AG 21-008 - KAISER PERMANENTERETURN TO: ��JW n ",la'n [ t�4 EXT: CQ
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
1. ORIGINATING DEPT./DIV: n_kA W1 0,V1
2. ORIGINATING STAFF PERSON: �, 61 e � �� EXT: '015 3 Z 3. DATE REQ.
4.
M
TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
A C ONTRACT AMENDMENT (AG#): V -06$ ❑ INTERLOCAL
❑ OTlIER
NAME OF CONTRACTOR: S --@.:i'maYlee *c'
ADDRESS: 300 S Z fi TELEPHONEZ�lo �1 D 7
E-MAIL: K F- FAX:
SIGNATURE NAME: 4m j TITLE
7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AIUTHORIITTY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: D 8 �� 9 l l —1 COMPLETION DATE:
9. TOTAL COMPENSATION $ ��fjI%1 C.� S ILGCO (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE -ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
RF,IMRI JRSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED ❑ YES ❑ NO IF YES,
RETAINAGE: RETAINAGE AMOUNT:
❑ PURCHASING: PLEASE CHARGE TO:
10. DOCUMENT/CONTRACT REVIEW
❑ PROJECT MANAGER
❑ DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
❑ LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
12
CONTRACT SIGNATURE ROUTING
PAID BY: ❑ CONTRACTOR ❑ CITY
❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED
INITIAL I DATE REVIEWED IN [TIAL / DATE. APPROVED
SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE:
SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE:
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:�
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL / DATE SIGNED
❑ LAW DEPARTMENT
❑ SIGNATORY (MAYOR OR DIRECTOR)
❑ CITY CLERK
❑ ASSIGNED AG#
UMR ffirfjla�
1 /2020
KAISER PERMANENTE
OCCUPATIONAL HEALTH PROGRAM
EMPLOYER: City of Federal Way
Guarantor Number: 2937266
THIS SERVICE AGREEMENT (this "Agreement") is entered into as of February 8, 2021 by and
between City of Federal Way (Employer), and Kaiser Foundation Health Plan of Washington
("Kaiser Permanente").
1. CUSTOMER INFORMATION
Agreement Manager Name:
Title:
Address:
City, State, Zip Code:
Phone:
Email
Jean Stanley
HR Manager
33325 8th Ave. S
Federal Way, WA 98003
253-835-2532
jean.stanley@cityoffederalway.com
2. KAISER PERMANENTE OF WASHINGTON INFORMATION
Kaiser Foundation Health Plan of Washington
Attention: Occupational Health
Email to: KPWA.healthatwork@kp.org
Toll Free Phone: (866) 967-9675
Secure Fax: (206) 877-0749
3. SERVICE(S)
3.1 Customer agrees to pay the specified fees for the Services indicated in Exhibit A - Fee
Schedule, see attached, in accordance with Section 3.2. Kaiser Permanente may modify
Services and/or fees charged for Services from time to time effective upon thirty (30) days
written notice to Customer. Unless Customer terminates the applicable Service or this
Agreement, in writing, within thirty (30) days after receiving notice of a modification,
Customer shall be deemed to have accepted any such modification(s). Notwithstanding
the foregoing, the fees charged for Services may be increased based on increases in the
actual cost of consumables and the fees set forth in Exhibit A — Fee Schedule shall be
deemed amended accordingly.
3.2 Kaiser Permanente shall invoice the Customer including a detailed data report showing
recent charges, amount paid, and outstanding balance for Services on a monthly basis and
the Customer shall pay invoiced amount within ninety (90) days after receipt of
invoice. Late payments may be subject to interest at a rate of 1.5% per month or the legal
rate, if lower ("Late Payment Interest").
Kaiser Permanente I Occupational Health Program
F 1, KAISER PERMANENTE :
OCCUPATIONAL HEALTH PROGRAM
lease make payments to:
Kaiser Foundation Health Plan of Washington
ATTN: Cash Desk
P.O. Box 34581
Seattle, WA 98124-1581
3.3 Customer shall promptly notify Kaiser Permanente of any disputed amounts upon receipt
of invoice, and such disputed amounts shall not be subject to Late Payment Interest,
provided the Customer: (a) assists Kaiser Permanente in resolving the dispute; and (b)
promptly pays amounts owing, if any, upon resolution of the dispute.
3.4 Customer will comply with applicable legal requirements in relation to this Agreement,
including, without limitation, any legal requirements applicable to the referral of
individuals to Kaiser Permanente for Services or the subsequent use of results reports, or
other information provided to Customer by Kaiser Permanente. Customer understands
that Kaiser Permanente may review medical records in connection with the provision of
Services and releases Kaiser Permanente from all liability with respect thereto or arising
therefrom.
4. HEALTH INFORMATION
To the extent information provided to, accessed by or created by Kaiser Permanente
constitutes Protected Health Information subject to the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations, or health information otherwise
subject to applicable federal and state health information privacy laws, Kaiser Permanente
agrees to, and Customer acknowledges that Kaiser Permanente will, use and disclose such
information only as permitted or required by those laws and any other applicable laws, rules, or
Kaiser Permanente policies.
S. TERM AND TERMINATION
5.1 The term of this Agreement shall commence five (5) business days after Kaiser
Permanente receives a copy of the Customer's signed agreement and shall continue in
effect until terminated as follows: (a) by either party without cause upon thirty (30) days -
notice to the other party; (b) by Customer in accordance with Section 3.2; or (c) by the
non -breaching party in the event the other party defaults in the performance of a
material obligation in this Agreement, provided such default is not promptly cured or
corrected after receipt of notice thereof from the non -breaching party, and the non -
breaching party provides written notice of termination to the defaulting party.
5.2 Upon termination of this Agreement for any reason, any fees owed to Kaiser Permanente
for Services performed prior to termination shall be paid by Customer to Kaiser
Kaiser Permanente I Occupational Health Program
tF ' KAISER PERMANEWEr
OCCUPATIONAL HEALTH PROGRAM
Permanente Washington within thirty (30) days after the effective date of such
termination.
6. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the internal laws of the
State of Washington without regard to its conflict of laws principles.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their duly
authorized representatives as of the Effective Date.
CUSTOMER:
Printed Name: Jean Stanley
Title: HR Manager
Date Signed: Feb 8, 2021
KAISER PERMANENTE:
By: 6A' - �-kda-7aYJ
Printed Name: Patricia Isaman, RN, MN
Title: Director, Occupational Health
Date Signed: 2.8.21
i
Kaiser Permanente I Occupational Health Program
F 1, KAISER PERMANEIITL,
OCCUPATIONAL HEALTH PROGRAM
EXHIBITA - FEE SCHEDULE
For all work -related injury care, Kaiser Permanente of Washington will bill at the Washington State
Department of Labor and Industry's current fee schedule.
Post-Accident/For Cause Drug Testing
Non -Federal Drug Screening 10 panel $45.00
Federal Drug Screening $55.00
Tuberculosis Skin Test
Tuberculosis (PPD) Skin Test $24.00
As Clinically Indicated:
Quantiferon Gold Test $220.00
Blood Draw, Venipuncture $9.00
Tuberculosis Health Risk Assessment $40.00
Hepatits B
Hepatitis B Vaccine - Only 1st►njection Authorized by Employer $65.00
Hepatitis B Antibody (Titer) $46.00
Immunization Admin $27.00
Blood Draw, Venipuncture $9.00
Interpretative Services
Interpretative Services, per hour $75.00
Audiometry Screen
Screening Test Pure Tone Air Only $36.00
Interpretive Services
Interpretive Services, per hour $75.00
Kaiser Permanente I Occupational Health Program
I I RETURN TO: � ew St `txi EXT: 95 3 a -
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
1. ORIGINATING DEPT./DIV: P I,i.man
2. ORIGINATING STAFF PERSON: EXT: O 5 3. DATE REQ. BY:
4. TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
❑ CONTRACT AMENDMENT (AG#): ❑ INTERLOCAL
❑ OTHER,J-
5. PROJECT NAME: e S C f Q aum(j'7 e n 4e C&Uw nh rr a�{
6. NAME OF CONTRACTOR: M
ADDRESS: 1300 $(4) 27447 j +w3 i )A C M651 TELEPHONE 24& $qz) cjo'f7
E-MAIL: Kaikl r.A. tanei La • 6+C6 FAX:
SIGNATURE NAME: e, ►g .-na 7 Q N , N TITLE j� I rtGt } p
EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: 080il a 1-1 COMPLETION DATE: P-t4. P _AjAI
TOTAL COMPENSATION $ - I-T 5 .Sew ,td (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED
❑ YES ❑ NO IF YES, $
RETAINAGE: RETAINAGE AMOUNT:
❑ PURCHASING: PLEASE CHARGE TO:
10. DOCUMENT/CONTRACT REVIEW
❑ PROJECT MANAGER
❑ DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
❑ LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
12. CONTRACT SIGNATURE ROUTING
PAID BY: ❑ CONTRACTOR ❑ CITY
❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED
INITIAL / DATE REVIEWED INITIAL / DATE APPROVED
SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE:
SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE:
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:^
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL / DATE SIGNER
❑ LAW DEPARTMENT _ oil A
❑ SIGNATORY (MAYOR OR DIRECTOR)
❑ CITY CLERK
❑ ASSIGNED AG# AG# 'C]�
COMMENTS:
��
1 /2020
FF'm'�, KAISER PERMANENTE,
OCCUPATIONAL HEALTH PROGRAM
EMPLOYER: City of Federal Way
Guarantor Number: 2937266
THIS SERVICE AGREEMENT (this "Agreement") is entered into as of August 9, 2019 by and between
City of Federal Way (Employer), and Kaiser Foundation Health Plan of Washington ("Kaiser
Permanente").
1. CUSTOMER INFORMATION
Agreement Manager Name:
Title:
Address:
City, State, Zip Code:
Phone:
Email
Jean Stanley
HR Manager
33325 8th Ave. S
Federal Way, WA 98003
253-835-2532
jean.stanley@cityoffederalway.com
2. KAISER PERMANENTE OF WASHINGTON INFORMATION
Kaiser Foundation Health Plan of Washington
Attention: Occupational Health
Email to: KPWA.healthatwork@kp.org
Toll Free Phone: (866) 967-9675
Secure Fax: (206) 877-0749
3. SERVICE(S)
3.1 Customer agrees to pay the specified fees for the Services indicated in Exhibit A - Fee
Schedule, see attached, in accordance with Section 3.2. Kaiser Permanente may modify
Services and/or fees charged for Services from time to time effective upon thirty (30) days
written notice to Customer. Unless Customer terminates the applicable Service or this
Agreement, in writing, within thirty (30) days after receiving notice of a modification,
Customer shall be deemed to have accepted any such modification(s). Notwithstanding
the foregoing, the fees charged for Services may be increased based on increases in the
actual cost of consumables and the fees set forth in Exhibit A — Fee Schedule shall be
deemed amended accordingly.
3.2 Kaiser Permanente shall invoice the Customer including a detailed data report showing
recent charges, amount paid, and outstanding balance for Services on a monthly basis and
the Customer shall pay invoiced amount within ninety (90) days after receipt of
invoice. Late payments may be subject to interest at a rate of 1.5% per month or the legal
rate, if lower ("Late Payment Interest").
Kaiser Permanente I Occupational Health Program
,7S
••s
KAISER PERMANEME..
OCCUPATIONAL HEALTH PROGRAM
lease make payments to:
Kaiser Foundation Health Plan of Washington
ATTN: Cash Desk
P.O. Box 34581
Seattle, WA 98124-1581
3.3 Customer shall promptly notify Kaiser Permanente of any disputed amounts upon receipt
of invoice, and such disputed amounts shall not be subject to Late Payment Interest,
provided the Customer: (a) assists Kaiser Permanente in resolving the dispute; and (b)
promptly pays amounts owing, if any, upon resolution of the dispute.
3.4 Customer will comply with applicable legal requirements in relation to this Agreement,
including, without limitation, any legal requirements applicable to the referral of
individuals to Kaiser Permanente for Services or the subsequent use of results reports, or
other information provided to Customer by Kaiser Permanente. Customer understands
that Kaiser Permanente may review medical records in connection with the provision of
Services and releases Kaiser Permanente from all liability with respect thereto or arising
therefrom.
4. HEALTH INFORMATION
To the extent information provided to, accessed by or created by Kaiser Permanente
constitutes Protected Health Information subject to the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations, or health information otherwise
subject to applicable federal and state health information privacy laws, Kaiser Permanente
agrees to, and Customer acknowledges that Kaiser Permanente will, use and disclose such
information only as permitted or required by those laws and any other applicable laws, rules, or
Kaiser Permanente policies.
5. TERM AND TERMINATION
5.1 The term of this Agreement shall commence five (5) business days after Kaiser
Permanente receives a copy of the Customer's signed agreement and shall continue in
effect until terminated as follows: (a) by either party without cause upon thirty (30) days -
notice to the other party; (b) by Customer in accordance with Section 3.2; or (c) by the
non -breaching party in the event the other party defaults in the performance of a
material obligation in this Agreement, provided such default is not promptly cured or
corrected after receipt of notice thereof from the non -breaching party, and the non -
breaching party provides written notice of termination to the defaulting party.
5.2 Upon termination of this Agreement for any reason, any fees owed to Kaiser Permanente
for Services performed prior to termination shall be paid by Customer to Kaiser
Kaiser Permanente I Occupational Health Program
'�'''� KAISER PERMANEW .:
OCCUPATIONAL HEALTH PROGRAM
Permanente Washington within thirty (30) days after the effective date of such
termination.
6. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the internal laws of the
State of Washington without regard to its conflict of laws principles.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their duly
authorized representatives as of the Effective Date.
CUSTOMER:
�+ x*� Stanity (Feb 2,:e x"; "1 PS I
Printed Name: Jean Stanley
Title: HR Manager
Date Signed: 0 2102` zo Zl
KAISER PERMANENTE:
: B ���
y
Printed Name: Patricia Isaman. RN, MN
Title: Director, Occupational Health
Date Signed: 1.29.2021
Kaiser Permanente Occupational Health Program
KAISER PERMANEWE.
OCCUPATIONAL HEALTH PROGRAM
EXHIBIT A - FEE SCHEDULE
For all work -related injury care, Kaiser Permanente of Washington will bill at the Washington State
Department of Labor and Industry's current fee schedule.
Post-Accident/For Cause Drug Testing
Non -Federal Drug Screening 10 panel $45.00
Federal Drug Screening $55.00
Tuberculosis Skin Test
Tuberculosis (PPD) Skin Test $24.00
As Clinically Indicated:
Quantiferon Gold Test $220.00
Blood Draw, Venipuncture $9.00
Tuberculosis Health Risk Assessment $40.00
Hepatits B
Hepatitis B Vaccine -Only 1stlnjection Authorized by Employer $65.00
Hepatitis B Antibody (Titer) $46.00
Immunization Admin $27.00
Blood Draw, Venipuncture $9.00
Interpretative Services
Interpretative Services, per hour $75.00
Audiometry Screen
Screening Test Pure Tone Air Only $36.00
As Clinically Indicated
Tympanometry (Impedance Testing) $45.00
Comprehensive Audiometry Threshold Eval & Speech R $118.00
Interpretive Services
Interpretive Services, per hour $75.00
Kaiser Permanente I Occupational Health Program f
"ZI
KAISER PFRMANEUTEO
OCCUPATIONAL HEALTH PROGRAM
EMPLOYER:
Guarantor Number:
City of Federal Way
THIS SERVICE AGREEMENT (this "Agreement") is entered into as of August 9, 2019 by and between
City of Federal Way (Employer), and Kaiser Foundation Health Plan of Washington ("Kaiser
Permanente").
1. CUSTOMER INFORMATION
Agreement Manager Name.:
Title:
Address:
City, State, Zip Code:
Phone:
Email
Jean Stanley
HR Manager
33325 8th Ave. S
Federal Way, WA 98003
253-835-2532
jean.stanley@cityoffederalway.com
2. KAISER PERMANENTE OF WASHINGTON INFORMATION
Kaiser Foundation Health Plan of Washington
Attention: Occupational Health
Email to: KPWA.healthatwork@kp.org
Toll Free Phone: (866) 967-9675
Secure Fax: (206) 877-0749
3. SERVICE(S)
3.1 Customer agrees to pay the specified fees for the Services indicated in Exhibit A - Fee
Schedule, see attached, in accordance with Section 3.2. Kaiser Permanente may modify
Services and/or fees charged for Services from time to time effective upon thirty (30) days
written notice to Customer. Unless Customer terminates the applicable Service or this
Agreement, in writing, within thirty (30) days after receiving notice of a modification,
Customer shall be deemed to have accepted any such modification(s). Notwithstanding
the foregoing, the fees charged for Services may be increased based on increases in the
actual cost of consumables and the fees set forth in Exhibit A — Fee Schedule shall be
deemed amended accordingly.
3.2 Kaiser Permanente shall invoice the Customer including a detailed data report showing
recent charges, amount paid, and outstanding balance for Services on a monthly basis and
the Customer shall pay invoiced amount within ninety (90) days after receipt of
invoice. Late payments may be subject to interest at a rate of 1.5% per month or the legal
rate, if lower ("Late Payment Interest").
Kaiser Permanente I Occupational Health Program }
KAISER PERMANENTEo
OCCUPATIONAL HEALTH PROGRAM
lease make payments to:
Kaiser Foundation Health Plan of Washington
ATTN: Cash Desk
P.O. Box 34581
Seattle, WA 98124-1581
3.3 Customer shall promptly notify Kaiser Permanente of any disputed amounts upon receipt
of invoice, and such disputed amounts shall not be subject to Late Payment Interest,
provided the Customer: (a) assists Kaiser Permanente in resolving the dispute; and (b)
promptly pays amounts owing, if any, upon resolution of the dispute.
3.4 Customer will comply with applicable legal requirements in relation to this Agreement,
including, without limitation, any legal requirements applicable to the referral of
individuals to Kaiser Permanente for Services or the subsequent use of results reports, or
other information provided to Customer by Kaiser Permanente. Customer understands
that Kaiser Permanente may review medical records in connection with the provision of
Services and releases Kaiser Permanente from all liability with respect thereto or arising
therefrom.
4. HEALTH INFORMATION
To the extent information provided to, accessed by or created by Kaiser Permanente
constitutes Protected Health Information subject to the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations, or health information otherwise
subject to applicable federal and state health information privacy laws, Kaiser Permanente
agrees to, and Customer acknowledges that Kaiser Permanente will, use and disclose such
information only as permitted or required by those laws and any other applicable laws, rules, or
Kaiser Permanente policies.
5. TERM AND TERMINATION
5.1 The term of this Agreement shall commence five (5) business days after Kaiser
Permanente receives a copy of the Customer's signed agreement and shall continue in
effect until terminated as follows: (a) by either party without cause upon thirty (30) days -
notice to the other party; (b) by Customer in accordance with Section 3.2; or (c) by the
non -breaching party in the event the other party defaults in the performance of a
material obligation in this Agreement, provided such default is not promptly cured or
corrected after receipt of notice thereof from the non -breaching party, and the non -
breaching party provides written notice of termination to the defaulting party.
5.2 Upon termination of this Agreement for any reason, any fees owed to Kaiser Permanente
for Services performed prior to termination shall be paid by Customer to Kaiser
Permanente Washington within thirty (30) days after the effective date of such
termination.
Kaiser Permanente I Occupational Health ProgramY
A KAISER PERMANEWEr-
OCCUPATIONAL HEALTH PROGRAM
6. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the internal laws of the
State of Washington without regard to its conflict of laws principles.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their duly
authorized representatives as of the Effective Date.
CUSTOMER:
Printed Name: Jean Stanley
Title: HR Manager
KAISER PERMANENTE:
By: I
Printed Name: Patricia Isaman, RN. MN
Title: Director, Occupational Health
Date Signed: Q Z �4/�} Date Signed
8/9/2019
Kaiser Permanente I Occupational Health Program
F- '1 KAISER PERMANEWEe
OCCUPATIONAL HEALTH PROGRAM
EXHIBIT A - FEE SCHEDULE
For all work -related injury care, Kaiser Permanente of Washington will bill at the Washington State
Department of Labor and Industry's current fee schedule.
Post-Accident/For Cause Drug Testing
Non -Federal Drug Screening 10 panel - Ens50G $45.00
Federal Drug Screening $55.00
Tuberculosis Skin Test
Tuberculosis (PPD) Skin Test $24.00
Ancillary
Quantiferon Gold Test $220.00
Blood Draw, Venipuncture $9.00
Tuberculosis Health Risk Assessment $40.00
Hepatits B
Hepatitis B Vaccine - Only 1selnjection Authorized by Employer $65.00
Hepatitis B Antibody (Titer) $46.00
Immunization Admin $27.00
Blood Draw, Venipuncture $9.00
Interpretative Services
Interpretative Services, per hour $75.00
Kaiser Permanente I Occupational Health Program :;