2010-2422010-242
Resolution Authorizing Entry into a "Services Agreement" with Health Quest Immediate Care
Center
At a regular meeting of the Town Board of the Town of Wappinger, Dutchess County, New
York, held at Town Hall, 20 Middlebush Road, Wappingers Falls, New York, on July 26, 2010.
The meeting was called to order by Christopher Colsey, Supervisor, and upon roll being called,
the following were present:
PRESENT: Supervisor - Christopher J. Colsey
Councilmembers - William H. Beale (arrived at 6:09 PM)
Vincent F. Bettina
Ismay Czarniecki
Joseph P. Paoloni
ABSENT:
The following Resolution was introduced by Councilman Bettina and seconded by
Councilwoman Czarniecki.
WHEREAS, the Town of Wappinger (the "Town") wishes to engage Health Quest Immediate
Care Center ("HQUICC"), an affiliate of Health Quest Systems, Inc., to provide it with certain
occupational health services for eligible members of its work force; and
WHEREAS, HQUICC is authorized and qualified to provide health care services to eligible
members of the Town's work force and has agreed to provide the Town with certain occupational health
services in accordance with the terms of a certain Services Agreement; and
WHEREAS, the Town and HQUICC have negotiated terms in accordance thereto and entitled
the document "Services Agreement" (the "Agreement") as copy of which is annexed hereto as Exhibit
"A" and is made apart hereof.
NOW, THEREFORE, BE IT RESOLVED:
1. The recitations above set forth are incorporated in this Resolution as if fully set forth and
adopted herein.
2. The Town Board hereby accepts the terms and conditions set forth and contained in the
"Services Agreement," a copy of which is annexed hereto as Exhibit "A."
3. The Supervisor to the Town, Christopher J. Colsey, is hereby directed and authorized to
execute said "Services Agreement" on behalf of the Town of Wappinger.
The foregoing was put to a vote which resulted as follows:
CHRISTOPHER COLSEY, SUPERVISOR
Voting:
AYE
WILLIAM H. BEALE, COUNCILMAN
Voting:
AYE
VINCENT F. BETTINA, COUNCILMAN
Voting:
AYE
ISMAY CZARNIECKI, COUNCILWOMAN
Voting:
AYE
JOSEPH P. PAOLONI, COUNCILMAN
Voting:
AYE
Dated: Wappingers Falls, New York
7/26/2010
The Resolution is hereby duly declared adopted.
XC
) JOHN C. MASTERSON, TOWN CLERK
SERVICES AGREEMENT
This Agreement, made as of 2010, (the "Agreement"), is by and
between Health Quest Immediate Care Center, an affiliate of Health Quest Systems, Inc., a New
York not-for-profit corporation with an office located at 45 Reade Place, Poughkeepsie, New
York 12601 ("HQUICC") and Town of Wappinger, a New York municipality with a principal
office at Middlebush Road, Wappingers Falls, New York 12590 (the "Employer").
RECITALS: The following recitals are hereby incorporated into the Agreement:
A. The Employer wishes to engage HQUICC to provide it with certain
occupational health services for eligible members of its work force.
B. HQUICC is authorized and qualified to provide health care services to eligible
members of the Employer's work force and agrees to provide the Employer with certain
occupational health services in accordance with the terms hereof.
C. The parties have elected to enter into this Agreement to memorialize their
obligations, as well as their agreements with respect to the provision of services by HQUICC to
the Employer.
NOW, THEREFORE, for good and valuable consideration, the parties agree as follows:
1. Services.
(a) HQUICC agrees to provide those occupational health services as
set forth on Exhibit A attached hereto, upon the request of the Employer and subject to the receipt
of consent from the eligible members of Employer's work force (the "Employees") pursuant to
the terms of this Agreement. HQUICC shall provide the Services at the location as set forth on
Exhibit B attached hereto. Employer shall provide HQUICC with a roster of the Employees.
Employer shall call (845) 297-2511, or such other telephone number as HQUICC shall specify
from time to time, no less than two (2) hours prior to a requested appointment time in order to
arrange for the provision of Services. Employer shall notify Employees of the scheduled times
and dates on which such Eligible Individuals are to receive Services from HQUICC and shall use
reasonable efforts to ensure that Eligible Individuals properly comply with the appointment
schedules. Employer shall be charged a no-show fee of the full amount of the agreed service for
his or her appointment, and does not cancel or reschedule his or her appointment at least twenty-
four (24) hours prior to the originally scheduled appointment time. Such no-show fee shall be
added to the monthly invoice for the month that the original appointment was scheduled.
HQUICC shall provide Medical Review Officer services as required by applicable statutes and
regulations.
(b) All Services performed by HQUICC shall require the consent of the
Employee. In addition to any consent form required by the Employer, each Employee shall also
be required to execute the consent form in the form of Exhibit C attached hereto. Should the
Employee refuse to authorize consent for treatment or evaluation, HQUICC shall notify
Employer of such refusal. In the event the Employee receives treatment and/or evaluation and
subsequently revokes consent prior to HQUICC's release of information to Employer, HQUICC
shall not release the information to Employer. However, Employer shall remain responsible for
1
payment to HQUICC for any treatment and/or evaluation received by Employee prior to the
revocation of consent.
(c) Employer acknowledges and agrees that HQUICC does not and will not
make any decisions regarding the employment eligibility of Employees or any other
employment-related decisions on behalf of Employer, and that HQUICC's obligations are
limited to providing the Services described this Agreement.
(d) HQUICC agrees to release medical information related to the Services to
Employer in accordance with Section 5 of this Agreement and in accordance with applicable
law.
2. Compensation. HQUICC shall receive as compensation for Services rendered to
Employees, payment on a fee-for-service basis in accordance with Exhibit D attached hereto,
as may be amended by HQUICC upon thirty (30) days notice to Employer. HQUICC shall
send Employer an invoice, on a monthly basis, for the Services rendered through the end of the
preceding month. Undisputed invoices shall be payable to HQUICC by Employer within thirty
(30) days of invoicing. The parties will use good faith efforts to resolve any disputed amounts
promptly. HQUICC will not require any Employee to provide a deposit or similar payment
with respect to Services rendered pursuant to this Agreement.
Duties of Employer.
(a) To the extent applicable, Employer shall provide HQUICC with
Employer's standard physical examination forms in quantities required by HQUICC to fulfill
its obligations under this Agreement. If Employer fails to provide its standard physical
examination forms, HQUICC shall use the form it typically uses for physical examinations
conducted for the purpose of employee health evaluations. HQUICC shall only be responsible
for completing the applicable information requested on Employer's forms and shall not be held
responsible for the failure to include any additional information not requested on such form.
(b) Employer also agrees to cooperate with
Services, including, but not limited to, providing HQUICC
Employees and any other information that is necessary to
Agreement.
4. Term and Termination.
HQUICC in the provision of
with access to any records of
perform its duties under this
(a) This Agreement shall be effective on the date hereof and shall continue
until terminated as provided below.
(b) This Agreement may be terminated:
either party; or
(i) upon mutual written agreement of the parties;
(ii) without cause upon thirty (30) days prior written notice by
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(iii) either party's failure within fifteen (15) days to cure any material
breach of this Agreement upon receipt of written notice regarding the nature of the breach from
the other party.
(c) Upon termination of this Agreement, neither party shall have any further
obligation hereunder except for obligations accruing prior to the date of termination.
5. Compliance with Laws Rules and Regulations. HQUICC represents, warrants
and covenants that throughout the term of this Agreement and during any applicable period
thereafter, it shall provide the Services in accordance with all applicable federal and state laws,
rules, regulations and agency guidelines.
6. Medical Records. HQUICC agrees to maintain adequate medical, financial and
administrative records for all care provided to Employees. No information shall be released to
Employer without the Employee's consent. HQUICC agrees to comply -with applicable laws
governing patient confidentiality, including but not limited to the Health Insurance Portability
and Accountability Act.
7. Confidentiality. Any data or information pertaining to the diagnosis, treatment
or health of an Employee shall be held confidential to the maximum extent permitted by law.
Both parties agree to maintain the confidentiality of information contained in the Employee's
medical records except for the dissemination of such records as required and permitted by law.
No information shall be released to Employer without the Employee's consent.
8. Indemnification. Employer agrees to indemnify and hold HQUICC harmless
from any and all claims, demands, losses, liabilities, actions, lawsuits and other proceedings,
judgments and awards, and costs and expenses (including reasonable attorney's fees), arising out
of (a) the negligence or intentional misconduct of Employer, its employees or agents in
connection with its obligations under this Agreement, (b) breach, misrepresentation or non-
fulfillment of any representation, covenant, or warranty made by Employer under this
Agreement, (c) any claim by an Employee related to any action affecting his/her employment by
Employer; and (d) the release of medical information by HQUICC to Employer. The provisions
of this section shall survive the termination, non -renewal or expiration of this Agreement.
9. Status of the Parties. It is expressly acknowledged by the parties that the parties
are independent contractors, contracting solely for the purposes set forth herein. Nothing in this
Agreement is intended nor shall it be construed to create an employer/employee, partner, agent
and principal, or joint venture relationship between the parties.
10. Notices. Any notice to be given under this Agreement shall be sufficient if in
writing, when delivered by hand, one (1) day after deposit with a nationally recognized
overnight carrier for next day delivery or three (3) days after sent by registered or certified mail,
return receipt requested, to the parties at the addresses set forth on the first page hereof.
11. Miscellaneous. This Agreement shall be governed by the laws of the State of
New York without regard to conflicts of law. The parties agree that the courts of Dutchess
County, New York, shall have exclusive jurisdiction and venue with respect to any litigation or
other proceeding between the parties arising out of or in connection with this Agreement. This
3
Agreement is the entire Agreement among the parties concerning the subject matter hereto and
supersedes all prior agreements, understandings, memoranda, and other such communications,
whether written or oral. If any provision of this Agreement or the application of any provision
hereto to any person or circumstance is held to be legally invalid, inoperative or
unenforceable, then the remainder of this Agreement shall not be affected, unless the invalid
provision substantially impairs the benefit of the remaining portions of this Agreement to all of
the parties. The failure by HQUICC to enforce or exercise any right(s) under this Agreement
or to insist on performance of any provisions of this Agreement at any time shall not operate or
be construed as a waiver to enforcement, exercise or insistence on performance at any other
time. This Agreement may not be assigned by either party without the prior written consent of
the other party. This Agreement shall be binding upon, and shall inure to the benefit of, the
parties hereto and/or their respective heirs, executors, administrators and permitted assigns.
This Agreement shall only be amended or modified by a written instrument signed by both
parties. This Agreement may be executed in counterparts and each such counterpart, when
taken together, shall constitute a single and binding agreement.
IN WITNESS WHEREOF, the parties hereto have duly executed this Agreement as
of the day and year first above written.
HEALTH QUEST IMMEDIATE CARE
CENTER
By:
Title:
TOWN OF WAPPINGER
By: Hon. Christopher J. Colsey
Title: Supervisor
4
EXHIBIT A
SERVICES
1. DOT PHYSICALS
HQUICC provides work organizations with physical examinations that meet all Department
of Transportation requirements in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49), and Rules and Regulations set forth in the Federal
Register/Vo1.54, No 230 DEC. 1, 1989 and/or that meet all requirements of Department of
Motor Vehicle regulations according to Article 19A.
The physical includes:
• Medical History
• Physical Examination
• Vision Testing (Documentation of results in Snellen values)
• Hearing Testing (Standard for 19A*; Audiogram for Federal)
*Per DOT regulations for 19A, if standard hearing test is failed, an
audiogram will be performed. There is no additional charge for this service.
• Urinalysis
• . Height, Weight, Blood Pressure and Pulse
• Documented on DOT forms
If clinically indicated and needed to certify:
• EKG
Please check which physical examination form you require:
Federal (For interstate transport; all transport of hazardous materials)
19A (DMV) (All transport of passengers)
REPORTING
The original copy of the exam will be returned to you as required as well as
recommendations and/or restrictions based on the results of the physical exam.
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2. DOT DRUG AND ALCOHOL TESTING PROGRAM
Health Quicc provides work organizations with a complete Drug and Alcohol Testing
Program that complies with and mirrors all Federal and state DOT regulations as
outlined in 49 CFR Part 40 and 46 CFR Part 16 and simplifies compliance for both
large and small organizations. The following details our services.
Requirements of Your DOT Drug and Alcohol Testing Program
The Department of Transportation mandates that regulated employers develop a drug
and alcohol testing program that includes all of the following asterisked elements.
Health Quicc's Annual Program includes all of these elements plus those in
parentheses:
■ Supervisor Training with documentation of training for reasonable suspicion
identification.
■ Drug Testing for Pre-employment; Reasonable Suspicion; Random; Post
Accident, Return to Duty and Follow-up.
■ Alcohol Testing for Reasonable Suspicion; Random; Post Accident; Return to
Work, Follow-up.
■ Random Testing Program and selection of drivers/operators for testing using
a DOT compliant, scientifically valid method -50% for drugs and alcohol,
plus an additional 10% for alcohol only.
■ HQUICC shall provide Medical Review Officer Services as required.
■ Individual reports for drug and alcohol testing results on DOT approved
forms.
■ Phone consultation with medical professionals.
■ Referral of any Employee who tests positive to Substance Abuse
Professionals.
■ Annual summary report in DOT mandated format.
C1
Regulations
Health Quicc shall provide all required DOT Drug and Alcohol Testing Programs that comply
with regulations as stated in the FEDERAL REGISTER 49 CFR parts 382, 391, 199, 219, and
procedures for testing as stated in 49 CFR part 40 and 46 CFR Part 16 which include testing for:
■ Random
■ Reasonable Suspicion
■ Pre-employment
■ Post Accident
■ Return -to -Duty
■ Follow-up
* Please note that Employees to be tested at HQUICC for reasonable suspicion must be
accompanied by a Company Supervisor or other designated Employer representative, keeping
the Employee's legal rights to privacy in mind.
Summary of Drug Testing Process
Drug testing is done by a SAMHSAlDHHS certified laboratory. Collection, testing and result
reporting of the drug testing process follow strict federal guidelines.
■ Photo ID required
■ Split specimen collection by trained clinicians through a strict chain of custody on a
DOT specified Chain of Custody form.
■ Temperature testing of collected sample.
■ Collection site monitored and secured to ensure that a non- tampered
specimen is collected.
■ Specimens sent by courier the day of collection.
■ Specimen tested by a SAMHSA/DHHS certified laboratory for the five required
drugs: Marijuana (THC), cocaine, opiates, phencyclidine (PCP) and amphetamines.
■ Test results are received promptly and reviewed by HUICC's physician designated
as your agency's Medical Review Officer (MRO).
■ Confirmation testing of all positive test results.
■ The MRO reports test results as positive or negative to the company requesting the
testing.
VA
■ Applicants and employees tested will be provided with test results.
Recommendations for work and/or necessary referrals according to test results will be
given by the Medical Review Officer to the Applicant/Employee and Company for
whom testing is being done.
Summary of Alcohol Testing Process
Alcohol testing is performed by a Certified Breath Alcohol Technician (BAT). Testing procedures
and result reporting follow strict guidelines as set forth in 49 CFR Part 40.
■ BATs trained to proficiency according to DOT model course.
■ Tests performed on Evidential Breath Testing (EBT) devices listed on the NHTSA
Conforming Products List.
■ Screening tests and confirmation tests performed on EBTs that print out results,
date and time, a sequential test number and the name and serial number of the
EBT.
■ Testing using DOT mandated alcohol testing forms.
■ Testing procedures that ensure accuracy, reliability, confidentiality and privacy.
■ Referral to a Substance Abuse Professional (SAP) when test is positive.
2a. PRE-EMPLOYMENT DRUG TESTING
Drug Testing performed with Physical Exam (10 Panel or DOT)
Evidential Breath Test (EBT) for Alcohol with Pre -placement Exam
Confirmation of positive EBT
2b. RANDOM DRUG AND ALCOHOL TESTING
The random drug and alcohol testing mandates include:
■ Random selection of drivers by a scientifically valid, DOT approved method, a
computer-based random number generator that is matched with social security number,
etc. Selection occurs quarterly.
Testing for drugs and alcohol at the rate of 50% of drivers holding a CDL license any
time such drivers are working.
■ Testing for drugs and alcohol at the rate of 50% for non -CDL drivers, any time such
drivers are working.
■ In addition to the above testing, Health Quicc shall test an additional 10% of all CDL
drivers for alcohol only, before, during, or after drivers are performing safety sensitive
functions.
■ Further, in addition to the above testing, Health Quicc shall test an additional 10% of all
non -CDL drivers for alcohol only, before, during, or after drivers are performing safety
sensitive functions.
■ Testing that is unannounced to drivers but meets the employers need for scheduling.
2c. TRAINING PROGRAM
The Federal Highway Administration mandates that:
Supervisors be trained about alcohol misuse for 1 hour
■ Supervisors be trained in reference to drug abuse for 1 hour
■ Drivers receive detailed information about the effects of alcohol and drugs,
employer policies, testing requirements and where to get help
2d. DRUG TESTING RESULT REPORTING AND RECORDKEEPING
Results of Controlled Substance Test as per 49CFR Part 40 will be sent to employer.
HQUICC will keep the Drug and Alcohol Testing records according to the DOT 5 year, 2 year
and 1 year detailed retention schedule set by the Federal Highway Administration.
0
EXHIBIT B
LOCATION OF SERVICES
Health Quicc offers three convenient office locations with the following operating hours:
Wappingers Falls Office
1530 Route 9
Wappingers Falls, NY 12590
Ph: (845) 297-2511
Fx: (845) 297-4993 .
Daily: 8am to l Opm
Newburgh Office
1418 Route 300
Newburgh, NY 12550
Ph: (845) 564-1418
Fx: (845) 566-1148
Monday — Friday: Sam to 8pm
Saturday: 9am to 5pm
Office
1110 Route 55
Lagrangeville, NY 12540
Ph: (845) 485-4455
Fx: (845) 485-4472
Monday — Friday: 8am to 6pm Saturday:
9am to 5pm
Health Quicc also provides on-site occupational health to businesses and organizations upon
request.
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1273302v.1
9
EXHIBIT C
CONSENT FORM
DOT PHYSICALS / DRUG & ALCOHOL TESTING CONFIDENTIAL CONTACTS
2009
The contact persons from your company for receipt of all confidential information will
be:
Company:
Address:
City:
State:
Zip:
Primary Contact:
Title:
Phone:
Fax Number:
Is fax confidential? ❑ Yes 0 No, Do not fax confidential info.
Secondary Contact:
Title:
Phone:
Fax Number:
Is fax confidential? Yes No, Do not fax confidential info.
Note: Confidential results and information cannot be disclosed to any person not named
above.
Results should be: (please choose one method)
❑ Faxed ❑ Mailed ❑ Phoned
Random Drug Testing Program (Please provide us the following)
1. # of Drivers in your Program
2. Roster of Drivers including Names, Social Security Number and Date of
Birth
1273302v.1
11
HEALTH QUEST
IA1VlED1ATE CARE CENTER
HEALTH QUEST SYSTEMS
Drug Screen Intake Form
Patient Name:
Last: First: Middle:
Street Address:
City, State, Zip
Date of Birth:
Social Security Number:
Sex: ❑ M ❑ F
Marital Status: ❑ Single ❑ Married
❑ Divorced ❑ Separated ❑
Widowed
Spouse Name:
Home Phone: ❑ Preferred
Cell Phone: ❑ Preferred
Work Phone: ❑ Preferred
Photo I.D. ICOC Completed: ❑ Split ❑ Single
Laboratory
Collector
Front Desk Name: Nurse:
Sent By: Comments:
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1273302v.]
PLEASE READ BEFORE COLLECTION OF SPECIMEN
If you have any questions, ask the collector before giving your specimen.
YOU CANNOT LEAVE THE FACILITY PRIOR TO YOUR SCREENING
1. Picture identification is required.
2. Remove all unnecessary outer garments (coat). Leave all other clothing on.
3. Wash and dry hands before collection.
4. The collector will accompany you to the restroom.
b. Your belongings will be locked in a box inside the restroom.
6. Urinate into the disposable specimen cup up to the amount required. The
collector will take the temperature of the specimen. This must be done within
FOUR (4) minutes of urinating. Temperature of specimen must be in range of
90 —100 degrees.
7. Flush toilet when the collector tells you.
8. You will be given the opportunity to wash your hands again after the collection.
9. Remain with the collector while the Chain of Custody form is completed and the
specimen is sealed.
10. If the employer requires a split specimen, the collector will pour the urine into two
separate bottles and will seal bottles in your presence.
11. If the temperature of the specimen is not in the 90 -100 degree range, it will be
sent to the laboratory and your employer will be notified. A second specimen
shall be obtained as soon as possible under direct observation of a collection site
staff member of the same gender.
I have read and understand the above procedures for urine drug screen collection.
Print Name: I signature: I Date:
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1273302v.1
EXHIBIT D
FEES
FEE SCHEDULE
1. DOT Physicals
DOT Ph
EKG (if
$80.00 per test
$50.00 per test
2. Drug Testing Program - Random Drug Program
❑ OPTION 1: Annual Program' 3350/year + Testing Fees
Invoiced each January, pro -rated at time of program activation.
❑ OPTION 2: Per Use $300.00/hr. + Testing Fees
Invoiced each time utilized. This is the default fee unless the annual program is
chosen.
Fees are per test only. (Random selection included)
Drug Testing $65.00 per test
Alcohol Testing $25.00 per test
MRO Service Fees As required $75.00 each use
Drug Testing of original specimen at other $150.00 each minimum
SAMHSA lab
Consult Services (including court I $300.00/hr.
3. Drug Testing Program - Pre-employment, post -accident, reasonable suspicion
and follow-up testing
Drug Testing
Alcohol Testing
MRO Service Fees
Drug Testing of original specimen at other
SAMHSA lab
Travel
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1273302v.1
$65.00 per test
$25.00 per test
As required $75.00 each use
$150.00 each minimum
Travel fees are $200.00/half day per
clinician and occur only when testing is
required at a site other than Health Quic
BILLING
An invoice will be sent at the end of the month for the physicals or other services
completed that month. The bill should be sent to:
Company:
Attention:
Address:
City:
State:
Zip:
Phone:
Fax:
Payment Terms: Net 30 Days
E 15
1273302v.1