HomeMy WebLinkAboutContract 46374 CITY SECRETi '
C117R?CT NO.
PROFESSIONAL SERVICES AGREEMENT
1. AGREEMENT BETWEEN PARTIES
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 of the State of Texas, acting by and through Susan Alanis, its duly authorized
Assistant City Manager, and TEXAS HEALTH HARRIS METHODIST HOSPITAL
FORT WORTH., d/b/a TEXAS HEALTH HARRIS METHODIST
OCCUPATIONAL HEALTH (the "PROVIDER"), acting by and through Lillie Biggins
its duly authorized President, Texas Health Harris Methodist Hospital Fort Worth
2. GENERAL
2.1 PROVIDER hereby agrees to provide the CITY, in accordance with medically
necessary or appropriate professional standards, a full range of occupational injury
medical treatment and 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
Q facilities and other locations as may be mutually agreed to in writing b PROVIDER
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a
and CITY.
Q C
2.4 Both parties recognize the non-exclusive nature of this Agreement and acknowledge
and agree that CITY is free to engage persons other than PROVIDER to furnish
injury-related occupational health care and workers' compensation services
compensable or defined under the Texas Labor Code, as currently in effect or
hereafter amended. PROVIDER further acknowledges that the CITY has elected
to contract with multiple vendors as preferred providers of occupational injury
medical treatment and health care services.
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2.5 PROVIDER is not authorized to furnish non-injury occupational health care services
under the terms of this Agreement, and CITY shall bear no responsibility for
compensating PROVIDER for any such services.
3. AGREEMENT TERM
3.1 The initial term of this Agreement shall commence on January 1, 2015 ("Effective
Date") and shall expire on December 31, 2017, unless terminated earlier in
accordance with the provisions of this Agreement.
3.2 CITY shall have the sole right to renew this Agreement for two additional 1-year
terms. If CITY desires to exercise an option to renew, CITY shall notify PROVIDER
in writing of its intention to renew at least 60 days prior to the end of the then-current
term. Compensation to be paid during any option term shall be the same as that
provided for in the Initial Term.
4. 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 specified medical
treatment and care provided to 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 Billing of all medical services related to a compensable on-the-job injury will be
submitted directly to the CITY's contractor / third party administrator ("TPA") for
workers' compensation claims in accordance with the Texas Labor Code and related
administrative rules, as outlined in Exhibit`B."
4.3 For any alleged on-the-job injury that the TPA determines is not a compensable
injury, CITY agrees to pay, through its TPA, for initial and follow-up office visits
(including medical treatments provided during those visits) that occur prior to the
TPA's determination.
4.5 For any alleged on-the-job injury that the TPA determines is a compensable injury,
the CITY, through its TPA, shall pay for care and services that are related to the
compensable injury with the amount of such payments to be determined according to
reasonableness and medical necessity of the treatment or service, in accordance with
Texas Department of Insurance —Division of Workers' Compensation ("TDI-DWC"
or"DWC")treatment guidelines and DWC-approved medical fee schedules.
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4.6 Billing issues, including contests, disputes, and requests for additional
documentation, shall be handled in accordance with Section 408.027 of the Texas
Labor Code or its successor.
5. RECORDS AND RECORDS MANAGEMENT
5.1 PROVIDER will adhere to and follow the governing guidelines as they pertain to the
protection and use of collected data (personal/medical information). CITY may, to
the extent permissible under applicable 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-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), 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.
5.3 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 law and
PROVIDER's 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 concerning 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.
5.4 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
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authorization and (ii) 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.
5.5 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 of this Agreement.
5.6 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 under
applicable law, shall have access to such reports and records during PROVIDER's
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
under applicable law, retrieve original copies of all reports and records relating to
terminated employees from PROVIDER at any time.
6. MINORITY BUSINESS ENTERPRISE (MBE)PARTICIPATION
6.1 In accord with the CITY Code of Ordinances, the CITY has goals for the
participation of minority 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 Because subcontracting opportunities for occupational injury medical treatment and
care services are negligible,no MBE goal has been set for this Agreement.
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7. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
("HIPAA")
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, amendments thereto, 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 HIPAA.
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
will 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 known 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"), 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
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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 5 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 Consistent with HIPAA requirements, report to appropriate federal and state
authorities violations of law relating to Protected Health Information.
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 of the 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.
7.3.2 Providing PROVIDER with any changes in, or revocation of, permission by an
individual to use or disclose Protected Health Information, if such changes
affect PROVIDER's 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.
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7.4 Termination for material breach of HIPAA by PROVIDER
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 HIPAA requirements of this Agreement and a cure is not possible;
or
7.4.3 If neither termination nor cure is feasible, report the violation to the Secretary.
7.5 Effect of Termination
7.5.1 Except as provided in Section 5, upon termination of this Agreement, for any
reason, PROVIDER shall return or destroy all Protected Health Information
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 further 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 to comply with requirements of
HIPAA.
7.6.2 The respective rights and obligations of PROVIDER under Section 7.5 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.
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8. TERMINATION
8.1 Written Notice
The CITY or PROVIDER may terminate this Agreement at any time, with or without
cause,by providing the other party with 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.
8.2 Non-a ro riation of Funds
In the event no funds or insufficient funds 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 PROVIDER 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'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 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 CONFIDENTIAL INFORMATION
PROVIDER hereby warrants to the CITY that PROVIDER has made full 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
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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 ("City Information") 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
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
extent permissible by applicable law, at reasonable times any directly pertinent
books, documents, papers and records of PROVIDER involving transactions
relating to this Agreement at no additional cost to the CITY. 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 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 for 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
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omissions of its officers, agents, servants, employees, contractors and subcontractors.
PROVIDER acknowledges that the doctrine of respondeat 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 INDEMNIFICATION
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 ALL PERSONS, OF ANY KIND OR
CHARACTER, WHETHER REAL OR ASSERTED, TO THE EXTENT
CAUSED BY THE NEGLIGENT ACT(S) OR OMISSION(S),
MALFEASANCE OR INTENTIONAL MISCONDUCT OF PROVIDER, ITS
OFFICERS,AGENTS, SERVANTS, OR EMPLOYEES.
12.2 PROVIDER COVENANTS AND AGREES TO, AND DOES HEREBY,
INDEMNIFY, HOLD HARMLESS AND DEFEND THE CITY, ITS
OFFICERS, AGENTS, SERVANTS AND EMPLOYEES, FROM AND
AGAINST ANY AND ALL CLAIMS OR LAWSUITS FOR EITHER
PROPERTY DAMAGE OR LOSS (INCLUDING ALLEGED DAMAGE OR
LOSS TO PROVIDER'S BUSINESS AND ANY RESULTING LOST
PROFITS) AND/OR PERSONAL INJURY (INCLUDING DEATH) TO ANY
AND ALL PERSONS, OF ANY KIND OR CHARACTER, WHETHER REAL
OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THIS
AGREEMENT, TO THE EXTENT CAUSED BY THE NEGLIGENT ACTS
OR OMISSIONS OR MALFEASANCE OF PROVIDER, ITS OFFICERS,
AGENTS, SERVANTS, OR EMPLOYEES.
13. ASSIGNMENT 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
consent 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 fully executed copy
of any such subcontract. Any attempted assignment or delegation of PROVIDER shall be
wholly void and totally ineffective for all purposes unless made in conformity with this
section.
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14. INSURANCE
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 that are required to be
in effect throughout the term of this Agreement and any renewals thereof and that are
to provide minimum coverage limits in accordance with this section.
14.2 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. Coverage shall be written in the following types and amounts:
14.3.1 Workers' Compensation—Statutory
Employers' Liability- $500,000/$500,000/$500,000
14.3.2 Commercial General (Public) Liability Insurance to include the following
types of coverage: Premises/Operations, Independent Contractors,
Products/Completed Operations,Personal Injury, and Contractual Liability.
(Combined Single Limit for Bodily Injury and Property Damage
$1,000,000 per Occurrence and $2,000,000 Aggregate)
14.3.3 Automobile Liability for Owned/Leased Vehicles, 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
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14.3.6Medical 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 shall have Medical Malpractice coverage with minimum limits of
$200,000 per medical incident,with a$600,000 aggregate limit.
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 terms, 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.
14.8.2 An endorsement stating that PROVIDER's insurance shall be deemed primary
and that any self-funded or commercial coverage maintained by the CITY shall
not be called upon to contribute to loss recovery.
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 to the change, or ten (10) days' notice for cancellation due to
nonpayment of premiums, which notice must be accompanied by a replacement
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Certificate of Insurance. All notices shall be given to the CITY at the following
address:
City of Fort Worth
Attn: Ron Josselet, Human Resources Manager
Occupational Health& Safety/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. If the CITY
notifies PROVIDER of any violation of such laws, ordinances, rules or regulations,
PROVIDER shall immediately desist from and correct the violation.
16. NON-DISCRIMINATION COVENANT
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
Professional Services Agreement Page 13 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
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:
To CITY: To PROVIDER
City of Fort Worth Texas Health Harris Methodist Hospital
Attn: Ron Josselet Fort Worth, d/b/a Texas Health Harris
1000 Throckmorton Methodist Occupational Health
Fort Worth TX 76102-6311 Attn: Camille Minor
Facsimile: (817) 392-7766 Address: 1651 W. Rosedale Street
E-mail: Suite 105
Ron.Josseletkfortworthtexas. ov Fort Worth,TX 76104
Facsimile: 817.878.5250
With copy to City Attorney's Office at Email: CamilleMinor @TexasHealth.org
same address.
18. SOLICITATION 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 term or
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.
Professional Services Agreement Page 14 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
21. GOVERNING LAW/VENUE
This Agreement shall be construed in accordance with the internal laws of the State of
Texas. If any action, whether real or asserted, at law or in equity, is brought on the basis of
this 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 of the remaining provisions shall not in any way be
affected or impaired.
23. FORCE MAJEURE
The CITY and PROVIDER shall exercise their best efforts to meet their respective duties
and obligations as set forth in this 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 (each
a"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 had the opportunity to review
and revise 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/MODIFICATIONS/EXTENSIONS
Professional Services Agreement Page 15 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
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. 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 granted 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.
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.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement in multiples this
1 st day of January, 2015.
CITY OF FORT WORTH: TEXAS HEALTH HARRIS
METHODIST HOSPITAL FORT
WORTH, d/b/a TEXAS HEALTH
By: HARRIS METHODIST
Susan s, Assistant City Manager OCC ATIONAL LTH
Date: ?•S' 2"D 1-57 , S
�� Lillie Biggins, President, Texas Health
�
ATTEST: ®� Methodist Hospital Fort Worth
By:
Mary Kays-e ty S o6retary
EST:
APPROVED AS TO FORM AND
LEGALITY*
{ Title: Terri A. eSio, Assistant General(,
By: 4 Counsel
Denis C. M troy, �s 'stant City Attorney
Poo
CONTRACT AUTHORIZATION: cwry ci,[; ii
M&C: C-27056 0G3t�N�� ��
Date Approved: 10/28/2014 =— ---
Professional Services Agreement Page 16 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
EXHIBIT A- SCOPE OF SERVICES
A.1. PROVIDER FACILITIES
A.l.l PROVIDER's facilities shall be of adequate size and capability to provide all necessary
health care for injured employees 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 CITY employees may access any other PROVIDER health care
facilities located in the Fort Worth/Dallas metroplex, or any other PROVIDER
locations in Texas and the United States as necessary.
A.1.2.2PROVIDER operates two (2) clinic locations in Fort Worth. 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 "C" to the Agreement. However, CITY personnel can
access either PROVIDER location as necessary.
A.1.2.3 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 6:00 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:
1651 W. Rosedale
Suite 105
Fort Worth, TX 76104
Phone: 817.250.4840
Fax: 817.878.5250
Professional Services Agreement Page 17 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
A.1.3 Convenience of Employees
The designated primary facility shall have at a minimum: telephone and fax numbers
for CITY employees; a CITY check-in desk;; a minimum of two (2) exam rooms; and a
sufficient number qualified medical doctors dedicated to the examination and treatment
of CITY employees.
A.1.4 Wait Times
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.1.5 Hours of Operation
PROVIDER must make contracted services available weekdays, Monday through
Friday from 7:00 a.m. to 6:00 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.1.6 Accreditation
PROVIDER shall maintain accreditation from the Joint Commission on Accreditation
of Healthcare Organizations (The Joint Commission).
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 Treating Doctors
Professional Services Agreement Page 18 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
A.2.4.1 PROVIDER agrees to employ or contract with occupational medicine
physicians to provide occupational injury medical treatment and care for
injured CITY employees. PROVIDER physicians shall be in good standing
with State of Texas regulatory agencies including the Texas Department of
Insurance, Division of Workers' Compensation (DWC) regarding being an
approved doctor on the Division's Approved Doctors List.
A.2.4.2 PROVIDER physicians shall perform and function as Treating Doctors, in
accordance with the Texas Labor Code and related Rules.
A.3 PANEL OF SPECIALTY PHYSICIANS AND HEALTH CARE PROVIDERS
A.3.1 PROVIDER agrees to assist the CITY to establish and maintain a panel of specialized
medical professionals/ physicians and other health care providers for referral as
necessary in the appropriate treatment of the CITY's employees who are injured in the
course and scope of their employment. PROVIDER also agrees to maintain the panel
during the initial term of this Agreement, as well as any of the option terms.
A.3.2 The panel will be composed of medical professionals / physicians, including but not
limited to Neurologists, Orthopedists / Orthopedic Surgeons, Neurologists /
Neurosurgeons, Plastic Surgeons, Psychologists, Psychiatrists, Pain Management
Specialists, Chiropractors, Physical and Occupational Therapists, Pain Management
Specialists, Oncologists, Pulmonologists and Cardiovascular Surgeons.
A.3.3 Each medical specialist must be willing to accept workers' compensation patients and
agree to be paid for services in accordance with the Texas Labor Code and related
Rules for medical services and fees.
A.3.4 PROVIDER agrees that Treating Doctors shall monitor performance of referral
specialists and other health care providers as to the following:
A.3.4.1 Usage of Treatment Guidelines adopted by the Texas Department of Insurance
—Department of Workers' Compensation("TDI-DWC")
A.3.4.2 Usage of Return-To-Work Guidelines adopted by the TDI-DWC
A.3.4.3 Medical Outcomes
A.3.4.4 Return-To-Work Outcomes
CITY shall require reports quarterly or more frequently as needed as to the performance
of referral specialists and other health care providers relating to A.3.4.1 through A.3.4.4
above.
A.3.5 PROVIDER also agrees to replace, if necessary, any or all of panel members as
warranted and agreed upon by the CITY.
A.3.6 PROVIDER shall coordinate with the CITY regarding the initial panel of doctors and
any changes to the members of the panel.
Professional Services Agreement Page 19 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
A.4 OCCUPATIONAL INJURY MEDICAL TREATMENT AND CARE
A.4.1 PROVIDER shall provide reasonable and necessary health care services to CITY
employees injured in the course and scope of their employment with the CITY, as
defined and instructed in the Texas Labor Code and related Rules.
A.4.2 Employees injured on the job will be referred to the PROVIDER medical facilities as
appropriate by the CITY, as a preferred provider of health care services. Employees of
the CITY currently retain the right to choose a different initial treating doctor as
allowed in the Texas Labor Code and related Rules.
A.4.3 If the injured employee chooses to seek initial and subsequent health care with
PROVIDER then the PROVIDER will become the employee's treating doctor and will
perform all of the necessary functions and responsibilities of a treating doctor as
required by the Texas Labor Code and related Rules.
AAA PROVIDER shall accelerate and expedite treatment and/or referrals for treatment of the
following CITY employees, in accordance with Section 504.055 of the Texas Labor
Code: (1) peace officers; (2) emergency medical care attendants, emergency medical
technicians, and paramedics; and(3) fire fighters.
A.4.5 Treatment Guidelines
PROVIDER shall specifically provide medical treatment and render services in
accordance with Treatment Guidelines adopted by TDI-DWC in the Rules, Chapter
137, "Disability Management". Any treatment that is not covered by the Guidelines
shall be documented and shall be based on other credible evidence-based medicine as
defined in Section 401.011(18-a) of the Texas Labor Code.
A.4.6 Return-To-Work Guidelines
PROVIDER shall specifically utilize the disability duration guidelines adopted by TDI-
DWC in the Rules, Chapter 137, "Disability Management, § 137.10"in coordinating an
employee's safe return to the CITY after an on the job injury. Specifically,
PROVIDER will effectively communicate and coordinate with the CITY's Return to
Work Program to ensure that injured employees are safely and appropriately returned to
restricted (modified) or full duty employment. Deviations from these Return-To-Work
Guidelines shall be documented in a treatment plan designed to (1) provide required
treatment of the employee in accordance with subsection A.4.5 above and (2) effect the
earliest return to work date the employee is medically able to do so.
Professional Services Agreement Page 20 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
A.4.7 Restrictions to Duty
PROVIDER shall recognize and discuss with injured CITY employees the general
availability of restricted or limited duty assignments provided by the CITY.
PROVIDER shall identify appropriate restrictions to duty based on CITY provided
detailed physical demand requirements of the injured employee's position, or of any
limited duty assignments that may be available to the injured employee.
A.4.8 DWC-073 "Work Status Report"
PROVIDER shall ensure that health care providers completely and accurately fill out
the TDI-DWC form DWC-073 "Work Status Report" on each CITY employee for each
medical evaluation or for medical treatment provided. PROVIDER shall provide each
such DWC-073 form to the CITY Occupational Health and Safety / Workers'
Compensation Division (the "OHS") within one (1) work day of the employee's office
visit or medical treatment event.
A.4.9 Preauthorization Requests; Requests for Reconsideration
A.4.9.1 PROVIDER shall ensure that requests for pre-authorization of medical services
and requests for reconsideration of pre-authorization denials shall include all
necessary medical documentation based upon the Treatment Guidelines to
support and justify the request prior to submission to the CITY's third party
claims administrator.
A.4.9.2In accordance with the Texas Labor Code §504.055, PROVIDER shall
accelerate and expedite the preparation and submission of preauthorization
requests relating to the following CITY employees: (1) peace officers; (2)
emergency medical care attendants, emergency medical technicians, and
paramedics; and(3)fire fighters.
A.4.9.3PROVIDER agrees to expedite preparation and submission of all
preauthorization requests and requests for reconsideration to the CITY's
contracted third parry claims administrator so as to minimize the amount of time
an employee may be off work, on limited duty, and/or awaiting medical
services. CITY agrees to include expedited preauthorization determinations and
expedited determinations of requests for reconsideration in the third parry
claims administrator's account handling instructions for the CITY.
A.5 REPORTS
A.5.1 CITY shall require quarterly and annual reports, or as otherwise required by CITY, as
to the performance of Treating Doctors, referral specialists and other health care
providers to include, but not necessarily limited to the following:
A.5.1.1 Usage of Treatment Guidelines adopted by the TDI-DWC
Professional Services Agreement Page 21 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
A.5.1.2 Usage of Return-To-Work Guidelines adopted by the TDI-DWC
A.5.1.3 Medical Outcomes
A.5.1.4 Return-To-Work Outcomes
A.5.2 CITY shall require additional reports including but not necessarily limited to the
following:
A.5.2.1 Utilization Report of CITY employees compared to utilization of other
employer (including other municipalities) in the Fort Worth/Dallas
Metroplex, to include injury frequency, cost by body area, age profile,
male to female profile, case duration and cost, referral utilization and
management,return-to-work outcomes and management
A.5.2.2 Average clinic wait times of CITY employees
A.5.2.3 Patient / Employee Satisfaction with medical treatment and services
provided
A.5.2.4 Services provided by Treating Doctor, and by category of treatment
and service provided—number and cost
A.5.2.5 Average length of time from date of medical evaluation to date of
submission of preauthorization requests and requests for
reconsideration
A.5.2.6 Monthly Report of CITY employees who fail to keep medical and/or
other health care appointments — dates and type of appointment.
Information and data for this report shall be captured and reported by
City Department.
A.6 WORKERS' COMPENSATION HEALTH CARE NETWORK
A.6.1 Certified Workers' Compensation Health Care Network
PROVIDER must be willing to participate in a workers' compensation health care
network certified under Chapter 1305 of the Insurance Code, if the CITY determines
that provision of medical benefits through a workers' compensation health care network
is available and practical to the CITY.
A.6.2 Direct Contract Network
In the event the CITY chooses to provide medical benefits to injured employees by
directly contracting with health care providers or through a health benefits pool
established under Chapter 172 of the Local Government Code and in accordance with
Section 504.053 of the Texas Labor Code,PROVIDER must be willing to participate in
such a panel or network of health care providers specifically developed by or on behalf
of CITY.
Professional Services Agreement Page 22 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
EXHIBIT B—OCCUPATIONAL INJURY MEDICAL TREATMENT AND CARE;
SCHEDULE OF COMPENSATION
B.1 Medical services/health care rendered by PROVIDER and the panel of medical specialists to
CITY employees injured in the course and scope of their employment with the CITY shall be
provided in accordance with the Texas Labor Code and Texas Department of Insurance,
Division of Compensation adopted Rules.
B.2 Compensation to PROVIDER and the panel of medical specialists shall be paid by the CITY
in accordance with the Medical/Professional Services and Fee Guidelines as specified in the
Texas Labor Code and Texas Department of Insurance, Division of Compensation adopted
Rules.
B.3 The following provisions of the Texas Labor Code relating to medical treatment and care,
compensation for services, reimbursement and medical fees specifically apply:
Chapter 408 Workers' Compensation Benefits
Sub-Chapter B. Medical Benefits
Chapter 409 Compensation Procedures
Section 409.009
Section 409.0091
Chapter 413 Medical Review
Sub-Chapter A General Provisions
Sub-Chapter B Medical Services and Fees
Sub-Chapter C Dispute Resolution
Sub-Chapter D Health Care Providers
Chapter 504 Workers' Compensation Coverage for Employees of Political
Subdivisions
Sub-Chapter C Benefits and Offsets
Section 504.055 Expedited Provision of Medical Benefits
Section 504.056 Intent of Expedited Provision of Medical Benefits
B.4 The following provisions of the Texas Department of Insurance, Division of Workers'
Compensation Rules (Texas Administrative Code, Title 28,Part B2)relating to medical
treatment and care, compensation for services,reimbursement and medical fees specifically
apply:
Chapter 126 General Provisions Applicable to All Benefits
Rule 126.9 Choice of Treating Doctor and Liability for Payment
Rule 126.14 Treating Doctor Examination to Define the Compensable
Injury
Professional Services Agreement Page 23 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
Rule 126.17 Guidelines for Examination by a Treating Doctor or
Referral Doctor after a Designated Doctor Examination to
Address Issues Other Than Certification of Maximum
Medical Improvement and the Evaluation of Permanent
Impairment
Chapter 133 General Medical Provisions
Sub-Chapter A General Rules for Medical Billing and Processing
Sub-Chapter B Health Care Provider Billing Procedures
Sub-Chapter C Medical Bill Processing/Audit by Insurance Carrier
Sub-Chapter D Dispute and Audit of Bills by Insurance Carriers
Sub-Chapter G Electronic Medical Billing, Reimbursement, and
Documentation
Chapter 134 Guidelines for Medical Services, Charges and Payments
Sub-Chapter A Medical Reimbursement Policies
Sub-Chapter B Miscellaneous Reimbursement
Sub-Chapter C Medical Fee Guidelines
Sub-Chapter E Health Facility Guidelines
Sub-Chapter F Pharmaceutical Fees
Sub-Chapter G Prospective and Concurrent Review of Health Care
Sub-Chapter I Medical Bill Reporting
Sub-Chapter J Reviews and Audits
Chapter 138 Disability Guidelines
Sub-Chapter A General Provisions
Sub-Chapter C Treatment Guidelines
Chapter 140 Dispute Resolution/General Provisions
Rule 140.6(d) Claims for Reimbursement of Medical Benefits
Chapter 180 Monitoring and Enforcement
Sub-Chapter B Medical Benefit Regulation
Professional Services Agreement Page 24 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
EXHIBIT C-PROVIDER'S RESPONSE TO CITY RFP
Professional Services Agreement Page 25 of 25
City of Fort Worth and Texas Health Harris Methodist Occupational Health
Fo-itTW-0R:T,H.
PURCHASING DIVISION
REQUEST FOR PROPOSALS(RFP)
for
MEDICAL PROVIDER OF OCCUPATIONAL HEALTH CARE SERVICES
RFP No.14-0225
Issued: August 13,2014
PROPOSAL SUBMISSION DEADLINE:
******* September 11,2014 by 1:30PM Central Time **+****
NO LATE PROPOSALS WILL BE ACCEPTED
L2SPONSES SHALL III DELIVERED TO: RESPONSES SHALL BE MAILED TO::
CITY OF FORT WORTH PURCHASING DIVISION CITY OF FORT WORTH PURCHASING DIVISION
LOWER LEVEL LOWER LEVEL
1000 THROCKMORTON STREET 1000 THROCKMORTON STREET
FORT WORTH,TEXAS 76102 FORT WORTH,TEXAS 76102
A Pre-proposal Conference will be held from 1:30 PM NAME AND ADDRESS OF COMPANY
to 3:30 PM on Wednesday,August 20,2014,in SUBMITTING PROPOSAL:
Purchasing Large Conference Room,City Hall,Lower
Level,1000 Throekmorton Street,Fort Worth,Texas Texas Health Harris Methodist Hospital Fort Worth
76102' dba Texas Health Harris Methodist Occupational He6h
I+OD ADDITIONAL INFORMATION 1651 W. Rosedale St., Suite 105
REGARDING THIS RFP PLEASE CONTACT: Fort Worth,Texas 76104
Doris Brent,Contract Compliance Specialist
Doris.Brent@IFor Worth'T'exas;gov Contact Person: Camille'Minor '
Title: Manager
RETURN THIS COVER SHEET WITH Phone:(817)250-4$89 Fax:(817).878-5250
RESPONSE TO: Email: camilleminor @texashealth.org
Doris Brent
Contract Compliance Specialist Signature: C�h Q'n�t:ILOf"
Purchasing Division ,
1000 Throckmorton Street,.Lower Level 1 ranted Name: Camille.Minor
Fort Worth,Texas 76102
Will contract be available for Cooperative Agreement use? (See Section 27,page 10)Yes X No
Acknowledgment of Addenda:#1 X #2 #3 #4 #5
e ® e e
e�
1651 W. Rosedale
Suite 105
Fort Worth, Texas 76104
September 11, 2014
Doris Brent
Contract Compliance Specialist
Purchasing Division
1000 Throckmorton Street, Lower Level
Fort Worth, Texas 76102
Dear Ms. Brent,
Please accept this RFP 14-0225, Medical Provider of Occupational Health Care Services
submission from Texas Health Harris Methodist Occupational Health. All requested information
and documents have been included in this packet for review by the City of Fort Worth and the
consultants selected for this project.
Thank you for your consideration,
Camille Minor
Clinic Manager
1851 W.Rosedale Suite 105,Fort Worth,Texas 76104 • 817-2504840 . 'TexasHealth.org
s e e
RFP No. 14-0225 Medical Provider of Occupational Health Care Services
Table of Contents
ExecutiveSumma .................................................................................................................................. 1
MBEUtilization Plan.♦.........o.q.uuooHM...wHb.HO•.HH.M.HM.N..H.N.HH.HHMH.HNH•HH.u................................. 5
Conflict of Interest Questionnaire: Attachment A..................................................................................9
Qualifications Questionnaire:Attachment C...... ..................... .......... ......... ......... .....................12
Fees and Char es Schedule:Attachment D....................................................................................... 20
FinancialInformation............................................................................................................................... 25
OrganizationalInformation..................................................................................................................... 26
LocationMap............................................................................................................................................ 27
OrganizationalChart............................................................................................................................... 28
Sample Reports........................................................................................................................................ 29
References. ....... . . ......... ........ .... ............................................. ... .... ....... 33
1651 W. Rosedale Suite 105, Fort Worth,Texas 76104 • 817-2504840 TexasHealth.org
i B
EXECUTIVE SUMMARY
Texas Health Harris Methodist Hospital Fort Worth (THFW) has provided sophisticated medical
services to the Tarrant County community since 1930, delivered with compassion and
commitment. In addition to providing quality services in our hospital facilities, THFW works with
the employer community to provide services tailored for their workforce. Among these services,
our comprehensive Occupational Health Clinic(s) provides services such as: injury and non-
injury care, drug screening and alcohol testing, clinical testing, exposure control programs,
medical surveillance and commercial driver's license programs. The Clinic(s) are committed to
providing quality healthcare as well as excellent customer service. in 2013, the overall customer
satisfaction score was 97.94% and likelihood to recommend was 97.51%.
The Occupational Health Clinic(s) are experienced in providing such services outlined in RFP
No. 14-0225 and fully understands the expectations set forth within. The responses below will
outline the services requested, the plan for delivery of services, and additional information to
assist in your selection process.
30. QUALIFICATIONS
30.1.1 Facilities
The Texas Health Harris Methodist Occupational Health Clinic is approximately 6,000 square
feet and is a department of Texas Health Harris Methodist Hospital Fort Worth. Texas Health
Resources owns and operates the clinic's facilities.
30.1.1 Clinic Locations
The Texas Health Harris Methodist Occupational Health Clinic is conveniently located at 1651
W. Rosedale, Suite 105, Fort Worth, Texas 76104, in the heart of Fort Worth's hospital district.
There is ample parking available for patients.
Texas Health Convenient Care Alliance is located at 2401 Westport Parkway, Suite 140, Fort
Worth, Texas 76177, in the fastest growing area of Fort Worth, the Alliance Corridor.
30.1.2 Primary Clinic Location
The primary location for City of Fort Worth employees will be the clinic located in the hospital
district. Upon being awarded as the medical provider of occupational health care services for
the City of Fort Worth, a dedicated telephone and fax line, City check-in desk, private waiting
room, and two designated exam rooms will all be provided. The clinic is staffed with a sufficient
number of medical providers.
30.1.3 Wait Times
The Texas Health Harris Methodist Occupational Health Clinic monitors its wait times on a
monthly basis. The average wait time is currently 12.73 minutes. The clinic will continue to
monitor wait times to ensure that the City's request to not exceed 15 minutes is met.
I Page
30.1.4 Hours of Operation
The clinic's current hours are Monday through Friday, 7 a.m. to 6 p.m. Upon being awarded the
medical provider of occupational health care services for the City of Fort Worth, the clinic will
extend its hours to 7 p.m., Monday through Friday. After-hours injury care is provided by the
Emergency Department at Texas Health Harris Methodist Hospital Fort Worth.
30.1.5 Accreditation.
Texas Health Harris Methodist Hospital Fort Worth is accredited by The Joint Commission,
formerly the Joint Commission on Accreditation of Healthcare Organizations,
30.2 Clinic Personnel
Full-time clinic physician — Michael P. Seeley, M.D. serves as the physician for the
Occupational Health Clinic. He has more than thirty years of experience treating patients with
injuries. He has been with the clinic since 1995. Dr. Seeley is certified by the American Board of
Family Practice and is a certified Medical Review Officer by the American Association of
Medical Review Officers. He is a Certified Medical Examiner by the Federal Motor Carrier
Safety Administration program.
Full-time nurse practitioner — Mary Sherwood, MSN, APRN, CFNP serves as the nurse
practitioner for the clinic. She is a Certified Medical Examiner by the Federal Motor Carrier
Safety Administration Program. She has 16 years of experience and has been with the clinic
since 2011.
Full-time registered nurses (RN) — The nursing team consists of three registered nurses who
are experienced in nursing triage and occupational health. Each member of the team has more
than 20 years of experience in their profession.
Physical and drug screen coordinator - The coordinator processes and communicates
results of drug screens and physicals, and all other screening services.
Case Management A registered nurse serves as case manager and helps coordinate the
care and treatment of injured workers. This may include arranging for a physician specialist or
for rehabilitation services.
Full-time patient care technicians (PCT)—PCT's are certified to perform drug screens, breath
alcohol testing, hearing exams, eye exams, pulmonary function testing, quantitative mask fit
testing, and venipuncture.
Radiology Staff The staff performs standard x-rays in the clinic and images are read by
licensed radiologists.
31.0 SCOPE OF SERVICES
31.1 Occupational Iniury Medical Treatment and Care: The Occupational Health Clinic(s)will:
Provide healthcare to City employees in accordance with Texas Labor Code, Title 5, 'Subtitle A
and the Texas Administrative Code, Title 28, Part 2.
2 Page
Wn==
Agree to become employees treating doctor in accordance all functions and responsibilities as
required by the City.
Accelerate and expedite treatment and or referrals for the following City employees: (1) peace
officers (2) emergency medical care attendants (3) paramedics (4) firefighters.
Assist the City in selection of preferred referral panel and specialist and refer injured employees
appropriately.
31.1.6 Treatment Guidelines: The Occupational Health Clinic(s)will:
Provide treatment in accordance with the Texas Department of Insurance, Division of Workers'
Compensation as found in Chapter 137, "Disability Management" of the Rules. The Clinic
utilizes the Official Disability Guidelines — Treatment and Workers Comp (ODG) and The
Medical Disability Advisor Workplace Guidelines for disability duration (MDA). If there is not an
established guideline, the clinic utilizes Occupational Medicine Guidelines established by the
American College of Occupational and Environmental Medicine and other resources for the
practice of evidence based medicine.
31.1.7 Return-To-Work Guidelines*, The Occupational Health Clinic(s) will:
Follow guidelines stated above in 31.1.6 for return-to-work.
*Upon completion of an audit performed in 2011 and 2013 by the Texas Department of
Insurance, Dr. Michael P. Seeley was recognized has a high performer in performance based
oversight.
31.1.8 Restrictions to Duty: The Occupational Health Clinic(s) will:
Recognize the City's duty restrictions and limited duty assignments that are available.
31.1.9 DWC-073 "Work Status Report"*: The Occupational Health Clinic(s) will:
Ensure that the work status reports are complete and returned to the City within 1 business day.
*Upon completion of an audit performed in 2013 by the Texas Department of Insurance, Dr.
Michael P. Seeley was recognized as a high performer in Documentation Work Status Measure,
Completeness of Work Status Form Measure and Documentation Supporting a Lumbar Spine
MRI Measure.
31.1.10 Preauthorization Requests: The Occupational Health Clinic(s) will:
Ensure that all necessary documentation based on treatment guidelines will be submitted to the
City's Claims Administrator.
Expedite treatment and or referrals for the following City employees: (1) peace officers (2)
emergency medical care attendants (3) paramedics (4)firefighters.
3 ( Page
e a
EN
31.1.11 Workers' Compensation Health Care Network: The Occupational Health Clinic(s) will:
Agree to participate in a workers' compensation healthcare network certified under Chapter
1305 or participate in a health benefits pool established under Chapter 172 of the Local
Government Code and in accordance with Section 504.053 of the Labor Code.
Texas Health Harris Methodist Fort Worth Occupational Health has experience and is currently
a provider for Tarrant County Administration's 504 Network.
31.2 Non-Iniury Occupational Health Care Services: The Occupational Health Clinic(s) will:
Provide pre-placement physical examinations, Department of Transportation (DOT) physical
examinations, fit for duty exams, physical demand job assessments, physical ability testing,
physical fitness assessments, medical surveillance exams, medical and work history
questionnaires, clinical testing services, immunization and infectious disease screening, and
respirator fit testing.
31.2.2 Drup Screening and Alcohol Testing: The Occupational Health Clinic(s)will
Provide drug and/or alcohol testing in accordance with 49 CFR Part 40 Department of
Transportation (DOT) regulations and report results to authorized City personnel.
Utilize Advanced Toxicology Network (ATN) as the City's authorized lab for all authorized
laboratory testing.
Dedicate a Medical Review Officer(MRO)for the City's account.
Follow the City's policy in regards to secondary sample testing and on-site testing and provide a
drug/alcohol testing manual to City designates.
31.2.3 Clinical Testing: The Occupational Health Clinic(s) will:
Provide pulmonary function, audiometric, X-rays, and electrocardiogram and ensure all
equipment used is calibrated and in good working order and performed by registered
technicians.
31.2.4 Exposure Control Program: The Occupational Health Clinic(s) will
Administer immunizations at Clinic locations or at designated City locations and provide all
medical information related to vaccines to employees and their immediate family members.
Conduct testing and monitoring to City employees exposed to communicable diseases, noise
lead, hazardous chemicals, or other potential hazards associated with the performance of their
job duties.
Provide necessary counseling relevant to urinary drug screening, human immunodeficiency
virus (HIV) testing and other health and safety related issues such as blood born pathogen
exposures and any other exposure associated with the City's workplace.
4) Page
31.2.5 Medical Surveillance: The Occupational Health Clinic(s) will:
Test and monitor City employees exposed to noise, lead, asbestos, hazardous chemicals or
other potential hazards associated with the performance of their job duties.
31.2.6 Commercial Driver's License (CDL) Program: The Occupational Health Clinic(s) will:
Actively participate and follow all US Department of Labor requirements and participate in the
City's Medical Review Board.
Dedicate a Medical Review Officer(MRO)to the City for participation in the City's CDL program.
31.2.7 Report and Validation Studies: The Occupational Health Clinic(s) will:
Provide the City with any necessary report in a timely manner and at no cost. See attached
examples.
31.2.8 Additional Services
The hospital offers a variety of services tailored for the workplace, including:
An Executive Health Program, Wellness for Life Mobile Screening Program, Vascular Screening
Program, Work Trax (Industrial Rehabilitation Program), CaPE Program (Communications and
Pronunciation Enhancement). See attached brochure for more information.
32.5 MBE Utilization Plan
Per the RFP instructions in Section 26.1, the M/WBE office was contacted and the Request for
Listing form was completed and a list of firms were submitted for review. It was concluded the
firms submitted were not certified by the North Central Texas Regional Certification Agency nor
were there any consultants or supplier opportunities available for the services provided within
this RFP.
As a hospital, Texas Health Harris Methodist Hospital Fort Worth is not required to register, but
its mix of diversity within the employee population will exceed the MBE requirement for the
purpose of this RFP. African-American population is 18%.
5 Page
"FORT WORTHO
September 4, 2014
Amber Fogelman
Texas Health Harris Methodist
Occupational Health Clinic
1651 W. Rosedale, Suite 105
Fort Worth, TX 76104
Dear Ms. Fogelman,
This is in response to your request for the attached listings to assist your company in seeking and g
utilizing MBE (African American) sub-consultants and/or suppliers:
Consultants Opportunities Requested Consultants Opportunities Provided
Pharmacy No MBE(AA) Firms Provided
EKG Interpretation No MBE(AA) Firms Provided
X-Ray Reads No MBE(AA) Firms Provided
Lab Testing Laboratory Services
Y
Supplier Opportunities Requested Supplier Opportunities Provided
Medical Supplies No MBE(AA)Firms Provided
The attached listings can be utilized up to two months from the date of this letter, per
City of Fort Worth's Business Diversity Enterprise Ordinance #20020-12-2011. If
additional commodities are needed within this 2-month period, please contact this office
and your request will be processed immediately. Thank you for your interest and if
M/WBE Office can be of further assistance feel free to contact at (817) 212-2674.
Sincerely, t
Adminstrative Technician
Housing and Economic Development Dept.
MinorityNVomen Business Enterprise Office
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
MINORITY/WOMEN BUSINESS ENTERPRISE
THE CITY OF PORT WORTH • 1000 T14ROCKMORTON STREET* FORT WORTH,TEXAS 76102
Phone(817)21;2-2674 ' Fax(8)7)212-2681
wo; ,J
ADDENDUM TO THE REQUEST FOR PROPOSALS
RFP 14-0225,MEDICAL PROVIDER OF OCCUPATIONAL HEALTH CARE
SERVICES
CITY OF FORT WORTH
PURCHASING DIVISION
ADDENDUM NO. I ' DATE ISSUED: August 27,2014
REQUEST FOR PROPOSALS NUMBER: 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 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.
All other terms and conditions remain the same.
JACK DALE
PURCHASING MANAGER
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COMPANY M, t�
SIGNATURI,; cam- F
NOTE: Company name and signature must be the same 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 30.1.4 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 (MBEs)it is no longer called
M/WBE.Does that mean that women-owned businesses are no longer considered towards
points for MBE?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
Services. Therefore,as June 1,2012,the City of Fort Worth MIWBE Office assigns Minority
Business Enterprise(MBE)African American(AA)subcontracting goals on all professional
contracts outside of Architectural 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
ATTACHMM,NT A
CONFLICT OF INTEREST DISCLOSURE REQUIREMENT
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 11 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 htlp:/lwww.ethics.statc.tx.us/forms/CIO.PdE
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.
1tF'P No. 14-0225,Medical Provider of Occupational Health Care Services,Page 19 of 52
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other. ersou doing business with local govern moll tal entity
OFFICE 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 questionnaire must be filed with the records administrator of the
local govenunent not later than the 71h 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. Name of person doing business with local governmental entity.
Texas Health Harris Methodist Hospital
Fn(otlataer Q Check this box If you are filing tin update to a previously filed questionnaire.
w requires that you file an updated completed questionnaire with the appropriate filung authority
than September 1 of the Year for which an activity described in Section 176.006(a), Local
Government Code, is pending and not later than the 7th business day after the date the originally filed
questionnaire becomes incomplete or utaccurate.)
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.
No conflict of interest;
4, Describe each affiliatiou 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.
No conflict of interest,
'i
R.FP No, 14-0225,Medical Provider of Occupational Health Care Services,Wage 20 of 52
CONFLICT OF IMMIZE ST QUI:STIONNATRE - + Ia ORM CIQ�
For vendor or other e� rsou doing businw with local govertninent.01 entity Page 2
S. Name of local government officer with whom tiler has affilhition 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 CQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income
from the filer 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 serves as an officer or director,or holds an ownership of 10 percent or more?
❑ Yes ❑ No
D. Describe each affiliation or business relationship.
6. Describe any other affiliation or business relationship that might cause a conflict of interest.
No conflict of interest.
7.
Signature of person doing business with the governmental entity Uate
RFP No. 14-0225,Medical Provider of Occupational Health Care Services,Page 21 of 52
ATTACHMENT C
QUALIFICATIONS QUESTIONNAIRE
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.MEDICAL PROVIDER GENERAL INFORMATION
1 Legal Name of Medical Provider Texas Health Harris Methodist Hospital Fort Worth
_ dba Texas Health Harris Methodist Fort Worth Occupational Health
Physical Address of Corporate 1301 Pennsylvania Avenue
Office or Headquarters
Ci I Fort Worth State TX Zip Code 76104
Telephone 817-250-2000 Fax
Website Address www.TexasHealth.or
2 Principal Owner(s)/Partners/Officers(add rows as necessary)
Texas Health Resources
3 Date Medical Provider was Founded/Opened/ Hospital founded 1930
Incorporated Occupational Health Clinic founded 1989
4 Total number of Medical Provider employees 4,350 Hospital employees
12 Occupational Health employees
5 Total number of Medical Provider employees working in 4,350 Hospital employees
Texas.
6 Total number of Texas licensed health care practitioners I Occupational Health employee practitioner
employed by Medical Provider.
7 Total number of Texas licensed health care practitioners 2 Occupational Health practitioners
on CITY's contract with Medical Provider,
8. Total number of current clients of Medical Provider with 200
locations in Texas
9 Total number of current Texas governmental/public 28
entity clients of Medical Provider
10 Total Amount of Medical Provider health care services billed from Texas locations in $ 1,134,511.00
Calendar Year 2013
I I Total Amount of Medical Provider health care services billed from Texas locations in $650,674.00
Calendar Year 2013 related to the treatment of on the job injuries.
12 Does Medical Provider have the capability to electronically report information to the CITY Yes
regarding services rendered on a detailed and summary format? No ❑
13 Can Medical Provider provide sample reports indicating the level of reporting capability of Yes
information or data to the City regarding services rendered? No
14 List below your three 3) largest current Texas clients:
Name of Client Fort Worth ISD
Address 100 N.University
City Fort Worth State TX Zip Code 76107
Length of Relationship with this entity 4 Years 14
Contact Name Alice Turner-Jackson Phone 817-814- Email Alice.turnerjackson
2990 _ ,fwisd.or
Name of Client Lockheed Martin
Address P.O.Box 748 MZ1864
City Fort Worth State TX Zip Code 76101
Length of Relationship with this entity #Years 9
Contact Name Charles Williams,MD Phone 817-777- Email Charles.b.williams
8182 1 1@Imco.com
Name of Client Alcon Laboratories
Address 6201 South Freeway
City I Fort Worth State I TX Zi Code j 76134
Length of Relationshi with_this entity #Years 1.0
Contact Name Laura Holmes,RN,BSN Phone 817-551- Email Lauraholmes@
4600 alconlabs.com
15 List below your three(3)largest Texas governmental/public entity clients;
Name of Gov.Entity City of Fort Worth Police Department
Address 350 West Belknap
City__ Fort Worth State TX Zip-_Code 76102
Length of Relationship with this entity #Years 8
Contact Name Leticia Saldivar Phone 817-392- Email
4237
Name of Gov.Enti Tarrant County Administration
Address 100 E.Weatherford
City Fort Worth State I TX Zip Code F76196
Length of Relationship with this entity #Years 14
Contact Name Charlotte Swint Phone 817-884- Email caswint@
2606 tarrantcount,.com
Name of Gov.Entity City of White.Settlement
Address 214 Meadow Park Drive`
City White Settlement State TX Zip Code 76108
Length of Relationship with this entity #Years l4 years
Contact Name Mark Huff Phone 817-246- Email mhuff @wstx.us
4971
16 Does Medical Provider anticipate any mergers,transfer of ownership, Yes El No
management reorganization,or departure of key personnel within the next 36
months that may affect the Medical Provider's ability to perform services
required in this RFP?
17 Has Medical Provider ever declared bankruptcy? Yes 0 No
18 Please provide the most current annual report and/or audited financial
statement prepared for Medical Provider.
19 Has Medical Provider been issued any penalty or fines from the Texas Yes No
Department of Insurance relating to any violation of the Texas Labor Code or
Rules since 1/1/2010?
20 Total amount of penalty or fines paid to the Texas Department of Insurance
relating to violation of the Texas Labor Code and Rules since 1/1/2010 by
Medical Provider.
21 Has anyone filed a complaint with the Texas Department of Insurance Yes No n
regarding any health care services rendered by Medical Provider or their
desi nated agents since 1/1/2010?
22� If Yes;please explain below:
23 Has Medical Provider been audited for compliance or otherwise investigated by the Yes Fj No El r
Texas Department of Insurance relating to workers' compensation medical claim
submissions or services rendered?
24 If Yes,please explain below;2011 audit by the Texas Department of Insurance recognized Dr.Michael P.
Seeley as a high performer in Performance Based Oversight.2013 audit by the Texas Department of Insurance
recognized Dr.Michael P. Seeley as a high performer in Documentation Work Status Measure,Completeness
of Work Status Form Measure and Documentation Supporting a Lumbar S me MRI Measure.
25 Has any health care practitioner,anticipated to provide health care or medical Yes❑ No Q
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[Q No
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
years?
28 If Yes,please identify the healthcare practitioner and provide a detailed explanation of the circumstances
involved. -
PART B.MEDICAL PROVIDER CONTACT
29 Provide the following information for designated contact that CITY may call regarding MEDICAL
PROVIDER proposal.
Name of Contact Camille Minor
Address 1651 W.Rosedale Suite 105
city Fort Worth State TX —Zip Code 76104
Tel.e hone 817-250-48$9 Fax 8I7=878-5250 : Email camilleminor(a)texashealth.or
PART C.MEDICAL PRACTICE GUIDELINES
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 of patients? Please describe
below.
Texas Health Harris Methodist Fort Worth Occupational Health incorporates the use of the Official Disability
Guidelines-Treatment in Workers'Comp(ODG)and The Medical Disability Advisor, Workplace Guidelines for
Disability Duration(MDA)in the treatment plans of all work related injuries treated in the clinic.If there is not a
guideline for a specific diagnosis,the clinic utilizes Occupational Medicine Practice Guidelines established by the
American College of Occupational and Environmental Medicine and other resources for the practice of evidence-
based medicine.The guidelines used are reviewed and presented to the patient at the time of the initial office visit.
Goals are set and documented in the plan of care per the guidelines for the patient's specific diagnosis.
31 Utilization of Treatment 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 care practitioners incorporate the treatment guidelines into medical
treatment regimens and treatment plans to manage patient care.
Texas Health Harris Methodist Fort Worth Occupational Health follows the Texas Department of Insurance,
Division of Workers' Compensation adopted rules for Medical Treatment Guidelines,Rule 137.100 by utilizing
The Medical Disability Advisor, Workplace Guidelines for Disability Duration(MDA),return to work guideline,
and the most current edition of the'Offdal Disability Guidelines-Treatment in Workers' Comp(ODG),stated above.
The guidelines used are reviewed and presented to the patient at the time of the initial office visit.Goals are set and
documented in the plan of care per the guidelines for the patient's specific diagnosis.
PART D.MEDICAL PROVIDER FACILITIES TO SERVICE CITY
33. Identify each MEDICAL PROVIDER facility anticipated to provide services to the City and complete the
below requested infornation for each facility and their personnel. Add additional sheets if necessary.
FACILITY I
Facility Name Texas Health Harris Methodist Fort Worth Occupational Health
Facility Address 165I W.Rosedale, Suite 105
Cit Fort Worth State TX' Zip Code°°76104
Telelod4one 817-250-4840 Fax 817-878-5250
Date Facility Founded/Opened 1089
Days/Hours of Operation Monda -Friday,7 a.m.to 6 p.m.
Name of Facility Office Mana er Camille Minor
Services to he Performed at this Facility,
Acute injury medical treatment for job-related injuries/occupational diseases Yes No
Reference;Attachment D,Subpart A of this RFP
Non-Injury Occu ational Health Care Services;
Breath Alcohol Tests[Ref.Attachment D Subpart B.1] Yes No
Urina Dru Screens(UDS)[Ref:Attachment D,Sub art B.2] Yes No[❑
Physical Examinations/Assessments[Ref Attachment D,Subpart B.3.] Yes[ No
Laboratory Testing[Ref:Attachment D,Subpart B.4 Yes No❑
Immunizations/Vaccinations Ref:Attachment D, Subpart 13,5 Yes No
Other Procedures/Services[Ref:Attachment D,Sub art B.6].. I Yes Z No
Health Care Practitioners at this Facilit
Please complete the following information for each Texas Licensed Health Care Practitioner serving this facility that
is anticipated to provide services to the CITY as outlined in this RFP.
Health Came Practitioner Name Medical Specialty Texas License# #Years #Years Practicins
Practicin.? at hisFacilit
Michael P.Seeley,MD Family Practice F4505 34 19
Mary Sherwood,MSN, Family Practice 453866 16 3
APRN,CFNP
PART D.MEDICAL PROVIDER FACILITIES TO SERVICE CITY (continued)
FACILITY 2
Facility Name Texas Health Convenient Care Alliance
Facility Address 2401 Westport Parkway,Suite 140
Cit Fort Worth State TX Zip Code` 76177
Telephone 817-693-2500 Fax 817-693-2510
Date Facility Founded/Opened June 15,2011
Days/Hours of Operation Monda Friday,8 a.m.to 5 p.m.
Name of Facility" Office Manager Crystal Johns,RN,BSN
Services to be Performed at this Facility:
Acute injury medical treatment for job-related injuries/occupational diseases Yes No
Reference: Attachment D.Subpart A of this RFP]
Non-Injury Occupational Health Care Services:
Breath Alcohol Tests f Ref: Attachment D,Subpart B.I] Yes No El
Urinary Drug Screens(UDS)[Ref.Attachment D, Subpart B.2 Yes No LJ
Physical Examinations/Assessments fRef.Attachment D,Subpart B.31 Yes No❑
Laboratory Testing RefAttachment D,Subpart B.4 __ Yes No
Immunizations/Vaccinations f Ref:Attachment D, Subpart B.51 Yes No (
Other Procedures/Services Ref:Attachment D,Subpart B.6] Yes No
Health Care Practitioners at this Facility:
Please complete the following,information for each Texas Licensed Health Care Practitioner serving this facility that
is anticipated to provide services to the CITY as outlined in this RFP.
Health Care Practitioner Name Medical Specialty Texas License# #Years #Years Practicing
- Practicin ? at this Facili
James Andrew Morgan, Family Practice K0532 16T 2
MD
Ronda Bell,APRN Family Practice AP123729 3.5 l
PART D.MEDICAL PROVIDER FACILITIES TO SERVICE CITY (continued)
FACILITY 3
Facility Name
Facility Address
I State Zip Code
Telephone Fax
Date Facility_ Founded/Opened
Days/Hours of Operation
Name of Facility Office Manager
Services to be Performed at this Facility:
Acute injury medical treatment for job-related injuries/occupational diseases Yes No El
[Reference:Attachment D,Subpart A of this RFP]
Non-Injury Occupational Health Care Services:
Breath Alcohol Tests Ref Attachment D,Subpart B.1. Yes No
Urinary Dru Screens DS Ref: Attachment D,Subpart B.2 Yes No
Physical Examinations/Assessments_f Ref:Attachment D, Subpart B.3] Yes No
Laboratory Testing[Ref.Attachment D; Subpart BAJ Yes No E]
Immunizations/Vaccinations f Ref'Attachment D, Subpart B.S], Yes No Q;
Other Procedures/Services[Ref.Attachment D, Subpart B.61 Yes No
Health Care Practitioners at this Facility:
Please complete the following information for each Texas Licensed Health Care Practitioner serving this facility that
is anticipated to provide services to the CITY as outlined in this RFP.
Health Care Practitioner Name Medical Specialty Texas License# #Years #Years Practicing
Practicing at this FacM-
PART D.MEDICAL PROVIDER FACILITIES TO SERVICE CITY (continued)
FACILITY 4
Facility Name
Facility Address
Cit State Zip Code
Telephone Fax
Date Facility Founded 1.Opened
Days/Hours of Operation
Name of Facility Office Manager
Services to be.Performed at this Facility:
Acute injury medical treatment for job-related injuries/occupational,diseases Yes No❑
[Reference:Attachment D,Subpart A of this RFP]
Non-Injury Occupational Health Care Services:
Breath Alcohol Tests fRef.Attachment D,Subpart B.1 Yes No
Urinary.Drug Screens(UDS)[Ref:AttachmentD,Subpart B.2] Yes No Q
Phvsical Examinations[Assessments Attachment D,Subpart B.3] Yes LJ No
Laboratory Testing, Ref: Attachment D,Subpart B.4] Yes No❑
Immunizations/Vaccinations[Ref.Attachment D, Subpart B.51 Yes❑ No 0
Other Procedures/Services[Ref:Attachment D,Subpart B.6] Yes❑ I No 0.
Health Care Practitioners at this Faeilit
Please complete the following information for each Texas Licensed Health Care Practitioner serving this facility that
is anticipated to provide services to the CITY as outlined in this RFP.
_Health Care Practitioner Name Medical Specialty Texas License# #Years- #Years Practicine
Practicing? at this Facility
PART D.MEDICAL PROVIDER FACILITIES TO SERVICE CITY (continued)
FACILITY S
Facitlt Nance
Facility Address
Ct State Zip Code.
Teie hone Fax 1
Date Fac,lity pounded t O rtad
Da`slHours_of 2poration
Name of Facility Office manager
rv'cs t §g PIrEgrmed-of jhJ#Facility,
Acute inJurymedical treatment forJob-related injuries/occupational diseases Yes No
Reference,Attachment-D,Sub' art kof this RI P
Non-lojury.0ccupational Health Care Services,
Breath Alcohol Tests Rd Attachment D Subpart B.l Yes No
Urinary Drug UDS Ftef:Attachment 15 Sub'art 8.2 Yes No
Ph sisal Examinations)7 AsscssmentY Itef:Attachment p,Subpart 8.3 Yes No
l aborato Testln Rci'.Attachment A Subpart R.4 Yes No
lnrtnunizations/Vaccittatlons l2ef Attachment D Subpart B.S Yes No
Other Procedures/Services Ref:Attachmant 0.Sub rt B.61 Yes Na
e 1 fi
Caro-Proctitiong-ast.9bli F4011W
Please complete the following information for each Texas Licensed Health Care Practitioner serving this faci)ity
that is anticipated to provide services to the CITY as outlined in this RFP.
Medical Snag ttv [i K Y�tICS
�t�rts}
t -
TO I'm BESTOF MY KNOWLEQGF THE ABOVE INFORMATION I5 TI211E ANI1 CORRECT. 3
Sinattirr of Authorized Re asdrtative: Date
Typed Name of Authorized Representative
For-- [J ori-k
Nance of Medical Provider/Proposer/Respondent
ATTACHMENT D
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
All 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 specific fees for services proposed by
MEDICAL PROVIDER to be provided to CITY employees. 'Services that are not offered shall be
indicated as"Not Offered".
B.1 Breath Alcohol Tests
Service Fee Service
Service Service Fee Service Fee Service Fee
Description Contract Year l Contract Year 2 Contract Year 3 Option Contract Option Contract
Year 4 Year 5
Breath Alcohol Test $25.00 $25.50 $26.01 $26.53 $27.06
Post-Job Offer
Breath Alcohol Test $25.00 $25.50 $26.01 $26.53 $27.06
Random
Breath Alcohol Test $25.00 $25.50 $26.01 $26.53 $27.06
Post Accident
Breath Alcohol Test $25.00 $25.50 $26.01 $26.53 $27.06
Follow-up
Breath Alcohol Test $25.00 $25.50 $26.01 $26.53 $27.06
Reasonable Suspicion
After hours Bream
Alcohol Test Not Offered Not Offered Not Offered Not Offered Not Offered
B.2 Urinary Drug Screens(UDS)
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
UDS-Non
Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Pre-Placement
UDS-Non
Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Random
UDS-Non -
Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Post-Accident
UDS-Non - -
Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Follow-up
UDS-Non
Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Reasonable Suspicion
UDS-Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Pre-Placement
UDS-Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Random
UDS-Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Post-Accident
UDS l ow-up Regulated
Follow-up $40.00 $40.80 $41.62 $42.45 $43.30
UDS-Regulated $40.00 $40.80 $41.62 $42.45 $43.30
Reasonable Suspicion
B.3 Physical Examinations/Assessments
Service Fee Service Fee Service Fee Service Fee "Service Fee
Service Option Option
Description Contract Year Contract Year Contract Year Contract Year Contract Year
1 2 3 4 $
Physical Examination
Post-Job Offer $45.00 $45.90 $46.82 $47.76 $48.72
Placement_
Physical Examination $45.00 $45.90 $46.82 $47.76 $48.72
-Other
DO'I'Physical
Examination $80.00 $81.60 $83.23 $84.89 $86.59
Post-Job Offer
Placement
DOT Physical $80.00 $81.60 $83.23 $84.89 $86.59
Recertification
Respirator Physical
Examination $65.00 $66.30 $67.63 $69.66 $71.75
Physical Demand Job $45.05-123.50 $46.41-125.97 $47.34-128.49 $48.29-131.06 $49.25-133.68
Assessments Varies,by test Varies by test Varies by test Varies by test Varies by test
Physical $58.00-$223.00 $59.16-$227.46 $60.34-$232.00 $61.55-$236.64 $62.78--$241.37
Fitness for Duty Varies b test Varies b test Varies b test Varies'b test Varies b test
Testin y Y Y-- Y y-
Physical $145.00 $147.90 $150.86 $153.88 $156.96
Medical Surveillance
Physical $68.00 $69.36 $70.75 $72.16 $73.60
Return to Work
B.4. Laboratory Testing
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
Blood Collection
Medical Surveillance $15.00 $15.30 $15.61 $15.92 $16.24
Exam
DrugScreen-Blood $185.00 $188.70 $192.47 $196.32 $200.25
Drug Screen-Re- $40.00. $40.80 $41.62 $42.45 $43.30
Test(Split Specimen)
Hemoccult(in $14.00 $14.28 $14.57 $14.86 $15.15
Center)
Glucose Finger Stick $14.00 $14.28 $14.57 $14.86 $15.15
Complete Blood $33.00 $33.66 $34.33 $35.02 $35.72
Count(CBC)
Blood Chemistry
20/23 $45.00 $45.90 $46;82 $47.76 $48.71
Hemoglobin A]C $41.00 $41.82 $42.66 $43.51 $44.38
Hydrocar/Oxyg
Volatiles - $133.00 $135.66 $138.37 $141.14 $143.96
Blood/Urinc
U/AManual $10.00 $10.20 $10.40 $10.61 $10.82
Microscopic
Blood-Lead $100.50 $102.51 $104.56 $106.65 $108.78
Blood-Chloroform $135.50 $138.21 $140.97 $143.79 $146.67
Blood-
Formaldehyde Screen $105.50 $107.61 $109.76 $111.96 $114.20
-
Blood-PCB $26.00 $26.52 $27.05 $27.59 $28.14
Blood-Hepatitis A $48.00 $48.96 $49.94 $5094 $51.96
Surface Antibody
Blood-Hepatitis B $44.00 $44.88 $45.78 $46.69 $47.63
Surface Antibody
Blood Hepatitis B $44.00 $44.88 $45.78 $46.69 $47.63
Surface Antigen
Blood-Hepatitis C $61.00 $62.22 $63.46 $64.73 $66.03
Antibody
Blood-HIV/z $58.00 $59.16 $60.34 $61.55 $62.78
Screen
Blood--HIV
Confirmation $82.00 $83.64 $85.31 $87.02 $88.76
(Wester Blot)
MMR Titer $51.00 $52.02 $53.06 $54.12 $55.20
Rabies Titer $98.00 $9996 $101.96 $104.00 $106.08
Hepatitis A Titer $20.00 $20.40 $20.81 $21.22 $21.65
Hepatitis B Titer _ $46.00 $46.42 $47.86 $48.82 $49.79
B.5 ImmunizationsNaceines
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
Rabies Vaccines/Is` $279.41 $284.99 $290.70 $296.51 $302.44
Injection
Rabies Vaccines/1" $279.41 $284.99 $290.70 $296.51 $30144
Injection
Rabies Vaccines/I" $279.41 $284.99 $290.70 $296.51 $302.44
Injection
Tetanus Toxoid $44.50 $45.39 $46.30 $47.22 $48.17
PPD(Mantoux) $20.00 $20.40 $20.81 $21.22 $21.65
TB Skin Test $20.00 $20.40 $20.81 $21.22 $21.65
Influenza(Flu Shots) $25.00 $25.50 $26.01 $26.53 $27.06
Hepatitis $85.00 $86.70 $88.43 $90.20 $92.00
Vaccine/IS'Injection
Hepatitis B $70.00 $71.40 $72.83 $74.28 $75.77
Vaccine/l"Injection
Hepatitis
Vaccine/2nd Injection $70.00 $71.40 $72.83 $74.28 $75.77
Hepatitis B $70.00 $71.40 $72.83 $74.28 $75.77
Vaccine/3rd Injection
Hepatitis B Surface $46.00 $46.92 $47.86 $48.82 $49.79
Antibod
Hepatitis A&B $135.00 $137.70 $140.45 $143.26 $146.13
Vaccine/I"Injection
Hepatitis &B $135.00 $137.70 $140.45 $143.26 $146.13
Vaccine/I"Injection
Hepatitis &B $135.00 $137.70 $140.45 $143.26 $146.13
Vaccine/]51 Injection
Varicilla Titer $25.00 $25.50 $26.01 $26.53 $27.06
Tdap(pertussis/ $50.00 $51.00 $52.02 $53.06 $54.12
whooping cough)
MMR Vaccine $75.00 $76.50 $78.03 $79.59 $81.18
Variciila Vaccine $123.00 $125.46 $127.97 $130.53 $133.14
B.6 Other Proeednres/Serviees
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
Audiogram 530.00 $30.60 $31.21 531.84 $32.47
Chest X•Ray
(1 View) $60.00 561.20 $62,42 $63.67 $64.95
X-Ray No charge No charge No charge No charge No charge ?
Interpretation
Pulmonary
Function Test $51.00 552,02 $53.06 $54.12 S55.20
EKG Resting $75.00 576.50 578.03 $79,59 $81.18
Functional $109 per 15 $1 11.18 per 15 $113.40 per 15 $115.67 per 15 $117.94 per 15
Capacity Testing minutes minutes minutes minutes minutes
OSHA Respirator
Questionnaire $13,00 515.30 $15,61 $15.92 S16.24
Respirator Fit $40.00 S40,80 $41,62 $42.45 $43.30
Test
Review otlniormeiion' $25.00 $25.50 $26.01 $26.53 527.06
Authorized Signature:
Name of Authorizing Authority t 'j 1 - - Date? ®�®!
TEXAS HEALTH RESOURCES
CONSOLIDATED BALANCE SHEETS
December 31,2013 and 2012
(Dollars in Thousands)
2013 2012
Assets
Current Assets:
Cash and cash equivalents $ 334,539 $ 448,503
Short-term investments 1,436 1,526
Receivables -
Patient, less allowance for doubtful accounts
of$117,898 in 2013 and$103,280 in 2012 402,477 361,091
Other, net 131,665 92,162
Assets limited as to use 226,762 254,394
Other current assets 106,870 95,495
Total current assets 1,203,749 1,253,171
Assets Limited as to Use 2,778,059 2,050,969
Properly and Equipment, net 1,781,225 1,696,318
Investments in Unconsolidated Affiliates 142,001 121,030
Goodwill and Intangible Assets, net 163,708 141,238
Other Assets, net 34,336 38,891
Total assets $$ 6,1 $ 5,301,617
LlabilMes and Net Assets
Current Liabilities:
Current portion of long-term debt $ 214,839 $ 209,634
Accounts payable 186,843 152,646
Estimated third-party payor settlements 39,790 38,412
Accrued salaries, wages, and employee benefits 225,313 213,180
Other accrued liabilities 163,985 161,970
Total current liabilities 830,770 775,842
Long-Term Debt, net of current portion 1,281,952 1,245,181
Other Noncurrent Liabilities 63,379 67,482
Total liabilities 2,176,101 _ 2,088,505__
Net Assets:
Net Assets of THR:
Unrestricted 3,692,334 3,013,216
Temporarily restricted 94,454 82,427
Permanently restricted 63,398 56,559
Total net assets ofTHR 3,850,186 3,152,202
Non-controlling ownership interest in equity of
consolidated affiliates unrestricted 76,791 60,910.
Total net assets 3;926,977 3,213,-112
Total liabilities and net assets $ 6,103,078 $ 6,3 7
See accompanying notes to consolidated financial statements.
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Occupational Health Clinic
1651 W.Rosedale,Suite 105
Fort Worth,TX 76104
East entrance to building
The entrance closest to 8th Ave
For more information,contact us at
817-250-4840 Texas Health
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Employee health and safety is just one of the many The nurse practitioner is then able to recommend and
things impacting a company's bottom line these days.
administer immunizations and medicines that may be
The Texas Health Harris Methodist Occupational Health needed to meet necessary health precautions.
Clinic offers a wide range of services designed to help Comprehensive Occupational Health Services
you keep your employees on the job. The Occupational Health Clinic can meet a variety of
occupational health needs for any sized company;ranging
From treatment of work related injuries,medical exams, from treatment of injuries to a full-blown occupational
tests and screenings to job analysis to rehabilitation, health program.
the Occupational Health Clinic can assist in many
aspects of employee health.The clinic is covered by a Services offered include, but are not limited to.
full time physician on the medical staff at Texas Health INJURY CARE
Harris Methodist Hospital Fort Worth,as well as nurse Injury Prevention and Treatment
practitioners.The availability of some on-site services and Timely return to work philosophy
24-hour emergency care through the hospital's emergency RN Case Management of injured workers
department,make it easy to access the services needed. Blood borne pathogen exposures
PHYSICALS
Customized On-Site Services
Customized medical examinations
Texas Health Harris Methodist Occupational Health Clinic DOT examinations
offers a variety of services that can be provided on-site at a OSHA examinations
company,keeping employees from having to lose work time. Employment related physicals
Services offered on-site include:immunization programs, Fire Fighter physicals(NFPA)
laboratory services,breath alcohol testing,drug screen Police/Law Enforcement physicals
collections,and certain types of physicals. Fitness for Duty
Return to Work
Case Management/Coordination of Services * Executive Physicals
To promote a smooth transition from injury to return- SCREENING SERVICES
to-work,an RN Case Manager coordinates the care Drug Testing-DOT&Non-DOT
and treatment of the injured worker.This may include Breath Alcohol Testing
arranging for a physician specialist or for rehabilitation Medical Review Officer(MRO)services
services.Texas Health Harris Methodist Fort Worth offers Electrocardiograms
a comprehensive selection of outpatient therapy programs Audiometric screening (CAOHC)
designed to help return injured workers to the workforce Vision screening (Suellen/Titmus)
as safely and quickly as possible.These services include: TB Testing
Physical Therapy,Occupational Therapy,CARP accredited Pulmonary Function Testing-(NIOSH)
Work Hardening and Work Conditioning,and a Hand Clinic OTHER SERVICES
with certified hand therapists. * Customized on-site services
In addition,the clinic can arrange for Functional Capacity * Ergonomic job assessments/Job Site Analysis
Development of functional job descriptions
Evaluations to help determine a worker's ability to perform *
their job and for ergonomic based job assessments and Rehabilitation services PT/OT,Work Hardening,
Work Conditioning
functional job descriptions. Vaccination/Immunization program
* Health,Safety and Wellness programs
Travel Health Services Comprehensive laboratory services
The Texas Health Harris Methodist Occupational Health X-ray services
Clinic also offers travel health services.Patients can meet Respiratory Mask Fitting
with a nurse practitioner for counseling prior to traveling * These services may be offered in conjunction with,or through,other
abroad to learn the health risks in the area traveling. departments within Texas Health Harris Methodist Hospital Fort worth.
_ Texas 1651 W.Rosedale,Suite 105
Harris Methodist Hospital* Fort Worth,Texas 76104
FORT WORTH TEL 817-250-4840
FAX 817-878-5250
Occupational Health wwwTexasHealth.org/occhealthfw
MEN=
SECTION ONE: To be completed on all referrals
Employee(Patient)Name Company Name&Phone#
❑ On the Job Injury: Date of Injury:
SECTION TWO: To be completed for ON THE JOB INJURIES
W/C Insurance Carrier: Phone#:
Adjustor name., Phone W. -
Date of Injury: Claim#:
❑ Submit medical expenses to company ❑ Submit medical expenses to insurance carrier
SECTION THREE: To be completed for company requested non-injury services and if
specific services are company required for ON THE JOB INJURIES
•DOT Drug Screen Vaccines,Etc.
•Urine Drug Screen-Non-DOT Panel ❑Hepatitis A
❑Quick Drug Screen ❑Hepatitis B
•Breath Alcohol Testing—DOT ❑influenza
•Breath Alcohol Testing-Non-DOT L3 MMR Vaccine
L3 Audiogram C3 Chickenpox Vaccine
L3 Pneumonia Vaccine
L3 Pulmonary Function Testing(PFT)
❑Tetanus/Diptheria/Pertussis
❑Respiratory Mask Fitting ❑Tetanus/Diptheria
❑Color Vision Screening ❑Travel Counseling
❑DOT Physical Examination ❑Travel Vaccination(s)
❑Pre-Employment Physical ❑Travel Medication(s)
❑Physical Exam: ❑TB Skin Test
❑X-ray: ❑Lab Titers:MMR-Chickenpox-Hep B
❑Electrocardiogram ❑Other:
❑Lift/Strength Test/EJF ❑requirements on file ❑Other:
SECTION FOUR: To be completed on all referrals
Authorized by(Name and Title):
Phone#: Date:
Additional Comments:
PHOTO ID REQUIRED FOR ALL DRUG SCREENS
Health 1651 W.Rosedale,Suite 105
rCfr) Harris Methodist HOSpifal• Fort Worth,Texas 76104
r0RTWORTH TEL 817-250-4840
FAX 817-878-5250
Occupational Health wwwTexasHealth.org/occhealthfw
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DIRECTIONS TO OCCUPATIONAL HEALTH
• Start out going WEST on PENNSYLVANIA AVE.toward 8TH AVE.
• Turn LEFT onto 8TH AVE.
• Turn RIGHT onto K ROSEDALE ST.
• Make a U-TURN at 9TH AVE.onto W. ROSEDALE ST.
• 1651 W. ROSEDALE ST.is on the RIGHT
• The clinic is located on the EAST END of the building.
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TEXAS HEALTH FORT WORTH
OCCUPATIONAL HEALTH ORGANIZATIONAL CHART
THFW
PRESIDENT
VICE PRESIDENT
PROFESSIONAL
SERVICES
DIRECTOR
OCCUPATIONAL
HEALTH CLINIC
MANAGER
OCCUPATIONAL
HEALTH CLINIC
OCCUPATIONAL
HEALTH CLINIC
STAFF
281Page
9/9/2014 Texas Health Harris Methodist Ho;:pital Page 1
Occupational Health
1651 W Rosedale Ave., Ste 105
Fort Worth,TX 76104
817-250-4840
Injury Management Report
Name: Injury [D: 1
Patient ID: 900-07-2044 D.O.D.: now Injury Date: 9/8/1014
Injury: 924.11 Acute contustion/abrasion to L knee
Abrasion to L ankle
916 Abrasion,lower extremity except foot
Days Lost: 0
Clinic Status: Light Duty as of; 9/8/2014 Days Lt Duty: 0
Pile Status: Open Estimated on: 9/8/2014
Company: White Settlement ISD Next Appt: 9/162014
Ins. Co: Claims Administrative Services Provider: Michael P.Seeley,MD
C106 No: Treatment: Follow up exam
Appointments
9/I6/20I4 15:30 POV Appt.Type Code: FOV
Practitioner: Michael P.Seeley,MD
Treatment: Follow up exam
Restrictions:
Treatments
9/8/2014 09:30 IOV Time In: 10:13 Time Out: 11:45 Appt.Type Code: IOV
Practitioner: Michael P.Seeley, MD
Treatment: Jinidal exam,It duty,ice,ROM after 2-3 days,recheck in
1 wk,OTC meds pm
q:li ORTSVNJURYUNJURYMANAGRMENT REPORT, <b>v7.26#0l94Vb>
09/09/2014 Texas Health Harris Methodist Hospital Page 1
Occupational Health
1651 W Rosedale Ave., Ste 105
Fort Worth,TX 76104
817-250-4840
Referral Count
For Date Range 08/01/2014 to 08/31/2014
For Company ID= LOCKHEED, TCOM,
For Treatment Appointment Status=A, T
For Treatment Code=REF
For Treatment Location ID= HMFWOHC
Treatment Medical Staff Referred To iof Referrals
Nicholas lagulli
Date Patient Name Patient ID Referred To Treatment Referred By Tyae Ot_Service
08/0712014 900-05-0504 Nicholas lagulli Michael Seeley
Subtotals for Nicholas Iagulli 1
Sherry Kondziela
Date Pati nt Natng Patient ID Referred To Treatment Referred By Type Of Service
08/11/2014 900-06-7555 Sherry Kondziela Michael Seeley
08/1812014 901-894682 Sherry Kondziela Michael Seeley
08/21/2014 900-06-7080 Sherry Kondziela Michael Seeley
08/26/2014 980-51-2982 Sherry Kondziela Michael Seeley
0812912014 900-07-0569 Sherry Kondziela Michael Seeley
Subtotals for Sherry Kondziela 5
Lockheed Physical Therapy
Dale Patient Name Patient ID Referred To Treat Mnt Referred By Tyne Of Service
08/1512014 900-07-1302 Lockheed Physical Michael Seeley
Therapy
Subtotals for Lockheed Physical Therapy l
Jiangping Liu
Date Patient Name Patient ID Referred To Treatment Referred By Tyoe Of Seance
08111/2014 900-06-9107 Jiangping Liu Michael Seeley
Subtotals for Jiangping Liu 1
Luiz Toledo
Date Patient Name Patient 1D Referred To TreLlmenl Referred 8Y Type Of Service
08/11/2014 ° 900-044137 Luiz Toledo Michael Seeley
Subtotals for Luiz Toledo 1.
Brian Webb
Date Patient Name Patient ID Referred To Treatment Referred By Tyne Of Servi0
08/18/2014 i ' 900-05-0504 Brian Webb Michael Seeley
Subtotals for Brian Webb 1
Grand Total Patient Referrals 10
q:RiEPORTSUNJURMEFERRALCOUNT v7.25a0095
9/9/2014 Texas Health Harris Methodist Hospital Page 1
Patient Stats Scheduling
For appointment date(s)from 08/01/2014 to 08/31/2014
For Appointment Status of T
Excludes Appointment Type of DUP
For Company ID of CTYOFWHI
For Appointment Location ID of HMFWOHC
Treatments
Date Time type Patient Company Pr_Q! v ider
08/1112014 13:00 DOT 1 !;' City of White Settlement SEELEY
08/22/2014 09:30 DOT City of White Settlement SEELEY
Total D.O.T.Physical 2
08/08/2014, ° 10.41 DSO K , City�of White Settl'emen't 7'1'C:NFTW.
08/221.OR16' 10:00 15k, City.t�f Wlutc Sentement:;. „ ° - 'l' G FTW
Total Drug Screen Collection Z 2 Walk In(s)
08/14!2014 15:30 FOV City of White Settlement SEELEY
08/21!2014 15:00 FOV City of White Settlement SEELEY
Total Follow up exam 2
08/08/2014 :10:40 toy: f City of:White..Settlement SEELEY
Total Initial exam a' I Walk In(s)
08/14/2014 10-.00 PRE City of White Settlement SEELEY
08/1 5/2014 09:30 PRE City of White Settlement SEELEY
08/18!2014 08:00 PRE City of White Settlement SEELEY
08118/2014 10:00 PRE City of White Settlement SEELEY
08119/2014 13!09° PRE City.ofsWhite,Settiemeni SEELEY
0812012014 10:00 PRE 1111 City of White Settlement SEELEY
Total Prepiacement Physical G I Walk In(s)
08/18/2014 16:30 SDR d111100411111100 City of White Settlement SEELEY
Total Scan diagnostic report 1
Total'Treatments 14 4 Walk In(s)
Grand Total 14 4 Walk In(s)
qAR-EP0KTSISCHEDt1LINGIPATJENT STATS SCHEDULING <b>0-5040183
I
09/09/2014 Texas Health Harris Methodist Hospital Page 1
Invoice Summary by Patient
Includes transactions for location HMFWOHC only!
For Invoice Header Status: P, R
Services billed for Patient ID: 925-24-6280
Phone;
!qw'C'}'7% Ra::p Pir!y wc!'sialua QWni Numbef i JQIr s-Qvsg1 tpi Ir-%Qirw Tld;d
211217 W P 847.0-Ground level fail/Acute cervical strain/Acute right
shoulder strain/Acute left shoulder strain..
Account: Texas Oncology Eighth Ave. Sharon Edwards 817-927-6334
insurance Pia r, Texas Oncology Sharon Edwards 817-927-6334
99213 07101/2014 Office Visit, est pt intermediate 1.00 126.11
126.11
211246 W P 847.0-Ground level fall/Acute cervical strain/Acute right
shoulder strain/Acute left shoulder strain,
Account Texas Oncology Eighth Ave. Sharon Edwards 817-927-6334
1,>1J^trace Fllaw Texas Oncology Sharon Edwards 817-927-6334
�;cY ^,^ Fort' c Oat �:s,,>,r, :nrt Qt ant,y t mMPUN
TWCC73 07/0112014 TWCC-73 Form 1,00 15.00
$
15-00
Charges: 141.11
Totals for Receipts:
Adjustments:
141.1 l
-a;.}.=E tal�J81111`*l.)i1`iJttt`F 4,S11121149.!.Rfif.11 4•YnS_;e.
� r
Texas Health Fort Worth
Occupational Health References
Fort Worth ISD
100 N. University
Fort Worth, Texas 76107
Alice Turner-Jackson
817-814-2990
alice.turneriacksonaftisd.org
Tarrant County Administration
100 E. Weatherford
Fort Worth, Texas 76107
Charlotte Swint
817-884-2606
caswint _tarrantcounty.com
City of White Settlement
214 Meadow Park Drive
White Settlement, Texas 76108
Mark Huff
817-246-4971
mhuff _wstx.us
331Page
M&C Review Page 1 of 3
Official site of the City of Fort Worth,Texas
FORTWORTH
COUNCIL ACTION: Approved on 10/2812014
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/me review.asp?ID=20444&councildate=10/28/2014 1/14/2015
M&C Review Page 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-Inoury 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/me review.asp?ID=20444&councildate=10/28/2014 1/14/2015
M&C Review Page 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
r
http://apps.cfwnet.org/council_packet/mc review.asp?ID=20444&councildate=10/28/2014 1/14/2015