach make us right company to assist the City in meeting its program objectives. Concentra assures the City that we will: • Leverage our decades of experience and use company best practices that are compliant with OSHA, DOT,ADA,City rules,and other applicable regulations and guidelines • Include all City-specified components in the examination process • Conduct drug and alcohol screenings in accordance with DOT standard,49.CFR Part 40 • Utilize our conveniently located Fort Worth Forest Park medical center to render primary services during the program,with other locations available as convenient alternatives • Employ only properly credentialed and trained medical professionals and support staff to perform the scope of work • Assign a designated team of qualified professionals to oversee the City's program and ensure continued compliance • Document patient visits and generate meaningful reports • Maintain records securely to ensure confidentiality of personal health information according to HIPAA guidelines Qualifications Service Sites Overview Concentra Medical Centers offer a full complement of healthcare services including, but not limited to, physical examinations,substance abuse testing,clinical services(hearing tests,pulmonary function tests,laboratory collections,vision screenings,X-rays),vaccinations,injury care,physical therapy,and wellness screenings.To accommodate our broader service offering,Concentra has extended clinic hours in many locations to include convenient evening and weekend hours for patient convenience. Facility Layout. Since inception,Concentra's affiliated physicians and management have continued to evaluate the layout of..our.centers to ensure we design each location to promote the most efficient patient flow throughout each area.Therefore,the physical dimension,layout,and staffing of each Concentra Medical Center varies depending on the location. ,� City of Fort Worth,iX.,RFP No.14-0225 Concentra ®gra Medical Provider of Occupational Health Care Services Our centers average in size between 3,100 and 9,000 square feet,maintain security services,most offer free parking on property or adjacent to the center,and all are handicapped-accessible and conform to all applicable federal,state,and local safety and disability laws.As 'escribed in the following table,each -- center's layout consists of support c-.-----� ------- .. • Waiting Room—seating for o Manager Office a restroom patients with a a Break Room a Records Storage Area television/magazines 8 Marketing Office a Telephone/Electrical Area x Business Office—work area for clerical staff Procedure Rooms—for minor a Audio Testing Room—a single- o Storage Area—for patient procedures person booth with a charts Exam Rooms microprocessor R Physical Therapy Area—with Lab Area—separate restrooms s Physician's Office whirlpool,treatment areas, (ADA-compliant)for drug and a Physician Station—with X-ray strength and flexibility alcohol collections,blood viewing areas and privacy to equipment, collection area enter patient data into hydroculator/freezer,and a Breath Analysis/Exam Room— computer system wide variety of therapy to maximize privacy for a X-ray Facilities(with darkroom modalities federally-mandated testing and file storage)—a full service j X-ray room Proposed Service Facilites Primary Service Site Of the hundreds of clinics we operate nationwid 16 are in Dallas/Fort Worth(DFW).As rnentione 2500 West Freeway(130) Concentra proposes that our Fort Worth Forest Ste.100 Park location serve as the primary service site Fort Worth,TX 76102 during this engagement.This facility maintains Z. Contact Information the necessary equipment and staffing resources and employs clinicians who are thoroughly Phone:8172882.8700 1.67 miles from the city's Fax:817.0'82.8707 knowledgeable of the state and federal oddress regulations applicable to the requested scope of Hours of Operation work.Please note that as with many other 8:00 am—8:00 pm(M-F) locations in the DFW market, our Fort Worth 8:00 am—5:00 pm(Sat.) Forest Park location offers extended evening and weekend hours to accommodate employees who may require services outside of normal working hours. This aligns with the City's requirement for evening and weekend hours as outlined in sections 30.1.2 and 30.1.4 of the RFP. Ad'ditiotfal Locations While the Fort Worth Forest Park serves as the primary facility for service delivery,Concentra's additional 15 locations in the DFW area will serve as secondary locations and are available as y City of Fort Worth,TX,RFP No.14-0225 Concent' Medical Provider of Occupational Health Care Services convenience necessitates. in the following table, we identify the four locations that are within 16 miles of the City's address, including address, hours of operation,and contact information. C onR' ent sp Arlington — 2160 `Lamar — 8:00 am-8:00 pm(M-F) North Blvd. Arlington TX 76006 972.988.0441 9:00 am-5:00 pm(Sat Sun) ! 1 Arlington 817,2613166 8:00 am-8:00 pm(M-F) South 511 E.1-20 Arlington TX 76018 817.275.S432 9:00 am-5:00 pm(Sat-Sun) Burleson 811 NE Alsbury Burleson TX 76028 817'293.7311 8:00 am-8-:00 pm(M-F) Blvd,Ste.800 817.551.1066 8:00 am-5:00 pm(Sat) Fort Worth Fort 817.3069777 Fossil Creek 4060 Santishell Dr. WorthTX 76137 817306.9780 8:00 am-5:00 pm(M-F) i Managing Grail Time and Total Time in Clinic As a clinical healthcare resource to the City,Concentra assures that we will make every reasonable effort to minimize wait time for the City's employees and applicants. However,because Concentra is a walk-in medical facility and injury care is prioritized,it has been our experience that wait time outliers occur periodically.Should wait time ever exceed the target time,a designated colleague will communicate the status to the patient a minimum of every 15 minutes. In addition,we can establish communication processes in which we notify the City's designated representative when wait time is expected to exceed the agreed upon timeframe. Regarding the services requested in the City's RFP: • Physicals:We perform physicals according to definitive service standards,which provide sufficient time to render comprehensive,quality care.Medical examinations and clinical procedures follow injury treatment. • Drug and Alcohol Testing:Of relevance,in a majority of our medical care centers implement"fast track"drug/alcohol testing services in which employees experience a 30 minute or less wait time for a drug specimen collection and alcohol testing. Concentra currently measures the patient's total time in clinic,which includes wait time,the time it takes the center staff to provide the service,and any wait times involved after the service is provided up until the patient is checked out of the center.In our DFW market,Concentra's average total time in clinic year to date is: Injury Care s Non-Injury Care ✓ Initial Visits 112 minutes ✓ Physical exams 106 minutes Recheck Visits 65 minutes ✓ Drug Screens 42 minutes ✓ Therapy Visits 66 minutes k D�vo� y� , City of Fort Worth,TX RFP No.14-0225 c®® ce �.�� Medical Provider of Occupational Health Care Services Program Management While consistently looking for opportunities to improve,Concentra has proven to be a valuable partner to the City for more than 10 years,as evidenced by the following: 2009 validation study illustrating that the City achieved a 600%cost savings when employees chose Concentra for work-related injury treatment Concentra's partnership with the City to develop a successful and well-renowned CDL Review Board; a model that has gained the attention of other large municipalities across the country Development of an innovative survey process that measures patient satisfaction specific to the City's employees,allowing City and Concentra leaders to collaboratively develop customized solutions as employees'healthcare needs and expectations evolve Many of Concentra's leaders who have worked closely with the City over the past decade to achieve these results will continue to serve in this capacity for the upcoming engagement. Based on their years of experience working with the City,as well as a firm understanding of the City's current and future needs,these individuals will lead our service delivery efforts to ensure successful program outcomes These leaders include: • Kevin k oe,h'e,DO, MPH, Regional Medical Director:7 years with Concentra;board certified in Occupational Medicine and Family Medicine • Jerry Francis, Sales Manager: 13 years with Concentra;more than 6 years of direct experience with the City's account 1 • Ryan Smith,Area Therapy Director:More than 6 years with Concentra;over 5 years as Physical Therapy Director at our Fort Worth Forest Park location o Dee Harrington,Area Operations Director: Operations leader overseeing six Concentra centers in the DFW metroplex In the following sections,we identify the local leadership team we propose to provide ongoing oversight and perform services during the upcoming engagement. Program Advisor During contract review and negotiation,we assign an initial contact to serve as a liaison between Concentra and the City.For this project,Mr erl v Y:1^cL, Sales Manager, serves as the City's first point of contact through contract execution.Mr. Francis currently supports client engagements in DFW, including the City.With a background and knowledge of the market and a direct relationship with the City,Mr. Francis is well equipped to continue supporting the City's program.Mr.Francis remains knowledgeable of contract deliverables and is available to answer the City's questions during this period of the engagement. As Sales Manager, Mr.Francis: Serres as Concentra's liaison to the City Leads and directs contract implementation ® Ensures a clear understanding of contract objectives and deliverables through the successful execution of programs and projects ® Negotiates work approach and specific deliverables based on expected contract outcomes Directs contract execution efforts to ensure programs are completed according to contract ar City of Fort Worth,TX�RFP No,14-0225 concert I.r® Medical Provider of Occupational Health Care Services Participates with center,area,and regional leadership teams to effectively monitor and maintain existing accounts and develop new business Mr Jules 5t - `-,jor Account Executive,will provide support and assistance to Mr. Francis,as needed, to ensure continued service excellence. Mr.Staten has been a Concentra employee for eight years and possesses direct experience overseeing many engagements with DFW clients. Operational Oversight Center Operations Director(COO)for the Fort Worth Forest Park center, Mr.David Lambing, AMT/RMA, serves as the City's day-to-day contact for program operations.In this role,Mr. Lambing regularly monitors processes and procedures for area clients to ensure ongoing compliance with relevant guidelines and program specifications. David Lambing,AMT/RMA As COD,Mr.Lambing: Center Operations Director Oversees day-to-day center operations 2 years with Concentra } fl Implements and ensures ongoing compliance with all -- -- — operational policies,procedures,and training programs within the center Manages patient care issues and other center issues requiring resolution Acts as a liaison between Concentra and our preferred vendors Additionally,Ms. Gaby Betancourt; City of Fort Worth Lead, ----— urt GabBetancourt will serve as a day-to-day contact for the City.Ms.Betancourt — will be invaluable to the success of the City's program and is City of Fort Worth.Lead available to answer questions,address issues,and ensure the 4 10 years with Concentra program continues to operate efficiently. Medical Oversight Center Medical Director(CMD)for the Fort Worth Forest Park center, Roy Kreusel, MD, provides primary oversight for clinical medical practices,ensuring continued compliance.In this role, Dr.Kreusel ensures that the medical interpretations and associated clearances comply with the most recent medical guidelines used by regulatory agencies.Dr.Kreusel's expertise of the guidelines and regulations relevant to the outlined scope of work will be instrumental in the provision of services for the City's program. r` As CMD,Dr.Kreusel: Roy streusel,MD Reviews all medical history and perform medical physical Center Medical Director examinations 14 years with Concentra m Understands all medical surveillance requirements of OSHA,DOT,ADA, FMLA,and other regulated examinations ® Reports the results of the medical evaluation to the employee,including any medical condition(s) identified during the medical evaluation Provides the recommendation as to whether the individual is medically certified to safely perform the essential job tasks - Forwards copies_of any_abnormal results,alon with patient instructions regarding primary care follow-up,to individuals who were instructed to seek(as appropriate)medical follow-up to address any medical conditions or lab abnormalities identified during the medical evaluation City of Fort Worth,TX+RFP No.14-0225 Concent ra Medical Provider of Occupational Health Care Services • Provides or arranges for a prescriptive rehabilitation and/or fitness program when indicated to aid in the individual's recovery from illness or injury and enhance his/her ability to safely perform essential job tasks • Reviews medical evaluations conducted by other physicians or medical providers • Reviews individual medical evaluations and aggregate data to detect evidence of occupational exposure(s)or clusters of occupational disease Physical Therapy and Functional Testing Oversight Center Therapy Director(CTD)for the Fort Worth Forest Pork center, Michael Murrell,, PT, DPT,provides oversight for the physical therapy services rendered as part of the program.Mr.Murrell is an expert in his field and possesses a wide breadth of knowledge overseeing these services for other area clients.Mr.Murrell i will utilize this expertise to deliver services that objectively Michael Murrell, Center Therapy Direire DPTctor assess the employee's functional abilities and expedite the • 5 years with Concentra return-to-work process. _ As CTD,Mr.Murrell: • Conducts an initial evaluation on physician referrals and develop appropriate treatment plans • Ensures that other treating medical professionals have the necessary information to appropriately evaluate the employee's functional ability • Communicates with all medical providers and the City regarding employees'diagnoses,sets expectations for return-to-work,emphasizes education and motivation,and discusses specific rehabilitation issues and early intervention opportunities • Develops knowledge of best demonstrated practices and specific quality indicators to measure and improve them • Participates with the evaluation of the effectiveness of the rehabilitation quality management process and assists in new and improved processes • Ensures compliance with rules and regulations established by the relevant licensing,certification, and accrediting bodies, including the ADA and other applicable guidelines We provide leadership personnel qualifications and credentials as Attachment C—Personnel Qualifications. Clinic Staff Concentra identifies healthcare professionals and support staff who possess the expertise and specific hands-on experience delivering services that are relevant to our core offering.Our staff includes any combination of physicians,mid-levels, nurses,physical therapists,radiology technicians,and medical assistants,and we assure the City that each individual is qualified to perform their assigned duties. • Medical/Therapy Professionals:Concentra will only utilize qualified and appropriately credentialed medical and therapy professionals to serve the needs of the City and its employees.These professionals are skilled in their respective area of expertise and undergo extensive annual training in addition to the continuing education classes that Concentra financially supports.Furthermore,the medical and therapy personnel in our clinic will be vigilant in applying their knowledge to recognize and diagnose potential exposures and resull:ing heahtli iKsues,-and will continue to monitor Texas, OSHA,DOT,ADA,and other applicable federal and state regulations to ensure that all associated services remain compliant. Concentra City of Fort Worth,TX b RFP No.14-0225 C oncen'r®.: Medical Provider of Occupational Health Care Services Support Staff.Concentra Medical Centers employ qualified support personnel whom we train and fully certify to perform their associated tasks.Specifically,our personnel include drug specimen collectors certified to perform DOT collections,certified Breath Alcohol Technicians(BAT), NIOSH- certified PFT testers,CAOHC-certified personnel to perform audiometric testing,certified radiologic technologists,certified medical assistants,and certified phlebotomists. Credentiaang Practices Concentra clinicians must undergo a stringent credentialing process.Once the Concentra Credentials Committee Chair/Medical Advisor clears the candidate,Concentra follows NCQA guidelines for credentialing,which requires primary source verification to verify the licensure,board certifications,and any provider sanctions.In addition,Concentra performs an EPLS query to identify if a candidate is barred from contracting with the federal government.Concentra uses secondary sources(copies of documentation)to verify curriculum vitae and DEA certifications.Finally,we check the National Practitioner Databank for malpractice history.Additionally,Concentra re-credentials our providers every three years and,in the interim,we monitor these providers'licensures for expiration to ensure that they remain active and current. Physician,mid-level,nurse,and therapy candidates for employment must pass.a very stringent credentialing process that includes,but is not limited to,the following:. • In-depth review of employment application and resume • Face-to-face interviews with Concentra Management personnel • Verification of clinical,peer,and employment references • Verification of negative test results for illegal drugs where applicable • Documentation of continuing education and training • Provide copies of ACLS/BCLS or PALS certifications Primary source verification of the following: Education and training State licensure(s) DEA and state controlled substance registration(if applicable) Board certification(if applicable to the provider) Work history(most recent five years),verified through the application and attestation;gaps of six months or more are verified/explained by the-provider Malpractice history is verified through the NPDB query Sanctions against licensure,verified through the licensure verification and the NPDB query Medicare/Medicaid sanctions,verified through the NPDB query and a query of the OIG Background check(including criminal and credit history for previous 10 years) Competency letters from previous employers Approval by contracting organization(government agency or commercial customer),if appropriate Approval from Concentra's Credentialing Committee All Concentra personnel,regardless of position, are required to have a background check consisting of a felony/misdemeanor check,Social Security validation and trace, national sex offender check(for staff rendering patient.care), national criminal search,credit history, and a check against the Office of Foreign Assets Control list. C �■aa/■/�m®@�,� City of Fort Worth,TX 4 RFP No.14-0225 o Ecen-'9 ® Medical Provider of Occupational Health Care Services Approach to the City's Scope of Ward. Concentra has performed occupational healthcare services since inception more than three decades ago.We reviewed the scope of work requirements set forth in the City's RFP,and we affirm that we are fully capable of performing all of the requested services with the highest level of success,efficiency,and professionalism. Furthermore,Concentra has written procedures on all DOT,OSHA,ADA,and other regulatory standards,including the testing(surveillance examinations,pulmonary function,audiometric, laboratory,etc.)required in each standard.Likewise,our 30+years rendering specialized injury treatment offers an advantage over our competitors.Concentra assures the City that our physicians possess the appropriate credentials to perform the City's desired occupational health services. Occupational injury Medical Treatment and Care Best-ire-Class Approach Through exhaustive research including engaging clients,patients,and vendors,as well as leveraging our 35-year history as an occupational health services provider,we identified four components a company must address for a best-in-class occupational medicine program.These four integrated ecosystems are critical to achieving a solution that assists in the prevention of workplace injuries and reduces employer costs. Today Concentra treats one in every seven work-related injuries/illnesses in the United States. We determined that to be truly"best-in-class,"each program component must exhibit the following specific characteristics,which we describe below our four keys to a best-in-class occupational medicine i program. Quality Medical Outcomes Employer Engagement ➢ Occupational medicine expertise and ➢ Educate employees regarding services to drive a clear philosophy understanding of scope of care 9 Open access to clinicians ➢ Encourage relationship building between provider and ➢ Focus on outcomes employer through reciprocal facility tours and staff Our extensive occupational medicine expertise introductions ensures informed recommendations that follow D Develop processes that enable interactive communications, regulatory guidelines. generate meaningful reports,and ensure compliance tracking We collaborate with employers to develop occupational health programs tailored to the specific needs of the workforce population. Patient Enga;em=nt Clear Communications 9 Focus on employee health and patient ➢ Structure and managed communications processes experience > Clinical informatics ➢ One facility for multiple services We follow a communication pathway,from the initial visit to The better the patient experience,the more likely case closure,that ensures employers and employees are they are to follow through on the treatment plan updated on cases. to a successful outcome. Medical Guidelines Concentra has always focused our approach on providing quality medicine that achieves the best outcomes;as such,currently published,evidence-based clinical practice guidelines direct the medical evaluation and treatment decisions of Concentra's clinicians.As a large medical practice,we are able to gather data on millions of cases across our network of centers:We use this data throughout the organization to improve practice.patterns,develop medical guidelines,support our research institute, and create an environment of continual learning for our clinicians. paua R ,r City of Fort Worth,TX a RFP No.14-0225 Concentra, Medical Provider of Occupational Health Care Services Our clinics will utilize the following medical practice standards: • Texas Labor Code Regulatory • Evidence based guidelines Occupational Health and Safety ACOEM guidelines Administration(OSHA) Official Disability Guidelines(ODG) ✓' Department of Transportation(DOT) ✓ Evidence-based clinical practice guidelines ✓ Company-specific exams ✓ Up-to-date online professional medical Americans With Disabilities Act(ADA), resource Family Medical Leave Act(FMLA) Concentra physician manual Standing orders/procedures Outcomes-based evaluation and education Mid-level providers—collaborative f United States Preventive Services Task agreements Force(USPSTF) Registered nurses Our Injury Care Philosophy Concentra tracks and documents employee visits consistently,ensuring proper documentation in accordance with local,state,and federal laws.Work status will immediately be faxed or emailed to the designated City contact to ensure timely communication.The content of each physician visit includes key elements in order to maximize the likelihood of a favorable outcome. Concentra's affiliated physicians treat and document an estimated 560,000 injuries each year,allowing us to study comprehensive outcome data.This evidenced-based,outcomes-focused approach set a standard of excellence for the healthcare industry and has proven effective in returning people to work, to play,and to life faster and more affordably,resulting in lower overall healthcare costs. Treatment and Follow-up Process management is the system that Concentra employs to treat injured workers,utilizing proven outcomes to medically manage care in order to achieve the highest patient satisfaction and shortest duration of care.We believe that the foremost method of cost control in the workers'compensation arena lies in the timeliness and management of a quality delivery system. Concentra's achieves this goal by utilizing aur four Keys to Success: early intervention, early motivation, early education, and self-responsibility.These factors contribute to Concentra's ability to reduce case duration for occupational injuries,thereby driving down the total costs our client's spend on workers' compensation.This philosophy of a sports medicine approach in a work environment will be integral in the success of Concentra's relationship with the City. Content management refers to the information obtained and conveyed between the physician and patient during the course of the evaluation,as well as the nature of the interaction.The content elements of the visit focus on achieving a good outcome in a timely and cost effective manner,as well as ensuring patient satisfaction with the encounter.Process management provides the structure of the practice,and content management is what fills that structure.Content management,when applied with process management,helps ensure good practice patterns as well as favorable outcomes of treatment. When Concentra hires clinicians,they are required to participate in a formal educational.program in the areas of: Content and process management Low back pain management,emphasizing a biopsychosocial model of disease JL City of Fort worth,TX RFP No.14-0225 Concentra Medical Provider of Occupational Health Care Services • Ethics • HIPAA awareness • Other topics related to the practice of occupational medicine In addition,Concentra provides clinicians with regular feedback on their occupational medical practice in the form of quarterly reports,which include such measures as percentage of cases taken off work, percentage of cases on work restrictions, rate of referral to specialists,case duration,and others. Concentra also provides national data for comparative purposes,including data on Concentra physicians considered to have best practices. All of Concentra's clinicians are trained in occupational health and each will have knowledge of the City's workers'compensation rules and regulations.As a current provider to the City,Concentra affirms we participate in a workers'compensation healthcare network certified under Chapter 1305 of the Insurance Code. Concentra also ensures that the physicians/providers are continually trained and updated on workers'compensation rules, best practices,OSHA, DOT, HIPAA,and all other applicable regulations. Return-to-work functional Testing Procedures Concentra's longstanding methodology and practice has been one of expediting the return-to-work process.Concentra's clinicians communicate immediately with employers,review job analyses,and, whenever possible,arrange for limited duty to avoid lost time from work.Concentra focuses on increasing the function of the employee,not just symptom reduction.This focus requires the Concentra staff to have a thorough understanding of the various jobs in the workplace,educating the employees on enhancing function,and support from the employee's front-line supervisors.This collaboration will lead to a successful return-to-work program. We include additional information regarding our approach to physical therapy later in our response. Referrals If,during a work-related visit,Concentra's provider discovers an employee has a secondary medical condition or a non-occupational condition that warrants an outside referral,our physicians seek the expertise of the local healthcare community.The strength of Concentra's local employer relationships necessitates our integration with area providers within the community to ensure the highest quality of continued care for our patients when services are beyond our realm of care.As such,our centers maintain relationships with community specialists(usually within the local hospital system);through these established relationships,Concentra effectively expedites the referral process. Selection of Qualified Specialists Concentra evaluates specialists based on several important factors,including,but not limited to the following: • Successful medical outcomes • Reputation in the community • Willingness to have open communication with the Concentra provider Ability to provide cost efficient services ® Whether or not the specialist is in the our client's network It is Concentra's practice to create specialist relationships through communicating directly with them and understanding their processes.Concentra has identified specialists that are the "best in class"and —----------- _.__-----____-_-.__-.___.____._ I,, City of Fort worth,TX RFP No.14-0225 C®ncen Ir Medital Provider of Occupational Health Care Services provide exceptional,quality services. During implementation,Concentra will work with the City to establish a customized referral network unique to the City's needs and specifications. Referral Process Concentra completes referrals as necessary and as quickly as possible in order to minimize employee loss time.Many medical care centers,including our Fort Worth Forest Park center,utilize a dedicated referral department with Concentra's Center Support Team(CST)to assist in coordinating routine referrals for diagnostic procedures and specialist care.Concentra CST schedules referral appointments for procedures,diagnostic testing,and specialist visits. Concentra centers have designated Referral Coordinators who are careful to observe any special handling instructions related to claim administrator notification, pre-authorization,or preferred provider networks. Medical Management Managing the case of an injured/sick worker is imperative for success.Concentra realizes that the job of the clinician does not end with the referral—it is the duty of the provider to work with the specialist on a prognosis and treatment plan.Concentra providers follow the medical care of every injured or ill worker treated within the Concentra network,from the very first visit until the patient goes back to full duty or reaches maximum medical improvement.The purpose of medically managing the case is to provide a proactive,physician-directed,cost containment and communication service to our client that assures quality healthcare delivered in the most cost effective manner possible. Specific medical case management procedures practiced by Concentra include: Maintaining constant communication,whether telephonically,face-to-face,or via Internet(with the appropriate security in place) Establishing preferred communication methods between the referring physicians and specialist providers Tracking all specialty referrals and reporting on the percent referred and type of referral Tracking the medical outcome of each referral made by our affiliated physician to ensure the successful resolution of the case Physical Examinations Pre-employment Physical Exams Medical •7 v o;­� Questionnaire Concentra has custom medical and work history questionnaires in both English and Spanish and can provide an array of comprehensive and mandated questionnaires necessary to maintain compliance. Examples of mandated questionnaires include the Asbestos Questionnaire and the Respiratory Medical Evaluation Questionnaire.The applicant/employee completes a thorough medical history questionnaire that includes medical,personal,occupational,family,and medication history. Once the questionnaire is completed,the Concentra Medical Director reviews the questionnaire and makes medical recommendations(in conjunction with the review of the applicant/employee's test results).Concentra immediately contacts any findings that pose an immediate danger to the life or health of the applicant/employee. -j-_­ the Fv,r v, the prehersivr phy5i,-o!exornination commences. - y PAPP 11 p I� City of Fort Worth,TX RFP No.14-0225 RC®1Wcen q.r® Medical Provider of Occupational Health Care Services Pre-placement Physical Examination Concentra has comprehensive policies and procedures outlining examination requirements in accordance with,DOT,OSHA,ADA and general occupational health.Concentra will orient and train all clinical staff on the requirements associated with the City's evaluations.Furthermore,Concentra realizes any medical examination must be performed post-offer and pre-placement and must be"job-related and consistent with business necessity"(29 CFR 1630.14(b)).The purpose of a post-offer physical examination is to ensure that the employee(or prospective employee)does not have a medical condition that precludes performing the job safely,that could be seriously aggravated by the job duties, or that could affect the safety of others in the workplace.To make this determination,the physician needs to evaluate the individual's health status,and the job requirements. While the City will define the specific examination components,we recommend that a thorough medical examination include at least the following: Complete medical history(family, • Skin and lymphatic examination occupational,health,disease) a Neurological evaluation Musculoskeletal examination o Evaluation of the cardiovascular system Evaluation of the respiratory system . Visual acuity and vital signs, including but Gastrointestinal examination not limited to, blood pressure Examination of head,eyes,ears,nose,throat In addition,we can perform any ancillary testing as requested and/or when indicated,and upon the City's approval. Return-to-worklModified Work Employees undergo a basic medical examination administered by a center physician,who determines if the patient is medically able to proceed with the functional test. In some cases,the employee may have a medical condition that precludes participation in a functional test(recent back/knee/shoulder surgery, an active hernia,a cardiac condition).In these cases,prior to administering any functional testing, Concentra requires clearance from the employee's personal physician.Once the physician completes the medical exam,the center's physical therapist conducts the functional test.Concentra may require additional testing,upon approval from the City,to ensure our examining clinician renders the proper medical decision.However,Concentra will not conduct any additional testing without exclusive authorization by a designated City contact. ®OT Examinations Concentra has been performing DOT examinations for our clients since inception. reievonce, we e formed DOT than 765,000 OT examinations notionally in 2013. We maintain comprehensive policies and procedures for these examinations and thoroughly train our staff on each testing component.Specifically,when performing these exams,the treating provider adheres to the physical examination components outlined in the Federal Motor Carrier Safety Administration's(FMCSA) regulations,§391.41-Physical Qualifications for Drivers.if the driver passes,the physician immediately generates the required Medical Examiner Certificate.Although the certificate is valid for 24 months, Concentra physicians may limit certification based on medical results.Concentra affirms that all providers who perform these exams possess the proper certification in accordance with the updated FMCSA guidelines. ._ ..... Dn 9'Y pp JL City of Fort Worth,Tx RFP No.?4-0225 L®nhen @ r® Medical Provider of Occupational Health Care Services Examination Purpose The purpose of this history and physical examination is to detect the presence of physical,mental,or organic conditions of such a character and extent as to affect the driver's ability to operate a commercial motor vehicle safely.The examination should be conducted carefully and should at least include all of the elements outlined below.History of certain conditions may be cause for rejection and may indicate the need for further testing and/or require evaluation by a specialist.Conditions may be recorded which do not,because of their character or degree,indicate that certification of physical fitness should be denied.However,these conditions should be discussed with the driver and he/she should be advised to take the necessary steps to insure correction,particularly of those conditions,which,if neglected,might affect the driver's ability to drive safely. Specifically,the physicians will examine: • General appearance and development a Abdomen and Viscera • Head-eyes a Genital-urinary and rectal examination • Ears 9 Neurological Throat w Spine,musculoskeletal Heart o Extremities Blood pressure(BP) 4 Laboratory and Other Testing Lungs 9 Diabetes j I Fitness-for-duty Exams The purpose of the evaluation is to find out if the employee can perform his or her job in a safe manner. Patients are given a comprehensive physical exam that focuses on individual's ability to perform the essential functions of their particular job. We recommend that a functional evaluation be performed(if the job has associated physical demands)in addition to the medical examination.A medical exam will reveal conditions that may affect the performance of the job;the functional exam will identify if the individual is capable of physically performing the essential functions of the job.The cost per exam is typically fixed,but may be dependent on the complexity of the health issue.(Additional testing, upon the City's approval,may be required to ensure that the proper medical decision is made.)No additional testing will be conducted without exclusive authorization by a designated client contact. A fitness for duty examination'is performed when an employee is: Having observable difficulty performing work duties in a manner that is safe for the employee,for the employee's coworkers,for the University,or for the public,as determined by the supervisor;or Posing an imminent and serious safety threat to self or others. ®rang Testing and Alcohol Testing For more than 35 years we have regularly performed pre-employment,post-accident,random,and reasonable cause drug testing services for our clients and affirm we can perform the requested drug screens for the City. Concentra believes that DOT Federal Regulation 49 CFR Part 40,which outlines Procedures for Transportation Workplace Drug and Alcohol Testing Programs,provides clear guidelines and high standards as it relates to drug and alcohol testing procedures.For more-than-two-decades;these. procedures have withstood various regulatory and legal challenges and have become known as the gold standard. Therefore, Concentra conducts all drug testing(DDT and non-DOT)in full compliance with DOT Regulation 49 CFR Part 40, and adheres to all Substance Abuse and Mental Health Services City of Fort worth,T X o RFP No.140225 C®ncen(Sr®: Medical Provider of Occupational Health Care Services Administration;SAMNSA)policies and procedures to ensure appropriate chain of custody. By following these procedures in federal,as well as non-federal testing,Concentra is able to simplify the collection process,offer the most defensible procedures for our collectors and clients,and provide the optimal level of confidentiality for the donors. As required by item 31.2.2.6 in the RFP,Concentra affirms that prior to the effective date of the agreement,we will provide two copies of our"Drug/Alcohol Testing Manual"to the City employee the City designates Drug Screen Collection and Testing Collectors Concentra's certification course meets and exceeds the DOT training model.To help ensure consistency among all Concentra markets in adhering to DOT regulations,we developed a three-phase Concentra Collector Certification Program. Our policy is that all collectors(new hires and existing)successfully complete each phase of the program prior to Concentra certifying the individual to perform drug screen collections.Concentra's intention is to maintain high standards and quality in the collection process. To that end, Concentra requires refresher training for all collectors every 2.5 years, although DOT regulations require refresher training to occur within five years. If the collector does not complete refresher training within the designated timeframe,we will not allow him/her to perform DOT collections. Collection Process Concentra will administer all drug tests using the split sample method as required by the DOT and will test all samples for substances outlined in the most recent regulations.The certified collector and appropriate laboratory adhere to the following guidelines: n Collect a minimum of 45 milliliters(ml.)of urine • Divide the specimen into two bottles,30 ml.in one and 15 ml.into a second bottle • Seal the specimen appropriately • Send each specimen to the laboratory • Once received,the lab analyzes the primary 30 ml.bottle;the second bottle is held in the laboratory pending a request from the employee for a second test in the event of a verified positive of the primary test.Concentra acknowledges that the employee will be responsible for the cost associated with testing of the second sample. Chain of Custody When collecting urine specimens,Concentra adheres to all SAMNSA policies and procedures to ensure appropriate chain of custody to document the integrity and security of the specimen from the time of collection until receipt by the laboratory. For DOT collections,we use the federal chain of custody form; for non-regulated drug screens,we use their non-federal chain of custody form. Specific to DOT testing,Concentra completes the federal chain of custody form in accordance with SAM HSA guidelines as we outline below: a Collector ensures that the name and address of the drug testing laboratory appear on the top of the Chain of Custody and Control Form (CCF)and the specimen ID number on the top of the CCF matches the specimen ID number on the labels/seals Collector provides the required information in step 1-on the-CCF-and.provides.a remark in step.2_if the donor refuses to provide his/her Social Security or employee ID number Collector gives a collection container to the donor to provide specimen City of Fort Worth,TX RFP No.14-0225 Concen'tr® Medical Provider of occupational Health Care Services After the donor gives the specimen to the collector,the collector checks the temperature of the specimen within four minutes,marks the appropriate temperature box in step 2 on the CCF,and provides a remark if the temperature is outside the acceptable range Collector checks the split or single specimen collection box; If no specimen is collected,the collector checks that box, provides a remark,discards Copy and distributes the remaining copies as required If it is an observed ollection,the collector checks that box and provides a remark Donor watches as the collector pours the specimen from the collection container into the specimen bottle(s),places the cap(s)on the specimen bottle(s),and affixes the labels)/seal(s)on the specimen bottle(s) • After affixing the labels/seals,the collector dates the specimen bottle label(s) • Donor initials affixed and dated specimen bottle label(s) a Collector turns to Copy 2(MRO Copy)and instructs the donor to(1)read the certification statement in ste;Y 5 and(2)sign,print name,date,provide phone numbers,and date of birth;if the donor refuses to sign the certification statement,the collector provides a remark in step 2 on Copy 1 • Collector completes str;Z(i.e.,provides signature,printed name,date,time of collection,and name of delivery service),immediately places the sealed specimen bottle(s)and Copy 1 of the CCF in a leak-proof plastic bag,releases specimen package to the delivery service, and distributes the other copies as required Medical Review Officer(MRO)Services i Concentra proposes to utilize Stephen Kracht, DO, of e5creen, Inc. (eScreen)for any required MRO services.The MRO service reviews and interprets non-negative test results obtained through the City's program to assure a scientifically valid result,and then determines whether a legitimate medical explanation could account for a laboratory-confirmed non-negative result.Specifically,the MRO typically makes three or more attempts during a 24-hour period to reach the donor, barring unforeseen circumstances(such as donor's phone disconnected). During the interview, the MRO does not typically analyze the collection process with the donor, br;t rather focuses on alternotive,iegitirrate medical explanations for test results. Utilizing an MRO decreases the risk of a non-negative result due to donor's ingestion of a lawfully prescribed substance.The MRO can ask medically related questions(which the City cannot under the ADA)and definitely ascertain a positive or negative result. The MRO always reviews the MRO copy of the Chain of Custody form for non-negative tests.If not transmitted priorto the lab results,the MRO assistant calls the collection site to request timely transmission of the MRO copy.If the Lob copy is not transmitted with the lab results,the MRO assistant calls the lab to request timely transmission of the Lab copy as well. The MRO will not initiate a donor interview until receiving the MRD cc,-, the and will not transmit verified results until receiving the Lab copy. If the MRO is unable to obtain either copy,the MRO will notify the City of a"canceled"test. Breath Alcohol Testing Concentra conducts breath alcohol testing using an evidential breath testing(EBT)device approved on the National Highway Traffic Safety Administration's(NHTSA)Conforming Products List for both screening and confirmation testing.To ensure quality results,each EBT device has a calibration check performed daily and after every-positive result(no exceptions);records-of-the calibration are placed on file with a retention period of five years. in addition,personnel performing breath alcohol testing are trained and certified as BATS in accordance with DOT guidelines. ,� City of Fort Worth,TX 4,RFP No.14-0225 Lo t�1cen bra Medical Provider of occupational Health Care Services Typically,breath alcohol tests that register less than 0.02 gms./2101 are reported as"negative"(for the purposes of DOT)and no additional testing is required.Breath alcohol tests that register 0.02 gms./2101 or greater require a second confirmatory test.If the confirmatory test is less than 0.02 gms./2101,the results are reported as"negative."Breath alcohol results that register 0.04 gms./2101 or greater on the confirmation test are immediately reported to the City. (A 0.04 gms./2101 is considered a DOT positive result). Laboratory Testing Concentra acknowledges the City's request that the medical provider utilize Advanced Toxicology Network(ATN)and affirms our ability to meet this requirement. We have many relationships with national laboratories,including ATN,and will work with ATN and the City to provide substance abuse and clinical testing,when needed. On-site Drug Testing Concentra acknowledges that the City may require infrequent on-site drug testing(less than four per month)during the contract period. Concentra affirms our ability to conduct on-site testing and will not charge the City an on-site service charge. In the event of unscheduled on-site testing,Concentra will charge the City an on-site fee plus the cost of services rendered. Clinical Testing Concentra acknowledges that the City may require various clinical testing as part of the examination process and we affirm our ability to meet this requirement.Concentra offers a selection of clinical testing services in our medical care clinics,which we perform on equipment that has been thoroughly examined and calibrated prior to testing.We can provide calibration reports to the City upon request. The following table outlines Coitcentra's clinical testing capabilities: 71 Con .� es 11 PIN Audiometric All audiometric testing conforms to the OSHA standard 29 CFR 1910.95.We have CAOHC- Testing certified technicians to perform the tests,and we will provide all certifications upon request. Concentra's services specific to audiometric testing include: • Audiometers that pause testing if ambient sound levels temporarily exceed OSHA levels • Immediate STS identification and retest capability CAOHC-certified hearing specialists • Acoustic Systems audio booth professionally designed and installed in each clinic • Daily equipment calibration • Microprocessor audiometers EKG Concentra will perform a 12-lead EKG that measures the electrical activity of the heart.A center (Resting) physician will read the EKG. Pulmonary A technician performs all pulmonary function testing in such a way as to allow real-time graphic Function and numeric data to verify the test validity.Data returns of VC,FEVI,PEFR,FEF 25%-7%and Testing FEV)/FVC are required. Vision A trained technician performs a vision test that meets OSHA standards for visual acuity.The technician screens far visual acuity with corrective lenses,lateral and vertical phorias;-sEereo depth perception,and color discrimination for red,green,and amber. City of Fort Worth,TX a RFP No.14-0225 Concen fir®. Medical Provider of Occupational Health Care Services I6 '•t^. y 9 a pp .pp sphygmomanomet,, id stethoscope.The examining physician must obtain z -jei, Jing for any person who does not meet normal pulse rate or blood pressure criteria. X-rays All posterior-anterior X-rays are performed by registered X-ray technicians and certified 13- readers will review selected chest X-rays in accordance with OSHA regulations. Immunizations/Exposure Control Program Concentra realizes that employees working in occupational settings may have the potential for exposure to infectious materials(e.g.,blood,tissue,specific body fluids and medical supplies,equipment,or environmental surfaces contaminated with these substances),depending on their job functions. Concentra will support treatment of employees exposed to bloodborne pathogens by medically managing the employee's occupational exposure including but not limited to:the determination of an exposure,vaccination administration,source testing,laboratory testing(HIV),recheck visits,post- exposure prophylaxis,and counseling. Concentra physicians provide the recommendations for the occupational exposure of blood and other potentially infectious materials(OPIM)in accordance with the Centers for Disease Control's(CDC) Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post Exposure Prophylaxis.The recommendations apply to situations in which a _ person has been exposed to a source person who either has,or is considered likely to have,human immunodeficiency virus(HIV),hepatitis B,and/or hepatitis C infection.The risk of hepatitis B infection is primarily related to the degree of contact with blood in the work place and to the hepatitis B e antigen (HBeAg)status of the source person. Concentra provides a comprehensive service offering to ensure the City's employees have the necessary vaccinations to prevent disease and protect their health.Concentra clinicians are trained,qualified,and readily able to provide a myriad of immunizations and infectious disease screenings for the City. We immunize all candidates and employees against infectious diseases in accordance with 29 CFR 1910.1030, "Bloodborne Pathogens". r. AM F—Z Aim y Hepatitis A Vaccine Vaccine can be offered to high risk(Hazmat,R. nse Team)and personnel with frequent or expected exposures to contaminated water Hepatitis S Vaccine and Titers As specified in CDC guidelines;a series of three vaccinations that occur throughout a six-month period Hepatitis C virus Screen Baseline and following occupational exposure HIV Screening Screening is available to all exposed personnel,as needed influenza Vaccine Concentra can administer flu vaccinations to all personnel annually,if desired. As appropriate,Concentra will discuss with the City the specifics regarding administering the shots and anticipated volumes. Measles,Mumps,Pubella In accordance with the CDC guidelines Vaccine(r✓iMR) Meningitis(Bacterial) in accordance with the CDC guidelines Polio Vaccine In accordance with the CDC guidelines ..-._. __..__.--._.__.. D—1-7 City of Fort Worth,TX R RFP No.14-0225 Medical Provider of Occupational Health Care Services Tetanus/c .itheria Vac& Booster every -0 years Tuberculosis Screen(PPD) Annually,or more frequently,according to CDC guidelines unless the member has a history of positive PPD.If positive by history,CDC guidelines for management and subsequent chest radiographic surveillance shall be followed. Medical Surveillance Evaluations Concentra has been performing medical surveillance testing for our clients for more than 30 years. Nationally,Concentra is responsible for thousands of our client's medical surveillance programs.We have comprehensive surveillance policies and procedures for each examination and all staff is trained in examination components. Concentra's staff will administer and maintain all necessary records associated with any OSHA medical surveillance requirement,including respiratory physicals in accordance with 29 CFR 1910.134,hearing tests—1910.95,and bloodborne pathogens—1910.1030.We also follow the recommendations of the CDC for the administration of hepatitis B vaccinations.We also abide by and assist our employers with the Recordkeeping Standard.Concentra has written guidelines on all OSHA standards,including the testing(examinations,pulmonary function,audiometric, laboratory,and respiratory fit testing)required in each standard.Concentra will also ensure that all personnel have the appropriate certifications to perform the audiograms and pulmonary function tests(CAOHC and NIOSH respectively). Respirator Clearance Concentra affirms our ability to deliver this service as part of the medical testing program.We describe our capabilities in the table below. _ „ f:?Fcw* :.. Respirator We acknowledge that the OSHA respirator questionnaire is a required component of the overall Medical respirator examination.As such,Concentra will utilize the OSHA Respirator Medical Evaluation Questionnaire Questionnaire when rendering services for the City.After the individual completes the questionnaire, the attending physician reviews the responses and makes medical recommendations irr'conjunction with the review of the employee's test results.If the individual answered"yes"to any of the questions in 1 through 9 of the questionnaire,ancillary tests,such as a medical exam and vital sign testipg,may be required at the discretion of the attending medical professional. Medical Eram Concentra recognizes that an evaluation may be required based on questionnaire responses and we affirm our ability to render this service.The respirator exam will include all components desired by the City and may consist of any combination of the following clinical services:chest X-ray,EKG,and/or pulmonary function testing.We will conduct the evaluation in accordance with OSHA standards,as outlined in 29 CFR 1910.134,and will perform all follow-up testing required as allowed by law and after obtaining authorization from the City. Fit Test(if OSHA and NiOSH provide the recommendations for those workers who may be required to wear required,for respirators due to environmental contaminants.A fit test determines the ability of each:individual an additional respirator wearer to obtain a satisfactory fit with an air-purifying respirator and/or supplied air fee) respirator.If desired,Concentra can perform fit testing for the City's employees for an additional fee. We perform qualitative fit testing in all of our clinics,=a select number of our facilitles also perform quantitative testing.All fit testing is performed in accordance with OSHA regulation 29 CFR 1910.134. i�.,r City of Fort Worth,TX -RFP No.14-0225 Conce ®tr®, Medical Provider of Occupational Health Care Services CDL Program Robert Hassett, DO,MPH, dice President, Medical Operations, has served on the City's CDL Review Board for more than eight years. Dr.Hassett provides medical oversight,consulting with the City to ensure that employee healthcare goals are in line with what is medically appropriate. Dr. Hassett is board certified by the American Osteopathic Board of Family Physicians,the American Osteopathic Board of Preventive Medicine,and holds a certification in occupational medicine. Data Collection and Reporting In all of our medical care centers,Concentra utilizes a provider database,referred to as OccuSource that enables Concentra to capitalize on superior knowledge of workplace injuries and their predictable outcomes.OccuSource supports daily management of information and patient flow within each center and offers unique,timely,and meaningful information to our customers on a daily,weekly,quarterly, bi- annual,and annual basis according to specific requirements.This benefits employers,employees,and payer groups by ensuring consistent guidelines,a user-friendly system,and statistical outcomes. OccuSource is proprietary to Concentra,and is far superior to similar programs in its ability to track patient care and provide outcomes data.As a cumulative database,OccuSource maintains demographic and visit information for all patients treated at our clinics,and is readily available to create several types of outcomes data.Concentra believes that OccuSource's ability to capture valuable information on all patient visits—more than 6 million visits annually—distinguishes this database from all others utilized in the occupational healthcare industry.OccuSource creates outcome reporting that not only provides _ valuable information for our clients,but also enables Concentra to utilize data to develop best demonstrated practice patterns. Standard Reporting Individual patient encounters provide the basis for the reporting system.The system creates a report-for each employee visit seen at Concentra and generates an email or fax notification(based on the City's preferences)to the City's designated contact.Concentra can set up notification for multiple contacts,if desired. The following table outlines examples of daily reports Concentra can generate for the City.Sample reports are available upon request. catuy Repo, enerated 4: VILLI LL)t)USa Uil 01 eacri injury VOt report includes the patient's name,company department,date of visit, check-in/check-out time,diagnosis,treating physician,restrictions on duty,next scheduled appointment,and anticipated date of maximum medical improvement Non-Injury Status Report 2 Generated at the conclusion of-each noninjury visit • Report includes patient name:ind,deniigraphics,date seen,time checked in and out of the center,resuits,.and renal ks Missed Appointment Letter o Generated the day after a-missed an appointment- Report includes the employee and employer demographics,time and date of the missed appointment,and physician's name ,� City of Fort Worth,TX♦RFP No.14-0225 C®ncen @ r® Medical Provider of Occupational Health Care Services Patient Referral • Generated whey i rei rr l to a specialist takes place Report includes basic demographics,billing information,specialist information,and referrals details(ie.,type of referral,reco'rnmendations, priority,notes) Utilization Management Reports In addition to our standard reports,Concentra offers our clients quarterly utilization reports that share key injury information.This report offers a roll up of all injuries treated at Concentra and provides detailed information specific to injury care services,including but not limited to the following: • Number of workers treated a Average days to discharge • Distribution of body type injured a Percentage of cases with off duty and limited • Number and percentage of cases closed duty days • Average visits per case • Average number of off duty and limited duty days • Percentage of cases referred to a specialist • Average cost per case provider • Comparisons of the project data to the entire • Percentage of cases referred to physical client market for the same period therapy Additional Services and Information Results Communication f Physicals Concentra will integrate,review, and report all medical information back to the City's decinnntPd representative within 24 hours of receipt of all relevant data.The report will provide a recommendation based on the results,any recommended referrals,and/or restrictions,and recommendations for necessary follow up to remedy the referral.The physician will note if additional testing is necessary and advise of the clearance status for job placement. if the results require supplemental testing,Concentra will notify the City's designated representative prior to performing any additional testing.Depending on the specific components tested for(i.e., blood or urine analysis), results may take up to five days to report. Drug Screens Concentra's average turnaround time for a negative drug screen result is 24-48 hours upon receipt at the lab.However,a positive result turnaround timeframe,including MRO review,varies for non-DOT and DOT tests,and may take 48 to 72 hours depending on the MRO verifications. • Non-DOT Positives—For a non-DOT positive drug test, MRO review is at the employer's discretion and results can take 48 to 72 hours upon receipt at the lab. DOT Positives—MRO review is required for all DOT positive drug tests.While we can report a confirmed positive result to the MRO within 48 hours,the average turnaround time for a positive DOT drug screen review by the MRO varies due to the responsiveness of the donor to the MRO in accordance with DOT regulations.The donor has up to five days to make contact with the MRO per DOT guidelines before the MRO reports a result. Unless otherwise noted,the MRO will conduct the MRO investigation in accordance with-the DOT guidelines. Breath Alcohol Testing We report breath alcohol testing results the same daythat we obtain the specimen. ,� City of Fort Worth,iX p RFP No.140225 C"®®e�ce fir® Medical Provider of Occupational Health Care Services Injury Services Concentra generates an activity status report immediately upon checkout that includes the following information: • General patient demographics • Basic employer information • Visit information,including name of treating provider and diagnosis • Patient status,including'any restrictions,return-to-work status,and date of anticipated maximum medical improvement(MMI) • Name of treating provider • Date,time,and provider for next scheduled appointment Concentra's medical and clinical expertise is unmatched. We have developed comprehensive policies and procedures for examinations,as well as drug/alcohol testing,injury care,return-to-work,preventive care,and more that comply with OSHA,DOT,ADA,and other regulatory guidelines.We provide a variety of healthcare services nationwide through our 300+urgent care centers and nearly 200 Health and Wellness Centers(HWC),and deliver comprehensive health and wellness programs. Solution Summary Concentra reviewed the City scope of work and we confirm our ability to perform the outlined services effectively and professionally.We believe Concentra's longevity in the healthcare marketplace,expert infrastructure,and consistency in delivering healthcare services—along with our reporting capabilities and comprehensive suite of services — differentiate us from our competitors. Concentra appreciates the opportunity to present our services and capabilities.We are confident that we can address all the outlined service requirements efficiently,professionally,and in accordance with regulatory standards.Concentra is prepared to deliver a best-in-class solution that exceeds the expectations of the City of Fort Worth,TX. 28 Conflict of Interest Questionnaire We include the completed Conflict of Interest Questionnaire as part of Attachment A—City-required Documents. 3. Qualifications Questionnaire We include the completed Qualifications Questionnaire as part of Attachment A—City-required Documents. 4. Fees and Charges Schedule Concentra appreciates the opportunity to present our proposed fee schedule for the City's program.We include the City's required Attachment D:Service Fees and Charges Schedule as Attachment D—Fees and Charges Schedule.We affirm all information contained herein is current,complete,accurate,and remains valid for 180 days following the due date,September 11,2014. City of Fort Worth,TX RFP No.14-0225 concentra., 1cen tr®., Medical Provider of Occupational Health Care Services 5. MBE Utilization Plan Concentra acknowledges that as of June 1,2012,the City implemented a new Business Diversity Ordinance(BDO).As a result,the City has implemented a 10%MBE utilization goal,specifically for African American firms certified by the North Central Texas Regional Certification Agency(NCRTCA). Over the past five years,Concentra has more than doubled the City's standard 10%MWBE utilization goal.In an effort to remain a strong community partner and maintain our longstanding relationship with the City,Concentra will continue our efforts to identify opportunities in which to engage qualified African American MBE firms and achieve the level of participation outlined in the City's RFP. Concentra currently maintains relationships with several thousand employers that have internal Diverse Supplier requirements.Typically,these organizations are municipal,federal,or federal contractors.In many cases Concentra,although not a minority or disadvantaged business enterprise,has been asked to participate toward our client's goals through our own sub vendoring efforts. Our process for compliance is as follows: • Meet with the local/area team to identify subcontracting opportunities • Write the Certification Agencies to obtain copies of M/WBE directories • Review internal tracking of M/WBE subcontractors and cross-reference with market/state • Generate letters to subcontractors indicating interest in subcontracting opportunities and a quote for services • Contact recruitment and placement organizations if a low number of subcontractors respond • Record and document qualified subcontractors as necessary 6. Financial information We include our more current year-end Annual Report and audited financial statement as part of Attachment E—Financial Information. 7. Organizational Information Experience'With the City Concentra considers it a privilege to have direct experience serving as the City's provider of the requested services.During the course of our relationship,Concentra has become intricately knowledgeable of the City's guidelines and operational procedures, and as a result, has established effective communication pathways and business relationships with the City's personnel to ensure we meet the City's needs on a continual basis.With a clear understanding of the demographics and workplace culture,Concentra offers the City compelling advantages.In addition,our designated provider possesses an intimate knowledge and the expertise necessary to perform medical examinations that comply with relevant guidelines and the City specifications.Concentra would consider it an honor to continue in our role as the City's clinical resource for the requested scope of work. p City of Fort Worth,TX+RFP No.140225 C"Oncen'g�a Medical Provider of Occupational Health Care Services Injury Care Experience c.oncentra's approach to patient care is "aggressively conservative —conservative in the practice of medicine, and aggressive in the management of the case, In our practice,Concentra employs the system of process management,which refers to monitoring and directing the processes and events that make up the structure and flow of an individual case,all with the focus of achieving the optimal outcome. These processes and events include many variables,such as frequency and timing of patient visits, communication with the patient's employer,and referral patterns for consultations and diagnostic testing. This analysis of comprehensive outcomes data proves that the following factors have a considerable impact on the ultimate outcome and cost of a workers'compensation case: ■ Treating the patient at frequent intervals in the initial period following an injury • Communicating with the employer about the activity/duty status of the injured employee a Monitoring referrals to ensure that a patient is evaluated in a timely manner • Paying attention to case closure following release to full-duty activity Non-injury Experience Concentra regularly performs physicals and conducts drug/alcohol testing for our clients'programs.We assure the City that only qualified individuals will perform the services in accordance with all local,state, and federal guidelines. To date in 2014, our DFW centers have collectively performed more than 50,000 physicals and 83,100 drug screens. Concentra's acquired experience performing the healthcare services desired by the City uniquely positions us to deliver a complete solution that exceeds the City's expectations.Our proposed program incorporates extensive expertise in the areas of examinations and other occupational healthcare services,and maintaining compliance with various regulatory agencies.As appropriate,we are happy to discuss our additional capabilities with the City. 'Customer Satisfaction Patient Experience Concentra's commitment to renew our focus on the patient experience began with creating new mission,vision,and values(MW)statements.These words defined our goal to provide superior customer service to every patient,during every visit.To ensure the message reached Concentra colleagues nationwide,we created the orange Book, designed to guide colleagues in their service delivery.Concentra expects our employees to abide by the principles set forth in the Orange Book to ensure continued service excellence to all Concentra employers and their employees.Ensuring a positive experience to every patient visiting our medical center is a key initiative throughout Concentra's organization,from our Executive Leadership Team to our local clinic staff.Our colleagues strive to redefine patient care by treating each patient to a welcoming,respectful,and skillful experience. Concentra assures the City that our local clinic staff shares this same passion and concern for our patients and each individual will work tirelessly to ensure the City's employees enjoy a positive experience. Measuring/Tracking Satisfaction As a leading national provider of occupational, urgent,preventive,and primary healthcare services, Concentra understands the importance of combining quality medicine with superior customer service. In ,� City of Fort Worth,TX+RFP No.14-0225 CoF�cen @ ra Medical Provider of Occupational Health Care Services fact,customer satisfaction and quality care are Concentra's top priorities.Concentra has developed a comprehensive customer service training program,and we continue to refine and expand upon that core foundation to ensure we consistently deliver superior services. To track satisfaction,Concentra imparts the following metrics: ■ Net Promoter Score(NPS)—This simple,yet powerful tool measures customer satisfaction and, in turn,serves as an indicator of customer loyalty and potential business growth.The NPS provides the means for gauging performance,establishing accountability,and prioritizing investments. Net Promoter indexes provide for actionable opportunities and benchmarks Concentra's data against industry norms.Franklin Covey's research unit, Westgate Research,conducts a 12-.question telephonic survey with a rating system from 1(unsatisfactory)to 10(excellent).The questions relate to facility appearance,wait time,perceptions of the medical provider,and quality of care.Patients can also convey specific comments about their experience.The firm performs all telephonic surveys in accordance with local,state,and federal confidentiality laws. Westgate Research gathers the acquired data and generates reports for Concentra's management team,as well as our clients.As of July 2014, Concentro's NPS for the South Central Region, which includes our DFW locations, is 61%. ■ flet Patient Experience Rating(NPER)—The NPER is the percentage of responses to the survey questions"Rate Your Overall Satisfaction"that are 9s and 10s(out of 10).The NPER is important because it is a predictor of whether someone is willing to recommend Concentra.Concentra tracks and.reports on the patient experience on a monthly basis.The NPER reflects how well Concentra fulfills our purpose and predicts our ability to continue serving patients in the future.The patient experience is as important as—if not more important than —any other measure of performance, as it is a predictor of whether an individual is willing to recommend Concentra.At Concentra,we exist to serve patients;therefore,a stellar patient experience is not something we strive for—it is our purpose.As of July 2014, Concentro's NPER for the South Central Region, which includes our DFW locations,is 55%. 8e Location Map In the graphic to the right,we include a map of all Concentra locations within the Fort Worth/Dallas extended metropolitan area.Each Concentra center is indicated by an orange marker. a,fi��. •'`�,, -YwYLI 4tt:3:. we. e t uv ( 9. Organizational Chart The following organizational chart depicts Concentra's proposed leadership team at the Fort Worth Forest Park center: PROJECT MANAGEMENT AND SERVICE DELIVERY Ooerations Mameement Medhal Management Theraov Maneeement David Lambing,AMT/RMA Roy Kreusel,MD Michael Murrell,PT,DPT Center Operations DMctor Cente -edical Director centerTherapy Director Fmnt0fFk&Speda11sts I( physicians Phystcal Therapists Medical As icmnts I Mid-levels PhyaltalTherapy Aasistams X-ray Techs I Norse, y City of Fort Worth,TX*RFP No.14-0225 Concentra Medical Provider of Occupational Health Care Services 100 Sample Reports We include sample reports for the City's review as part of Attachment F—Sample Reports. 11. References Concentra offers the following three current client references for the City's review.We encourage the City to contact these entities as they can attest to our ability to perform a variety of healthcare services per each client's specifications and in full compliance with all regulatory guidelines. Concenvaa q r'i;�a`_•��lrr-. ��r�, o.s1�,,:l.ri-_ - - _. ._ _..'��'�ci_r"{ ��,�'=-jam_��----- - ��j,s�, s_��i� _x— _ -- --�v ,oiores LeWis,Empioyet Sandra Vera-Summers,HK Benefits Director Coordinator/Risk Managem-t._ Addb 1500 Marilla Street 6A-N 101 S.Mesquite St,Sty. 10 505 Barton Springs Road,Ste.750 Dallas,TX 75201 Arlington,TX 76010 Austin,TX 78704 Phone 214.670.7391 817.459.6869 512.974.3334 Services Employer services,injury Employer services,injury care Injury care,employer services care,health and wellness City of Fort Worth,TX RFP No.14-0225 Concentra a fir® Medical Provider of Occupational Health Care Services Attachment A City-required Documents F 4 . oit5 PURCIIASING DIVISION REQUEST FOR PROPOSALS(R") for MEDICAL PROVIDER OF OCCUPATIONAL HEALTH CARE SERVICES RFr No.14-0225 Issued:August 13,2014 PROPOSAL SUENIISSION DEADLINE: ******!Agp September 114 2014 by 1:30PM Central Time NO LATE PROPOSALS WILL BEACCEPY—ED wsv0TO- 1 sr�is 5s ii. CITY OF FORT WORTH PURCHASING DIVISION ITY OF FORT WORTH PURCHASING DIVISION LOWER LEVEL LOWER LEVEL 1000 TBROCKMORTON STREET 1000 THROCKMORTON STREET FORT WORTR TEXAS 76102 FORT WORM TEXAS 76102 A Pre-proposal Conference will be held from 1.30 PM NAM AND ADDRESS OF COMPANY to 3:30 PM on Wednesday,August 20,2014,in SUBMITTING PROPOSAL: Purchasing Large Conference Room,City Iffall,LowerOccupational Health Centers of the Southwest,PA, Level,1000 Throckmorton Street,Fort Worth,Texas dba Concentra Medical Centers 76102. 5080 Spectrum Drive,Suite 120OW 1s ADDITIONAL INFOPJ"TION Addison,TX 75001 REGARDING THIS R"PRASE CONTACT: Doris Brent,Contract Compliance Specialist DoirisXrent@ForkWorthTexas.gov Contactperwn: Jules Staten Title- MajorAcGount Executive RETURN THIS COVER SJIEET WITH Phone:(817) 313.66521 Fax:(817)_882.8707 RESPONSE TO: Doris Brent Email: jul--Ato @conceV.com Contract Compliance Specialist Purchasing DivisionAdene G.King 1000 Throclunorton Street,Lower Level Printed'lalne: Authorized Representafive Fort Worth,Texas 76102 Will contract be available for Cooperative Agreement use? (See Section 27,page 10)Yes_No Y-- Acknowledgment of Addenda:#1 Y,_#2 #3 #4 #5 AIDDE"UM TO THE REQUEST FOR PROPOSALS RFP 14-0225,MEDICAL.PROVIDER OF OCCUPATIONAL BEALTH CARE SERVICES CITY OF FORT WORTH PURCIIASMG DIVISION ADDENDUM NO.1 DATE ISSUED:August 27,2014 REQUEST FOR PROPOSALS NUMMER: 14-0225 ORIGINAL PROPOSAL SUBMISSION DATE:September 11,2014 CLARIFICATIONS: 1. Questions and Answers received through pre-proposal conference and email are hereby incorporated,in full text,page 2. REVISIONS: 1. Revision to RFP 14-0225,dated August 13,2014,is hereby issued to amend the following provision: Section 31.0,Scope of Work,Subsection 31.2.7 is revised to read:Medical Provider will provide reports to City designated-individuals in atimely manner.Specific reports may include,but are not limited to the"Utilization Management Report,""Activity Status Report;""Non-Injury Status Report,""Patient Referral Report,"and"Patient Visit Information."Reports will be generated at no additional cost to the City. All other terms and conditions remain the same. JACKDALE PURCHASING P4A NiAGER a Hare HHH®H H®HHHH®®®HHH H9 G08HH®®ama meHmHmmHH BBgH HH®mH AH HHBHH@HHHHHHa700HHHH®p®ON09 COWANY NAW, ccupational Health Centers of the Southwest,PA,dba Concentra Medical Centers SIGNATURE: 1 A A 7 Arfene G.King,Authorized Represent. NOTE: Company name and signature mus be the some as on the bid documents. Questions and Answers(Q&A)for City of Fort Worth RFP 14-0225 MEDICAL PROVIDER OF OCCUPATIONAL HEALTH CARE SERVICES Q1. In Section 30 Qualifications,Subsection 301.4 Hours of Operation,it states that hours of operation at all Fort Worth facilities shall at a minimum be from 7:00 a.m.to 7:00 p.m.Does that mean that all of our facilities must be open during those hours,or just our main clinic? Al. The City hopes to procure a vendor who can have more than one facility open during the minimum hours requested in Section 30 Qualifications,Subsection 30.1.4 Hours of Operation.Please clearly state your company's capabilities regarding hours of operation in your response to this RFP. Q2. In Section 26.0 Involvement of Minority Business Enterprises(1l4BEs)it is no longer called M/WBE.Does that mean that women-owned businesses are no longer considered towards points for MSE?Is the goal for this RFP for 10%MBE only(African American)? A2. Yes,women-owned businesses are no longer considered towards points•for MBE.The last disparity study conducted by the City of Fort Worth indicated that Women-owned,Hispanic- owned,Asian-owned and Native American-owned businesses met parity for subcontracting opportunities on professional contracts outside of Architectural and Engineering t Services. Therefore,as June 1,2012,the City of Fort Worth M/WBE Office assigns Minority Business Enterprise(MBE)African American(AA)subcontracting goals on all professional contracts outside ofArchitectural and Engineering Services. Q3. In Section 31.0,Scope of Work,Subsection 31.2.7 Reports and Validation Studies,can you please clarify what an OCCU 300 Report is? A3. -Section 31.0,Scope of Work,Subsection 31.2.7 is revised to read:Medical Provider will provide reports to City designated individuals in a timely manner.Specific reports may include,but are not limited to the"Utilization Management Report;""Activity Status Report;""Non-Injury Status Report,""Patient Referral Report,"and"Patient Visit Information."Reports will be generated at no additional cost to the City. A revised copy of the RFP will be posted with this Addendum. RFP 14-0225,Medical Provider of Occupational Health Care Services,Page 2 of 2 ATTACHIVEVIENT A CONFLICT OF INTEREST DISCLOSURE BE Pursuant to Chapter 176 of the Local Government Code, any person or agent of a person who contracts or seeks to contract for the sale or purchase of property,goods,or services with a local governmental entity(i.e.The City.of Fort Worth)must disclose in the Questionnaire Form CIQ ("Questionnaire')the person's affiliation or business relationship that might cause a conflict of interest with the local governmental entity.Bylaw,the Questionnaire must be filed with the Fort Worth City Secretary no later than seven days after the date the person begins contract discussions or negotiations with the City, or submits an application or response to a request for proposals or bids, correspondence, or another writing related to a potential agreement with the City.Updated Questionnaires must be filed in conformance with Chapter 176. A copy of the Questionnaire Form CIQ is enclosed with the submittal documents.The form is also available at htto://www.ethics.state.tx.us/forms/CIO.vd If you have any questions about compliance,please consult your own legal counsel. Compliance is the individual responsibility of each person or agent of a person who is subject to the filing requirement.An offense under Chapter 176 is a Class C misdemeanor. RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 19 of 52 Not Applicable CONFLICT OF INTEREST QUESTIONNAIRE I+ORM CIQ For vendor or other person doing business with local governmental entity OMCE USE ONLY This questionnaire is being filed in accordance with chapter 176 of the Local Date Received Government Code by a person doing business with the governmental entity. By law this questiomaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006,Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. 1. lame of person doing business with local governmental entity. 2. Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.005(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. Not Applicable 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local governmental entity that is the subject of this questionnaire. Not Applicable RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 20 of 52 Not Applicable CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For eorlor aiwr ath� e�s®n¢u;�ar�g business with lneak goverjuineutal eatjit�� ���2 __-- _. -__ __- __. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A,B,or C is YES.) This section, item 5 including subparts A,B, C&D,must be completed for each officer with whom the filer has affiliation or business relationship. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filler of the questionnaire? ❑ Yes ❑ No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? ❑ Yes ❑ No C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer seines as an officer or director,or holds an ownership of 10 percent or more? ❑ Yes ❑ No D. Describe each affiliation or business relationship. Not Applicable 6. Describe any other affiliation or business relationship that might cause a conflict of interest. Not Applicable Signature of person doing business with the governmental entity Date RFP No. 140225,Medical Provider of Occupational Health Care Services,Page 21 of 52 ATTAO MENT C OIIALI�CATIOI�IS QUESTI:®NNA]FRE The purpose of this Questionnaire is to assist in the initial stages of selecting a Medical Provider to provide occupational health care services as requested by the City. All questions must be answered. PART A.AMRICAL PRQV DER CENTEIPAIL 1tNk®RMATIOIol 1 Legal Name of'Mcdical Provider Occupational Health centers of the Southwest PA,dba Concentra Medical Centers Phvsical Address of Corporate 5080 Spectrum Drive,Suite 120OW ??lace or Headquarters C,i y Addison State Tx Z' Code 75001 Telephone $00232.3550 Fax i:bsite Add-mm www.concentra.com 2 tp_0 ;;l Fartners (add rov ,as neceSS 1'1.1_nrr�cgar . VD.Pnesident,Treasurr,and Cc F-,--�te:Secretary Roy A R . ur:dare,M0,Senior Vice Prpsw,er :_nd Ch e':Ve,6 al Officer 3 Date Medical Provider was Founded/Opened I Incorporated 1979 4 Total number of Medical Provider employees 8,800+ S Total number of Medical Provider employees working in Texas. Approximately 300 6 Total number of Texas licensed health care practitioners More than 200 employed by Medical Provider. 7 Total number of Texas licensed health care practitioners Concentra does not keep records on contracted medical on C1'TY's contract with Medical Provider. personnel. 8 Total number of current clients of Medical Provider with Appmximatety 30,800 locations in Texas 9 Total number of current Texas girw rnmental/public entity clients of Medical Provide-, list uro�award 0;Concentra can provide a complete p 10 Total Amount of Medical Provi �;r : "lth care services billed from Texas locations in $ Calendar Year 2013 Approx.$109m 11 Total.Amount of Medical Provider health care services billed from Texas locations in $ Calendar Year 2013 related to the treatment of on the job injuries. Approx Wrn 12 Does �Jf,�0;(a l a---wider have the capability to electronically report information to the CITY Yes X regard i, rendered on a detailed and summary format? No ❑ 13 1 Can Mr.,dical Pro rider provide sample reports indicating the level of reporting capability of Yes x information or data to the City regarding services rendered? No 14 List below your three(3)largest current Texas clients: Name of Client HEB Grocery Address 646 S.Main St. City San Antonio Mate_ TX -: Co(ld — 76204 -- Length of Relationship with this enti #Years 19+ Contact Name Linda Bade Phone 1800305.7587 Email 702 SW 8th St, —B�ertanvflle _State I AR Zip Code 72716 i"R0aiic-k0A)with this ent&y #Yeats 15, Store IviapagersEllPhone 1 501.2 3,4000 E `Tame 0 LT,I i UPS add- —rm 2925 Merrell Rd ity FMMz Stat. TX Zip Code 75229 ).,mgth o1'Rct.6on6hiPw4f,thi,;oldly 'V 15+ t'notact Nath -n,, ,ma Lee P ior 2,14.914.9359 Email 15 List below your three(3)larges 1 1 V-4:11,�-,Bts: Name of Gov.Entity C4 of Fort Worth Atfi,.rc� 1000 Throckmorton St. C i ty Wc I State TX 76102 (if'RLI at,0 f!ship wM' this entity. #YeaTs 8f Na Co-ILCI Jqalyl-,i Ran Josselet Phone BIT392.7766 0 Names City of Houston -o Name 611 Walker St. Citi; citt Houston state TX Zip Code 77002 9 Years 13+ Ungth of RelabonsliljL��Ath this ent'x C f Jim Wthafic Phone Email Nal nc of�ov, Entity CttyofSan Antonio Ade, cess 343 W.Houston St,Suite 405 0011 1 Sc-,- Bute TX Zip Code 78205 v!-41i dii,("i1fi'V Years 12+ NLJ,11C I �:Xj Aiwa Phone 1210.207.7316 Email 16 d-cr anticipate any mergers,transfer of ownership, yes No xQ mana&.;ment or departure of key personnel within the next 36 months that may affect the Medical Provider's ability to perform services required in this RVEP? 17 Has Medical Provider ever declared bankruptcy? yes No 18 Please provide the most current annual Mort and/or audited financial X statement prepared for Medical Provider. 19 Has Medical Provider been issued any penalty or flues from tk Texas Yes'Q No Department of Insurance relating to any violation of the Texas Labor Code or Rules since 11112010? 20 Total amount of penalty or fines paid to the Texas Department of Insurance .relating to viol;,;ion of the Texas Labor Code and Rules since 111/2010 by N/A Medical Provif.!a,,-, I 21 Has anyone i co-mulaint vAtb the Texas Department of Insurance Yes 0 No FRI -regarding any, — rendered by Medical Provider or their desibnaied �. 22 If Yes.1 plca,=t, 4 rlr L; i ow: 23 Has Provider been audited for compliance or otherwisr,Lnvestigated by the Yes Q No Texas Department of Insurance relating to workers'compensation medical claim submissions or services rendered? 24 If Yes,jlease explain below: RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 38 of 52 25 Has any health care practitioner,anticipated to provide health care or medical Yes❑ No[x services to the City solicited in this RFP,employed by or contracted with Medical Provider been disciplined by any State licensing board or regulatory agency in the past 5 years. 26 If Yes,please identify the healthcare practitioner and provide a detailed explanation of the circumstances involved. 27 Has anyone filed a complaint regarding any health care practitioner, Yes No x anticipated to provide health care or medical services to the City solicited in this RFP,with any State licensing board or regulatory agency in the past 5 ears? _ 28 If Yes,please identify the healthcare practitioner and prows a detailed explanation ofthe circumstances involved. PART R.A DICAL PROVIDER CONTACT 29 1 Provide the following information for designated contact that CTI'Y may call regarding MEDICAL PROVIDER ro osal. Name of Contact Jerry Francs,Sales Manager Address 2500 West Freeway,Suite 100 City jAddlson I State JTX Zip Code 75001 Telephone j 214.649.1213 1 Fax 1817.882.8707 gm jerry_francis@ooncentra.com PART C.MEDICAL PRACTICE GIIIDELINES 30 Use of Scientific,Evidence Based Medicine--To what extent does Medical Provider incorporate scientific, evidence based medicine into health care practitioners'medical treatment and care ofpatients? Please describe below. please refer to our proposal narrative. 31 Utilization of Ircutment Guidelines—To what extent does Medical Provider follow Texas Department of Insurance,Division of Workers'Compensation adopted rules for Medical Treatment Guidelines,Rule 137.100? Please describe below.How health can practitioners incorporate the treatment guidelines into medical treatment regimens and treatment plans to manage patient care. Please refer to our proposal narrative. RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 39 of 52 PART A MLI-)ICAL)PROVIDER FACMITI[ES TO SERVICE CITY 33. Identify each MEDICAL PROVIDER facility anticipated to provide services to the City and complete the below requested information for each facility and their personnel. Add additional sheets if necessary. FACILITY Facility Name Fort Worth Forest Park Facility Address 2500 West Freeway(130),Ste.100 Cit Fort Worth state T, Zip COaT76102 phone 9700 12:c 0r l 3 of N1 Sat:8am bPri-, David Lambing, Ak,4 �RMA Director � ryjo?_es has he vk:i ioi med at htqxftL1jWtx;, A - - -I T­ ihmenrtt'ubparr A oj'tH,,K"131 Urairy Drug Screens Ls No 111,af:Aljachmcntl),Subpart I33] Yes EJ No ,Saab vartBAJ Yes ElNoO -uwhment D,Subpart B.5] Yes X No F-1 oCner ProccdLv L, --,it,2,lanae rt D.,SubpartP.6] Yes X3 1 No Ll -sat this Twi 1, Please complete the followfill-, (Jc,l-nA.'Jealih Care Practitioner serving this facility that is anticipated to proqde o tA.,,L'L i Y ct.otAh'111"xt in this lei FS. Ucidth Cm Practitioner Nam __gja�License #-fens #Years Racticin Practiein aL Us Facility Ray Kreusel,MD 0ccup-itional Health F4179 25+years 10+ Mark Morris,Do Occupational I iealth H8268 22 years 8+ RFP No. 14-0225,B4edical Provider of Occupational Health Care Services,Page 40 of 52 PART A11MP CAL PR®VEDER FACYF IMS TQ URYL4 E= (continued) FACWTY 2 Facility Name --o sit Creek Facility Address ( 060 5andshell Dr. Cit Fort Worth State ZiiP Code 76137 Tei iln.r.; 3r o y (7.306.9780 Date F',.t;3laij F'irtirr�,,. /C7i`rbc:; �t r>! ❑ck:ned in 1998 D2}cIIIJErS {f' 00, iVamo C1T Fa.-i!y t] Ai ;, fW1a*nagei sha Paris,Center Operations Director Sarvrcegto he il'prlurrtr�d_attltis�aciiltrs -- l1. tiflLt"It1C:Ll1r:i•? if-iju k-S/oCs.apatk?aa diseases Yes� NQ❑ i_C.1,L3 ti r tPtdr eiit1,3, S'Bogart A of 1.6 i^�RFP N Care oYt•Ilctt��Ctcc;t�,:�.Itio:i:zi 14c�,ii� PT ;oeCw�c;s: Prettl; .dt'o d foi4s I,tie•f:Atfiocl: cmtD,Stirrr:rtB.11 Yes El No❑ -t.1 5 7f,Ly' T i"' )o.r.tllS [f7 ;Aitachrm a�L,5 ubarfB.2] Yes No Phy I:zi s. arni:7am+u,s' A ; ter i?zf: Attcac.IararrtD,Sub art B.3 Yms LX] NoLj L (Lith) systingIR;f; Arm chrrar. 1),Suhpi ,`AI _r �j No❑ Iml�l]'iJr.1 DClS/VaL ,1tiazit n.[R'J t)iiacb-.It r 0,Sobf<_ . 3.5] Yes:C,X No Otbol.Rioc;t.dure5 ti r ylA,t;S 1 i�x i i 7;S1TtI; i 1 t `Lib n,t'.61 Yes NO❑ Health Care Practitioners at Bais F Ic tterL- r 4 U?13 1C,3tsi 4:hr,I0florN!,ri_711f�st]�.i4?tit :u.'7 I,ic(vAQd Acalt'h fare PracClb}C�Yr,. ,ti`�i.��F_Gg i is fac`e14Y djai is im i_,1j.)ated t t 4-."s C11„ ,.t _ ra w HeaI[b t ra Practltir:;, Pic. I fectic_I 5 a'tv T Texas 7 icense# # errs #Years Psadipmg 1 sac'c' ac drss Facilia Genrcr:tJie;ii owsk"-ml) Occupkonal Heatth H0686 25+years With Concentra for 20+years Kenneth Baldwin,DO Family Practice D8501 41 years With Concentra fbi 18+years RFP No.14-0225,Medical Provider of Occupational Health Care Services,Page 41 of 52 Concentra has fourteen(14)additional clinics in the DFW metroplex;The Fort Worth locations will serve as the primary locations PART D.NEDICAL PROVIDER FACILIM TO si VICE CIjY (continued) E1sCff-Y 3 Facili Name Facility Address Ci state Zip Code Telephone Fax Date Facility Founded/O ened Days/Hours of Operation Name of Facility Office Manager :•ics/occupati<,fal diseases Yes Nn❑ No Bi-u;l,r'l,wilof 1 egs i:t'' r'�{:tii.i•,'[ , ,.:'„ ,-- �-----_�._.._ �`t;h5FJ NO LI llrinaryU�u� �a': �� ;Ui)w3l_'�'1_ 1 �I No Physical ExamitiLa-ions U NO Le�1'317i1iii'y fSCi11;� 4;i:��tt4Ui].III(.+rt iit!hS•-'.� I fie.>S Lh No 0 1137 �.3�".s�;:'i+CI1ti r ��I C iI7JifUls•rJ�i::i: 1 '.;,. 'f r I b, [ .....:.f ,�� i }`r;;, WO 01- / 9 I 'if;4ti�1tG�:tiF3i LT1G It lJa ii asI l�,ci z r, 0 ff t,t;ornl+lctr i},r talk a�;�, ,i,ilb(m>ii�on for each Texas:�i c7rscki Heatth Cadre Practitioner serving this bfacility that i i���r��i��r raa�,ae s::� icc�to 11w CITY as outlined in this RFP. � eat Car. , 'r;wici 'aim•; z P i iicai Specialty Texas License# Years #Yeacs P�acticirae E Praciici na? t ' Facili , r RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 42 of 52 Concentra has fourteen(14)additional clinics in the DFW metroplex;The Fort Worth locations will serve as the primary locations PART D.MDICAL PRO30ER FACILITIES TO SERVICE CITY (continued) FACILITY 4 Facilli-Flame Facility Address rat—I State Zip Code Tele home Fax Date Facility Founded/Opened Days/Hours of Operation Name of Facility Offce 1blpager Services to be Performed at this Facil' r Acute Injury medical treatment for job-related injuries/occupational diseases Yes❑ NoEj jlReforence:Attachment D Subpart A of this RFP] Non-Injury Occupational Health Care Services: Breach alcohol Tests[lief Attachment D,Subpart B.1] `res❑ No❑ UEIn t.V Diu--Scroons(ODS) of AttaOmant D! Snc,iaartB.2] ; �e s F! No❑ . Ph:4 id,f,l t xpmanarittrts }F,c:;Attacbmc r D Subpart B.3 '`des�] No❑ ?A�s 4smesa � _ Laboratory Testing f:Attachment D.S itlopaxl?;4 Yes[_J No Immunizations/Vaccinations f Aftr chnl n a,, ,Lib art B 5] Yes Other Procedures/Services of Attachrao .Ij,�ubpai t 13,6; -'es n No Health Care Practitioners at this Facilit Please complete the following information for each Texas Licensed tfcaltb Care-Praebtione.r scrvirig this ri,41ty ihut is amici ated to provide services to the CITY as outlined in this RFP. Health Care Practitioner Name Medical SMialty Texas License li IftauYear ae;icing j�.cn L ;' ' �i illus H SvttEiy t RFP No.14-0225,Medical Provider of Occupational Health Care Services,Page 43 of 52 Concentra has fourteen(14)additional clinics in the DFW metroplex;The Fort Worth locations Will serve as the primary locations PART D MEDICAL faQVIDDEYP Y+ACIIY.YTIE :[0 SERVICE MY (continued) (continued) U�ITYI Facility Name Facility Address Cit State Zip Codi TAcphone Fax Cip—acd N'Meoffacil,'i_,Of&L, Yes No Yes No Yes NO El frt 133] Yes No❑ Yes No B. El 51 Tyes No F7 S, Yes[l -ichTexas X.ej3sc(_" ffealthCart �i-actitioner serving this facilityP."1 -3 outfil-'d in tbi�-'_J"R 1.J,_..._ �7e355 #Years 11racticing at this Adlity TO THE BEST OF MY KNOWLEDGEM ABOVE NFIORKATION IS TRUE AND CORRECT. , Signature of-Authorized Representative De. Arlene G.King Authorized Representative Typed Nam ofAuthorized Represeattive Occupational Health Centers of the Southwest,PA, dba Concentra Medical Centers Name dMedical Provider/Proposer/Respondent RFI.'No.14-0225,Medical Provider of Occupational Health Caro Services,Page 44 of 52 Corporations Section y John Steen P.O.Box 13697 r Secretary of State Austin,Texas 78711-3697 Office of the Secretary of State Certificate of Fact The undersigned, as Secretary of State of.Texas, does hereby certify that the document,Articles Of Association for OCCUPATIONAL HEALTH CENTERS OF THE SOUTHWEST, P.A. (file number 80997203), a Professional Association, was filed in this office on January 25, 1985. It is further certified that the entity status in Texas is in existence. - In testimony whereof, I have hereunto signed my name officially and caused to be impressed hereon the Seal of State at my office in Austin,Texas on January 23,2013, John Steen Secretary of State Come visit us on the iniernet at http:riwMv.sos.state.tx.us% Phone:.(512)463-5555 Fax:(512)463-5709 Dial:7-1-1 for Relay Services ,� City of Fort Worth,TX RFP No.14-0225 Concentra, Medical Provider of Occupational Health Care Services Attachment B Legal/Risk Documents September 11,2014 Attachments r PROFESSIONAL SERVICES AGREEMENT 1. AGREEMENT BETWEENPARTIES This PROFESSIONAL SERVICES AGREEMENT("Agreement")is made and entered into by and between the CITY OF FORT WORTH(the"City"),a home rule municipal corporation ofthe State of Texas,acting by and through Susan Alanis,its duly authorized Assistant City Manager,and Occupational Health Centers of the Southwest.P A d/b/a Concentra Medical Centers -("Provider"}ee6ng-bSarA threWh{Au&erind 8*AarA —its dial•m4herizerf0fflieial Titie}_ +-- romratted:9*Teu4 Justified,spam Before: 0 pt,Line spadrg: MuM*0.99 B, 2. GENERAL Tab stops:Not at 1.68'+3.65" 2.1 Provider hereby agrees to provide the City, in accordance with medically necessary or appropriate professional standards,a full range of occupational health care services,as outlined in Exhibit "A",including any attachments thereto,all of which are hereby made part of this Agreement for all purposes. Exhibit"A"constitutes,at least in part,a proposal presented by Provider to the City prior to the Effective Date of this Agreement as hereafter defined. Therefore, in the event there is any conflict between the provisions and conditions of the proposal and the provisions and conditions set forth in the body of this t Agreement,the provisions and conditions set forth in the body oftit&this Agreement shall control. 2.2 City and Provider both recognize and acknowledge the professional nature of this Agreement. Being cognizant that issues of interpretation and performance will inevitably arise,both parties agree to consult with web other and covenant to negotiate in the utmost good faith in order to ensure performance of this Agreement without hindrance. 2.3 Services under this Agreement will be provided at Provider current facilities, at a subcontractor's facilities(if the subcontractor and the facilities are approved in writing by the City prior to such services being provided),and at such City facilities and other locations as may be mutually agreed to in writing by Provider and City. 2.4 To the extent that the services to be performed under this Agreement constitute services compensable or defined under the Texas Labor Code, as currently in effect or hereafter amended, or constitute services performed by persons other than Provider and covered by the"Police and Fire Physical Assessment Contracts"(hereafter definedl both parties recognize the non-exclusive nature of this Agreement. The"Police and Fire Physical Assessment Contracts"are defined as(a)those certain contracts entered into by the City for the performance of.(�)post-offer physicals for persons offered jobs by the CVs Police and Fire Departments;(ii)routine physical fitness assessments for persons employed by the CPTY's Police and Fire Departments;and(iii)such other matters as are contained in such contacts,and(b)any renewals thereof. 2.5 Provider agrees to provide and maintain a panel of specialized medical professionals/physicians for referral as necessary in the appropriate treatment of the City s employees who are injured in the course and scope of their employment,The panel will be composed of medical professionals/physicians,including but not limited to Neurologists, Orthopedists, Neurosurgeons, and Plastic Surgeons.Provider also agrees to maintain the panel during the initial tern of this Agreement,as well as any of the option terms.Provider agrees to monitor performance of and replace,if necessary,any or all of panel members as warranted. 3. ,AGREEMENT TERM 0(Tnt0:+l3ady L d:Font:10.5 pt Bold,UnderBne, __...___ olor:Aldo,(Intl)+Body(Casbrl), ` cale:100% _ 3.1 The initial term of this Agreement shall commence on January 1,2015("Effective Date")and - tted:cont 10.5 p�Bold UnderBne, shall expire on December 31,2017, unless terminated earlier in accordance with the provisions of this (CaWo Agreement. I Eit�-The parties may^'-^" ale-�M mutually agree to reriz' this Agreement for two additional one-year terms.If Qty—the—partes desires to exercise an option to renew, the party requesting the renewal shall notify Pmvider-the other party in writing of its intention to renew at lea; sixty(60)days prior to the end of the then- current term.Compensation to be paid during any option term shall she.9afnas'`�'F—v a-a fer in the'_�� ' TeRamutuallK agreed upon between the parties. Any chances to tha terms and cundittotIs or exterisions of this Agreement shall be effective only when reduced to an amendment which icS_ren s this Ar_reenle. executed by a duly authorized representative of each party. 3-2 ' -- Formatted: No bullets or numbering 4. MOICING AND COMPENSATION _ era d: 10.5 pt Bold,Underline, ------ -------------------------- =;?ine cerin;,alto,(Intl)+Bpdy(Calibd) 4.1 The Parties agree the Schedule for Compensation as shown in the attached Exhibit"B"isorrraa .Fora:10.5 pt,Bold,Undedtne, acceptable as the compensation to be paid to Provider for specified services provided to the City during the (Inn)+Body(C-Abri) initial contract period and the subsequent option periods,if exercised by the City.The parties acknowledge that additional services provided by Provider to the City may become desirable and agree to conduct negotiations on such additional services in good faith to arrive at mutually agreeable terms for such additional services with respect to performance and compensation. Any additional services will be reflected by a separate agreement or by a written amendment to this Agreement signed by the parties. 4.2 Billing of all medical services related to a compensable on the job injury will be submitted directly to the City's third party workers'compensation claims administrator in accordance with the Texas Labor Code and related administrative rules. 4.3 For occupational health care services other than medical treatment of compensable on the job injuries,Provider shall issue monthly invoices to the City and will provide the City sufficient documentation _ to reasonably substantiate the invoices.The invoice shall be broken down by City department and shall list the name,City employee identification number, dates of service,and service provided.The invoice shall be provided to the City on or before the 10th day of the month following the end of the month in which services were provided. City shall pay such invoices in accordance with City Financial Management Services i procedures and requirements.Invoices are due and payable within thirty(301 days from the date the invoices are received by the City. 4.4 In the event of a disputed or contested billing,only the portion so contested will be withheld from payment,and the undisputed portion will be paid.The City will exercise reasonableness in contesting any bill or portion thereof No interest will accrue on any contested portion of the billing provided,however, that City shall make payment in full to Provider within si (601 days of the date the contested matter is resolved. 5. RECORDS AND RECORDS MANAGEMENT _________ �_- Formatters:Font.10.5 pt,Bold,Underline, ------...'---'-----...----- Underli;Bod:y olor:Auto,(Intl)+Body(Calibrt) 5.1 Provider will adhere to and follow the governing guidelines as they pertain to the protection and Forma :Font:10.5 pt,Bold,Underline, use of collected data(personal/medical information). City may,to the extent permissible under applicable (Intl)+ (Calibri) law,obtain copies of such records solely for its internal purposes and agrees to reimburse Provider for the cost of such copies at the rate published in the Texas Administrative Code in effect as of the time copying is performed. 5.2 Upon termination or expiration of this Agreement,Provider agrees to return to the City,or its designated agent all medical records delivered to Provider on or about the Effective Date(the"Pre-existing Medical Records").Upon receipt of authorization from the affected City employees or their representatives for Provider to view and use the"Pre-Fxisting Medical Records"(which authorization may be given at any time so long as it is in accordance with applicable law concerning confidentiality of medical records), Provider may keep copies thereof at its sole copying expense,or may subsequently request copies thereof from the City and shall reimburse the City at the rate published the Texas Administrative Code in effect as of the time copying is performed. It is recognized that additional medical records created by Provider in the performance of this Agreement, regardless of form or medium of storage("New Medical Records")shall be and remain the property of Provider and shall not be moved or transferred from Provider except in accordance with applicable Iaw and Provider policies as set forth in this Agreement or as otherwise approved in advance and in writing by the City.Before requesting New Medical Records from Provider,City shall obtain from City's employee(or that person's legal representative) authorization to release copies of medical records in accordance with applicable state and federal law conceming the confidentiality of medical records,provided,however,that Provider agrees to use all reasonable efforts to obtain the written consent of each patient seen by Provider under this Agreement authorizing Provider to release copies of such"New Medical Records"to the City upon its request therefor.Upon expiration or termination of this Agreement,Provider shall retain the originals of all "New Medical Records"in its possession,and City shall,to the extent permissible by applicable law,have the right to receive copies.City agrees to reimburse Provider for the cost of such copies at the rate published in the Texas Administrative Code in effect as of the time copying is performed. 5.3 Provider agrees that no medical records covered by the terms of this Agreement will be altered or destroyed unless(i)the City has provided express written authorization and(iii)destruction of such records is otherwise permitted under applicable law.City recognizes that medical records will,from time to time,cease to have administrative,financial,and/or legal value to either City or Provider and City and Provider agree to utilize appropriate records retention and destruction schedules for the purpose of lawful and efficient records management. 5.4 Provider will exercise appropriate care to preserve necessary and useful medical records generated during the term of this Agreement.Provider will timely notify and solicit City's input concerning any change or modification to any system or process change involving the management,use,storage,and retention of medical records generated during the term of this Agreement to allow the City to ascertain if any issues or consequences,legal,financial, or practical,are reasonably foreseeable because of the facility or systems modifications. City and Provider agree to negotiate in good faith to address any such issues and consequences in a manner equitable to both parties and consistent with the purposes ofthis Agreement. 5.5 All reports and records provided to Provider by the City shall remain the sole property of the City. Provider shall store and maintain such reports and records separately from any other documents and in a manner and location that is easily accessible to City staff members.The City,to the extent permissible corder applicable law,shall have access to such reports and records during Provider normal working hours and will provide Provider with reasonable advance notice of a need for access. Provider shall treat as strictly confidential all reports and records provided by the City and shall not release any such reports or records,or any portion of their contents,to third parties without the City's advance written consent.Provider shall not copy or reproduce any such records or reports,unless(i)the City has provided advance written consent and (ii)such reproduction is otherwise permitted under applicable law.The City will provide a list of terminated employees annually to Provider.Provider will separate records relating to terminated employees from other records.The City may,to the extent permissible murder applicable law,retrieve original copies of all reports and records relating to terminated employees from Provider"a written notice from the City at its sole expense and at any time. 6. MINORITY 16USI NEM ENTERPRISE(ME)PARTICIPATION 6.1 In accord with the City Code of Ordinances,the City has goals for the participation of minority and woman business enterprises in City Agreements.Provider acknowledges the MBE goal established for this Agreement,as set forth below,and its commitment to meet that goal.Any misrepresentation of facts (other than negligent misrepresentation) and/or the commission of fraud by Provider may result in the termination of this Agreement and debarment from participating in City contracts for a period of time of not less than three(3)years. 6.2 The established goal for this Agreement is 10 percent (10%) of the value of non-injury occupational health services portion of the Agreement. Provider agrees to furnish, on a quarterly basis, documentation of MBE participation as may be reasonably requested by the City.The first quarterly report for the City's second Fiscal Quarter(months of January,February,and March 2015)shall be submitted on or before April 30,2015,and each subsequent quarterly report shall be submitted at the end of the month immediately following the end ofthe-City's Fiscal Quarter. F 7. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILrrY ACT ("WAA") 7.1 Compliance. In the conduct of performing their obligations under this Agreement,the parties shall comply in all material aspects with all applicable federal,state and local laws and regulations,including, without limitation, the Health Insurance Portability and Accountability Act of 1996 and any associated administrative regulations(collectively,"HIPAA").Each Party agrees to abide by the policies and procedures applicable to the relationship created hereunder for the privacy and security of Protected Health Information; as such term is defined in H1PAA.Provider agrees not to use or further disclose Protected Health Information other than as permitted or required by this Agreement or as required by law. Provider wi71 assume the responsibility as a business associate in accordance with HIPAA on behalf of the City as it relates to non- occupational injury care services.In addition,Provider shall: 7.1.1 Use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Agreement. 7.1.2 Mitigate,to the extent practicable,any harmful effect that is(mown to Provider of the use or disclosure of Protected Health Information by Provider in violation of the requirements of this Agreement. 7.1.3 Report to the City any use or disclosure of the Protected Health Information not provided for by this Agreement. 7.1.4 Ensure that any agent, including a subcontractor, to whom Provider provides Protected Health Information received from,or created or received by Provider on behalf of the City, agrees to the same restrictions and conditions that apply through this Agreement to Provider with respect to such information. 7.1.5 Make internal practices,books,and records,including policies and procedures and Protected Health Information received from,or created or received by Provider on behalf of the City available to the Secretary of the Department of Health and Human Services or his or her designee("Secretary"I in a time and manner designated by the Secretary to determine Provider compliance with HIPAA. 7.1.6 Provide access,at the request of the City,and in the time and manner designated by the City,to Protected Health Information in a Designated Record Set,to the City or,as directed by the City,to an individual in order to meet the requirements under 45 CFR 164.524. 7.1.7 Make any amendment(s)to Protected Health Information in a Designated Record Set that the City directs or agrees to pursuant to 45 CFR 164.526 at the request of the City or an individual,and in the time and manner designated by the City. 7.1.8 Document such disclosures of Protected Health Information and information related to such disclosures as would be required for the.City to respond to a request by an individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528. 7.1.9 Provide to the City or an individual,in time and manner designated by the City, information collected in accordance with Section 4 of this Agreement,to permit the City to respond to a request by an individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528, 7.1.10 Use Protected Health Information to report violations of law to appropriate federal and state authorities consistent with HIPAA. 7.2 Permitted Uses and Disclosures by Provider Except as otherwise limited in this Agreement,Provider may use or disclose Protected Health Information on behalf of,or to provide services to,the City for the proper management and administration by Provider or to carry out the legal responsibilities of Provider. 7.3 Obligations ofthe City The City shall inform Provider of Privacy Practices and Restrictions by: 7.3.1 Providing Provider with the notice of privacy practices that the City produces for Occupational Health and Safety. 7.32 Providing Provider with any changes in,or revocation of,permission by individual to use or disclose Protected Health Information,if such changes affect Provider permitted or required uses and disclosures. 7.3.3 Providing notification to Provider of any restriction to the use or disclosure of Protected Health information that the City has agreed to in accordance with 45 CFR 164.522. 7.4 Termuntion for material breach of H1PAA by Providec_Upon the City's knowledge of a material breach by Provider the City shall either. 7.4.1 Provide an opportunity for Provider to cure the breach or end the violation and terminate the Agreement if Provider does not cure the breach or end the violation,within the time specified by the City; 7.4.2 Immediately terminate this Agreement if Provider has breached a material term of the F- HIPAA requirements of this Agreement and a cure is not possible,or 7.4.3 If neither termination nor cure is feasible,the City shall report the violation to the Secretary. 7.5 Effect of Termination 7.5.1 Except as provided in Section 4, upon termination of this Agreement, for any reason, Provider shall return or destroy all Protected Health irdbrmation received from the City,or created or received by Provider on behalf of the City.This Provision shall also apply to Protected Health information that is in the possession of subcontractors or agents of Provider.Provider shall retain no copies of the Protected Health information as described in this paragraph. 7.5.2 In the event that Provider determines that returning or destroying the Protected Health information is infeasible,Provider shall provide to the City notification of the conditions that make return or destruction infeasible. Upon the City's determination that return or destruction of the Protected Health information is infeasible,Provider shall extend the protections of this Agreement to such Protected Health information and limit farther uses and disclosures of such Protected Health information to those purposes that make the return or destruction infeasible,for so long as Provider maintains such Protected Health information. 7.6 Miscellaneous 7.6.1 The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for the City t4 comply with requirements of HIPAA. 7.6.2 The respective rights and obligations of Provider under the section 6.5 of this Agreement shall survive the termination of this Agreement. 7.6.3 Any ambiguity in this Agreement shall be resolved to permit Provider to comply with the Privacy Rule of HIPAA. S. TERMIATION 8.1 Written Notice The City or Provider may terminate this Agreement at any time,with or-without cause,by providing the other J party with si. 60)days'written notice of termination.Upon the receipt of any such notice,Provider shall immediately discontinue all services and work and the placing of all orders or the entering into contracts for all supplies,assistance,facilities and materials in connection with the performance of this Agreement and shall proceed to cancel promptly all existing contracts insofar as they are chargeable to this Agreement. 82 Non-appropriation ofFunds In the event no fiords or insufficient fiords are appropriated by the City in any fiscal period for any payments due hereunder,City will notify Provider of such occurrence and this Agreement shall terminate on the last day of the fiscal period for which appropriations were received without penalty or expense to the City of any kind whatsoever,except as to the portions of the payments herein agreed upon for which funds shall have been appropriated. 8.3 Duties and Obligations of the Parties following Termination In the event that this Agreement is terminated prior to the expiration of the then current term,Provider shall, to the extent permissible by applicable law, provide the City with copies of all completed or partially completed documents prepared under this Agreement.City agrees to reimburse Provider for the cost of such copies at the rate published in the Texas Administrative Code in effect as of the time copying is performed. City shall pay PiDvider for services actually rendered up to the effective date of termination and Provider shall continue to provide the City with services requested by the City and in accordance with this Agreement — up to the effective date of termination.If Provider treatment of a City employee is commenced before the effective date of termination of this Agreement and continues beyond that date,City shall continue to pay Provider for medically appropriate services necessary to complete such treatment in accordance with the Texas Labor Code and Administrative Rules until such care is completed.The City also shall pay Provider for services actually performed in accordance herewith prior to such termination,less such payments as have been previously made, in accordance with a final statement submitted by Provider documenting the performance of such work. 9. DISCLOSURE OF CONFLICTS AND CONFIDE1 TL4 L DWORMATION Provider hereby warrants to the City that Provider has made felt disclosure in writing of any existing or potential conflicts of interest related to services to be performed under this Agreement.In the event that any conflicts of interest arise after the Effective Date of this Agreement,Provider hereby agrees immediately to make full disclosure to the City in writing.Provider,for itself and its officers,agents and employees,further agrees that it shall treat all information provided to it by the City as confidential and shall not disclose any such information to a third party without the prior written approval of the City.Provider shall store and maintain City information in a secure manner and shall not allow unauthorized users to access,modify, delete,or otherwise corrupt City information in any way.Provider shall notify the City immediately if the security or integrity of any City information has been compromised or is believed to have been compromised. 10. RIGHT TO AUDIT J 10.1 Provider agrees that the City shall,until the expiration of five(5)years after final payment under this Agreement,have access to and the right to examine,to the r--tent permissible by applicable law,at reasonable times any directly pertinent books, documents, papers and records (excluding confidential proprietary business data)of Provider involving transactions relating to this Agreement at no additional cost to the City to access Provides space to conduct such audit Provider agrees that the City shall have access during normal working hours to all necessary Provider facilities and shall be provided adequate and appropriate work space in order to conduct audits in compliance with the provisions of this section.The City shall give Provider reasonable advance notice of intended audits. Provider agrees to photocopy such documents as may be requested by the City.City agrees to reimburse Provider for the cost of copies at the rate published in the Texas Administrative Code in effect as of the time copying is performed. 10.2 Provider further agrees to include in all its subcontractor agreements hereunder a provision to the effect that the subcontractor agrees that the City shall,until expiration of five(5)years after final payment of the subcontract,have access to and the right to examine at reasonable times any directly pertinent books, documents,papers and records of such subcontractor involving transactions related to the subcontract,and further that City shall have access during normal working hours to all subcontractor facilities and shall be provided adequate and appropriate work space in order to conduct audits in compliance with the provisions of this paragraph. City shall give subcontractor reasonable notice of intended audits.Subcontractor shall be required to photocopy such documents as may be requested by the City. City agrees to reimburse subcontractor far the cost of copies at the rate published in the Texas Administrative Code in effect as of the time copying is performed. 11. INDEPENDENT CONTRACTOR It is expressly understood and agreed that Provider shall operate hereunder as an independent contractor as to all rights and privileges granted herein,and not as_agent representative or employee of the City.Subject to and in accordance with the conditions and provisions of this Agreement,Provider shall have the exclusive right to control the details of its operations and activities and be solely responsible for the acts and omissions of its officers,agents,servants,employees,contractors and subcontractors.Provider acknowledges that the doctrine of respondent superior shall not apply as between the City, its officers,agents, servants and employees,and Provider its officers,agents,employees,servants,contractors and subcontractors.Nothing herein shall be construed as the creation of a partnership or joint enterprise between City and Provider. 12. LIABILITY AND I NDEAEWICATION 12.1 PROVIDER SHALL BE LIABLE AND RESPONSIBLE FOR ANY AND ALL PROPERTY LOSS,PROPERTY DAMAGE AND/OR PERSONAL INJURY(INCLUDING DEATH)TO ANY AND Ate-PERSONS, ASSERTED,—TO THE EXTENT CAUSED BY THE NEGLIGENT ACT(S) OR OMISSION(SI MALFEASANCE INTENTIONAL MISCONDUCT OF PROVIDER, ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES f1II,E PERFORMING THE SERVICES UNDER THIS AGREEMENT. 12.2 PROVIDER COVENANTS AND AGREES TO,AND DOES HEREBY,INDEMNIFY,HOLD -- Famtattsd:Jusftd,Indent:Lefto",Flrst HARMLESS AND DEFEND THE CITY, ITS OFFICMS, AGENTS, SERVANTS AND Ine; U > 4.63" EMPLOYEES, FROM AND AGAINST ANY AND ALL CLAIMS OR LAWSUITS FOR EITHER PROPERTY DAMAGE OR LOSS (DICLUDDIG ALLEGED 9AAWE GR LOSS TO RGN�� AND/OR PERSONAL INJURY(INCLUDING DEATH)TO ANY.6 Af�PERSONS,OF MW vn m ne nvA D Ar FER nrc=cREg D C A T OR SERTED,ARISING OUT OF OR IN CONNECTION WITH THE SERVICES PERFORMED UNDER THIS AGREEMENT,TO THE EXTENT CAUSED BY TflE SOLE NEGLIGENT ACTS OR OMISSIONS QR F PROVIDER, ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. PROVIDED HOWEVER T14AT IN NO EVENT SHALL PROVIDER BE LIABLE FOR CLAIMS OR LEGAL ACTIONS THAT ARE THE RESULT OF CITY'S NEGLIGENT OR WILLFUL MISCONDUCT. FURTHERMORE,PROVIDER SHALL NOT BE LIABLE FOR ANY CONSEOUENTL4L INCIDENTAL PUNUWZ INDIRECT SPECIAL OR ANY OTHER FORM OF EXEMPLARY DAMAGES REGARDLESS OF WHETHER THE LEGAL THEORY FOR ANY SUCH DAMAGES IS BASED IN CONTRACT TORT OR OTHER LEGAL THEORY. X12.3 - 13. ASSIUGNMENT AND SUBCONTRACTING Provider shall not assign or subcontract any of its duties,obligations or rights under this Agreement without the express prior written consent of the City.If the City grants consent to an assignment,the assignee shall execute a written agreement with the City and Provider under which the assignee agrees to be bound by the duties and obligations of Provider under this Agreement.Provider and Assignee shall be jointly liable for all obligations under this Agreement prior to the date of assignment.If the City grants corisent to a subcontract, the subcontractor shall execute a written agreement with Provider referencing this Agreement under which the subcontractor shall agree to be bound by the duties and obligations of Provider under this Agreement as such duties and obligations may apply.Provider shall provide the City with a frilly executed copy of any such subcontract. 14. MURANCE 14.1 Prior to commencement of any work pursuant to this Agreement,Provider shall provide the City's Occupational Health and Safety Division and Risk Management Division with certificate( s)of insurance documenting policies ofthe followingminimum coverage limits that are to be in effect. 142 The City reserves the right to review the insurance requirements of this section during the effective period of the Agreement and any extension or renewal hereof,and to modify insurance coverage and limits when deemed necessary and prudent by the City's Risk Manager based upon changes in statutory law, court decisions, or circumstances surrounding this Agreement, but in no instance will the City allow modification whereupon the City may incur increased risk. 14.3 Provider's financial integrity is of interest to the City;therefore,subject to Provider's right to maintain reasonable deductibles,Provider shall obtain and maintain in full force and effect for the duration of the Agreement,and any extension hereof, at Provider's sole expense, insurance coverage written on an occurrence basis,except Technology and Professional Liability,which may be written on a claims-made basis.All insurance required under this Agreement must be written by a company that is authorized and admitted to do business in the State of Texas and that is rated A-VII or better by A.M.Best Company or similar rating acceptable to the City. or through the use of a wholly owned insurance subsidiary ("captive") as an alternative risk financing program. Vendor shall provide fidly audited financial statements for the captive at the request of the City..Coverage shall be written in the following types and amounts: 14.3.1 Workers'Compensation-Statutory Employers'Liability-$500,000 I$500,000 1$500,000 14.3.2 Commercial General(Public)Liability Insurance to include the following types of coverage: Premises/Operations, Independent contractors, ProductstCompleted Operations, Personal Injury,and Contractual Liability. (Combined Single Limit for Bodily Injury and Properly Damage$1,000,000 per Occurrence and$2,000,000 Aggregate) 14.3.3 Automobile Liability for Owned/Leased vehieles,Non-Owned vehicles,and Hired Vehicles (Combined Single Limit for Bodily Injury and Property Damage$1,000,000 per accident) 14.3.4 Commercial Umbrella-$1,000,000 per occurrence$1,000,000 Aggregate 14.3.5 Technology Liability-$1,000,000 per Claim,$1,000,000 Aggregate 14.3.6 Medical Professional Liability-$1,000,000 per medical incident and$3,000,000 Aggregate 14.4 For coverage underwritten on a claims-made basis,the retroactive date shall be coincident with or prior to the Effective Date of the Agreement and the certificate of insurance shall state the coverage is claims- made and indicate the retroactive date. 14.5 All required insurance shall be maintained for the duration of the Agreement and for five(5)years following completion of the service provided under the Agreement An annual certificate of insurance submitted to the City shall evidence such insurance coverage. 14.6 Provider additionally warrants that any physician providing health care to City employees she have Medical Malpractice coverage with minimum limits of$200,000 per medical incident with a$600,000 f 14.7 CITY shall be entitled,upon request and without expense,to receive copies of the policies and all endorsements thereto as they apply to the limits required by the City,and may make a reasonable request for deletion,revision,or modification of particular policy teras,conditions,limitations or exclusions(except where policy provisions are established by law or regulation binding upon either of the parties hereto or the underwriter of any such policies).Upon such request by the City,Provider shall exercise reasonable efforts to accomplish such changes in policy coverage and shall pay the cost thereof. 14.8 Provider agrees that with respect to the above-required insurance, all insurance contracts and Certificate(s)of Insurance will contain the following required provisions: 14.8.1 With the exception of Workers' Compensation and Professional Liability policies,name the City and its officers,employees,officials,agents,and volunteers as additional insureds in respect to operations and activities of or on behalf of the named insured performed under the Agreement with the City. 14.82 An endorsement stating that Providets insurance shall be deemed primary and non- contributory with respect to any insurance or self-insured retention carried by the City for liability arising out of operations under the Agreement with the City. 14.8.3 Provider`s Workers'Compensation and Employers'Liability policy will provide a waiver of subrogation in favor of the City. 14.9 Provider shall notify the City in the event of any notice of cancellation,non-renewal or material change in coverage and shall give such notices not less than thirty(30)days prior,or per policy terms and conditions to the change,or ten(10)days'notice for cancellation due to nonpayment of premiums,which notice must be accompanied by a replacement Certificate of Insurance.All notices shall be given to the City at the following address: City of Fort Worth Attu:Ron Josselet,Human Resources Manager Occupational Health&Safety I Workers'Compensation Division 1000 Throckmorton Street Fort Worth,Texas 76102 A copy must also be sent to the City's Risk Manager at the same address. 14.10 If Provider fails to maintain the aforementioned insurance,or fails to secure and maintain the aforementioned endorsements,the City may obtain such insurance,and deduct and retain the amount of the premiums for such insurance from any sums due under the Agreement;however,procuring of said insurance by the City is an alternative to other remedies the City may have,and is not the exclusive remedy for failure of Provider to maintain said insurance or secure such endorsement.In addition to any other remedies the City may have upon Provider's failure to provide and maintain any insurance or policy endorsements to the extent and within the time herein required,the City shall have the right to order Provider to stop work hereunder,and/or the right to withhold any payment(s)that become due to Provider hereunder until Provider demonstrates compliance with the requirements hereof. 14.11 Nothing herein contained shall be construed as limiting in any way the extent to which Provider may be held responsible for payments of damages to persons or property resulting from Provider's or its subcontractors'performance of the work covered under this Agreement. 15. COMPLIANCE WITH LAWS ORDINANCES,RULES AND REGULATIONS In fulfilling its obligations under this Agreement,Provider agrees to comply with all applicable federal,state and local laws,ordinances,rules and regulations,ff the City notifies Provider of any violation of such laws, ordinances,rules or regulations,Provider shall immediately desist from and eoireot the violation: t Provider,for itself,its personal representatives,assigns,subcontractors and successors in interest,as part of the consideration herein,agrees that in the performance Provider's duties and obligations hereunder,it shall not discriminate in the treatment or employment of any individual or group of individuals on any basis prohibited by law. If any claim arises from an alleged violation of this non-discrimination covenant by Provider its personal representatives,assignees,subcontractors or successors in interest,Provider agrees to assume such liability and to indemnify and defend the City and hold the City harmless from such claim. 17. NOTICES Notices required pursuant to the provisions of this Agreement shall be conclusively determined to have been delivered when(i)hand-delivered to the other party,its agents,employees,servants or representatives;(ii) delivered by facsimile with electronic confirmation of the transmission;or(iii)received by the other party by United States Mail,registered,return receipt requested,addressed as follows: �-'- Formatted.Frrght: 0.63",Space Before: 0 pt TO CITY: ' -- Formatted:R ght o.63" City of Fort Worth Attn:Ron Tosselet -' Formatted:wght: 0.63°,Space Before: opt 1000 Throckmorton Fort Worth TX 76102.6311 Facsimile:(817)392-7766 -- For-rrmatWd:Fright: 0.0- E-mail: .63"E mail:Ron.losselet@fortworthtexas..gov To PROVIDER Occupational Health Centers ofthe Southwest.P.A-d/b/a Concentra Medical Centers 5080 Spectrum Drive,Suite 1200W Addison_Texas 75001 Attn: Legal-Contracting 19. SOLICIT'AT'ION OF EMPLOYEES Neither the City nor Provider shall,during the term of this Agreement and additionally for a period of one year after its termination,solicit for employment or employ,whether as employee or independent contractor, any person who is or has been employed by the other during the term of this Agreement,without the prior written consent of the person's employer. 19. GOVERNMENTAL POWERS It is understood and agreed that by execution of this Agreement,the City does not waive or surrender any of its governmental powers. 20. NO WAIVER The failure of the City or Provider to insist upon the performance of any tern of provision of this Agreement or to exercise any right granted herein shall not constitute a waiver of the City's or Provider's respective right to insist upon appropriate performance or to assert any such right on any future occasion. 21. GOVERNING LAW/VENUE This Agreement shall be construed in accordance with the internal laws of the State of Texas.Ifany action, whether real or asserted,at law or in equity,is brought on the basis of thus Agreement,venue for such action shall lie in state courts located in Tarrant County,Texas or the United States District Court for the Northern District of Texas,Fort Worth Division. 22. SEVERABILITY If any provision of this Agreement is held to be invalid,illegal or unenforceable,the validity,legality and _enforceability ofthe remaining provisions shall not in anyway be affected or impaired. The City and Providers Agreement.If either party is unable,either in whole or part,to fulfill its obligations under this Agreement due to acts of God;strikes,lockouts,or other industrial disturbances;acts of public enemies;wars;blockades; insurrections;riots;epidemics;public health crises;earthquakes;fires;floods; restraints or prohibitions by any court,board,department,commission,or agency of the United States or of any state;declaration of a state of disaster or of emergency by the federal,state,county,or City government in accordance with applicable law;issuance of a Level Orange or Level Red Alert by the United States Department of Homeland Security,any arrests or restraints,civil disturbances;explosions, or some other reason beyond the party's reasonable control(collectively,"Force Majeure Event"),the obligations so affected by such Force Majeure Event will be suspended only during the continuance of such event. 24. HEADINGS NOT CONTROLLING Headings and titles used in this Agreement are for reference purposes only and shall not be deemed a part of this Agreement. 25. REVIEW OF COUNSEL The parties acknowledge that each party and its counsel have reviewed and revised this Agreement and that the normal rules of construction to the effect that any ambiguities are to be resolved against the drafting party shall not be employed in the interpretation of this Agreement or exhibits hereto. 26. AMENDMENTS I MODIFICATIONS I EXTENSIONS No extension,modification,or amendment of this Agreement shall be binding upon a party hereto unless such extension,modification,or amendment is set forth in a written instrument that is executed by both parties. 27. ASSIGNMENT-DELEGATION No right,interest or obligation of Provider under this contract shall be assigned or delegated without the written agreement of the City.Any attempted assignment or delegation of Pro-eider shall be wholly void and totally ineffective for all purposes unless made in conformity with this paragraph. 28. ENTIRETY OF AGREEMENT This instrument(including any exhibits and attachments hereto and any documents incorporated herein by reference)contains the entire understanding and agreement between the City and Provider,their assigns and successors in interest,as to the matters contained herein.Any prior or contemporaneous oral or written agreement purporting to vary from the terms of this document is hereby declared null and void. 29. SIGNATURE AUTHORITY Each person signing this Agreement hereby warrants that he/she has the legal authority to execute this Agreement on behalf of his/her respective party,and further warrants that such binding authority has been planted by proper order,resolution,ordinance,or other authorization of the entity.The other party is fully entitled to rely on this warranty and representation in entering into this Agreement. [SIGNATURE PAGE FOLLOWS] r r IN WITNESS WHEREOF,the parties hereto have executed this Agreement in multiples on this the dey of 2014. CITY OF FORT WORTH OCCUPATIONAL HEALTH CENTERS OF THE SOUTHWEST,P.A.D/B/A CONCENTRA MEDICAL CENTERS Assistant City Manager W.Tom Fogarty,M.D.,President Date: Date: APPROVED AS TO FORM AND LEGALITY: Assistant City Attomey ATTEST: Mary Kayser City Secretary CONTRACTAUTHORIZATION: M&C: ,� City of Fort Worth,TX t RFP No.14-0225 C®®p�cen bra Medical Provider of Occupational Health Care Services Attachment C Personnel Qualifications 'once � ® Centers i ,Addrossi 2500 Nest Freeway,Stta, 100 Fort Worth,TIX 76102 Telephone: (817)882.8700 Fax: (917)83248707 Roy Krousel, M.D. �'�Uo�vsf��ps A N/A Residencies i P 1980 a 1982 Family Practice residency DDB Army Medical Center,Augata,GoorSk i 1f1�17aSb.1j) . D 1979—1982 Family Practice Intemship j DDE Army Medical Center,AugusA Georgia ' PmfessionaYGraduate Schools ' A 1975 m 1979 Doctor of Medicine University of'Texas Medical Sohoa1 at Houston,Bloustou,TX j ➢ 1976 Post graduate work in Microbiolo0p I Univorsity orr Texas Medical School at Hanston,Houston,TX Undergraduate Schools > 19'7101975 Bachelor of Scieace Texas A& I Univerafby,Y gsviile,TX Work Experl!gngs- > 2000 Preseat Coaaeiatra Medical Centem Fort North,,TX Canter Medical Director 1998—2000 Nvate consultant 1995®1998 Concentra Medical Centem,Fort Wbitb,T 'dice President of Medical Affair.,for the Soudavest region > 191,12 1995 Advanced Occupational Health Czars,Fort Worth,TX President and Owner - uur4snm -.— ----- 7 IIYgI rglMbii a.q -_— r i Work EXPeCLence L._afd. � D 1990 d 1992 Medical&Surgical Clinic Assoofidou,P.A.,Port Worth,TX i Occupational Mediae 1985— 1990 Medical&Surgical Clinic Association,P.A.,Fort Wortb,TX Family Practicelocaupational.Medichle j > 1982-1985 Bayne-Jones Hospital,Dept.of Fordly Praotice,Fort Polk,LA ! F°amily Msdicirte dogitei Alm1rAMeMS° Feoulty Angaintm );� NIA PlUlai9io so > NIA L°ce ses Gerd o�etl"o s. �oerd�° L 1 > Texas Adedical Licemse,P4179 q Board eligible, family practice Proesslonal Assaciations+ la None I Foreign Lsno u-sa es., ! > None, Referelioeso j Available ort request, 1 � t n ' r irk y`•;C �?;ii?r^ "•'r k :yr4Y=;r.r- 're..;:'-h��..; .7-;'hC—^ :iia;.e: ;.,;+r-�;:`: Ys;cr;�.^?rj•orrY�r:?�c.,.Y• r-r �lr.�ss r.•:CTr�r-tsFr s+'rt`, a MY�JS'..'�.!''`..15.^34ti.Js'..}}'.�i`3a'NJJYetilJ.'"C•::: /..•F F 5.'S._l_J v _�r'Sl.,.'�^-l"fT '-Y'�`^. . .'{::',✓ TEXAS CONTROLLED SUBSTANUS-REGI TRT MON CERTIFICATE TEXAS DEPARTMENT OF PUBLIC SAFt fY i REGULATORY SERVICES DIVISION,LICENSING AND REGI5f .T:)hl SERVICE '• CowlROLLEO SU@STANCES REGISTRmo( i,PO Box 4087,AUS`'l:1,Tom 78773 } "'S REGISTRATION NUMBER DATE EXPIRED FEE PAIDjHE TE-AS COW ROLLED SUBSTANCES ACT,CHAPTER 481 OF THE HEALTH sti AND%t;UY CODE,PROVIDES THAT THE TEXAS DEPARTMENT OF PUBLIC h VV0118877 11/3012015 YES SAFETY MAY DENY A CONTROLLED SUBSTANCES REGISTRATION OR THAT A CONITtI°.Lm SUBSTANCES REGISTRATION MAY BE SUSPENDED OR REVOKED, r SCHEDULES BUSINESS ACTIVITY DATE ISSUED _ $fk 2,2N.8.3N,4,5 PRACTITIONER 05/03/2014 ?r 4r k:. REGISTERED NAME AND ADDRESS \ � res ROY GLENN KREJSEL,MD ' ' 855 E 2ND STREET , FORT WORTH,TX 78102 THIS F GISTRATION IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, F CONTH.L,LOCATION,OR BUSINESS ACTIVITY AND NOT VALID AFTER THE $ EXPIRA ION DATE. �r !2 NARJ9(r,% CERTIFICATE.MUST BE'RE'sADILY RETRIEVABLE AT ALL 7II11IES _ L- � � �4�.�+ry.'ri`y.?,�+.fi^�',�ma7�va�, �•sM1,�.•sn: .xx*-. Y� "�}'^Sa`c'*:�. _��"'��_^" 7'r".:,-�yt.y{�,,, .n.'L r= 'r, '•}: •,��..7'`•r uC�v`.�L�.��'L',''{4.\.c-7.eM ll, -:_-Li:.t'sA.31-CiGiei.�Eiaa: ��.-t •cn'�tif:=:�Lwi�':tea-'."�::'•i-�•:•:;''�:�i6 "'�' Yk=ti-.1+.s'�-�i�.��f: �i��• .1•+ "�''� TEXAS DEP&RTMENT OF PU13LIC SAFETY . { ��DPS REGISTRATION NUMt3EF1}^5 yU:4TEE�X,PlAED � i W0118877 CHEDU OY2o15 i ' S h'5 LES �'��^-`,.• '}••-• may;.�}:,•`. • .� 2,2N,3,311,-,4a`, : i F;REGISTEnMNAM AIJU;ADDRESS.1:<_ e.'3•..7= V��� ROY GLEN W,REUSE 14 855 E 2ND STREET" FORT WORTS t,TX ' : C_�G`«.� L'�!•�aett' C'^1�•i M a'""'.. � �'YI.Ti.Y.0 vf^tF•�'�~'.�' 1• EQUAL OPPORTULOITY EMPLOYER COURTESY k SERVICE-PROTECTION Vg r y� rc m rf} (� _..- I�b:a trati.-I Of C r re4 g®yI � ' In.Reco H gni#ionOfSucccssf-u7Compkior l : . ..a. ss ui k� I c l rr { -Bsic,S1C ! - �Lopp 01cl .; r. iw rr1 22862345-2946 . Lune 7.4014 (.lune 2016) YIA .&iY + Certification Number CertificationDatq CExpuatroii;Date,}`, 1mjct'pi's Signature r� ,_"_3�i<'Y '.FT 1... 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Ajocrims Modleaal Amoclatflataa(A.MA.) Amrrkun 0vtaaopgTbic Asymelaation(A,O.tL) American vatume^of accupatioraeltinvironmentai bled.(A.C.O.11h'1.I sig mu4igma PhI4101na">r Frater dly Anwrivan College of Gcnerul t'ratctitlunury tA, ,G,Pi p I011ieO MA araL4; Who.4 Who in the 9awthwext 1999-29IN Who's Who In Relence anal Engineering 20002001 Whae'pa Who lu the Wu rid 211012002 Who's Who in the Warld 2002.2)1)3 Wbo't�Who M the World 203.2004 Who's Who 1st the World 2404-200.. r r r !'ubl%, i•uliare,�,: (genu-dedV-PO e:Monlh} Mwilcticr Mr M WAlurl itit)ugrial Conten-Tciitu r In Chief-Morch 2001 -prescnr The,Pkyir len A Sooro aWedtgine-"C;liuical Pearls"-Apri12004, J nae Ztlli.3. hxtra-currivolo SetuurPastor;tilt.Calvary Mlsohinary lupfialChurob ticminarSan: Tyndale SeminarvlRiWc College-1002 ie present C:erliticuta in Pastoral Studics-rcovived 3001. Referinees: ,wi lable upon Requcr(. Name --"� �*--,-' Mark E Aqorrb DA). swr+•• .y ¢S\\'--lal`•• .i'D:C?X�N� :'4i4P.'"+.�• •a:1f' "Dn ...l' c'.i• 4.• .L t ' 'Ya •E'1:t 'a]l. .,:� , 80X:2029 AUSTIN,TEXAS'S&Z88=2029. 71. r• LICENSE%• r = i t V F'EFiMITNUMBER .!(,:� _ �:, :,' EXR[R4TIOIV. igE: H826$ 1 .:fr,'.:i:'. 1 \�;• d'i ,. ': f18i31;�20y4" .. s MAI liL I':iIirMN I1;Ii)�ri.l.S,.,Q :�� .::i•I?• - 1>!.• tt - .� 'r .. &a t li'I £71, f��'�IVIIE =� i. ,�:: il: 1�<;.,� s FO ri 'Vx 7 ITH .'), 7611#4320. TFIISCEFi•G'IFIES'TkKI -, E:-?C_NScEIPEW T:HOIDER,NAMED A 6NUfr E&t6TiEFIECIN-HAS PROVIDEDJ-HIS'BOAFID' THUNFORMAT.1 'IFLJ 7 SAND,HAS PAbTHEEEE FORREGtgT--R ION FbR'THE PpFIOD4NDIGATED'AB0VE 1` ' Pi Ffi18E?k< ER"fHIS BOARD.NOTIFIEU'OFGHANGE OF-ADDRESS .'-;X�xV:•uv, M .;R\..7.'�• 1 u.v;: +m.y b.!Ya .•.v». f'a'u.•. .}rttftN{• lt•• W�.ia RVSGN nx%:. ,,7. 1 CY3.1,2RTCULUM VITAE George Niemlrowsld,M.D. 2100 East Randol M11 Road Arlington, Texas 7601.1 (817)261-5166 George_Niemirowski@Concentra.com G 1UP� ry^XIh��.aN,lu,•� `. t'�I�1�irfillli.=5'. I..,..i '. 'aN '.al"•dltr..l,i� •�,b11�16r;u�. �miiUl , ••i,, 6�•I 11� � � l�i'• t,r 1977-1983 Texas A&M University--B.A,Biology/Chemistry Minor 1981 --1985 University of Texas Medical Branch-M•D, 1985- 1986 Internship at John Sealy hospital in Galveston, TX 15,01%3"'.�txX�I�' •� 4t'r,;3;i' ° •Y'I^ Rh;.•ri.. i •.,,, ,1 r rrr'I,��,�I I •'Iilil��.I'd,•1�.��'�yi 1991 -Present Concentra Medical Centers,Arlington,Texas Clinic Physician from 1991 to 1993, Center Medical Director from 1993 to present 1987- 1991 Business and Industry]health Group (minis Physician practicing Occupational Medicine, This center acquired by OceuSystems/Occupational Health Centers in 1991. OccuSystems changed its name to Concentra kc.lConcentra Medical Centers 198.6- 1987 Spech=Lrnergency Services Locum Tenons at various RR's and clinics. Did a fair amount of work at PrimaCare LI• iLi''yi t 1 II (V. t I .��ti""•I't • Cmu iairi 4t .. �' .• - t° �ItF•is�' I.:r�i�2iYl` y�Ohl .x American College of Occupational and Environmental Medicine k CONCENTRA MEDICAL CENTERS Address: 2100 N.Hwy. 960,Ste.2201 Grand Prairie,TX 75050 Telephone, (972)988-0441 Fax: (972)641.0054 Ken Baldwin, D.O. EDUCA TION.- Fellowships 0 NIA Residencies IV, NZA Internship > 1970- 1971 Dallas Osteopathic I4ospital,Dallcss,TQC Professional/Graduate Schools > 19661-1970 Doctof of Osteopathy Kawas City Collogc of Osteopathic Medicine,Kansas City,Missouri Undergruduato Schools D 1962--19643 Completed admission requirements to enter osteopathic program and Kansas City Collegc of t xcopatblc Medicine,a degree was not required at that time,lacked two hours of completing degree Oldahumat University,Norman,OK,northeastern UvAversity9 T'alequah,CHIC Work Experience: 1996-Present Concentra Medical Centers,Grand Prairie,TX Center Medical Director 1995 Present Federal Medical.Center at Fort Worth,Fort Warth,'TX Conrract k'ltysiclan 9 1996-1997 Health Partners Medical Group, Southlakv,TX Family Medicine 1992-1996 Ready Care Medical Clinic of Bedford,Bedford,TX 1=andly Wdicine 1973 - 1994 Private/Genoral Practice,Dallas;TX r Baldwin CV I a Work Experience (-','®ntd. 1971 -- 1992 gallas Memorial Hospital,Dallas,TX 'Various positions including Chief of Staff,Director of Outpatient Services,Director of Intern/Resident Co=nittee,Chairman of General Practice Department, Chairman of Intem/Resident Committee, Chairman of OB/GYN'Departtnent Hos ltai Appointments: );- /A Faculty Appointments: P NIA Publications: � NIA Licenses, Certifications, Boards. P, Texas Medical License,D8501 > Board cextified,.46meAcan Osteopathic Board of General Practice Professional Associations: P, American College of Occupational and Envirorartaental Medicine A American 06teapathic Association Texas Osteopathic Medical Association Foreign Languaqes: ;', None References: Available an request. I Baldwin CV 2 CURRICULUM VITAE Robert Hassett, DO MPH 15800 Midway Road Addison,Texas 75001 (972)720-7906 LICENSURE: State of Texas,obtained July 1985 to present,permit#,0-8165 CERTIFICATION: Basic Cardiac Life Support BOARD CERTIFICATION: American Osteopathic Board of Family Physicians,Certificate 6018 American Osteopathic Board of Preventive Medicine,Board Certified in Occupational Medicine,Certificate#804 POST GRADUATE: Northeast Community Hospital,Bedford,TX from July 1984 to Ally 1985 EDUCATION Rotating internship in 200 bed hospital. GRADUATE: Medical College of Wisconsin,Masters of Public Health May 2000 EDUCATION Texas College of Osteopathic Medicine,Fort Worth,TX from July 1980 to May 1984. Obtained Doctor of Osteopathy. Graduated Cum Laude. University of Note Dame,South Bend IN from August 1974 to May 1978 BS degree in Preprofessional Studies MEDICAL: Arlington Minor Emergency Clinic from April 1986 to April 1991. EXPERIENCE Medical Director from August 1988 to April 1990 Beltline Minor Emergency Clinic,Irving TX July 1985 to October 1986 Primacare Medical Centers 1986 to 1991 Garland Community Hospital Emergency Room May 1991 to March 1993 Satellite Medical Center,Ft. Worth TX August 1991 to July 1993 University Medical Group,Ft. Worth TX March 1993 to July 1994 Advanced Occupational Healthcare/Concentra Medical Centers,Health Services Ft. Worth August 1994 to May 1998 Area Medical Director for North Texas Region from May 1998 to present Regional Medical Director for North Texas region from 1999 to 2005 AVP Medical Operations South Central Zone 2006 to present PUBLICATIONS: Section contributor to Concentra's provider manual: Clinic charges,Respiratory protection,Pesticides Chapter contributor:•`Low Back Pain:An Evidence-Based:Biopsychosocial Model for Clinical Management" 2002 OEM Press Chapter Contributor Clinics In Occupational Medicine"The Role of imaging of Work Related Upper Extremity Disorders" Volume 5 Number 2 PROFESSIONAL: American Osteopathic Association(AOA) ASSOCIATIONS American College of Occupational Medicine(ACOEM) American College of Osteopathic Family Practitioners(ACOFP) American Osteopathic College of Occupational and Preventive Medicine Served on Medical Advisory Committee for Texas Workers Compensation as Commission Alternate 2002-3003,Primary Osteopath 2003-2005, Vice Chair 2005. MEDICAL: Family Practice and Occupational Medicine SPECIALTY REFERENCES: Provided on request. ^u W KARVII kr E Certificate Of Completion This certifies that on 2/23/2010 10:47:00 AM J aelde King Successfully completed the following training course and associated requirements Intoximeters BAT Training { Colleague Signature___'/ ���� � Signature of Colleague Manager Certificate of Completion Drug Screen Collector Qualification Trai.ni Jackie King s successfully completed Qualification and Proficiency Training and is foul Knowledgeable in the Procedures as documented In the Concentra Drug Screen Collection Manual and 3.epartment of Transporation Mandatory Guidelines, Federal Workplace Dirt Program* 12/96/2009 )ervisor,-Co centra Medical Centers j Date !�/r r 12(16/2009 ancy4-1., oncentra edioal Centers Date 96r ' e DOT operating administrations'rules require that employers conduct drug testing according to provisions of 49 dures for Transportation Workplace Drug Testing Programs". Final Rule published in the Federal Register on Dec( 49854),revised on February 15,1994,as"Procedures For Transporation Workplace Drug and Alchohol Testing Pr 0)amended 7/96,rewritten effective December 18,2000. The procedures in 49 CFR Part 40 are based on the D, mrta. Urine Specimen Collection Guidelines written by the ce of Drug and Alcohol Policy and Compliance pL f 14,eIrfificate of Coni.1plet,-1411 Jennifer Adams Has successfully coinpleted the Breath Alcohol Technician Training Course _X_Proficient in CFR Part 40 Procedures _X Proficient in Operation of EBT Alcomonitor CC EBT Name/Model No. Jackie Ding nn;t 11,2012 Insuvctor.ConcentraMc6cnl Cemer9 Date Concen v'xa- Uvftilicate of C� Ompleti Drug Screen Collector Qualification Training Jennifer Adams Has successfully completed Qualification and Proficiency Training and Is found to be Knowledgeable in the Procedures as documented in the Concentra Drug Screen Collection Manual and U.S.Department of Transportation Afandatary Guidelines,Federal Workplace Drug Testing Program April 11,2012 Jackie Kiag ,�y Date Monitor Concentra' The DOT operating adlnta$trafiansrales require Ural employers eondacl drag lesthq according to provhlalis Of49 CFR Part 40,aProcedraes for 4✓or6place Drug Testing Programs,"FimrlRalepublished.in fie Federal Register on December 1,1989,(54 FR 49854),revised on February 15,1994,, Traasporlation 11'arkplace Drag and AlcabolTesting Programs"(59 FR 7340)amended 7/96,reiVritlen effective December 18,20RO. Tile pracedures in based ae dre Deparnnent ofTrnnsportatlar Urine Speclrnen C011ec!!on'Guidelbies rorilteu by the Office of Drug andAlcohof Po(iCy and Cmi�Fiaaceprrb cnale U Gloria Tafolla Breath Alcohol Technician Training Course X Proficient in CFR Part 40 Procedures _X—Proficient in Operation of EBT —)IC Proficient in RBT IV Alcomonitor CC EBT Name/Model No. Jackie King July 15,2013 Instructor.cojivenh,Li Ceiiws pate Concen't Certificate of Cami)letiq "I" Drug Screen Collect®r Qualificat.i®u Training Gloria Tafolta Has successfully completed Qualification and Proficiency Training and Is found to be Knowledgeable in the Procedures as documented in the Concentra Drug Screen Collection Manual and U.S.Department of Transportation Mandatary Guidelines,Federal Workplace Ding Teating Program C®nceWlra" ;UI C July 15,2013 l J citie Monitor B oncen itra Date The DOT opemtheg adrrdnJs[ratlars'odes require drat employee conduct drug testing according to provisions of 49 CFR Pare 40,"Procedures for'.. Workplace Drug TesthegPragraus."Final Rude published In the Federal Register on December 1,1989,(54 FR 49854),revised on February 15,1994,m Transporta6ar R'orkpkceDrng aadAlcabol Tesdng Pmgramrs"(59 FR 7340)antenrded 7/96,rewriitetu effective December 38,2090. The procedures in 4 based on Nee Departiheid of Trdhsporrdtion Ur4ne Specimen Collation G04'elinas written by de Office of Drug and Alookol Policy and Compliance pabl, Tor t hi riF t'�•€'�it.c�tftda+'�3 Certificate Of°Completion:, This certifies that on 12/3/2009 Gabriela Betancourt Successfully completed the foIlowing training course and associated requirements Int®ximeters BAT Training Colleague Signature(J/—&/ 14674 Signature of Colleague Mans Certificate of Completion Drug Screen Collector Qualification Tra Gabriela Betancourt Has successfully completed Qualification and Proficiency Training and is Knowledgeable in the Procedures as documented in the Concentra Drug Screen Collection Manual and I.S. Department of Transporation Mandatory Guidelines, Federal Workplaci Program* ,�14" t� 4020125 I.6, c.n..tr.Medical Centers Date 4/2/2012 E lroficiencyDei uve Concentra adlealCenters Date *The DOT operating administrations'rules require that employers conduct drug testing according to provision 'Procedures for Transportation Workplace Drug Testing Programs". Final Rule published In the Federal Register 54 FR 49354),revised on February 15,1994,as"Procedures For TranspoFation Workplace Drug and Alchohol Te 734 `amended 7196,rewritten effective December 18,2000 The procedures in 49 CFR Part 40 are based of rranst.. 3tion Urine Specimen Collection Guidelines written b,, 2 Office of Drug and Alcohol Policy and Compli Concenwtxx Cynthia Gordon Has Successfully Completed Breath Alcohol Technician Training Course _X Proficient in CFR Part 40 Procedures _X Proficient in Operation of EBT ,�c.�Monx�OY EST Name/Model No. 5/1/2013 11:1 Proficiency iver,Con entry Medical Centers Date Certificate of Completion Drug Screen Collector Qualification °Tralnit Cynthia Gordon Has successfully completed Qualification and Proficiency Training and is foun Knowledgeable in the Procedures as documented in the Concentra Drug Screen Collection Manual and .S. Department of Transporation Mandatory Guidelines, Federal Workplace Dru Program* 5/1/2013 11:15:00 Supervisor,Concentra Medical Centers Date 5/1/2013 11:15:00 roficiency�Delc®ntra Medical Centers Date AL ,, .The DOT operating administrations'rules require that employers conduct drug testing according to provisions of 49+ Procedures for Transportation Workplace Drug Testing Programs". Final Rule published in the Federal Register on Dec* ;4 FR 49854),revised on February 15,1994,as"Procedures For Transporation Workplace Drug and Alchohol Testing Pr 7340)amended 7/96,rewritten effective December 16,2000. The procedures in 49 CFR Part 40 are based on the DE 'ransportatlon Urine Specimen Collection Guidelines written by the Office of Drug and Alcohol Policy and Compliance pu 2r C erdific at e—af—C-oni--plefih- Drug Screen Collect®r Qualification Training Alex Kl eren,,,. Has successfully completed Qualification and Proficiency Training and Is found to be Knowledgeable in the Procedures as documented in the Concentra Drug Screen Collection Manual acid. U.S.Department of Transportation Mandalay Guidelines,Federal Workplace Drug Testing Program Concen't. SM!Mbe,26,2013 :.14 xi.9Date Monitor Concenl'ra,- The DOT operating reties require that entployea mtdaef drug rating according lopmsftlans of 49 CFR Part 40,"Procedures for 5 PVorkplace Drug TesfingPrograins.,r Final Rule pubUshed In the rederatRegister an Dere?,,her 1,1989,(54 FR 49854),rgrised on Feb,,wj,15,7994,. T nsporiatiat Worltplace Orrtg aerl Alcolio!Tesllug Pragrants"(59 FR 7340)amended T/90,reivrittett effective December 18,2000. The procedures iu4 Certificate of Completion Alex Kleren Frac Successfully Completed Breath Alc®hol Technician. Train=i:n:g: Course _„X Proficfentin'CFR,,P.art40Procedures X_„Prof rent 11h,Operation of EBT OCA EBT NamelModel No. _ 2 11/9201 iclency Deli Conc tra Medical Centers Date Certificate of Completion ®rug Screen Collector Qualification Trair Amy Galvan Has successfully completed Qualification and Proficiency Training and is fc Knowledgeable in the Procedures as documented in the Concentra Drug Screeri Collection Manual and U.S. Department of 3ransporation Mandatory Guidelines, Federal Workplace[ Program'` 911912012 5:32 Supervi �,C`oncentra adi al Centers Date 9/19/2012 5:32 Proficienc�rt� dical Centers Date v'r .The DOT operating administrations'rules require that employers conduct drug testing according to provisions of "Procedures for TransportatlDn Workplace Drug Testing Programs". Final Rule published in the Federal Register on r ,(54 FR 49854),revised on February 15,1994,as"Procedures For Transpgratien Workplace'Drug and Alchohol Testin, 7340)amended 7/96,rewritten effective December 18,2000. The procedures in 49 CFR Part 40 are based on th, Transoortation Urine Specimen Collection Guidelines written by the Office of Drug and Alcohol Policy and CompliancE 01. r Certificate of Completion Amy Gaivan Has Successfully Completed Breath Alcohol Techniciam Training Course X_Proficient in CFR Part 40 Procedures Proficient in Operation of EBT th�COMDViI �Ur ooa3t�4 EBT Name/Model No. 9121/20121217:00 roficiency D iv ,Conc&<ra Medical Centers Date Certificate of Completion Virginia Paredes Has Successfully Completed Breath Aicohcl Technician Training Course _X Proficient in CFR Part 40 Procedures _X Proficient in Operation of EBT (I�YUIOfl 1 7>^ C- DD 1371-'1 EBT Name/Model No. i . 6/201201 'roficiency Deliver, o ce tra Medic Centers Dat Certificate of Completion Drug Screen Collector Qualification Trainir Virginia Paredes i successfully completed Qualification and Proficiency Tralning and is foun Knowledgeable in the Procedures as documented In the Concentra Drug Screen Collection Manual and )epartment of Transporation Mandatory Guidelines, Federal Wo ftlace Dru Program" 9128120112:56-.00 lsor,Concent Medical Centers Date t L y� 9/2812011 2:56:00 nc Deliv r,Conr�p 4•a Medical Centers Date DOT operating administrations'rules require that employers conduct drug testing according to provisions of 49 Ures for Transportation Workplace Drug Testing Programs". Final Rule published In the Federal Register on DecE 19854),revised on February 15,1994,as"Procedures For Transporation Workplace Drug and Alchohol Testing Pr ,)amer 1 7/96,rewritten effective December 18,2000. The .edures In 49 CFR Part 40 are based on the D< )rtation._,ine Specimen Collection Guidelines written by the Oft, of Drug and Alcohol Policy and Compliance pu AE AMERICAN REGISTRY OF PLEASE VERIFY THAT ALL INFORMATION IS CORRECT NOTE 01 OL®C70Cr TECHNOLOGISTS@ ANY CORRECTIONS ON THE REVERSE SIDE OFTHIS FORM. 1255 NORTHLAND DRIVE ARAT ZD9 307694 ST.PAUL,MN-66120-1155 TELEPHONE(651}687-0048 www,arrt.org r � THE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOAI57S*' UEE aAIOINXL C,NAO FU0.VENPtCATlO`I ID.NurrAer VaiNTlpu Ertl Ur OCT20,14 MARK T. r- MARY T.FP,R T(R)(ARRTSM7 � T FIX,R. a5�7 REAGA4 DR FOR WORTH DR ;,. FORT W©FIT TY<7'61116'-17044I ' FORT WORTH,TX 76116-7044 nigrr 10'r➢7 2C Imo' Status In CE Comptranc�;'� y 081 O12D 1,4'., Categories Renewed:R � rbM e y, BEE BACK OF CARD FOR REGISTRATION CATEGORIES _ x } M . J' kd � {• � ry R t 1 YF;y �I kA--%rt1'fi'eate of Completion Drug Screen Collector Qualification TraininE Warkfix Ilas successfully completed Qualification and Proficiency Training and Is found to be Knowledgenble in the Procedures as documented in the Concentra Drug Screen CoBeegion Manual and US. Daaparrmgnr afTmosportntion Mandatory Guidelines,Federal Warkplaco Drug Testing 1'rogmm /[� U Jude 1¢,2010 Renee Downs Date •ProficiapGy DDativeerrm 5. /. f dune 16,2010 Steve Young 1. Date Ce4a Operations Director Concer bw The DOTop—fl a.Ti Dhbal(wu'rules rvqulre nkatempbyers condpub9ehetllnuct"rug fesFede2tfW according to provisions of49 CFR Part 40,'P.-d—: irensparfA9ort Wodgf/ace mg iasgng Programs'Final Rule the Y 11e91.....December 1,1889,f54 OR 1101),revised o fkbvery 19,1994,as"Procedures FarT spHrleU-W kpleo.D.g entl Alcohol Tesnng Progiam8"W FR 7949J--&d 7196,rewdtlwr ---.- _�9 L'reDecemherlB,YOao_ihapwadur8a1n.49.CPR.RartAaa a.based.orz7ha-0apartmert6ofSanspo,rtNlon.UdnaSpxJmen�sol78cgcn— Gurdelte wdden by fbe oflce of Drug end Alcohol Pogcy and Compliance published August T9a1 Certificate of Completion Drug Screen Collector Qualification Train Kelly Strange ias successfully completed Qualification and Proficiency Training and is fo Knowledgeable in the Procedures as documented in the Concentra Drug Screen Collection Manual and �. Department of Transporation Mandatory Guidelines, Federal Workplace L Program* 4/2112011 3137 Supervisor,Concentra Medical Centers 0 ate 4/21/2011 3:37 'iciency[Deliver,Concentra Medical Centers Date `The DOT operating administrations'rules require that employers conduct drug testing according to provisions of xedures for Transportation Workplace Drug Testing Programs". Final Rule published in the Federal Register on t FR 49854),revised on February 15,1994,as"Procedures For Transporation Workplace Drug and Alchohol Testis 1340)--ended 7/96,rewritten effective December 18,2000. The procedures in 49 CFR Pali 40 are based on th, nspor, an Urine Specimen Collection Guidelines written by t )Mce of Drug and Alcohol-Policy and Complianc, i .1- ncemram Certificate ®f Completion Kelly Strange Has Successfully Completed Breath Alcohol Technician! Training Course X_Proficient in CFR Part 40 Procedures X Proficient in Operation of EBT Ad Cb w onAtyz Cc, n )379 EBT Name/Model No. 613120112:50:00 F :y Dei er,Conc tra Medical Centers Date L Ida Batts Breath Alcohol Technician Training Course Proficient in CFR Part 40 Procedures —X—P-roficient in Operation of EBT Alcomonitor CC EBT Namel Model No. Jackie King 11/08/2013 Uertificate of Com.plett Drug Screen Collector Qualification Training Iia Batts Has successfully completed Qualification and Proficiency Training and Is found to be Knowledgeable in The Procedures as documented.in the Concentra Drug Screen Collection Manual anal. 11,S.Departmentol'Transportation Mandatory Guidefines,FederalWorkplace Drug TwdngProgram J/ / once�'ra�" i .a1 6 //1r'o�l _. - 11/D812013 / Jackie Toig Il / Dlfonitor once �"ra _. . . D n itl The DOT operodiug admintswataas'rales require that employers condacl drug resting according to provisions of 49 CFR Pari 48,"Pwudures far Workplace Drtg Tesllag Pragraun."Piaal Rale pubUsUd in the Fedeunl Ragisier on December 1,J999,(54 FR 49854),revised au Pebraary 15,1994r r T—isporradon Workplace Drag and A/cal o/Tesdug Prggrium"(59 FR 7340)ane ended 7196,reivririen effective December 18,2000.The procedures in based on 1111,Deparimm'lrof Transporialiar Urtne Spechnen Collection Guidelines written by dre Office of Drug and Alcohal Policy and CompUehce pub Candise Ehlers Breath Alcohol Technician Training Course X_Proficient in CFR Part 40 Procedures Proficient 0' Operation of EBT Alcomonitor CC EBT Name/Model No. 7aelde"King i v20aO13 once 9`ra Certificate of Completic Drug Screen Collector Qualification Training Candise Ehler'.s . Has successfully completed Qualification and Proficiency Training and Is found to be Knowledgeable in the Procedures as documented in the Concentra Drug Screen CoDection.Manui<al and U.S.Department of Transportation Mandatory Guidelines,Federal workplace Drug TesilpgProgram 12/1912013 Conce iara. Date Jackie King 12/1912018 Perceptor Concenwl` Expiration Date *ne DOT eperadng athuttiigradoas'rides require ilia'employers conduct ding rasdag according to provislons of 49 CFR Part 46,"Procedures for Tri wrkpiace Drug Testiue Programa"Final Rule publlshed In the Federal Register on Decunber 1,1989,(54 FR 49854),revised or Februaq,15,1994,as" }mrsportddon Workplace Drug and Alcohol Testhrg Progran's"(59 FR 7340)ameruled 7/96,rervrtae'r eJfecave Decenrher 18,3000. Tim procedums br 49 aced on dm papennruu of7Ymrspor'adeu Urb+e Spscirueu Colteceiorr Cuidalurer rvrlt[ur by rha Oma ajDrug and Alrolral Policy mrd CanpOaace publish I City of Fort Worth,TX 4 RFP No.14-0225 Concen Itra, Medical Provider of Occupational Health Care Services Attachment Fees and Charges Schedule i ATT_ ACffiff2a II SERVICE FEES AND CHARGES SCHEDULE This form is required. Failure to complete and return all schedules may result In rejection of proposal. A. OCCUPATIONAL INJURY MEDICAL TREATMENT SERVICES Ali occupational injury medical treatment shall be provided and billed by MEDICAL PROVIDER and paid by the CITY in accordance with the Texas Labor Code,Title 5,Subtitle A,Chapter 408"Workers' Compensation Benefits"and Chapter 409, Sub-Chapters A and B, and in accordance with the Texas Administrative Code,Title 28,Part B,Chapters 133 through 137. Any and all disputes regarding fees for occupational injury medical treatment services shall be resolved in accordance with the Texas Labor Code,Title 5,Subtitle A,Chapter 410"Adjudication of Disputes", and in accordance with the Texas Administrative Code,Title 28,Part B,Chapters 140 through 149. B. NON-INJURY OCCUPATIONAL HEALTH CARE SERVICES MEDICAL PROVIDER shall specify below individual and speeific fees for services proposed by MEIDICAL PROVIDER to be provided to CITY employees. Services that are not offered shall be Indicated as"'Not Offered". B.1 Breath Alcohol Tests Service Service Fee Service Fee Service Fee Service Fee Service Fee Description Contract Year 1 Contract Year 2 Contract Year 3 Option Contract Option Contract Year 4 Year 5 Breath Alcohol Test Post-Job Offer $18.00 $18.00 $18.00 $18.00 $18.00 i Breath Alcohol Test $18.00 $18.00 $18.00 $18.00 $18.00 Random Breath AlcoholTest $18.00 $18.00 $18.00 $18.00 $18.00 Post Accident Breath Alcohol Test $18.00 $18.00 $18.00 $18.00 $18.00 Follow-up ' Breath Alcohol Tat $18.00 $18.00 $18.00 $18.00 $18.00 Reasonable Suspicion After hours Breath $18.00 $18.00 $18.00 $18.00 $18.00 Alcohol Test k f RFP No. 14-0225,Medical Provider of Occupational Realdt Care Services,Page 45 of 52 i k i B.2 Urinary Drug Screens COS) Service Service Fee Service Fee Service Fee Service Fee Service Fee Description Contract Year Il Contract Year 2 Contract Year 3 Option Contract Option Contract Year Year UDS-Non Regulated $40.00 $40.00 $40.00 $40.00 $40.00 Pre-Placement UDS-Non Regulated $40.00 $40.00 $40.00 $40.00 $40.00 Random UDS-Non Regulated $40.00 $40.00 $40.00 $40.00 $40.00 Post-Accident UDS-Non Regulated $40.00 $40.00 $40.00 $40.00 $40.00 Follow-up UDS-Non Regulated $40,00 $40.00 $40.00 $40.00 $40.00 Reasonable Sus icion UDS-Regulated $40.00 $40.00 $40.00 $40.00 $40.00 Pte-Placement UDS-Regulated Random $40.00 $40.00 $40.00 $40.00 $40.00 LIDS-RegulatedX00 $40.00 $40.00 $40.00 $40.00 t A Posccide UDS-Regulated $40.00 $40.00 $40.00 $40.00 $40.00 Follow-up UDS-Regulated $40,00 $40.00 $40.00 $40.00 $40.00 Reasonable Suspicion B.3 Physical Examinations/Assessments Service Fee Service Fee Service Fee Service Fee Service Fee Service Option Option Contract Year Contract Year Contract Year Description 1 2 3 Contract Year Contract Year 4 5 Physical Examinaiion Post-Job Offer $40.00 $40.00 $42,00 $44.00 $46.00 Placement Physical Examination $40.00 $40.00 $42,00 $44.00 $46.00 -Other DOT Physical Examination $40.00 $40.00 Post-Job Offer $42.00 $44.00 $46.00 Placement DOT Physical $40.00 $40.00 $42.00 $44.00 $46.00 Recertification Respirator Physical $35.00 $35.00 $37.00 $39.00 $41.00 Examination Physical Demand Job $350,00 $350.00 $350.00 $350.00 $350.00 Assessments RFP No.14-0225,!Medical Provider of Occupational Hoalth Care Swim,Page 46 of 52 Physical Fitness for Duty $45.00 $45.00 $47.00 $49.00 $51.00 Testing Physical $100.00 $100.00 $100.00 Medical Surveillance $100.00 $100.00 Physical $40.00 $40.00 Retu_rntoWork $42.00 $44.00 $46.00 BA Laboratory Testing Service Fee Service Fee Service Fee Service Fee Service Fee Service Contract Year Contract Year Contract Year Option Option Description4 2 3 Contract Year Contract Year _ 4 5 Blood Collection Medical Surveillance $235.00 $235.00 $235.00 $235.00 $235.00 Exam DrugSoraen-Blood $165.00 $165.00 $165.00 $165.00 $165.00 DrugScreen-Re- $175.00 $175.00 $175.00 $175.00 $175.00 Test(Split Specimen) Hetuoccult(in $8.00 $8.00 $8.00 $8.00 $8.00 Center) Glucose Finger Stick $13.00 $13.00 $13.00 $13.00 $13.00 Complete Blood $15.00 $15.00 $15.00 $15.00 $15.00 Count(CBC) Blood Chemistry $38.00 $38.00 $38.00 $38.00 $38.00 2023 HemoglobinAIC $58.00 $58.00 $58.00 $58.00 $58.00 HydrocadOxyg $75.00 $75.00 $75.00 yolatnes - $75.00 $75.00 Blood/Urine UTAManual $33.00 $33.00 $33.00 $33.00 $33.00 Microscopic Blood-Lead $70.00 $70.00 $70.00 $70.00 $70.00 Blood-Chloroform $127.00 $127.00 $127.09 $127.00 $127.00 Blood- FonmaidehydeScreen $100.00 $100.00 $100.00 $100.00 $100.00 Blood-PCB $130.00 $130.00 $130.00 $130.00 $130.00 Blood-Hepatitis A $65.00 Surface Antibody $65.00 $65.00 $65.00 $65.00 Blood-HepetilisB $90.00 $90.00 $90.00 $90.00 $90.00 Surface Antibody Blood Hepatitis B $40.00 $40.00 $40.00 $40.00 $40.00 Surface Antigen RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 47 of 52 i t Blood-Hepatitis C Antibody $97.35 $97.35 $97.35 $97.35 $97.35 Blood-Htv $47,00 $47.00 $47.00 $47.00 $47.00 Sereen Blood-HIV Confirmation $65.00 $65.00 $65.00 $65.00 $65.00 (Western Blot) MMR Titer $147.00 $147.00 t:::$147.(0)O $147.00 $147.00 Rabies Titer $95.00 $95.00 $95.00 $95.00 $95.00 HeQatitis A Titer $65.00 $65.00 $65.00 $65.00 $65.00 Hepatitis B Titer $55.00 $55.00 $55.00 $55.00 $55.00 R5 IMmunizations/Vaceines Service Fee Service Fee Service Fee Service)Fee Service Fee Service Option Option Contract Year Contract Year Contract Year Description 1 2 3 'Contract Year Contract Year � 5 Rabies Vacciaesn" Injection $185.00 $185.00 $185.00 $185.00 $185.00 Rabies Vaccinesh" Injection $185.00 $185.00 $185.00 $185.00 $185.00 Rabies Vaccines/1" Injection $185.00 $185.00 $185.00 $185.00 $185.00 Tetanus Toxoid $20.00 $20.00 $20.00 $20.00 $20.00 PPD(Mantoux) $15.00 $15.00 $15.00 $15.00 $15.00 TB Skin Test $15.00 $15.00 $15.00 $15.00 $15.00 hilluenza(Flu Shots) $15.00 $15.00 $15.00 $15.00 $15.00 Hepatitis A $65.00 $65.00 $65.00 $65.00 $65.00 Vaccine/1-Injection Hepatitis B 00 00 $55 00 $55 $55. . . Vaceinell"Injection _ $55.00 $55.00 Hepatitis $55.00 $55.00 $55.00 $55.00 $55.00 Vaccinenad Injection Hepatitis $55.00 $55,00 $55.00 Vaccine5id Injection $55.00 $55.00 Hepatitis B Surface $90.00 $90.00 $90.00 $90.00 $90.00 Antibody Hepatitis A&B Vaceine/1"Iajection $120.00 $120.00 $120.00 $120,00 $120.00 RFP No. 14-4225,Medical Provider of Occupational Health Care Services,Page 48 of 52 Hepat ssA&B $120.00 $120.00 $120.00 $120.00 $120.00 Vaccine/i Injection Hepatitis A&B $120.00 $120.00 $120.00 $120.00 $120.00 Vaccindl"Injection Varicille Titer $82.00 $82.00 $82.00 $82.00 $82.00 Tdap(pertussis/ $7000 $70.00 $70.00 whooping cough) $70.00 $70.00 MA&Vaccine $80.00 $80.00 $80.00 $80.00 I $80.00 VaricillaVaccine $125.00 $125.00 $125.00 $125.00 $125.00 1B.6 Other Procedures/Services Service Fee Service Fee Service Fee Service Fee Service Fee Service Contract year Contract Year Contract Year Option Option ileription 1 2 3 Contract Year Contract Year 1 4 5 Audiogram $20.00 $20.00 $20.00 $20.00 $20.00 I CheatXRay (1 View) $52.00 $52.00 $52.00 $52.00 $52.00 X-Ray Inteiprtwion $34.50 $34.50 $34.50 $34.50 $34.50 Pulmonary Function. $21.00 $21.00 $21.00 $21.00 $21.00 Test EKGResting $65.00 $65.00 $65.00 $65.00. $65.00 Functionalcapacityacity Testi $35.66115 minutes $35.66/15 minutes $35.66/15 minutes $35.66/15 minutes $35.66115 minutes Testing OSHA Respirator Qucstionnaire $25.00 $25.00 $25.00 $25.00 $25.00 Respirator Pit Test $38.00 $38.00 $38.00 $38.00 $38.00 Review of $15.00 $15.00 $15.00 $15.00 $15.00 kh mation Authorized Signature: „/ Arlene G.King,Authorized Representative Name of Authorizing Authority: Occupational Health Centere of the Southwest,PA Date: ]/®0 1014 dba Concentra Medical Cen ers ADDITIONAL SERVICE COMPONENTS Service Description Year i Year 2 Year 3 Year 4 Year 5 HPE Level 4 $75.00 $75.00 $79.00 $83.00 $87.00 HPE Level 5 $125.00 $125.00 $131.00 $137.00 $143.00 HPE Development $350:00 $350.00 -$350.00 $350.00 $350.00 - HPE Admin Fee $100.00 $100.00 $100.00 $100.00 $100.00 RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 49 of 52 ' City of Fort Worth,TX o RFP No.140225 Concentra. Medical Provider of Occupational Health Care Services Attachment E Financial Information - -- --- Ai+-..L......n Table of Contents EM 8. FINANCIAL STATEMENTS AND SUPPLEMENTARY DATA Humana Inc. CONSOLIDATED BALANCE SHEETS Ds¢ember3l. 2013 2012 [m m0110m,euspt Am amosmts) ASSETS Current assets: Cash and cash equivalents $ 1,138 $ 1,306 Investment securities 8,090 8,001 Receivables,less allowance for doubtful accounts of$118 in 2013 and$94 in 2012: 950 733 Other current assets 2,122 1,670 Total current assets 12,300 11,710 Property and equipment,net 1,218 1,098 Long-term investment securities 1,710 1,846 Goodwill 3,733 3,640 Other long-terns assets 1,774 1,685 Total assets $20,735 $19,979 LIABILITIES AND STOCKHOLDERS'EQUITY Current liabilities: Benefits payable $ 3,893 $ 3,779 Trade accounts payable and accrued expenses 1,821 2,042 Book overdraft 403 324 Unearned revenues 206 230 Total current liabilities 6,323 6,375 Long-teal debt 2,600 2,611 _.Future policy benefits payable 2,207 1,858 her long-term liabilities 289 288 Total liabilities 11,419 11,132 Commitments and contingencies(Note 15) Stockholders'equity: Preferred stock,$1 par;10,000,000 shares authorized;none issued 0 0 Common stock,$0.16 2/3 par,300,000,000 shares authorized;196,275,506 shares issued in 2013 and 194,470,820 shares issued in 2012 33 32 Capital in excess of par value 2,267 2,101 Retained earnings 8,942 7,881 Accumulated other comprehensive income 158 386 Treasury stock,at cost,42,245,097 shares in 2013 and 36,138,955 shares in 2012 (2,084) (1,553) Total stockholders'equity 9,316 8,847 Total liabilities and stockholders'equity $20,735 $19,979 The accompanying notes are an integral part of the consolidated financial statements. 89 Table of Contents Humana Inc. CONSOLIIDATE1D STATEMENTS OF INCOME For the veer ended Dnmber 31, 2013 2012 2011 (In.chief%merptper ehve rmults) Revenues: Premiums $38,829 $37,009 $35,106 Services 2,109 1,726 1,360 Investment income 375 391 366 Total revenues 41,313 39,126 36,832 Operating expenses: Benefits 32,564 30,985 28,823 Operating costs 6,355 5,830 5,395 Depreciation and amortization 333 295 270 Total operating expenses 39,252 37,110 34,488 Income from operations 2,061 2,016 2,344 Interest expense 140 105 109 Income before income taxes 1,921 1,911 2,235 Provision for income taxes 690 689 816 Net income $ 1,231 $ 1,222 $ 1,419 Basic earnings per common share $ 7.81 $ 7.56 $ 8.58 Diluted earnings per common share $ 7.73 $ 7.47 $ 8.46 Dividends declared per common share $ 1.07 $ 1.03 $ 0.75 The accompanying notes are an integral part of the consolidated financial statements. 90 Table of Contents Humana Luc. CONSOLIDATED STATEMENTS OF CASH FLOWS For thevar mded Deamher 31. 2013 2012 2011 Un ndmom) Cash flows from operating activities Net income $ 1,231 $ 1,222 $ 1,419 Adjustments to reconcile net income to net cash provided by operating activities: Depreciation and amortization 426 338 303 Stock-based compensation 92 82 67 Net realized capital gains (22) (33) (11) Provision(benefit)for deferred income taxes 42 (80) 22 Provision for doubtful accounts 37 26 31 Changes in operating assets and liabilities,net of effect of businesses acquired: Receivables (251) 326 (106) Other assets (330) (253) (183) Benefits payable 109 (41) 256 Other liabilities 313 300 194 Unearned revenues (24) (43) 26 Other 93 79 61 Net cash provided by operating activities 1,716 1,923 2,079 Cash flows from investing activities Acquisitions,net of cash acquired (187) (1,235) (226) i Proceeds from sale of business 34 0 0 Purchases of property and equipment (441) (410) (346) Proceeds from sales of property and equipment 4 0 10 Purchases of investment securities (3,261) (3,221) (3,678) Maturities of investment securities 1,077 1,497 1,623 — — Proceeds from sales of investment securities 1,592 1,404 1,259 Net cash used in investing activities (1,182) (1,965) (1,358) Cash flows from financing activities Receipts(withdrawals)from contact deposits,net (150) (397) (378) Proceeds from issuance of senior notes,net 0 990 0 Repayment of long-team debt 0 (36) 0 Common stock repurchases (531) (518) (541) Dividendspaid (168) (165) (82) Excess tax benefit from stock-based compensation 8 22 15 Change in book overdraft 79 18 (103) Proceeds from stock option exercises and other,net 60 57 72 Net cash used in financing activities (702) (29) (1.017) Decrease in cash and cash equivalents (168) (71) (296) Cash and cash equivalents at beginning of year 1,306 1,377 1,673 Cash and cash equivalents at end of year $ 1,138 $ 1,306 $ 1,377 Supplemental cash flow disclosures: Interest payments $ 146 $ 110 $ 114 Income tae payments,net $ 734 S 745 $ 874 Details of businesses acquired in purchase transactions: Fair value of assets acquired,net of cash acquired $ 196 S 1,535 $ 266 Less:Fair value of liabilities assumed (9) (300) (40 Cash paid for acquired businesses,net of cash acquired $ 187 $ 1,235 $ 226 The accompanying notes are an integral part of the consolidated financial statements. 93 p ��ii g��77 City of Fort Worth,TX a RFP No.14-0225 Concentra tl a Medical Provider of Occupational Health Care Services Attachment F Sample Reports Claim Number: Concentra Medical Centers Service Date: 11/01/2004 1735 South Redwood Road.Sutra 116 SLC,UT 84104 Phone:(601)972-4434 Fax:(801)720-7999 Non-Injury Status Report Patient: Smith,Jane M. SSN: 987-654321 Address:123 Easy Street Employer Location: Some Company Contact:Greg Smith Jackson,TN 98765 Address: 123 Front Street Rote: Warehouse Manager Nome: (601)555-1234 Jackson,TN 98765 Phone: (601)555-1255 Ext.:301 Work: Ext.: Auth.by: Fax: (601)555-7999 This Visit: Time In: 03:30 pm Time Out: 04:21 pm Visit Type:'New Pre-employment Physical Non Regulated UDS Physicals-Pre-Placement Audiogram Result Status: Able to perform essential functions No medical restrictions Recommend further evaluation Remarks: Left ear with decreased high frequency loss. Status-Non-Injury Q 1996.2004conceniraManagedCars,Inc.ANRights Reserved. ANEEDErtlpicryer RevislonDate: 08/0912004 Concentra Medica[ Centers 1735 South Redwood Road,Suite 115 SLC,UT 84104 Phone:1601)972-4434 Fax:(801)720-7999 Employer: ABC Company 456 Front Street Jackson,TN 84104 Phone:(601)555-0010 Fax: (601)555-7999 Re: John Doe Employer: ABC Company 123 Easy Street Location: ABC Company Jackson, TN 84104 SSM 123-45-6789 Claim#: Injury Date: 11/01/2004 Dear Jane Jones: This letter is to inform you that you have missed your appointment with our Medical Center. We are concerned about you and we want you to know that failure to keep your scheduled medical appointment could affect your benefit eligibility. The following appointment was missed Sam Smith, MD at 11/04/2004 09:30 am It is our policy to notify you in writing when you miss an appointment and notify your employer and the insurance company. if you have questions or wish to reschedule,please call. Sincerely, Concentra Medical Centers cc:Adjuster AA/EEO Employer Concentra Medical Centers Service Date: 02/02/2004 1735 South Redwood Road,Suite 115 SLC,ur 84104 Phone: (601)972-4434 Fax: (601)720.7999 Patient Referral Referred by: Barry M.Diskant,MQ Patient Information: Patient: Doe,John Employer Location:ABC Company Contact:Greg Smith SSN: 123-45-6789 Address: 456 Fr ont Street Rote: Warehouse Manager Address: 123 Easy Street Jackson,TN 39206 Phone: (601)555-1255 Ext.:301 Jackson,TN 39206 Auth.by: Jim J ones Fax: (601)555-7999 Home Phone:(601)555-1234 Work Phone:(601)555-4321 Ext: DOI: 02/0112004 Diagnosis:924,21 Ankle Contusion-Right Program: 719.47 Ankle/Foot Pain-Right 928.20 Crush Injury,Foot-Right Billing Information: Carrier: Some Insurance Billing: Some Insurance Address;12345 E Street Address: 12345 E Street IRVINE,CA 92620 IRVINE,CA 92620 Phone: (800)555-6543 Claim#: Fax: (601)555-3456 Notes: Referred to: Centralized Referral Destination:Provider Notes: Referral: Provider Type: Physical Therapist Provider Specialty: Occupational Medicine Recommendation: Employer Notified: No Priority: Routine *"NOTE TO THE ABOVE FACILITY OR PHYSICIAN: Please send a copy of all reports on this patient to the above insurance carrier,employer,and this - center. pinnwn rnlnrn nil nrJ.vi..nl v rnr.e En•Mn nl...un nn,�Mr r referral p 1aes•2aoacancenuaManaged Cate,Inc.All Rights Resemed. AAIEEO Employer Revision Date: 07/2212003 EXHIBIT D - OMITTED BY MUTUAL AGREEMENT Professional Services Agreement Occupational Health-Concentra Ex D Contract Compliance Manager: By signing I acknowledge that I am the person responsible for the monitoring and administration of this contract,including ensuring all performance and reporting requirements. 3 Name of Employee Signature i AL k C Title i I ❑ This form is N/A as No City Funds are associated with this Contract Printed Name Signature M&C Review Page 1 of 3 Official CITY COUNCIL AGENDA FORT 111 COUNCIL ACTION: Approved on 10/28/2014 DATE: 10/28/2014 REFERENCE NO.: **C-27056 LOG NAME: 14CONCENTRA OHS CODE: C TYPE: CONSENT PUBLIC NO HEARING: SUBJECT: Authorize Execution of a Professional Services Agreement with Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers, for Non-Injury Occupational Health Care Services for an Anticipated Annual Cost of$316,106.17 and Authorize Execution of Professional Services Agreements with Primary Health, Inc. d/b/a Care Now, Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers, Texas Health Harris Methodist Hospital Fort Worth d/b/a Texas Health Harris Methodist Occupational Health and Nova HealthCare, P.A., as Preferred Providers of Occupational Injury Medical Care and Treatment Services with All Costs to be Billed to Individual Claim Files (ALL COUNCIL DISTRICTS) RECOMMENDATION: It is recommended that the City Council: 1. Authorize the execution of a Professional Services Agreement with Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers, as the City's sole provider of non-injury occupational health care services with an estimated annual cost of$316,106.17; and 2. Authorize the execution of individual Professional Services Agreements with Primary Health, Inc. d/b/a Care Now, Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers, Texas Health Harris Methodist Hospital Fort Worth d/b/a Texas Health Harris Methodist Occupational Health and Nova HealthCare, P.A., as preferred providers of occupational injury medical treatment and services with all costs to be billed to individual claim files as allocated loss expenses. DISCUSSION: The purpose of this Mayor and Council Communication is to approve Agreements for both injury and non-injury related occupational health care. On September 29, 2009, (M&C C-23812) the City Council authorized execution of a contract with Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers (Concentra), to provide both non-injury occupational health care services to the City of Fort Worth and to provide medical treatment and services to employees injured on the job. The final renewal option was set to expire on September 30, 2014, but the City Council authorized a three-month extension through December 31, 2014 to facilitate a new bidding process (M&C C-26914). Request for Proposals (RFP) No. 14-0225 was issued and advertised in the Fort Worth Star- Telegram on August 13, 2014, seeking proposals for a medical provider(s) of occupational health care services. A total of four proposals were received in response to the RFP. The four proposers were Primary Health, Inc. d/b/a Care Now (Care Now), Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers, Texas Health Harris Methodist Hospital Fort Worth d/b/a Texas Health Harris Methodist Occupational Health (Harris) and Nova Health Care, P.A. (Nova). The proposal evaluation factors included responsiveness to the RFP, the medical provider's capability and expertise to provide the services requested, MBE participation and cost. Proposals were http://apps.cfwnet.org/council_packet/mc review.asp?ID=20444&councildate=10/28/2014 6/16/2017 M&C )Zeview rage 2 of 3 reviewed by an evaluation committee consisting of staff from the Human Resources, Police and Fire Departments and the M/WBE Office. The evaluation committee recommends that Concentra be awarded a contract for Non-Injury Health Care Services and that all four proposers be awarded contracts as preferred providers for Occupational Injury Medical Care and Treatment Services. Non-Injury Occupational Health Care Services: Concentra has provided occupational health care services to the City for the past 14 years. Concentra is one of the nation's largest occupational health care providers and currently provides services to the City for both occupational injury medical treatment and for non-injury occupational health care services. The non-injury services being provided include alcohol and drug screens, flu shots and other types of vaccinations, medical screenings, Department of Transportation commercial driver's physicals, pre-employment physicals and return-to-work physical abilities tests. As noted above, the evaluation committee recommends engaging Concentra as the sole provider for these non-injury occupational health care services, which have an estimated annual cost of $316,106.17. Occupational Injury Medical Care and Treatment Services: Care Now was founded in 1993 and operates 24 occupational injury and urgent care clinic locations in the Fort Worth/Dallas Metroplex, five of which are in Fort Worth. Care Now is accredited by the Accreditation Association for Ambulatory Health Care, Inc. Concentra Medical Centers is a subsidiary of Humana, Inc., and was established in 1979. Concentra operates 16 occupational injury and urgent care clinic locations in the Fort Worth/Dallas Metroplex, two locations of which are in Fort Worth. As noted above, Concentra has previously provided these services to the City. Texas Health Harris Methodist Hospital has provided medical services to Tarrant County since 1930 and is accredited by the Joint Commission on Accreditation of Healthcare Organizations. Texas Health Harris Methodist operates two occupational injury clinics in Fort Worth. Nova HealthCare, P.A., was founded in 1993 and operates nine occupational injury clinics in the Fort Worth/Dallas Metroplex, two of which are in Fort Worth. By contracting with all four providers for occupational injury medical care, treatment and services, the City is able to offer City employees a wide choice of primary occupational medical treatment providers through 11 Fort Worth clinics and 40 additional clinic locations throughout the Fort Worth/Dallas Metroplex. Contracting with four providers also enables Staff to work with these preferred providers to achieve better return-to-work outcomes for City employees, to provide a wide range of quality health specialty providers and to better manage the costs of workers' compensation medical care. Medical care and treatment services for occupationally injured City employees are characterized as allocated loss adjustments and are invoiced to the individual claim files of each injured worker. The costs for these services are included in the amounts allocated in the budget for workers' compensation claims. Claims are processed and paid on behalf of the City by Corvel Enterprise Comp., the City's contracted Third Party Workers' Compensation Claims Administrator(City Secretary Contract No. 44004). Medical care and treatment services fees are paid at State of Texas regulated medical fee guidelines adopted by the Texas Department of Insurance, Division of Workers' Compensation and there is no variation in fee amounts. M/WBE OFFICE - Occupational Health Centers of the Southwest, P.A. d/b/a Concentra Medical Centers is in compliance with the City's BDE Ordinance by committing to 10 percent MBE (African American) participation on this project for the Non-Injury Occupational Health Care and other related health care services. The City's MBE (African American) goal on this project is 10 percent. Additionally, the Occupational Injury Medical Care and Treatment Services Agreements for this solicitation is not applicable to the goal because the purchase of these types of services is from source(s) where subcontracting opportunities are negligible. http://apps.cfwnet.org/council_packet/mc review.asp?ID=20444&councildate=10/28/2014 6/16/2017 M&C �eview Wage 3 of 3 RENEWAL TERMS - On City Council approval, all of these Agreements will have an initial three-year term, beginning January 1, 2015 and each Agreement will allow for up to two, one-year renewals. Execution of the renewal Agreements will not require additional City Council authority, provided that funds have been appropriated to pay the City's obligations during the renewal terms. FISCAL INFORMATION/CERTIFICATION: The Financial Management Services Director certifies that funds are available in the current operating budget, as appropriated, of the Workers' Compensation Insurance Fund. TO Fund/Account/Centers FROM Fund/Account/Centers FE73 539120 0147310 $316,106.17 Submitted for City Manager's Office by: Susan Alanis (8180) Originating Department Head: Brian Dickerson (7783) Additional Information Contact: Margaret Wise (8058) ATTACHMENTS http://apps.cfwnet.org/council_packet/mc_review.asp?ID=20444&councildate=10/28/2014 6/16/2017