HomeMy WebLinkAboutContract 29505 CITY SECRETARY
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CONTRACT FOR PROFESSIONAL SERVICES
This Contract for Professional Services ("Agreement") is made and entered into by and
between the City of Fort Worth ("City"), a home-rule municipality situated in portions of
Tarrant, Wise and Denton Counties, Texas, acting herein by and through Charles Boswell, its
duly authorized assistant city manager, and MedAlert Healthcare Systems, Inc., MedAlert, acting
through Dr. Joseph Osei, its duly authorized CEO/President, hereinafter referred to as MedAlert.
1. Services to be provided:
a. MedAlert agrees to provide to City, in accordance with medically necessary or
appropriate professional standards, a full range of occupational health care services,
as outlined in Appendix "A", including any exhibits thereto, all of which is hereby
made a part of this Agreement for all purposes. Appendix "A" constitutes, at least in
part, a proposal presented by MedAlert 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 this Agreement shall control.
b. City and MedAlert 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 assure performance of this Agreement
without hindrance.
c. Services under this Agreement will be provided at MedAlert's current facilities, at a
subcontractor's facilities if the subcontractor and the facilities are approved in writing
by the City, and at such City facilities and other locations as may be mutually
agreeable to MedAlert and City.
d. To the extent that the services to be performed under this Agreement constitute
services compensable under the Texas Workers Compensation Act, as in effect or
constitute services performed by persons other than MedAlert and ctji�;.; tl ,,�
Police and Fire Departments' Contracts (hereafter defined), both parties recognize the
non-exclusive nature of this Agreement. The "Police and Fire Departments'
Contracts" are defined as (a) those certain pre-existing contracts entered into by the
City for the performance of post-offer physicals for persons offered jobs in the City's
police and fire departments, and such other matters as are contained in such contracts,
and (b) any renewals thereof.
e. MedAlert agrees to provide and maintain a network of medical professionals
/physicians as listed in the Proposal, which shall include at the following: 4 general
surgeons; 6 orthopedic surgeons; 1 foot/ankle surgeon; 1 dentist; 2 doctors of
dermatology; 1 plastic surgeon; 1 knee surgeon; 3 hand surgeons; 1 ear nose and
throat doctor; and 1 podiatrist. The Specialist Network will be composed of Medical
Professionals/Physicians, including but not limited to Neurologists, Orthopedists, and
Plastic Surgeons. MedAlert also agrees to maintain the Specialist Network during the
initial term of this Agreement as well as any of the option terms. MedAlert agrees to
monitor performance of and replace, if necessary, any or all of the members of the
Specialist Network.
2. Compensation:
a. The parties agree that the Schedule for Compensation as shown in Exhibit `B"
attached hereto is acceptable as the compensation to be paid to MedAlert for lab
and case management services for the City. The parties acknowledge that an
additional services provided by MedAlert to the City may become desirable and
agree to conduct negotiations on such additional services in good faith to arrive at
mutually agreeable performance and compensation. Any additional services will
be reflected by a written amendment to this Agreement signed by the parties.
b. MedAlert shall issue monthly invoices for all services provided under this
Agreement and will provide the City sufficient documentation to reasonably
substantiate the invoices. Invoices are due and payable within 30 days from the
date the invoices are received by the City. Any payments not timely made will be
subject to interest at the rate of 10% per annum. In the event of a disputed or
contested billing, only that portion so contested will be withheld from payment, and
the undisputed portion will be paid. The CITY will exercise reasonableness in
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MEDALERT HEALTH CARE SYSTEMS,INC.
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contesting any bill or portion thereof. No interest will accrue on any contested
portion of the billing until mutually resolved.
Schedule for Compensation
Services Costs
A. Occupational Injuries:
Initial Visits 80% of TWCCFG
Treatment of Injuries 85% of TWCCFG
B. Occupational Medical Services (Non-injury)
Health Assessments
Post-offer/Promotional/Retum-to-work (RTW) $23.00
Other lab tests/Counseling
HIV $25.00
HIV Counseling $23.00
Lead Levels $25.00
Miscellaneous Tests To be negotiated prior to request
Health and Safety Education:
DOT training No charge
Inoculations and titers:
Hepatitis A $50.00
Hepatitis A titers $15.00
Hepatitis B $50.00
Hepatitis B titers $50.00
Rabies Injections At MedAlert's Cost
Rabies titers At MedAlert's Cost
Tetanus/Diphtheria injections $15.00
Influenza At MedAlert's Cost(Currently$9.00)
PPDs (TB skin test) $10.00
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MEDALERT HEALTH CARE SYSTEMS,INC.
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Hearing:
Audiograms $15.00
Counseling $10.00
Respiratory Protection:
Pulmonary Function Test $20.00
Counseling $5.00
Miscellaneous Procedures & Services:
Blood Pressure (only) No charge
Worksite Visits No charge
Eye Examination $10.00
Referrals to ADA Coordinator No charge
C. Urine/Drug Screenings.
Tests
Random $23.00
Post-offer/Promotional/RTW $23.00
Post-Accident $23.00 + additional
fee for post accident
24 hour service
D. Other Services
Case Management (EIP) $55.00/hr
(CPT Code-99429-billed to TPA)
Job Analysis $100.00/hr
(CPT Code-97537-billed to TPA)
3. Term
a. Unless terminated earlier as provided in this Agreement, the Initial Term of this
Agreement shall commence on February 1, 2004 for execution ("Effective Date") and
shall terminate on January 31, 2005 (Expiration Date').
b. Options to Renew and Notice:
City shall have the sole right to renew this Agreement for an additional four 1-year
terms. If City desires to exercise the first option to renew, City shall notify MedAlert in
writing at least 90 days prior to the end of the initial term or any option term that has
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been exercised of its intention to renew. Compensation to be paid during any option term
shall be that as provided for in the original term.
4. Records and Records Mana ement:
a. MedAlert will adhere and follow the governing guidelines as it pertains to the
protection and use of collected data (personal/medical information). MedAlert will
solicit City's input concerning any such modifications in order to ascertain if any
issues or consequences, legal, financial, or practical, are reasonably foreseeable
because of facility or system modifications. City and MedAlert agree to negotiate in
good faith to resolve any such issues and consequences in a manner equitable to both
parties and consistent with the purposes of this Agreement.
b. Upon the termination or expiration, MedAlert agrees to return all Pre-existing
Medical Records back into the physical custody of City or an agent of the City, as
City may designate in writing at that time. Upon receipt of authorization from the
affected City employees or their representatives for MedAlert to view and use the
Pre-existing 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), MedAlert may keep copies thereof at its sole copying expense, or may
subsequently request copies thereof and shall reimburse City for its reasonable
copying charges of such records.
c. It is additionally recognized that additional medical records created by MedAlert in
the performance of this Agreement, regardless of form or medium of storage ("New
Medical Records") shall be and remain the property of MedAlert and shall not be
removed or transferred from MedAlert, except in accordance with applicable law and
MedAlert's policies, provided that such policies are set forth in this Agreement or
have been approved in advance and in writing by the City. Before requesting New
Medical Records from MedAlert, City shall obtain from City's employee or legal
representative authorization to release copies of medical records in accordance with
applicable state and federal law concerning the confidentiality of medical records;
provided, however, that MedAlert agrees to use all reasonable efforts to obtain the
written consent of each patient seen by MedAlert under this Agreement authorizing
MedAlert to release copies of such New Medical Records to the City upon its request
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therefore. Upon termination of this Agreement, MedAlert shall retain the originals of
all New Medical Records in its possession, and City shall have the right to receive
copies.
d. MedAlert agrees that no medical record covered by the terms of this Agreement will
be altered or destroyed without express authorization by City. City recognizes that
medical records will from time to time cease to have administrative, financial and/or
legal value to either City or MedAlert, and City and MedAlert agree to utilize
appropriate record retention and destruction schedules for the purpose of lawful and
efficient records management.
e. MedAlert will exercise appropriate care in the management, use, storage and
retention of City records to preserve necessary and/or useful modifications of the
facility and systems used by MedAlert for records management may be indicated
from time to time. MedAlert will solicit City's input concerning any such
modifications in order to ascertain if any issues or consequences, legal, financial, or
practical, are reasonably foreseeable because of facility or system modifications. City
and MedAlert agree to negotiate in good faith to resolve any such issues and
consequences in a manner equitable to both parties and consistent with the purposes
of this Agreement.
f. All reports and records provided to MedAlert by the City shall remain the sole
property of the City. MedAlert 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 shall have full access to such reports and
records during MedAlert's normal working hours and will provide MedAlert with
reasonable advance notice of a need for access. MedAlert 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. MedAlert shall not copy or reproduce any such
records or reports without the City's advance written consent. The City will provide
a list of terminated employees annually to MedAlert. MedAlert will separate these
records from other records. The City may retrieve original copies of all such reports
and records from MedAlert at any time.
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5. Termination:
a. City may terminate this Agreement at any time for any cause or without cause by 90-
day notice in writing to MedAlert. Upon the receipt of such notice, MedAlert 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.
b. Upon termination of this Agreement for any reason, MedAlert shall provide the City
with copies of all completed or partially completed documents prepared under this
Agreement.
c. If MedAlert's 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 MedAlert for medically-appropriate services necessary to complete such
treatment at MedAlert's usual and customary rates until such care is completed, and
the City also shall pay MedAlert 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 MedAlert documenting the
performance of such work.
6. Indemnification:
MedAlert shall be liable for, and shall indemnify and hold the City and its officers, agents
and employees harmless from, any loss, damage, liability or expense for damage to
property and/or personal injuries, including death, to any person, including, but not
limited to officers, agents or employees of MedAlert or its contractors or subcontractors,
which may arise out of any negligent or grossly negligent act, error or omission or
malfeasance by MedAlert, its officers, agents, servants, employees, contractors and/or
subcontractors. MedAlert shall defend at its ovum expense any suits or other proceedings
brought against the City, its officers, agents, servants and/or employees based on or
resulting from any such negligent or grossly negligent act, error or omission or
malfeasance; and shall pay all expenses and satisfy all judgments which may be incurred
by or rendered against MedAlert, its officers, agents, servants, employees, contractors
and/or subcontractors, or the City, its officers, agents, servants and/or employees in
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connection with any such negligent or grossly negligent act, error or omission or
malfeasance. It is understood that the foregoing is not intended to cover matters to the
extent to which City, its officers, employees or agents have been found to be negligent or
grossly negligent or to have committed malfeasance.
7. Insurance:
a. MedAlert shall not commence work under the Agreement until it has fully complied
with all insurance requirements set forth in this Agreement and such insurance has
been approved in writing by the City, nor shall MedAlert allow any subcontractor to
commence work on its subcontract until all similar insurance of the subcontractor has
been so obtained and approval given by the City.
b. Workers' Compensation Insurance: MedAlert shall take out and maintain during the
life of this Agreement statutory Workers' Compensation Insurance for all of its
employees performing any of the services hereunder, and, in case any work is sublet,
MedAlert shall require the subcontractor similarly to provide Workers' Compensation
Insurance for all of the latter's employees unless such employees are covered by the
protection afforded by MedAlert's insurance. MedAlert will additionally acquire
Employer's Liability coverage in the following amounts:
Employer's Liability
$100,000 Each accident/occurrence
$100,000 Disease—per each employee
$500,000 Bodily Injury/Disease—Policy Limit
c. Commercial General Liability Insurance: MedAlert shall take out and maintain
during the life of this Agreement such commercial general liability insurance as shall
protect MedAlert and any subcontractor performing work covered by this Agreement
from claims for personal injuries, including death, as well as from claims for property
damages or losses which may arise from operations under this Agreement, whether
such operations be done by MedAlert or by any subcontractor or by anyone directly
or indirectly employed by either of them. The amount of such insurance shall be as
follows:
(1) CSL(combined single limit) per occurrence: $1,000,000 minimum
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(2) Aggregate: $2,000,000 minimum
d. Professional Liability: Professional liability or medical malpractice insurance shall
be required in the minimum amount of$1,000,000 per incident and $2,000,000 claim.
e. Auto Liability. Automobile liability insurance in the minimum amount of$1,000,000
CSL(combined single limit) per accident shall be required.
f. Additional Insurance Requirements:
1. The City, its officers, employees and servants shall be endorsed as an additional
insured on MedAlert's insurance policies excepting employer's liability insurance
coverage under MedAlert's workers' compensation insurance policy.
2. Certificates of insurance shall be delivered to the City of Fort Worth, Human
Resources Department, 1000 Throckmorton Street, Fort Worth, TX 76102, prior
to commencement of work on the contracted project.
3. Any failure on part of the City to request required insurance documentation shall
not constitute a waiver of the insurance requirements specified herein.
4. Each insurance policy shall be endorsed to provide the City a minimum thirty
days notice of cancellation, non-renewal, and/or material change in policy terms
or coverage. A ten days notice shall be acceptable in the event of non-payment of
premium.
5. Insurers must be authorized to do business in the State of Texas and have a
current A.M. Best rating of A: VII or equivalent measure of financial strength and
solvency.
6. Deductible limits, or self-funded retention limits, on each policy must not exceed
$10,000.00 per occurrence unless otherwise approved by the City.
7. Other than worker's compensation insurance, in lieu of traditional insurance, City
may consider alternative coverage or risk treatment measures through insurance
pools or risk retention groups. The City must approve in writing any alternative
coverage.
8. Workers' compensation insurance policy(s) covering employees employed on the
project shall be endorsed with a waiver of subrogation providing rights of
recovery in favor of the City.
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9. City shall not be responsible for the direct payment of insurance premium costs
for MedAlert's insurance.
10. MedAlert's insurance policies shall each be endorsed to provide that such
insurance is primary protection and any self-funded or commercial coverage
maintained by City shall not be called upon to contribute to loss recovery.
11. In the course of the project, MedAlert shall report, in a timely manner, to City's
officially designated contract administrator any known loss occurrence which
could give rise to a liability claim or lawsuit or which could result in a property
loss.
12. MedAlert's liability shall not be limited to the specified amounts of insurance
required herein.
13. Upon the request of City, MedAlert shall provide complete copies of all insurance
policies required by these contract documents.
8. Disclosure of Conflicts:
MedAlert warrants to the City that it has made full disclosure in writing of any known
existing or potential conflicts of interest related to the services to be performed
hereunder. MedAlert further warrants that it will make prompt disclosure in writing of
any known conflicts of interest, which develop subsequent to the signing of this
Agreement.
9. Right to Audit.
a. MedAlert agrees that the City shall, until the expiration of three (3) years after final
payment under this Agreement, have access to and the right to examine any directly
pertinent books, documents, papers and records of MedAlert involving transactions
relating to this Agreement. MedAlert agrees that the City shall have access during
normal working hours to all necessary MedAlert facilities and shall be provided
adequate and appropriate workspace in order to conduct audits in compliance with the
provisions of this section. The City shall use its best efforts to give MedAlert not less
than 7 working days' advance notice of intended audits.
b. MedAlert further agrees to include in all its subcontractor agreements hereunder a
provision to the effect that the subcontractor agrees that the City shall, until the
expiration of three (3) years after final payment under the subcontract involving
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transactions 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 advance notice of
intended audits.
c. MedAlert agrees to photocopy such documents as may be requested by the City. City
agrees to reimburse MedAlert for the cost of copies at the rate published in the Texas
Administrative Code in effect as of the time copying is performed.
10. Prohibition of Assi ent:
Neither party hereto shall assign, sell, convey or otherwise transfer its interest herein
without the prior written consent of the other party, and any attempted assignment, sale,
conveyance or transfer of all or any part hereof without such prior written consent shall
be void.
11. M/WBE Goals
MedAlert has committed to meet the City's goal of 10% of the total dollars received from
sections B and C of the Schedule for Compensation be paid to Minority/Women Business
enterprises (M/WBE). Failure to comply may result in MedAlert being classified as non-
responsive and being barred from City work for a period of not less than six months.
MedAlert agrees to furnish documentation of M/WBE participation such as canceled
checks, etc., or such evidence as may be deemed applicable and proper by the City on a
quarterly basis, beginning May 1, 2004, during the initial Term and any Renewal Term of
this Agreement.
12. Nondiscrimination:
MedAlert covenants and agrees that it will take all necessary actions to insure that, in
connection with any work under this Agreement, MedAlert, its officers, agents, servants,
employees, associates and subcontractors, will not discriminate in the treatment or
employment of any individual or groups of individuals on the ground of race, color,
religion, national origin, age, sex, sexual orientation, familial status or physical handicap
unrelated to job performance, either directly, indirectly or through contractual or other
arrangements.
13. Choice of Laws; Venue
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a. This Agreement shall be construed in accordance with the internal law of the State of
Texas.
b. Should any action, whether real or asserted, at law or in equity, arise out of the terms
of this Agreement, venue for said action shall be in Tarrant County, Texas.
14. Performance Guarantees
Performance Guarantees are outlined below for MedAlert. The Performance Guarantees
are established to benefit, evaluate and improve upon the efforts of MedAlert during
throughout the term of this Agreement and any option period. The Performance
Guarantee's are established to evaluate progress, improvement, satisfaction and
efficiency of services rendered for the City. MedAlert shall prepare quarterly reports to
monitor the status of the Performance Guarantees The Performance Guarantees are as set
forth below.
ANNUAL INCENTIVES
Wait time Matrix-Objective: City of Fort Worth Employee will not Credited Annually if not
wait for more than 30 minutes to be seen (initiate service) by a reached: Expected Credit:
healthcare professional (for both a scheduled appt. time or walk-in Yr 1= $2500; Yr 2=$2500;
with appropriate authorization) Initial injury care wait time does not Yr 3=$2500 Yr 4= $2500
apply due to the fact that these cases will be immediately triaged
and seen accordingly.
Expected Time Scale: Yr.1=40 min; Yr. 2=30 min; Yr. 3=30 min;
Yr. 4=25 min.
Injured Worker Satisfaction-Objective: Based on satisfaction Credited Annually if not
questionnaire, expected percentage reaching percentiles. reached: Expected Credit:
Expected Satisfaction Scale: Yr.1=70%; Yr.2=75%; Yr.3=80%; Yr. Yr 1=$2500; Yr 2=$2500;
4=85% Yr 3= $2500; Yr 4=$2500
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Primary Care Entity Utilization Rate-Objective: Credited Annually if not
reached: Expected Credit:
(48% from previous vendor) MedAlert will increase the rate at Yr 1=$2500; Yr 2=$2500;
which The City of Fort Worth Employees utilizes the Primary Care Yr 3=$2500; Yr 4=$2500
Entity(MedAlert) by 5% per yr. (rounding 48%to 50% for initial
reference point)
Expected Utilization Rate: Yr.1=55%; Yr.2=60%; Yr.3=65%; Yr.
4=70%
Initial Contact- Objective: A 3-pt contact completed within 48 Credited Annually if not
hours of referral received. reached:
Expected Completion Scale: Yr 1=$1000; Yr 2= $1500;
Yr 1=75% Complete; Yr.2=80%; Yr.3=85%;Yr.4=90% Yr 3=$2000; Yr 4=$2500
Limited EIP Program- Objective: The initial contact of"E- Credited Annually if not
Intelemed" is limited to 4-weeks per task assignment. reached:
Expected Task Assignment Scale: Yr 1-$1200; Yr 2=$1200; Yr
Yr 1=75% Complete; Yr.2=80%; Yr.3-85%; Yr.4=90% 3=$1500; Yr441500
Employee Feedback Satisfaction- Credited Annually if not
Objective: Quarterly follow up survey sent to injured workers reached:
managed under E-Intelemed system to determine customer Yr 1=$1500; Yr 2=$1500
satisfaction. Yr 3=$1500; Yr 4=$1500
Expected Satisfaction Scale:
Yr 1=75%; Yr 2=80%; Yr 3=85%; Yr 4=85%
15. Multiple Counterparts:
This Agreement may be executed in multiple counterparts, each to constitute an original,
but all in the aggregate to constitute one agreement as executed.
16. Independent Contractor
This Agreement will not be construed in any form or manner to establish a partnership,
joint venture or agency, express or implied, nor any employer-employee, borrowed
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servant or joint enterprise relationship by and among the parties. MedAlert shall be an
independent contractor and shall be responsible at all times for directing its employees in
the course of their duties.
17. Entire Agreement
This Agreement, including its attachments and schedules, constitutes the entire Agreement,
supersedes all prior written or oral understandings, and may only be changed by a written
amendment executed by both parties. The following attachments and schedules are hereby
made a part of this Agreement:
1. Appendix A—Scope of Services
2. Appendix B—Sample Reports
EXECUTED on this day of yki—lb , 200
ATTEST: CITY OF FORT WORTH
.y By:
Gloria Pearson a Charles Boswell
Assistant City Attorney Assistant City Manager
App oved as to form and legality MedAler re Systems,Inc.
BY:
Assistant ity Attorney Dr. Jose h Osei
CEO/President
C, ,itract- Authorization
Date
CONTRACT FOR PROFESSIONAL SERVICE "
MEDALERT HEALTH CARE SYSTEMS,INC. ,t' �� f "'
Page 14 of 14
Appendix `A'
Drug and/or Alcohol Testing
a. MedAlert agrees to provide to the City Drug and/or Alcohol testing in accordance to 49 CFR
part 40 DOT guidelines for collection, handling, testing, and reporting of results. The City
will have the opportunity to identify a specific person(s) who will be eligible to receive all
results of drug and alcohol testing. The City will also have the opportunity to identify one or
more specific persons who will have access to all positive post accident drug screen results.
(The aforementioned persons will be identified by the City and set to written confirmation.)
b. MedAlert will utilize `Lab One' for all laboratory testing. MedAlert will provide to the City,
at no cost to the City, necessary software to allow processing and receiving test results
directly from `Lab One'.
c. MedAlert will employ (in house/ on staff) a minimum of 4 Medical Review Officers. At this
time, Dr. Brian Rogers, D.O. is the physician designated by MedAlert as the primary MRO
working with the City Employees.
d. In the event a City Employee requests testing of the `B' vial, the employee will be expected
to remunerate MedAlert the cost involved for said testing before the process will is initiated.
e. Two copies of MedAlert'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.
f. Infrequent on-site drug testing may be conducted at no 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.
Office Hours and Locations
a. MedAlert will operate 4 different clinics located in Tarrant County. The primary facility
designated to serve the City employees will be located at 711 Pennsylvania Ave., Fort
Worth, Texas 76104, such clinic being hereinafter referred to as the "City Clinic". The
City Clinic has a projected completion date of March 1", 2004. If a certificate of
occupancy is not issued by April 20, 2004 and the City Clinic is not open to receive City
employees by April 30, 2004, liquidated damages shall be assessed in the amount of
$5,000. For each day after April 30, 2004 that a certificate of occupancy has not been
issued and the City Clinic is not open to receive City employees, liquidated damages in
the amount of $166.00 per day will be assessed. Liquidated damages, if any, to be
assessed hereunder shall be withheld from any payments otherwise payable to MedAlert
hereunder.
b. Starting on February 1", 2004, City employees will be able to seek treatment at any of the
following locations:
Fort Worth Clinic: 6450 Brentwood Stair Rd.
Phone: 817-429-5055
Fax: 817-429-4166
Arlington Clinic: 185 South Watson Rd.
Phone: 817-640-1111
Fax: 817-640-1156
Haltom City Clinic: 3189 Denton Hwy.
Phone: 817-831-0999
Fax: 817-831-2228
c. The regular hours of operation for all clinics are as follows:
Monday—Friday 8:00 AM—6:00 PM
Saturday 9:00 AM—3:00 PM
d. Extended hours of operation for the MedAlert `City Clinic' will occur on Wednesday
from 6:00 am until 8:00 pm.
Reports
a. MedAlert utilizes the Stolas Occupational Health Software System. Through MedAlert's
remote module the City will be provided access to information regarding a patient's status,
appointments and case management files Reports will be provided on a monthly status with a
quarterly summary management report. See Appendix B for sample reports.
b. MedAlert will provide to the city information regarding frequency and type of injuries seen
by MedAlert, frequency of visits, and resolution of worker's compensation cases. MedAlert
will work with each department to design specific reports and protocols so that reported data
meets the specific needs of each department.
c. MedAlert will work with the City to develop an Exposure Counseling Program for the
employees of the City. Summary Management reports regarding utilization of the Exposure
Counseling Program will be available quarterly. At this time MedAlert has identified Dr.
Brian Rogers, D.O. as the physician who will lead this program.
APPENDIX A 2
MEDALERT HEALTHCARE SYSTEMS,INC.
Page 2 of 6
d. All reports produced by MedAlert will be provided in a timely manner (duration will be
limited to specific type of report being generated).
e. IMO reports (summary management reports and update reports) will be provided to the City,
TPA and MedAlert on a Monthly Basis with a Quarterly summary review.
Other Services
a. At least one of MedAlert's Medical Staff working at the MedAlert `City Clinic' will be
expected to conduct at least one City workplace visit each quarter on site at the City for each
of the twenty-six (26) departments. This action will be performed to allow the MedAlert
medical staff to develop a better understanding of the different occupations, required
functional abilities, and the potential injuries that might occur. MedAlert will also attend
and/ or conduct a presentation of various safety topics (relevance identified by the City
Safety Committee and all presentation material pre-approved by the Occupational Health and
Safety Department) once a quarter at the discretion of the City and at no charge.
b. MedAlert will conduct on-site flu vaccinations for the City employees at the pre-approved on
site location. This will be identified and approved by the City Workers' Compensation
Manager and put in writing as to place, time of delivery of service. The cost for this service
will be $9 per person or equal to the cost of the vaccine and related supplies. (The cost of Flu
vaccine can vary from season to season) In addition, MedAlert will provide flu vaccines to
one dependent spouse. The City shall determine a process for prior signage. The cost for the
dependent will be deducted from the employee's paycheck and MedAlert will be reimbursed
for the approved cost of the vaccine. There shall be no on-site charges for such service, other
than as allowed in this paragraph.
c. MedAlert may provide Department of Transportation (DOT) certification physicals for $27
per person.
d. MedAlert will assist the City with developing a Return to Work Program at no cost to the
City.
e. MedAlert will perform On-Site Job Analysis/Ergonomic Hazards Assessment that include
identification of potential safety hazards, identification and measuring of critical dimensions
and forces associated with performing a given task, and written to meet the standards of the
American with Disabilities Act. All on-site services shall be approved in writing by the
APPENDIX A 3
MEDALERT HEALTHCARE SYSTEMS,rNC.
Page 3 c f 6
City's Worker's Compensation Risk Manager and/or Safety Director prior to such services
being provided The cost for on-site Job Analysis would be determined by degree of
involvement but shall not exceed an hourly fee of$I 00.00/hr and shall be billed directly to
the TPA for the service allocated as an expense to a claim with a CPT dedicated code.
APPENDIX A 4
MEDALERT HEALTHCARE SYSTEMS,INC.
Page 4 of 6
f. MedAlert is able to conduct `Fitness Assessment/Testing' for any department deemed
appropriate by the City. Assessment/ Testing can include but is not limited to the following:
Cardiovascular.Testing (treadmill), Strength assessment, Pulmonary Function Testing, body
fat analysis, flexibility assessment, etc. The number of elements incorporated shall
determine the cost of this service, the staff utilized to administer the assessment, and supplies
utilized to administer the assessment. The Fitness Assessment Testing or Post Offer
Screening will be conducted as a pre-approved service by the City and will charged to the
City as an allocated expense for such services in the cost schedule.
g. Injury Management Organization, Inc. is a service partner strategically partnered with
MedAlert; however, as an independent entity that will provide services which are exclusively
delivered by IMO, which will include: -Early Intervention Programs such as the "B-
Intelemed" Case Management Services and Job Analysis for the City during this contract
period with MedAlert.
h. The primary physician shall be Dr. Mark Morris. The primary physician shall. not be
replaced without the written approval of the City.
Billing
a. All billing associated with `work-related' injuries will be directed to Barron Risk. The City,
and if necessary in conjunction with Barron Risk, will set forth a plan to insure remuneration
(partial or in-full) to MedAlert for any and all `injury care' provided in good faith. (i.e.
MedAlert treats an injured employee of the city, authorized by supervisor per authorization
slip, and at a later date the injury is denied as compensable. Since initial care was authorized
by a City employee/ supervisor and provided in good faith, MedAlert is entitled to
remuneration of services provided form initial visit to time of notification of claim denial.)
b. Regarding a denied claim, payments made to MedAlert for the City would not deem services
provided as an acceptance of liability.
c. Services provided by Injury Management Organization, Inc. will be billed directly to the
TPA. The appropriate TWCC/ CPT codes, description of services and protocol will be
followed as standard order during this contract. IMO will be paid as described in the attached
document and compensated accordingly at thirty (30) days from the date of the invoice date.
T 77
_ �•_ ,_-.fl 1.5�.. _ 1.�.
APPENDIX A 1-
MEDALERT HEALTHCARE SYSTEMS,INC. _
Page 5 of 6
Appendix `B'
Sample Reports are provided to indicate the content of information requested:
• Utilization Analysis By Injury Area
• Incidence Rate Comparison
• Cost and Frequency of Injury by Body Part
• Injury Analysis Comparison
• Open Case Report
• Employer Volume—Visit Types within Entity Locations
• Visit Activity Report by Provider
• Referral Activity Report
APPENDIX A 6
MEDALERT HEALTHCARE SYSTEMS,INC.
Page 6 of 6
Appendix `B'
Sample Reports are provided to indicate the content of information requested:
• Utilization Analysis By Injury Area
• Incidence Rate Comparison
• Cost and Frequency of Injury by Body Part
• Injury Analysis Comparison
• Open Case Report
• Employer Volume—Visit Types within Entity Locations
• Visit Activity Report by Provider
• Referral Activity Report
APPENDIX A 5
MEDALERT HEALTHCARE SYSTEMS,rNC.
Page 5 of 5
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Date : 12/30/2003 ' Page 1 of 1
Time :05::;0:48 pn;
MedAlert Industrial Health
CPT Usage Report - Patient by Location - Summary Only 01
Visits(12/20/2003- 12/3012003)
Location(MedAlert-Arlington- MedAlert-Arlington) Procedure (Office Exam Est Brief-Office Exam Est Brief)
Location Name Items Voided Items Amount Void Amount
MedAlert-ArlingtoQ-/ 1 26.00 0.00
--------------------------------------------------------------------------------------- -------------------------------------------
Total Number of Items : 1 Total Amount 26.00
Total Voided Items Total Void Amount 0.00
------------------------------------------------------------------ ---------------------------------------•------------------------
Net Total Items 1 Net Total Amount 26.00
'acs -.• c. i'slj �
� �•i 4 li p •�I
Date :12/30/2003 Page 1 of 1
Time :05:30:59 pm
MedAlert Industrial Health
CPT Usage Report - Patient by Location
Visits(12/20/2003- 12/30/2003)
Location(MedAlert-Arlington- MedAlert-Arlington) Procedure (Office Exam Est Brief- Office Exam Est Brief)
Visit Date Case No Patient Name SSN Guarantor Name Amount Void
Office Location: MedAlert-Arlington
OV11 T Office Exam Est Brief
12/22/2003 10925 Palmer,Camille M. 450-67-9445 Providence Risk 26.00
--------------------------------------------------------------------------------------------------------------------------
Total Number of Items 1 Total Amount 26.00
Total Voided Items 0 Total Void Amount 0.00
----------------------------------------------------------------------------------------------------------------------------
Net Total Items 1 Net Total Amount 26.00
Date : 12/30/200 Page 1 of 1
Time :05:33:06 prn
MedAlert Industrial Health
CPT Usage Report - Employer by Service Type
Employer(Dallas City-Civil Service Department- Dallas City- Civil Service Department)Procedure (Physical Asbestos-With Xrays-
Physical-Medical History)
Service Type Sub Type Contract Rate
Procedure Code and Description
Dallas City-Civil Service Department
Preplacement Exam
Phyp Physical Preplacement 25.00
Phyp Physical PrePlacement 25.00
---------- ----------------------------------------------------------
Total Items: 2
-----------------------------------------------------------------------
Date 12/30/2003 Page 1 of 1
Time 05:40:19 pm
MedAiert Industrial Health
Patient Report by Employer
Employer Name Service
Patient Name Case# First Visit Type MRN Guarantor Name
7-11 #12532
Morales, Martina G 17612 05/13/2003 Workers Broadstire Insurance-Florida
7-11 #30463
Wright, Billy J 1578 11/08/2002 Workers Broadstire Insurance-Florida
Yusoof, Mohammed 2309 11/29/2002 Workers Broadstire Insurance-Florida
Waite, Lisa M 13638 04/10/2003 Workers Broadstire Insurance-Florida
A& E Motor
Fontenot, Irving L 5743 02/04/2003 Substance A& E Motor
Morley, Robert 7367 02/17/2003 Substance A& E Motor
Runyan, Roger L 7388 02/17/2003 Substance A& E Motor
Johnson, Eddie 14470 04/17/2003 Substance cs/Iv A&E Motor
Carpenter, Robert J 17799 05/14/2003 Substance cs/cs A& E Motor
Tignor, Brad P 18125 05/16/2003 Substance cs/cs A& E Motor
Craver, Douglas W 18376 05/19/2003 Substance cs/cs A& E Motor
Ragland, Charles D 18554 05/20/2003 Substance cs/cs A& E Motor
Washington,Jessie 19156 05/23/2003 Substance cs/cs A& E Motor
Harrison,James 23748 07/01/2003 Substance jlw/cs A&E Motor
Bentley, Ricky F 27178 08/01/2003 Substance jlw A& E Motor
Atwood,Clancy B 30031 08/26/2003 Substance Iv/jlw A& E Motor
Starr, Robert W 31665 09/10/2003 Substance cs A&E Motor
Soto,John R 33036 09/22/2003 Substance Iv A& E Motor
Daie : 1230/2003 Page 1 of 2
Time : 05:39:49 pm
MedAlert Industrial Health
Patients by Diagnosis
Visit Range: 12/30/2003- 12/30/2003
Diagnosis Range: -
Case No. Patient Name Age Phone Employer Diagnoses
38614 Alecio, Elida 56 (817)795-1789 Vecta 840.9 842.00 841.0 726.
44384 Almaraz, Ricardo 42 (817)926-9803 Oak Cliff Mirror& Glass
44285 Anderson, Willie 52 (972)557-4980 Solvay Engineered Polymers
38432 Arnett, Irma 41 (972) 775-6752 Sanders Esters Unit 846.0 724.3 724.4 722.
44385 Bell, Stephanie 21 (817)881-1149 Laramar Group#19
44377 Blandin, Jay S. 26 (817)845-8619 Dominos Pizza Distribution
42982 Brown, Sherron 41 (817)459-2563 Kinder Care 847.2 847.1 724.4 728.
44314 Clark, Nathan 23 (682) 557-6110 Robertson Fleet Service
44335 Clement, Quentin W 30 (817) 763-5055 Turbomeca-Microturbo
44383 Corral, Carlos 49 (817) 531-8790 United States Cold
44292 Dale,Terry 59 (972)366-8160 Jack Cooper Transportation
44379 Derrough, Reginald 41 (214)330-7867 Solvay Engineered Polymers
44312 Dixon, Jerry 53 (214) 376-2537 Arnold Transport
44355 Evans, Martin L 41 (817) 645-6216 Transcar Auto Shippers, Inc.
44328 Folsom, David 49 (817) 501-8918 Lonestar Drivers
44299 Foster, Karen 51 (972)641-9655 Labone Inc.
44387 Garberson, Virginia 58 (817) 861-0795 Lockheed Martin Aeronautics
4262 Harris,Tina 32 (817)417-4810 McLane Foods 354.0 727.04
44324 Holt, Brandon 24 (817) 846-6831 Walmart 1801
44395 Jones, Darryl 40 (817) 536-4415 Walmart 1801
44294 Jouett, John 46 (817) 514-6493 Robertson Fleet Service
44329 Kaylor, Nicholas 23 (817)459-3381 Oak Cliff Mirror&Glass
44293 Kerr, Michael 51 (817)503-9276 Robertson Fleet Service
44368 Lane,John R.T. 22 (972)352-5611 Lowe's Home Center Inc
Daie : 1;L/30/2003 Page 2 of 2
Time : 05:39:49 pm
MedAlert Industrial Health
Patients by Diagnosis
Visit Range: 12/30/2003- 12/30/2003
Diagnosis Range: -
Case No. Patient Name Age Phone Employer Diagnoses
44288 McNeill, Steve 37 (817)795-2391 Solvay Engineered Polymers
44323 Meinecke,Juergen 44 (817)308-1266 Labone Inc.
42569 Miller,Jonathan 20 (817)572-•7050 Lowe's 1511 840.9
44382 Monsivais,Antonio 52 (214)941-3827 United States Cold
44303 Oliver, Ronald 33 (817)795-0202 Special Distribution
42881 Peel,Andrew M 25 (817)426-1093 Lowe's 1511 847.2 847.1
1694 Perez, Eva 45 (817)683-9577 Revcor Molded Products 847.0 842.00 841.0 846.
44317 Perkins, Edward C 51 (817)572-5707 Jack Cooper Transportation
44392 Robles,Jacob 28 (972) 647-2095 Dominos Pizza Distribution
44341 Rosales, Magdeleno 24 (972)253-5766 Larry Miller Roofing
44363 Saldivar, Ricardo 33 (972) 606-4502 Federal Express-Osler
39584 Shoemake,John 60 (817)469-9593 Fiesta Mart Inc 60 883.1
44318 Steele, Thadeus 25 (972)641-6700 Oak Cliff Mirror& Glass
36264 Talamantez,Jason 28 (817)303-5406 Fiesta Mart Inc 60 604.0 789.00 788.1
44296 Thornton,Jeff R. 46 (817)308-0746 Horizon Freight
44367 Watkins, LaShe N. 28 (817) 881-7978 Total Enterprise
1
Date : 12/30/2003 Page 2 of 2
Time : 05:39:26 pm
MedAlert Industrial Health
Patient Activity Report by Employer
Visits (12/1/2003- 12/30/2003)
Patient Name Claim Number Discharged Date
SSN DOB Diagnosis Work Status History
DOI Case#
Visit Type Visit Date Next Visit Date
Employer Demographics:
A Truck Express
2323 Chalk Hill
Dallas, TX 75212
------ -------- ----------------------
--------------------------------------------------------- -------- - -.
Howard, Charles T
455-72-6096 09/10/1950
12/16/2003 43354
Exams 12/16/2003
Perez, Everado S
456-43-7112 04/05/1974
12/22/2003 43921
Substance Test 12/22/2003
Date : 12/30/2003 Page 1 of 2
Time : 05:39:26 pm
MedAlert Industrial Health
Patient Activity Report by Employer
Report Option Summary Page
Employer(1 Clean Plane-A Window Cleaning Company)
Visit Types (-)Service Types (- )Visits (12/1/2003- 12/30/2003)
Data 12/30/2003 Page 1 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers (1 Clean Plane-Adecco-Fossil Creek) Service Types (Workers Comp-Workers Comp)
Patient Name DOI Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: 7-11 #12532 Contact: Phone:
Morales, Martina G 05/07/2003 07/22/2003 847.1 Sprain/Strain Thoracic
17612 CL Mark Morris, DOH8268 724.1 Pain Thoracic Spine
(817)845-3677 458-06-2005
Employer Name: A-1 Omamental Contact: Phone:
Cano,Jose 01/23/2003 03/12/2003 944.00 Burn Hand Unspecified Site, Unspe(
5345 cs/lv RC Jose Trevino, MDH8873
(214)219-4281 464-19-3170
Garcia, Juan 02/04/2003 02/06/2003 921.1 Contusion Eyelids/Periocular Area
5769 NS Jose Trevino, MDH8873
(214)663-5759 413-06-4851
Employer Name: AAA Cooper Transportation Contact: Preston Warren Phone: (972)266-9045
Pace, Jason A 05/19/2003 07/10/2003 840.0 Sprain/Strain Acromioclavicular Join
19728 CC Jose Trevino, MDH8873
(972)266-9045 451-71-6066
Barron, Richard 06/09/2003 06/30/2003 846.0 Sprain/Strain Back, Lumbosacral Oo
20937 CC Jose Trevino, MDH8873
(214)339-0730 548-41-3627
Employer Name: Aarons Distribution Center#C0506 Contact: Bob Barr Phone: (972)206-0499
Mancinas, Juan 11/11/2003 12/01/2003 924,21 Contusion Ankle
39518 NR Brian Rogers, DOJ6034 845.00 Sprain/Strain Ankle, Unspecified Siti
(972)641-3049 457-91-5430 718.87 Developmental Dislocation of Joint
Employer Name: ABC Roofing Supply-Dallas Contact: Jim Brown Phone: (214)630-3940
Cooper, Loyce 05/21/2003 05/30/2003 918.1 Superficial Injury Cornea
18791 cs/Iv NS Jose Trevino, MDH8873
(214)391-2022 451-06-3807
Date 12/30/2003 Page 2 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers (1 Clean Plane-Adecco-Fossil Creek)Service Types (Workers Comp-Workers Comp)
Patient Name DOI Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: ABF Freight-Dallas Contact: Lisa/AI Michael Phone: (877)377-7956
Edwards, Marcus 02/05/2003 02/13/2003 846.0 Sprain/Strain Back, Lumbosacral (jo
5858 RC Margie Prioleau (dls), PA-C 724.1 Pain Thoracic Spine
(902)567-6163 461-04-2170
Tucker, Ray A 01/03/2003 01/06/2003
9536 cs/cs CC Jose Trevino, MDH8873
(817)429-6072 465-66-5401
Payne, Danny 03/10/2003 03/12/2003 840.0 Sprain/Strain Acromioclavicular Join
9627 GS/IV NS Jose Trevino, MDH8873 726.1 Rotator Cuff Syndrome of Shoulder
(972)303-2239 418-23-7515
Walker,Terry 03/26/2003 03/28/2003 846.0 Sprain/Strain Back, Lumbosacral Qo
11726 1 RC Jose Trevino, MDH8873 724.1 Pain Thoracic Spine
(817)858-0546 457-25-1430
Vasquez,Jesse G 03/24/2003 05/30/2003 920, Contusion Face/Scalp/Neck Except
12752 cs/Iv NS Jose Trevino, MDH8873 847.0 Sprain/Strain Neck
(817)468-9446 462-90-4096 844.0 Sprain/Strain Knee, Lateral Collates
Squire, Dennis C 04/29/2003 05/01/2003 923.3 Contusion Finger/Fingernail
15764 Ig RC Patricia Ewing (dls), PA-C 883.0 Wound Finger(s)(nail)w/o Complics
(972)285-1517 459-84-2670
Employer Name: ABF Freight-Fort Worth Contact: Ray Jarrett Phone: (817)335-6221
Holland, Russell 04/08/2002 10/18/2002 842.00 Sprain/Strain Wrist, Unspecified Sit(
22 NR Mark Morris, DOH8268
(817)238-098 451-31-0011
Neal, Billy Ray 02/25/2003 08/15/2003 840.0 Sprain/Strain Acromioclavicular Join
8210 RC Mark Morris, DOH8268
(817)551-1829 462-98-2943
Holland, Larry W 09/03/2003 09/15/2003 842.10 Sprain/Strain Hand, Unspecified Sit(
30930 NR Mark Morris, DOH8268
(817)441-7458 562-72-7678
Kitchen, Donald R. 07/02/2003 10/27/2003 846.0 Sprain/Strain Lumbosacral Qoint)(lic
37221 NI Mark Morris, DOH8268 724.2 Lumbalgia or Lumbago
(817)457-8557 458-78-1577
Date 12/30/2003 Page 3 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers(1 Clean Plane-Adecco-Fossil Creek)Service Types (Workers Comp-Workers Comp)
Patient Name DOI Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: Able Driver Staffing Contact: Sirena McDermott Phone: (972)647-2000
Turner, Kevin T 03/2212003 04/09/2003 840.0 Sprain/Strain Acromioclavicular Join
11320 NS Jose Trevino, MDH8873 726.1 Rotator Cuff Syndrome of Shoulder
(972) 313-4588 429-55-8221
Ellis, John 06/27/2003 07/17/2003 928.3 Crushing Injury Toe(s)
23506 CC Jose Trevino, MDH8873 924.3 Contusion Toe/Toenail
(817)514-6450 467-75-0943
Employer Name: Action Automatic Sprinkler Contact: Melissa Brown Phone: (800)550-2287
Mize, Mackie M 07/15/2003 08/06/2003 923.11 Contusion Elbow
26352 cs NS Jose Trevino, MDH8873 841.0 Sprain/Strain Radial Collateral Ligar
(214)549-2783 426-84-9885
Employer Name: Adampac, Inc. Contact: Evelyn Romero Phone: (817)649-2196
Villa,Joanna 03/26/2003 04/03/2003 924.10 Contusion Lower Leg
11795 NS Jose Trevino, MDH8873
(817)633-4659 636-50-5839
Ibarra, Roman 06/19/2003 07/08/2003 883.0 Wound Finger(s)(nail)w/o Complic,
22314 CC Jose Trevino, MDH8873
(817)563-0088 636-70-5941
Employer Name: Adecco Employment-South Office Contact: Carolyn Magilley Phone: (817)261-8682
Mabry, Leamon C 12/08/2003
42581
(817)485-9224 064-60-6587
n�`
Date : 12/30/2003 Page 4 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers (1 Clean Plane-Adecco-Fossil Creek) Service Types (Workers Comp-Workers Comp)
Patient Name DOI Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: Adecco-#02144 1/Denton Contact: Phone:
Diaz, RobertA 01/21/2003 01/21/2003 692.0 Dermatitis, Due to Detergents
4695 NI Tara Jueschke(hc), PA-C
(940)387-5370 459-45-5593
Robertson,John 02/03/2003 02/17/2003 372.05 Conjunctivitis,Acute Atopic
5507 RC Tara Jueschke (hc), PA-C
(940)321-0794 508-62-8734
Clark, Darrel W 06/06/2003 06/24/2003 692.4 Dermatitis, Due to Other Chemical F
21115 NS Jose Trevino, MDH8873
(940) 383-4112 467-87-4101
Clayborne, Clay A 09/18/2003 09/18/2003 692.0 Dermatitis, Due to Detergents
32797 NI Sue Nguyen(ftw), PA-C
(817) 735-8806 452-73-1076
Vallejo, Cecilia 10/19/2003 12/17/2003 923.20 Contusion Hand(s)Except Finger(s)
37303 NS 842.10 Sprain/Strain Hand, Unspecified Sit(
(682)465-1716 458-89-6409 923.21 Contusion Wrist
842.00 Sprain/Strain Wrist, Unspecified Sit(
Smith, Linda K 12/11/2003 12/29/2003 924.11 Contusion Knee
42902 RC Patricia Ewing (hc), PA-C
(940) 566-7932 446-52-3339
Date : 12/30/2003 Page 5 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers(1 Clean Plane-Adecco-Fossil Creek)Service Types(Workers Comp-Workers Comp)
Patient Name DOI Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: Adecco-Exel Logistics Contact: Carolyn Magilley Phone: (817)608-2231
Castanon,Armando 04/07/2003 04/10/2003 883.0 Wound Finger(s)(nail)w/o Complics
13592 RC Tara Jueschke(hc), PA-C
(817)626-2837 547-73-5124
Cano, Elizabeth 06/02/2003 06/13/2003 924.20 Contusion Foot/Heel
19975 NS Jose Trevino, MDH8873
(817) 980-4990 452-65-1764
Suson, David A 09/17/2003 09/30/2003 845.00 Sprain/Strain Ankle, Unspecified Sit,
32510 NR Dominic Nguyen, MDK7463 845.10 Sprain/Strain Foot, Unspecified Site
(817)444-3533 461-65-5747
Woods, Rosalyn R 10/01/2003 10/21/2003 842.10 Sprain/Strain Hand, Unspecified Sit(
34589 CC Mark Morris, DOH8268 842.00 Sprain/Strain Wrist, Unspecified Sit(
(817) 293-7788 457-31-2063
Finley, Lutricia 11/07/2003 11/17/2003 920. Contusion Face/Scalp/Neck Except
39301 CC Mark Morris, DOH8268 847.0 Sprain/Strain Neck
(817)536-8060 463-25-0971 922.3 Contusion Of Back.
Date 12/30/2003 Page 6 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers (1 Clean Plane-Adecco-Fossil Creek)Service Types (Workers Comp-Workers Comp)
Patient Name DOI Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: Adecco-Fossil Creek Contact: Joyce Dominguez Phone: (817)847-9269
Reyna,Juana 08/20/2002 01/08/2003 923.20 Contusion Hand(s)Except Finger(s)
1709 RC Tara Jueschke(hc), PA-C 842.00 Sprain/Strain Wrist, Unspecified Site
(817)838-9422 627-68-3942
Galan, Hector 11/16/2002 11/18/2002 883.0 Wound Finger(s) (nail)w/o Complic:
1888 NS Jose Trevino, MDH8873
(817)975-4457 467-15-0012
Weaver, Lemuel 11/22/2002 11/27/2002 881.00 Open Wound of the Forearm
2095 NS Jose Trevino, MDH8873
452-91-2207
Salmeron,Victor 11/22/2002 11/26/2002 915.2 Blister to Finger w/o Infection
2106 RC Tara Jueschke (hc), PA-C
(903)524-3831 456-83-1347
Thongkham,Thomas 11/22/2002 11/29/2002 883.0 Wound Finger(s) (nail)w/o Complics
2160 NS Jose Trevino, MDH8873
(817)834-3960 535-02-4117
Chambers,Theodore 12/02/2002 12/12/2002 891.0 Wound, Knee/Leg/Ankle w/o Compli
2404 RC Dominic Nguyen, MDK7463
(817) 534-3660 455-15-6308
Jackson, Richard R 12/09/2002 12/13/2002 846.0 Sprain/Strain Back, Lumbosacral(jo
2722 NS Mark Morris, DOH8268 847.1 Sprain/Strain Thoracic
(817)282-6716 452-67-7842
Moffatt,Timothy W 03/26/2003 06/09/2003 847.0 Sprain/Strain Neck
11866 CC Jose Trevino, MDH8873
(817)282-5270 587-31-9422
Lugo,Joann G 04/09/2003 04/09/2003 682.3 Cellulitis and Abscess of Upper Arm
13552 NI Tara Jueschke (hc), PA-C E905.3 Hornets, Wasps, and Bee Sting
(817)740-0822 464-61-9773
Maltos, Elizabeth 04/09/2003 04/16/2003 930. Foreign Body External Eye
13781 NS Jose Trevino, MDH8873 918.1 Superficial Injury Cornea
(817)335-5271 463-79-2939
Martinez,Jessie M 05/17/2003 05/27/2003 841.0 Sprain/Strain Radial Collateral Ligar
18504 RC Mark Gordon (hc), PA-C
(817)625-9062 453-72-5999
Date 12/30/2003 Page 7 of 7
Time : 05:38:13 pm MedAlert Industrial Health
Open Case Report
Employers(1 Clean Plane-Adecco-Fossil Creek)Service Types (Workers Comp-Workers Comp)
Patient Name DO[ Last Visit Diagnosis
Case Number MRN VT Provider
Phone Number SSN
Employer Name: Adecco-Fossil Creek Contact: Joyce Dominguez Phone: (817)847-9269
Edge,Wilbert Mae 05/23/2003 06/13/2003 842.00 Sprain/Strain Wrist, Unspecified Sit(
19124 CC Jose Trevino, MDH8873 726.4 Bursitis, Hand,Wrist
(817) 798-17 366-38-9651
Diaz, Leaonarda J 07/25/2003 08/20/2003 881.0 Wound Elbow/Forearm/Wrist w/o C(
26273 NR Mark Morris, DOH8268
(817)- 602-82-7556
Miles, Gloria 08/27/2003 11/18/2003 847.1 Sprain/Strain Thoracic
30187 CC Mark Morris, DOH8268 846.0 Sprain/Strain Back, Lumbosacral Qo
(817) 361-0465 451-13-4269 841.0 Sprain/Strain Radial Collateral Ligar
842.00 Sprain/Strain Wrist, Unspecified Sitt
Smith, Linda 09/08/2003 10/31/2003 924.11 Contusion Knee
31441 RC Dominic Nguyen, MDK7463 844.0 Sprain/Strain Knee, Lateral Collates
(817)- 587-11-4365
Kaufman, Kathleen A 10/08/2003 12/29/2003 842.00 Sprain/Strain Wrist, Unspecified Sit(
34959 NS 354.9 Mononeuritis of Upper Limb, Unspe(
(817)246-6596 150-56-9352 842.10 Sprain/Strain Hand, Unspecified Sit(
727.03 Trigger Finger(acquired)
Hammond,Angela C 11/15/2003 12/30/2003 842.00 Sprain/Strain Wrist, Unspecified Sit(
40986 RC Cherie Bennett(hc), PA-C 727.05 Other Tenosynovitis Hand and Wriv
(817)457-1857 455-23-6395
DeHoyos, Cesar 12/16/2003 12/26/2003 844.0 Sprain/Strain Knee, Lateral Collaterr
43377 RC Cherie Bennett(hc), PA-C 843.0 Sprain Iliofemoral
(817)922-9642 454-79-5999
Duckett, Terry L 12/17/2003 12/30/2003 845.00 Sprain/Strain Ankle, Unspecified Sit,
43467 PTF Sonny Tyler, PTA
(817)999-9658 458-06-1681
Upadhyaya, Bhasker K 12/17/2003 12/30/2003 840.9 Sprain/Strain Shouider/Upper Arm, t
43547 PT Dorothy Brown, LPT1009090 848.8 Sprain/Strain Other Specified Sites
(817)358-1900 457-55-6057 843.0 Sprain Iliofemoral
t
nate 12/30/2003
Time 05:34:27 om Page 6 of 11
MedAlert Industrial Health
Employer Activity
Prepared For: Scott Corbo
Dallas City- Police Department
2014 Main Street
Dallas, TX 75201
Service Type : Physical Exam DriverSafety
Patient Case# SSN MRN DOB DOI Discharged Date
Diagnosis Office Visits Visit Date Provider --------------------Work Status------------------
Adams,Joseph B 44386 455-57-9693 jlw/Iv 02/12/1968 12/30/2003
Exams 12/30/2003 Decker(dis)
Jones,Douglas D 44353 585-194133 jlw/cs 02/10/1967 12/30/2003
Exams 12/30/2003 Decker(dis)
Khanhkham, Bruce 44284 25043-2116 Iv/Ig 02/05/1966 12/30/2003
Exams 12/30/2003 Ewing (dis)
Martin,Garland W 44378 524-84-1819 jlw/Iv 03/25/1963 12/30/2003
Exams 12/30/2003 Decker(dis)
Montemayor, Ronnan J 44362 111-11-1111 jlw/cs 05/14/1947 12/30/2003
Exams 12/30/2003 Decker(dis)
Rangel, Mark J 44342 467-67-1336 jlw/cs 04/12/1968 12/30/2003
Exams 12/30/2003 Ewing (dis)
Youngblood, Freddie 44330 16946-4454 jlw/cs 09/14/1955 12/30/2003
Exams 12/30/2003 Decker(dis)
.:e
Date 12/30/2003 Page 1 of 2
Time 05:35:36 pm
MedAlert Industrial Health
Employer Volume - Visit Types within Entity Locations
Occupational Medicine
Employer(Dallas City-Civil Service Department- Dallas City-Civil Service Department)Visit Type (-)
Entity: MedAlert-Dallas Ending Date 12/2003 for 3 Months by Count
Oct 03 Nov 03 Dec 03
Dallas City-Civil Service Department
MedAlert-Dallas
Exams Count=2 Total= 119.00
# 0 1 1
% 0.00 50.00 50.00
$ 0.00 74.00 45.00
% 0.00 9.50 3.90
Special Services Count= 1 Total=0.00
# 1 0 0
% 50.00 0.00 0.00
$ 0.00 0.00 0.00
% 0.00 0.00 0.00
Onsite-Dallas
Flu Shots Count=3 Total=5,805.00
# 1 1 1
% 50.00 50.00 50.00
$ 3,990.00 705.00 1,110.00
% 100.00 90.50 96.10
Totals: 2 2 2
3.990.00 779.00 1,155.00
--------------------------------------------------------------
Grand Total: 6 5,924.00
Date 12/30/2003 Page 2 of 2
Time 05:35:36 pm
MedAlert Industrial Health
Employer Volume - Visit Types within Entity Locations
Occupational Medicine
Employer(Dallas City-Civil Service Department- Dallas City-Civil Service Department)Visit Type( )
Entity: MedAlert-Dallas Ending Date 12/2003 for 3 Months by Count
Oct 03 Nov 03 Dec 03
Grand Total Count= 6 Tota! = 5,924.00
# 2 2 2
$ 3,990.00 779.00 1,155.00
Date 12/30/2003 Page 1 of 11
Time 05:34:27 pm
MedAlert Industrial Health
Employer Activity
Summary Page
Employer(Dallas City- Civil Service Department- Dallas City-Water Department)Visit Type
Date Range: 12/30/2003 - 12/30/2003
Entity: MedAlert-Dallas
Date 12/30/2003
Time 05:34:27 om Page 2 of 11
MedAlert Industrial Health
Employer Activity
Prepared For: Neal Floyd
Dallas City- Equip Bldg Sery Department
2014 Main Street
Dallas, TX 75201
Service Type : Workers Comp
Patient Case# SSN MRN DOB DOI Discharged Date
Diagnosis Office Visits Visit Date Provider --------------------Work Status-----------------
Harrington,Willie 40876 461-92-8349 cs 12/09/1951 11/20/2003 11/24/2003
Contusion Knee New Injury 11/21/2003 Ewing (dls)
Sprain/Strain Knee, Lateral Collateral Ligame Recheck 11/24/2003 Ewing (dis)
Narrative Report 11/24/2003 Trevino
Recheck 12/22/2003 Ewing (dls)
Physical 12/23/2003 Brown
Physical 12/29/2003 Brown
Physical 12/30/2003 Brown
Date : 12/30/2003 Page 1 of 4
Time : 05:41:24 pm MedAlert Industrial Health
Procedure Analysis Report
Provider isits (12/20/1903- 12/30/2003)
Providers (Roge - ogers (hc)) Not Including YTD
Proc STD Charges Pakt�mt
Adjustments
Code Description Rate Count AvgAmt Count Count AvgAmt
Rogers, Brian
2001 Lab CBC Complete Blood Count w/Differential 10.00 14 10 13 (10) 0 0
85025 Lab, Complete Blood Count with Differential 13.43 1 13 1 (13) 0 0
85027 Lab-Complete CBC,Automatic 7.44 1 7 1 (6) 1 (1)
86701 Lab, HIV-1 Antibody 15.51 2 15 1 (15) 0 0
86706 Lab, Hep B Surface Antibody 18.76 1 18 1 (18) 0 0
86803 Lab, Hep C Antibody 24.93 1 24 0 0 0 0
90703 Injection-Tetanus 18.00 21 18 16 (16) 11 (2)
90782 Injection Procedure 11.48 94 11 42 (8) 24 (6)
99071 Educational Supplies 10.00 5 10 0 0 0 0
99201 Office Visit, New Brief 34.00 1 34 0 0 1 (34)
99204 Office Visit-New Extended 106.00 1 106 1 (106) 0 0
A4323 Supply-Eye Saline Solution 5.00 15 5 11 (4) 7 0
A4460 Supply-Wound Care/Dressing Changes 15.00 41 15 31 (5) 21 (11)
A4465 Supply-Elbow Tennis Splint Blue/Foam/Flannel 12.00 2 12 2 (12) 0 0
A4550 Supply-Surgical/Wound Care Trays 10.00 55 10 31 (8) 21 (2)
A4565 Supply-Arm Sling Felt Pad Blue 5.00 2 5 2 (4) 2 0
A4570 Supply-Metal Toad Splint Padded 3.00 1 3 1 (2) 1 0
A6260 Supply-Wound Cleanser 15.00 16 15 10 (5) 6 (11)
A64-10 Supply-Eye Patch, Sterile, each 10.00 2 10 2 (5) 0 0
A6421 Supplies-Wound Care/Dressing Change 10.00 34 10 14 (7) 6 (2)
A6438 Premium Elastic Wrap No Gel/Ice Packs 6.00 5 6 3 (7) 2 0
Absph Physical Asbestos-With Xrays 100.00 1 100 1 (100) 0 0
Arco Isokin/Multi 75.00 1 50 0 0 0 0
Arcon Isokin/Multi L Bac 41.66 7 59 7 (55) 0 0
ARCOT Therapy Physical Performance Test 36.00 30 36 1 (216) 1 (24)
Asbph Asbestos Physical-Without Xrays 70.00 2 70 2 (70) 0 0
Asbqu Asbestos Questionaire 15.00 9 11 7 (15) 0 0
Asphy Asbestos Physical with Xray 100.00 5 100 5 (100) 0 0
Aud Audiometry Pure Tone 15.00 47 15 39 (14) 1 (3)
bodfa Body Fat Anaylsis 10.00 2 10 1 (10) 0 0
CVis Color Vision (Ishihara) 10.00 10 8 8 (10) 0 0
Dot Physical DOT 30.00 210 28 149 (28) 3 (16)
DR01 Drug-Silvadene Cream 10.00 1 10 1 (10) 0 0
DR02 Drug, Tobradex Opth Solution 5ml 20.00 1 20 1 (20) 0 0
E0114 Supply-Crutches 45.00 1 45 1 (23) 1 (21)
E0230 Supply-Gel/Ice Packs 10.00 9 10 7 (8) 6 (1)
E0238 Supply-Ezy Gel Wrap Elastic 13.00 11 13 9 (11) 7 (1)
Ebt Breath Alcohol Testing 15.00 42 15 32 (14) 2 (2)
Ekg Electrocardiogram 45.00 9 45 8 (45) 0 0
IF Injection-Influenza Vaccine 15.00 46 15 1 (690) 0 0
Impai Impairment Rating Evaluation 300.00 18 283 7 (297) 3 (40)
IRC Injection-Rocephin 250mg 30.00 1 28 1 (28) 0 0
J0696 Injection Rocephin, per 250mg 19.00 61 19 10 (57) 9 (10)
J1020 Injection Depo-Medrol 4.00 27 4 15 (3). 9 (1)
J1094 Injection Dexamethasone Acetate 1 MG 1.00 26 1 9 (1) 5 0
J1885 Injection Toradol per 15 mg 8.00 17 8 1 (15) 1 (16)
J2000 Lidocaine 5.00 65 5 31 (3) 25 (2)
L1815 Supply-Knee Brace Cartilage bg el P/O w/comf 50.00 1 50 1 (42) 1 (7)
Date 12/30/2003 Page 2 of 4
Time : 05:41:24 pm MedAlert Industrial Health
Procedure Analysis Report
Visits(12/20/1903- 12/30/2003)
Provider Providers (Rogers- Rogers (hc)) Not Including YTD
Proc STD Charges Payments Adjustments
Code Description Rate Count AvgAmt Count AvgAmt Count AvgAmt
L1825 Supply-Knee Support Elastic 16.00 1 16 1 (16) 0 0
L1830 Supply-Knee Immobilizer Foam Open/Closed 48.00 3 48 1 (48) 0 0
L1902 Supply-Ankle Support P/O Heavy BG Elastic 15.00 2 15 0 0 0 0
L1906 Supply-3-D Walking Boot 129.50 2 129 0 0 0 0
L1930 Supply-Ankle Support-Canvas or Other 34.00 3 34 3 (29) 3 (4)
L3260 Suppply-Post Op Shoe Male/Female 12.00 2 12 1 (10) 1 (1)
L3805 Supply-Abd. Thumb/Wrist 8" Ultimate 29.00 2 29 1 (26) 1 (2)
L3810 Supply-Abd Thum b/Wrist/Forearm 10.5" 36.00 2 36 1 (30) 1 (5)
L3908 Supply-Wahoo/Jonah Wrist Support abd 18.00 1 18 1 (16) 1 (1)
L3909 Supply-Wrist Support 8" Ultimate Ezy 23.00 2 23 1 (11) 1 (11)
L3914 Supply-Wrist Forearm Support 10.5' Ultimate 27.00 2 27 1 (22) 1 (4)
L3928 Supply-Finger/Thumb Splint bg Velcro 10.00 10 10 5 (8) 5 (1)
L3934 Supply-Metal Prong Finger Protector Padded 2.00 6 2 6 (1) 3 0
L4350 Supply-Rigid Ankle Support Adjustable 40.00 6 40 7 (36) 5 (5)
L8210 Supply-Stockinette Synthetic(Ace Bandage) 32.00 5 32 3 (29) 1 (8)
Lbmp Lab, Basic Metabolic Profile 14.79 1 14 1 (14) 0 0
Lcbc Lab Complete Blood Count 16.00 4 18 3 (16) 2 (13)
Lchai Lab Collection Hair Follicle 15.00 2 15 2 (15) 0 0
Ldp Lab Dimension Profile 45.00 8 45 8 (45) 0 0
Lds Lab Drug Screen 30.00 74 28 49 (29) 3 (3)
Ldsc Lab Drug Screen Collection 15.00 41 14 33 (14) 1 (1)
Ldscn Lab Drug Screen Collection Nida 15.00 77 14 60 (14) 1 (14)
Ldse Lab Drug Screen-Escreen 10.00 18 10 2 (10) 0 0
Ldsn Lab Drug Screen/Nida 40.00 37 36 24 (35) 1 (20)
LT Lifting Test 40.00 20 40 8 (40) 0 0
Lua Lab Urinalysis 7.13 6 6 3 (7) 1 (7)
Lvp Venipuncture 15.00 1 10 1 (10) 0 0
NCSM1 NC Stat-Median X1 64.00 3 75 3 (75) 0 0
NCSMT NC STAT Medial Nerve 71.00 2 71 0 0 0 0
NCSUT NC STAT Ulnar Neurve 71.00 2 71 0 0 0 0
OMTT Osteopathic Manipulation Treatment 1-2 Body 37.54 1 37 0 0 0 0
OP Over-Payment 0.00 1 0 1 (190) 0 0
OV01T Office Exam New Brief 43.00 6 35 2 (40) 2 (23)
OV03T Office Exam New Intermediate 114.00 22 114 8 (92) 7 (24)
OVO4T Office Exam New Extended 163.00 49 163 22 (147) 15 (23)
OV05T Office Exam New Comprehensive 207.06 77 207 56 (180) 52 (28)
OV06T Office Exam Opth New Comprehensive 152.00 13 152 9 (138) 7 (17)
OV11T Office Exam Est Brief 26.00 11 27 6 (25) 7 (9)
OV12T Office Exam Est Limited 45.00 2 45 0 0 0 0
OV13D Office Exam-Est Intermediate 66.00 1 66 0 0 0 0
OV13T Office Exam Est Intermediate 63.00 261 63 158 (56) 135 (7)
OV14T Office Exam Est Extended 99.00 255 99 179 (86) 159 (13)
OV15T Office Exam Est Comprehensive 144.00 48 144 42 (126) 38 (19)
OV16T Office Exam Opth Est Comprehensive 113.00 7 113 6 (98) 6 (14)
OV17T Office Exam Opth Est Extended 76.00 2 76 1 (75) 1 0
P005 Lab Basic Chemistry Panel 10.00 2 10 1 (10) 0 0
Pft Pulmonary Function Test 30.00 32 30 18 (30) 0 0
PFTT Pulmonary Function Testing. 49.00 3 49 3 (42) 3 (6)
Phyp Physical PrePlacement 30.00 81 29 69 (27) 9 (11)
Phyrw Physical-Return To Work 40.00 9 40 8 (45) 0 0
Date,: 12/30/2003 Page 3 of 4
Time : 05:41:24 pm MedAlert Industrial Health
Procedure Analysis Report
Visits (12/20/1903- 12/30/2003)
Provider Providers (Rogers- Rogers(hc)) Not Including YTD
Proc STD Charges Payments Adjustments
Code Description Rate Count AvgAmt Count AvgAmt Count AvgAmt
Phys Physical Exam 30.00 1 30 1 (30) 0 0
Rapid Rapid/Lab Drug Screen 30.00 6 30 8 (30) 0 0
Resfi Respirator Phy. 30.00 22 27 11 (30) 0 0
Resqu Respirator Questionnaire 15.00 12 0 0 0 0 0
S1 Supply, Wound Care Kit 10.00 3 10 0 0 3 (10)
S2 Supply,Wound Care Tray 15.00 1 15 1 (15) 0 0
S3 Supply, Suture Removal Tray 10.00 1 10 2 (10) 1 (10)
S4 Supply, Surgical Tray 15.00 3 15 2 (13) 3 (6)
S9 Supply, Dressing 10.00 5 10 2 (8) 5 (8)
Sch School Physical 20.00 3 20 5 (20) 0 0
Spec Specimen 0.00 236 0 0 0 0 0
Stres Stress Test 250.00 1 250 0 0 0 0
SU01T Surgical Drainage of Skin Abcess 124.00 6 124 3 (92) 2 (12)
SU03T Surgical Drainage of Hematoma/Fluid 144.00 8 144 3 (84) 2 (49)
SU04T Surgical Debride Infected Skin 59.00 2 59 0 0 0 0
SU05T Surgical Removal of Nail Plate 92.00 1 92 0 0 0 0
SU06T Surgical Repair Superficial Wound(s)2.5 cm 181.00 16 181 13 (147) 11 (29)
SU07T Surgical Repair Superficial Wound(s)2.5-7.5 192.00 13 192 7 (150) 5 (33)
SU08T Surgical Repair Superficial Wound(s)7.5-12.5 223.00 1 223 1 (199) 1 (23)
SU09T Surgical Layer Closure of Wound(s)2.5 cm 208.00 1 208 1 (187) 1 (20)
SU10T Surgical Layer Closure of Wound(s)2.5-7.5 cm 253.00 7 253 5 (222) 5 (30)
SU11T Surgical Initial Treatment of Bums 92.00 1 92 0 0 0 0
SU12T Surgical Dressing/Debridement/Bums 90.00 5 90 0 0 0 0
SU13T Surgical Injection of Tendon Sheath/Ligament 71.00 13 71 9 (59) 8 (12)
SU14T Surgical Remove Foreign Body from Eye 75.00 4 75 1 (75) 0 0
SU17T Surgical I & D Hematoma, Seroma, or Fluid 143.00 1 143 1 (143) 0 0
SU21T Surgical Simple Repair Face under 2.5 cm 191.43 2 191 2 (177) 1 (28)
SLIT Office Exam- New Surgical 33.00 39 33 14 (30) 7 (7)
TEST Therapy Electric Stimulation 20.00 1 20 1 (20) 0 0
TUST Therapy Ultrasound 15.00 1 15 1 (15) 0 0
TV14T Therapy P/T Eval 89.99 1 76 1 (76) 0 0
TW73 Medical Reports TWCC73 15.00 242 15 140 (13) 128 (2)
TWC69 TWCC 69/Report of Medical Evaluation 15.00 121 15 68 (13) 55 (2)
Void Void Services 0.00 2 0 0 0 0 0
XABT Xray Abdomen 36.00 1 36 0 0 1 (36)
XANT Xray Ankle 36.00 12 36 8 (32) 7 (4)
Xch1 Xray, Chest 1V 40.00 9 35 9 (35) 0 0
XCH1T Xray Chest 1 View 34.00 1 34 0 0 0 0
XCH2T Xray Chest 2 View 43.00 6 43 5 (37) 5 (5)
XCVT Xray Cervical Spine 63.00 6 63 4 (56) 3 (9)
XELT Xray Elbow 38.00 6 38 2 (36) 1 (3)
XFNT Xray Fingers 28.00 3 28 2 (28) 0 0
XFOT Xray Foot 36.00 7 36 5 (31) 4 (5)
XHAT Xray Hand 36.00 14 36 8 (31) 8 (4)
XHPT Xray Hip 41.00 5 41 2 (38) 1 (4)
XKNT Xray Knee 39.00 11 39 6 (35) 6 (3)
XLLT Xray Lower Leg 36.00 2 36 1 Rgj -7- (6)
XIs2 Xray, Lumbar Spine 2V 55.00 5 25 5 (25) .0 0
XLS4T Xray Lumbosacral Spine 4V 64.00 13 64 7 (56) 6 (8)
XLST Xray Lumbosacral Spine 57.00 13 57 8 (54} 4 (4)
Dai" 12/30/2003 Page 4 of 4
Time ; 05:41:24 pm MedAlert Industrial Health
Procedure Analysis Report
Provider Visits (12/20/1903- 12/30/2003)
Providers (Rogers- Rogers (hc)) Not Including YTD
Proc STD Charges Payments Adjustments
Code Description Rate Count AvgAmt Count AvgAmt Count AvgAmt
XPET Xray Pelvis 36.00 2 36 0 0 0 0
XRC2T Xray Rib 2 View 41.00 4 41 3 (36) 3 (4)
XSET Xray Spine Entire 78.00 1 78 1 (68) 1 (9)
XSHT Xray Shoulder 39.00 6 39 3 (39) 0 0
XSKT Xray Skull 64.00 1 64 2 (60) 1 (6)
XTHT Xray Thoracic 57.00 7 57 4 (50) 4 (6)
XWRT Xray Wrist 36.00 13 36 7 (33) 5 (3)
Rogers (hc), Brian
73030 Xray--Shoulder-(2V) 60.00 1 60 1 (60) 0 0
90782 Injection Procedure 11.48 2 11 42 (8) 24 (6)
A4465 Supply-Elbow Tennis Splint Blue/Foam/Flannel 12.00 1 12 2 (12) 0 0
A4550 Supply-Surgical/Wound Care Trays 10.00 1 10 31 (8) 21 (2)
A6421 Supplies-Wound Care/Dressing Change 10.00 1 10 14 (7) 6 (2)
Arcon Isokin/Multi L Bac 41.66 2 50 7 (55) 0 0
Aud Audiometry Pure Tone 15.00 3 15 39 (14) 1 (3)
Dot Physical DOT 30.00 3 28 149 (28) 3 (16)
Ebt Breath Alcohol Testing 15.00 1 15 32 (14) 2 (2)
J1020 Injection Depo-Medrol 4.00 1 4 15 (3) 9 (1)
J1094 Injection Dexamethasone Acetate 1 MG 1.00 1 1 9 (1) 5 0
J2000 Lidocaine 5.00 1 5 31 (3) 25 (2)
L3934 Supply-Metal Prong Finger Protector Padded 2.00 1 2 6 (1) 3 0
L4350 Supply-Rigid Ankle Support Adjustable 40.00 2 40 7 (36) 5 (5)
Lds Lab Drug Screen 30.00 6 27 49 (29) 3 (3)
Ldsc Lab Drug Screen Collection 15.00 2 15 33 (14) 1 (1)
Ldscn Lab Drug Screen Collection Nida 15.00 1 10 60 (14) 1 (14)
Ldsn Lab Drug Screen/Nida 40.00 1 40 24 (35) 1 (20)
OVO4T Office Exam New Extended 163.00 2 163 22 (147) 15 (23)
OV05D Office Exam-New Comprehensive 217.00 1 217 1 (100) 1 (117)
OV05T Office Exam New Comprehensive 207.06 1 207 56 (180) 52 (28)
OV13T Office Exam Est Intermediate 63.00 15 63 158 (56) 135 (7)
OV14T Office Exam Est Extended 99.00 11 99 179 (86) 159 (13)
OV15T Office Exam Est Comprehensive 144.00 4 144 42 (126) 38 (19)
OV17T Office Exam Opth Est Extended 76.00 1 76 1 (75) 1 0
Phyp Physical PrePlacement 30.00 7 27 69 (27) 9 (11)
Pts1 Supply-Theraputty 25.00 1 25 1
(25) 0 0
Pts8 Supply-4 oz Biofreeze 20.00 2 20 1 (20) 1 (20)
Rapid Rapid/Lab Drug Screen 30.00 4 15 8 (30) 0 0
S3 Supply, Suture Removal Tray 10.00 3 10 2 (10) 1 (10)
S41 Supply, Coban 10.00 1 10 1 (10) 0 0
S5 Supply, Eye Tray 15.00 1 15 1 (9) 1 (6)
S9 Supply, Dressing 10.00 1 10 2 (8) 5 (8)
Sch School Physical 20.00 2 20 5 (20) 0 0
Spec Specimen 0.00 10 0 0 0 0 0
TW73 Medical Reports TWCC73 15.00 4 15 140 (13) 128 (2)
TWC69 TWCC 69/Report of Medical Evaluation 15.00 9 15 68 (13) 55 (2)
XELT Xray Elbow 38.00 1 38 2 (36) 1 (3)
XFNT Xray Fingers 28.00 1 28 2 (28) 0 0
XLST Xray Lumbosacral Spine 57.00 1 57 8 (54) 4 (4)
XSKT Xray Skull 64.00 1 64 2 (60) 1 (6)
D-ze : 12/30/2003
Time,: 05;40:40 pm Page 1 of 1
MedAlert Industrial Health
Procedure Analysis Report
Visits (12/30/2003- 12/30/2003)
Summary Not Including YTD
Proc STD Charges Payments Adjustments
Code Description Rate Count AvgAmt Count AvgAmt Count AvgAmt
OP Over-Payment 0.00 1 0 1 (5) 0 0
TESD Therapy-Electric Stimulation 21.00 8 21 0 0 0 0
TEST Therapy Electric Stimulation 20.00 5 20 0 0 0 0
TJMD Therapy-Joint Mobilization 34.00 12 34 0 0 0 0
TMMD Therapy-MMT Hands 36.00 1 36 0 0 0 0
TMRD Therapy-Myofascial Release 34.00 2 34 0 0 0 0
TPBD Therapy-Paraffin Bath 10.00 3 10 0 0 0 0
TPPD Therapy-Phonophoresis 21.00 5 21 0 0 0 0
TTAD Therapy-Therapeutic Activities 37.00 2 37 0 0 0 0
TTAT Therapy Therapeutic Activities 35.00 2 35 0 0 0 0
TTED Therapy-Therapeutic Exercise 36.00 30 36 0 0 0 0
TTET Therapy Therapeutic Exercises 35.00 20 35 0 0 0 0
TV13D Therapy-P/T Re-Eval 50.76 7 50 0 0 0 0
TV14D Therapy-P/T Eval 94.11 2 94 0 0 0 0
Date : 12.'30/2003 Page 1 of 2
i ime ;05:42:27 pm
MedAlert Industrial Health
Visit Activity Report by Provider
Including Time In and Time Out
Visits (12/30/2003- 12/30/2003)Not Including Charges
Office Location (MedAlert-Arlington-MedAlert-Arlington)Providers(-)
Provider Condensed (1 line per visit)
Vis Date Patient Name VT Employer Name ST Case# In Out Total
MedAlert-Arlington
** Undefined **, ** Undefined '*
12/30/2003 Alecio, Elida CC Vecta Workers 38614
Peel,Andrew M RS Lowe's 1511 Workers 42881 ( /
Garberson,Virqinia EX Lockheed Martin Physical 44387 3:53p / /
Robles,Jacob EX Dominos Pizza DOT Exam 44392 4:22p / /
Visit Count: 4
MA Tech,
12/30/2003 Perez, Eva SS Revcor Molded Workers 1694 12:32p / /
Kerr, Michael DS Robertson Fleet Substance 44293 08:40a / 09:06a /0:26
Jouett,John DS Robertson Fleet Substance 44294 08:43a /09:07a 10:24
Thornton,Jeff R. DS Horizon Freight Substance 44296 08:47a l l
Foster, Karen SS Labone Inc. Lab Only 44299 09:04a / 09:20a /0:16
Clark, Nathan DS Robertson Fleet Substance 44314 10:12a / 10:28a 10:16
Meinecke,Juerqen SS Labone Inc. Lab Only 44323 10:58a / 11:31a /0:33
Folsom, David DS Lonestar Drivers Substance 44328 11:11a / /
Evans, Martin L DS Transcar Auto Preplacement 44355 1:13p / /
Watkins, LaShe N. CL Total Enterprise Substance 44367
Watkins, LaShe N. DS Total Enterprise Substance 44367 2:16p /2:38p /0:22
Lane,John R.T. DS Lowe's Home Center Substance 44368 2:22p / /
Blandin,Jay S. DS Dominos Pizza Substance 44377 2:59p /3:15p 10:16
Monsivais,Antonio SS United States Cold Preplacement 44382 3:28p / /
Corral, Carlos SS United States Cold Preplacement 44383 3:33p /4:38p /1:05
Bell, Stephanie DS l aramar Group#19 Substance 44385 3:46p /4:37p 10:51
Jones, Darryl DS Walmart 1801 Substance 44395 4:37p / /
Visit Count: 17
Rogers, Brian
12/30/2003 Harris, Tina RC McLane Foods Workers 4262 1:01p l l
Talamantez, Jason RC Fiesta Mart Inc 60 Workers 36264 1:56p /3.31p /1:35
Arnett, Irma RC Sanders Esters Unit Workers 38432 1:34p / 2:40p /1:06
Shoemake, John RC Fiesta Mart Inc 60 Workers 39584 1:03p / 1:49p 10:46
Miller,Jonathan RC Lowe's 1511 Workers 42569 1:35p /2:17p /0:42
Brown, Sherron RC Kinder Care Workers 42982 2:41p / 3:49p 11:08
Anderson, Willie EX Solvay Engineered Respirator 44285 08:10a / 08:53a 10:43
McNeill, Steve EX Solvay Engineered Respirator 44288 08:16a / 09:09a /0:53
Dale,Terry NI Jack Cooper Workers 44292 08:33a /09:31a 10:58
Oliver, Ronald EX Special Distribution DOT Exam 44303 09:37a / 10:10a 10:33
Dixon, Jerry EX Arnold Transport DOT Exam 44312 10:08a / 12:18p /2:10
Perkins, Edward C NI Jack Cooper Workers 44317 10:25a / 11:09a 10.44
Steele, Thadeus EX Oak Cliff Mirror&Glass Preplacement 44318 10:27a / 12:00p 11:33
Holt, Brandon NI Walmart 1801 Workers 44324 10:58a / 12:40p /1:42
Kaylor, Nicholas EX Oak Cliff Mirror&Glass Preplacement 44329 11:08a / 1:27p /2.19
Clement,Quentin W NI Turbomeca-Microturbo Workers 44335 11:10a / 12:20p /1:10
Rosales, Maqdeleno NI Larry Miller Roofing Workers 44341 11:44a / 1:29p /1:45
Saldivar, Ricardo NI Federal Express-Osler Workers 44363 2:11p / 3:13p /1:02
Derrouqh, Reqinald EX Solvay Engineered Respirator 44379 3:03p / 3.49p 10:46 {
Cate : 12/30/2003 Page 2 of 2
Tin,,. :05:42:27 pm MedAlert Industrial Health
Visit Activity Report by Provider
Including Time In and Time Out
Visits (12/30/2003- 12/30/2003) Not Including Charges
Office Location (MedAlert-Arlington- MedAlert-Arlington)Providers(-)
Provider Condensed (1 line per visit)
Vis Date Patient Name VT Employer Name ST Case# In Out Total
MedAlert-Arlington (Continued)
Rogers, Brian (Continued)
Almaraz, Ricardo CL Oak Cliff Mirror&Glass Preplacement 44384 / /
Almaraz, Ricardo EX Oak Cliff Mirror&Glass Preplacement 44384 3:46p /4:40p /0:54
Visit Count: 21
Visit Count for MedAlert-Arlington 42
Total Visit Count: 42
Date :12/30/2003 Page 1 of 2
Time'05'43:12 pm
MedAlert Industrial Health
Ch Number Summary Report by Guarantor
Occ. Med Cases
Batch Close Date (12/30/2003- 12/30/2003)
Check Number(-)
Guarantor( Adolphus Hotel WC-C& L Foods Inc)
Adecco-Exel Logistics i
Check Number: #800540
Case/Acct# Patient Name Visit Date Pay Amount
33666 Bartosh, Cody W 09/25/2003 (14.00)
32086 Conchas, Umaro 09/12/2003 (14.00)
32087 Garcia, Jaime 09/12/2003 (14.00)
37224 Hermosillo, Monica 10/27/2003 (14.00)
36533 Loevng,Vanny 10/21/2003 (14.00)
35893 Pitre, Guillermine O 10/16/2003 (14.00)
(14.00)
32667 Quangvan,Thom 09/17/2003 (14.00)
37772 Sanchez,Albino 10/30/2003 (14.00)
Total Check##800540 (126.00)
Aig Insurance
Check Number: #33032356
Case/Acct# Patient Name Visit Date Pay Amount
41079 Perches,Jorge 12/03/2003 (56.53)
(13.50)
Total Check##33032356 (70.03)
Check Number: #33034058
Case/Acct# Patient Name Visit Date Pay Amount
8649 Fowler,Angelika M 12/02/2003 (56.53)
Total Check##33034058 (56.53)
Check Number: #33034731
Case/Acct# Patient Name Visit Date Pay Amount
25417 Martinez, Lidia 12/03/2003 (56.53)
(13.50)
Total Check##33034731 (70.03)
ARCMI Of Texas
Check Number: #01461790
Case/Acct# Patient Name Visit Date Pay Amount
37277 Pearce III, Charles M 11/06/2003 (56.53)
Total Check##01461790 (56.53)
Check Number: #01461798
Case/Acct# Patient Name Visit Date Pay Amount
38094 Freeman, Elvira 11/21/2003 (56.53)
(13.50)
Total Check##01461798 (70.03)
Check Number: #01461898
Case/Acct# Patient Name Visit Date Pay Amount
42065 Bishop, Ashley 12/04/2003 (9.00)
(31.50)
Total Check##01461898 (40.50)
Date :12/30/2003 Page 2 of 2
Time-05:43:12 pm
MedAlert Industrial Health
Check Number Summary Report by Guarantor
Occ. Med Cases
Batch Close Date (12/30/2003- 12/30/2003)
Check Number(-)
Guarantor( Adolphus Hotel WC-C& L Foods Inc)
Broadstire Insurance-Florida
Check Number: #6140091575
Case/Acct# Patient Name Visit Date Pay Amount
2708 Catanach, Clarence 12/10/2002 (13.50)
Total Check##6140091575 (13.50)
Date :12-'30/2003 Page 1 of 4
Time :05:41:55 pm
MedAlert Industrial Health
Referral Activity Report - By Date
Date(12/01/2003-12/30/2003)CallBack(-)
Referred(-) Referral Types(-)
Date Referral Source Patient Name MRN Case/Acct #
Referral Type
12/01/2003
Consultation form Roberts, Clifford cs/Ig 41594
Count: 1
Advance Imaging,
MRI Scroggins, Howard L Ig/cs 40116
Count: 1
Ortho Neuro Imaging,
MRI Temple,Tory L Ig/Ig 29224
Count: 1
12/0312003
Ortho Neuro Imaging,
MRI Evans, Jason L cs/Ig 41497
Appointment made Nowell,Wayne Jr. 41804
Count: 2
12/0512003
Consultation form Avila,Antonio B cs/Ig 32064
Talamantez, Jason 36264
Appointment made Kinler, Marc 36434
Appointment made Kinler, Marc 36434
Count: 4
Khubchandani,Zubin
Appointment made Nowell,Wayne Jr. 41804
Count: 1
Kielgaard,
1 st Call to Specialist Cheeks, Lajuliet Y 35121
Count: 1
Westkaemper,John
Consultation form Hernandez, Fidel C cs/Ig 42119
Count: 1
12/08/2003
I
Date :1'30/2003 Page 2 of 4
Time :05:41:55 pm
MedAlert Industrial Health
Referral Activity Report - By Date
Date(12/01/2003-12/30/2003)CallBack(-)
Referred(-) Referral Types(-)
Date Referral Source Patient Name MRN Case/Acct #
Referral Type
Westkaemper,John
Consultation form Felton,Arlie M jlw/cs 42379
Count: 1
12/10/2003
Consultation form Osornio, Rita cs/cs 36179
Count: 1
Cruz, Erwin
Consultation form Richardson, Eric D jlw/cs 24570
Consultation form Scroggins, Howard L Ig/Gs 40116
Count: 2
Westkaemper,John
Consultation form Duran,Jose M Ig 36155
Count: 1
12/11/2003
Consultation form Cassio, Juan P 42843
Count: 1
Advance Imaging,
MRI Zarate,Alfredo jiw/Iv 41573
Count: 1
Beg, Saeed
Consultation form Cruz, Crescencio jiw/Ig 42978
Count: 1
Westkaemper,John
Consultation form Poteat, Faye J Ig/Ig 34740
Count: 1
12/12/2003
Consultation form Orozco, Samuel CS/Iv 3 805
Count: 1
Date :12-'30/2003
Page 3 of 4
Time :05:41:55 pm
MedAlert Industrial Health
Referral Activity Report - By Date
Date(12101/2003-12/30/2003) Calleack(-)
Referred(-) Referral Types(-)
Date Referral Source Patient Name MRN Case/Acct #
Referral Type
Ogunro, Olayinka, MD,FACS
Consultation form Staton,Jonathan T jiw/Ig 37244
Count: 1
12/17/2003
Fadahunsi, Patrick
Consultation form Nieto, Gustavo I cs/Iv 41562
Count: 1
12/18/2003
Westkaemper,John
Appointment made Duran, Jose M Ig 36155
Count: 1
12/1912003
Westkaemper,John
Consultation form Motley,Joseph A jlw/cs 7265
Count: 1
12/22/2003
Beavers, Bruce
Consultation form Parham, Charles Ig/Iv 43012
Count: 1
Westkaemper,John
Consultation form Agbonlahor, Peter N Ig/Iv 34783
Count: 1
12/26/2003
Consultation form Phifer,Christi S jlw/cs 44151
Count: 1
Westkaemper,John
Consultation form Gee, David L jlw/jlw 41954
Count: 1
12/29/2003
Date :12/30/2003 Page 4 of 4
Time :05:41:55 pm
MedAlert Industrial Health
Referral Activity Report - By Date
Date(12/01/2003-12/30/2003) CallBack(-)
Referred(-)Referral Types(-)
Date Referral Source Patient Name MRN Case/Acct #
Referral Type
Beg,Saeed
Consultation form Whittaker, Norman T cs/jlw 44225
Count: 1
Ogunro, Olayinka, MD,FACS
Orthopedic Guerra, Ernesto cs 30578
Count: 1
12/30/2003
Johnson, Larry
Consultation form Carrion, Sugey cs/Iv 41282
Consultation form Zarate,Alfredo jlw/Iv 41573
Count: 2
Total Count: 34
Spp a�.�J
ill 15 ,
Date :12/302003 Page 1 of 8
Time :05:37:36 pm
MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: Adecco-#02144 1/Denton
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Tennison, Bobby
12/09/2003 786.2 Cough 8 0 0 0
514, Pulmonary Congestion and
Smith, Linda K
12/11/2003 924.11 Contusion Knee 20 0 0 0
Date : 12/30.2003 Page 2 of 8
Time :05:37:36 pm MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: Adecco-Fossil Creek
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Mabry, Leamon C
12/09/2003 845.00 Sprain/Strain Ankle, Unspecified 21 0 0 0
Sewell, Russell L
12/14/2003 883.0 Wound Finger(s) (nail)w/o 13 0 0 0
DeHoyos, Cesar
12/16/2003 844.0 Sprain/Strain Knee, Lateral 15 0 0 0
843.0 Sprain Iliofemoral
Duckett,Terry L
12/17/2003 845.00 Sprain/Strain Ankle, Unspecified 14 0 0 0
Upadhyaya, Bhasker K
12/17/2003 840.9 Sprain/Strain Shoulder/Upper 14 0 0 0
848.8 Sprain/Strain Other Specified
843.0 Sprain Iliofemoral
Hamilton, Christina D
12/20/2003 930. Foreign Body External Eye 3 0 0 0
918.1 Superficial Injury Cornea
Date : 12/30;2003 Page 3 of 8
Time :05:37:36 pm MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: Adolphus Hotel
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Figueredo, Maria A
12/06/2003 924.8 Multiple Contusions-Lower 22 0 0 0
923.8 Contusion Upper Limb Multiple
922.3 Contusion Of Back.
E885. Fall on Same Level from Slipping,
Ochoa,Oliverio
12/06/2003 940.0 Chemical Burn Eyelids/Periocular 16 0 0 0
943.0 Burn Upper Limb, Except
Galvan, Louretta J
12/16/2003 844.0 Sprain/Strain Knee, Lateral 15 0 0 0
Cruz, Elvira
12/26/2003 841.0 Sprain/Strain Radial Collateral 2 0 0 0
924.11 Contusion Knee
E885. Fall on Same Level from Slipping,
Dats :12/30!2003 Page 4 of 8
Time :05:37:36 pm MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: Air B P
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Gott, Matthew
12/29/2003 843.0 Sprain Iliofemoral 2 0 0 0
Date :12/30/2003 Page 5 of 8
Time :05:37:36 pm MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: American Environmental Specialities
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Petrozzelli,Angela
12/24/2003 692.6 Dermatitis, Due to Plants 7 0 0 0
Date : 12/30/2003 Page 6 of 8
Time :05:37:36 pm
MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: American Porcelain Enamel
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Ly, Binh
12/22/2003 941. Burn Face/Head/Neck 9 0 0 0
Date : 1213C/2003 Page 7 of 8
Time :05:37:36 pm MedAlert Industrial Health
Diagnosis Analysis Summary
Employer Name: American Red Cross/Chisholm Trail Charity
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Eanes,Jacob
11/17/2003 983.0 Inhalation of Chemicals 27 0 0 0
Hawthorne, Harold
12/22/2003 E812. Other Motor Vehicle Traffic 9 0 0 0
Dats :12/3C/2003 Page 8 of 8
Time :05:37:36 pm MedAlert Industrial Health
Diagnosis Analysis Surnmary
Employer Name: Americanos Bus USA LLC
Patient Name Employer Treatment Work Status
Date of Injury Department Diagnosis Days (1) (2) (3)
Ojeda,Gonzalo
12/20/2003 846.0 Sprain/Strain Lumbosacral (joint) 9 0 0 0
843.0 Sprain Iliofemoral
Date :12/30/2003
Time:05:37:36 pm M ert Indu trial Health
Diagnosis Analysis ummary
Control Information
1st Visit Range: 12/01/2003- 12/30/2003
Type: New Injury
Discharged Range:00/00/0000-00/00/0000
Diagnosis Range: . - .
Employer Range: 1 Clean Plane-Americredit Fianancial Services
SIC:
IC:
Case:0
City of Fort Worth, Texas
Mayor and Council Communication
COUNCIL ACTION: Approved on 11/18/2003
DATE: Tuesday, November 18, 2003
LOG NAME: 14MEDALERT REFERENCE NO.: **C-19855
SUBJECT:
Authorization to Enter an Agreement with MedAlert Industrial Health, Inc. as the Medical Provider for
Occupational Health and Safety Services
RECOMMENDATION:
It is recommended that the City Council authorize the City Manager to execute a contract with MedAlert
Industrial Health, Inc. as the medical provider for occupational health' and safety services beginning
February 1, 2004, through January 31, 2005, with four (4) one-year options to renew.
DISCUSSION:
Concentra Medical Centers is the current provider of occupational health services for City
employees. Some of the services provided by Concentra Medical Centers include medical treatment for on-
the-job injuries, drug and alcohol testing and counseling, pre-employment physicals, and vaccinations. The
contract with Concentra Medical Centers expires on January 31, 2004.
On July 23, 2003, the Human Resources Department initiated a competitive process by soliciting
qualifications of potential providers. Eight (8) responses were received from the following
companies: MedAlert Industrial Health, Inc., Concentra Medical Centers, Care Now, Occupational Health
Systems of Texas, Medcor, Susan Steele Work Assessments, Sports Rehabilitation Specialists, Inc., and
the Center for Rehabilitative Medicine.
A ten (10) member committee consisting of employees from the Police, Fire, Transportation and Public
Works, Water, Code Compliance, and Human Resources Departments assisted in reviewing all
proposals. The review was based on the qualifications of the organization, staff qualifications, pricing,
approach/methodology, and M/WBE participation.
Representatives from the committee and a registered nurse from the Public Health Department conducted
an on-site visit of the top two (2) finalists. The committee recommended MedAlert Industrial Health, Inc.
(MedAlert) as the service provider, and staff concurs with the recommendation. MedAlert was selected
based on its comprehensive approach to occupational medicine, and ability to partner with the City to
provide cost effective, quality occupational health services.
MedAlert will also provide additional services such as early intervention through Injury Management
Organization. This service will enhance the communication between the injured employee, supervisor, and
the medical provider, and reduce the amount of time employees are away from work.
Services were priced on a per unit basis. It is anticipated that the cost for all services will be approximately
$658,000. It is estimated the City will spend $492,000 for occupational injuries, $123,000 for occupational
medical services, and $43,000 for drug testing in FY2003-2004. Based on the average utilization from the
previous year, MedAlert's proposal is approximately $110,000 less than the proposal submitted by the
current provider. The MedAlert pricing for all services is listed on Attachment A.
T nnnama• 1 dNAPTI A T FRT
Currently, MedAlert's primary Fort Worth clinic is located approximately 7.5 miles from City Hall. However,
MedAlert has committed to construct a new facility at 711 Pennsylvania Avenue, approximately 1 mile from
City Hall. The newly constructed clinic will be 3,500 square feet, which will include exam rooms, a physical
therapy area, a lab, a drug screening area, and an x-ray and development area. The personnel at this
facility will include physicians and medical staff dedicated to City employees. The anticipated date of
completion of the facility is April 2004.
M/WBE - MedAlert is in compliance with the City's M/WBE Ordinance by committing to 10% M/WBE
participation. The City's goal on this project is 10%.
FISCAL INFORMATION/CERTIFICA-TION:
The Finance Director certifies that funds are available in the current operating budgets, as appropriated, of
the Workers' Compensation Fund and the General Fund.
TO Fund/Account/Centers FROM Fund/Account/Centers
FE73 534600 0147310 $492-000.00
FE73 539120 0147310 $123,000.00
GG01 539120 0144000 $43,000.00
Submitted for City Manager's Office by: Richard Zavala (Acting) (6222)
Originating Derartment Head: Anthony Snipes (Acting) (7783)
Additional Information Contact: Janina Flores (7766)
Lovaname: 14MEDALERT