3.01 3.1
SERVICESUens Falls Hospital-Dnig Testing&Physicals—Fee hicrease—5-4-15
RESOLUTION AUTHORIZING RATE CHANGES IN AGREEMENT
BETWEEN TOWN OF QUEENSBURY AND GLENS FALLS HOSPITAL -
CENTER FOR OCCUPATIONAL HEALTH -
FOR SUBSTANCE TESTING SERVICES AND PHYSICAL EXAMS
RESOLUTION NO.: ,2015
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, by Resolution No.: 26,2015, the Queensbury Town Board authorized an
Agreement with the Glens Falls Hospital — Center for Occupational Health (Center) for provision of
such services as physical exams and substance testing in accordance with Federal Motor Carrier Safety
Regulations(FMCSR)for the Town during 2015, and
WHEREAS, by letter dated March 16, 2015, the Center advised the Town that it will be
implementing a modest increase on certain services effective June 1, 2015 per the fee schedule attached
to such March 16'h letter presented at this meeting,
NOW, THEREFORE, BE IT
RESOLVED, that the Queensbury Town Board hereby approves and authorizes the change in
rates as set forth in the March 16th, 2015 letter and fee schedule from the Glens Falls Hospital—Center
for Occupational Health(Center)presented at this meeting, and
BE IT FURTHER,
RESOLVED, that the Town Board further authorizes and directs the Town Supervisor to sign
any documentation or take any actions necessary to effectuate the terms of this Resolution.
Duly adopted this 4h day of May, 2015, by the following vote:
AYES
NOES
ABSENT:
•
Glens Fa 1s Hospital
CENTER FOR OCCUPATIONAL
HEALTH
March 16, 2015
Dear Valued Client:
It has been a very long and difficult winter and we are thrilled to see spring on the way. We
would like to thank you for the opportunity to partner with you in managing your healthcare and
regulatory needs.
Glens Falls Hospital continuously evaluates the needs of the community, the services that we
provide, and our charges. As with all businesses, we must adjust our rates from time to time to
keep pace with rising costs so we can continue to serve you effectively. This is to let you know
that we are implementing a modest increase on certain services effective June 1, 2015 per the
attached fee schedule. Any services that do not appear on the attached fee schedule will remain
Y pp
at their current pricing.
The other responsibility that we have is to increase our ability to communicate with you and add
any additional services so we can help you accomplish your goals. Therefore, we are seeking
your input as to how the Center for Occupational Health can become a better partner. We have
attached a company specific protocol for you to review and revise so we can update our records
with your current contact information.. Please..take.a few moments to,complete and return this
vital information to us either by mail, fax (518) 926-2165, or electronically to
cparadis @glensfallshosp.org. You may mark directly on the Company Profile or complete the
attached blank form. Please pay particular attention to details such as the type of respirator you
are using, if applicable.
We appreciate the opportunity to continue to serve you and your employees. Please contact us
regarding any questions or concerns that you may have.
Sincerely,
Cathy Rei c en, PT, DPT
Manager, Center for Occupational Health
enclosures
102 Park Street, Suite B-2 • Glens Falls,New York 12801 & (518)926-2140 a Fax(5I8)926-2151
135 North Road Wilton,New York 12831 G (518)926-4822 C Fax(518)926-1905
Fails Hospital
CENTER FOR OCCUPATIONAL
HEALTH
If your company has company specific forms that are utilized in the Center for Occupational Health, we would appreciate
an updated, clean copy sent by email to cparadis @glensfallshosp.org
Please list any comments or services your company is looking for but are not found above and identify the
person(s)we should contact:
Center for Occupational Health
Glens Falls Hospital
Service Components Charge
AUDIOMETRIC SERVICES
_ Audiogram Testing is performed in booth meeting ANSI Specifications $16.00
Audiogram at Worksite Testing is performed in booth meeting ANSI Specifications and is transported to the worksite. $20.00
Audiogram Review by Physician Audiogram is reviewed by a Certified Physician as required of Hearing Conservation Programs. $25.00
DRUG&ALCOHOL TESTING
Testing is conducted using DOT approved breath alcohol instrument for evidential use. (Intoxilyzer
200 and 240) DOT standards consider breath testing positive when the measurement is 0.02 or
Breath Alcohol Testing greater. When a positive breath sample is obtained,a confirmation test is conducted 15 minutes later
with an additional test charge. $25.00
Urine is collected and sent to a SAMI-ISA certified laboratory and reviewed by a Medical Review
Expanded Opiate Panel Officer. Substances tested: Amphetamines(Methamphetamines,MDMA,MDA), Barbiturates,
Benzodiazepines,Cocaine,Marijuana,Methadone,Methaqualone,Phencyclidine,Propoxyphene,
Expanded Opiates(Codeine, Morphine,Oxycodone,Oxymorphone,I-Iydrocodone,Hydromorphone). $38.00
IMMUNIZATIONS AND LAB TESTING
Tetanus Diphtheria Vaccine(Td) $30.00
MMR(Measles/mumps/rubella)Vaccine $80.00
---- PHYSICAL EXAMS
Performed by NRCME provider. Includes physical exam,5 foot whisper test,urine dip,visual
DOT Physical acuitiy/Color,Medical Examiner's Certificate $100.00
Complete Physical Basic physical,review of OSHA questionnaires $75.00
Basic Physical(Pre-placement,Fit for Duty) Includes height,weight,pulse,blood pressure,urine dip $60.00
OTHER/SCREENING TESTS
Pulmonary Function Test $35.00
Respirator Fit Testing, Worksite;Quantitative Use of Portacount $28.00
Any additional forms needing completion. For example: if two physicals are performed at the same
Form Fee time only one will incur a physical exam charge,the other will incur a form fee. $25.00
VOCATIONAL REIlAB
Ergonomic Analysis $80.00
JPA/Pre-Work Screen - $70.00
Effective 6/1/20:15
•
RESOLUTION AUTHORIZING AGREEMENT BETWEEN
TOWN OF QUEENSBURY AND GLENS FALLS HOSPITAL-
CENTER FOR OCCUPATIONAL HEALTH -
FOR SUBSTANCE TESTING SERVICES AND PHYSICAL EXAMS
RESOLUTION NO.: 26,2015
INTRODUCED BY: Mr. William VanNess
WHO MOVED ITS ADOPTION
SECONDED BY: Mr. Doug Irish
WHEREAS, the Queensbury Town Board wishes to enter into an Agreement with the
Glens Falls Hospital —Center for Occupational Health (Center)to provide such services as physical
exams and substance testing in accordance with Federal Motor Carrier Safety Regulations
(FMCSR)for the Town during 2015, and
WHEREAS, the Center has offered to perform such services in accordance with the terms
and provisions of the letter-form Agreement dated December 5,2014 and presented at this meeting,
NOW,THEREFORE,BE IT
RESOLVED, that the Queensbury Town Board hereby approves the letter-form Agreement
between the Town of Queensbury and the Glens Falls Hospital — Center for Occupational Health
(Center) substantially in the form presented at this meeting to provide such services as physical
exams and substance testing 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 letter-form Agreement and the Town Supervisor and/or Town Budget Officer to take
any other action necessary to effectuate the terms of this Resolution.
Duly adopted this 5th day of January, 2015,by the following vote:
AYES : Mr. Clements, Mr.Irish,Mr. VanNess, Mr. Strough,Mr. Metivier
NOES : None
ABSENT: None
-- Glens Falls Hospital
, .
CENTER FOR OCCUPATIONAL
HEALTH
102 Park Street,Suite B-2 Glens Falls,New York 1280]
(518)926-2140•Fax(518)926-2151
135 North Road •Wilton,New York 12831
(518)926-4822•Fax(518)926-I 905
December 5, 2014
Ms. Victoria LaMarque
Town of Queensbury
742 Bay Road
Queensbury, NY 12804
RE: Contract Renewal 1/1/15 through 12/31/15
Dear Ms. LaMarque,
The Center for Occupational Health is pleased to offer you services to meet the healthcare and/or
compliance needs of your organization. This letter will serve as a formal agreement for those services. If
agreed, the Center for Occupational Health (COH) will be providing the following occupational health
services for employees of the Town of Queensbury.
DOT SERVICES
• DOT Physical; Includes physical, DOT vision test, and urine dip $100.00
• Urine drug screens, 5 or 10 panel $35.00
Includes: collection, lab testing, MRO review
• Urine drug screens, Expanded opiate panel $38.00
• Evidential Breath Alcohol test $25.00/test
• Randomization of drug/alcohol program No charge
• On-call after hours/holiday $75.00/hour, 2 hour minimum
RESPIRATOR EXAM:
• Respirator Physical Exam $30.00
• Pulmonary Function Test $35.00
• Respirator Fit Test $25.00
• Annual Respirator Questionnaire Review $10.00 (no charge with physical)
ADDITIONAL SERVICES
• Job Placement Assessment $65.00
• Audiogram $16.00
• Audiogram Review by physician if a confirmed STS $25.00
• EKG,with MD interpretation, if medically indicated $35.00
• Fit for Duty Pre-Employment Exam $65.00
Includes: health history, urine dip, vision chart
• Return to Work Evaluation $30.00
WORK INJURY MANAGEMENT*
Rates are based on provider assessment. The treating provider will assign a level of visit according to the
complexity of the injury. Initial Visits will range from $45 to$75; follow-up visits will range between
$25 to$45. Please note that any open Workers' compensation cases will be billed at the prevailing New
York State workers' compensation rate.
Page 2: Town of Queensbury and the Center for Occupational Health
The Emergency Care Center(ECC) at Glens Falls Hospital (GFH) is available when the Center for
Occupational Health (COH) is closed. If follow-up is necessary the employee will be referred to COH.
Please inform the ECC that the employer is a client of COH.
Drug/Alcohol Testing
All urine drug testing specimens collected by COH (DOT and/or non-DOT)will be sent to a SAMHSA
(Substance Abuse Mental Health Services Administration) certified laboratory for drug urinalysis testing
as required in 49 CFR Part 40.39. Emit immunoassay screening is used as the initial drug test and gas
chromatography/mass spectrometry (GCMS) is the authorized confirmation method.
All alcohol testing(DOT and/or non-DOT)conducted by COH will be provided on an Evidential Breath
Testing(EBT) device. The Center uses the CMI Intoxilyzer 200,which is on the Conforming Products
List (CPL) approved by the National Highway Traffic Safety Administration (NHTSA). A certified
Breath Alcohol Technician (BAT)will perform all EBT's. The BATs have met the requirements set forth
by 49 CFR Part 40. The cutoff level for detection of alcohol is 0.02 (g/1).
The Center for Occupational Health is pleased to have four physicians who are certified by the Medical
Review Officer Certification Council: Michael Holland,MD, MROCC; Kenneth Stein,MD,MROCC;
William R. Rogers, MD, MROCC; and Ruth Light, MD,MROCC. Certificates available upon request.
COH has a 24-hour paging system for after hours, post accident and reasonable suspicion testing. To
access the system, call 832-1389 and leave a contact name and phone number. The on-call technician
will return the call promptly with instructions for meeting the employee. A company supervisor must
accompany the employee for all after-hours testing.
Substance Abuse Professional (SAP)referral information will need to be available for your employees in
the event of a positive test result. If the Town of Queensbury is aligned with an EAP(Employee
Assistance Program)they may very well provide this service. There may be choices listed in the yellow
pages under counselors/counseling or on the web under http://saplist.com/or http://www.eap-
sap.com/sap/I-NY.htm. I recommend that you check with any you might consider using to see if they
satisfy the Substance Abuse Professional requirements of DOT.
If you need information regarding the DOT Federal Highway Administration regulations and your
responsibilities as the employer, we would suggest the following websites:
http://www.dot.gov/odapc/NEW DOCS/part40.html?proc
http://www.fmcsa.dot.gov/safety-security/safety-initiatives/drugs/drug-guidelines.pdf
http://www.dot.gov/sites/dot.dev/files/does/ODAPC%20EmployerGuidelinesOctober012010.pdf
http://www.druqfreeworkplace.gov/pdf/workplace-kit.pdf
Random Selection:
A computer random selection process uses the names of the drivers you have in the random pool. It is
extremely important that the random pool be accurate at all times to ensure a successful program.
Participating consortium members are responsible for keeping COH updated with any changes, (e.g.
terminations or new hires). COH complies with the DOT requirements of testing at least 50%of the
drivers in the pool for drugs and 10%of the drivers in the pool for alcohol on an annual basis.
. Page 3: Town of Queensbury and the Center for Occupational Health
Random Consortium Employer Responsibilities:
In order to manage the consortium to meet DOT requirements the employer has the following
responsibilities:
• Keep COH up-to-date with current employees,
• Do not give advance notice to selected random employees,
• Discreetly notify selected employees just before, during, or immediately after performing safety-
sensitive work, to report to the collection site immediately for testing with proper ID,
• Contact COH if randomly-selected employees cannot be tested and the reason,
• Send employees for pre-employment testing before they begin performing safety-sensitive
functions, even if they are a current employee changing jobs within the company.
• Other responsibilities delineated by the FMCSA and available in the links above
Non-compliance could result in heavy fines from DOT for each day that you are not in compliance. Non-
compliance also causes problems for COH in managing the consortium and ensuring testing quotas are
met, and can affect our ability to run this consortium, and may compromise the integrity of the entire
program. Failure to meet these responsibilities will result in your company being dropped from the
Center for Occupational Health's random consortium.
COORDINATION OF SERVICES
All services will be coordinated through Cathy Reichen at(5l 8) 926-2140. Should you require any
additional services, please call at any time to discuss your needs.
AVAILABILITY OF SERVICES
Hours of operation at 100 Park Street, Pruyn Pavilion in Glens Falls are:
Monday through Thursday 6:30 am - 5:00 pm; Friday 6:30 am -4:00 pm
Hours of operation at 135 North Road in Wilton are:
Monday—Thursday 7:30 am - 5:00 pm; Friday 7:30 pm -4:00 pm
COMMUNICATION
The employees of the Town of Queensbury will be requested to sign a consent form allowing testing
and/or treatment to be conducted and permitting the release of information to the designated individual
from the Town of Queensbury. A copy will be kept in the employee's medical file at the Center for
Occupational Health.
STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
GFH and Town of Queensbury shall comply with 45 C.F.R. Parts 160 and 164 (hereinafter referred to as
"HIPAA"). Information obtained from your employees in accordance with this Agreement constitutes
protected health information ("PHI")under HIPAA. Town of Queensbury is considered a"business
associate" for purposes of this Agreement and HIPAA to the extent the employee health records are
provided to Town of Queensbury as the employer. Any release of employee health records provided to it
by GFH must comply with HIPAA requirements. The Town of Queensbury must advise GFH when
violations of HIPAA have occurred.
BILLING
Invoices for COH charges will be submitted on a monthly basis to and payment is expected within thirty
days. Payment outstanding greater than 30 days will be charged 1.5%per month. Charges for ECC visits
will be billed through the hospital billing system.
Page 4: Town of Queensbury and the Center for Occupational Health
LENGTH OF THIS AGREEMENT
This agreement is intended to cover only the indicated occupational health services for your employees
through 12/31/15. Thereafter this Agreement will be automatically renewed for one year periods unless
sooner terminated by either party. In the event that the fee structure changes, said information will be
provided through a sixty(60) days advance written notice. Either party may terminate this Agreement
upon forty-five (45) days written notice.
Please feel free to contact me if you have any questions. If this agreement meets your approval,please
sign below on both copies and return all originals for signature to:
Connie Paradis
Center for Occupational Health
2 Broad Street Plaza
Glens Falls, NY 12801
After all signatures are obtained, one original will be mailed to you for your records. Thank you for
choosing our services at the Center for Occupational Health.
Glens Falls Hospital Town of•.--nsbury
OP-)
Ann Marie Hatch • n Strough
Exec. Director,Adirondack Medical Services Town Supervisor
Date 01 ( S f 5 Date 6 /�—'