STATEMENT OF WORK CHOICES



FORM E: Service SelectionDepartment of State Health ServicesTuberculosis Prevention and Elimination Program Open Enrollment Application OE#HHS0000682Contractor:________________________________________Note: Contractor may choose multiple service options FORMCHECKBOX (A.) CHEST X-RAY AND RADIOLOGIC INTERPRETATION WITH CT SCANPURPOSE Contractor will provide chest radiographs, computed tomography scans ("CT Scans") and radiological interpretation for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI"). CONTRACTOR RESPONSIBILITIESContractor will:Accept System Agency referrals for chest radiographic images and/or CT Scans for patients with suspected/confirmed TB or LTBI. Referral forms will be delivered to the Contractor by the patient directly or by the System Agency provider via fax or secure email. Perform the procedure(s) requested on the referral form within five (5) calendar days of receipt of the referral form. The requested procedures may be one or more of the following: Radiologic examination, chest; single view, frontal;Radiologic examination, chest; two views, frontal and lateral;Radiologic examination, chest; two views, frontal and lateral; with apical lordotic procedure;Radiologic examination, chest; two views, frontal and lateral; with oblique projections; andCT Scan, chest; frontal and back.Provide requested images and interpretations to System Agency or it's designee within three (3) to five (5) calendar days after images have been taken.Ensure radiographic images and/or CT Scans are of good professional quality and clearly readable. Output should be on film or digital media as directed by the System Agency. Perform procedures required under this Contract using radiation machines (including x-ray machines) that are currently registered with the System Agency Radiation Safety Licensing Branch and are compliant with all state and federal requirements. Ensure that all individuals who operate radiation machines (including x-ray machines) for human use meet all applicable credentialing requirements, including (but not limited to) System Agency rules found at 25 Texas Administrative Code Chapter 140 regarding medical radiologic technologists.Employ personnel who are licensed in Texas to provide the professional services required under this Contract for patient(s) with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress. Provide written interpretation and impression for patient(s) diagnosed with TB disease to determine treatment response using the following terminology: “no change,” “improving” or “worsening.”Repeat no more than 3% of chest radiographic images due to poor image quality or obscured image.Obtain and maintain in good standing all applicable licenses or registrations for radiation producing devices or radiation sources (such as x-ray machines or CT scanners) and comply with all applicable provisions of Texas Health and Safety Code Chapter 401 and Texas Radiation Control Rules, 25 TAC §289.201 et seq. that are needed to provide the services under this Contract. Failure to obtain, or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (B.) CHEST X-RAY AND RADIOLOGIC INTERPRETATION w/o CT SCAN PURPOSEContractor will provide chest radiographs and radiological interpretations for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI").CONTRACTOR RESPONSIBILITIESContractor will:Accept System Agency referrals for chest radiographs and radiological interpretations for patients with suspected/confirmed TB or LTBI. Perform the procedure(s) requested on the referral form within five (5) calendar days of receipt of the referral form. The requested procedures may be one or more of the following: Radiologic examination; chest; single view, frontal;Radiologic examination; chest, two views, frontal and lateral;Radiologic examination; chest, two views, frontal and lateral; with apical lordotic procedure;Radiologic examination; chest, two views, frontal and lateral; with oblique projections; andChest, frontal and back.Return requested images and written interpretations of findings to System Agency or its designee within three (3) to five (5) days after images have been taken.Provide written interpretation and impression for patients diagnosed with TB disease to determine treatment using the following terminology: “no change,” “improving” or “worsening.”Provide radiographic images that are of good professional quality and clearly readable. Output should be on film or digital media as directed by the System Agency. Repeat no more than 3% of chest radiographic images due to poor image quality or obscured image.Perform procedures required under this Contract using radiation machines (including x-ray machines) that are currently registered with the System Agency Radiation Safety Licensing Branch and are compliant with all state and federal requirements. Ensure that all individuals who operate radiation machines (including x-ray machines) under this Contract meet all applicable credentialing requirements, including but not limited to System Agency rules found at 25 TAC 140 regarding medical radiologic technologists.Maintain personnel licensed in Texas to provide the professional services required under this Contract for patients with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress. Obtain and maintain in good standing all applicable licenses, or registrations for radiation producing devices or radiation sources (such as x-ray machines or CT scanners) and comply with all applicable provisions of Texas Health and Safety Code Chapter 401 and Texas Radiation Control Rules, 25 TAC §289.201 et seq. that are needed to provide the services under this Contract. Failure to obtain or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (C.) MEDICAL LABORATORY SERVICESPURPOSEContractor will provide medical laboratory tests and laboratory blood tests for patients referred by System Agency.CONTRATOR RESPONSIBILITIESContractor will:Perform requested laboratory tests upon receipt of a completed System Agency referral form, sent with the patient or sent with a collected blood specimen. Provide the following laboratory tests, as requested in the referral form:Complete blood count ("CBC") with platelets; Liver function panel (including aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, bilirubin, and total serum protein);Kidney function tests (including creatinine and blood urea nitrogen); Viral hepatitis B infection panel (including hepatitis B surface antigen, hepatitis B surface antibody and hepatitis B core antibody);Viral hepatitis C panel (including anti-HCV antibody and HCV RIBA);HIV tests; andCoagulation tests (including Partial Thromboplastic Time (PTT), Prothrombin Time (PT) and Prothrombin Time/International Normalized Ratio (PT/INR) Notify TB Program Manager by phone immediately and in no event more than 24 hours of finding any critical lab values that may require urgent therapeutic action. "Critical lab value" is defined as any test result that may require rapid clinical attention to avert significant patient morbidity or mortality.Maintain throughout the term of the Contract Clinical Laboratory Improvement Amendments (CLIA) or College of American Pathologists (CAP) certification or accreditation, as applicable. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (D.) RADIOGRAPHIC INTERPRETATION (Contracting with a Company that Employs the Health Care Professionals)PURPOSE Contractor will provide professional radiological interpretations for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") disease or latent TB infection ("LTBI") for the purpose of diagnosis or medical assessment of progress. CONTRACTOR RESPONSIBILITIESContractor will:Provide System Agency a written expert interpretation and impression for patients referred by System Agency who have been diagnosed with TB or LTBI within 48 hours of receiving a request for services. Provide written interpretations and impressions for patients with TB or LTBI to determine treatment response using the following terminology: “no change,” “improving” or “worsening.”Obtain and maintain in good standing all applicable licenses or registrations for radiation producing devices or radiation sources (such as x-ray machines or CT scanners) and comply with all applicable provisions of Texas Health and Safety Code Chapter 401 and Texas Radiation Control Rules, 25 TAC §289.201 et seq. that are needed to provide the services under this Contract. Failure to obtain, or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate.Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (E.) RADIOGRAPHIC INTERPRETATION (Working Directly with a Health Care Professional)PURPOSE Contractor will provide expert radiological interpretations for patients with suspected/confirmed tuberculosis (TB) disease or latent TB infection (LTBI) that are referred by System Agency for the purpose of diagnosis or medical assessment of progress.CONTRACTOR RESPONSIBILITIESContractor will:Provide to System Agency within 48 hours of receiving a request for service a written expert radiographic interpretation and impression for patient(s) diagnosed with TB or LTBI to determine ply with all applicable provisions of Texas Health and Safety Code Chapter 401 of the Texas Health and Safety Code and Texas Radiation Control Rules at 25 TAC §289.201 et seq. that are needed to provide the services under this Contract.Provide written interpretation and impression for patient(s) diagnosed with TB disease to determine treatment response using the following terminology: “no change,” “improving” or “worsening.”Ensure that all its employees, volunteers, and subcontractors providing services under this contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. Failure to obtain or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. FORMCHECKBOX (F.) RADIOGRAPHIC IMAGING with CT ScanPURPOSE Contractor will provide chest radiographs and computed tomography scans ("CT Scans") for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI").CONTRACT RESPONSIBILITIESContractor will:Accept and complete System Agency referrals for chest radiographic images and/or CT Scans for patients with suspected/confirmed TB or LTBI. Referral forms will be delivered to the Contractor by the patient directly or by the System Agency provider via fax or secure email. Perform the procedure(s) requested on the referral form within five (5) calendar days of receipt of the referral form. The requested procedures may be one or more of the following: Radiologic examination, chest; single view, frontal;Radiologic examination, chest; two views, frontal and lateral;Radiologic examination, chest; two views, frontal and lateral; with apical lordotic procedure;Radiologic examination, chest; two views, frontal and lateral; with oblique projections; andCT Scan, in accordance with the referral.Perform 100% of the referrals received from System Agency.Provide requested images to System Agency or it's designee within three (3) to five (5) calendar days after images have been taken.Provide radiographic images and/or CT Scans that are of good professional quality and clearly readable. Output should be on film or digital media as directed by the System Agency.Perform procedures required under this Contract using radiation machines (including x-ray machines) that are currently registered with the System Agency Radiation Safety Licensing Branch and are compliant with all state and federal requirements. Ensure that all individuals who operate radiation machines (including x-ray machines) for human use meet all applicable credentialing requirements, including (but not limited to) System Agency rules found at 25 Texas Administrative Code Chapter 140 regarding medical radiologic technologists.Employ personnel who are licensed in Texas to provide the professional services required under this Contract for patient(s) with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress. Repeat no more than 3% of chest radiographic images due to poor image quality or obscured image.Obtain and maintain in good standing all applicable licenses or registrations for radiation producing devices or radiation sources (such as x-ray machines or CT scanners) and comply with all applicable provisions of Texas Health and Safety Code Chapter 401 and Texas Radiation Control Rules, 25 TAC §289.201 et seq. that are needed to provide the services under this Contract. Failure to obtain or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (G.) RADIOGRAPHIC IMAGING w/o CT ScanPURPOSEContractor will provide chest radiograph imaging only for patients with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI") who are referred by System Agency.CONTRACTOR RESPONSIBILITIESContractor will:Accept System Agency referrals for chest radiographic images for patients with suspected/confirmed TB or LTBI. Referral forms will be delivered to the Contractor by the patient directly or by the System Agency provider via fax or secure email. Provide any of the following chest radiograph procedures and clearly document the procedure type on the referral form: Radiologic examination, chest; single view, frontal;Radiologic examination, chest; two views, frontal and lateral;Radiologic examination, chest; two views, frontal and lateral; with apical lordotic procedure; andRadiologic examination, chest; two views, frontal and lateral; with oblique projections.Perform radiographic images within five (5) calendar days of receiving a referral.Provide requested images to System Agency or it's designee within three (3) to five (5) calendar days after images have been taken.Provide radiographic images that are of good professional quality and clearly readable. Output should be on film or digital media as directed by the System Agency. Repeat no more than 3% of chest radiographic images due to poor image quality or obscured image.Perform procedures required under this Contract using radiation machines (including x-ray machines) that are currently registered with the System Agency Radiation Safety Licensing Branch and are compliant with all state and federal requirements.Ensure that all individuals who operate radiation machines (including x-ray machines) for human use meet all applicable credentialing requirements, including (but not limited to) System Agency rules found at 25 Texas Administrative Code Chapter 140 regarding medical radiologic technologists.Employ personnel who are licensed in Texas to provide the professional services required under this Contract for patient(s) with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress.Obtain and maintain in good standing all applicable licenses or registrations for radiation producing devices or radiation sources (such as x-ray machines or CT scanners) and comply with all applicable provisions of Texas Health and Safety Code Chapter 401 and Texas Radiation Control Rules, 25 TAC §289.201 et seq. that are needed to provide the services under this Contract. Failure to obtain, or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. Ensure that all its employees, volunteers providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (H.) MEDICAL EVALUATIONPURPOSE The Contractor in collaboration with System Agency will provide medical evaluation and management in Texas for patients with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI") for the purpose of diagnosis and appropriate drug treatment.CONTRACTOR RESPONSIBILITIESContractor will:Perform medical evaluation and management for patients at baseline and during treatment to monitor for potential adverse drug reactions, including at least a monthly history of symptoms related to adverse drug reactions for the medications prescribed and appropriate clinical assessment or laboratory tests for adverse drug reactions as described in the American Thoracic Society (ATS) Treatment of Tuberculosis (2003) or latest version, available at services within the scope of the Contractor’s license, certification, registration or other legal authorization, at the location(s) and in the manner specified in this Contract.Consult with System Agency medical experts, as needed, and System Agency staff to provide medical evaluation and management, which includes reviewing a patient’s history and diagnostic tests such as bacteriology and chest radiography studies directed towards detection of signs and symptoms of TB disease. With System Agency consultation, provide medication orders for appropriate treatment in accordance with ATS Treatment of Tuberculosis (2003) or latest version and Centers for Disease Control and Prevention 2000 (CDC) Targeted Tuberculin Testing and Treatment of Latent TB Infection or latest version. Consult with System Agency expert TB physician for the treatment of pediatric or drug resistant TB disease, and/or if the treating physician has concerns. Within 15 days of the date of service, provide written documentation of the findings of medical evaluation related to diagnosis, response to therapy, and assessment for potential adverse drug reactions during treatment. Contractor will sign the TB-400A or TB-400B for treatment medication orders. Contractor will submit all documentation, including the TB-400A and TB-400B, to the applicable System Agency nurse case manager or Local Health Department nurse.Obtain and maintain all applicable licenses, certifications, permits, registrations and approvals to conduct its business and to perform the services under this Contract. Failure to obtain or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies the Department deems appropriate. Contractor will notify System Agency within five (5) business days of any revocation of licenses, certifications, permits, or registrations. FORMCHECKBOX (I.) ALTERATION OF THE FORM OF TUBERCULOSIS (TB) DRUGSPURPOSE The Contractor will provide pharmaceutical compounding of anti-tuberculosis drugs for pediatric or adult patients with unique medical needs. CONTRACTOR RESPONSIBILITIESContractor will:Maintain for the duration of this Contract an active and unrestricted registration with the Texas State Board of Pharmacy (TSBP) as a licensed pharmacist.Upon receipt of a written request and/or referral from a System Agency Nurse Case Manager (NCM), the Contractor will alter the form of drugs provided to Contractor by System Agency and appropriately label the container containing the altered-format drug. Contractor will receive rifampin, isoniazid, pyrazinamide, ethambutol or other medications in tablet form that are generally considered second-line medications for the treatment of plete 100% of all written requests or referrals received from System Agency within three (3) to five (5) days of receipt of the request or referral.Obtain and maintain in good standing all applicable licenses, certifications, permits, registrations and approvals with Texas State Board of Pharmacy or such other licensing board to conduct its business and to perform the services under this Contract. Failure to obtain or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. Contractor will notify System Agency within five (5) days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (J.) TB SKIN TESTS(Please note that no DSHS region is currently using contractors to provide tuberculin skin testing services. Local health departments and regions may provide TB testing supplies to community based organizations that are participating in a targeted testing project for high-risk populations, but the organizations are not paid for administering and reading the tuberculin skin tests.)PURPOSEThe Contractor will administer and read tuberculin skin tests ("TST") as requested by System Agency.CONTRACTOR RESPONSIBILITIESContractor will:Under the standing delegation orders of a physician, administer and read TST within 48 to 72 hours of administration as requested by System Agency Nurse Case Manager or designated System Agency tuberculosis program staff. Administer 100% of the TST referred by System Agency and conduct TST in accordance with System Agency's written procedures. Usepurified protein derivative (PPD) and syringes provided to Contractor by System Agency for administering the TST.Before administering TST under this Contract, complete a training course on how to administer the skin test, measure the induration (not redness) at the injected site in millimeters with a skin test ruler, and interpret the test as positive or negative based on size of induration and the patient’s risk factors. Document the test results in the patient’s record or on a TB-340 contact investigation form. All positive test results must be documented on the TB340 contact investigation form.Read and interpret the skin test at a place and time agreed upon by the patient and Contractor. Administer TST to patients who are identified as contacts to a case. Notify the System Agency Nurse Case Manager or designated tuberculosis System Agency program staff, immediately and in no event later than 24 hours of administration of a positive test or adverse reaction to the TST. FORMCHECKBOX (K.) PROFESSIONAL SERVICES (DOCTORS, NURSES, AND OTHER HEALTH CARE PROFESSIONALS) (Immunizations Scope)PURPOSEContractor will serve as the authorizing physician for the health service region in the administration of immunizations for contracted counties.CONTRACTOR RESPONSIBILITIESContractor will:Under the standing delegation orders ("SDOs") of a physician, sign the Orders for Immunizations and Immunization Emergencies within ten (10) days of receipt. The orders will be prepared by the System Agency regional office utilizing the SDO from the Immunization Action Coalition and following the recommendations and guidelines with the most current information from the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and System Agency immunization guidelines.Obtain and maintain all applicable licenses, certifications, permits, registrations and approvals to conduct its business and to perform the services under this Contract. Failure to obtain or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies the System Agency deems appropriate. Contractor will notify System Agency within five (5) days of any revocation of licenses, certifications, permits or registrations.Sign the Texas Vaccines for Children (TVFC) program enrollment form within ten (10) business days of receipt. FORMCHECKBOX (L.) Please refer to the Primary Healthcare Open Enrollment # OE # 537-131387 located at FORMCHECKBOX (M.) LABS CBC, HEPATIC FUNCTION PANELPURPOSEContractor will provide Complete Blood Count and/or Hepatic Function Panel tests for patients referred by System Agency.CONTRACTOR RESPONSIBILITIESContractor will:Perform complete blood count test or hepatic function panel tests for patients referred by System.Notify System Agency by phone within 24 hours of any critical lab values which may require urgent therapeutic action. Critical lab values are defined as any test result that may require rapid clinical attention to avert significant patient morbidity or mortality. Maintain throughout the term of the Contract Clinical Laboratory Improvement Amendments (CLIA) or College of American Pathologists (CAP) certification or accreditation, as applicable. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. FORMCHECKBOX (N.) HIV/STDPURPOSEContractor will provide Sexually Transmitted Disease (STD) testing, diagnosis and/or treatment services to clients referred by System Agency Health Service Region ## (HSR-#). CONTRACTOR RESPONSIBILITIESContractor will:Provide medical management in accordance with the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease Treatment Guidelines 2010 () and all current CDC treatment guidelines for System Agency-referred clients and their sexual contacts/partners. Will provide services, testing and treatment to 100% of HSR # referrals.Provide STD testing, diagnosis and/or treatment at: (insert location) , by referral and appointment arranged on behalf of the identified client or their sexual partners/contacts by HSR (Insert #) headquartered at (Insert address) (Insert Phone Number).Use supplies provided by HSR# for purposes of testing and treatment provided under this Contract. Comply with all applicable federal and state regulations and statutes, including, but not limited to Texas Health and Safety Code Chapters 81 and 85, and 25 Texas Administrative Code Chapter 97. FORMCHECKBOX (O.) TB OpticalPURPOSE Contractor will provide optical services to clients referred by System Agency.CONTRACTOR RESPONSIBILITIESContractor will:Upon receipt of referral from Service Agency , perform services listed below within the scope of the individual’s license, certification, registration or other legal authorization, at the location(s) and in the manner specified in this Contract:Eye Specialist Consult - Eye Exam; Fundus Photos (Retinal Photography) – Take photos of the inner lining of the eye;Fluorescein Angiogram –This is a test of the retinal circulation that will give the doctor more information about the eye problem; andOptical Coherence Tomography (OCT) - The OCT is used to help diagnose and make treatment decisions on any condition that causes changes in the macula.Provide services, testing and treatment to 100% of referrals.Maintain the expertise required to provide services under this Contract and maintain all licenses, certifications, registrations or other legal authorizations in good standing during the term of this Contract. Contractor will notify System Agency within five (5) days of any revocation of licenses, certifications, permits, or registrations.(P.) RADIOLOGIC INTERPRETATION WITH CT SCANPURPOSE Contractor will provide computed tomography scans ("CT Scans") and radiological interpretation for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI"). CONTRACTOR RESPONSIBILITIESContractor will:Accept System Agency referrals for CT Scans for patients with suspected/confirmed TB or LTBI. Referral forms will be delivered to the Contractor by the patient directly or by the System Agency provider via fax or secure email. Perform the procedure(s) requested on the referral form within five (5) calendar days of receipt of the referral form. The requested procedures may be one or more of the following: CT Scan, chest; frontal and back.Provide requested images and interpretations to System Agency or it's designee within three (3) to five (5) calendar days after images have been taken.Ensure CT Scans are of good professional quality and clearly readable. Output should be on film or digital media as directed by the System Agency. Perform procedures required under this Contract using radiation machines (including x-ray machines) that are currently registered with the System Agency Radiation Safety Licensing Branch and are compliant with all state and federal requirements. Ensure that all individuals who operate radiation machines (including x-ray machines) for human use meet all applicable credentialing requirements, including (but not limited to) System Agency rules found at 25 Texas Administrative Code Chapter 140 regarding medical radiologic technologists.Employ personnel who are licensed in Texas to provide the professional services required under this Contract for patient(s) with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress. Provide written interpretation and impression for patient(s) diagnosed with TB disease to determine treatment response using the following terminology: “no change,” “improving” or “worsening.”Obtain and maintain in good standing all applicable licenses or registrations for radiation producing devices or radiation sources (such as x-ray machines or CT scanners) and comply with all applicable provisions of Texas Health and Safety Code Chapter 401 and Texas Radiation Control Rules, 25 TAC §289.201 et seq. that are needed to provide the services under this Contract. Failure to obtain, or any revocation, surrender, expiration, non-renewal, inactivation or suspension of any such license, certification, permit, registration or approval constitutes grounds for termination of this Contract or other remedies System Agency deems appropriate. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations.(Q.) ECG with Interpretation PURPOSEContractor will provide 12-lead electrocardiogram (ECG) with interpretation for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI").CONTRACTOR RESPONSIBILITIESContractor will:Accept System Agency referrals for 12-lead electrocardiograms with interpretations for patients with suspected/confirmed TB or LTBI. Perform the 12-lead electrocardiogram(s) requested on the referral form within five (5) calendar days of receipt of the referral form. Tracing to include routine measurement of heart rate, PR, QRS, and QT interval at a minimum. Return requested 12-lead electrocardiogram with interpretation of findings to System Agency or its designee within three (3) to five (5) days after reading was done.Maintain personnel licensed in Texas to provide the professional services required under this Contract for patients with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations.(R.) ECG without Interpretation PURPOSEContractor will provide 12-lead electrocardiogram (ECG) for patients referred by System Agency with suspected/confirmed tuberculosis ("TB") or latent TB infection ("LTBI").CONTRACTOR RESPONSIBILITIESContractor will:Accept System Agency referrals for 12-lead electrocardiograms for patients with suspected/confirmed TB or LTBI. Perform the 12-lead electrocardiogram(s) requested on the referral form within five (5) calendar days of receipt of the referral form. Tracing to include routine measurement of heart rate, PR, QRS, and QT interval at a minimum. Return requested 12-lead electrocardiogram results to System Agency or its designee within three (3) to five (5) days after reading was done.Maintain personnel licensed in Texas to provide the professional services required under this Contract for patients with suspected/confirmed TB disease or LTBI for the purpose of diagnosis or medical assessment of progress. Ensure that all its employees, volunteers, and subcontractors providing services under this Contract obtain and maintain in active status all licenses, certifications, permits, registrations and approvals required to perform their duties under this Contract. Contractor will prohibit any person who does not hold a current, active required license, certification, permit, registration or approval from performing services under this Contract. Contractor will notify System Agency within five (5) calendar days of any revocation of licenses, certifications, permits or registrations. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download