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HomeMy WebLinkAboutAnnual Physicals for Firefighters 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: 2/11/2026 Department: Fire Department Vendor Name: OMP OccMed Physicians Sign Date: 2/11/2026 Ending Date: no ending term Amount of Original Contract: $41,800.00 Is this an amendment or change order to original contract? Yes or No Amended Contract Amount: Purpose: annual physicals for firefighters For Clerk's Office to fill out Date uploaded to Gateway: 4 Pphysicians 1714 Charlestown New Albany Rd, Jeffersonville, IN 47130 Contact for Occ Med Physicians: Amy McCulloch (0) 812-271-4240 Email: amy@occmedphysicians.com SERVICES AGREEMENT Client Name: Jeffersonville Fire Department Effective Date: January 30. 2026 This Services Agreement ("Agreement') is entered into by and between Occupational Medicine Physicians ("OMP"). an Indiana company. and the undersigned client ("Client"). The Client agrees to the following terms and conditions, and to the selected services outlined below. Quality Assurance: Occupational Medicine Physicians is committed to maintaining the highest standards of proficiency. training, and compliance across all services provided. We ensure that our staff members are properly trained, certified, and qualified in accordance with all applicable regulations and industry standards. Training records and certifications are available to Clients upon request. Occupational Medicine Physicians adheres to all relevant regulatory requirements and ethical standards to deliver high-quality, reliable services to our customers. Payment Terms: The client agrees to make payment in full within thirty (30)days of the billing statement. Billing options are ACH, PayPal. Credit card (over the phone with a 4% manual card entry fee) or mail a check to: Occupational Medicine Physicians 1714 Charlestown New Albany Rd Jeffersonville, IN 47130 ACH: Routing Number- 083000137 Account Number - 599097352 Term of Agreement: Either party can terminate this Agreement with written (by email. or mail) notice. with or without cause. Service Fees: Fees for each service type are outlined in the applicable appendix and may include standard rates, after-hours surcharges, onsite fees, claims administration fees, wait time charges, and/or travel or cancellation fees. Confidentiality: Occupational Medicine Physicians maintains strict confidentiality in handling all client and individual health information. We adhere to all applicable confidentiality and privacy standards. including but not limited to HIPAA, DOT regulations. and other relevant federal. state. and industry-specific requirements. Information will only be disclosed to authorized parties, such as designated employer representatives, Medical Review Officers (MROs), laboratories, or as required by law. formal written consent, or court order. Indemnification: By signing this Agreement, the Client acknowledges and agrees to the utilization of Occupational Medicine Physicians services per the DOT/DHHS/Occupational Medicine Physicians protocol and agrees to hold harmless Occupational Medicine Physicians from all claims, including but not limited to losses. damages, injuries to persons, or act of negligence, arising out of Occupational Medicine Physicians use of said procedures on behalf of the Client. However, no indemnification or hold harmless shall apply to Occupational Medicine Physicians own negligence in not reasonably following said procedures/protocols for employer health services as such may be amended from time to time. When required, the Client agrees to follow all Federal, DOT, and State Regulations relating to services rendered. Arbitration Clauses: In the event. a dispute arises between the parties as to the duties or compensation under this Agreement, such dispute shall be submitted for arbitration under the then-existing rules established by the American Arbitration Association. Attorney's Fees: If any contested action is brought to enforce, modify, interpret, or void the provisions of this Agreement. then the prevailing party shall be entitled to reasonable attorneys' fees as well as appropriate relief Entire Agreement: This Agreement constitutes the entire Agreement between the Parties with respect to Services and supersedes all prior agreements and understandings within terms and conditions. This Agreement may not be amended or modified in any respect except by an agreement in writing executed by both Parties. Severability: In the event that any of the provisions of this Agreement are deemed invalid or unenforceable, the remaining provisions shall be construed and enforced as if the invalid or unenforceable provisions were. Waiver of Breach: Non-action by any Party in response to a breach of any provision of this Agreement shall not operate or be construed as a waiver of any rights hereunder or acceptance of any subsequent breach of any provision of this Agreement. Any waiver must be in writing and signed by the applicable Party. Change of Information: Each Party agrees to notify the other, in writing, of any changes in address, hours of service, phone number. or other contact information. The undersigned understands and agrees to the terms and services outlined in this agreement. Service Selection: Please check all services being requested. [ Annual Physical Exams Note: Specific services are detailed in their respective appendices. Please complete all sections in full Company Information Street Address/City/State/Zip: 2204 East 10"' Street Jeffersonville, IN 47130 Company Contact: Jason Sharp Phone #: 812-285-6445 Fax#: Email:jsharp@cityofjeff.net #of Employees: 92 Billing Information (if different from above) Street Address/City/State/Zip: daoy vs , -. �e crs sc>c,i L\-1\�5 Contact: ac\rNe Phone#: \c2, -3 y Fax#: `ata. aZ33- 3o3a Email: Who Would You Like To Receive The Following?: Physical Exam Results: Recipient Name S� Phone#: �12 - o28b " 3Za) Secure Fax #: \a - a`33 3b3a Secure Email: S\c-Nc_.zR. yOC � • -\e . SIGNATURES Client Representat' Signature: : Printed Name & fit[. ` - 'tA.a'r� Date: -AN`� Occupational Medicine P ysicians Representative Signature .R Printed Name 8YTitle:Account Executive Date: February 2 2026 Appendices Appendix A -Annual Physical Exams (2026) APPENDIX A-ANNUAL PHYSICAL EXAMS Annual Physicals: Includes occupational health history, OSHA respirator questionnaire, physical exam, labs-Complete blood count. Comprehensive Metabolic Panel, Lipid Panel, Hemoglobin A1C &Prostate Specific Antigen (50 and older or earlier if indicated by family history, exposure. etc. at the discretion of the Medical Provider), EKG & Spirometry. Scheduling: Must be coordinated in advance with OMP PHYSICAL EXAM FEES: Firefighter Annual Physical Exam -$100 Includes: • OSHA Respiratory Questionnaire review • OSHA Respiratory Physical Exam determination • Vital signs(temperature, pulse, respirations, blood pressure) • Height and weight • Urinalysis • Visual acuity and depth perception Additional Testing • Audiogram—$45 • EKG—$60 • Spirometry—$50 • Chest X-ray(2 view)—$80 Laboratory Testing* • Complete Blood Count(CBC)with differential—$25 • Comprehensive Metabolic Panel(CMP)—$50 • Lipid Panel with Total Cholesterol—$20 • Hemoglobin AlC—$25 • PSA(men age 50 and over)—$20 • Hemoccuft blood test—$5 • *Blood draws will be conducted on three mutually agreed upon dates at Fire department headquarters. Treadmill Stress Test • $194.09(if indicated) • Billed by vendor providing the stress test. • Stress test vendor options include: Personalized Prevention-Clarksville, IN or Norton Diagnostic Centers(Dutchmans Pkwy or Dixie Hwy). 0 IVI P OCcMed Physicians 1714 Charlestown New Albany Rd, Jeffersonville, IN 47130 Contact for Occ Med Physicians: Amy McCulloch (0)812-271-4240 Email: amy@occmedphysicians.com SERVICES AGREEMENT Client Name: Jeffersonville Fire Department Effective Date: January 30, 2026 This Services Agreement ("Agreement") is entered into by and between Occupational Medicine Physicians ("OMP"), an Indiana company, and the undersigned client ("Client"). The Client agrees to the following terms and conditions, and to the selected services outlined below. Quality Assurance: Occupational Medicine Physicians is committed to maintaining the highest standards of proficiency, training, and compliance across all services provided. We ensure that our staff members are properly trained, certified. and qualified in accordance with all applicable regulations and industry standards. Training records and certifications are available to Clients upon request. Occupational Medicine Physicians adheres to all relevant regulatory requirements and ethical standards to deliver high-quality, reliable services to our customers. Payment Terms: The client agrees to make payment in full within thirty (30) days of the billing statement. Billing options are ACH, PayPal, Credit card (over the phone with a 4% manual card entry fee) or mail a check to: Occupational Medicine Physicians 1714 Charlestown New Albany Rd Jeffersonville, IN 47130 ACH: Routing Number- 083000137 Account Number- 599097352 Term of Agreement: Either party can terminate this Agreement with written (by email, or mail) notice. with or without cause Service Fees: Fees for each service type are outlined in the applicable appendix and may include: standard rates. after-hours surcharges. onsite fees, claims administration fees, wait time charges, and/or travel or cancellation fees. Confidentiality: Occupational Medicine Physicians maintains strict confidentiality in handling all client and individual health information. We adhere to all applicable confidentiality and privacy standards, including but not limited to HIPAA. DOT regulations, and other relevant federal, state. and industry-specific requirements. Information will only be disclosed to authorized parties, such as designated employer representatives, Medical Review Officers (MROs), laboratories, or as required by law, formal written consent, or court order. Indemnification: By signing this Agreement, the Client acknowledges and agrees to the utilization of Occupational Medicine Physicians services per the DOT/DHHS/Occupational Medicine Physicians protocol and agrees to hold harmless Occupational Medicine Physicians from all claims. including but not limited to losses, damages, injuries to persons, or act of negligence, arising out of Occupational Medicine Physicians use of said procedures on behalf of the Client. However, no indemnification or hold harmless shall apply to Occupational Medicine Physicians own negligence in not reasonably following said procedures/protocols for employer health services as such may be amended from time to time. When required, the Client agrees to follow all Federal. DOT. and State Regulations relating to services rendered. Arbitration Clauses: In the event, a dispute arises between the parties as to the duties or compensation under this Agreement, such dispute shall be submitted for arbitration under the then-existing rules established by the American Arbitration Association. Attorney's Fees: If any contested action is brought to enforce. modify, interpret, or void the provisions of this Agreement, then the prevailing party shall be entitled to reasonable attorneys' fees as well as appropriate relief. Entire Agreement: This Agreement constitutes the entire Agreement between the Parties with respect to Services and supersedes all prior agreements and understandings within terms and conditions. This Agreement may not be amended or modified in any respect except by an agreement in writing executed by both Parties Severability: In the event that any of the provisions of this Agreement are deemed invalid or unenforceable, the remaining provisions shall be construed and enforced as if the invalid or unenforceable provisions were. Waiver of Breach: Non-action by any Party in response to a breach of any provision of this Agreement shall not operate or be construed as a waiver of any rights hereunder or acceptance of any subsequent breach of any provision of this Agreement. Any waiver must be in writing and signed by the applicable Party. Change of Information: Each Party agrees to notify the other, in writing, of any changes in address, hours of service, phone number, or other contact information. The undersigned understands and agrees to the terms and services outlined in this agreement. Service Selection: Please check all services being requested Annual Physical Exams Note: Specific services are detailed in their respective appendices. Please complete all sections in full Company Information Street Address/City/State/Zip: 2204 East 10'h Street Jeffersonville, IN 47130 Company Contact: Jason Sharp Phone#: 812-285-6445 Fax #: Email:jsharp@cityofjeff.net # of Employees: 92 Billing Information (if different from above) Street Address/City/State/Zip: Same as above Contact: Phone#: Fax #: Email: Who Would You Like To Receive The Following?: Physical Exam Results: Recipient Name Phone#: Secure Fax #: Secure Email: SIGNATURES f Client Representativ Signature: Printed Name&IITitle: '�t J( k�Ac��'L Date: 1 .� Occupational Medicine P ysicians Representative Signature- 4 � Printed Name&Title:Account Executive Date. February 2. 2026 Appendices Appendix A — Annual Physical Exams (2026) APPENDIX A— ANNUAL PHYSICAL EXAMS Annual Physicals: Includes occupational health history. OSHA respirator questionnaire, physical exam. labs-Complete blood count, Comprehensive Metabolic Panel. Lipid Panel, Hemoglobin A1C & Prostate Specific Antigen (50 and older or earlier if indicated by family history, exposure. etc. at the discretion of the Medical Provider). EKG & Spirometry. Scheduling: Must be coordinated in advance with OMP. PHYSICAL EXAM FEES: Firefighter Annual Physical Exam — $100 Includes: • OSHA Respiratory Questionnaire review • OSHA Respiratory Physical Exam determination • Vital signs(temperature, pulse, respirations, blood pressure) • Height and weight • Urinalysis • Visual acuity and depth perception Additional Testing • Audiogram—$45 • EKG—$60 • Spirometry—$50 • Chest X-ray(2 view)—$80 Laboratory Testing* • Complete Blood Count(CBC)with differential—$25 • Comprehensive Metabolic Panel (CMP)—$50 • Lipid Panel with Total Cholesterol—$20 • Hemoglobin A1C—$25 • PSA(men age 50 and over)—$20 • Hemoccult blood test—$5 • *Blood draws will be conducted on three mutually agreed upon dates at Fire department headquarters. Treadmill Stress Test • $194.09(if indicated) • Billed by vendor providing the stress test. • Stress test vendor options include: Personalized Prevention-Clarksville, IN or Norton Diagnostic Centers(Dutchmans Pkwy or Dixie Hwy).