Banner Occ Health LOA FY2025
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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. 05/05/22
1
May 17, 2024
City of El Mirage FEIN: 86-6000767
Alexis Hermosillo
10000 N. El Mirage Rd.
El Mirage, AZ 85335
Dear Alexis Hermosillo:
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, 2024 (the “Effective
Date”) and will continue for a period of 2 year(s). Any extension periods agreed to in writing by
both parties. 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 July 1, 2023 (Contract # 5331-02-53702).
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
$59.75
AZ POST Medical Exam
$157.50
Breath Alcohol Test
$40
CMP/CBC/Lipids
$68.25
EKG
$52.50
Exercise Stress Test
$250
Hepatitis B Declination
$15.75
Hepatitis B Vaccine
$105 each
PFT
$42
DocuSign Envelope ID: F73FC9EB-1CBD-488A-8ACC-59F1CC84A625
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. 05/05/22
2
Injury Care for Workers Compensation billed according to State fee schedule.
Baseline:
Physical exam
$131.25
Detailed medical hx questionnaire $0
Med/Resp clearance-$0
Health Risk Appraisal-$0
Gross Body Skin Cancer Screening-$0
Urine Drug Screen 5 panel
$47.25
Audio
$36.75
Chem/HDL/CBC/CK-
$57.75
CXR 2 view-
$131.25
EKG-
$52.50
Pulmonary Function Testing-
$42
OSHA respiratory Questionnaire-
$26.25
Titmus Vision Exam-
$17
Urine Dip-
$5.25
Stress Test-
$250
Optional Labs/immunizations:
MMR Vaccine
$110
MMR Titer
$75
Varicella Vaccine
$200
Varicella Titer
$63
TB Skin Test
$35
HIV Test
$95
Annual Exams:
Physical exam
$131.25
Detailed medical hx questionnaire $0
Med/Resp clearance-$0
Health Risk Appraisal-$0
Gross Body Skin Cancer Screening-$0
Audio-
$36.75
Chem/HDL/CBC/CK-
$57.75
CXR 2 view- (every 5 years or if medically indicated) $131.25
EKG-
$52.50
Pulmonary Function Testing
$42
OSHA respiratory Questionnaire-
$26.25
Titmus Vision Exam
$17
Urine Dip-
$5.25
Stress Test- (every other year, 40+ annually, NFPA does not require a treadmill every year) $250
PSA Men 40+
$40
Optional Labs/immunizations:
MMR Vaccine
$110
MMR Titer
$75
Varicella Vaccine
$200
Varicella Titer
$63
TB Skin Test
$35
HIV Test
$95
DocuSign Envelope ID: F73FC9EB-1CBD-488A-8ACC-59F1CC84A625
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. 05/05/22
3
HIV Post Exposure Prophylaxis (PEP) Pricing (needle sticks, blood exposures):
1. Nurse Triage Call
$85.00
2. Licensed Practitioner Intervention
$220.00
3. Initial Visits
$105.00
4. Results Visits
$55.00
5. Follow-up Visit (1 week if on meds)
$78.00
6. Follow-up Visit (2 weeks if on meds)
$78.00
7. Follow-up Visit (3 weeks if on meds)
$78.00
8. Follow-up Visit (4 weeks if on meds)
$78.00
9. Follow-up Visit (12 weeks)
$78.00
10. Follow-up Visit (24 weeks)
$78.00
Costs billed in addition to visits:
Patient Testing:
1. ALT Liver function
$30.00
2. Blood Chem/CBC/UA (if on meds)
$45.00
3. Hepatitis B Titer
$60.00
4. Hepatitis B Vaccine
$105.00
5. Hepatitis C Test
$95.00
6. HIV Test
$95.00
7. Tetanus
$50.00
8. Tdap
$68.00
9. HBIG
Market price
10. Hep C RNA
$350.00
Source Testing:
1. HIV Test
$95.00
2. Hepatitis C Test
$95.00
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
**
Truvada-HIV
$985.00*
*
Ondanstron-Nausea (used as needed, price per pill)
$5.00**
**All prices are subject to change.
DocuSign Envelope ID: F73FC9EB-1CBD-488A-8ACC-59F1CC84A625
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. 05/05/22
4
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
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 State of 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 602-747-1262.
Sincerely,
Amanda Carranza
Senior Director,
Banner Occupational Health & Emplyee Health Services –Arizona, LLC
Date: ____________________________________
ACCEPTED AND AGREED:
City of El Mirage
By: ______________________________________
Name: ___________________________________
Title: ____________________________________
DocuSign Envelope ID: F73FC9EB-1CBD-488A-8ACC-59F1CC84A625
May 17, 2024 | 3:42 PM MST
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. 05/05/22
5
Date: ____________________________________
DocuSign Envelope ID: F73FC9EB-1CBD-488A-8ACC-59F1CC84A625