CONTRACT 3907B Amendment CLOSED39074
"t"ENDMENT TO
AGREEMENT NO. 3907 BETWEEN
THE CITY OF EL SEGUNDO AND
U.S. HEALTHWORKS OF CALIFORNIA, INC.
THIS 2ND AMENDMENT ( "Amendment ") is made and entered into this 1st day of October,
2010, by and between the CITY OF EL SEGUNDO, a general law city and municipal corporation
existing under the laws of California ( "CITY "), and U.S. HEALTHWORKS OF CALIFORNIA,
Inc., incorporated under the laws of the State of California ( "CONTRACTOR ").
Pursuant to Agreement No. 3907 ( "Agreement "), executed by the parties on or about
February 25, 2009 and subsequently amended, the term of the agreement is extended until
September 30, 2011.
2. This Amendment may be executed in any number of counterparts, each of which will be an
original, but all of which together constitute one instrument executed on the same date.
3. Except as modified by this Amendment, all other terms and conditions of Agreement No.
3907 remain the same.
4. Exhibits A and B are incorporated by reference
IN WITNESS WHEREOF the parties hereto have executed this contract the day and year
first hereinabove written.
CITY OF EL SEGUNDO U.S. HEALTHWORKS OF CALIFORNIA, INC.
Jack Wayt,
City Manager
ATTEST:
Cindy Mo e:
City Clerk
APPROVED
MARK D. H]
By:
Karl Fl.- Berger, AssistVt City A
C-
Presid 1t c ee-rok e`t — -r ►e Q
Taxpayer ID No. 95-46432,L911
EXHIBIT "A"
Workers Compensation Service Protocols
Services, Medical Provider /Entity will make determinations and provide medical
services to treat occupational injuries to Covered Employees as reasonably required to
cure or relieve the effects of such injury and in compliance with Labor Code 4610, Labor
Code 4603.4, and Title 8, Ca. Code of Regs. 9785.
Referrals. Medical Provider will provide referrals for medically necessary services,
provided that referrals are authorized by the Employer or its Claims Administrator in
compliance with Company's rules, regulations, procedures and policies, as amended
from time to time by Company.
Medical Responsibility. Medical services and referrals shall be provided in
accordance with generally accepted clinical and ethical standards.
Notification. Medical Provider will immediately notify Employer or its Claims
Administrator of any finding of inappropriate behavior, concerns with the progression of
treatment plan (due to lack of cooperation from injured worker) or misrepresentation
from an injured worker claiming a workers' compensation injury against the Employer.
3 9 0 7 i�"., -so Ai
EXHIBIT "B" - COMPENSATION SCHEDULE
ATTACHMENT A
USHealthworks
Pre - employment costing for each medical evaluation component
Audiogram
$15
Physical Examination
$30
Chest X -Ray (1 view)
$30
Chest X -Ray (2 view)
$40
Lumbar Spine (2 view)
$30
Non - Regulated LIDS
$45
(Drug screen - insta- check)
$40
PPO (TB test)
$15
Pulmonary Function Test
$35
** Stress Treadmill
(performed at Westchester Center for Heart and Health)
Other miscellaneous services
DOT Random drug testing
(Regulated)
$55
Reasonable Suspicion
(BAT and confirmation)
$80
DMV Physical
$40
Stress EKG w/ over read
$47
Tetanus
$45
Hepatitis A (2 series)
$90 each
Hepatitis B (3 series)
$85 each
3907-.
EXHIBIT "B" - COMPENSATION SCHEDULE
ATTACHMENT B
USHealthworks
Medical Exam Component Profiles Cost
Battalion Chief
$175
Building Inspector
$100
Building Safety Manager
$100
Business Services Manager
$100
City Engineer
$100
Civil' Engineer Associate
$100
Community Cable Program Spec/ Manager
$100
Computer Graphics Designer
$100
Crime Prevention Analyst
$100
Crime Scene Investigator
$100
Custodian
$100
Dispatcher
$100
Environmental Safety Manager
$100
Equipment Maintenance Supervisor
$100
Equipment Mechanic
$100
Facilities Maintenance Mechanic/ Supervisor
$100
Fire Prevention Specialist
$100
Firefighter/ Engineer/ Captain
$175
Fleet Supervisor
$100
General Services Manager
$100
Information Systems Manager
$100
Library Network Assistant
$100
Librarian/ Senior Library Asst/ Library Page/ Clerk
$100
License Permit Specialist
$100
Lifeguard
$135
Maintenance Craftsworker
$100
Network Assistant
$100
Park Maintenance Worker
$100
Planning Manager/ Senior Planner/ Asst Planner
$100
Police Assistant
$100
Police Cadet
$100
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EXHIBIT "B" - COMPENSATION SCHEDULE
USHealthworks
Medical Exam Component Profiles Cost
Police Officer
$165
Police Service Officer
$135
Police Volunteer
$100
Pool Center Maintenance Technician
$100
Pool Manager
$100
Principal Fire Prevention Specialist
$100
Program Coordinator
$100
Public Works Director
$100
Public Works Street Maintenance Worker/
Lead/ Supervisor
$100
Rangemaster
$100
Recreation and Parks Director
$100
Recreation Leader/ Coordinator
$100
Recreation Supervisor (plus Aquatics)
$100
Revenue Inspector
$100
Sedentary
$100
Special Events Coordinator
$100
Street Maintenance Worker 1 /II
$100
Technical Services Analyst
$100
Tree Maintenance Worker
$100
Utilities Manager
$100
Video Specialist
$100
Wastewater Supervisor
$100
Wastewater/ Water Maintenance Worker
$100
Water Supervisor
$100
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