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4.22
2022 ORGANIZATIONAL MEETING1Standard Medical Division of Mountain Medical Services-Drug Testing&Physicals
RESOLUTION AUTHORIZING AGREEMENT BETWEEN TOWN OF
QUEENSBURY AND STANDARD MEDICAL TESTING SERVICES, A
DIVISION OF MOUNTAIN MEDICAL SERVICES, FOR PROVISION OF
CERTAIN HEALTH CARE SERVICES DURING 2022
RESOLUTION NO.: ,2022
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, the Queensbury Town Board wishes to enter into an Agreement with Standard
Medical Testing Services, a division of Mountain Medical Services, (SMTS) for provision of
certain healthcare services such as physical exams and substance testing in accordance with Federal
Motor Carrier Safety Regulations(FMCSR) for the Town during 2022, and
WHEREAS, SMTS has offered to perform such services in accordance with the terms and
provisions of the Contractual Agreement presented at this meeting,
NOW,THEREFORE,BE IT
RESOLVED, that the Queensbury Town Board hereby approves and authorizes the
Contractual Agreement between the Town of Queensbury and Standard Medical Testing Services, a
division of Mountain Medical Services, for provision of certain healthcare services such as physical
exams and substance testing for the Town during 2022 in substantially the form presented at this
meeting,with the costs for such services to be paid for from the appropriate accounts, and
BE IT FURTHER,
RESOLVED, that the Town Board further authorizes and directs the Town Supervisor to
execute the Contractual Agreement in substantially the form presented at this meeting and any other
needed documentation and the Town Supervisor and/or Town Budget Officer to take any other
actions necessary to effectuate the terms of this Resolution.
Duly adopted this 3 d day of January, 2022,by the following vote:
AYES
NOES
ABSENT:
eruices
S d Medical S
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MOUNTAIN MEDICAL
Contractual Agreement
This agreement is made between Standard Medical Testing Services, a division of Mountain
Medical Services, located at 597 Bay Road, Queensbury, NY 12804 and with Town of
Queensbury having an address a 742 Bay Rd Queensbury,NY 12804.
This agreement shall be in effect from January 1, 2022-Dec 31, 2022.
The responsibilities and obligations and liabilities shall survive the term of this agreement.
This agreement may be cancelled by either party after thirty days of written notification.
Both parties to this agreement are independent contractors, and nothing contained herein shall
be construed to place the parties in the relationship of partners,joint venture, principal-agent or
employer-employee, and neither party shall have the power to obligate or bind the other
whatsoever beyond the terms of this agreement.
Standard Medical Testing Services, a division of Mountain Medical Services, will be
compensated for its services as follows:
Yearly Administrative Fee: 10 or more employees $150.00
9 or less employees $ 75.00
Urine Drug Screens, 5 panel Dot $ 48.00
Urine Drug Screen, 10 panel expanded $ 50.00
Alcohol Breath Testing $ 36.00
JPA/Functional Capacity $ 70.00
DOT/CDL Physicals they do not pay for
NO Show/late Cancellation $ 30.00
Hep B Vaccine $ 95.00
Audiogram $ 35.00
Fit For Duty, PE $110.00
Respirator PE, includes PFT& Fit $130.00
Onsite Charge - Other than Randoms $100.00
NO Show Fee- $ 30.00
Observed Urine Collection $25.00
In addition, should there be after hours, post accident testing/reasonable suspicion, there shall
be a flat rate fee of$120.00 per hour with a minimum two hour charge.Also there will be a
mileage charge of 56.5 cents per mile applied.
Shy Bladder wait time is$40.00 per hour, including after 5 pm closing time.
The fee for split specimen re-testing of positive specimens (including shipping, lab fees and
chain of custody)shall be $250.00.
The review of all Positive drug screens will be$100.00, regardless of final outcome. This
includes the MRO time for contacting physicians, donors and specialists whom the employee is
being treated by.
Payment of invoices is expected within 30 days of receipt of invoice payable to Mountain
Medical Services, PO BOX 13395, Belfast Maine, 04915.. A late fee/interest fee of 1.5%
monthly will be applied to outstanding invoices over 30 days old. We accept payment
online at www.guickpayportal.com. Code is on Invoice.
Standard Medical Testing Services a division of Mountain Medical Services attests that it will
keep all information obtained from Town of Queensbury for the purpose of testing confidential
unless otherwise required to disclose said information by applicable law, regulation, or
subsequent agreement.
The provisions of the Agreement shall be construed, interpreted and governed by the
substantive laws of the state of New York, including all matters of construction, validity and
performance.
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed as of
the day and year executed below:
Standard Medical Testing Services
Merrie Lynn Towle, BSN
Mountain Medical Services Town of Queensbury
Dr. Michael P. M. Pond, MD
Name: -W9,7 ' Name:
Title: Director of Occupational Medicine Title:
Date:Awgiiw ! 100210 Date:
IV
Please execute this agreement, retain the original, and forward a duplicate to Standard Medical
Testing Services at 597 Bay Road, Queensbury, NY 12804
Standard Medical Testing Services Mountain Medical Services
A division of Mountain Medical
Merrie Lynn Towle, BSN Michael Pond, MD/MRO
597 Bay Road 1927 Saranac Avenue
Queensbury,NY 12804 Lake Placid,NY 12945
518-744-6560 518-523-7575
fax:518-409-8441 FAX: 518-523-7577
www.standardmedicalservices.com www.mountainmedical.net
standardmedicalservicesOgmail.com
354 Broadway,Saranac Lake,NY 12983
2 Hospital Drive,Massena,NY 13662
3372 St.Rte.11,Suite H,Malone,NY 12953
.. S . rd Medical Services
MOUNTAIN MEDICAL
In regards to:Drug and Alcohol Screening Program
Designated Employee Representative,
1
We welcome you to the Standard Medical Services,a division of Mountain Medical Services,Drug and Alcohol
Workplace Programs. Standard Medical Services will work closely with your facility to provide ongoing support
pertaining to the implementation of your program for a drug-free workplace.
Standard Medical Services requests that your company provide an updated employee list(including new employees as
well as employees that have been terminated)at your earliest convenience. Please provide the drivers license number of
the employee and if the employee will be a part of the DOT testing pool or non-DOT testing pool. Forms are included
for your convenience.
As you already know,Confidential Contact(Designated Employee Representative/DER)information is also needed.We
need there to be two contacts'in the event that one is unavailable.Please include names,phone numbers,as well as email
addresses where these contacts can be reached.
Enclosed is your Drug and Alcohol Testing Contract.Please make a copy for your records and sign and send one
back to us,along with an updated employee list and driver's license numbers. Please return the contract signed,
consortium certificate agreement and Company Designated Employee Representative Form.
If we do not receive a copy back we will ASSUME you no longer want to
participate in our CONSORTIUM.
If you have any questions please feel free to contact me at our Queensbury office.
Thank you,
Merrie Lynn Towle, ,BSN
Standard Medical Testing Services Mountain Medical Services
a division of Mountain Medical Services
597 Bay Road 1927 Saranac Avenue
Queensbury,NY 12804 Lake Placid,NY 12945
Phone: 518-744-6560 Phone: 518-523-7575
Fax: 518-409-8441
www.standardmedicalservices.com www.mountainmedical.net
standardmedicalservices@gmail.com 354 Broadway,Saranac Lake,NY 12983
2 Hospital Drive,Massena,NY 13662
3372 St.Rte..11,Suite H,Malone,NY 12953
S+ rd Medical Services
•56R=SCAUroux OOCUPA770NALZ(&UT rt47DS
MOUNTAIN MEDICAL
Consortium Certificate Agreement
According to the US Department of Transportation rules and regulations,a company must implement a drug and alcohol
testing program. Included in these regulations are requirements that owner-operators,small motor carriers or
municipalities must join a consortium to handle testing procedures,and under 382.4010(6)(i),you must have a written
agreement from the consortium on file. Standard Medical Testing Services/Mountain Medical has agreed to act as the
consortium.
I hereby certify I am knowledgeable of the requirements for conducting urine collection,the duties of the Medical
Review Officer,Breath Alcohol Technician,the Substance Abuse Professional,and the use of DHHS certified laboratory,
and all the requirements of the US Department of Transportation regulations,49 CFR Part 40.
I further certify that I am familiar with the random selection requirements and have on file all documents required by
382 and I will provide those documents in case of an audit from the US Department of Transportation on one of my
clients. I hereby agree to comply with all such regulations governing the procedures in performing drug and alcohol
testing for the below listed owner-operator/motor carrier/municipality.
Name of Owner-operator/Munici ali /Motor Carrier:
Address of Owner-operator/Municipality/Motor Carrier:
Phone Number:
Contact Person:
Email Address:
Dated This Day of Year
Signature of Consortium Official:
Standard Medical Testing Services Mountain Medical Services
a division of Mountain Medical
Merde Lynn Towle, BSN Michael Pond,MD/MRO
597 Say Road 1927 Saranac Avenue
Queensbury,NY 12804 Lake Placid,NY 1294S
518-744-6560 518-523-7575
fax:518-409-8441 FAX: S18-523-7S77
www.standardmedicalservices.com www.mountainmedical.net
standardmedicalservices@gmail.com
3S4 Broadway,Saranac Lake,NY 12983
2 Hospital Drive,Massena,NY 13662
3372 St.Rte.11,Suite H,Malone,NY 12953
Please execute this agreement,retain the original,and forward a duplicate to Standard Medical Services for our files
1
•• • '+ ••
••.. S ndard Medical Services
MOUNTAIN MEDICAL
Company Designated Employee Representative Form
Date:
Company Name:
Company Address:
Company Mailing/Billing Address(if different):
HOW WOULD YOU LIKE RESULTS: Emailed Fazed Mailed
ALL INFORMATION BELOW IS MANDATORY-WE NEED 2 DER'S
Primary DER(Designated Employer Representative) Alternate DER(Designated Employer Representative)
Name: Name:
Company Phone: Company Phone:
Company Fax: Company Fax:
DER Cell Phone: DER Cell Phone:
DER Home Phone: DER Home Phone:
DER email: DER email:
Standard Medical Testing Services Mountain Medical Services
a division of Mountain Medical
597 Bay Road 1927 Saranac Avenue
Queensbury,NY 12804 Lake Placid,NY 12945
518-744-6560
Faz 518-409-8441 518-523-7575
www.standardmedicalservices.com www.mountainmedicaI.net
standardmedicalservices(a)gmail.com
354 Broadway,Saranac Lake,NY 12983
2 hospital Drive,Massena,NY 13662
3372 St.Rte.11,Suite H,Malone,NY 12953
••. S rdMedxcal Services
MOUNTAIN MEE>ICAL
Please use this form to notify us in the event of a termination within your company. It would be greatly
appreciated if you could return one of these forms to us if you drop an employee.This will help to keep an updated
employee list in our system,for efficient testing statistics.If you run out or lose these forms please feel free to can
us and we will be happy to send more to you.
ammmm Tuc"imAnam1unto rum
Company Name:
Employee Name:
Termination/Retirement Date:
Authorized Signature Date
Standard Medical Testing Services Mountain Medical Services
A division of Mountain Medical
597 Bay Road 1927 Saranac Avenue
Queensbury,NY 12804 Lake Placid,NY 12945
518-744-6560 518-523-7575
fax: 518-409-8441
www.standardmedicalservices.com www.mountainmedical.net
standardmedicalservicesC&gmail.com
354 Broadway,Saranac Lake,NY 12993
2 Hospital Drive,Massena,NY 13662
3372 St.Rte.11,Suite H,Malone,NY 12953
/VtQU NTA1 N A4E1:>I4--AL
S�Nd+ Medical Services
Please use this form to notify us in the event of a new hire within your company. It would be
greatly appreciated if you could return one of these forms to us if you add an employee.This will
help to keep an updated employee list in our system,for efficient testing statistics.If you run out or
lose these forms please feel free to call us and we will be happy to send more to you.
NEW HIE Form
Company Name:
Employee Name:
Date of Hire:
Drivers lic# State issued:
Employee DOB:
Authorized Signature Date
Standard Medical Testing Services Mountain Medical Services
a division of Mountain Medical Services
597 Bay Road 1927 Saranac Avenue
Queensbury,NY 12804 Lake Placid,NY 12945
518-744-6560 518-523-7575
Fax:518-409-8441
www.standardmedicalservices.com www.mountainmedical.net
standardmedicalservicesagmail.com
354 Broadway,Saranac Lake,NY 12983
2 Hospital Drive,Massena,NY 13662
3372 St.Rte.11,Suite H,Malone,NY 12953
After Hours
Standard Medical Services
a division of Mountain Medical Services
597 Bay Road
Queensbury, NY 12804
Meet at employee entrance of building...when you are in
parking lot you will see steps up to door on side of building
Before Sam or after 4:30pm M-T
Before Sam or after 4pm on Fridays
Weekends/Holidays or if we happened to be
closed
• A Supervisor MUST escort the Employee for testing
• CALL # 518-338-8411
• 2ND # 518-744-6608
• 3RD # 518-696-3602