COEM and Banner Occ Health Clinics agreement

DocuSign Envelope ID: 2C94A1A4-1B52-4441-BFAA-F953A1BE931A

AS

ae

7 Banner Occupational
Health Clinics

July 1, 2023

City of El Mirage FEIN: 86-6000767
Dawn Kurek

10000 N. El Mirage Rd.

El Mirage, AZ 85335

Dear Dawn 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 July 1, 2023 (the “Effective
Date”) and will continue for a period of 1 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, 2021 (Contract # 533 1-02-53702).

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
Hepatitis B Vaccine $100 each

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

PFT

DocuSign Envelope ID: 2C94A1A4-1B52-4441-BFAA-F953A1BE931A

$40

Injury Care for Workers Compensation billed according to State fee schedule.

Baseline:

Physical exam

Detailed medical hx questionnaire $0
Med/Resp clearance-$0

Health Risk Appraisal-$0

Gross Body Skin Cancer Screening-$0

$125

Urine Drug Screen 5 panel (this is a standard panel we can go up to a 14 panel if needed) -$45

Audio

Chem/HDL/CBC/CK-

CXR 2 view-

EKG-

Pulmonary Function Testing-
OSHA respiratory Questionnaire-
Titmus Vision Exam-

Urine Dip-

Stress Test-

Optional Labs/immunizations:
MMR, Varicella, HEPB, HIV
MMR, Varicella, Tdap, HepB, TB Skin test

Annual Exams:

Physical exam

Detailed medical hx questionnaire $0
Med/Resp clearance-$0

Health Risk Appraisal-$0

Gross Body Skin Cancer Screening-$0
Audio-

Chem/HDL/CBC/CK-

$35
$55
$125
$45
$40
$25
$15
$5
$200

$125

$35
$55

CXR 2 view-$125 (every 5 years or if medically indicated)

EKG-

Pulmonary Function Testing
OSHA respiratory Questionnaire-
Titmus Vision Exam
Urine Dip-

Stress Test-

PSA Men 40+
Optional Labs/immunizations:

MMR, Varicella, HEPB, HIV

MMR, Varicella, Tdap, HepB, TB Skin test

HIV Post Exposure Prophylaxis (PEP) Pricing (needle sticks, blood exposures):
$80.00

$175.00
$100.00
$50.00

1. Nurse Triage Call

2. Licensed Practitioner Intervention
3. Initial Visits

4. Results Visits

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

$45
$40
$25
$15
$5

$200 (every other year, 40+ annually, NFPA does not require a treadmill every year)

-$35

DocuSign Envelope ID: 2C94A1A4-1B52-4441-BFAA-F953A1BE931A

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
5. Hepatitis C Test $90.00
6. HIV Test $90.00
7. Tetanus $45.00
8. Tdap $65.00
9. HBIG Market price
10. Hep C RNA $350.00
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):

Isentress-HIV -

$420.00
kK
Truvada-HIV
$985.00*
*
Ondanstron-Nausea (used as needed, price per pill) $5.00**

**4 [I 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

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

DocuSign Envelope ID: 2C94A1A4-1B52-4441-BFAA-F953A1BE931A

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 an 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 at 602-255-7515.

Sincerely,

Amanda (avranra

Amanda Carranza
Occupational Health Support Director
Banner Occupational Health - Arizona, LLC

June 19, 2023 | 12:04 PM MST
Date:

ACCEPTED AND AGREED:
City of El Mirage

By:

Name:

Title:

Date:

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