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#12-5813 (Quest Diagnostics, Inc.)
Blueprint for Wellness® R ECEIVE=D NOV 14 2012 RISK MANAGEMENA Quest i Diagnostics MASTER SERVICE AGREEMENT FOR BLUEPRINT FOR WELLNESS SERVICES QUEST DIAGNOSTICS CLINICAL LABORATORIES, INC., A DELAWARE CORPORATION AND A A WHOLLY OWNED SUBSIDIARY OF QUEST DIAGNOSTICS INCORPORATED, ( "QUEST DIAGNOSTICS ") Aarees to provide Blueorint for Wellness Services to: Customer Name (corporate name) Collier County Government New or renewal client/ ears with Blueprint for Wellness I New X Renewal 4th year client Subcontract name Karen Eastman, Wellness Program Manager OR Jeff Customer Contact/Title Walker, Director Risk Management Customer Contact Information Street Address 3311 East Tamiami Trail City State, Zip Naples, FL 34112 Karen Eastman 239.252.8906 OR Jeff Walker Phone Number 239.252.6092 kareneastman collier ov.net OR Email Address 'effwalker collier ov.net Other comments or requirements: Term of the Agreement 10/1/2012 to 9/30/2016 Quest requires a 30 day close before opening a new Note that an "Event' means a health fair /screening at one screening program. location for a fixed, uninterrupted period of time. One -time Event An electronic Invoice should be sent monthly to: Allegiance Benefit Plan Management Inc. 2806 Garfield St Missoula, MT 59801 Attn: Jessica DoubledayPhone: 406.532.3506 Customer Billing Address Billing will be monthly as Jessica .doubleday @askallegiance.com services are encountered unless otherwise arranged. [ ] Same as contact address above Partial program completion will be billed in last billing invoice. Other Specify: Blueprint for Wellness Sales Account Executive N/A Wellness Program Supervisor: Wellness Program Specialist: Blueprint for Wellness Account Representatives Wellness Account Manager: Erin Gaither Wellness Health Educator: Client Wellness Program Name if an Eligible Participants 2012 -2013: 1100 Spouses 2013 -2014: 1900 Employees 2014 -2015: 1100 Spouses 2 015 -2016: 1900 Employees Estimated % participation 80 % expected to participation each year CIlent/Participant Registration Key Registration Keys: Wellness Specialist will work with client to develop a unique key Screening Program [CCG] Urine Cotinine CCGCotin BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness® Quest i Diagnostics BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Al c Retest [CCGA1 C] Lipid Panel Retest [CCGLipid] 1c and Lipid Retest CCGBoth Employee Participant ID: Collier County Government Wellness Program Participant ID? Employee ID # Participant ID requested as it must appear in the Customer Spouse Participant ID: Collier County Government Employee eligibility file and on participant paperwork. ID # + -02 Each participant must be uniguely identified. Incentive: qualify to increase coverage from Basic to Select or Premium without increasing their contribution to the health plan Incentive for employee participation: Special Notes: Must complete Lab and HRA through Quest Breakout Aggregate Data Reports on Eligibility grouping(s) Each screening year, Collier County Government will receive an OurCompany Profile (Aggregate Report), OurCompany Profile (Aggregate Report) Cohort Report, Up to 10 breakout reports (breakout codes must be provided in the eligibility files each year), telephone review of OurCompany Profile, up to 6 additional analytic slides. Additional reports outside the standard analytics package will be at an additional charge and outlined in Attachment E (if needed) Minimum of 40 participants required for each report Person to receive the reporting: Collier County Government De- Identified — Aggregate Data Reporting* and Community Health Partners (OurCompany Profile) Report(s) required by:30 days after each screening program 'Min. of forty (40) Participants required for De- Identified year closes Aggregate Report or sub groups in break out reports. [X] Participation report. (standard twice monthly reporting) Participant Statistical Reporting to Client customization Fee Eligibility file will be provided by: Collier County Government [ ] SSN used for unique ID Using a modified SSN will not be unique to a population. Eligibility File of Participants An eligibility file is required, with additions as needed to keep a Target delivery date for "go live" file: 2 weeks before closed registration. scheduler opens each year. Will participation be allowed if employee and /or Updates files sent [ ] daily, [X] weekly, [ ] monthly spouse are not included in the eligibility file? NOTE: This is an "open registration" and can not be used with [ ] NO data feeds for a wellness program. [X] YES — approval process to add participants: Community Health Partners must approve Registration opens: November 1, 2012 close: September 30, 2013 Program Dates First Event: 1/21/2013 or No events Medical Authority A Physician Wellness Third Party [X] Quest Diagnostics provides Medical Director ordering Provider Network Physician contracted through and oversight. Quest Diagnostics or Customer-supplied Customer provided: Name: BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness AQuest Diagnostics 6 (if Customer arranges for Medical Authority, Customer must Medical License Number: provide physician information for requisition, resulting, and State of Issuance and license: CA and NY require physician abnormal reports) licensed in their state to act as Medical DirectorlAuthodly. General Descri tion: MyHealth Profile - Online participant registration and scheduling. Health questionnaire, Onsite venipuncture collections at employer- designated locations nationwide (minimum of 20 participants required per event), Offsite venipuncture collections at Quest Diagnostics Patient Service Centers (PSCs) locations nationwide with eReq online test confirmations (no participant minimum), Biometric measurements for all participants, Customized laboratory test solution (defined below), Physician results for participants with current labs, Physician /medical oversight, including outbound calls to employees with "Alert" values, MyHealth Profile provided online (3 -5 days) and mailed to each participant's home (2 weeks), OurCompany Profile and results review to share aggregated, population - level results from all participants, Standard process Services Requested (modules and pricing, below) NOTE: Standard Quest Diagnostics a -req used unless special to report physician results Retesting for Urine Cotinine, Hemoglobin A1c, and Lipid Exception requested and approved. Panel Main Screening Program: Comprehensive Panel (Collier Gov 2010 Comp 320780) - total cholesterol, HDL, calculated LDL, Triglycerides, calculated cholesterol /HDL ratio, TSH and Free T4, BUN, Creatinine, Bun / Creatinine ratio, calcium, albumin, total protein, globulin, A/G ratio, alkaline phosphatase, ALT, AST, total and direct bilirubin, GGT, Glucose, Hemoglobin A1c, chloride, potassium, sodium, iron TIBC, Iron /TIBC, % Saturation, Ferritin, CBC Hemogram, Serum Cotinine (eReq) Cotinine Retest: Cotinine, Urine 58860 Laboratory Tests Included Hemoglogin Al Retest: Hemoglobin A2c w /eAG 16802 List Panels, any specific tests or restrictions Lipid Panel Retest: Fasting Lipid Screen 14852 [X] Venipuncture (Lab Testing) and / or [ ] Fingerstick (on -site only) ** see additional charges, METHOD of COLLECTION/TESTING minimums and state level restrictions Other or NA [X] Blood Pressure [X] HT [X] WT [X] BMI Biometric Measurement Data Requested [XI Waist X Hi p [XI Waist/Hip Ratio Health Questionnaire (Online, English) [X] Online, English (delivery and format) GINA compliant Health Other delivery or format requested. Questionnaire N/A Participant Reporting Online Report included Paper & Online Paper Only (" All programs include Online, English version) X Paper option if desired MyHealth Profile * / ** X Custom delive or format requested should be captured below: BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. 0 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness 41) i -4Quest Diagnostics m fC t l? M 5 to Health Profile* /" *" M Test Profile With the MyHealth Profile - Metabolic Syndrome is included and is in the online version of reporting only. ** If MyHealth Profile or My5 to Health Profile is selected above Waist Circumference and BMI are program options, if both are in the screening program then you must select [ ] Waist Circumference OR [ ] BMI for Metabolic Syndrome scoring. ** *Approval required: "Online Only" My 5 to Health requests [ ] NA — Not Applicable - Participant reporting not required [ ] Custom Inserts: User Guide for Understanding Your Wellness Report @ $0.75 /Insert PROGRAM DESCRIPTIONS AND FEES Main Screening Program: October 1, 2012 — September 30, 2013 Comprehensive Panel Onsite Events and Patient Service Centers $131.00 per participant October 1, 2013 — September 30, 2014 Comprehensive Panel Onsite Events and Patient Service Centers $131.00 per participant October 1, 2014 — September 30, 2015 Comprehensive Panel Onsite Events and Patient Service Centers $136.00 per participant October 1, 2015 — September 30, 2016 Comprehensive Panel Onsite Events and Patient Service Centers $142.00 per participant Urine Cotinine: October 1, 2012 — September 30, 2013 Patient Service Centers Only $40.00 per participant October 1, 2013 — September 30, 2014 Patient Service Centers Only $41.20 per participant October 1, 2014 — September 30, 2015 Patient Service Centers Only $42.85 per participant October 1, 2015 — September 30, 2016 Patient Service Centers Only $45.00 per participant Hemoglobin A1c Re -Test: October 1, 2012 — September 30, 2013 Patient Service Centers Only $24.00 per participant October 1, 2013 — September 30, 2014 Patient Service Centers Only $24.72 per participant October 1, 2014 — September 30, 2015 Patient Service Centers Only $25.71 per participant October 1, 2015 — September 30, 2016 Patient Service Centers Only $27.00 per participant Lipid Panel Re -Test: October 1, 2012 — September 30, 2013 Patient Service Centers Only $34.50 per participant October 1, 2013 — September 30, 2014 Patient Service Centers Only $35.54 per participant October 1, 2014 — September 30, 2015 Patient Service Centers Only $36.96 per participant October 1, 2015 — September 30, 2016 Patient Service Centers Only $38.81 per participant Physician Forms see Attachment Q: Hemoglobin Al Retest $19.00 per form Lipid Panel Retest $19.00 perform BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness® Quest i Diagnostics [ ] NO ATTACHMENTS NEEDED (PSC only / No extras) BLUEPRINT FOR WELLNESS SERVICES: In accordance with the program- specific details set forth herein and on the ATTACHMENTS listed above (collectively the "Agreement "), Quest Diagnostics agrees to provide certain LABORATORY TESTING, BIOMETRIC MEASUREMENT and HEALTH QUESTIONAIRE SERVICES (the "Services ") as more specifically described in this Agreement in accordance with Quest Diagnostics' Response to Customer's Solicitation #12 -5813 ( "Response ") and in accordance with the Terms and Conditions of Customer's Solicitation #12 -5813 "Wellness Program Biometric Measurement and Laboratory Testing Services ( "Customer's Solicitation "), incorporated herein by reference. This Agreement contains the entire understanding between the parties and any modifications to this Agreement shall be mutually agreed upon in writing by Quest Diagnostics and the Customer Project or Contract Manager or his designee, and the Customer will be in compliance with the Customer Purchasing Policy and Administrative Procedures in effect at the time such services are authorized. The Services provided by Quest Diagnostics include the following: i. Registration and Scheduling of participants in accordance with the MSA and /or ATTACHMENTS A and B attached hereto (if selected by Customer) offered via online access or by calling a toll -free wellness scheduling number. ii. Provision of all supplies and test kits necessary to provide the Services. iii. Based upon the specific Program components, identified in the MSA and /or attached ATTACHMENTS A and B, selected by Customer, the Services include collection of biometric data, shipment of specimens to the testing laboratory, and testing of laboratory specimens. For Fingerstick, the Services include collection and testing of specimen and results reporting. For InSure Fit, the Service includes mailings. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 5 [X J Events (venipuncture and /or Fingerstick) - Attachment A [ ] InSure FIT Program - Attachment B [X ] Datal-ink Identified Data /PHI Transfer - Attachment C Program Attachments [ ] Rewards Incentive Management - Attachment D he identified attachments are [X] Decision Support Advanced Analytics - Attachment E pplicable to this Agreement. [ ] Reach Marketing Services - Attachment F ,II attachments must be initialed, [ ] Champion Training - Attachment G xcept for the Data Agreement, which [ ] Workforce View - Attachment H lust be signed. [ ] Encourage - Attachment I [ ] Activate - Attachment J [ ] Telephonic Health Coaching - Attachment K [X ] Primary Care Physician (PCP) Reporting - Attachment L Home Collection Kit - Attachment M BLUEPRINT FOR WELLNESS SERVICES: In accordance with the program- specific details set forth herein and on the ATTACHMENTS listed above (collectively the "Agreement "), Quest Diagnostics agrees to provide certain LABORATORY TESTING, BIOMETRIC MEASUREMENT and HEALTH QUESTIONAIRE SERVICES (the "Services ") as more specifically described in this Agreement in accordance with Quest Diagnostics' Response to Customer's Solicitation #12 -5813 ( "Response ") and in accordance with the Terms and Conditions of Customer's Solicitation #12 -5813 "Wellness Program Biometric Measurement and Laboratory Testing Services ( "Customer's Solicitation "), incorporated herein by reference. This Agreement contains the entire understanding between the parties and any modifications to this Agreement shall be mutually agreed upon in writing by Quest Diagnostics and the Customer Project or Contract Manager or his designee, and the Customer will be in compliance with the Customer Purchasing Policy and Administrative Procedures in effect at the time such services are authorized. The Services provided by Quest Diagnostics include the following: i. Registration and Scheduling of participants in accordance with the MSA and /or ATTACHMENTS A and B attached hereto (if selected by Customer) offered via online access or by calling a toll -free wellness scheduling number. ii. Provision of all supplies and test kits necessary to provide the Services. iii. Based upon the specific Program components, identified in the MSA and /or attached ATTACHMENTS A and B, selected by Customer, the Services include collection of biometric data, shipment of specimens to the testing laboratory, and testing of laboratory specimens. For Fingerstick, the Services include collection and testing of specimen and results reporting. For InSure Fit, the Service includes mailings. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 5 Quest Blueprint for Wellness® A Diagnostics A iv. The delivery of the participant and program specific outcomes report to the Participant and /or to DataLink (Attachment C) recipients as otherwise directed by the Customer and approved and accepted by Quest Diagnostics. v. If Customer requires electronic delivery of identifiable personal health data to Customer or a third party on behalf of Customer, a separate DataLink Data /PHI transfer attachment, ATTACHMENT C, must be completed at the time of the MSA agreement. 2. PAYMENT TERMS: Customer agrees to pay Quest Diagnostics for the Services upon receipt of a proper invoice and in compliance with Section 218.70, Fla. Stats., otherwise known as the "Local Government Prompt Payment Act." Quest Diagnostics reserves the right to add a charge of the lesser of one and one -half percent (1 'h %) per month, or the maximum rate the law permits, on all amounts thirty (30) or more days past due. Quest will bill via an electronic invoice which should be sent monthly to the County's Benefit Plan Management company (currently Allegiance Benefit Plan Management, Inc.). The County will notify Quest in writing of any changes to this invoicing process. Notwithstanding the above, and in an effort to avoid any doubt, Customer agrees that it is ultimately responsible for any payments due Quest Diagnostics. 3. MEDICAL AUTHORITY: Customer acknowledges and agrees that only a person who is authorized under applicable state /federal law to order those clinical laboratory tests included in the Blueprint For Wellness screening program ( "Testing ") shall order all Testing (such person shall be referred to as an "Authorized Provider "). a. In the event Customer provides such Authorized Provider themselves, Customer represents and warrants that the Authorized Provider meets all state /federal laws applicable to the ordering of Testing. Alternately, in the event Customer elects to have Quest Diagnostics arrange for an Authorized Provider, Quest Diagnostics shall represent and warrant that this Authorized Provider meets all state /federal laws applicable to the ordering of Testing. b. Quest Diagnostics shall report laboratory results only to such Authorized Provider, unless such Authorized Provider gives permission for Quest Diagnostics to release the lab results to such employee participants as desired. If Customer is providing such Authorized Provider, the requirement to allow release of results directly to the participant must be included in Customer's contract with such Authorized Provider. c. Authorized Provider is responsible for contacting participants with alert, critical, and significantly out of range laboratory results. d. While the Authorized Provider may set his /her own alert values, critical ranges are not modifiable. 4. LEGISLATIVE /REGULATORY CHANGE: In the event federal or state legislative and /or regulatory changes impact Quest Diagnostics clinical reference laboratory business, Quest Diagnostics will retain the right, upon prior written notice to Customer, to immediately amend this Agreement to fully comply with any legislative or regulatory changes. If any Authority creates, enforces, interprets and /or implements laws, rules, regulations, or otherwise takes a position (or threatens to do so), that Quest Diagnostics is required to extend the pricing under this Agreement to any third party including but not limited to Medicare, Medicaid or any other governmental program, Quest Diagnostics may notify Customer of the occurrence of one of the foregoing events and increase the pricing under this Agreement to the pricing levels of any such governmental program, BFW MSA rev. May 2012 6 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. 0 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness® Quest Diagnostics provided that if Customer notifies Quest Diagnostics of an objection to such increase in prices within ten (10 ) days of Customer's receipt of notice from Quest Diagnostics, this Agreement will terminate with respect solely to the jurisdiction of such Authority upon Quest Diagnostics receipt of Customer's notice. For purposes of this section, "Authority" shall include, but is not limited to, any court, legislative or authority or body, and /or any branch of state, federal or local government (e.g., the Office of Inspector General, Department of Justice, Department of Health and Human Services, Centers for Medicare and Medicaid Services, and /or any state Medicaid agency Department of Health Care Services). All other amendments or modifications to this Agreement shall be by mutual agreement of the parties. 5. TERMINATION: This agreement term will be for one (1) year with one (1) three (3) year renewal upon mutual written agreement of the parties. Either party may terminate this Agreement upon thirty (30) days written notice. Notwithstanding the foregoing, if there is a determination that this Agreement is not in compliance with applicable law, regulation or government requirement, this Agreement may be either modified in writing by the parties to bring the Agreement in compliance, or terminated by either party upon ten (10) days written notice to the other party. 6. INDEMNIFICATION: To the maximum extent permitted by Florida law, Quest Diagnostics shall indemnify and hold harmless the Customer, its officers and employees from any and all liabilities, damages, losses and costs, including, but not limited to, reasonable attorneys' fees and paralegals' fees, to the extent caused by the negligence, recklessness, or intentionally wrongful conduct of Quest Diagnostics or anyone employed or utilized by Quest Diagnostics in the performance of this Agreement. This indemnification obligation shall not be construed to negate, abridge or reduce any other rights or remedies which otherwise may be available to an indemnified party or person described in this paragraph. This section does not pertain to any incident arising from the sole negligence of the Customer. 7. INSURANCE: Quest Diagnostics shall agree to maintain, at its own expense and throughout the term of this Agreement, the following insurance coverage. Notwithstanding anything to the contrary contained herein, Quest Diagnostics may utilize self insurance for all or any portion of the minimum limits of insurance required to be carried. [Remainder of this page intentionally left blank] BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 7 Blueprint for Wellness® A AQuest Diagnostics 8. ENTIRE AGREEMENT: This Agreement, including applicable executed ATTACHMENTS, constitutes the entire understanding between the parties regarding the subject matter hereof and supersedes all prior understandings, arrangements and agreements relating to the subject matter hereof. 9. INDEPENDENT CONTRACTORS: It is expressly understood and agreed by the parties hereto that Quest Diagnostics and Customer will at all times be and act as independent contractors. 10. NON - SOLICITATION: During the terms of this Agreement, Customer shall not solicit any employee or independent contractor of Quest Diagnostics that has provided Services to Customer and /or Customer's client, for purposes of supplying Services directly to Customer without the prior written consent of Quest Diagnostics. 11. TRADEMARKS: Neither party shall use the trademark, tradename, nor service mark of the other party for any purpose without the prior written consent of the other party, however, Customer authorizes the use of its name and /or logo as a participant in the Blueprint for Wellness program. 12. FORCE MAJEURE: Neither party shall be liable for failure to perform any duty or obligation that said party may have under the Agreement where such failure has been caused by any event, foreseen or unforeseen, outside the reasonable control of the party who had the duty to perform and that renders performance impossible or impracticable, including but not limited to, acts of God, terrorist acts, fire, strike, inevitable accident, war, or any other event, like or unlike those listed above (collectively, "Force Majeure Event ") but only to the extent prevented by the Force Majeure Event. 13. DISPUTE RESOLUTION: Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. 0 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. E:3 TYPE LIMITS Checked • Workers' Compensation Statutory Limits of Florida Statutes 440 and Federal Government Statutory Limits and Requirements • Employer's Liability $500,000 X $1,000,000 • Commercial General Liability X $1,000,000 per occurrence $2,000,000 per occurrence bodily (Occurrence Form) patterned bodily injury and property injury and property damage after the current ISO form with damage no limiting endorsements. X Professional Liability X $1,000,000 per occurrence $2,000,000 per occurrence Insurance 1 1 $1,000,000 aggregate $2,000,000 aggregate Collier County Board of County Commissioners shall be named as the Certificate Holder. NOTE - -The "Certificate Holder" should read as follows: Collier County Board of County Commissioners Naples, Florida No County Division, Department, or individual name should appear on the Certificate. No other format will be acce table. Cancellation Notice required on Agreements exceeding 6 months. Notice will be delivered in accordance with the policy provisions. The contract name and number shall be included on the certificate of insurance. Collier County must be added as "ADDITIONAL INSURED" on the Insurance Certificate for Excess Liability. 8. ENTIRE AGREEMENT: This Agreement, including applicable executed ATTACHMENTS, constitutes the entire understanding between the parties regarding the subject matter hereof and supersedes all prior understandings, arrangements and agreements relating to the subject matter hereof. 9. INDEPENDENT CONTRACTORS: It is expressly understood and agreed by the parties hereto that Quest Diagnostics and Customer will at all times be and act as independent contractors. 10. NON - SOLICITATION: During the terms of this Agreement, Customer shall not solicit any employee or independent contractor of Quest Diagnostics that has provided Services to Customer and /or Customer's client, for purposes of supplying Services directly to Customer without the prior written consent of Quest Diagnostics. 11. TRADEMARKS: Neither party shall use the trademark, tradename, nor service mark of the other party for any purpose without the prior written consent of the other party, however, Customer authorizes the use of its name and /or logo as a participant in the Blueprint for Wellness program. 12. FORCE MAJEURE: Neither party shall be liable for failure to perform any duty or obligation that said party may have under the Agreement where such failure has been caused by any event, foreseen or unforeseen, outside the reasonable control of the party who had the duty to perform and that renders performance impossible or impracticable, including but not limited to, acts of God, terrorist acts, fire, strike, inevitable accident, war, or any other event, like or unlike those listed above (collectively, "Force Majeure Event ") but only to the extent prevented by the Force Majeure Event. 13. DISPUTE RESOLUTION: Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. 0 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. E:3 Blueprint for Wellnesso Quest i Diagnostics by negotiation. The negotiation shall be attended by representatives of Quest Diagnostics with full decision - making authority and by County's staff person who would make the presentation of any settlement reached during negotiations to County for approval. These persons shall meet within ten (10) business days after delivery of notice, in writing of the existence and subject matter of the dispute ( "Notice of Dispute "). Failing resolution, by negotiation within thirty (30) business days after delivery of the Notice of Dispute and prior to the commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through the International Institute for Conflict Prevention & Resolution ( "CPR ") under the CPR Mediation Procedure in effect on the effective date of this Agreement. Either party may commence mediation by delivering to CPR and the other party a written request for mediation, setting forth with specificity the subject matter of the Dispute and the relief requested. Unless otherwise agreed, the parties will select a mediator from CPR's Panel of Neutrals, certified by the State of Florida, and, if unable to select a mediator by mutual agreement, agree to have CPR select a mediator under the CPR Mediation Procedure. Each party shall bear its own costs and expenses, but those related to the compensation of the mediator and /or the administration of the mediation, if any, shall be borne by the parties equally. The mediation shall be completed within thirty (45) business days of its commencement. The mediation shall be attended by representatives of Quest Diagnostics with full decision - making authority and by County's staff person who would make the presentation of any settlement reached at mediation to County's board for approval. Should either party fail to submit to mediation as required hereunder, the other party may obtain a court order requiring mediation under section 44.102, Fla. Stat. Any suit or action brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in the state of Collier County, Florida, which courts have sole and exclusive jurisdiction on all such matters. 14. ORDER OF PRECEDENCE: In the event of any conflict between or among the terms of this Agreement, the Response, and Customer's Solicitation #12 -5813 "Wellness Program Biometric Measurement and Laboratory Testing Services ", herein incorporated by reference, the Agreement shall take precedence. In the event of any conflict between the Services as described in the Response and Customer's Solicitation, the Services described in the Response shall take precedence. [Signature Page Immediately Follows] BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. E Blueprint for Wellness® IN WITNESS WHEREOF, the parties hereto have executed this Master Blueprint for Wellness Services on October? , 2012. ATTEST: ., Dwight E:'Brock Q%-k of Courts .T } By. Date&a r First WOess TType /print witness nameT SecQ d Witness _ - \ J i CA A S'ti rA _._ TTyp rint witnes ameT Approved as to form and legal suffic*,,ncy: .- z, A"' T:�VQ eA I L unty Attorney S r 0 — Print Name BFW MSA rev. May 2012 Quest ► Diagnostics Service Agreement for BOARD OF COUNTY COMMISSIONERS COLLIER COUNTY, FLORIDA By: C� Fred W. Coyle, Chairman Quest Diagnostic Clinical Laboratories, Inc., a Delaware corporation and wholly owned subsidiary of Quest Diagnostics Incorporated tractor G " Signat / — Steven L. Burton / ��- VP — Health and Wellness Services Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 10 Blueprint for Wellness® ATTACHMENT A Blueprint for Wellness Employer Onsite Wellness Event(s) Quest i Diagnostics Customer Name / Account #(s) Collier County Government / 97560562 Number of Events requested Approximately 20 DATE LOCATION (V) or (F) TBD TBD V Requested Date(s) Location(s) of Event(s) Specify Venipuncture (V) or Fingerstick (F) next to each Date(s) to be confirmed by Blueprint for Wellness Staff. List each individual location and # of eligible participants at each. Event Staffing Commitment * Three (3) weeks before each Event • Wellness Specialist will confirm with the customer the number of participants, event hours, and *Staffing Commitments finalized less than three (3) weeks prior to the Event require prior approval and may be assessed additional charges schedule Event staffing three weeks prior to each as set forth in Section 1 of the Terms of Service, below. event date. ( Venipuncture and /or Fingerstick) Additional Terms of Service Applicable to Onsite Events: The Services provided by Quest Diagnostics are as follows: a. Collection Services to obtain /collect all specimens from participants at an "Event', where applicable. Additional charges will apply when: (i) Paramedical examiner is required to collect specimens, or be onsite for Event management, between the hours of 9:00 PM and 6:00 AM Monday- Saturday and between the hours of 6:00 PM Saturday and 6:00 AM Monday (additional charge of $30 per hour, per examiner applies). (ii) Staffing of the Event is requested less than three (3) (or as otherwise defined in the MSA) weeks prior to the Event (additional $7 per - participant charge). (iii) Paramedical examiner is required to travel more than fifty (50) miles each way to /from the Event from the ExamOne office where the paramedical examiner is based on current IRS mileage BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 11 Blueprint for Wellness® : -4 D agnostics FEW Q0 reimbursement guidelines over 50 miles to and from Event. If an overnight stay is required, Customer will be billed actual lodging /food expenses. (iv) Small Event Staffing is requested in advance for Venipuncture Events with fewer than 20 participants a "Small Event Staffing Fee" will be applied. For a Fingerstick Event location with < 40 participants but > 20 in that day a special "Small Event Equipment Fee" will apply. (v) FINGER STICK OPTIONS and LIMITATIONS: a. Nevada — Finger Stick programs in NV require a 10% higher per participant fee and a per event location permit fee of $350. New York — Finger Stick programs in NY require a 10% higher per participant fee Maryland — Finger Stick programs are NOT permitted at this time. Tennessee — Finger Stick programs are NOT permitted at this time. Massachusetts - Finger Stick programs cannot include Triglycerides, and so are not recommended. b. Buy -up for Walk in supplies: Client can contract to allow for 10% walk -ins per Event by agreeing to pay for the extra 10% of test cassettes. The decision can be secured when Event scheduling is closed, which is 3 weeks prior to the date of the event per location. [ ] Client would like to be presented with the option to secure additional 10% coverage for walk -in participants.$10.00 per participant - 10% additional optional per Event Total Cost [ $ ] (vi) Participant handout Brochures: WelCoa brochure on [ Subject matter ?? ] educational handouts are available for event distribution to participants in packs of 50 each for $25.00 per pack of 50 a. [ ] packs of 50 @ $25.00 /pack Total cost [ $ ] N/A $20 extra each participant Event " under 20 minimum g Fee ($200 maximum fee) +$150.00 (< 40 location /day eauipment is set ua) Finger Stick for < 20 participants not available (One location - one day) ** The surcharges specified above are one time per Event fees added in addition to Blueprint for Wellness per - participant charges for Services. • If additional Event staffing beyond the recommended number or extra hours are requested there will be a fee of $60 per hour for each additional examiner or $35/ hour for each clerical staff person. . BFW MSA rev. May 2012 12 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness® i �Quest Diagnostics 2. Event Minimum, No -Show Participants and Event Cancellation Charges: At least three (3) weeks prior to an Event, Customer and Quest Diagnostics will finalize a Staffing Commitment ( "Staffing Commitment ") which allows Quest Diagnostics to schedule staffing for the Event based upon the number of expected participants and length of the Event. At the point the Staffing Commitment is finalized, Customer will be responsible for paying no -show, minimum, and cancellation charges. A. Event Minimum and Hourly Participant Flow: Unless a Small Group Event is arranged in advance, Quest Diagnostics will only schedule and staff Events with a minimum of 20 Expected Participants and where at least 10 participants per hour can be processed by Examiners. • For purposes of this section, "Event" means one wellness screening /health fair held at a single location for a continuous period of time. • For an Event that is expected to have less than 20 Expected Participants, Customer may make arrangements in advance for Quest Diagnostics to staff for a Small Group Event. • Fingerstick programs have a location minimum of 40 participants scheduled to execute the screening unless otherwise contracted for "small event equipment fee ". Small Group Event (< 20) charges are further described in Section 1. B. No -Show Participant Charges: No -Show participants in excess of 10% of the scheduled /expected number for an Event at the time of Staffing Commitment will result in a charged no -show at a rate of $20.00 (venipuncture) or $30.00 (Finger Stick) for each participant in excess of 10 %. For example: If an Event is held for 100 Expected Participants and there are 80 Actual Participants, Customer will be charged a No -Show Charge of $20 for 10 Participants. [100 Expected Participants x 90% No -Show Threshold] = 90 and [90 minimum required participants — 80 Actual Participants] x $20 = $200 No -Show Penalty. C. Event Cancellation Charges: (Customer postponement of an Event is equivalent to a cancellation.) • Venipuncture Event cancelled after the Staffing Commitment has been finalized, Customer shall be responsible for paying $20.00 for each Scheduled /Expected Participant. • Fingerstick Event cancelled after the Staffing Commitment has been finalized, Customer shall be responsible for paying $30.00 for each Scheduled /Expected Participant. Collier County Government Board of County Commissioners Print Name: Title: Chairman Date: October 23, 2012 Quest Diagnostics Clinical a Lab ries, Inc., a Delaware corporation and a w lly owned subsidiary of Quest Print Name: Steven L. Burton Title: VP Health andlWelibess Services Date: Appr as t fora® e t sufficiency bWiQAT, KOCK,CLERK BFW eputy County Attorney Quest, Que t' t a i I �Iueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks,D Quest Diagnostics Incorporated. All rights reserved. 13 Blueprint for Wellness ATTACHMENT C Blueprint for Wellness DataLinkTM Quest i Diagnostics r Name / Account #(s) I Collier County Government / 97560562, 97561098, 97561109 Blueprint for Wellness Datal-ink Flexible data interfaces and data file transfer options offered to link clients with key health partners help achieve their wellness program goals and objectives. Request to transmit identified Personal Health Information (PHI) Customer has directed Quest Diagnostics to release participant test results or other identifiable health information (the "Data ") to Customer's Group Health Plan, third party disease management vendor, wellness provider or other third party ( "Authorized Third Party "). Customer represents and warrants that: (i) it will ensure the confidentiality of the Data in compliance with the requirements of HIPAA, (ii) has provided the appropriate notice to participants in Customer's HIPAA Notice of Privacy Practices (the "Notice ") to allow such a disclosure and the the disclosure of the Data is consistent with the Notice, (iii) access to the Data by Customer's Group Health Plan will be limited to only those employees who require access to the Data for the proper performance of their duties, (iv) the Data received by the Authorized Third Party will solely be used for disease management or other Customer health benefits management purposes, (v) any Authorized Third Party receiving the Data per Customer's request is a HIPAA compliant "Business Associate" of Customer, and the terms of the agreement between Customer and the Authorized Third Party restricts the use of the Data for any purposes other than to provide disease management or other wellness provider services, (vi) the Data received by Customer or the Authorized Third Party will not be used for healthcare treatment purposes, as the Data provided is not in the form of a regulatory mandated laboratory report; and (vii) in no event may Customer or the Authorized Third Party receiving the Data use the Data in a way that places Quest Diagnostics at a commercial disadvantage, such as by providing the Data to Quest Diagnostics competitors or by using the Data to populate a physician desktop management system (also referred to as Electronic Medical Records or Electronic Health Records). Customer acknowledges that Quest Diagnostics does not control the final output of how the Customer, or Authorized Third Party, presents and utilizes the Data, and that Customer is solely responsible for the manner in which the Data is used by Customer or Authorized Third Party under this Agreement. Customer shall defend, indemnify and hold harmless Quest Diagnostics (including its employees, directors, officers and agents) for claims of any nature associated with the use of the Data for purposes that are identified as being prohibited under this Agreement, including without limitation the use of the Data for healthcare treatment purposes. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 14 Blueprint for Wellness® Quest i Diagnostics For the avoidance of doubt, Customer, as well as any Authorized Third Party, may not sell or otherwise commercialize the Data. Scope of Services Requested: • Customer requests Standardized data transmission(s) to Business Associate(s) identified below via secured FTP. ❑ Single Standardized data feed per program, is provided at No- Charge. In the Interface Request below, Standard CSV, Standard HL7 and Custom HL7 formats are all considered Quest Diagnostics standardized interface formats. ❑ Additional Standard data feed(s), charged at a rate of $3,500 per feed • Customer requests Custom data transmission(s) to Business Associate(s) identified below via secured FTP. ❑ Each Custom Report will be charged at a rate of $5,000 per feed, plus a development fee quoted at a rate of $200 /hour based on specifications DataLink Additional Terms of Service: 1. Thirty days are needed to set up a Standardized data feed. 2. Setup time required for a Custom Report is generally longer than for a Standardized feed, and is quoted with the development fee. 3. Custom Reports can only be provided at the end of the program; transmissions may not occur during the program. 4. If interfaces have previously been designed for a targeted health partner, the turnaround for a new feed is approximately half. 5. Data collected from venipuncture screenings is generally transmitted to third parties two -to -five days following collection. 6. Data collected from alternate sources (Fingerstick, physician result forms or home collection kits for example) is generally transmitted to third parties seven -to -ten days following receipt of results. DataLink Data Interface Request BFW MSA rev. May 2012 15 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. Blueprint for Wellness® i �Quest Diagnostics Collier County Government Board of County Commissioners Print Name: Fred W- coyle Title: Chairman Date: October 23, 2 012 A'('fr 'tT r BFW MSA rev. May 2012 CLERK .C- Quest Diagnostics Clinical Laboratories, Inc., a Delaware corporation and a wh ll, wned subsidiary of Quest Dia ost s Incorporated Print Name: Title: VP Health and Weoess Services Date: d �Z- Awrqdw to fOnWA 1100"d - - -, t jzy.. t 7 7 eputy County Attorney Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 16 Business ... .. Co. Name: Service: Address: Contact: Phone /Email: ❑ Standard CSV ❑ Secured Email ❑ Secured FTP ❑ Standard HL7 ❑ Secured Email ❑ Secured FTP ❑ Custom HL7 El Email ❑ Secured FTP ❑ Custom Report ,= Secured Email ❑ Secured FTP Data Date Additional Development Fees hrs. @ $200 /hr. $ Total Estimated DataLink Charges $ Collier County Government Board of County Commissioners Print Name: Fred W- coyle Title: Chairman Date: October 23, 2 012 A'('fr 'tT r BFW MSA rev. May 2012 CLERK .C- Quest Diagnostics Clinical Laboratories, Inc., a Delaware corporation and a wh ll, wned subsidiary of Quest Dia ost s Incorporated Print Name: Title: VP Health and Weoess Services Date: d �Z- Awrqdw to fOnWA 1100"d - - -, t jzy.. t 7 7 eputy County Attorney Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 16 Blueprint for Wellness® ATTACHMENT E Blueprint for Wellness Decision SupportTM Quest i Diagnostics Name / Account #(s) I Collier County Government / 97560562, 97561098, 97561109 Blueprint for Wellness Decision Support An analytics -based approach to looking behind the client's aggregate data to identify trends, insights, and specific subsets of the client workforce at risk for chronic illness, increased medical cost, and time lost off the job. Decision Support Package Tiers and Fees (see Package Components detailed on page 2): ❑ Tier 1: < 200 Participants @ $1,500 ❑ Tier 2: 200 — 999 Participants @ $2,250 ❑ Tier 3: 1,000 — 4,999 Participants @ $4,000 ❑ Tier 4: 5,000+ Participants @ $5,000 ❑ Additional reports @ $200 per report ❑ Additional analytics consultation, analyses, and /or presentations quoted at $200 per hour Decision Support Additional Terms of Service: 1. Staff travel and expenses and all other direct expenses such as printing, A/V equipment, room rental and /or digital communication expenses for media -based delivery are passed through at cost. Upon request of the customer, attendance reports, participation rosters and /or a summary of attendee feedback via evaluation form and the number of attendees can be provided free of charge. 2. Eligibility provided by the client must include the data needed to provide additional data breakout reports. 3. Reporting and breakouts will only be provided on populations with 40 or more participants. 4. Client and Quest Diagnostics will agree to the timeframe and scope of the deliverables, prior to the beginning of the analysis 5. Proper planning up front for data analytics when planning for a program will allow for a more detailed analysis. Proper planning includes a discussion about requested break out reports, intended goal of the program, and eligibility information required to allow for ease of reporting. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. 0 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 17 Blueprint for Wellness® Quest i Diagnostics Standard Analvtics and Decision Support Package Components Service Description Standard Analytics Package Decision Support Package Partici an t Level Reports Presentation -- Pricin Reports —� �- -- - - - - - Presentation , ❑ Tier 3 @ $4,000 Tier 1:.. < 200 Partici ants OurCompany Profile - Aggregated OurCompany Profile - Breakouts* (up to 3) Cohort if a ro riate Telephone review of OurCompany Profile* ay Profile !-_ Tele hone review of d urC_ompa9 rofile an Profile - F Estimated Total Decision * u to'6 appropriate) Tier 2: 200 - 999 Partici ants OurCompany Profile - Aggregated OurCompany Profile - Breakouts* (up to 6) Cohort if appropriate) Telephone review of OurCompany Profile burcompany Profile - elephone review of $2,250 rggregated- urCo_mpany Profile = urCompany Profile nal tic Slides (unto 6 reakouts to 10) - - -- - ohort if appropriate) Tier 3: 1,000-4,-n Partici ants OurCompany Profile - Aggregated Ourcompany Profile - Breakouts* (up to 10) Cohort (if appropriate) Telephone review of OurCompany Profile Analytic Slides (up to 6) Dnsite Presentation up $4,000 DurCompany Profile -`_ .__ o 1 location ull PowerPoint deck re ated —1 urCom anv Profile - with Integrated reakouts* (up to 15 nalytics (Up to 5 ohort_Eappropnate) ollow -up slides) Tier 4 : 5,6004 Participants OurCompany Profile - Aggregated OurCompany Profile - * Breakouts (up to 15) Cohort (if appropriate) Onsite Presentation (up to 1 location) Full PowerPoint deck with Integrated Analytics nsite Presentation u 0 3 locations) ' $5,000 urCom an Profile - ated " -- � - urCom�an Profile - * reakouts (up 20) ull PowerPoint deck 1 ith Integrated nal tics (! to 5 — ohort (if appropriate) ollow -u slides * With Operations Specialist ** Ability to produce Breakout Reports depends upon data fields supplied in the Eligibility File. Advanced planning for reports is critical. Service Description Unit Price Charges ❑ Tier 1 @ $1,000 Decision Support Package ❑ Tier 2 @ $2,250 $ ❑ Tier 3 @ $4,000 ❑ Tier 4 @ $51000 Additional Reports Ye ports @ $200 /re ort $ Additional Consultation, Analysis or Presentations hours @ $200 /hour $ Estimated Total Decision $ Support Charges Collier County Government Board of County Commissioners a Print Name: Bred W. Co BFW MSA rev. May,2012' TI:QT Quest Diagnostics Clinical Inc., a Delaware corporation and subsidiary of Quest Print Na)fie: Steven L. Burtoh /-b K' eL 18 Quest, Quest M� the ass' &a ted. g I for Wellness and all asso i i pd trademarks of QWj,b$�'ol�icR diagnostics Incorporat ed. �� BY: �ni m h « Deputy County Artr; ,, slewwft Blueprint for Wellness® Title: Chairman Date: pr-:t nhar 91, 2n1 9 BFW MSA rev. May 2012 Quest i Diagnostics Title: VP Health and Wellness Services Date: Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. 0 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 19 I% Quest Blueprint for Wellness® : 7 Diagnostics ATTACHMENT L Primary Care Physician Results Report Form Option Quest Diagnostics offers Customers the option to allow Eligible Participants to submit Primary Care Physician ( "PCP ") results in lieu of completing the wellness screening. Quest Diagnostics will provide the Customer with the Physician Results Report Form — Exhibit 1 to this Attachment - to distribute to Eligible Participants as well as a process for returning that form for data entry and program credit. Result data entry will be completed by Quest Diagnostics within ten (10) business days of receipt of the form. Tests results from the Physician Results Report Form can be presented to the Participant in either the MyTest Profile, My 5 to Health Profile, or MyHealth Profile format, depending on whether a Health Questionnaire is part of the base program, and are available for inclusion in any Third Party data feeds for which Datal-ink Agreements (Attachment C) are in place. Data will be combined with primary product for comprehensive OurCompany Profile and will be reported to the Customer in the same format as tested results. Quest Diagnostics makes no representations or warranties, express or implied, as to the suitability for purpose, accuracy or reliability of information provided by the PCP to Quest Diagnostics used to populate the MyTest Profile, My 5 to Health Profile, or MyHealth Profile. NOTE: This form and process can not be used to adjust or correct measured results in the Blueprint for Wellness screening programs. The standard result intake profile can be customized to include any or all of the options below, consistent with the Customer's primary program; select the appropriate measures below: X Weight Ibs X Height X Blood Pressure X I Waist Circumference Pricin O tions *: X Glucose X Total Cholesterol X LDL Cholesterol X HDL Cholesterol X Tri I cerides X H bA1c ) eAG (Estimated X Average Glucose MyTest Profile X $19.00/participant My 5 to Health Report ) $25.001 artici ant MyHealth Profile $28.00/pa rtici pant Reprocessing Fee for handling of Invalid Forms ) $10.00/pa rticl pant * *Custom Testing panel review and approval required) $20.00/participant Customization of Program Materials or Process $3,500.00 Fee if > 25% of total utilization is Physician Forms *Pricing assumes that Customer programs include no more than 25% of their volume in Physician Forms. If the program includes more than 25% Physician Forms, then an additional set up fee will apply. * *Intake of any additional results will be considered a custom request and will require review, approval and custom pricing. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 20 Blueprint for Wellness® Collier County Government Board of County Commissioners ATTL$' '' -! p?wlow : KS CLERK `�A t r) n t � t" �- • Ap ved as to form ga ufficiewy Deputy County Attorney BFW MSA rev. May 2012 ► AQuest Diagnostics Quest Diagnostics Clinical Laborat ies, Inc., a Delaware corporation and a thA lyl pwned subsidiary of Que abnQsUe8-tncornorated Print Dame: Steven L. Burton Title: VP Health and Wellness Services Date: d � Z- Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. @ 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 21 Blueprint for Wellness® Exhibit 1 Quest i Diagnostics TEMPLATE FORM - Primary Care Physician Results - Specialist` pecialist will provide" Word Version Physician Result Form *Com leted form must be faxed to 855- 794 -1391 w Patina m114_ eimelliteSS ..rol"attttNfbt'ttltidnl` Account (to be filled in prior to sending to account) QLS Number (provided by Quest) (to be filled in prior to sending to account) ness ❖ The information provided on this form will be keat confidential. Wellness Participant Information: • Physician Results Collection Form Option is available for those participants who can not participate at an on -site event or PSC. By submitting this form, you are requesting your physician to report laboratory and biometric results to Quest Diagnostics for your Health Risk Screening. • You are responsible for ensuring your doctor returns this form by the deadline. If your form is received after XXX, your results will not be processed. • For an individual participant only one physician form can be submitted. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 22 ImI ll�� +Ip +i Ir it nl Date of Testing Testing and measurements must have been completed between XX and XX. a pp IhI yy�i S �I� l�l �yi+tt°u�ljlll k Ufyl I�`in °3'FR kliIu VIII N , i<i�>l rbfll� �v r w �"� t�ril „i, � �er,t*1 rap ��tt�t tt 4'` �1e,Ia I�,III rtatil III I, Waistline Measurement (in inches) Blood Pressure --Systolic Diastolic Fasting Blood Glucose (mg/dl) Confirmed Patient Fasted: ❑ YES Triglycerides (mg/dl) HDL Cholesterol (mg/dl) Total Cholesterol (mg/dl) LDL Cholesterol (mg/dl) (Arid in additional tests) III �� ysician or ystcian esignee s Signature Date Physician's Name (please print) UPIN/NPI Phone Number Wellness Participant Information: • Physician Results Collection Form Option is available for those participants who can not participate at an on -site event or PSC. By submitting this form, you are requesting your physician to report laboratory and biometric results to Quest Diagnostics for your Health Risk Screening. • You are responsible for ensuring your doctor returns this form by the deadline. If your form is received after XXX, your results will not be processed. • For an individual participant only one physician form can be submitted. BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 22 Blueprint for Wellness® Quest i Diagnostics • Physician results cannot be combined with or used to override any actual measured results by Quest Diagnostics. For questions please contact the Blueprint for Wellness Customer Support Center by email at wellness2guestdiagnostics.com or by calling 866- 908 -9440 available (Mon — Fri 7 am — 8:30 pm CST and Sat 7:30 am — 4 pm CST). BFW MSA rev. May 2012 Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. © 2000 -2012 Quest Diagnostics Incorporated. All rights reserved. 23 A� °r CERTIFICATE OF LIABILITY INSURANCE DATE /2012 IYYYY) 0,26120, 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH & MCLENNAN COMPANIES 1166 AVENUE OF THE AMERICAS NEW YORK, NY 10036 CONTACT NAME: PHONE FAX ac No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 37986-MAIN-ALL-11-12 iNSURER A: Travelers Prop. Casualty Co. Of America 25674 INSURED QUEST DIAGNOSTICS INCORPORATED INSURER B : The Travelers Indemnity Company 25658 INSURER C: Lexington Insurance Company 19437 3 GIRALDA FARMS MADISON, NJ 07940 INSURER D: INSURER E: INSURER F : EACH OCCURRENCE $ COVERAGES CERTIFICATE NUMBER: NYC- nnR _s99aaa_n1 0C1 /IQlnk1 kll RA12=0• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INTR TYPE OF INSURANCE ADDL MAP SUER WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM /DD/YYYY LIMITS GENERAL LIABILITY ' EACH OCCURRENCE $ C OMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ CLAIMS -MADE 7 OCCUR PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ �GENL AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ POLICY PRO LOC $ A AUTOMOBILE LIABILITY T02JCAP- 266T3603- TIL -11 12/3112011 12/31/2012 COMBINED SINGLE LIMIT Ea accident $ 3,000,000 ANY AUTO X BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE PER $ $ C UMBRELLA LIAB OCCUR 8125869 12131(2011 12/31/2012 EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB X CLAIMS -MADE AGGREGATE $ 5,000,000 DED I X I RETENTION $ 2,000,000 GL -Self Insured Retention $ A WORKERS COMPENSATION TC2JUB- 266T3523-11 (DED) 12/31/2011 12/31/2012 X vuc STATU- OTH- B AND EMPLOYERS' LIABILITY Y/ N TORY LIMITS 1 FIR -1 2,000,000 ANY PROPRIETOR /PARTNER /EXECUTIVE TRKUB- 266T3535 -11 (RETRO) 12/31/2011 12/31/2012 OFFICER /MEMBER EXCLUDED? � NIA E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ 2,000,000 Mandatory in NH) ( If yes, describe under E . DISEASE - POLICY LIMIT 1 $ 2,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) (Professional Liability / Claims Made - Self Insured Retention - $5,000,000 - 12/31/11 - 12/31/12) COLLIER COUNTY, IS INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY CONTRACT, COLLIER COUNTY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BOARD OF COUNTY COMMISSIONERS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 3327 TAMIAMI TRAIL EAST ACCORDANCE WITH THE POLICY PROVISIONS. NAPLES, FL 34112 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Marla Nicholson IJ'IWtfl3 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD