COLLECTION SITE MANAGEMENT SERVICE AGREEMENT
This Service Agreement (this "Agreement") is entered into this day of , ("Effective Date") by and between First Advantage Occupational Health Services Corp., with its headquarters located at 1100 Alderman Drive, Alpharetta, Georgia 30005 (“FAOHS”) and , with its headquarters located at ("Provider").
WHEREAS, Provider is a provider of drug, alcohol or occupational health testing services (collectively, "Services"); and WHEREAS, FAOHS maintains a Provider Network for the purpose of offering Services to its customers; and
WHEREAS, Provider desires to participate in FAOHS's Provider Network and to be included on any provider lists distributed by FAOHS to its customers; and
WHEREAS, in exchange for including Provider in FAOHS's Provider Network, FAOHS requires that the Services provided by Provider adhere to the terms and conditions set forth herein; and NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree to the following:
1. T ERM OF AGREEMENT
This Agreement will remain in effect for a period of one year from the Effective Date. The term of this Agreement will renew automatically for successive one year periods unless terminated by either party, in writing, at least sixty (60) days prior to the next anniversary of the Effective Date.
2. PROVISION OF SERVICES
Provider will provide the Services selected in Section 7 of this Agreement in accordance with the terms of this Agreement and the invoicing instructions communicated by FAOHS in writing from time to time. Provider shall render the Services in a professional manner which promotes availability, adequacy and continuity of such services. Provider shall remain solely responsible for the quality of its Services and shall render such services in accordance with generally accepted collection site practices and professionally recognized standards relating to the furnishing of collection site services. Provider shall prepare and maintain appropriate records related to the Services performed by Provider hereunder. FAOHS shall have the right to audit, copy and inspect said records and accounts during normal business hours with ten (10) business day’s prior written notice, and for a period of at least three (3) years from the date of final payment under this Agreement. All records and accounts relating to financial matters shall be in a format consistent with generally accepted accounting principles. Further, Provider shall maintain the chain of custody procedure of both DOT and non-DOT specimens throughout the collection, testing and communication process of those specimens and their results. Provider agrees to immediately notify FAOHS if it receives a Notice of Proposed Exclusion (NOPE) or a Public Interest Exclusion (PIE) from the DOT. Provider hereby represents and warrants that it is not currently subject to a NOPE or PIE.
3. COMPLIANCE WIT H LAWS
a. Provider hereby represents and warrants that it will comply with all applicable laws, statutes, ordinances, administrative or executive orders, rules and regulations as they relate to Provider's performance of Services under this Agreement including, but not limited to, the Department of Transportation's Procedures for Workplace Drug and Alcohol Testing Programs, 49 C.F.R. Part 40, as such procedures may be amended from time to time.
b. Provider affirms that it will provide necessary data to FAOHS for the purpose of facilitating payment. Provider acknowledges that disclosures required for payment operations are specifically allowed under the Health Insurance Portability and Accountability Act Medical Privacy Regulations, 45 C.F.R. §§164.502(a)(1)(ii) and 164.502(a), as the same may be modified from time to time.
c. Provider agrees to maintain or obtain such licenses and Training Certifications as are necessary to allow Vendor to perform its testing services under this Agreement, including but not limited to Department of Health and Human Services (DHHS), SAMHSA and CAP/AACC certifications. Specimen collection and testing will be performed only by Collectors and Certified Breath Alcohol and Screening Test Technicians trained and certified in accordance with 49 C.F.R. Part 40. Certificates of Training described in this Section shall be furnished to FAOHS upon request.
4. CONFIDENT IAL INFORMAT ION
In order to maintain confidentiality, Provider and FAOHS agree to keep confidential and to take all reasonable precautions to prevent the unauthorized disclosure of any and all records and results required to be prepared or maintained by this Agreement to the extent consistent with applicable laws and regulations. All results, DOT and non-DOT, shall be communicated and maintained by Provider consistent with the confidentiality required by applicable law, including DHHS Guidelines. All DOT results will only be released only in accordance with the confidentiality provisions and procedures set forth in 49 C.F.R. Part 40.
Provider will immediately notify FAOHS, in writing to FAOHS, if Provider suspects, has reason to believe or confirms that any such records or results are or have been lost, stolen, compromised, misused or used, accessed or acquired in an unauthorized manner or by any unauthorized person. Provider shall remain solely liable for all costs associated therewith and shall further reimburse FAOHS for any expenses it incurs due to Provider's failure to prevent such impermissible use or access, or any actions required as a result thereof.
Provider acknowledges that, upon unauthorized acquisition or access of or to personally identifiable information, including but not limited to that which is due to use by an unauthorized person or due to unauthorized use (a "Security Event"), Provider shall, in compliance with law, notify the individuals whose information was potentially accessed or acquired that a Security Event has occurred, and shall also notify any other parties as may be required in FAOHS's reasonable discretion. Provider agrees that such notification shall not reference FAOHS or the product through which the personal information was provided, nor shall FAOHS be otherwise identified or referenced in connection with the Security Event, without FAOHS's express written consent. Provider shall provide samples of all proposed materials to notify consumers and any third-parties, including regulatory entities, to FAOHS for review and approval prior to distribution. Provider shall be solely responsible for any other legal or regulatory obligations which may arise under applicable law in connection with such a Security Event and shall bear all costs associated with complying with legal and regulatory obligations in connection therewith. Provider shall remain solely liable for claims that may arise from a Security Event, including, but not limited to, costs for litigation (including attorneys' fees), and reimbursement sought by individuals, including but not limited to, costs for credit monitoring or allegations of loss in connection with the Security Event, and to the extent that any claims are brought against FAOHS, shall indemnify FAOHS from such claims.
5. REQUIRED INSURANCE COVERAGES
a. Provider shall obtain, pay for, and maintain insurance in full force and effect during the term of this Agreement as follows:
i. Workers' compensation and employers' liability insurance with limits to conform with the lesser of the amount required by applicable law or one million dollars ($1,000,000) per occurrence;
ii. Commercial general liability insurance with limits not less than one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate for bodily injury, death, and property damage, including personal injury and contractual liability;
iii. Professional liability insurance (Errors and Omissions) with limits not less than three million dollars ($3,000,000) annual aggregate for all claims each policy year.
iv. FAOHS shall be a named insured in the Professional liability insurance.
b. Certificates of Insurance evidencing all coverages described in this Section shall be furnished to FAOHS upon request.
c. Provider shall give thirty (30) days' prior written notice to FAOHS of cancellation, non-renewal, or reduction in amount of any policy.
6. INDEMNIFICAT ION
The parties acknowledge that Provider is an independent contractor in all respects and is not acting as an employee or agent of FAOHS, and that FAOHS is not exercising control or direction with respect to the services being provided by Provider. Provider therefore agrees to indemnify, defend and hold FAOHS and each of its customers harmless from any and all actual or threatened causes of action, claims, damages, losses, legal fees, regulatory fines and/or damages of any nature relating to any act or omission, error, negligence or willful misconduct of Provider in its performance of Services hereunder. Provider hereby acknowledges and agrees that FAOHS's customers are third party beneficiaries of this Section 5. FAOHS agrees to indemnify and hold Provider harmless from all causes of action, claims, damages, losses, legal fees, regulatory fines and/or damages of any nature relating to any act or omission, error, negligence or willful misconduct of FAOHS. In the event of any such claim, lawsuit or other matter covered by this Indemnification clause, the party against whom the claim is being made agrees to promptly notify the other party of such claim.
7. BILLING AND PAYMENT
a. Invoices provided to FAOHS must include the donor's name, donor's social security number, employer name, date of service, type of service provided and chain of custody # and must be sent to: First Advantage Occupational Health Services Corp., at , or by fax at 704-943-5361, or mail at PO Box 67, Onalaska, WI 54650.
b. Invoices must be provided to FAOHS within thirty (30) days of the date of service, preferably via electronic transmission (e-mail or fax). Upon request, FAOHS will provide its preferred e-mail format.
c. In no event will FAOHS pay invoices received more than six (6) months after the date of service. This rule applies regardless of whether the claim was previously denied due to insufficient information.
d. Provider will give FAOHS a list of any other facilities for which it is responsible for setting up accounts so that FAOHS may bill those facilities accordingly.
8. SERVICES AND PRICING
Provider agrees to provide the following services at the prices indicated. If Provider's fee matches the “suggested preferred provider pricing” (“SPPP”), Provider will be identified as a Preferred Provider, which
allows FAOHS to direct its customers toward high-value, cost-effective providers in given locations. If you are not able to provide a service at the SPPP, please insert your fee for service in the space provided.
Alcohol Test
Offered / SPPP$20.00 / Price
$ / Service
Breath Alcohol Confirmation - DOT
$20.00 / $ / Breath Alcohol Confirmation - NonDOT
$20.00 / $ / Breath Alcohol Test - DOT
$20.00 / $ / Breath Alcohol Test - NonDOT
$10.00 / $ / Saliva Instant Alcohol Test - DOT
$10.00 / $ / Saliva Instant Alcohol Test - NonDOT
Drug Test
Offered
/ SPPP
$10.00 / Price
$ / Service
Blood Draw Only
/ $15.00 / $ / Hair Collection
/ $10.00 / $ / Saliva Drug Collection
/ $10.00 / $ / Urine Drug Collection - DOT
/ $10.00 / $ / Urine Drug Collection - NonDOT
Fingerprint / Service
Offered
/ SPPP
$2.50 / Price
$ / Service
Ink Card FingerPrinting
/ $2.50 / $ / LiveScan FingerPrinting
/ $2.50 / $ / Finger Print Onsite
/ $12.00 / $ / Fingerprint capture (supplies provided)
Miscellaneous Services
Offered
/ SPPP
$25.00 / Price
$ / Service
After-hours BAT
/ $25.00 / $ / After-hours per event fee
/ $25.00 / $ / After-hours Hair
/ $15.00 / $ / After-hours hourly fee
/ $25.00 / $ / Mobile BAT After Business Hours
/ $40.00 / $ / Mobile Per Event Fee After Business Hours
/ $25.00 / $ / Mobile Hair After Business Hours
/ $15.00 / $ / Mobile Hourly After Business Hours
/ $15.00 / $ / After-hours UDS
/ $15.00 / $ / Mobile Service Normal Business Hours
/ $15.00 / $ / Mobile UDS After Normal Business Hours
/ $25.00 / $ / Mobile BAT Normal Business Hours
/ $30.00 / $ / Mobile Per Event Fee Normal Business Hours
/ $25.00 / $ / Mobile Hair Normal Hours
/ $15.00 / $ / Mobile Hourly Fee Normal Business Hours
/ $0.55 / $ / Mobile Mileage Normal Hours
Physical Exam
Offered SPPP
$15.00 / Price
$ / Service
Audiometric Test Interpretation
$30.00 / $ / Audiometric Test
$10.00 / $ / Back Evaluation
$20.00 / $ / Blood Pressure Reading
$35.00 / $ / Chest X-Ray
$30.00 / $ / EKG
$40.00 / $ / EKG with Interpretation
$35.00 $ Flu Shot
$10.00 $ Glucose Fingerstick
$60.00 $ Hepatitis A Vaccine
$60.00 $ Hepatitis-B Series 1 Vaccine
$60.00 $ Hepatitis-B Series 2 Vaccine
$60.00 $ Hepatitis-B Series 3 Vaccine
$5.00 $ Color blindness test
$15.00 $ Isometric Test
$25.00 $ Kraus Weber -Abbreviated Exam
$40.00 $ Measles / Mumps / Ruebella Vaccine
$20.00 $ Fingernail Clipping
$50.00 $ Physical Ability Screen
$30.00 $ Pulmonary Function Test/ Spirometry
$30.00 $ Physical Exam. DOT
$30.00 $ Physical Exam. NonDOT
$30.00 $ Respirator Fit Test
$10.00 $ Respirator Fit Questionnaire
$10.00 $ Step Test
$10.00 $ TST TB Test
$35.00 $ Tetanus, Diptheria, Pertussis
$35.00 $ Tetanus / Diphtheria Vaccine
$60.00 $ Titer-Hepatitis A
$60.00 $ Titer-Hepatitis B
$60.00 $ Titer-Hepatitis C
$60.00 $ Titer-MMR
$60.00 $ Titer-Mumps
$60.00 $ Titer-Rubeola\Rubella
$60.00 $ Titer-Varicella
$10.00 $ Treadmill Test
$10.00 $ T-Spot TB Blood Draw
$70.00 $ Varicella Vaccine
$5.00 $ Basic Vision Test (stand alone)
$25.00 $ Chest X-Ray Interpretation
9. PRODUCT PURCHASE
a. FAOHS hereby agrees to purchase, and Provider hereby agrees to sell the Products for the price per Product set forth above, together with applicable taxes and shipping and handling charges. Invoices are due and payable upon receipt and considered past due thirty (30) days after receipt of invoice.