HomeMy WebLinkAboutOccMed Physicians (BPW approved 1/14/26) City of Jeffersonville
Government Contract Coversheet
Please note: All information MUST be completely filled out and submitted to Clerk's Office
within 48 hrs of execution.
Date Submitted to Clerk: 1/14/2026
Department: Safety
Vendor Name: OccMed Physicians
Sign Date: 2/1/2026
Ending Date: 2/1/2027
Amount of Original Contract: per visit
Is this an amendment or change order
to original contract? No
Amended Contract Amount:
Purpose: City Occupational Med, Vaccinations, Drug Testing
For Clerk's Office to fill out
Date uploaded to Gateway:
Occ
i
January 12, 2026
Medical Providers
Dennis McClain, M.D., City of Jeffersonville
FACEP,ABEM,MROCC Attn: Brian Smith, Director of Occupational Health and Safety
Medical Director 500 Quartermaster Court
Barbara Elliott,APRN Jeffersonville, IN 47130
Manager
Dear Brian,
Elissa Grider,APRN
Thank you for the opportunity to provide a proposal for occupational health services for
Amy McCulloch, BSN, the City of Jeffersonville. We appreciate the discussion regarding your current needs and
RN,COHN-S are pleased to outline pricing for the services reviewed.
Proposed Occupational Health Services & Pricing:
• DOT Physical Examination: $99
• DOT Physical Follow-Up Visit:$40
• Pre-Placement Examination (Non-DOT): $75
• Drug Screen Collection Only: $25
• Rapid 10-Panel Drug Screen:$50
(Includes Medical Review Officer(MRO)services and laboratory confirmation)
• Breath Alcohol Test:$35
• Hepatitis B Vaccine:$80 per dose
• Work-Related Injury Treatment:
Fee-based according to injury severity and billed at reasonable and customary rates
We look forward to the opportunity to partner with the City of Jeffersonville in providing
high-quality occupational health services that support employee safety,timely return-to-
work, and regulatory requirements.
Please feel free to contact me directly with any questions or if additional information is
needed.
Kind regards,
Amy McCulloch, BSN, RN,COHN-S
Account Executive
Occupational Medicine Physicians
Phone: 812-271-4240
Email:Amy@occmedphysicians.com
1714 Charlestown New Albany Road I Jeffersonville,IN 47130
Phone:812-271-4240 I Fax:812-670-5720 I www.occmedphysiclans.com
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Services Requested
Physicals:
DOT Physical
• Preplacement
i Childcare
Fit for Duty/Return to Work
OSHA Respirator Clearance Exam
Other
Workers' Comp Injury Treatment
Workers' Comp Injury Treatment?(Required)
K. Yes
O No
Do you require a post accident drug and alcohol screen?(Required)
4K Yes
C No
Drug and Alcohol Screenings
Test Type
14 DOT—Send out
IP Non-DOT—Send out
Rapid
51. Collection Only(Company supplied CCF)
Hair Drug Screen
Panel Type
✓ 5 panel
• 9 panel
rA 10 panel
• DOT
n Other
Breath Alcohol Test
• DOT
tO Non-DOT
Lab Tests
El Varicella Titer
Hep B Titer
MMR Titer
L TB QuantiFERON Gold
• Lead Level
r3 Zinc Protoporphyrin(ZPP)
• Other
Vaccines
Vaccinations
Hepatitis B
'-e Flu
W Flu High Dose
PK Tetanus
Fer COVID
On-Site Vaccine Clinics
Click for more details.
Vaccine Clinics (Flu, COVID-19, Shingles, RSV, etc.)
Other Services
Other Services
'" PPD/TB Skin Test
C3 Positive TB Reactor Exam
Spirometry
Audiograms
11 Other
Company Information
Company Address Re uired �f►.f, --��,,!!
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Postal Code IVb____.
Number of Employees(Required)
Com an Contact(Required)
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Com an Phone(Required)
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Contact Email(Required) by/D:44 / of jtfl. vier
Contact Phone(Required)
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Billing Terms
• Invoices will be emailed. Please let us know if you'd also like mailed invoices.
• ACH payment preferred. ACH information is located on the invoice.
• Payment Terms-Net 15
Billing Information
Billing Address Same as Above
Same as Above
Billing Address
Street Address' __ . ._.. Address Line 2 .. City_._____ State/Province/
/Postal Code.
Contact
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Email
Email Address for Invoice
Bill Workers' Comp Injury Treatment to:
Select at least one:(Required)
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Workers' Comp Carrier
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Workers' Comp Carrier Billing Info
Carrier Name(Required)
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Contact(Re uired)
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Phone(Re uired)
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Street Address.-56°QI r ddrtess Line _2 . __ __.._..._._ CitylY10o1-0.1-1C.-State/Province/
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Polio Number(Required)
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Effective Date
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Third Party Administrator (TPA)
TPA Name
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Phone
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Authorized Company Contacts
Drug and Alcohol Screening Results:
Reci ient Name
3CiU S►A
Title
Secure Email
Phone
Secure Fax
Workers' Comp Injury Treatment:
Workers Comp Injury Treatment Contact Same as Above
X Same as Above
Name
Title
Email
Phone
Fax
Physical Results:
Physical Results Contact Same as Above
17( Same as Above
Reci ient Name
Title
__..._______I
Secure Email ff
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Phone
Secure Fax
Special Instructions
Special Instructions
APPENDIX A VACCINE CLINIC SERVICES
Vaccines Offered: Flu(standard and high-dose), COVID-19 (Comirnaty/SpikeVax), Shingles
(Shingrix), RSV(Abrysvo),Hepatitis B, TDAP.
When signing the agreement, parties agree to the following:
Logistics: Prior to signing this agreement, Client will provide details about their health insurance
plan to allow ABH to verify the Client is in network.
1. Definition of Clinic:
o a.)A clinic begins at the time the Client requests it start until the last vaccine is administered.
2. Hours of Services: AirBioHealth's standard vaccine service hours are 7:00am to 5:00pm,
Monday through Friday
3. Scheduling: ABH will use an online scheduler such as SignUpGenius
4. Travel: Requests for clinics more than a 50-mile radius from ABH will be considered for
approval with additional quoted travel fees based upon the unique needs of the situation.
5. Set-up and Take-down:
o a.) 30 minutes prior
o b.) 30 minutes after
6. Supplies: ABH will provide all medical supplies necessary to conduct the clinic.
o a.)Vaccines supplied to ABH by our distribution and billing partner—Vaxcare.
o b.)Disclaimer: In the event of a nationwide vaccine shortage, or inability of our distribution
partner to obtain vaccine, ABH will not be held liable. In the event this occurs we will
communicate such with your time in a timely manner.
7. Insurance verification: Client will provide a group member listing if vaccines are to be billed to
their health insurance plan.
8. Consent Form: Each participant will be required to review and sign a consent form prior to
receiving services.
9. Vaccine Clinic Setting: Client agrees to provide a safe and clean environment, and will provide
tables, chairs,trash cans, wireless internet access and any other furnishings required.
10. Crowd Control: ABH is not responsible for crowd control or security.
Minimums: Client will be charged the greater of participant minimum(15)or the number of
actual participants.
Cancellation and Rescheduling:
1. Canceling or rescheduling a clinic less than 7 business days prior to the event for reasons other
than Force Majeure Event, Client will incur a cancellation fee.
2. Cancellation notices to be communicated with ABH contact noted above.
Reporting: After vaccination clinic,ABH will provide a report of the number of participants and
services provided.
Payment:
1. Direct pay by Client: Client will be responsible for payment of fees related to onsite fees,travel
expenses, and associated administrative fees not covered by health insurance payer
2. Claims Billing: ABH partners with Vaxcare for billing to third party payers covered by
employers' health insurance plan. (In the event,third party payer does not reimburse Vaxcare for
vaccine cost, or administration fees,the client will be responsible)
APPENDIX C - PHYSICAL EXAMS
Location Services H
Clinic Location DOT Physical M
(AirBioHealth) Non-DOT Physical 9:
1714 Charlestown New Albany Rd, Jeffersonville,IN Lift Test Si
47130 Childcare Physical Cl
Onsite Fee(up to 3 hours) M
Extended Onsite Fee per additional hour 9:
Onsite Location Travel Fee (over 50 miles from ABH):
(Location provided by client) f
Quoted he
Cancellation Fee(less than 7 days prior)
*Lift Test-Fee determined by requirements of test.
Consent(Required)
` I accept the terms of the service agreement.
Please sign below to confirm consent to the service agreement(Required)