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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 2 (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. 5 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. 10 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: 12 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: 13 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 14 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