HomeMy WebLinkAboutSH21-014 Amendment to Occupational Medicine Service AgreementRECEIVED
JITIA 16 2029
KITTMAS COUNTY SHERIFF
This AMENDMENT, effective the I" day of June 2021, amends the AGREEMENT dated April
7t' 2021 between KVH Workplace Health (Clinic) and the Kittitas County Sheriff (Client), a
copy of which is attached hereto. Other than the terms specifically referenced herein, all other
terms and conditions of the existing AGREEMENT remain in full force and effect.
This AMENDMENT is entered into by the authority of section 9 of the AGREEMENT which
allows for the modification of the AGREEMENT when such modification is in writing and
signed by a duly authorized representative of the Parties to the AGREEMENT.
The purpose of this AMENDMENT is to ensure that the prices set in Exhibit "A" to the original
AGREEMENT are corrected to reflect the correct pricing structure. These prices are a reflection
of a standardized billing structure intended to ensure that the prices charged to all organizations
are accurate and equitable.
The following tests or examinations are impacted, with the original and corrected prices:
ORIGINAL PRICE AMENDED PRICE
AUDIOGRAM: $55.00 $56.00
EKG: $75.00 $76.00
SPIROMETRY: $60.00 $75.00
No other pricing or other term of the original AGREEMENT is changed in any manner
whatsoever.
IN WITNESS WHEREOF, the parties have executed this instrument to be effective as of the
Effective Date first above written.
For the Clinic: Jx� For the Client:—
Dale Scott Olander Clayt6n Myers
Chief Financial Officer Sheriff
KV - _
Kittitas Valley Healthcare
Yo-wr H&H4 e for Hea.Ltk
KVH Workplace Health
General Information
Pricing
Company Name:
Kittitas County Sheriff's Office
Physical Street Address:
307 W. Umptanum Rd.
City, State, Zip:
Ellensburg, WA 98926
Mailing Address (if different from physical):
❑Standard: $83
Primary Contact:
Kim Dawson
Office Phone:
509-962-7089
Contact Email:
Kim.dawson@co.kittitas.wa.us
Office Fax:
❑Standard: $40
Secondary Contact (if applicable):
❑Standard: $45
Secondary Contact Phone:
[]Standard: $75
Guarantor Information
®Check if the same as physical address
Services
Pricing
Physical Examination
❑Standard: $100
Audiogram
❑Standard: $56
Venipuncture
❑Standard: $22
CMPI4+LP+CBC/D/Plt+TSHw/rflx T4F
❑Standard: $83
Non -Federal Drug Screen, 5 panel
❑Standard: $45
EKG
❑Standard: $76
U/A with micro
❑Standard: $27
Stool Guaiac
❑Standard: $40
Range of Motion
❑Standard: $45
Spirometry
[]Standard: $75
PA Chest X -Ray (1 view)
❑Standard: $100
L Spine X -Ray
❑Standard: $60
T Spine X -Ray
❑Standard: $60
Optional Services
Hep B Titer
❑Standard: $60
Hep B Injections, each (series of 3)
❑Standard: $103
PSA (if medically indicated)
❑Standard: $100
Total w/o Optional Services
$772
Lab and MRO
LabCorp house account
Forms/ Reporting Results
Report results via email to Kim Dawson