Banner and COEM Agreement

Y:\BCC_3\SHSLegal\FORMS, TEMPLATES AND LANGUAGE PROVISIONS\Templates\ Provider\Occupational Health 
Services Agreement Letter (LOA) Template.doc 
LB/CGC Approved -12/30/19 Rev. 8/6/21 
1 
 
  
 
 
 
October 9, 2021 
 
 
City of El Mirage                                                                                             FEIN: 86-6000767 
Dawn Kurek 
10000 N. El Mirage Rd. 
El Mirage, AZ 85335 
 
Dear Ms. Kurek:  
 
Thank you for choosing Banner Occupational Health --Arizona, LLC, an Arizona limited liability 
company (“Banner”), as the occupational healthcare provider for City of El Mirage 
("Company").     
 
The term of this letter agreement (this "Agreement") will begin on November 9, 2021 (the 
“Effective Date”) and will continue for a period of 2 year(s).  Any amendments will be effective 
for at least one year.  This Agreement may be terminated by either party at any time, without 
cause and without penalty, by giving the other party at least 30 days’ prior written notice. As of 
the Effective Date, this Agreement terminates, supersedes, and replaces the letter agreement 
between Company and Banner dated effective November 9, 2020 (Contract # 5331-02-53702 
A5).  
 
Banner is committed to providing Company with employee medical evaluations and health 
screenings as required by Company’s personnel policies or as requested by Company, subject to 
federal and state law.  The services to be provided and prices that will be charged are outlined 
below.  All services provided by Banner will be subject to the terms of this Agreement.   
 
Services:       
10 Panel Drug Screen  
 
$57 
AZ POST Medical Exam 
 
$150 
Breath Alcohol Test 
 
 
$40 
CMP/CBC/Lipids 
 
 
$65 
COVID-19 Antibody Testing  
$75 
COVID-19 PCR Nasal Swab Testing $110 
EKG 
 
 
 
 
$50 
Exercise Stress Test 
 
 
$250 
Hepatitis B Declination 
 
$15 
DocuSign Envelope ID: CA22CB53-5EAC-4FCE-A22E-B070E3A42C8A

Y:\BCC_3\SHSLegal\FORMS, TEMPLATES AND LANGUAGE PROVISIONS\Templates\ Provider\Occupational Health 
Services Agreement Letter (LOA) Template.doc 
LB/CGC Approved -12/30/19 Rev. 8/6/21 
2 
 
  
Hepatitis B Vaccine 
 
 
$100 each 
PFT 
 
 
 
 
$40 
Injury Care for Workers Compensation billed according to State fee schedule. 
 
HIV Post Exposure Prophylaxis (PEP) Pricing (needle sticks, blood exposure): 
1. Nurse Triage Call 
$80.00  
 
2. Licensed Practitioner Intervention 
$175.00 
3. Initial Visit 
$100.00 
4. Results Visit 
$50.00 
5. Follow-up Visit (1 week if on meds) 
$75.00 
6. Follow-up Visit (2 weeks if on meds) 
$75.00 
7. Follow-up Visit (3 weeks if on meds) 
$75.00 
8. Follow-up Visit (4 weeks if on meds) 
$75.00 
9. Follow-up Visit (12 weeks) 
$75.00 
10. Follow-up Visit (24 weeks) 
$75.00 
 
Costs billed in addition to visits: 
 
Patient Testing: 
1. ALT Liver Function 
$25.00 
2. Blood Chem/CBC/UA (if on meds) 
$40.00 
3. Hepatitis B Titer 
$60.00  
4. Hepatitis B Vaccine 
$100.00 each 
5. Hepatitis C Test 
$90.00 
6. HIV Test 
$90.00 
7. Tetanus 
$50.00 
8. Tdap 
$65.00 
9. HBIG 
Market Price 
10. Hep C RNA 
$350.00 
 
 
Source Testing: 
1. HIV Test 
$90.00 
2. Hepatitis C Test 
$90.00 
3. Hepatitis B Antigen 
$60.00 
 
Medications: 
One week supply of the following medications (maximum of four (4) weeks on meds) (Pricing below is estimated 
pricing as medications and pricing fluctuate based on medical standard and market prices): 
 
1. Isentress-HIV 
$420.00** 
2. Truvada-HIV 
$985.00** 
3. Ondanstron-Nausea (used as needed, price per pill) 
$5.00** 
 
**All prices are subject to change 
 
Upon Company's request, Banner will provide reports to Company unless applicable law 
requires Banner to maintain the confidentiality of the reports and to only provide them to the 
employee, in which case the employee must authorize Banner to disclose them to Company.  
Company will be solely responsible for the use and dissemination of these reports.  Company 
DocuSign Envelope ID: CA22CB53-5EAC-4FCE-A22E-B070E3A42C8A

Y:\BCC_3\SHSLegal\FORMS, TEMPLATES AND LANGUAGE PROVISIONS\Templates\ Provider\Occupational Health 
Services Agreement Letter (LOA) Template.doc 
LB/CGC Approved -12/30/19 Rev. 8/6/21 
3 
 
  
will hold Banner harmless from claims arising out of the disclosure and use of information 
reported to Company. 
 
Banner may be required to obtain informed consent from the employee before Banner can 
perform certain services.  When an informed consent is required, Banner will work to obtain the 
informed consent. 
 
This Agreement will be governed by the internal substantive law of the Arizona, without regard 
for the conflict of law principles thereof.    
 
This Agreement contains the entire agreement between the parties with respect to the subject 
matter hereof.  All prior negotiations between the parties are merged in this Agreement, and 
there are no understandings or agreements other than those incorporated herein. This Agreement 
may not be modified except by a written instrument signed by both parties to this Agreement.  
Any other arrangements between the parties are the subject of one or more separate agreements, 
all of which are listed in one or more databases maintained by Banner. 
 
We look forward to meeting your occupational health needs.  Should you wish to discuss the 
terms of our services, please call Rebecca Twyman-Adams at 602-255-7515. 
 
Sincerely, 
 
 
 
Amanda Carranza  
Occupational Health Support Director 
Banner Occupational Health –Arizona, LLC 
  
Date: ____________________________________ 
 
ACCEPTED AND AGREED: 
 
City of El Mirage 
 
By: ______________________________________      
Name: ___________________________________ 
Title: ____________________________________ 
Date: ____________________________________ 
DocuSign Envelope ID: CA22CB53-5EAC-4FCE-A22E-B070E3A42C8A
October 11, 2021 | 8:00 AM MST