No preview available
HomeMy WebLinkAboutC05-024 Colorado Department of Public Health and Environment – Maternal and Child Health Services 8lJS - Od).If, ;;; 2- DEP ARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PSD-MCH DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 05-00410 CONTRACT AMENDMENT #1 This AMENDMENT is rnade this 5TH day of JANUARY, 2005, by and between: the state of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as "the State"; and, BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY (a political subdivision of the state of Colorado), whose address or principal place of business is 500 Broadway, Eal!le, Colorado 81631, for the use and benefit of the Eal!le County Health & Hurnan Services, whose address or principal place of business is 551 Broadway, Eal!le, Colorado 81631, hereinafter referred to as "the Contractor". WHEREAS, the United State Department of Health and Human Services ("HHS"), through the Maternal and Child Health Services Block Grant (MCH) has awarded the State Title V federal funds under Notice of Grant A ward ("NGA) number B04MC02394-01-00 (See, Catalog of Federal Domestic Assistance ("CFDA") nurnber 93.994); WHEREAS, the parties thereafter entered into a Contract (Original Contract), dated June 23, 2004, contract encumbrance number PO FLA MCHOS00220, contract routing nurnber 05 FLA 00220, whereby the Contractor was to provide to the State the development and enhancement of community-based systems of care for the maternal and child populations; WHEREAS, pursuant to section 25-1.5-101 (j) (1), CR.S., as amended, the General Assembly ofthe state of Colorado has declared that the state "has, in addition to all other powers and duties imposed upon it by law, the powers and duties to disseminate public health information." WHEREAS, pursuant to section 25-1.5-10 I (r), C.R.S., as amended, states that the state can, "operate and maintain a program for children with disabilities to provide and expedite provision ofheahh care services to children who have congenital birth defects or who are the victims of burns or trauma or children who have acquired disabilities". WHEREAS, pursuant to section 25-1-709 (10 (a), C.R.S., as amended, further states that "[tJhe program and services ofregional health departments shall include to the greatest extent possible, but not be limited to personal health services, including: maternal and child health services; program for children with disabilities". WHEREAS, to accomplish its statutory duties, the State determined that public health services are desirable in the Contractor's region and the State and the Contractor mutually agree that the most efficient and effective way to provide the public health services is at the local level. Page I of 4 \VHEREAS, pursuant to section 29-1-201, C.R.S. as amended, encourages govemrnents to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function, service, or facility lawfully authorized to each of the cooperating or contracting entities. WHEREAS, pursuant to section 29-1-201, C.R.S., as amended, further states that all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code. WHEREAS, the State desires to add a "no cost" change within the current term of the Original Contract; WHEREAS, all required approvals, clearances, and coordination have been accomplished frc:m and with all appropriate agencies. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: 1. Consideration for this Amendment to the Original Contract, contract encumbrance number PO FLA MCHOS00220, contract routing number 05 FLA 00220, consists of the payments and services which shall be made pursuant to this Amendment, and [use strikeout if this is a $0.00 Amendment] the promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Contract, which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment }". All terms, conditions, and provisions of the Original Contract, unless specifically modified herein, are to apply to this Amendment as if those terms, conditions, and provisions were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Contract is, and shall be, modified, altered, and changed in the following respects only: A. A new paragraph 9. is added to Part B. ofthe Original Contract, "DUTIES AND OBLIGATIONS OF THE CONTRACTOR" on Page 5 of 18. This new paragraph 9. reads as follows: 9. Contractor shall comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIP AA); a HIP AA Business Associate Memorandum of Understanding, is incorporated herein by this reference, made a part hereoC and attached hereto as "Exhibit A". 4. The effective date of this amendment is Aprill, 2005, or upon approval by the State Controller, whichever is later Page 2 of 4 5. Except for the General Provisions and Special Provisions of the Original Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Contract, the terms and provisions of this Amendment shaH in all respects supersede, govern, and control. The Special Provisions shall always control over other provisions of the Original Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Original Contract concerning the absence of bribery or corrupt influences and personal interest of State employees are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 3 of 4 IN WITNESS WHEREOF, the parties hereto have executed this Amendment on the day first above written. Contractor: State of Colorado Bill Owens, Governor BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY (a political subdivision of the state of Colorado) for the use and benefit of the Eagle County Nursing Service By: By: (SI a ure of Individual) Executive irector ./fv.A Ni-bvtWYl "/ DEPARTMENT OF PUBLIC (N ame of Individual) HEALTH & ENVIRONMENT BOCC Chair Date: Position (Title) 84-6000762 Federal Employer ID Number By: (SEAL) Attorney General By: )'), By: ;VIA Co~orate Date: I Town/City/County ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for goods and/or services provided. State Controller Leslie M. Shellefelt By: Date: Page 4 of 4 t e iJ i/- ;; 3e: . L 2- A TI,q(.:HMENT 1 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PREVENTION SERVICES DMSION DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 05-00220 INTERGOVERNMENTAL CONTRACT (Mixed Funds) This Contract is made this 23RD day of JUNE, 2004, by and between: the state of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as "the State"; and, BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY (a political subdivision of the state of Colorado), whose address or principal place of business is 500 Broadway, Ea2.le, Colorado 81631, for the nse and benefit of the Ea2.le County Health & Human Services, whose address or principal place of business is 551 Broadway, Ea2.le. Colorado 81631, hereinafter referred to as "the Contractor". WHEREAS, pursuantto section 25-1.5-101 G) (I), C.RS., as amended, the General Assembly ofthe state of Colorado has declared that the state 'bas, in addition to all other powers and duties imposed upon it by law, the powers and duties to disseminate public health infonnation." WHEREAS, section 25-1.5-101 (r), C.RS., as amended, states that the state can, "operate and maintain a program for children with disabilities to provide and expedite provision ofhea1th care services to children who have congenital birth defects or who are the victims of burns or trauma or children who have acquired disabilities". WHEREAS, section 25-1-709 (10 (a), C.RS., as amended, furthec states that "(t]he program and services of regional health departments shall include to the greatest extent possible, but not be limited to personal health services, including: maternal and child health services; program for children with disabilities". WHEREAS, to accomplish its statutory duties, the State has determined that public health services are desirable in the Contractor's region. WHEREAS, the United State Department of Health and Human Services (''HHS''), through the Maternal and Child Health Services Block Grant (MCH) has awarded the State Title V federal funds undec Notice of Grant Award ("NGA) number B04MC02394-01-00 (See, Catalog of Federal Domestic Assistance ("CFDA") number 93.994). WHEREAS, the State's Prevention Services Division (PSD) is charged with the administration offunds from the Title V MCH Block Grant to improve the health and well being of the maternal and child/adolescent populations through assessing population needs, in1luencing health policy, engaging in strategic planning and coordinating/implementing best practices and evidenced-based programs; WHEREAS, the authority for the administration of the Title V MCH Block Grant, including the maternal, child and children with special health care needs resides in Title V of the Social Security Act, SS 501-509; Page I of 18 - WHEREAS, each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three (3) distinct population groups with the MCH funds; WHEREAS, the three (3) distinct population groups are: "the perinatal population", which is defined to include women of childbearing age, pregnant women, and mothers; the "child and youth population", which is defined to include infants, children, and adolescents from birth through age twenty (20); and, the "childrm with special health care needs population" (CSHCN), which is defined as those childrm who have, or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally, WHEREAS, the State has formulated a comprehmsive statewide plan to carry out a Maternal and O1ild Health Program, funded by Title V MCH dollars. WHEREAS, as part of the comprehensive plan, iris the express intent of the state to support local public health agencies in contributing to a coordinated, efficient statewide program which focuses on specific MCH performance measures set by the MCH state and Federal agencies; WHEREAS, local public health agencies, working in partnership with other community organizations, facilitate the development and enhancement of community-based systems of care for the maternal, and child population; WHEREAS, the goal of these systems is to ensure that all families have access to direct care services, as well as, enabling and populations-based services that address the issues and health problems delineated in the MCH performance measures; WHEREAS, as of the made date of this Contract, the State has a currently valid Group II purchasing delegation agreement with the division of finance and procurement within the Colorado Department of Personnel and Administration; WHEREAS, section 29-1-203, c.R.S., as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to die fulles4 extent possible to provide any function, service, or facility lawfully authorized to each of the cooperating or contracting entities; WHEREAS, aU state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code; WHEREAS, as to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereofremains available for subsequent encumbering and payment of this Contract in Fund Number 100, Organizational Unit Code 6520,6810 and 6830, Appropriation Code 581, 606,611, and 665, and Object Code 5120, under Contract Encumbranc~ Number PO FLA MCH0500220; WHEREAS, as to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereofremains available for subsequent encumbering and payment in Fund Number 100, Organizational Unit Code 6810, Appropriation Code 609 and Object Code 5120 under Contract encumbrance number PO FLA HCP05000001 for the Traumatic Brain Injury Services; and, WHEREAS, all required approvals, clearances, and coordination have been accomplished from and with all appropriate agencies. Page 2 of 18 NOW THEREFORE, in consideration of their mutnal promises to each, stated below, the parties hereto agree as follows: A. EFFECTIVE DATE AND TERM. The proposed effective date of this Contract is October 1, 2004. However, in accordance with section 24-30-202(1), C.RS., as amended, this Contract is not valid until it has been approved by the State Controller, or an authorized designee thereof The Contractor is not authorized to, and shall not, commence performance under this Contract until this Contract has been approved by the State Controller. The State shall have no financial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Contract. !fthe State Controller approves this Contract on or before its proposed effective date, then the Contractor shall commence performance under this Contract on the proposed effective date. If the State Controller approves this Contract after its proposed effective date, then the Contractor shall only commence performance under this Contract on thatlater date. The initial term of this Contract shall commence on the effective date of this Contract and continue through and including September 30, 2005, unless sooner terminated by the parties pursuant to the terms and conditions of this Contract Unless expressly modified by the Contract, the total term of this Contract, including all automatic renewals, bilateral options to renew, and extensions, may not exceed that period oftime authorized in the original procurement method used to select the Contractor. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. 1. The Contractor, in accordance with the terms and conditions of this Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the "Scope ofW ork", which is incorporated herein by this reference, made a part hereof and attached hereto as "Attachment A". 2. Title V, Section 504 (b) (6). Title V funds may not be used to pay for any item or service (other than an emergency item or service) furnished by an individual or entity convicted of a criminal offense under the Medicare or any State health care program (i.e., Medicaid, Maternal and Child Health, or Social Services Block Grant Programs). 3. The Contractor agrees to provide services to all Program participants and employees in a smoke-free environment in accordance with Public Law 103-227, also known as "the Pro-OliIdren Act ofI994", (Act). Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions offacilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where WIC coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $ 1,000 for each violation andlor the imposition of an administrative compliance order on the responsible entity. By signing this Contract, the Contractor certifies that the Contractor win comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. Page 3 of 18 - 4. The Contractor certifies, to the best of its knowledge and belief, that no federally appropriated funds have been paid or will be paid by or on behalf of the Contractor, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of this Contract, and the extension, continuation, renewal, amendment, or modification of this Contract, or any grant, loan, or other cooperative agreement that utilizes Federal funds. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress, an officer or employee of Congress in connection with this Contract, or any other grant, loan, or other cooperative agreement, then the Contractor shall complete and submit Standard Form - LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. The Contractor shall require that the language of this certification be included in the award documents for sub awards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certifY and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. This certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, US. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 5. The Contractor will not charge for services those individuals of families at or below the official poverty guidelines, updated periodically in the Federal Register by the US. Department of Health and Human Services under the authority of 42 US.C. 9902(2), in accordance with Title V, Section 501 (I) (B) and Section 505 (5) (D). The 100 percent of poverty gross income guideline for farm or non-fann families is currently at $9,310 for a famiIyof I, $12,490 for a family of2; $15,670 for a familyof3; $18,850 for a family of 4; $22,030 for a family of5; $25,210 for a familyof6; $28,390 for a family of7; and $31,570 for a family of 8. For families of more than eight, add $3,180 for each additional member. (The same increment applies to smaller family sizes also.) If any charges are imposed for services to clients who are above the 100% of poverty level, such charges must be on a sliding scale which takes into account the client's family size, income and resources. These charges and the sliding fee scale must be made available to the general public and to all clients and must be based on the agency's usual and customary cost for the service. Clients must understand they will not be denied services for inability to pay any of the sliding fee charges. 6. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Contract. Except for purposes directly connected with the administration oftms Contract, no information about or obtained from, any applicant or recipient shall be disclo~ed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal guardian must provide consent or, as otherwise properly ordered by a court of competent jurisdiction. The Contractor shall have written policies governing the access to, and duplication and dissemination of, all such information. The Contractor shall advise its employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. Page 4 of 18 7. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter, they shall be advised that the Contractor will provide an interpreter if the client so chooses. 8. The services or activities under this Contract may be carried out by the Contractor itself, or through subcontracts with other providers or, through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some, or all, of the services that are to be performed under this Contract. However, a subcontractor is subject to all of the terms and conditions of this Contract. Additionally, the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Contract. If the Contractor desires to subcontract some, or all, of the services that are to be performed under this Contract, the Contractor shall obtain the prior, express, written consent of the State before entering into any subcontract. C. DUTIES AND OBLIGATIONS OFTIJE STATE. I. In consideration of those services satisfactorily and timely performed by the Contractor under this Contract, the State shall cause to be paid by HCP to the Contractor a sum not to exceed THIRTEEN THOUSAND SIX HUNDRED TWENTY-TWO DOLLARS. ($13,622.00) for the initial term of this Contract, the State shall cause to be paid by the State Genetics Implementation Grant to the Contractor a sum not to exceed TWO THOUSAND EIGHT HUNDRED FIFTY- EIGHT DOLLARS. ($2.858.00) for the initial term of this Contract, and the State shall cause to be paid by MCH to the Contractor a sum not to exceed TIJREE TIJOUSAND TWO HUNDRED FORTY-EIGHT DOLLARS. ($3.248.00) for the initial term of this Contract, for a total financial obligation of NINETEEN THOUSAND SEVEN HUNDRED TWENTY -EIGHT DOLLARS. ($19.728.00). Of the total financial obligation referenced above, TWELVE TIJOUSAND TWO HUNDRED THIRTY-SIX DOLLARS. ($12.236.00) are identified as attributable to a funding source of the United States government and, SEVEN THOUSAND FOUR HUNDRED NINETY-TWO DOLLARS, ($7,492.00) are identified as attributable to a funding source of the state of Colorado. Page 5 of 18 Payments under this Contract shall be a combined monthly payment with a portion of each payment from the HCP, State Genetics Implementation Grant and MCH funds and are subject to verification by the State that the Contractor has fully and satisfactorily complied with the tams and conditions of this Contract. Monthly reimbursements under this Contract for the period of October l, 2004 through September 30, 2005 shall be paid to the Contractor by the State based upon one-twelfth (1112) of the total financial obligation referenced above in first paragraph ofe. I., or ONE THOUSAND SIX HUNDRED FORTY-FOUR DOLLARS, ($1,644.00) for each of the twelve (12) months of the initial tam of this Contract. The total cumulative reimbursements may not exceed the total financial obligation of the State for this Contract period. 2. In addition to the budget referenced in paragraph C. 1. above for the initial tam of this Contract, the Contractor shall be reimbursed by HCP for traumatic brain injury services for a sum not to exce~ Eieht Hundred Fiftv Dollars ($850.00) per child upon receipt of an invoice, Payment pursuant to this Contract for the Traumatic Brain Injury Services shall be made as earned, in whole or in part, from available Federal and State funds encumbered in an amount not to exceed ONE HUNDRED ELEVEN THOUSAND THREE HUNDRED FIFfY DOLLARS ($111,350.00) Statewide for Federal Fiscal Year 200S (October 1, 2004 throue.h and includine. September 30, 2005). Of this total financial Obligation, ZERO DOLLARS. (SO.OO) are identified as attributable to a funding source of the federal government and, ONE HUNDRED ELEVEN THOUSAND THREE HUNDRED FIFIY DOLLARS ($111,350.00) are identified as attributable to a funding source of the state of Colorado. The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or taminate this Contract in its entirety. 3. Payments under this Contract shall be made either through the State's Electronic Fund Transfer system or, upon the Contractor's periodic submission of a "Contract Reimbursement Statement". 4. Reirnbursement under this Contract, and any renewal or extension hereof, shall be made to the Contractor on a monthly basis. Accordingly, the Contractor shall be paid one twelfth (1/12) of the State's financial obligation under this Contract each month for the first eleven (11) months. The final or twelfth (12th) payment for the initial tam of this Contract, and any renewal or extension hereof, is contingent upon the State's timely rcx:eipt of a Final Expenditure Report from the Contractor utilizing the "Application Budget and Final Expenditure Report" form incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment B", The Contractor shall submit one Final Expenditure Reports on the "Application Budget and Final Expenditure Report" for the MCH, HCP, and Genetics funds combined, The final payment is also contingent upon the State's timely rcx:eipt of the signed submission of the "Core Public Health Services Expenditure Report" form, incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment C". 5. The State shall reimburse the Contractor for actual indirect costs up to the Prevention Services Division's maximum of twenty-five percent (25%) when the Contractor's indircx:t rate is based on Direct Costs, twenty-seven percent (27%) when the Contractor's indircx:t rate is based on Salary Only, or thirty percent (30%) when the Contractor's indircx:t rate is based on Salary and Fringe where no other dircx:t costs are charged. Page 6 of 18 6. The State HCP Office shall assure the HCP Regional Office provides technical assistance and that the technical assistance is coordinated with the Public Health Nursing Consultant in the Office of Local Liaison at the State. 7. The State is responsible to ensure that the program planning, evaluation, and monitoring requirements as described in this Contract and the Attachments are met by the Contractor. To fulfill these responsibilities, the State has the right to make site visits and schedule any other meetings at the Contractor's location. 8. The state may allocate more or less funds available on this contract using a Funding Letter substantially equivalent to "Attachment D" and bearing the approval of the State Controller or his designee. The funding letter shall not be deemed valid until it shall have been approved by the State Controller or his desigJie~. The Funding Letter shall be used strictly to increase or decrease Federal funds only. lfboth State and Federal funds are being increased and/or decreased at the same time then the contract modification method found in paragraph C. 9. below shall be used. 9. Contract Renewal, Extension, and Modification. The State, with the concurrence of the Contractor, may prospectively renew or extend the term of this Contract, or increase or decrease the amount payable under this Contract through a "Limited Amendment" that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as" Attachment E". To be effective, this Limited Amendment must be signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate thereof The parties understand that this Limited Amendment shall be used only for the following: A. To increase or decrease the level of funding during the current term of the Original Contract due to an increase or decrease in the amount of goods and/or level of services being provided based upon the existing Scope of Work and/or established pricing and/or established Budget/pricing; B. To revise specifications within the current Scope of Work and/or Budget that increase/decrease the level of funding during the current term of the Original Contract; C. To renew or extend the tenn of the contract with appropriate changes in the amount of funding that results in a new total financial obligation of the State based upon: a. the same Scope of Work and pricing, or b. revised specifications to the previously defined Scope of Work. D. To make changes to the specifications to the original Scope of Work, project management/manager identification, notice address or notification personnel, or the period of performance, that result in "no cost" changes to the Budget. Upon proper execution and approval, this Limited Amendment shall become a fonnal amendment to this Contract. 10. Other Contract Modifications. If either the State or the Contractor desires to modifY the terms and conditions of this Contract other than as provided for in paragraph C. 8 and C. 9. above, then the parties shall execute a standard written amendment to this Contract initiated by the State. The standard written amendment must be executed and approved in accordance with all applicable laws and rules by all necessary parties including the State Controller or delegate. Page 7 of 18 D. GENERAL PROVISIONS. 1. Because this Contract involves the expenditure of federal, state, or private funds, this Contract is subject to, and contingent upon, the continued availability of those funds for payment pursuant to the terms and conditions of this Contract. If those funds, or any part thereof, become unavailable as determined by the State, then the State may immediately terminate this Contract. 2. The parties warrant that each possesses actual, legal authority to enter into this Contract. The parties further warrant that each has taken all actions required by its applicable law, procedures, rules, or bylaw to exercise that authority, and to lawfully authorize its undersigned signatory to execute this Contract and bind that party to its terms. The person or persons signing this Contract, or any attachments or amendments hereto, also warrant(s) that such person(s) possess(es) actual, legal au1hority to execute 1his Contract, and any attachments or amendmepts hereto, on behalf of that party. 3. The Contractor is a "public entity" within the meaning of the Colorado Governmental Immunity Act (CGIA), section 24-10-101, f1 seq., C.RS., as amended. Therefore, at all times during the initial term of this Contract, and any renewals or extensions hereof, the Contractor shall maintain such liability insurance, by commercial policy or self-insurance, as is necessary to meet its liabilities under the CGIA Ifrequested by the State, the Contractor shall provide the State with written proof of such insurance coverage. 4. The Contractor certifies that, as of the effective date of this Contract, it has currently in effect all required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary to properly perform the services and/or deliver the products specified in this Contract. The Contractor also warrants that it shall maintain all required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary to properly perform this Contract, without reimbursement by 1he State or other adjustment in the Contract price. Additionally, all employees or subcontractors of the Contractor performing services under this Contract shall hold, and maintain in effect, all required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary to perform their duties and obligations under this Contract. Any revocation, withdrawal or nonrenewal of any required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary for the Contractor, or its employees and subcontractors, to properly perform its duties and obligations under this Contract shall be grounds for termination of this Contract by the State for default without furthcr liability to the State. 5. If1his Contract involves federal funds, or compliance is othttWise federally mandated, then the Contractor shall comply wi1h the requirements of the following: A. Office of Management and Budget Circulars A-21, A-87, A-I02, A-I10, or A-I22, as applicable; B. the "Hatch Act" (5 US.c. 1501-1508) and Public Law 95-454, Section 4728. These federal statutes declare that federal funds cannot be used for partisan political purposes of any kind by any person or organization involved in the administration offederally- assisted programs; C. the "Davis-Bacon Act" (40 US.c. 276A-276A-5). This federal Act requires that all laborers and mechanics employed by contractors or subcontractors to work on construction projects financed by federal assistance must be paid wages not less than those established for the locality of the project by the Secretary of Labor; Page 8 of 18 D. 42 US.e. 6101 g1 seq., 42 US.C. 2000d, 29 US.C. 794. These federal Acts mandate that no person shall, on the grounds of race, color, national origin, age, or disability, be excluded from participation in or be subjected to discrimination in any program or activity funded, in whole or in part, by federal funds; E. the "Americans with Disabilities Act" (Public Law 101-336; 42 U.s.e. 12101, 12102, 12111-12117,12131-12134,12141-12150,12161-12165, 12181-12189, 12201- 12213 and47US.e. 225 and47US.e. 611); F. if the Contractor is acquiring an interest in real property and displacing households or businesses in the performance of this Contract, then the Contractor is in compliance with the "Uniform Relocation Assistance and Real Property Acquisition Policies Act", as amended, (Public Law 91-646, as amended, and Public Law 100-17, 101 Stat. 246 - 256); G. when applicable, the Contractor shall comply With the provisions of the "Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments" (Common Rule); and, H. Section 2101 of the Federal Acquisition Streamlining Act ofl994, Public Law 103-355, which prohibits the use of federal money to lobby the legislative body of a political subdivision of a State. 6. If this Contract involves federal funds, or compliance is otherwise federally mandated, then by signing and submitting this Contract, the Contractor affirmatively avers that: A- the Contractor is in compliance with the requirements of the "Drug-Free Workplace Act" (Public Law 100-690 Title V, Subtitle D, 41 US.e. 701 et seq.); B. the Contractor is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; the Contractor shall to comply with all applicable regulations pursuant to Executive Ordcr 12549, including, Debarment and Suspension and Participants' Responsibilities, 29 e.F.R 98.510 (1990); and, e. the Contractor shall comply with all applicable regulations pursuant to Section 319 of Public Law 101-121, Guidance for New Restrictions on Lobbying, including, Certification and Disclosure, 29 C.F.R 93.110 (1990). 7. To be considered for payment, billings for payments pursuant to this Contract must be received within a reasonable time after the period for which payment is requested; but in no event no later than sixty (60) calendar days after the relevant pcrformance period has passed. Final billings under this Contract must be received by the State within a reasonable time after the expiration or termination of this Contract; but in no event no latcr than sixty (60) calendar days from the effective expiration or termination date of this Contract. 8. Unless otherwise provided for in this Contract, ''Local Match" shall be included on all billing statements, in the column provided thcrefore, as required by the funding source. 9. The Contractor shall not use federal funds to satisfY federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. Page 9 of 18 10. In accordance with Office of Management and Budget (OMB) Circular A-133 (Audits of States, Local Governments, an~ Non-Profit Organizations), if the Contractor receives federal fimds from any source, including State pass through monies, in an aggregate amount in excess of $300,000.00 (June 24, 1997), in a State fiscal year (July 1 through June 30), then the Contractor shall have an annual audit performed by an independent certified public accountant which meets the requirements ofOMB Circular A-B3. If the Contractor is required to submit an annual indirect cost proposal to the State for review and approval, then the Contractor's auditor shall audit the proposal in accordance with the requirements of OMB Circulars A-21 (Cost Principles for Educational Institutions), A-87 (Cost Principles for State, Local and Tnoal Governments), or A- 122 (Cost Principles for Non-Profit Organizations), whichever is applicable. The Contractor shall furnish one (I) copy of the audit report(s) to the State=s Accounting Office within thirty (30) calendar days of issuance; but in no event later than nine (9) months after the end of the Contractor's fiscal year. If(an) instance(s) of noncompliance with federal laws and regulations occurs, then the Contractor shall take all appropriate corrective actiQn(s) within six (6) months of the issuance of (a) report(s). 11. The Contractor shall grant to the State, or its authorized agents, access to the records and financial statements of the Contractor that directly relate to its performance under this Contract. The Contractor shall retain all such records and financial statements for a period of six (6) years after the date of issuance of a final audit report. This requirement is in addition to any other audit requirements contained in other paragraphs of this Contract. 12. Unless otherwise provided for in this Contract, for all contracts with terms longer than three (3) months, the Contractor shall submit a written progress report specifying the progress made for each activity identified in this Contract. These progress reports shall be submitted in accordance with any applicable procedures developed and prescribed by the State. The preparation of progress reports in a timely manner is the responsibility of the Contractor. If the Contractor fails to comply with this provision, then the failure: may result in a delay of payment of funds; or, termination of this Contract. 13. The Contractor shall maintain a complete file of all records, documents, communications, and other materials that directly relate to this Contract. These materials shall be sufficient to properly reflect all direct and indirect costs oflabor, materials, equipment, supplies, and services, and other costs of whatever nature for which a contract payment was made. These records shall be maintained according to generally accepted accounting principles and shall be easily separable from other records of the Contractor. Copies of all such records, documents, communications, and other materials shall be the property of the State and shall be maintained by the Contractor, in a central location as custodian for the State, on behalf of the State, for a period of six (6) years from the date of final payment under this Contract, or for such further period as may be necessary to resolve any pending matters, including, but not limited to, audits performed by the federal government. Page 10 of18 14. The Contractor authorizes the State, or its authorized agents or designees, to perform audits or make inspections of those records that directly relate to its performance lDlder this Contract. Audits and inspections may be made at any reasonable time during the term of this Contract and for a period of three (3) after the termination or expiration date of this Contract. The Contractor shall permit the State, or any other dilly authorized governmental agent or agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Contract. Monitoring may include, but is not limited to: internal evaluation procedures, examination of program data, special analyses, on-site checks, formal audit examinations, or any other reasonable procedures. All monitoring shall be performed by the State in a manner that does not lDldnly interfere with the work of the Contractor. 15. Subject to the Public (Open) Records Act, section 24-72-101, f!1 seq., CRS., as amended, if the Contractor obtains access to any records, files, or other information of the State in connection with, or during the performance of, this Contract, then the Contractor shall keep all such records, files, or other information confidential and shall comply with all laws and regulations concerning the confidentiality of all such records, files, or information to the same extent as such laws and regulations apply to the State. Any breach of confidentiality by the Contractor, or third party agents of the Contractor, shall constitute good cause for the State to cancel this Contract, without liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor, or third party agents of the Contractor, does not constitute a waiver of any subsequent breach by the Contractor, or third party agents of the Contractor. 16. Unless otherwise provided for in this Contract, or in a written amendment executed and approved pursuant to Fiscal Rules of the state of Colorado, all material, information, data, computer software, documentation, studies, and evaluations produced in the performance of this Contract for which the State has made a payment lDlder this Contract are the sole property of the State. 17. If any copyrightable material is produced lDlder this Contract, then the State, and any applicable federal funding entity, shall have a paid in full, irrevocable, royalty free, and non-exclusive license to reproduce, publish, or otherwise use, and authorize others to use, the copyrightable material for any purpose authorized by the Copyright Law of the United States as now or hereinafter enacted. Upon the written request of the State, the Contractor shall provide the State with three (3) copies of all such copyrightable material. 18. If required by the terms and conditions of a federal or state grant, the Contractor shall obtain the prior approval of the State and all necessary third parties prior to publishing any materials produced lDlder this Contract If required by the terms and conditions of a federal or state grant, the Contractor shall also credit the State and all necessary third parties with assisting in the publication of any materials produced lDlder this Contract Page 11 of 18 - 19. If this Contract is in the nature of personal/purchased services, then the State reserves the right to inspect services provided under this Contract at all reasonable times and places dming the term of this Contract "Services", as used in this clause, includes services performed or written work performed in the performance of services. If any of the services do not conform with the terms of this Contract, then the State may require the Contractor to perform the services again in conformity with the terms of this Contract, with no additional compensation to the Contractor for the reperformed services. When defects in the quality or quantity of the services cannot be corrected by reperformance, then the State may: require the Contractor to take all necessary action(s) to ensure that the future performance conforms to the terms of the Contract; and, equitably reduce the payments due to the Contractor under this Contract to reflect the reduced value of the services performed by the Contractor. These remedies in no way limit the other remedies available to the State as set forth in this Contract. 20. If> through any cause attributable to the action(s) or inaction(s) of the Contractor, the Contractor: fails to fulfill, in a timely and proper manner, its duties and obligations under this Contract; or, violates any of the agreements, covenants, provisions, stipulations, or terms of this Contract, then the State shall thereupon have the right to cancel this Contract, in whole or in part, for cause by giving written notice thereofto the Contractor. The written notice shall be given to the Contractor no less than thirty (30) calendar days before the proposed cancellation date and shall afford the Contractor the opportunity to cure the default or state why cancellation is otherwise inappropriate. If this Contract is cancelled for default, then all finished or unfinished data, documents, drawings, evaluations, hardware, maps, models, negatives, photographs, reports, software, studies, surveys, or any other material, medium or information, however constituted, which has been or is to be produced or prepared by the Contractor under this Contract shall, at the option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to, and accepted by, the State. If applicable, the Contractor shall return any unearned advance payment it received under this Contract to the State. Notwithstanding the above, the Contractor is not relieved ofliability to the State for any damages sustained by the State because of the breach of this Contract by the Contractor. The State may withhold any payment due to the Contractor under this Contract to mitigate the damages of the State until such time as the exact amount of those damages is determined. If> after canceling this Contract for default, it is determined for any reason that the Contractor was not in default, or that the action(s) or inaction(s) of the Contractor was excusable, then such cancellation shall be treated as a termination for convenience, and the respective rights and obligations of the parties shall be the same as if this Contract had been terminated for convenience as described below. Page 12 of 18 21. The State may, when the interests Qf the State so require, terminate this CO'ntract, in whole or in part, for the convenience of the State. The State shall give written notice O'fterminatiO'n to' the ContractO'r. The written notice shall specify the part(s) of the Contract terminated. The written notice shall be given to' the Contractor nO' less than thirty (30) calendar days before the effective date of termination. }fthis Contract is terminated for convenience, then all finished or unfinished data, documents, drawings, evaluations, hardware, maps, models, negatives, photographs, reports, software, studies, surveys, or any other material, medium or information, however constituted, which has been or is to' be produced Qr prepared by the Contractor under this Contract shall, at the option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable cQmpensation for any services or supplies delivered to, and accepted by, the State. If applicable, the ContractQr shall return any unearned advance payment it received under this Contract to the State. This paragraph in no way implies that a party has breached this Contract by the exercise of this paragraph. If this CO'ntract is terminated by the State as prQvided for herein, then the Contractor shall be paid an amount equal to the percentage of services actually perfO'rmed for, or goods actually delivered 'to, the State, less any payments already made by the State to' the ContractQr for thQse services Qr gO'ods. However, ifless than sixtypercent(60%) of the services or goods covered by this Contract have been performed or delivered as of the effective date of termination, then the Contractor shall also be reimbursed (in addition to the above payment) fO'r that portion of those actual "out-of-pocket" expenses (not otherwise reimbursed under this Contract) incurred by the Contractor during the term of this Contract that are directly attributable to' the uncompleted portion of the services, or the undelivered portion of the goods, cQvered by this Contract. In no event shall reimbursement under this clause exceed the total financial obligatiQn Qfthe State to the Contractor under this Contract. If this Contract is canceled for default because Qf a material breach of this Contract by the CQntractor, then the above prQvisiO'ns for cancellation for default shall apply. 22. Neither the Contractor nor the State shall be liable to' the other for any delay in, Qr failure O'f perfQrmance of, any CQvenant or promise contained in this 0mtract to' the extent that the delay or failure is caused by a supervening cause. As used in this Contract, "supervening cause" is defined to mean: an act of God, fire, explosion, action of the elements, strike, interruption O'f transpQrtation, ratiQning, CQurt action, illegality, unusually severe weather, war, O'r any other cause which is beyond the control of the affected party and which, by the exercise Qfreasonable diligence, could nQt have been prevented by the affected party. A delay or failure to perform that is caused by a supervening cause shall not constitute a material breach of this Contract or give rise to any liability for damages therefor under this Contract. 23. The enforcement of the terms and conditions of this Contract, and all rights of action related to that enforcement, shall be strictly reserved to the State and the Contractor. Nothing contained in this CO'ntract shall give rise to, or allow, any claim or right of action whatsoever to or by any third person. Nothing contained in this Contract shall be construed as a waiver of any provision of the Colorado Governmental Immunity Act, section 24-10-101 gtseq., C.RS., as amended. Any person or entity, other than the State or the Contractor, who may receive services or benefits under this Contract shall be deemed an incidental beneficiary only. 24. To the extent that this Contract may be executed and performance of the obligations of the parties may be accomplished within the intent of this CQntract, the terms of this Contract are severable. If any term or provision of this Contract is declared invalid by a court of competent jurisdiction, or becomes inoperative for any other reason, then that invalidity or failure shall not affect the validity of any other term Qr provision of this Contract. Page 13 of 18 25. The waiver of a breach of a term or provision of this Contract shall not be construed as a waiver of a breach of any other term or provision of this Contract or, as a waiver of a breach of the same term or provision upon subsequent breach. 26. If this Contract is in the nature of personal/purchased services, thm, except for accounts receivable, the rights, duties, and obligations of the Contractor shall not be assigned, delegated, or otherwise transferred, except with the prior, express, written consent of the State. 27. Unless otherwise provided for in this Contract, this Contract shall inure to the benefit of, and be binding upon, the parties hereto and their respective successors and assigns. 28. Unless otherwise provided for in this Contract, the Contractor shall notitY the State, within five (5) working days after being served with a summons, complaint, or other pleading in any case that involves any services provided under this Contract and "Which has been filed in any federal or state court or administrative agency. The Contractor shall deliver copies of any documents that it was served with to the State within five working (5) days of the date of service. 29. This Contract is subject to such modifications as may be required by changes in applicable federal or state law, or federal or state implementing rules, regulations, or procedures of that federal or state law. Any required modification(s) shall be automatically incorporated into, and be made a part of, this Contract as of the effective date of the change as if that change was fully set forth herein. Except as provided above, no modification of this Contract shall be effective unless that modification is agreed to in writing by both parties in the form of a written amendment to this Contract that has been previously executed and approved in accordance with the Fiscal Rules of the state of Colorado. 30. Unless otherwise provided for in this Contract, all terms and conditions of this Contract, and the attachments or exhibits hereto, that may require continued performance or compliance beyond the termination or expiration date of this Contract shall survive that tcrmi:nation or expiration date and shall be enforceable as provided for herein. 31. Unless otherwise provided for in this Contract, no term or condition of this Contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections, or other provisions of the Colorado Governmental Immunity Act (CGIA), section 24- 10-101, ~ seQ., C.RS., as amended. Liability for claims for injuries to persons or property arising out of the alleged negligence of the State or the Contractor, their departments, institutions, agencies, boards, officials, and employees is controlled and limited by the provisions of section 24-10-101 et seQ., C.RS., as amended. 32. The captions and headings used in this Contract are for identification only, and shall be disregarded in any construction of the terms, provisions, and conditions of this Contract. 33. The exclusive venue for any action related to this Contract shall be in the City and County of Denver, Colorado. Page 14 of 18 34. All attachments or exhibits to this Contract are incorporated herein by this reference and made a part hereof as if fully set forth herein. In the event of any conflict or inconsistency between the terms of this Contract and those of any attachment or exhibit to this Contract, the terms and conditions of this Contract shall control. 35. This Contract is the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall have any force or effect whatsoever, unless embodied herein in writing. No subsequent novation, renewal, addition, deletion, or other amendment haeto shall have any force or effect unless embodied in a written amendment to this Contract executed and approved in accordance with applicable law. E. SPECIAL PROVISIONS. 1. CONTROLLER'S APPROVAL. CRS 24-30-202 (1) This contract shall not be deemed valid until it has been approved by the Controller of the State of Colorado or such assistant as he may designate. 2. FUND AVAILABILITY. CRS 24-30-202 (5.5) Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being appropriated, budgeted, and otherwise made available 3. INDEMNIFICA nON. To the extent authorized by law, the contractor shall indemnifY, save, and hold harmless the State against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees incurred as a resuh of any act or omission by the Contractor, or its employees, agents, subcontractors, or assignees pursuant to the terms of this contract. No term or condition of this contract shall be construed or interpreted as a waiver, express implied, of any of the immunities, rights, benefits, protection, or other provisions for the parties, of the Colorado Governmental Immunity Act, CRS 24-10-101, et seq., or the federal tort claims act, 28 U.S.c. 2671 et seq., as applicable as now or haeafter amended. Page 15 of 18 4. INDEPENDENT CONTRACTOR. 4 CCR 801-2 THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE. NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE OR SHALL BE DEEMED TO BE AN AGENT OR EMPLOYEE OF THE STATE. CONTRACTOR SHALL PAY WHEN DUE ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAXON ANY MONIES PAID BY THE STATE PURSUANT TO THIS CONTRACT. CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE CONTRACTOR OR THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. CONTRACTOR SHALL HAVE NO AUTHORlZA TION, EXPRESS OR IMPLIED, TO BIND THE STATE TO ANY AGREEMENTS, LIABILITY, OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN. CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKERS' COMPENSATION (AND PROVIDE PROOF OF SUCH INSURANCE WHEN REQUESTED BY THE STATE) AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE AMOUNTS REQUIRED BY LAW, AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR, ITS EMPLOYEES AND AGENTS. 5. NON-DISCRIMINATION. The contractor agrees to comply with the letter and the spirit of all applicable state and federal laws respecting discrimination and unfair employment practices. 6. CHOICE OF LAW. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation, execution, and enforcement of this contract. Any provision of this contract, whether or not incorporated herein by reference, which provides for arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws, rules, and regulations shall be considered null and void. Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint, defense, or otherwise. Any provision rendered null and void by the operation of this provision win not invalidate the remainder of this contract to the extent that the contract is capable of execution. At all times during the performance of this contract, the Contractor shall strictly adhere to all applicable federal and State laws, rules, and regulations that have been or may hereafter be established. 7. SOFfW ARE PIRACY PROHIBITION GOVERNOR'S EXECUTIVE ORDER. No State or other public funds payable under this Contract shall be used for the acquisition, operation or maintenance of computer software in violation of United States copyright laws or applicable licensing restrictions. The Contractor hereby certifies that, for the term of this Contract and any extensions, the Contractor has in place appropriate systems and controls to prevent such improper use of public funds. If the State determines that the Contractor is in violation of this paragraph, the State may exercise any remedy available at law or equity or under this Contract, including, without limitation, immediate termination of the Contract and any remedy consistent with United States copyright laws or applicable licensing restrictions. Page 16 of 18 8. EMPLOYEE FINANCIAL INTEREST. CRS 24-18-201 & CRS 24-50-507 The signatories aver that to their knowledge, no employee of the State of Colorado has any personal or beneficial interest whatsoever in the service or property described herein. Page 17 of 18 - IN WITNESS WHEREOF, the parties hereto have executed this Contract on the day first above written. CONTRACTOR: STATE: BOARD OF COUNTY COMMISSIONERS OF STATE OF COLORADO EAGLE COUNIY Bill Owens, Governor (a political subdivision ofthe state of Colorado) for the use and benefit of the Eagle County Nursing Service By: T~if;f- By: Name: For the utive Director Title: Chair DEPARTME T OF PUBLIC HEALTH FEIN: 84-6000762 ANDE NT Date: -7-;2?,-0 L/ Date: (Seal) PROGRAM APPROVAL: By: By: J~4J~ APPROVALS: COLORADO DEPARTMENT OF LAW O~CEOFTHEATTORNEYGENERAL Ken Salazar, Attorney General By: r-lo- Date: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M. Shenefelt By, ~~ I-r-C C1yt~0.p~ Revised: 09/08/03 Date: \ \0 ~ 0-1 Page 18 of 18 - Attachment A CONTRACT Scope of Work Under this Contract, a local public health agency, such as the Contractor shall provide the core public health services on behalf of the prenatal population, the child and adolescent population, and the children with special health care needs as described and defined in "Attachment F', "Core Public Health Services Delivered by MCH Agencies", which is incorporated herein by this reference, made a part hereof, and attached hereto. A. Maternal and Child Health (MCH) The Contractor shaIl provide leadership, in coordination with public and private community partners to: 1. Contribute to the accomplishment of the State's priorities, performance measures, and outcome measures, as identified in <<Attachment G", which is incorporated herein by this reference, made a part hereof, and attached hereto; 2. Work with public and private community partners to plan for the development and maintenance of resources that assure access to direct care and services for vulnerable women, children, and adolescents, such as those who are low-income, uninsured, underinsured, or who live in rural or underserved areas or who are :from ethnic or cultural minority communities and may experience language or cultural barriers to services; 3. Facilitate outreach and enrollment efforts, including having information and applications on site, to increase enrollment of eligible children and adolescents, including those with special health care needs, in Medicaid (Colorado Baby CarelKid's Care Program) or Colorado O1ild Health Plan Plus+ (CCHP); and 4. Refer families participating in any and all programs in its agency such as WlC, EPSDT, Immunization Oinics, Family Planning, HCP, etc. to appropriate enabling and direct care service programs in the community. All pregnant women in need of resources for prenatal medical care shall be provided with information about programs such as Prenatal Plus, WlC, etc., as needed. The Contractor shaIl provide all individuals seeking reproductive health services: with information about pregnancy planning, the consequences of unintended pregnancies, and, referrals to comprehensive family planning services. 5. Include the maternal and child health population in the five year community health assessment written for the State's Office of Local Liaison. 6. Include one or more MCH objectives in the "Annual Community Health Plan", submitted to the State's Office of Local Liaison. Page 1 of5 B. Health Care Program for Children with Special Needs (HCP) 1. Contractor Shall engage in defined core public health activities designed to enhance the health status of children with special health care needs. The "Suggested Children with Special Health Care Need Activities", attached hereto as "Attachment H", which is incorporated herein by this reference and made a part hereof, may be used if appropriate as guidance. These activities may include direct or enabling services, population-based activities and infrastructure building activities as described in" Attachment F", "Core Public Health Services Delivered by MCH Agencies" . 2. The Contractor shall contribute to Western Slope HCP Regional Office's Plan for Cbildren with Special Health Care Needs (CSHCN), which shall be carried out in federal fiscal year 2004 - 2005 (October 1,2004 through September 30,2005). The Western Slope HCP Regional Office Plan is designed to: contribute to the accomplishment of the MCH 6 Core Outcomes and Performance Measures, as identified in "Attachment I", incorporated herein, by this reference, made a part hereof Contributions shall consist of, but are not limited to, completing requests :from the HCP Regional Office to provide county specific data related to resources and needs of the population of CSHCN and participation in trainings or other learning activities sponsored by the State Genetics Implementation Grant in order to support families and local providers in understanding and accessing recommended follow up. 3. The Contractor shall work collaboratively with the state's delegated HCP Regional Office staff for: orientation and training of new staff, as needed; consuhation on HCP policies and procedures; consultation and technical assistance on community systems building efforts and community needs assessment activities, as needed; consultation, monitoring and oversight on documentation in IRIS; and for ensuring adequate and timely communication with the HCP Regional Office multidisciplinary team and by meeting as least once annually all together for a multi-county team meeting. 4. Contractor shall ensure that all IRIS users attend IRIS Training and meet the "Nursing Services Standards for Usage ofIRIS II", and any subsequent amendments thereof, attached hereto as "Attachment J", incorporated herein, by this reference, made a part hereof HCP Regional Offices shall assist in assuring this training. 5. Contractor shall implement the "IRIS n Security Policy and Procedures", and any subsequent amendments thereof, attached hereto as "Attachment K, incorporated herein by this reference, made a part hereof 6. The IRIS System, as provided by HCP, shall be used to document the contractor's core public health services that support meeting the MCH 6 Outcomes for CSHCN. 7. Contractor's "Five-Year Community Health Assessment Report", which is referenced within the County Nursing Service contract Scope of Work, shall include county's population ofCSHCN. The assessment report shall include information regarding the MCH 6 Core Outcomes for CSHCN. Copy of the current Five Year Community Health Assessment Report shall be sent to State's delegated HCP Regional Office Team Leader. In addition, a copy of the county's "Annual Community Health Plan" shall be sent to State's delegated HCP RO Team Leader by January 30, 2005. Page 2 of5 8. The Contractor shall serve families who are determined to fallwder the MCH definition of CSHCN: "Children with special health care needs are those who have or are at riskfor a chronic physical developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." (Developed by the Federal Bureau of Maternal Child Health in 1995.) Recipients served shall be children residing or whose families have residence in Eagle Cowty. 9. If the Contractor has agreed to provide Traumatic Brain Injury services wder this Contract, then the Contractor shall provide care coordination for families who have children with Traumatic Brain Injury (TBI) through the TBI Trust Fwd Pilot Project as part of the HCP multi-county region in accordance with the following process: A. The Care Coordinator shall receive notification from the HCP Multi-Cowty Regional Office (HCP RO) of referrals and provide care coordination for up to one (1) year for each child B. The Care Coordinator shall contact the family to set up an appointment to develop a care coordination plan. e. The Care Coordinator shall develop a care coordination plan, that is reasonable to accomplish within one (1) year, by reviewing the needs described on the TBI Trust Fund application and asking the family to describe their priority wants or needs. D. The Care Coordinator shall complete the HCP Care Coordination Plan Form, sign the plan and obtain a signature from the family. E. The Care Coordinator shall utilize the HCP RO multi-disciplinary team for care coordination assistance. F. Upon obtaining a signed care coordination plan, the Care Coordinator shall send an invoice in the amount ofEie:ht Hundred Fifty Dollars ($850.00) per child to: Rasa Eglite Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver, CO 80246 G. The Care Coordinator shall implement the care coordination plan. H The Care Coordinator shall enter, or request assistance from the HCP RO to enter, demographic information, registration, status, referrals, concerns, and encounters into the IRIS Database to document care coordination plan, activities, and outcomes. I. The Care Coordinator shall have care coordination plans available for Audit purposes. J. The Care Coordinator shall provide the state family satisfaction survey to the families that received care coordination at the end of the one-year period and encourage them to respond. Page 3 of5 K. The Care Coordinator shall use the "HCP Policy and Procedures for Care Coordination Services for O1ildren and Youth with Traumatic Brain Injury", incorporated herein, by this reference, attached hereto as "Attachment L", for documentatiou of services on the IRIS database and maintaining client records. L. The Contractor and Care Coordinator shall comply with any and all local agency HIP AA regulations; take all appropriate steps to maintain client confidentiality; and obtain any necessary written permissions or agreements for data analysis or disclosure of protected health information, in accordance with the Health Insurance Portability and Accountability Act of 1996 (mp AA) regulations, including, but not limited to, authorizations, data use agreements, business associate agreements, as necessary. Failure to comply with any applicable provision of HIP AA shall constitute a breach of this Contract. 10. The Contractor shall retain and use all HCP Specialty Clinic revenues generated by the contractor to support HCP clinic activities such as: clinic supplies, clinic equipment, clinic fiuniture, or parent/professional stipends. 11. The Contractor agrees that any charges for attendance and services at HCP Specialty Clinics sponsored by the Program must conform to the "Sliding Fee Schedule for HCP Clinics, "Attachment M" and any subsequent amendments thereto, attached hereto, incorporated herein by this reference, made a part hereof 12. On or before December I, 2004, the Contractor shall submit to the State for review and approval a "Final Expenditure Report" for federal fiscal year 2003-2004 (October 1,2003, through September 30, 2004) HCP services. A sample format has previously been referenced in the Contract as "Attachment B", on Page 6 of 18, in the first paragraph of C. 4. The agency's Director or Authorized Representative shall sign the final expenditure report prior to submitting to the State. The final payment for the term of October 1,2003, through September 30,2004 is contingent upon the State's timely receipt of the fully completed and signed Final Expenditure Report, which shall be sent to: Aida Diaz Prevention Services Division Colorado Department of Public Health and Environment PSD-BCP-A4 4300 Cherry Creek Drive South Denver, CO 80246 13. On or before December 1,2004, the Contractor shall submit to the State Section n of the "Core Public Health Services Expenditure Report" form showing the Contractor's actual budget allocations for the provision of services to the population of children with special health care needs for the federal fiscal year 2003-2004 (October I, 2003, through September 30, 2004). A sample format has previously been referenced in the Contract as "Attachment C", on Page 6 of 18, in the second paragraph ofC. 4. The agency's Director or Authorized Representative shall sign the report prior to submitting to the State. The final payment for the term of October 1, 2003, through September 30, 2004 is contingent upon the State's timely receipt of the fully completed and signed Core Public Health Services Expenditure Report, which shall be sent to Aida Diaz, at the address provided in B. 12 above. Page 4 of5 C. MCH and HCP: 1. Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Contract. 2. The Contractor shall cooperate with the State to ensure that the program planning,. evaluation, and monitoring requirements as descnoed in this Contract and the Attachments are met. This cooperation includes, but is not limited to participation in mutually agreed upon site visits at the Contractor's location. 3. Contractor shall retain and use all revenues generated by the individual MCH Programs for services in those programs. 4. Contractor is encouraged to attend regional teleconferences, meetings, and/or videoconference meetings, as appropriate, that the state may organize to address priority MCH/HCP needs, promote learning groups, increase skills as MCH/HCP practitioners and/or carry out state and local MCH planning activities. Page 5 of5 Attachment B APPUCAnON BUDGET AND EXPENDITURE REPORT FORM CONTRACTOR: FOR THE PERIOD: PROJECT: CHECK WHICH TYPE OF REPORT IS BEING SUBMITTED: BUDGET_ ANAL EXPENDITURE REPORT_ Annual #of Total SOURCE OF FUNDS Salary months Amount Received Rate Budget FTE Required OTHER* from CDPHE PERSONAL SERVICES: ConlraclualIFee for Service Supervising Personnel Fringe Benefits: Rate.. Total Personal Sefvlces $ $ $ OPERATING EXPENSES(which are not part of ind"treCt): Total Ooentino $ $ $ TRAVEL (In-statelOut-state) Total Travel $ $ $ Conlraclual Total Contractual $ $ $ Total Direct Costs IPersonal SeIvlces Travel+ContractuaD $ $ $ AOMlNISTRATlVEIlNOIRECT COST Total Admlnistratlvellndh'ect Costs $ $ $ TOTAL PROJECT COST $ $ $ .Soun:e of funding for "Otbef" (Match or In-Idnd) Le. Maternal and ChIld Health programs localloountv funOlOO $ State tier l'::Hlb funOlOO $ Medicaid lwl! not be used to match} $ Patient fees $ 00ler Ilist\ $ $ $ TOTAL $ May the NON FEDERAL funds be used as match? YES_ NO Signature of Agency's Director or Authorized Representative Date P>ge 101 t Attachment C MATERNAL AND CHILD HEALTH CORE PUBLIC HEALTII SERVICES EXPENDITURE REPORT CONTRACTOR: ~ DUE DATE: December 1, 2004 (For The Period Of October 1,2003 through September 30,2004) Please provide actual numbers for how the funds were used in the period of October 1,2003 through September 30,2004. MATERNAL AND CHILD REALm FUNDING REPORT FOR THE CORE PUBLIC REALm SERVICES SECflON I AMOUNT AND PERCENTAGE ALLOCATED TO: DOLLARS PERCENTAGE ClllLD REALm I: I I PERINATAL REALm TOTAL CHILD HEAI.:rn PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPUlATION-BASED SERVICES INFRAS1RUCIURE BUllDING SERVICES TOTAL 100% PERINATAL REALm PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPUlATION-BASED SERVICES INFRAS1RUCTURE BUILDING SERVICES TOTAL 100% SECflON n AMOUNT OF FUNDS ALOCATED TO CHll.-DREN wrrn SPEClAL NEEDS 1$ I CHILDREN wrrn SPEClAL NEEDS PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPUlATION-BASED SERVICES INFRAS1RUCTURE BUILDING SERVICES TOTAL 100% NOTE: Administrative costs can be allocated to each of the above categories as appropriate. Signature of Agency's Director or Authorized Representative Date Page 1 ofl Attachment D SAMPLE FUNDING LETTER Exhibit Date: State Fiscal Year: TO: (contractor's name here) . SUBJECT: Funding Letter No. In accordance with Paragraph of contract routing number , between the State of Colorado Department of or Higher Ed Institution (aqency name) (division) and (contractor's) covering the period of (contract start date) through (contract end date), the undersigned commits the following funds to the contract: The amount of funds available and specified in Paragraph is {increased/decreased) by (i amount of channel to a new total funds available of ($_) to satisfy orders under the contract. Paragraph is hereby modified accordingly. This funding letter does not constitute an order for services under this contract. This funding letter is effective upon approval by the State Controller or such assistant as he may Designate. APPROVALS: State of Colorado: Bill Owens, Governor By: Date: For the Executive Director/College President Colorado Department of or Higher Ed institution By: Date: For (Division) ALL CONTRACTS MUST BE APPROVl:D BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date belQw, the State of Colorado may not be obligated. to pay for goods and/or services provided. State Controller Leslie M. Shenefelt By: Date: Dale Issued: February 10,2003 Attachment E DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER **-***** LIMITED AMENDMENT #* This limited Amendment is made this ~ day of*********, 200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South. Denver. Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY. Oefal type of entity), whose address or principal place of business is Street Address. City. State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entaed into a contract dated ******** **. ****, with contract encumbrance number PO *** **********, and contract routing number ** *** *****, whereby the Contractor was to provide to the State the following: (briefly describe what the Contractor was to do under the original contract - indent this paragraph) (Please cboose one of the fol1owing four options and tben delete this beading and tbe otber tbree options not selected:) The State promises to (choose one and delete the other)increast'idecrease the amount offunds to be paid to the Contractor by ****H**** Dollars, ($*.**) during the current term of the Original Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other)increasedJdecreased work unda the Original Contract The State promises to pay the Contractor the sum of H******** Dol1ars, ($*.**) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Contract for the renewal tcrm of**** years/months, ending on ******** **, ****. The State promises to [choose one and delete the other)increast'idecrease the amount offunds to be paid to the Contractor by ********** Dollars, ($*.**) for the renewal term of*H* (choose one and delete the other)years/months, ending on ******H H, ****, in exchange for the promise of the Contractor to perform the Ichoose one and delete the other)increasedJdecreased specifications to the Scope of Work described herein. The State hereby exercises a "no cost" change to the (insert those tbat apply and delete tbose tbat don't]budget, specifications within the Scope of Work, project management/manager identification, notice address or notification personnel, or performance period within the [choose one and delete the otherJcurrent term of the Original Contract or renewal term of the Original Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties haeto agree as follows: 1. Consideration for this Limited Amendment to the Original Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the original contract, contract routing number ** *** *****, [insert the following language here if previous amendment(s), change order(s), renewal(s) have been processed]as amended by [include aD previous amendment(s), change order(s), renewal(s) and their routing numbers], [insert the following word here if previous amendment(s), change order(s), renewal(s) have been processed]collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Contract is and shall be modified, altered, and changed in the following respects only: A [Use this paragraph when changes to the funding level of the Original Contract occur doring the current term of the Original Contract)This Limited Amendment is issued pursuant to paragraph *. *. of the Original Contract identified by con~act routing number ** *** *****. '. This Limited Amendment is for the current term of********* **, ****. through and including ********* ** ,****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is [choose one and delete the other]increasedldecreased by ********** Dollars. ($*.**) for an amended total financial obligation of the Stateof********** DOLLARS. ($*.**). [delete any portion ofthis sentence that is not applicable]The revised specifications to the original Scope of Work and the revised Budget, if any, are incorporated herein by this reference and identified as "Attachment *" and "Attachment *". The first sentence in paragraph *. *. of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A [Use this paragraph when the Original Contract will be renewed for another term]This limited Amendment is issued pursuant to paragraph *. *. of the Original Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of ********* **. ****. through and including ********* **. ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, ($*.**) for an amended total financial obligation of the State of********** DOLLARS, ($*.**). This is an [choose one and delete the other)increaseldecrease of ********** Dollars, ($*.**) of the amount payable from the previous term. (delete any portion of this sentence that is not applicable]The revised specifications to the original Scope ofW ork and revised Budget, if any, for this renewal term are incorporated herein by this reference and identified as "Attachment *" and "Attachment *". The first sentence in paragraph *. *. of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A [Use tbisparagraph when there are "no cost changes" to the Budget, the specifications within the original Scope of Work, allowable contract provisions as noted, or performance period.]This Limited Amendment is issued pursuant to paragraph *. *. of the Original Contract identified by contract routing number ** *** *****. This Limited Amendment [choose those that apply and delete those tbat don't)modifies the Budget in (identify location in contract], modifies the specifications to the Scop.e of Work in (identify location in contract), modifies the project management/manager identification in (identify location in contract], modifies the notice address or notification personnel in [identify location in contract], modifies tbe period of performance in (identify location in contract) of the Original Contract. The revised (choose those that apply and delete those that don't)Budget, specifications to the original Scope of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated herein by this reference and identified as "Attachment *". All other terms and conditions of the Original Contract are reaffirmed. 4. The effective date of this Amendment is date, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Page 2 of 4 5. Except for the Genaal Provisions and Special Provisions of the Original Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the tams and provisions of the Original Contract, the terms and provisions of this Amendment shall in all respects supersede, govern, and control. The Special Provisions shall always control over otha provisions of the Original Contract or any subsequent amendments thaeto. The representations in the Special Provisions to the Original Contract concerning the absence of personal intaest of state of Colorado employees is presently reaffinned. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFfER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 3 of 4 IN WITNESS WHEREOF, the parties hereto have executed this Form Amendment on the day first above written. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR) STATE OF COLORADO Oegal type of entity) Bill Owens, Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT ArrEST: PROGRAM APPROVAL: If the Contractor is a corporation or governmental entity, tben an attestation By: is required. (Seal, if available.) By: City, City and County, County, Special District, or Town Clerk or Equivalent Corporate Secretary or Equivalent ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires tbat tbe State Controller approve all state contracts. Tbis limited amendment is not valid until the State Controller, or sucb assistant as he may delegate, bas signed it. The contractor is not autborized to begin performance until tbe contract is signed and dated below. If performance begins prior to tbe date below, tbe State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER Leslie M. Sbenefelt By: Date: Fonn: LATlO-31-03GN Page 4 of 4 Attachment F CORE PUBLIC HEALTH SERVICES DELIVERED BYMCH AGENCIES DIRECT HEALTH CARE SER VICES: (GAP FILLING) Examples: Basic Heahh Services, and Heahh Services for CSHCN ENABLING SERVICES: Examples: Transportation, Translation, Outreach, Respite Care, Health Education, Family Support Services, Purchase of Health Insurance, Case Management, Coordinatioo with Medicaid, WlC, and Education POPULATION-BASED SERVICES: Examples: Newborn Screening, Lead Screening, Immunization, Sudden Infant Death Syndrome Counseling, Oral Health, Injury Prevention, Nutrition and Outreach/Public Education INFRASTR UCTURE BUILDING SERVICES: Examples: Needs Assessment, Evaluation, PlanniDg, Policy Development, Coordination, Quality Assurance, Standards Development, Monitoring, Training, Applied Research, Systems of Care , and Information Systems MCHBiD~ 10/20197 Page I of2 DEFINITIONS OF THE FOUR TYPES OF SERVICES BY WInCH THE CORE PUBLIC HEALTH SERVICES ARE PROVIDED BY MATERNAL AND ClllLD HEALTH PROGRAMS AS DEFINED BY THE MATERNAL AND CHILD HEALTH BUREAU As of October 1, 2003 1. Direct Health Care Services Direct health care services are defined as basic health services. Such services are generally delivered "one on one" between a health professional and a patient in an office, clinic or emergency room. Basic services include what most consider to be ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x-ray services, dental care, and pharmaceutical products and services. State Title V programs may support services such as prenatal care, child health, school health and fumily planning by directly operating programs or by funding local providers. Direct health care services also include health care serviceS fur children with special needs. 2. Enabling Services Enabling services are defined as services that allow or provide for access to and the derivation of bene fits from the array of basic health care services. Enabling services include transportation, translation, outreach, respite care, health education, fumily support services, purchase of health insurance, case management, and coordination of care. These kinds of services are especially necessary for the low-income population which is disadvantaged, geographically or culturally isolated, and fur those with special and complicated health needs. 3. Population-Based Services Population-based services are defined as services which are intended and available for the entire population, rather than for a selected group of individuals. Disease, prevention, health promotion and statewide outreach come under this heading. Oral health, injmy prevention, nutrition and outreach and public education are topics which also belong in this category. Population-based services are generally available fur women and children regardless of whether they receive care in the public or private sector or whether or not they have health msmance. 4 Infrastructure Building Services Infrastructure building services are defined as those services that are directed at improving and maintaining the health status of a population. Included among those services are development and maintenance of health systems, standards, and guidelines, training, data, and planning. Needs assessment, evaluation, policy development, quality assmance, infurmation systems, and applied research are all contained within the infrastructure umbrella. H:\Contracts\FY 05\MCH.HCP Combined CNS ContractslAltacbm<:nt F . Page 2. Pyramid DdiniOOns.doc Page 2 on Attachment G MATERNAL AND CIllLD HEALTH (MOl) PRIORITIES, PERFORMANCE MEASURES, AND OUTCOME MEASURES As of October 1, 2003 Colorado MCH Priorities L Reduce teen pregnancy and unintended pregnancy in women of all ages 2. Improve perinatal outcomes 3. Reduce child and adolescent morbidity and increase health and safety in child care settings 4. Reduce overweight among children and adolescents, addressing physical activity and nutritional habits 5. Improve efforts to reduce unintentional and intentional injury, addressing motor vehicle crashes, suicide, child abuse and other violence 6. lmprove innnunization rates for all children 7. Increase access to health care (including behavioral health care) 8. Improve state and local infrastructure by increasing capacity to analyze data, carry out evaluations, develop quality standards, and assure availability of services to all children, including children with special health care needs 9. Reduce substance abuse (alcohol, tobacco, and drugs) 10. Improve oral health and access to oral health care National PeTfonnance Measures 1. The percent of infants who are screened for conditions mandated by their State-sponsored newborn screening programs (e.g. phenylketonuria and hemoglobinopathies) and receive appropriate follow-up and referral as defined by their state 2. The percent of children with special health care needs age 0 to 18 years whose funilies partner in decision making at allleveIs and are satisfied with the services they receive ,. . 3. The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing comprehensive care wi1hin a medical home 4. The percent of children with special health care needs age 0 to 18 whose funilies have adequate private and/or public insurance to pay for the services they need 5. The percent of children with special health care needs age 0 to 18 whose fmrilies report the community-based service systems are organized so they can use them easily 6. The percent of youth with special health care needs who received the services necessary to make a transition to all aspects of aduh life Page 1 00 7. The percent of children of 1910 35 month olds who have received full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Hemophilus Influenza, and Hepatitis B 8. The rate of birth (per 1,000) fur teenagers aged 15 through 17 years 9. Percent of third grade children who have received protective sealants on at least one permanent molar tooth 10. The rate of deaths to children aged 14 and younger caused by mo1or vehicle crashes per 100,000 children 11. Percentage of mothers who breast feed their infants at hospital discharge 12. Percentage of newborns who have been screened fur hearing impairment befure hospital discharge 13. Percent of children without health insurance 14. Percent of potentially Medicaid-eligible children who have received a service paid by the Medicaid program 15. The percent ofvery low birth weight infunts among all live births 16. The rate (per 100,000) of suicide deaths among youths 15 through 19 17. Percent ofvery low birth weight infunts delivered at fucilities fur high-risk deliveries and neonates 18. Percent of infunts born to pregnant women receiving prenatal care beginning in the first trimester State Performance Me2sures 1. The proportion of high school students reporting having drunk: alcohol in the past month 2. The proportion of all pregnancies that are unintended 3. The incidence of maltreatment of children younger than 18 (including physical abuse, sexual abuse, emotional abuse, and/or neglect) 4. The proportion of high school students reporting regular use of tobacco products 5. The proportion of children and adolescents attending public schools who have access to research-based health education and to basic preventive and primary, physical and behavioral health services through school-based health centers 6. The percent of Medicaid-eligible children who receive dental services as part of their comprehensive services 7. The rate of homicides among teens 15-19 8. The proportion ofWIC children who are overweight 9. The percent of women with inadequate weight gain during pregnancy 10. The rate of injury hospitalization among children 19 and younger Page 2 00 Nationally Chosen Outcome Measures 1. The infmt mortality rate per 1,000 live births 2. The ratio of the black infmt mortality rate to the white infmt mortality rate 3. The neonatal mortality rate per 1,000 live births 4. The postneonatal mortality rate per 1,000 live births 5. The perinatal mortality rate per 1,000 live births State Chosen Outcome Measure 1. The low birth weight rate per 1,000 live births Revised My 15, 2003 H:\ContnoctsIFY 05\MCH.HCP Combined CNS Conlncts\Altacbm<nt G . MCH Priorilies and PCIfunnance Mcasure3 lB-04.00e Page 3 on Attachment H HEALTH CARE PROGRAM FOR CIllLDREN WITH SPECIAL NEEDS (HCP) SUGGESTED CIllLDREN WITH SPECIAL HEALTH CARE NEED ACTIVITIES TO FULFILL REQUIREMENTS FOR MCH LOCAL HEALTH CONTRACTS AND COUNTY PRELIMINARY AND STRATEGIC PLANS As of October 1,2003 The fullowing suggested strategies are offered as guidance to local public health agencies in de1ining how current or new services fit within the core public health functions. The Maternal and Child Health contract between local agencies and Colorado Department of Public Health and Environment (CDPHE) requires needs assessment oflocal comnnmities. Local public health staff is currently doing many of the fullowing activities. The CDPHE Health Care Program fur Children with Special Needs (HCP) and Public Health Nursing consultant staffwill provide technical assistance, as needed in assisting local public health agencies to define which of these - or other activities - are most appropriate fur addressing the needs of children with chronic illnesses and disabilitieS. 1. Direct Services 1.1 Seek out funding resources and work with specialty providers to establish alternative funding somces for fumilies. 1.2 Work with health providers so that they appropriately refer funilies to state and local resomces that can fund or diScOlmt specialty medical care services. 1.3 Offer access to SELECT specialty care through HCP Specialty Clinic program. However no direct payment for services is available through HCP. 2. Enabling Services 2.1. Conduct an initial interview with a defined population (NICU, SSI, etc.) ofnew fumilies to help them determine their need fur infurmation, referral and/or care coordination using a standard tool such as the "Family Status Profile" furm 2.2. Assist fumilies who have insurance coverage, including private insurance, CHP+ and Medicaid and those in managed care plans, to understand their benefits and their disenrollment and grievance procedures. 2.3. Refer fumilies to agencies and services for which they are eligible and assist them with the registration or application process, e.g., WIC, CHP+, Baby CarelKids Care, Medicaid, SSI, Part C, Voc Rehab, Mental Health, etc. Follow-up with the funiIy to assure the funiIy was able to make the suggested contacts. 2.4. Determine the status of primary care and innmmizations and make appropriate referrals. Work in collaboration with the EPSDT outreach worker if the child is on Medicaid to assure that EPSDT benefits have been explained and an EPSDT screen has been completed and billed. 2.5. Initiate or participate in the development of a Care Plan, IFSP (Individual Family Service Plan), or IEP (Individual Educational Plan) with the funiIy and medical home when it has been determined that a funiIy would benefit from care coordination. This includes a statement of the funiIy's strengths and needs as identified by the funiIyand strategies for enhancing the child's Page 1 0[5 development. Include a statement of major outcomes to be achieved by the child and funily. State the criteria, procedures and time lines. Docmnent periodic statements of progress towards meeting funily goals and the need fur modifications or revisions. The process fur the development of a care plan, IFSP, or IEP should include all the disciplines involved with the child's care, i.e., medical home, audiologist, CHIP therapist, social worker, funilyadvocate, OTIPT, dietitian, speech therapist, etc. 2.6. Follow-up with funily according to plans written on care plan, lFSP, or IEP. Should HCP staffhave no direct role in the lFSP or IEP, or are not doing care coordination, assure that a contact with each fumily is made at least once a year to assure that the child and funily are receiving necessary services and that the funily is aware of commmrity resomces available to them. 2.7. Make home visits when appropriate. (Situations might include complex medical or surgical conditions or when resomces or help can be provided relating to the home environment) 2.8. Work in concert with the EPSDT outreach worker to review monthly listing ofSSI recipients and Contact SSI fumilies to assure that health care needs are being met If there are needs which HCP can meet, assure that children are enrolled in the program. 2.9. Meet periodically with staff from local agencies such as social services, representatives from th e Commmrity Centered Board, mental health and special education services from local schools to collaborate around services to individual children and their fumilies. 2.10. Work with the older children and their fumilies to fucilitate transition from pediatric services to adult health care services. (To begin at about age 12 years.) 2.1L Work with NICU. Consortium contacts in hospitals to identifY needs of newborns as the child prepares to leave the hospital to return to the community. Make contact with other community resomces as needed. 2.12. Design and maintain a clinic structure including identitying and scheduling clinic providers, fucilities, and equipment. Set clinic dates. Seek referrals by contacting local doctors, Child Find, interagency councils, and Community Center Boards to infurm them of the clinics. Distribute the local HCP clinic schedule to appropriate agencies and individuals. 2.13. Organize, schedule and staff each clinic using guidelines provided in the HCP Procedure Manual. Obtains a HCP application on each child scheduled for clinic and a consent for service signed by the parent or legal.guardian. Provide the clinician with Medicaid and private insurance billing infurmation and collect clinic support fees. 2.14. Complete a Clinic Encounter Form fur each clinic patient After each clinic submit Encounter Forms, a copy of the attendance list (schedule) and the dictation.to the assigned Regional Office. 2..15. Assure that fumilies have transportation to each clinic and that appropriate and competent interpretation services are available. 2.16. Depending on the complexity of the child's condition and the needs of the funily, appropriate team members shall attend, when available, and participate in the HCP Specialty clinics. 2.17. Evaluate the clinic caseload, waiting list and sunnnaries yearly to determine the nmnber and type of specialty clinics needed. Report findings to the Regional Office Team Leader and State Nursing Consultant Page 2 of5 2.18. Identify existing primary health care and specialty providers and support resomces including translation, transportation and respite care. 3. Population-based Services 3.1. Promote public health services available to children, ie., HCP, WlC, EPSDT, and Immunization, by using local media, posters and attendance at health fUrs, etc. 3.2. Develop and maintain liaisons with the local community resomces to maintain open communication, to promote the services ofHCP and other services available to children with special needs, and to establish a netwoIk fur working together to eliminate gaps or duplication of services and supports. 3.3. Assme that HCP staff is knowledgeable in Early Childhood Connections (part C of IDEA), IFSPs, Service Coordination, Procedural Safeguards and eligibility criteria. 3.4. Assure that HCP staffis knowledgeable in the eligibility criteria and referral procedmes fur Medicaid, SSI, Children's Medical Waiver 200, Children's Home Care Based Services Waiver (Katie Beckett - Model 200 Waiver), and EPSDT. Assme that EPSDT case managers are knowledgeable about HCP services. 3.5. Assure that training opportunities are provided to staff on cultural competency and funily-centered care. 3.6. Establish or maintain interagency collaboration through periodic meetings with representatives of the local human services agencies, the Comnnmity Center Board, the mental heal1h agency and special education services from the school district to understand their services, to learn about their eligibility criteria, and to provide them with infurmation about HCP and other resources within the local commmrity. 3.7. Participate in the community's early child identification process as an active member of the community team. This participation could include assigning staff time to directly participate in a community sponsored identification process or coordinating the agency's services such as EPSDT, HCP and WlC, with other effurts so as to provide on-going systems of early identification for children 0-21 years. 4. Infrastructure-building .Services 4.1. Know the numbers of children in the counties served by the agency and be able to estimate the nmnber of children with special health care needs. Know the target population of children who could potentially benefit from HCP services and the actual number of children currently registered with HCP. Analyze large discrepancies between target and actna1 caseloads. 4.2. Know and analyze the numbers of children enrolled on HCP fur care coordination only. Page 3 of5 4.3. Coordinate and/or participate in conducting a co:mnmnity needs assessment with public and private agencies, organizations, providers and parents which identifies problems or voids within the service delivery system fur children with special health care needs, defines the problems and determines the services or changes necessary to meet the identified needs. Elements involved in this process include: 4.3.1. Involvement in tracking and data collection effurts of the co:mnmnity concerning the number of children with special health needs, the types of services needed, the types of services available, the accessibility of services, the quality of the services, whether the services are cu1tu:rally competent and fnnily centered, and a method to receive customer feedback about the services. 4.3.2. Awareness of and collaboration with other community agencies and projects regarding data that is being collected and use of the data to most effectively enhance the community service system for children with special needs. 4.3.3. Establishment of mechani<m1s to include strong fnnily participation in the development of all assessments. 4.3.4. Coordination with other agencies and organizations to jointly smvey the community including funiIies, providers and hmnan service agencies and development of a process to provide feedback to those who participated in the answering of the smveys. 4.4. Provide assessment reports to the community. 4.5. Coordinate and/or participate in the community planning process to develop policies goals and objectives based on the community needs assessment. 4.6. Develop local networks and partnerships with other community resomce agencies to determine policies to support the development of comprehensive, community-based systems of care including identification, assessment, intervention and referral services for children with special health care needs. 4.7. Develop referral and follow-up care systems using available resomces such as Colorado Responds To Children With Special Needs (CRCSN), NICU ConsortiUIll, Universal Newborn Hearing Screening Programs, and hospital discharge planners, to identifY children who may need support, care coordination and/or referral to community resomces. 4.8. Establish a mechanism for including input from parents regarding cmrent services, planning, policy development, implementation and evaluation ofHCP paid service benefits as well as comnmnity/health services for all children with special health care needs. The process should include a means to provide feedback to funiIies about decisions made in these areas. 4.9. Develop and maintain a system of parent support that includes: 4.9.1. Parent to parent support and/or support groups; 4.9.2. Internal practices that support advocacy for fnnily needs and problem solving; 4.9.3. Information and education; 4.9.4. Linkages with community agencies to assure the availability and adequacy of resources to support the needs of funiIies. Page 4 of5 4.10. Assure that there is community parent representation from fmriIies who have children with special needs in the community service system effurts. (For example, attending meetings, contacting representatives, providing input into quality and quantity oflocal services.) 4.11. Participate actively in a community interagency council (lCC) by meeting regularly for the pmpose of planning and policy development. (These can be a formal or informal group of agencies, providers and parents who are interested in working together to discuss services fur children with special needs, to identify barriers and gaps in the service delivery system. to develop collaborative plans fur removing the barriers and gaps including writing commnnity-based grants fur improvement oflocal systems. Revised June 17,2003 H:\ConIracts\FY O5\MCH-HCP Combine<! CNS ConIncta\Altacbmmt H - Suggested CSHCN AcIivili<$.doc Page 5 of5 Attachment I MATERNAL AND ClIILD HEALTH (MCH) CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) 6 CORE OUTCOMES AND PERFORMANCE MEASURES As ofOctobec 1,2003 Outcome #1: Families of children with special health care needs (CSHCN) win partner in decision making at an levels, and will be satisfied with the services they receive. 1. Peccent of families of CSHCN reporting satisfaction with the quality of regular source of primary care, getting refecrals and appointments for needed services, coordination between primary and specialty care ovecall scrvices. 2. Peccent of parents ofCSHCN who report satisfaction with their level ofinvolvementlinput in setting concerns and priorities to make decisions about their child's care plan. 3. Peccent of parents of CSHCN who report knowing the steps to take when they are not satisfied with the secvices their child/family receives. 4. Number of parents of CSHCN who are supported financially for their involvement in state and local activities. 5. Numbec of parents of CSHCN who report that they are effective partners in policymaking at the state and local levels. Outcome #2: All children with special health care needs win receive coordinated ongoing comprehensive care within a medical home. 1. Peccent of CSHCN with a regular source of primary medical care through a primary care providec. 2. Percent ofCSHCN whose regular source of care communicates in a way that is clear and undecstandable to the family. 3. Percent of parents whose regular source of primary medical care identifies, discusses, and addresses the comprehensive needs of their child and family. 4. Percent of CSHCN whose regular source of primary medical care ensures age-appropriate well-child checks, including: vision, hearing, developmental, behavioraJ/mental health, oral health, newborn screening, immunizations. 5. Percent of parents of CSHCN who receive referrals and assistance from their regular source of primary medical care in accessing needed/desired services. Outcome #3: All families of children with special health care needs will have adequate private and/or public insurance to pay for the services they need. L Percent of CSHCN with insurance that covers costs of needed services, including: mental health, dental care, age-appropriate well-child checks, durable medical equipment, ancillary services, non-durable medical supplies, care coordination, prescriptions, specialty care, related therapies (e.g., PT, OT, speechllanguage, audiology), in-home nursing. Page I of3 2. Amount of out-of-pocket costs paid by families ofCSHCN, including costs of mental health, dental care, age-appropriate well-child checks, durable medical equipment, ancillary scrvices, non-durable medical supplies, respite care, transportation, care coordination, prescriptions, specialty care, related therapies (e.g., PT, OT, speecManguage, audiology), in-home nursing, home modifications, carlvan modifications. 3. Percent of CSHCN who can choose the providers of their choice. 4. Percent of CSHCN whose insurance provides: timely approval for needed care, ovecall parental satisfaction, clear information, about coverage resources, and complaint procedures to providers and parents. Outcome #4: All children win be screened early and continuously for special health care needs. 1. Percent of infants whose mothers began prenatal screening in the first trimester of pregnancy, for smoking, alcohol, ~gs, tests for birth defects, HW, physical abuse. 2. Percent of infants and families being tracked for special health care needs and developmental delays. 3. Percent of children receiving age-appropriate well-child checks including: vision, hearing, developmental, behavioral, mental health, oral health, metabolic, and EPSDT (if implemented in state). 4. Percent of children receiving needed follow-up due to failed screening or risk factors: vision, hearing, developmental, behavioral, mental health, oral health, and metabolic. Outcome #5: Services for children with special health care needs and their families will be organized in ways that families can use them easily. 1. Percent of parents ofCSHCN who have a single coordinated service plan that involves all providers and a lead service coordinator who communicates with the family. 2. Percent of parents of CSHCN who report that they are able to access comprehensive services for their child and family. 3. Percent of parents of CSHCN who have specialty care available in their region of the state. 4. The degree to which the state service system has an enrollmentleligibility process that links families of CSHCN (and their medical home) with a wide variety of public and private services and resources. 5. Number of privatelpublic partnerships to provide commooity-based, comprehensive medical services fOT CSHCN, e.g., data sharing, contracts, MOAs. Outcome #6: All youth with special health care needs (SHCN) wiD receive the services necessary to make appropriate transitions to adult health care, work and independence. L Percent of youth with SHCN who by age 14 have a transition plan that addresses employment, transportation, housing, independent living, physical and mental health and necessary accommodations; and percent of youth with SHCN by age 16 have a transition plan that includes appropriate agencies as part of the transition planning team. 2. Percent of youth with SHCN whose regular source of primary medical care facilitates the transition from pediatric to adult providers. Page 2 of3 3. Percent of adult health care providers who are prepared to serve youth with SHCN. 4. Percent of youth who report satisfaction with the information and training they received to make informed decisions about their health care and other services. 5. Percent of youth with SHCN who receive necessary scrviceslsupports by age 21: Health insurance, Post- secondary education, Employment, Transportation, Housing, Personal care attendant, SSI, SSA-related work incentives, e.g. PASS, 1619 a & b. H:\Con1Ia<1s\FY O5IMCH.HCP CombiDed CNS Conln<:1ll\Attachmt:ut I. MCH CSHCN 6 CoR oc. 8; PMs.OOc Page 3 on - Attachment J Health Care Program for Children with Special Needs (HCP) HCP Large Nursing Services Standards for Usage of IRIS n L Data Entry L Agency will use the HCP Regional Office for consultation and technical assistance for all IRIS data entry, IRIS training, and IRIS users security approval. 2. HCP Policies and Procedures will be followed as described in the HCP Policy and Procedure Manual, IRIS Help File, HCP County Contract and IRIS Training Materials. U. Documentation of Activities 1. Community Encounters yvill be entered to provide documentation of systems building and population based activities. (Community meetings, outreach, screening, training activities) 2. Person Referrals will be entered to document all referrals. Referral outcome will be entered for each refecral. 3. Person Encountecs will be entered to document person contact and person concerns. Care coordination will be entered when care coordination is being provided for specific concerns. 4. HCP Clinic data will be entered before clinic date on IRIS Clinic Schedule. Outcome will be entered after the clinic date for all HCP clinics. (Only for counties providing HCP Clinics). lll. Data entry for HCP Caseload on IRIS t. CSHCN County Caseload on IRIS includes all CSHCN with whom agency staff have had person encounters and/or provided referrals within previous twelve months of the reporting period. 2. Each person receiving any level of care coordination scrvices will have a Person Encounter entered showing a concern score. The concern score is determined by number of concerns with care coordination being provided by HCP staff Concern outcome will be updated as needed or at least yearly. 3. Person Refecrals will be entered for all children receiving resource and refecral services. 4. A clinic visit is enteced on clinic visit screen each time a person attends a HCP clinic. lll. IRIS Security 1. The IRIS IT Security Policy and Procedures will be followed. All new IRIS usecs and current staff and supervisors will sign the IRIS Security form and Secure Web User 10 Form and submit to the state office as requested. IRIS passwords will be changed every sixty days along with the ClTRlX password Both passwords win be kept confidential and will not be shared. IV. IRIS Training 1. New HCP employees will complete the HCP Training CDs including security, multi-disciplinary training and program orientation. New IRIS users will complete IRIS training at the State HCP Office. The Regional HCP Office win provide IRIS training using the IRIS Train the Trainer materials when new users are not able to attend state training. New IRIS users will not be given IRIS access until both IRIS training and HCP Training CD have been completed. Revised June 7, 2004 H:\Crntrncts\FY 05\MCH.HCP C<mbined CNS Contracts\Altachment J . Large NS County IRIS Standards 05.doc Attachment K Health Care Program for Children with Special Needs (HCP) IRIS n Security Policy, Procedures and Guidelines Security policy and procedures protect personal health information and IRIS data. The following IRIS security procedures are required for County Nursing Services, Health Departments and HCP Regional Offices: I. IRIS Users (HCP Staff) a. IRIS users including current users, supervisors and new users will sign a Security and Secure Web User ID Form before a pecsonal ID and password are assigned for access to ClTRIX and the IRIS database. Users will sign a new security form as requested by State HCP Office. b. IRIS users will have a personal ID and password assigned by the State HCP Office aftec completing IRIS training. c. IRIS users will not allow new agency staff, another agency staff pecson, staff from another program or any person to have access or use their ClTRIX/IRIS ID and password. d. New IRIS users will complete IRIS and security training as defined in the IRIS Standards. 2. An agency supervisor will sign the security form for each HCP/IRlS user indicating the access level the staff person needs. Forms will be sent to the State HCP office to request a new ID and password for new staff or when duties change for current staff A new 10 and password will be issued based on the request of the supervisor and the discretion of the State HCP Office. Agency supecvisors will not allow or request access for any staff that does not have the need to access HCP pecson specific data on IRIS. 3. Local Health Department, HCP Regional Office and Nursing Service agencies will have agency policies and procedures for IRIS security and confidentiality. All staffwill be trained on the importance of security and confidentiality. 4. Agency supervisors will contact the State HCP office and request that an ID and password be expired when an IRIS user leaves the HCP Program or no longec needs IRIS access. IRIS Usecs will be deactivated if they have not signed onto IRIS within six months. Agency supervisors will notifY the State HCP office to request a specific person's ID/password be disabled when a security breach is suspected. A new ID and/or password will be issued based on the request of the supervisor and the discretion of the State HCP Office. 5. Agency supcrvisors will supervise and monitor access to the IRIS Database. Agency supervisors will not allow sharing ofIDs or passwords. 6. Agency supervisors will monitor/implement HCP policies and procedures for release ofinformation and consent for clinic services including HIP AA disclosures as defined with local agency HIP AA policy. (The Health Insurance Portability and Accountability Act of 1996 (HIP AA) 164.528 regarding accounting for disclosures. ) 7. Security for IRIS access to Newborn Evaluation, Screening, and Tracking (NEST) data will be predefined with business rules and HCP Policies and Procedures. The agency will identify staff members that have a "need to know" for public health information from the NEST database. Page I of2 8. The IRIS Security Policy and agency HIP AA procedures will be followed when providing care coordination for refecrals and requests for follow-up from NEST data. 9. When an IRIS user forgets a personal password, they will call the IRIS Help Line or the State HCP office for assistance. The IRIS Help Line staffwill re-set the personal password to a default password. The IRIS user wiD immediately change the default password to a secure personal password as defined in training material. 10. Agency supervisors will require IRIS users to change their IRIS password every 60 days when the CITRIX password is changed. Passwords will be changed more frequently if it is suspected that the p~ord has been compromised. Revised May 28, 2004 H:\Cootn>cts\FY 05\MCH-HCP Ccmbined CNS Ccntn>cl8\Altaduncnt K - IRIS n Security Policy 05 - CNS.doc Page 2 of2 Attachment L Health Care Program for Children with Special Needs (HCP) Policy and Procedures Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1,2004 - September 30, 2005 Page 1 ofl2 - Health Care Program for Children with Special Needs (HCP) Policy and Procedures Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1, 2004 - September 30, 2005 I. OverviewofCare Coordination Services For Children and Youth With Traumatic Brain Iniury (TBO Traumatic Brain Injury Care Coordination is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services . . required to meet individuals' needs, using connnunication and available resources to promote quality, cost effective outcomes. TBI Care Coordination operates with an underlying premise that when individuals reach their optimal level 0 f wellness and functional capability, everyone benefits: the individual and family being served, their connnunity support systems, the healthcare delivery system, and . . msurance earners. The primary functions ofTBI Care Coordination are: i) To maximize individual and family understanding and participation through education and support. ii) To advocate for individual wellness and autonomy through advocacy, connnurucation and identification of service resources. iii) To optimize access to appropriate connnunity services. iv) To integrate and coordinate service delivery by multiple sources and to prevent fragmentation of services. HCP Care Coordination Services for Traumatic Brain Injury follow HCP Policies and Procedures and are applied consistently by Care Coordinators in all HCP Regions of the state. The term "individual/family" refers to whoever has legal responsibility for the person receiving program services. This may be the parent of a minor, an emancipated youth, a guardian, a county department of social services, or another party having legal responsibility for the program participant. Page 2 of 12 II. Trainin1!: HCP Staff Regional/County HCP staff/care coordinators attend training before providing care coordination services and receiving funding for TBI Care Coordination. The State HCP office will keep records ofHCP staffwho have completed training for TBI Care Coordination. HCP staff must participate at required HCP TBI Care Coordination training or if unable to attend must complete the following steps before providing TBI Care Coordination: i) Read provided Power Point Presentation and Handouts ii) View HCP Training Video iii) Read the Brainstars Manual iv) Submit a completed Care Coordination Sample Plan to the Regional Office Team Leader and/or State Nursing Consultant. For review and approval v) Discuss Questions/Concerns with the HCP Regional Office Team Leader and/or State Nursing Consultant ill. Elieibility and Referral Process 1. Eligibility - The Brain Injury Association of Colorado (BIAC) will perform client intake and determine eligibility for the Colorado Traumatic Brain Injury Program Once the family is determined to be eligible the family is approved for a 12-month period of care coordination funded by the Colorado Traumatic Brain Injury Trust Fund. Eligible dates for a 12 month period beginning on the date the care coordination plan is signed. BIAC will refer eligible families/individuals under age 21 to the state HCP Office (CDPHE) for care coordination services. Families/individuals seeking program services will contact BIAC directly to begin the application process through one of the following options: A) Tbe family/individual contacts the Brain Injury Association of Colorado directly. B) Families/individuals contacts the state HCP office or the HCP Regional or County Nursing Agency. Tbe HCP office informs the family/individual that the Brain Injury Association of Colorado will complete the application process and determine eligibility for program services. The HCP office provides contact information for BIAC to the family and family contacts BIAC. C) Family/individual contacts the state HCP office or the HCP Regional Office or County Nursing Agency. HCP contacts the Brain Injury Association of Colorado on behalf of the family/individual, and provides the family/individual's contact information so that the Brain Injury Association may contact the family/individual to begin the application process. HCP will notify BIAC within two (2) business days of its initial contact with the family/individual seeking services. Page 3 of 12 2. Referral Process A) BIAC refers eligible families/individuals under age 21 to State RCP office (CDPHE) for care coordination services. B) State HCP office forwards referrals to the appropriate Regional HCP Office. C) The Regional HCP Office forwards all referrals to the appropriate HCP County Nursing Agency. 3. Wait List - Program services are subject to available funding. If the demand and need for care coordination services exceeds the available funding, state HCP office will maintain a wait list of eligible persons. A) Wait list is maintained in order of the date of referral, and individuals shall receive program services on a first-come, first-served basis. B) Persons are also put on the waitlist when the demand is too great for an HCP regional or county nursing office's capacity. The HCP regional or county nursing office and the state HCP office referral manager determine HCP office capacity. C) The HCP office referral manager reviews active caseload and the number of new referrals received each month to determine if additional new referrals can be referred to Regional Offices. 4. Referral Packet The referral packet includes the signed application from the Brain Injury Association of Colorado, documentation of diagnosis and any supporting eligibility information, signed informed consents, and signed subrogation fonn. A) BIAC sends referral packet for eligible persons to State HCP office referral manager B) Referral manager assures completeness of referral packet contents, including signatures. C) Referral manager forwards referral packet to the RCP regional or county office. D) Referral manager documents the referral in the state HCP TBI database. IV. Implementing Care Coordination Services 1. Assignment of Care Coordinators HCP solicits and considers the family/individual's preferences when assigning a Care Coordinator within the capacity of the RCP staff Factors such as gender, age, culture, language, location, and hours of availability may be considered as part of this process. A) The RCP Regional and/or County Office assigns a Care Coordinator to the family/individual. B) Care Coordination assignments are documented in IRIS. Page 4 of 12 2. Developing the Care Coordination Plan A) The HCP Care Coordinator and family/individual develop the care coordination plan together. The plan reflects the family/individual's own identification of service needs. The care coordination plan is not a clinical treatment plan and does not reflect clinical treatment goals or objectives. In selecting specific service providers, the Care Coordinator should assist the family/individual to choose from among available providers, taking into consideration any preferences the family/individual may have concerning the service providers. Factors such as gender, age, culture, language, location, pediatric specialty, experience with children with special needs and hours of availability may be considered as part of this process. The care coordination plan identifies financial assistance programs the family/individual is receiving, or may be eligible to apply for within the corrnnunity or at the State or federal level. B) Document plan on "Health Care Program for Children with Special Needs (HCP) Care Coordination Child/Family Plan of Care" form provided by state HCP. Refer to figure #1. C) Each outcome/goal must have a documented expected date outcome/goal is to be achieved. D) Each outcome/goal must state specific actions/interventions in a logical sequence. E) For every action/intervention there must be documented an assigned responsible person. F) Evaluation of outcome goal status will be documented during and at the end of the 12 month period of care coordination services. 3. Signing the Care Coordination Plan The family/individual who receives program services must agree to the terms of the care coordination plan. A) Family/individual signs original agreed upon care coordination plan form. B) HCP Care Coordinator signs and initials original care coordination form and gives copy of form to family/individual. C) Any additionally assigned HCP Care Coordinator that is involved in modifications or evaluation of the plan's status must initial and sign the original form. Page 5 of 12 - 4. Approval of Care Coordination Plans The Regional HCP Office and/or State HCP Office reviews and provides consultation for new care coordination plans. A) Shortly after State HCP sends the referral packet to the HCP regional or county office, assigned State staffwill contact that local office to provide consultation. B) HCP Regional and county offices keep a hard copy of completed and signed care coordination plans on file. C) State HCP office completes a follow up review of a monthly random sample of25% of new care coordination plans. D) For ongoing consultation, as needed, local offices can contact State and/or Regional office personnel. 5. Duration of Care Coordination Services CDPHE shall provide the care coordination services included in the care coordination plan for a period of twelve (12) months from the date of signature on the completed care coordination plan. IfDPHE and/or the family/individual determine that care coordination services are no longer necessary before the end of the twelve-month perio~ DPHE shall place the client on "inactive" status. If the family/individual requests and needs additional care coordination services after being placed on inactive status and before the end of the twelve-month period, DPHE shall place the client on "active" status and resume services to the family/individual. At the conclusion of the twelve-month period, DPHE shall close the individual's case. A family/individual may submit a new application for care coordination services to the Brain Injury Association of Colorado at any time. V. Client Records Upon completion and signing of a care coordination plan, the HCP regional or county office opens and maintains a client record for the individual receiving services. The client record includes the following: A) Application for benefits, documentation of eligibility, and signed client agreements and consent for release of medical records. (The Brain Injury Association of Colorado provides these documents, and they are included in the referral packet sent from the state HCP office.) B) The signed Care Coordination plan. C) Progress notes for each contact with the family/individual receiving services. Progress notes can be either hard copy written notes or can be documented in the IRIS database as client encounter notes. If the chart is needed for audit purposes, the IRIS encounters are printed and included in the chart. D) Completed satisfaction surveys from the client, the client's family, or other stakeholders. Page 6 of 12 E) Record of any client appeals and grievances, and responses to these appeals and grievances from the State HCP Office. Documentation for client appeals and grievances are entered in progress notes. See above. F) The client's Social Security Number which cross-checked for client identification. 1. Maintenance of Client Records The Regional, State and County HCP Offices maintain all client records in a locked and secure area following the lllP AA guidelines on security and confidentiality of all written or oral communications regarding the family/individual receiving benefits. Client records are available, on request, to any State or Federal agency with review and audit authority, specifically State and Regional HCP agencies and Department of Human Services (DHS). All client care coordination records are the property ofDHS and shall be surrendered to DHS upon request. 2. Sharing Client Records/Care Coordination Information A) Health Insurance Portability and Accountability Act (IllP AA) HCP Regional and County Agencies shall comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996. HCP staff and care coordinators follow County lllP AA policies and procedures for security and confidentiality. HCP staff provides County Privacy Practices during first contact with families. Disclosures of Personal Health Infonnation are documented on approved County Disclosure Fonn B) Consent/Authorization - The family/individual receiving care coordination benefits signs an HCP authorization to allow communication between County, State and Regional HCP Offices; all service providers listed in the care coordination plan and the State Department of Human Services (DHS). RCP Offices use their own agency's current HIP AA consent/authorization fonns. C) Disclosure Tracking - The RCP County and Regional RCP Offices document any disclosures/sharing of the client's records on the agency's lllP AA disclosure fonn D) Privacy Practice Policy - The HCP County and Regional RCP Offices provide the individual/families receiving services the current agency's lllP AA privacy practice policy. Page? ofl2 VI. IRIS Documentation Specific TBI Care Coordination information is documented on IRIS by either the HCP regional or county office. The procedures are as follows: 1. Enter demographic information from the BIAC Application. (PrograIIl, Person and Household screens). 2. Enter time elapsed since injury. This information is available from the BIAC application and Household screens. This information is entered on the Program screen. 3. Enter "TBI Care Coordination" as the benefit type on benefit calculator. Enter the approved 12 month date range from the TBI application as eligibility dates. (Benefits Calculator) 4. "Active" status is automatically aSsigned by IRIS when the registration process, encounters and/or referrals are completed and entered. To change the child's status to "inactive", a new Benefits Calculator is added for "TBI CC Inactive". The ending date is changed to the date the status change is entered. 5. A "Welcome Letter for Care Coordination" is mailed to individual/family. IRIS generates an auto encounter to document the correspondence. (HCP Letter) 6. Enter client encounters to document all contacts with the individual/family. 7. New concerns are added as necessary with each encounter. (Concerns) 8. Progress notes are entered to document progress on the care coordination plan. See also Section III Client Records. (Client Encounter). 9. Enter aU referrals to document the family's being referred to community resources, medical providers, etc. (Client Referral Screen). 10. Enter services the child is currently receiving when care coordination with HCP begins and services the family starts during care coordination with HCP. (Client Services Screen) 11. Change the benefit type and ending eligibility dates on the Benefits Calculator when the individual/family no longer needs HCP Care Coordination i.e. "Closed - moved from state". NOTE: Care Coordination Care Plan will be added to IRIS after July 1, 2004 and documentation will be entered in IRIS on the Care Plan Tab on the Client Chart. The care plan will be printed from IRIS as an IRIS Report and then signed by the family and the care coordinator. Vll. Reimbursement for Care Coordination The fixed price for care coordination services reimbursement is $850 per client per year. The fixed price per person covers all of the care coordination services the client needs for a period of twelve (12) consecutive months after the care coordination plan is completed and signed. Services may be provided to an individual for up to one year. However, services shall be discontinued and the client placed on "inactive" status if tbe individual's need for care coordination services has been met prior to the end of 12 months, or if the individual no longer qualifies for services (e.g. he/she moves out of state). Page 8 of 12 Once a care coordination plan is signed, the care coordinator will send the HCP care coordination invoice (provider) to Rasa Eglite with a check box assuring the plan is signed. Rasa will log the infonnation and initiate payment process. vm. Quality Assurance The State HCP Office, in collaboration with HCP regional and county offices, completes quality improvement activities on a yearly basis. State and Regional HCP ensures that all Care Coordinators are appropriately and consistently trained, apply the policies and procedures for care coordination services, and participate in audits of care coordination care plans, client records, IRIS documentation and family satisfaction surveys. The State HCP office: A) Evaluates the outcomes of the care coordination services provided by detennining whether the quality of clients' lives have been maintained or improved as a result of receiving services. B) Evaluates administrative processes, such as customer service, and response to appeals and grievances; and C) Uses results of quality improvement activities to plan and improve HCP care coordination services and administrative systems. State HCP documents its quality improvement efforts and makes information on quality improvement activities and results available to clients, families and other stakeholders. 1. Customer Satisfaction Surveys State HCP requests that families/individuals who receive program services complete a Customer Satisfaction Survey when an individual goes on "inactive status", and at the end of twelve months when the case is closed. HCP provides assurances to clients that their responses will be confidential. HCP uses the results of satisfaction surveys to evaluate the outcomes of the services provided and the administrative referral and documentation system A) HCP Regional or county office sends family the "Customer Satisfaction Survey" provided by State HCP office. B) Survey is sent out when family goes on "inactive status" and/or at end of 12-month service period. D) Regional and county office staff instructs family to complete survey and return to State HCP office. E) State HCP office compiles and shares survey data and results Page 9 of 12 2. Annual Quality Improvement Report State HCP submits an Annual Quality Improvement Report to Department of Human Services, September 30th each year. The Report includes: i) A quality improvement program description outlining the administrative structure and operation of the quality improvement program; ii) Results of the previous year's quality improvement activities iii) A work plan describing the planned activities on what? 3. Client Appeals and Grievance Process Regional and County HCP Agencies are familiar with and follow the HCP Grievance and Appeal process to ensure that families receiving care coordination for TBI receive fair treatment and, support to enable them to advocate for appropriate and helpful care coordination services. Individuals who are eligible for services, and other individuals acting on behalf of eligible individuals) shall have a right to appeal decisions ofHCP to deny, reduce, suspend or terminate program services. The HCP appeal/grievance process is a fonnal mechanism for providing feedback regarding the HCP administrative processes, as wen as assuring consistency and fair treatment in policy implementation. A primary function of the grievance process is to provide HCP management feedback regarding policies. The process is an integral part of Quality Assurance and includes annual review oflogs and other records, to identify patterns of dissatisfaction and reconnnend policy changes. Appeals and Grievances may address issues including but not limited to: i) quality of care coordination services provided by HCP ii) timeliness of care coordination services iii) dissatisfaction with a Care Coordinator or HCP staff iv) accessibility ofHCP Care Coordinator or HCP staff v) availability ofHCP Care Coordinator or HCP staff The HCP Director has overall responsibility for assuring the HCP Appeal Grievance Process protects the family and/or individual rights. lbis activity is adminis~ered through the Quality Assurance Committee. The assigned State HCP staff person is responsible for the day-to-day operation of this process, including accepting the complaints, researching and documenting the issues, coordinating follow-up and calling the QA Committee as needed. The QA Committee will review the reports for all appeals and grievances during the past ]2 months during the yearly quality assurance review. Page 10 of 12 HCP Appeal and Grievance Process A) Provide to families/individuals the Appeal and Grievance policies and procedures as part of the care coordination planning process. The care coordinator will describe the procedures and give the family a copy of the written procedures when the care coordination plan is signed. The HCP state office will provide these written procedures to all local HCP offices. B) Regional, County and/or State HCP Office become aware of families/individuals and other person's dissatisfaction with a decision to deny, reduce, suspend or terminate services and/or request to access Appeal and Grievance process. C) CountylRegional HCP office documents the issues, and follows up with the appropriate Regional/C~)Unty HCP staff/Care Coordinator to resolve the problem. D) The Regional/County HCP office staff then contacts the family and explains how the issue is being addressed. Within 10 calendar days. The Regional/County HCP staff provides the family with the written appeal/grievance process and explains the next steps (See E, F below) if they are not satisfied with the resolution. E) Family remains dissatisfied and/or wishes to proceed with Appeal and Grievance Process. Regional/County HCP Office assists the family to call the State HCP Office and/or calls the State HCP Office on the family's behalf State HCP requires that the family put the complaint in writing within ninety (90) calendar days from the date of the follow- up call? The State HCP Office staff contacts both the Regional/County HCP Office staff and the family to discuss possible solutions to the family's complaint. F) If the State HCP Office staff assigned to cover all appeal/grievance calls and the family cannot come to resolution, the Quality Assurance HCP State Committee meets within thirty (30) calendar days of the family's letter received date. The committee includes the HCP Director. The decision of the special committee is final. The care coordinator and family can attend the meeting to testify. G) The State HCP office will document the process by maintaining the following information for each complaint: date received complainant name, address, and phone number area coordinator name and agency description of the complaint action taken including documentation of phone calls, meetings, etc. resolution date resolved This will be documented in the state project referral database. Page 11 of 12 Contact Information Brain Injury Association of Colorado (BIAq 4200 W. Conejos Place, Suite 524 Denver, CO 80204 Phone: 303-355-9969 800-955-2443 FAX: 303-355-9968 www.biacolorado.org Rasa Eglite, HCP TBI Referral Manager Health Care Program for Children with Special Needs (HCP) PSD - HCP A4 Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80426-1530 Phone: 303-692-2411 800-886-7689 (ext.2411) FAX: 303-753-9249 rasa. eglite@state.co.us H:\Contracts\FY 05\MCH.HCP Combined CNS ContrsGts\Attachment L - TBI CC Policies and Pr0cedure8 5.14-04.doc Page 12 of 12 Attachment M COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT HEALTH CARE PROGRAM FOR ClllLDREN WITH SPECIAL NEEDS (HCP) SLIDING FEE SCHEDULE FOR HCP CLINICS Effective October 1, 2003 The Health Care Program for Children with Special Needs (HCP) is committed to the HCP Sponsored Specialty Clinics. We want to ensure that throughout Colorado fnnilies have access to the HCP clinics. HCP has designed a Clinic Support Fee Schedule to oftSet the inftastructure cost of the clinics. The clinic physician will bill Medicaid and private insurance for all children who have Medicaid or private insurance benefits. This policy does not address the statewide Developmental Evaluation Clinic System. A Audiology/Otology, Orthopedic, Pediatric Cardiology, Pediatric Neurology, Rehabilitation, and Spinal Defects Clinics 1. Clients on Medicaid will not be charged a clinic support fee. 2. Clients not on Medicaid: a. will be charged a clinic support fee for all clinic visits. The funily will be assessed a: (1) $5 feepecvisit for a rating of133% FPG or less (2) $10 fee per visit for a rating of134 to 185% FPG (3) $30 fee per visit for a rating of 186 to 211 % FPG (4) $50 fee per visit fur a rating of212 to 399% FPG (5) $75 fee per visit fur a rating of 400 to 450% FPG (6) $100 fee per visit for a rating of 451 % FPG or greater b. and will pay all labs and x-rays ordeced out of clinic. 4. All clinic patients must be registered with HCP and complete a financial statement included in the HCP application. families who choose not to complete the financial statement will be charged the maximum fee on the schedule per visit 5. The clinic sites and ROs shall negotiate the percent each of them shall receive of the Clinic Support Fees collected from the funilies. The fees collected are to support HCP clinic activities such as: clinic supplies, clinic equipment, clinic furniture or parent/professional stipends. Records on the distnbution of collected Clinic Support Fees shall be maintained according to HCP policy. Page 1 of2 B. Pediatric Oinies Children attending an HCP Pediatric Clinic: 1. Upon refecral from the child's pcp requesting a diagnostic evalnation and/or continuing consultation from the pediatrician, the child may be seen in the HCP Pediatric Clinic. 2. Families not on Medicaid will be charged a clinic support fee. (HCP is providing access fur these fumilies, but not paying fur services to children.) 3. Family pays all labs and x-rays ordered out ofclinic. Revised August 11, 2003 J:\HCI'COMMON\CON1RACnl\FY 04\a)UN1YNS\ATIACHMEN'TIl. LARGll COUN1lES\ATIACHMIlNTH. CUNlC SllDINO FllR SCHIlDut:RDOC Page 2 of2 EXHIBIT A HIP AA BUSINESS ASSOCIATE Memorandum of Understanding The parties to this Business Associate Memorandum of Understanding ("MOU") are the Colorado Department of Public Healtb and Environment ("State" or "Department") and the Board of County Commissioners of Ea21e County ("Contractor," or "Associate"). This MOU is effective as of October 1, 2004 or the compliance date of the Privacy Rule (defined below), whichever first occurs (the "MOU Effective Date"). RECIT ALS A. The Department is a business associate of the Colorado Department of Human Services ("Covered Entity" or "CE") and as such must comply with applicable requirements Health Insurance Portability and Accountability Act of 1996, 42 U.S.c. S 1320d - 3120d- 8 ("HIP AA"), which requires that ifthe Department subcontracts any covered function and discloses protected health information to a subcontractor, the Department must enter into a business associate agreement with such a subcontractor. B. The Department wishes to disclose certain information to Associate pursuant to the terms of the Contract, some of which may constitute Protected Health Information ("PHI") (defined below). C. Department and Associate intend to protect the privacy and provide for the security of PHI disclosed to Associate pursuant to the Contract in compliance with the Health Insurance Portability and Accountability Act of 1996,42 U.S.C. S 1320d - 1320d-8 ("HIP AA") and its implementing regulations thereunder by the U.S. Department of Health and Human Services (the "Privacy Rule") and other applicable laws, as amended. D. As part ofthe HIP AA regulations, the Privacy Rule requires the Department to enter into a contract containing specific requirements with Associate prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 160.103, 164.502(e) and 164.504(e) of the Code of Federal Regulations ("C.F.R.") and contained in this MOU. E. Authority exists in the Law and Funds have been budgeted, appropriated and otherwise made available and a sufficient uncommitted balance thereof remains available for encumbering and subsequent payment of this contract under Fund Number 100, Organizational Unit Code 6520, 6810 and 6830, Appropriation Code 581,606,611, and 665, and Object Code 5120 under contract encumbrance number PO FLA MCH0500220. Colorado MOD Subcontracting Covered Functions Rev. 3104 Page 1 of 10 F. Authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Number 100, Organizational Unit Code 6810, Appropriation Code 609 and Object Code 5120 under contract encumbrance number PO FLA HCPOsOOOOOl for the Traumatic Brain Injury Services. G. Required approval, clearance and coordination have been accomplished from and with appropriate agencies. The parties agree as follows: l. Definitions. a. Except as otherwise defined herein, capitalized terms in this MOU shall have the definitions set forth in the HIP AA Privacy Rule at 45 C.F.R. Parts 160 and 164, as amended. In the event of any conflict between the mandatory provisions of the Privacy Rule and the provisions of this MOO, the Privacy Rule shall control. Where the provisions of this MOO differ from those mandated by the Privacy Rule, but are nonetheless permitted by the Privacy Rule, the provisions of this MOU shall control. b. "Protected Health Information" or "PHI" means any information, whether oral or recorded in any form or medium: (i) that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (ii) that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual, and shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.50l. c. "Protected Information" shall mean PHI provided by CE to the Department or to Associate or created or received by Associate on CE's behalf. To the extent Associate is a covered entity under HIP AA and creates or obtains its own PHI for treatment, payment and health care operations, Protected Information under this MOU does not include any PHI created or obtained by Associate as a covered entity and Associate shall follow its own policies and procedures for accounting, access and amendment of Associate's PHI. 2. Statement of Work and Responsibilities. The Scope of Work for purposes ofthis MOO is contained in the Contract between the Department and Associate dated June 23,2004. 3. Payment Amount and Billing Procedure. The consideration for Associate performing its obligations under Section 2 above, is set forth in the Contract between the Department and Contractor dated June 23, 2004. 4. Term. The term of this MOU begins on the MOU Effective Date, as set forth in the opening paragraph of this MOU, and runs through and including September 30,2005. Colorado MOD Subcontracting Covered Functions Rev. 3/04 Page 2 of 10 5. Obligations of Associate. a. Permitted Uses. Associate shall not use Protected Information except for the purpose of performing Associate's obligations under and as permitted by the terms ofthis MOU. Further, Associate shall not use Protected Information in any manner that would constitute a violation of the Privacy Rule if so used by CE, except that Associate may use Protected Information: (i) for the proper management and administration of Associate; (ii) to carry out the legal responsibilities of Associate; or (iii) for Data Aggregation purposes for the Health Care Operations of CEo Additional provisions, if any, governing permitted uses of Protected Information are set forth in Attachment A-I. b. Permitted Disclosures. Associate shall not disclose Protected Information in any manner that would constitute a violation of the Privacy Rule if disclosed by CE, except that Associate may disclose Protected Information: (i) in a manner permitted pursuant to this MOU; (ii) for the proper management and administration of Associate; (iii) as required by law; (iv) for Data Aggregation purposes for the Health Care Operations of CE; or (v) to report violations of law to appropriate federal or state authorities, consistent with 45 C.F.R. Section 164.502(j)( 1). To the extent that Associate discloses Protected Information to a third party, Associate must obtain, prior to making any such disclosure:(i) reasonable assurances from such third party that such Protected Information will be held confidential as provided pursuant to this MOU and only disclosed as required by law or for the purposes for which it was disclosed to such third party; and (ii) an agreement from such third party to notify Associate within one business day of any breaches of confidentiality of the Protected Information, to the extent it has obtained knowledge of such breach. Additional provisions, if any, governing permitted disclosures of Protected Information are set forth in Attachment A-I. c. Appropriate Safeguards. Associate shall implement appropriate safeguards as are necessary to prevent the use or disclosure of Protected Information otherwise than as permitted by this MOU. Associate shall maintain a comprehensive written information privacy and security program that includes administrative, technical and physical safeguards appropriate to the size and complexity of the Associate's operations and the nature and scope of its activities. d. Reporting of Improper Use or Disclosure. Associate shall report to the Department in writing any use or disclosure of Protected Information other than as provided for by this MOU within three (3) business days of becoming aware of such use or disclosure. e. Associate's Agents. If Associate uses one or more subcontractors or agents to provide services under this MOU, and such subcontractors or agents receive or have access to Protected Information, each subcontractor or agent shall sign an agreement with Associate containing substantially the same provisions as this MOU and further identifying CE as a third party beneficiary with rights of enforcement and indemnification from such subcontractors or agents in the event of any violation of such subcontractor or agent agreement. Associate shall implement and maintain appropriate sanctions against agents and subcontractors that violate such restrictions and conditions and shall mitigate the effects of any such violation. Colorado MOU Subcontracting Covered Functions Rev. 3/04 Page 3 of 10 f. Access to Protected Information. Associate shall make Protected Information maintained by Associate or its agents or subcontractors in Designated Record Sets available to the Department for inspection and copying within seven (7) business days of a request by the Department to enable CE to fulfill its obligations to permit individual access to PHI under the Privacy Rule, including, but not limited to, 45 CF.R. Section 164.524. g. Amendment of PHI. Within seven (7) business days of receipt of a request from the Department for an amendment of Protected Information or a record about an individual contained in a Designated Record Set, Associate or its agents or subcontractors shall make such Protected Information available to CE for amendment and incorporate any such amendment to enable CE to fulfill its obligations with respect to requests by individuals to amend their PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.526. If any individual requests an amendment of Protected Information directly from Associate or its agents or subcontractors, Associate must notify the Department in writing within three (3) business days of the receipt of the request. Any denial of amendment of Protected Information maintained by Associate or its agents or subcontractors shall be the responsibility of CEo h. Accounting Rights. Within seven (7) business days of notice by the Department of a request for an accounting of disclosures of Protected Information, Associate and its agents or subcontractors shall make available to the Department the information required to provide an accounting of disclosures to enable CE to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 CF.R. Section 164.528. As set forth in, and as limited by, 45 CF.R. Section 164.528, Associate shall not provide an accounting to CE of disclosures: (i) to carry out treatment, payment or health care operations, as set forth in 45 C.F.R. Section 164.506; (ii) to individuals of Protected Information about them as set forth in 45 CP.R. Section 164.502; (iii) pursuant to an authorization as provided in 45 CF.R. Section 164.508; (iv) to persons involved in the individual's care or other notification purposes as set forth in 45 C.F.R. Section 164.510; (v) for national security or intelligence purposes as set forth in 45 C.F.R. Section 164.512(k)(2); (vi) to correctional institutions or law enforcement officials as set forth in 45 CF.R. Section 164.512(k)(5); (vii) incident to a use or disclosure otherwise permitted by the Privacy Rule; (viii) as part of a limited data set under 45 C.F.R. Section 164.514( e); or (ix) disclosures prior to April 14,2003.. Associate agrees to implement a process that allows for an accounting to be collected and maintained by Associate and its agents or subcontractors for at least six (6) years prior to the request, but not before the compliance date of the Privacy Rule. At a minimum, such information shall include: (i) the date of disclosure; (ii) the name of the entity or person who received Protected Information and, if known, the address of the entity or person; (iii) a brief description of Protected Information disclosed; and (iv) a brief statement of purpose of the disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the individual's authorization, or a copy of the written request for disclosure. In the event that the request for an accounting is delivered directly to Associate or its agents or subcontractors, Associate shall within five (5) business days of the receipt of the request forward it to the Department in writing. It shall be CE's responsibility to prepare and deliver any such accounting requested. Associate shall not disclose any Protected Information except as set forth in Section 5(b) ofthis MOU. Colorado MOU - Subcontracting Covered Functions Rev. 3/04 Page 4 of 10 l. Governmental Access to Records. Associate shall make its internal practices, books and records relating to the use and disclosure of Protected Information available to the Secretary ofthe U.S. Department of Health and Human Services (the "Secretary"), in a time and manner designated by the Secretary, for purposes of determining CE's compliance with the Privacy Rule. Associate shall provide to the Department a copy of any Protected Information that Associate provides to the Secretary concurrently with providing such Protected Information to the Secretary. J. Minimum Necessary. Associate (and its agents or subcontractors) shall only request, use and disclose the minimum amount of Protected Information necessary to accomplish the purpose of the request, use or disclosure, in accordance with the Minimum Necessary requirements ofthe Privacy Rule including, but not limited to, 45 C.F.R. Sections I 64.502(b ) and 164.514(d). k. Data Ownership. Associate acknowledges that Associate has no ownership rights with respect to the Protected Information. L Retention of Protected Information. Except as provided in Section 7(e) of this MOU, Associate and its subcontractors or agents shall retain all Protected Information throughout the term of this MOU and shall continue to maintain the information required under Section 5(h) of this MOU for a period of six (6) years after termination of the Contract. m. Notification of Breach. During the term of this MOU, Associate shall notify the Department within two business days of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI and/or any actual or suspected use or disclosure of data in violation of any applicable federal or state laws or regulations. Associate shall take (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. n. Audits, Inspection and Enforcement. Within seven (7) business days of a written request by the Department, Associate and its agents or subcontractors shall allow the Department to conduct a reasonable inspection of the facilities, systems, books, records, agreements, policies and procedures relating to the use or disclosure of Protected Information pursuant to this MOU for the purpose of determining whether Associate has complied with this MOU; provided, however, that: (i) Associate and the Department shall mutually agree in advance upon the scope, timing and location of such an inspection; (ii) the Department shall protect the confidentiality of all confidential and proprietary information of Associate to which the Department has access during the course of such inspection; and (iii) the Department shall execute a nondisclosure agreement, upon terms mutually agreed upon by the parties, if requested by Associate. The fact that the Department inspects, or fails to inspect, or has the right to inspect, Associate's facilities, systems, books, records, agreements, policies and procedures does not relieve Associate of its responsibility to comply with this MOU, nor does the Department's (i) failure to detect or (ii) detection, but failure to notify Associate or require Associate's remediation of any unsatisfactory practices, constitute acceptance of such practice or a waiver of the Department's enforcement rights under this MOD. Colorado MOU - Subcontracting Covered Functions Rev. 3/04 Page 5 of 10 o. Safeguards During Transmission. Associate shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of Protected Information transmitted to CE pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such Protected Information is received by the Department, and in accordance with any specifications set forth in Attachment A-I. p. Restrictions and Confidential Communications. Within seven (7) business days of notice by the Department of a restriction upon uses or disclosures or request for confidential communications pursuant to 45 C.F.R. 164.522, Associate will restrict the use or disclosure of an individual's Protected Information, provided Associate has agreed to such a restriction. Associate will not respond directly to an individual's requests to restrict the use or disclosure of Protected Information or to send all communication of Protected Information to an alternate address. Associate will refer such requests to the Department so that the Department can coordinate with the CE and prepare a timely response to the requesting individual and provide direction to Associate. 6. Obligations of the Department and CEo a. Safeguards During Transmission. The Department and CE shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of PHI transmitted to Associate pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such PHI is received by Associate, and in accordance with any specifications set forth in Attachment A-I. b. Notice of Changes. The Department shall provide Associate with a copy of CE's notice of privacy practices produced in accordance with 45 C.F.R. Section 164.520, as well as any subsequent changes or limitation(s) to such notice, to the extent such changes or limitations may effect Associate's use or disclosure of Protected Information. The Department shall provide Associate with any changes in, or revocation of, permission to use or disclose Protected Information, to the extent it may affect Associate's permitted or required uses or disclosures. To the extent that it may affect Associate's permitted use or disclosure of PHI, the Department shall notify Associate of any restriction on the use or disclosure of Protected Information that CE has agreed to in accordance with 45 C.F.R. Section 164.522. CE may effectuate any and all such notices of de-identified information via posting on CE's web site. Associate shall review CE's designated web site for notice of changes to CE's HIP AA privacy policies and practices on the last day of each calendar quarter. 7. Termination. a. Without Cause. Either of the parties shaH have the right to terminate this MOD by giving the other party twenty-one (21) calendar days notice. If notice is given, the MOD will terminate at the end of twenty-one (2 I) calendar days, and the liabilities of the parties hereunder for further performance of the terms of the MOU shaH thereupon cease, but the parties shaH not be released from duty to perform up to the date of termination. Colorado MOD - Subcontracting Covered Functions Rev. 3/04 Page 6 of 10 b. Material Breach. Any material breach by Associate of any provision of this MOU, as determined by the Department, shall be grounds for immediate termination of the Contract by the Department. Any dispute concerning the performance of this MOD which cannot be resolved at the divisional level shall be referred to superior departmental management staff designated by each department. Failing resolution at that level, disputes shall be presented to the executive directors of each department for resolution. Failing resolution by the executive directors, the dispute shall be submitted in writing by both parties to the State Controller, whose decision on the dispute shall be final. This dispute resolution mechanism is in addition to, and not in lieu of, any other reporting or other requirement of federal or state law concerning alleged privacy violations. c. Reasonable Steps to Cure Breach. If the Department knows of a pattern of activity or practice of Associate that constitutes a material breach or violation of the Associate's obligations under the provisions ofthis MOU or another arrangement and does not terminate this MOU pursuant to Section 7(a), then the Department shall take reasonable steps to cure such breach or end such violation, as applicable. If the Department's efforts to cure such breach or end such violation are unsuccessful, the Department shall either (i) terminate this MOU, if feasible or (ii) if termination of this MOU is not feasible, the Department shall report Associate's breach or violation to the CE, the Colorado Attorney General's Office and to the Secretary of the U.S. Department of Health and Human Services. d. Judicial or Administrative Proceedings. Either party may terminate this MOD, effective immediately, if (i) the other party is named as a defendant in a criminal proceeding for a violation of HIP AA, the HIP AA Regulations or other security or privacy laws or (ii) a finding or stipulation that the other party has violated any standard or requirement of HIP AA, the HIP AA Regulations or other security or privacy laws is made in any administrative or civil proceeding in which the party has been joined. e. Effect of Termination. (1) Except as provided in paragraph (2) of this subsection, upon termination of this MOD, for any reason, Associate shall return or destroy all Protected Information that Associate or its agents or subcontractors still maintain in any fOlm, and shall retain no copies of such Protected Information. If Associate elects to destroy the PHI, Associate shaH certify in writing to the Department that such PHI has been destroyed. (2) If Associate believes that returning or destroying the Protected Information is not feasible, Associate shall promptly provide the Department notice of the conditions making return or destruction infeasible. Upon mutual agreement of the Department and Associate that return or destruction of Protected Information is infeasible, Associate shall continue to extend the protections of Sections 5(a), 5(b), 5(c), 5(d) and 5(e) of this MOD to such information, and shall limit further use of such PHI to those purposes that make the return or destruction of such PHI infeasible. Colorado MOD - Subcontracting Covered Functions Rev. 3/04 Page 7 of 10 - 8. No Waiver oflmmunity. No term or condition of this MOU shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions of the Colorado Governmental Immunity Act, CRS 24-10-101 et seq. or the Federal Tort Claims Act, 28 U.S.c. 2671 et seq. as applicable, as now in effect or hereafter amended. 9. Defense. To the extent any legal action against either party is not covered by the Risk Management Fund or other authorized self-insurance fund for tort claims, each party shall defend itself at its own expense in any action by third parties. 10. Disclaimer. The Department makes no warranty or representation that compliance by Associate with this MOU, HIP AA or the HIP AA Regulations will be adequate or satisfactory for Associate's own purposes. Associate is solely responsible for all decisions made by Associate regarding the safeguarding of PHI. II. Certification. To the extent that the Department determines an examination is necessary in order to comply with CE's legal obligations pursuant to HIP AA relating to certification of its security practices, the Department or its authorized agents or contractors, may, at the Department's expense, examine Associate's facilities, systems, procedures and records as may be necessary for such agents or contractors to certify to the Department the extent to which Associate's security safeguards comply with HIP AA, the HIP AA Regulations or this MOU. 12. Amendment. a. Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of this MOU may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements ofHIPAA, the Privacy Rule, the Final HIPAA Security regulations at 68 Fed. Reg. 8334 (Feb. 20, 2003),45 C.F.R. S 164.314 and other applicable laws relating to the security or privacy of PHI. The parties understand and agree that the Department must receive satisfactory written assurance from Associate that Associate will adequately safeguard all Protected Information. Upon the request of either party, the other party agrees to promptly enter into negotiations concerning the terms of an amendment to this MOU embodying written assurances consistent with the standards and requirements ofHIPAA, the Privacy Rule or other applicable laws. The Department may terminate the MOU upon thirty (30) days written notice in the event (i) Associate does not promptly enter into negotiations to amend this MOU when requested by the Department pursuant to this Section or (ii) Associate does not enter into an amendment to this MOU providing assurances regarding the safeguarding of PHI that CE, in its sole discretion, deems sufficient to satisfy the standards and requirements ofHIPAA and the Privacy Rule. b. Amendment of Attachment A-I. Attachment A-I may be modified or amended by mutual agreement of the parties in writing from time to time without fonnal amendment of this MOD. Colorado MOU - Subcontracting Covered Functions Rev. 3/04 Page 8 of to 13. Assistance in Litigation or Administrative Proceedings. Associate shall make itself, and any subcontractors, employees or agents assisting Associate in the performance of its obligations under this MOD, available to the Department, at no cost to the Department up to a maximum of 30 hours, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against the Department, CE, its directors, officers or employees based upon a claimed violation of HIP AA, the Privacy Rule or other laws relating to security and privacy of PHI, except where Associate or its subcontractor, employee or agent is a named adverse party. 14. No Third Party Beneficiaries. Nothing express or implied in this MOD is intended to confer, nor shall anything herein confer, upon any person other than the Department, CE, Associate and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. 15. Interpretation. This MOD shall be interpreted as broadly as necessary to implement and comply with HIP AA and the Privacy Rule. The parties agree that any ambiguity in this MOD shall be resolved in favor of a meaning that complies and is consistent with HIP AA and the Privacy Rule. 16. Survival of Certain Terms. Notwithstanding anything herein to the contrary, Associate's obligations under Section 7(d) ("Effect of Termination") and Section 14 ("No Third Party Beneficiaries") shall survive termination of this MOD and shall be enforceable by CE as provided herein in the event of such failure to perform or comply by the Associate. 17. Representatives and Notice. a. Representatives. For the purpose of this MOD, the individuals listed below are hereby designated as the parties' respective representatives. Either party may from time to time designate in writing new or substitute representatives. Colorado MOU - Subcontracting Covered Functions Rev. 3/04 Page 9 of lO b. Notices. All required notices shall be in writing and shall be hand delivered or given by certified or registered mail to the representatives at the addresses set forth below. StatelDepartment Representative: Name: Kathv Watters Title: Director, Children and Youth with Special Health Care Needs Department and Division: Colorado Department of Public Health and Environment Prevention Services Division Address: 4300 Cherry Creek Drive South PSD-HCP-A4 Denver, Colorado 80246 ContractorlBusiness Associate Representative: Name: Kathleen Forinash Title: Director Department and Division: Eagle County Health and Human Services Address: P. O. Box 660 Eagle, CO 81631 18. Availability of Funds. Payment pursuant to this MOD, ifin any part federally funded, is subject to and contingent upon the continuing availability of federal funds for the purposes hereof. If any of said federal funds become unavailable, as determined by the Department, either party may immediately terminate or seek to amend this MOD. 19. Audits. In addition to any other audit rights in this MOD, Associate shall permit the Department and any authorized federal agency to monitor and audit records and activities which are or have been undertaken pursuant to this MOD. 20. No Assignment. Except as otherwise provided, the duties and obligations of Associate shall not be assigned, delegated or subcontracted except with the express prior written consent of CEo Any subcontractors or agents used by BA to perform any services in connection with this MOU shall be subject to the requirements of this MOD. Colorado MOU - Subcontracting Covered Functions Rev. 3/04 Page 10 oflO A TT ACHMENT A-I This Attachment sets forth additional terms to the HIP AA Business Associate MOU dated October 1, 2004, between the Colorado Department of Public Health and Environment (CDPHE) and Board of County Commissioners of Eagle County (Associate). This Attachment may be amended from time to time as provided in Section 12(b) of the MOU. 1. Additional Permitted Uses. In addition to those purposes set forth in Section 5(a) ofthe MOU, Associate may use Protected Information as follows: The Associate may disclose aggregate reports that conform to HIP AA de-identification definitions contained in HIPAA S 164.514 (b) (1) or (2). 2. Additional Permitted Disclosures. In addition to those purposes set forth in Section 5(b) of the MOU, Associate may disclose Protected Information as follows: The Associate may disclose aggregate reports that conform to HIP AA de-identification definitions contained in HIP AA 9 164.514 (b) (1) or (2). 3. Subcontractor(s). The parties acknowledge that the following subcontractors or agents of Associate shall receive Protected Information in the course of assisting Associate in the performance of its obligations under the MOU: Associate's Health Care Program for Children with Special Needs discipline coordinator contractors. 4. Receipt. Associate's receipt of Protected Information pursuant to the MOU shall be deemed to occur as follows, and Associate's obligations under the MOU shall commence with respect to such PHI upon such receipt: Delivery of copies of eligibility applications, including ICD-9 diagnosis and any other information that can be used in the treatment of the traumatic brain-iniured child. This information may be in paper or electronic format. 5. Additional Restrictions on Use of Data. Associate shall comply with the following restrictions on the use and disclosure of Protected Information: N/A 6. Additional Terms. (This section may include specifications for disclosure format, method of transmission, use of an intermediary, use of digital signatures or PKI, authentication, additional security of privacy specifications, de-identification or re- identification of data and other additional terms.] The Associate will secure HIP AA- compliant authorization to allow disclosure of personally identifiable data to the CDPHE TBI Surveillance program. Authorization fonn to be used is attached as Attachment A-2 to the MOU. Page 1 of I - ATTACHMENT A-2 Health Care Program for Children with Special Needs (HCP) Telephone: (303) 692-2370; FAX: (303) 782~5576 Colorado Traumatic Brain Injury (TBI) Program AUTHORIZATION TO RELEASE PATIENT INFORMATION OBTAIN FROM: (Who is releasing the information") RELEASE TO: (Who is receiving the informationry) Colorado Department of Public Health and Environment Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs (HCP) Injury Epidemiology Program I PSD-HCP-A4 Traumatic Brain Injury Surveillance Project 4300 Cherry Creek Drive South PSD-IE-A4 Denver. CO 80246-1530 4300 Cherry Creek Drive South Denver. CO 80246.1530 SPECIFIC IDENTIFYING INFORMATION BEING REQUESTED: PA TIENT NAME: ADDRESS: CITY COUNTY STATE _ZIP DA TE OF BIRTH: GENDER (Circle): M F RACE (Optional) PERSON AUTHORIZED TO SIGN FOR PATIENT: RELATIONSHIP TO PATIENT: I ADDRESS (Ifdifferent Irom patient's) I I DA TE OF HOSPIT AUZA TION FOR TBI: HOSPITAL NAME: I PURPOSE FOR DISCLOSURE: (What is the information to be used for?) Public health analysis. The Injury Epidemiology Program will group this information to describe children who received services, compare thi" group to all children hospitalized with TBI, and estimate the need for TBI services. I understand that signing this authorization is not a condition of receiving services. I understand that a copy or facsimile of this authorization is to be considered as valid as the original and that this authorization will expire 365 days from the date of signature. I also understand that I may revoke this authorization at any time and that I will be asked to sign the Revocation Section on the back of this form. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes. Patient Signature DateITime Person authorized to sign lor patient Date/Time Address Relationship to Patient Phone City State Zip HCP StaffSignaturerritle (if signed in person) Date/Time Page I of2 - \. REVOCATION SECTION I do hereby request that this authorization to disclose personal information of Name of Patient signed by on , Name of person who signed Authorization Date of Signature be rescinded effective . I understand that any action taken on this (Date/Time) authorization prior to the rescinded date is legal and binding. Patient Signature Date/Time Person authorized to sign for patient Date/Time Address Relationship to Patient Phone City State Zip Witness Signature/Title DatelTime Page 2 of2