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1st Amendment 09/17/2014 AMY HEAVILIN, CPA CLERK OF CIRCUIT COURT & COMPTROLLER - > MONROE COUNTY,FLONIDA 4-palAll DATE: October 03, 2014 TO: Teresa Aguiar, PHR, CPM Director of Employee Services ATTN: Christine Diaz FROM: Lindsey Ballard, D.0 At the September 17, 2014, Board of County Commissioner's meeting the Board granted approval and execution of Item C23 Amend Contract New Truman Medical to provide testing for Nicotine Products. Attached is a duplicate original of the above-mentioned for your handling. Should you have any questions please do not hesitate to contact this office. cc: County Attorney (electronic copy) Finance(electronic copy) File 500 Whitehead Street Suite 101,PO Box 1980,Key West,FL 33040 Phone:305-295-3130 Fax:305-295-3663 3117 Overseas Highway,Marathon,FL 33050 Phone:305-289-6027 Fax:305-289-6025 SCANNED 88820 Overseas Highway,Plantation Key,FL 33070 Phone:852-1145 Fax:305-852-7146 IO 3.IiLF FIRST AMENDMENT TO CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES This is an amendment("Amendment") dated 910Y is entered into by and between Monroe County ("County') and New Truman Medical. ("Contractor"). WHEREAS, the County and Contractor entered into a Contract for Employment Physical Services ("Agreement") on March 19, 2014, whereby New Truman Medical agreed to furnish employment physical services; and WHEREAS, the incorrect facility address is reflected in Section 1. Scope of Services of the current contract; and WHEREAS, it is now necessary to amend the contract to include testing for nicotine products; NOW THEREFORE, in consideration of the mutual covenants contained herein the parties agree to amend the Agreement as follows: 1. Section 1. Scope of Services of the agreement is revised to reflect that the employee will be tested at the physician's facility located at 540 Truman Ave., Key West, FL 33040. 2. Section One, Scope of Services, of the agreement is revised to include fees for testing of nicotine as follows: SERVICE FEE Urine Testing for When requested, a $40.00 per test Nicotine nicotine test will be performed by the physician and will be either scheduled or done on a walk-in basis. 3. All other terms and conditions of the Agreement remain in full force and effect. 1 IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be ,the day and year first above written. 10 (E EAJ$ n Board of County Commissioners { Atie,t)A eavilin, Clerk of Monroe County Deputy Clerk Mayor/Chairman • (CORPORATE SEAL) New Tr Attest: By Print Name Title MONA E COUNTY ATTORNEY A ROVE AS Ty M. YNTHIA L. ALL ASSISTANT COUNTY O TTDOFiNEY Date- 2 A RO® CERTIFICATE OF LIABILITY INSURANCE °"TE'"""'°°"""' �- 07/02/14 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 ADDmONAL INSURED,the pollcy(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 A'CT NAME Joseph Santiago,CPIA,CPII,PIAM Advanced Professronal Services PHONE Etl' (9S4)7256112 FAX WC No): (954)7256115 240 Lock Road ADDRESS gI Yanas tlanas o@e vancedd professional.com Deetdd Berth.FL 33442 INSURER(S)AFFORDING COVERAGE NAIL♦ Plane (954)725-6112 Fax (954)7256115 NSURER A: Lancet Indemnity INSURED NSURER B: Gilbert Shapiro,MD NSURER C: 540 Truman Ave. NSURER c: Key West,FL 33040 (305)296-9145 NSURER E: NSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 PAD CLAIMS. INSR TYPE OF INSURANCE AODLSUBR POLICY EFF POLICY EXP LTR JNSR WYD POLICY NUMBER (MMIDDIYYY11MMMINTYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE 250,000.00 DAMAGE TOED ECOMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) A IO CLAIMS-MADE El OCCUR LR091289001415 MEDEXP(Any one person V Medical Professional Liability 07/01/2014 WIO1I2015 PERSONAL&ADV INJURY L _ ---_ GENERAL AGGREGATE 750,000.00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO C POLICY O PIFP ❑ LOG AmomomLE LIAspLIIY (CLOMBleNQD?SINGLE LIMIT $ C ANY AUTO BODILY INJURY(Per person) $ p AAUONED 0,0 SCHEDULED BODILY INJURY Per aweeml $ NUTOW NED PROPERTY AMAGE [_. HIRED AUTOS ] AUTos Iveramdentg $ ❑ LI $ C UMBRELLA LIAB C OCCUR EACH OCCURRENCE $ E EXCESS LIAB C CLAIMS-MADE AGGREGATE $ G °ED L] RETENTIONS _$ WORKERS COMPENSATION WC Mils EMPLOYERS'LIABILITY YIN TORYIIMITS ❑ FR ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ M nItl b MEMBER EXCLUDED? N I A (/yeq ry In uH)ar EL.DISEASE-EA EMPLOYE $ IDESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERAllONSI LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Specialty:Family Practice-No Surgery pp q,GEfaEM Endorsement:Stephanie A.Gallaher,ARNP Y'\ IC DA WAIVE N/A _ C� I e- C.{v-i..cfnt -HR- CERTIFICATE HOLDER CANCELLATION VIA AIN00J 3011NOW •11 813 'min SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioners THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1100 Simonton St.,item L- ,life halo] AUTHORISED REPRESENTATIVE Key West,FL 33040- L I�L1 11 L • D� �o� 8l1� ©1988-2010ACORDCORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD