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HomeMy WebLinkAboutC05-278 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 06-00713 TASK ORDER PSD-MCH This Task Order is made this 26TH day of AUGUST, 2005, by and between: the state of Colorado, acting by and through the COLORADO 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, the (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 use 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". FACTUAL RECITALS Pursuant to section 25-1.5-10 I G) (I), C.R.S., as amended, the General Assembly of the 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." Section 25-1.5-101 (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 of health care services to children who have congenital birth defects or who are the victims of burns or trauma or children who have acquired disabilities". To accomplish its statutory duties, the State has determined that public health services are desirable in the Contractor's region. 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 Award ("NGA) number B04MC04248 (See, Catalog of Federal Domestic Assistance ("CFDA") number 93.994). 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, influencing health policy, engaging in strategic planning and coordinating/implementing best practices and evidenced-based programs. 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. 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. These three (3) distinct population groups are: "the perinatal population", which is defmed 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 "children with special health care needs population" (CSHCN), which is defined as those children 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. Page I of 10 NOW, THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: A. PERIOD OF PERFORMANCE AND TERMINATION. The proposed effective date of this Task Order is October 1,2005. However, in accordance with section 24-30-202(1), C.R.S., as amended, this Task Order 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 Task Order until this Task Order 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 Task Order. If the State Controller approves this Task Order on or before its proposed effective date, then the Contractor shall commence performance under this Task Order on the proposed effective date. If the State Controller approves this Task Order after its proposed effective date, then the Contractor shall only commence performance under this Task Order on that later date. The initial term of this Task Order shall commence on the effective date of this Task Order and continue through and including September 30, 2006, unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order. In accordance with section 24-103-503, C.R.S., as amended, and Colorado Procurement Rule R-24-103-503, the total term of this Contract, including any renewals or extensions hereof, may not exceed five (5) years. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. I. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit A". 2. The State and the Contractor have determined that the Contractor is a business associate under HIPAA in regards to the TBI services in this Task Order. Contractor hereby agrees to, and has an affirmative duty to, execute the State's current HIPAA Business Associate Agreement, which is attached hereto as "Exhibit B", and incorporated herein by this reference. This Business Associate Agreement shall be fully and properly executed by the Contractor and returned to the State at the time the Contractor signs the primary task order of which this exhibit is a part. e. DUTIES AND OBLIGATIONS OF THE STATE. I. In consideration of those HCP services satisfactorily and timely performed by the Contractor under this Task Order, the State shall cause to be paid to the Contractor a swn not to exceed THIRTEEN THOUSAND SIX HUNDRED TWENTY-TWO DOLLARS, ($13,622.00) for the initial term ofthis Task Order. Of the HCP financial obligation, Six Thousand One Hundred Thirty Dollars, ($6,130.00) 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. 2. In consideration of those State Genetics Implementation Grant services satisfactorily and timely performed by the Contractor under this Task Order, the State shall cause to be paid to the Contractor a sum not to exceed TWO THOUSAND EIGHT HUNDRED FIFTY-EIGHT DOLLARS, ($2,858.00) for the initial term of this Task Order. Of the State Genetics Implementation Grant financial obligation, Two Thousand Eight Hundred Fifty-Eight Dollars, ($2,858.00) are identified as attributable to a funding source of the United States government and, Zero Dollars, ($0.00) are identified as attributable to a funding source of the state of Colorado. Page 3 of]O B. The type(s) of service(s) or program(s) increased or decreased and the new level of each service or program; C. The amount of the increase or decrease in the level of funding for each service or program and the new total financial obligation; D. A provision stating that the Task Order Change Order Letter is effective upon approval by the State Controller, or designee, or its proposed effective date, whichever is later. Upon proper execution and approval, a Task Order Change Order Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract, and the Additional Provisions of the Task Order, if any, the Task Order Change Order Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the task order change order letter process may be used only for increased or decreased levels of funding, corresponding adjustments to service or program levels, and any related budget line items. Any other changes to this Task Order, other than those authorized by the task order option to renew letter process described below, shall be made by a fonnal amendment to this Task Order executed in accordance with the Fiscal Rules of the state of Colorado. If the Contractor agrees to and accepts a proposed Task Order Change Order Letter, then the Contractor shall execute and return that Task Order Change Order Letter to the State by the date indicated in that Task Order Change Order Letter. If the Contractor does not agree to and accept a proposed Task Order Change Order Letter, or fails to timely return a partially executed Task Order Change Order Letter by the date indicated in that Task Order Change Order Letter, then the State may, upon written notice to the Contractor, tenninate this Task Order no sooner than thirty (30) calendar days after the return date indicated in the Task Order Change Order Letter has passed. This written notice shall specify the effective date oftennination of that Task Order. Ifa Task Order is tenninated under this clause, then the parties shall not be relieved of their respective duties and obligations under that Task Order until the effective date of tennination has passed. Increases or decreases in the level of contractual funding made through the task order change order letter process during the initial, or renewal, term of a Task Order may only be made under the following circumstances: E. If necessary to fully utilize appropriations of the state of Colorado and/or non- appropriated federal grant awards; F. Adjustments to reflect current year expenditures; G. Supplemental appropriations, or non-appropriated federal funding changes resulting in an increase or decrease in the amounts originally budgeted and available for the purposes of a Task Order; H. Closure of programs and/or termination of related contracts or task orders; I. Delay or difficulty in implementing new programs or services; and, 1. Other special circumstances as deemed appropriate by the State. Page 5 of 10 2. Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Task Order. 3. The Contractor shall cooperate with the State to ensure that the program planning, evaluation, and monitoring requirements as described in this Task Order 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. 4. Contractor shall retain and use all revenues generated by the individual MCH Programs for services in those programs. 5. The State is responsible to ensure that the program planning, evaluation, and monitoring requirements as described in this Task Order 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. 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 State's Office of Local Liaison. 7. 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). 8. 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-Children Act of 1994", (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 of facilities 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 and/or the imposition of an administrative compliance order on the responsible entity. By signing this Task Order, the Contractor certifies that the Contractor will 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 7 of 10 12. Contractor shall ensure that the provisions of Section 60 I 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 commun icate 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. 13. The services or activities under this Task Order 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 Task Order. However, a subcontractor is subject to all of the terms and conditions of this Task Order. Additionally, the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Task Order. If the Contractor desires to subcontract some, or all, of the services that are to be performed under this Task Order, the Contractor shall obtain the prior, express, written consent of the State before entering into any subcontract. Page 9 of 10 IN WITNESS WHEREOF, the parties hereto have executed this Task Order as of the day first above written. CONTRACTOR: STATE: BOARD OF COUNTY COMMISSIONERS OF ST A TE OF COLORADO EAGLE COUNTY Bill Owens, Governor (a political subdivision of the state of Colorado) for the use and benefit of the Eagle County Nursing Service By: ~ By: Nam : - For the Executive Director Title. Ir DEPARTMENT OF PUBLIC HEALTH FEIN: 4-6000762 AND ENVIRONMENT Date: Date: (Seal) ATTEST: ~~~~~" PROGRAM APPROVAL: ;/J'",';:. ,"'" .-, ~ li~;~1')~~) ~ ~ By:, -: ~"''':m(/'/.~y: __ City, City and Co nty, County, '~~~~)~;.'~,..,? W Special District, or Town Clerk or EqUivalent APPROV ALS: 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. ST A TE CONTROLLER: Leslie M. Shenefelt By: Date: Revised: Ili5/04 Page JO of]O EXHIBIT A STATEMENT OF WORK To Task Order Dated 08/26/2005 - Contract Routing Number 06 FLA 00713 . This Statement of Work is for the three maternal and child health (MCH) populations, which cover prenatal, child/adolescent, and children and youth with special health care needs. Because there are some tasks pertaining to all three MCH populations, some tasks pertaining only to the prenatal and child/adolescent populations and other tasks pertaining only to the children and youth with special health care needs population this Statement of Work has been set up in three Sections; A. Maternal and Child Health (MCH), B. Prenatal and Child/ Adolescent, and C. Health Care Program for Children with Spe~ial Needs (HCP). It is important to note that when the Contractor is requested to submit a report in an item in Section A the information provided is to be for all three MCH populations. A. Maternal and Child Health (MCH) 1. Under this Task Order, 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 A-I", "Core Public Health Services Delivered by MCH Agencies", which is incorporated herein by this reference, made a part hereof, and attached hereto. 2. Submission of Actual Budget Allocations for Federal Fiscal Year 2004-2005. On or before December 1,2005, the Contractor shall submit to the State one (l) "Core Public Health Application and/or Expenditure Report" fonn showing the Contractor's actual budget allocations for the three (3) maternal and child populations, i.e., prenatal, child and adolescent, and children and youth with special health care needs (CYSHCN), for the federal fiscal year 2004-2005 (October 1,2004, through September 30, 2005). A sample fonn, which the Contractor shall utilize, is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A-2. The completed report shall be submitted via electronic mail to: Sally Merrow at: sallv.merrow(ii)state.co.us 3. Submission of Numbers Served Report for Federal Fiscal Year 2004-2005. On or before January 15,2006, the Contractor shall submit to the State, for review and approval, a completed "Number of Individuals Served (Unduplicated) Under Title V Report", for those services provided by the Contractor in federal fiscal year 2004-2005 (October I, 2004, through September 30, 2005). A sample fonn, which the Contractor shall utilize, is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A-3. This report shall be submitted via electronic mail to: Jan Reimer at: ian.reimer(ii)state.co.us B. Prenatal and Child/Adolescent The Contractor shall provide leadership, in coordination with public and private community partners to: 1. Contribute to the accomplishment of the State's priorities, perfonnance measures, and outcome measures, as identified in "Attachment A-4", which is incorporated herein by this reference, made a part hereof, and attached hereto; Page I of5 2. The Contractor shall contribute to the Western Slope HCP Regional Office's Plan for CYSHCN, which shall be carried out in federal fiscal year 2005 - 2006 (October I, 2005 through September 30,2006). The Western Slope HCP Regional Office Plan is designed to: contribute to the accomplishment of the MCH 6 Core Outcomes and Perfonnance Measures, which is incorporated herein by this reference, made a part hereof and attached hereto as "Attachment A-6". Contributions shall consist of, but are not limited to, completing requests from the Hep Regional Office to provide county specific data related to resources and needs of the population of CYSHCN and participation in trainings or other learning activities sponsored by the State Ge~etics 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 (RO) staff for: orientation and training of new staff, as needed; consultation 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 of IRIS II", and any subsequent amendments thereof, attached hereto as "Attachment A-7", incorporated herein by this reference, made a part hereof. HCP ROs shall assist in assuring this training. 5. Contractor shall implement the "IRIS II Security Policy and Procedures", and any subsequent amendments thereof, attached hereto as "Attachment A-8, 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 of CSHCN. 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 the State's delegated HCP RO Team Leader. In addition, a copyofthe county's "Annual Community Health Plan" shall be sent to the State's delegated HCP RO Team Leader by January 30, 2006. 8. The Contractor shall serve families who are detennined to fall under the MCH definition of CSHCN: "Children with special health care needs are those who have or are at 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." (Developed by the Federal Bureau of Maternal Child Health in 1995.) Recipients served shall be children residing or whose families have residence in Eagle County. 9. If the Contractor has agreed to provide Traumatic Brain Injury services under this Task Order, then the Contractor shall provide care coordination for families who have children with Traumatic Brain Injury (TBI) through the TBI Trust Fund 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-County Regional Office (HCP RO) of referrals and provide care coordination for up to one (I) year for each child. Page 3 of 5 10. 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 A-IO", 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 A-]", "Core Public Health Services Delivered by MCH Agencies". ]]. The Contractor shall ret~in and use all HCP Specialty Clinic revenues generated by the contractor to support HCP clinic activities such as: clinic supplies, clinic equipment, clinic furniture, or parent/professional stipends. 12. The Contractor agrees that any charges for attendance and services at specialty clinics sponsored by HCP must conform to the "Clinic Support Fee Schedule" for HCP Clinics, "Attachment A- 11" and any subsequent amendments thereto, attached hereto, incorporated herein by this reference, made a part hereof. Page 5 of 5 Attachment A-l CORE PUBLIC HEAL TH SERVICES DELIVERED BY MCH AGENCIES DIRECT HEALTH CARE SERVlCES: (GAP FILLING) Ex amples: Basic Health Services, and Health Services for CSHCN ENABLING SERVICES: Examples: Transportation, Translation, Outreach, Respite Care, Health Education, Family Support Services, Purchase of Health Insurance, Case Management, Coordination with Medicaid, WI C, 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 INFRASTRUCTURE BUILDING SERVICES: Examples: Needs Assessment, Evaluation, Planning, Policy Development, Coordination, Quality Assurance, Standards Development, Monitoring, Training, Applied Research. Systems of Care, and Infonnation Systems MCHS/DSCH 10/20/97 Page I of 5 Core Public Health Services Local Activities for Prenatal Care Direct Services . Provision of prenatal care/family planning services Enablinc. Services . PN+ program services/Nurse Family Partnership Services . Medicaid/CHP+ infonnation/enrollment . Translation services . Transportation . Prenatal care/resource referrals and/or care coordination . Client health education regarding breastfeeding, seat belts, immunization, smoking cessation, etc. Population-Based Services . Prenatal Weight Gain Campaign . Unintended Pregnancy Prevention projects . Breastfeeding Promotion campaign . Medicaid/CHP+ countywide outreach Infrastructure Buildinc. . MCH community needs assessment . Perinatal Periods of Risk Analysis . Local MCH Plans, progress reports and evaluations . Local Prenatal! Prenatal Plus/PRAMS data collection and analysis Page 3 of 5 Core Public Health Services Local Activities for Children and Youth with Special Health Care Needs Direct Services . Provision of multi-disciplinary clinical services at HCP Specialty Clinics, D&E clinics Enabling Services . Intensive Individual Care Coordination services- Colorado Traumatic Brain Injury Trust Fund Program, HCP Clinics, Contracted Managed Care Organizations, families with no other source for care coordination . Infonnation, resource and referral to all families, providers, organizations . Family Advocacy Population Based Services . Tracking and follow-up of Newborn Metabolic Screening . Tracking and follow-up of Newborn Hearing Screening . Tracking and monitoring for CRCSN Notification program . Gap filling screening- Newborn Hearing, Early Vision . Medical Home training, awareness campaign . MedicaidlCHP+/SSI outreach . Public Education- Newborn Hearing Screening, Early Vision, Developmental Screening (including mental and emotional), Infrastructure Services . Administration of Specialty and D&E Clinics . Needs assessment, Planning, & Evaluation and reporting- HERJ\t1AN, other . Data Collection/analysis- IRIS, HERMAN, State and National data. . Interagency & inter-organizational agreements- Part C, Respite programs, other . Participate in development of local/state Data Systems- IRIS, NEST . Participate in state/local standard development and dissemination- NB Hearing Screening and Follow Up, Early Vision Screening and Follow Up, Care Coordination . Participate in interagency workgroups to provide leadership for priority setting, planning & policy development Page 5 of 5 Attachment A-2 MA TERNAL AND CHILD HEALTH CORE PUBLIC HEALTH SERVICES BUDGET APPLICATION AND EXPENDITURE REPORT CONTRACTOR: INSTRUCTIONS: When completing this form consider the Local Activities guidance in At1achment A-I and allocate the associated costs and percentages for your agency. Please indicate which report this form is being submitted for by placing a check mark in the box located in front of the report's name. D Budget Expenditure Report: Due Date: December 1,2005 (For The Period Of October I, 2004 through September 30, 2005) Please provide actual numbers for how the funds were used in the period of October I, 2004 through September 30, 2005. D Budget Application: Due Date: May 1,2006 (For The Period of October 1,2006 through September 30, 2007) Based on your county plan, please estimate the following based on your MCH funding formula contract amounts for the period of October 1,2006 through September 30,2007. , MATERNAL AND CHILD HEALTH REPORTlNG FOR THE CORE PUBLIC HEALTH SERVICES SECTION I AMOUNT AND PERCENTAGE ALLOCATED TO: DOLLARS PERCENTAGE CHILD AND ADOLESCENT HEALTH PRENA TAL HEALTH TOTAL 100% CHILD AND ADOLESCENT PERCENT AGE ALLOCA TED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLfNG SERVICES POPULA TION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% PRENA TAL HEALTH PERCENT AGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULA TION-BASED SERVICES INFRASTRUCTURE BU1LDING SERVICES TOTAL 100% SECTlON lJ AMOUNT OF FUNDS ALLOCA TED TO: DOLLARS CHILDREN AND YOUTH WITH SPECIAL I I HEAL TH CARE NEEDS CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS PERCENT AGE ALLOCA TED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLfNG SERVICES POPULATION-BASED SERV1CES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% NOTE Administrative costs can be allocated to each of the above categories as appropriate Page 1 of 1 Attachment A-3 MATERNAL AND CHILD HEALTH INSTRUCTIONS FOR COMPLETING AND SUBMITTING THE NUMBERS SERVED REPORT (Tables I & II) For the period of October 1, 2004 through September 30, 2005 Due Date: January 15, 2006 Estimates are acceptable and are preferable to no data. Please estimate to the best of your ability. Columns 2-6 must equal Column 1 and the table is designed to add your Input automatically. If a person can be counted in more than one category in a year, select one class only in which to report them If you cannot provide any information in health insurance coverage, put your total number of clients in column (6), Number Unknown. These data are compiled at the state level and submitted to the Maternal and Child Health Bureau for Form 7 in the MCH Block grant application. If you need assistance in filling out this form, call Sue Ricketts, Prevention Services Division, Colorado Department of Public Health and Environment, 303-692-2316, or email her at sue.ricketts@state.co.us Submit the Numbers Served Report, via e-mail, no later than 500 PM on January 15, 2006, to: Jan Reimer at: jan.reimer@state.co.us Page 1 of 3 Attachment A~3 County: [Name of County] Prepared by: [Person filling out form] Program: [Name of Program] Telephone: [Work number] Email: [Work email] Table I Number of Individuals Served (Unduplicated) Under Title V By Class of Individuals and Health Coverage, FY 2005 October 1, 2004 through September 30, 2005 Column (1) will automatically total across columns (2) through (6). Columns (1) to (6) will automatically total for Total MCH Population. Input information in yel/ow shaded areas only. (1) (2) (3) (4) (5) (6) Number Number Number Number with with with Unduplicated Count by with Title XIX Other No Number Class of Individual Served Medicaid (CHIP) Insurance Coverage Unknown start here: Pregnant women receiving prenatal care" Infants under age one (not elsewhere) Children age 1-22 (not elsewhere) Children with special health care needs Other individuals (not elsewhere) Total MCH Population (automatic) Please take the Total Number shown in Column 1 for Children DO NOT REMOVE CELL PROTECTION IN and estimate the number in each of these age groups: GRAY AREAS!! Age 1-4 Age 5-9 Age 10-14 Age 15.19 Age 20-22 Unknown Total of ages: Total shown above for children age 1-22: Difference: The totals should match and the difference should be zero. Page 2 of 3 Attachment A-3 * Fill out Table" if you serve pregnant women County: [Name of County] Prepared by: [Person filling out form] Program: [Name of Program] Telephone: [Work number] Email: [Work email] Table II Number of Deliveries Served by Title V Unduplicated Count by Race and Ethnicity, FY2005 October 1, 2004 through September 30, 2005 Input information in yellow shaded areas only. More cells>>> (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Total Oth. Asian or Other Non- and American Pacific and Total Total Hisp- Un- Total All Races White" Slack Indian Islander Unknown Ethnicities Hispanic anic kn. Pregnant women start here: start here: receiving pnc 0 0 hi:;::,> > <:,f", "'.'!i"i'V .. Count Hispanics in the White column, unless they belong to one of the other racial groups. Total in Table I for Pregnant women: Total in Table II for Pregnant women: Difference: These totals should match and the difference should be zero. Total All Races Col. (1): Total Ethnicities Col. (7): Difference: These totals should match and the difference should be zero. Page 3 of 3 Attachment A-4 1\1 A TERNAL AND CHJLD HEALTH PRIORITIES, PERFORMANCE MEASURES, AND OUTCOME MEASURES As of October I, 2005 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. Improve immunization rates for all children 7. I ncrease 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 Performance Measures L 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 ] 8 years whose families partner in decision making at all levels 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 within a medical home 4. The percent of children with special health care needs age 0 to 18 whose families 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 ] 8 whose families 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 adult life Page I of 3 1. Nationally Chosen Outcome Measures I. The infant mortality rate per] ,000 live births 2. The ratio of the black infant mortality rate to the white infant mortality rate 3. The neonatal mortality rate per 1,000 live births 4. The postneonatal mortality rate per] ,000 live births 5. The perinatal mortality rate per 1,000 live births State Chosen Outcome Measure I. The low biJ1h weight rate per] ,000 Jive births Revised June 23, 2005 Page 3 of 3 Attachment A-S MA TER,~AL AND CHILD HEALTH TEN ESSENTIAL PUBLIC HEALTH SERVICES TO PROMOTE MATERNAL AND CHILD HEALTH I. Assess and monitor maternal and child health status to identify and address problems. 2. Diagnose and investigate health problems and health hazards affecting women, children, and youth. 3. Inform and educate the public and families about maternal and child health issues. 4. Mobilize community partnerships between policymakers, health care providers, families, the general public, andothers to identify and solve maternal and child health problems. 5. Provide leadership for priority-setting, planning, and policy development to support community efforts to assure the health of women, children, youth and their families. 6. Promote and enforce legal requirements that protect the health and safety of women, children, and youth, and ensure public accountability for their well-being. 7. Link women, children, and youth to health and other community and family services, and assure access to comprehensive, quality systems of care. 8. Assure the capacity and competency of the public health and personal health workforce to effectively address maternal and child health needs. 9. Evaluate the effectiveness, accessibility, and quality of personal health and population-based maternal and child health services. 10. Support research and demonstrations to gain new insights and innovative solutions to maternal and child hea Ith- re lated problems. Page I of] Attachment A-6 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) 6 CORE OUTCOMES AND PERFORMANCE MEASURES As of October], 2003 Outcome #1: Families of children with special health care needs (CSHCN) will partner in decision making at all levels. and will be satisfied with the services they receive. . I. Percent offamilies ofCSHCN reporting satisfaction with the quality of: regular source of primary care, getting referrals and appointments for needed services, coordination between primary and specialty care overall services. 2. Percent of parents of CSHCN who report satisfaction with their level of involvement/input in setting concerns and priorities to make decisions about their child's care plan. 3. Percent of parents of CSHCN who report knowing the steps to take when they are not satisfied with the services their child/family receives. 4. Number ofparents ofCSHCN who are supported financially for their involvement in state and local activities. 5. Number of parents ofCSHCN who report that they are effective partners in policymaking at the state and local levels. Outcome #2: All children with special health care needs will receive coordinated ongoing comprehensive care within a medical home. I. Percent of CSHCN with a regular source of primary medical care through a primary care provider. 2. Percent ofCSHCN whose regular source of care communicates in a way that is clear and understandable 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, behavioral/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. I. 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, aT, speech/language, audiology), in-home nursing. Page I 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 infonnation and training they received to make informed decisions about their health care and other services. 5. Percent of youth with SHCN who receive necessary services/supports by age 2 J: Health insurance, Post- secondary education, Employment, Transportation, Housing, Personal care attendant, SSI, SSA-related work incentives, e.g. PASS, 16 J 9 a & b. Last Revised June 17,2003. Page 3 of 3 Attachment A-7 Health Care Program for Children with Special Needs (HCP) HCP Small Nursing Services Standards for Usage ofJRIS Jl I. Policy and Procedures and IRJS Training l. Agency will use the HCP Regional Office and the IRIS Help Desk for consultation and assistance with IRIS data entry, IRJS training, and IRJS users security approval. 2. HCP Policies,and Prucedures will be followed as described in the IRJS Help File, HCP Policy and Procedure Manual, agency contract and training materials. 11. Documentation of Infrastructure and Population Activities l. IRIS Community Encounters will be documented to provide documentati9n of inrrastructure and population based activities. (Examples: Community meetings, outreach, screening, training, and capacity building activities) 111. Documentation of Enabling and Direct Care Activities l. CYSHCN County Caseload on IRIS includes all CYSHCN with whom agency staff have had person encounters and/or provided referrals within previous twelve months of the reporting period. 2. IRIS Person Encounters will be entered to document person contact and person concerns. Assure assessment of concerns/needs is updated as needed or at least yearly, including outcome for concerns. 3. IRIS Person Referrals will be entered to document all referrals, Assure referral outcome is entered for each referral. IV. IRJS Security I. The IRIS II Security Policy and Procedures will be followed. All new IRJS users and current staff and supervisors will sign the IRJS Security Fonn and Secure Web ID FOnTI and submit to the HCP State Office as requested. IRJS passwords will be changed every sixty days along with the CITRJX password. Both passwords will be kept confidential and will not be shared. V. IRIS training I. New HCP employees will complete the HCP Training CDs including security, multi-disciplinary training and program orientation. New IRIS users will complete IRJS training at the State HCP Office. The Regional HCP Office will provide IRJS 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 IRJS access until security fOnTIS are signed and both IRIS training and HCP Training CD have been completed. Revised June 10, 2005 Page I of I Attachment A-8 Health Care Program for Children with Special Needs (HCP) IRIS II 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 a. IRIS users including current users, supervisors and new users will sign a Security and Secure Web User ID Form before a personal ID and password are assigned for access to CITRJX and the IRIS database. Users will sign a new security form as requested by State HCP Office. b. IRJS users will have a personal ID and password assigned by the State HCP Office after completing IRJS training. c. IRIS users will not allow new agency staff, another agency staff person, staff trom another program or any person to have access or use their CITRJX/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 /IRIS 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 ID and password will be issued based on the request of the supervisor and the discretion of the State HCP Office. Agency supervisors will not allow or request access for any staff that does not have the need to access HCP person specific data on IRIS. 3. Local Health Department, HCP Regional Office and Nursing Service agencies will have agency policies and procedures for I RIS security and confidentiality. All staff will 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 longer needs IRIS access. IRJS Users will be deactivated if they have not signed onto IRJS within six months. Agency supervisors will notity 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 supervisors will supervise and monitor access to the IRIS Database. Agency supervisors will not allow sharing of IDs or passwords. 6. Agency supervisors will monitor/implement HCP policies and procedures for release of information and consent for clinic services including HIPAA disclosures as defined with local agency HIPAA policy. (The Health Insurance Portability and Accountability Act of ] 996 (HIP AA) 164.528 regarding accounting for disclosures) 7. Security for IRIS access to Newborn Evaluation, Screening, and Tracking and CRCSN data will be predefined with business rules and HCP/IRIS Policies and Procedures. The agency will identify staff members that have a "need to know.. for public health information fTom the IRIS database Page] of 2 Attachment A-9 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) Policy and Procedures for Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1,2005 - Septem ber 30, 2006 Page] of] ] II. TRAINING 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 of HCP staff that 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: A. Read provided Power Point Presentation and Handouts B. View HCP Training Video e. Read the Brainstars Manual D. Submit a completed Care Coordination Sample Plan to the Regional Office Team Leader and/or State Nursing Consultant. For review and approval. E. Discuss Questions/Concerns with the HCP Regional Office Team Leader and/or State Nursing Consultant. III. ELIGIBILITY AND REFERRAL PROCESS A. Eligibility: The Brain Injury Association of Colorado (BlAC) will perfonn client intake and detennine eligibility for the Colorado Traumatic Brain Injury Program. Once the family is detennined 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 ] 2-month period beginning on the date the care coordination plan is signed. BlAC 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 BlAC directly to begin the application process through one of the following options: 1. The family/individual contacts the Brain Injury Association of Colorado directly. 2. Families/individuals contacts the state HCP office or the HCP Regional or County Nursing Agency. The HCP office informs the family/individual that the Brain Injury Association of Colorado will complete the application process and detennine eligibility for program services. The HCP office provides contact infonnation for BlAC to the family and family contacts BlAe. 3. 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 infonnation so that the Brain Injury Association may contact the family/individual to begin the application process. HCP will notifY BL"',C within two (2) business days of its initial contact with the familylindividual seeking serv Ices. P3ge 3 of ] ] 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 familylindividual is receiving, or may be eligible to apply for within the community or at the State or federal level. 2. Document plan on "Health Care Program for Children with Special Needs (HCP) Care Coordination Child/Family Plan of Care" fonn provided by state HCP. Refer to figure # I . 3. Each outcome/goal must have a documented expected date outcome/goal is to be achieved. 4. Each outcome/goal must state specific actions/interventions in a logical sequence. 5. For every action/intervention there must be documented an assigned responsible person. 6. Evaluation of outcome goal status will be documented during and at the end of the I 2-month period of care coordination services. C. Signing the Care Coordination Plan: The family/individual who receives program services must agree to the terms of the care coordination plan. l. Familylindividual signs original agreed upon care coordination plan form. 2. HCP Care Coordinator signs and initials original care coordination fonn and gives copy of fonn to family/individual. 3. Any additionally assigned HCP Care Coordinator that is involved in modifications or evaluation of the plan's status must initial and sign the original fann. D. Approval of Care Coordination Plans: The Regional HCP Office and/or State HCP Office reviews and provides consultation for new care coordination plans. l. Shortly after State HCP sends the referral packet to the HCP regional or county office, assigned State staff will contact that local office to provide consultation. 2. HCP Regional and county offices keep a hard copy of completed and signed care coordination plans on file. 3. State HCP office completes a follow up review of a monthly random sample of 25% of new care coordination plans. 4. F or ongoing consultation, as needed, local offices can contact State and/or Regional office personnel. Page 5 of II C. Sharing Client Records/Care Coordination Infonnation: I. Health Insurance Portability and Accountability Act (HIPAA): 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 HIPAA 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 Form. 2. 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). HCP Offices use their own agency's current HIPAA consent/authorization fonns. 3. Disclosure Tracking: The HCP County and Regional HCP Offices document any disclosures/sharing of the client's records on the agency's HIPAA disclosure fonn. 4. Privacy Practice Policy: The HCP County and Regional HCP Offices provide the individual/families receiving services the current agency's HIPAA privacy practice policy. VI. IRIS DOCUMENT A nON Specific TEl Care Coordination infonnation is documented on IRIS by either the HCP regional or county office. The procedures are as follows: A. Enter demographic infonnation from the BLAC Application (Program, Person and Household screens). B. Enter time elapsed since injury. This information is available from the BIAC application and Household screens. This infonnation is entered on the Program screen. C. 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) D. IRIS automatically assigns "Active" status 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 CCInactive". The ending date is changed to the date the status change is entered. E. A "Welcome Letter for Care Coordination" is mailed to individual/family. IRIS generates an auto encounter to document the correspondence. (HCP Letter) F. Enter client encounters to document all contacts with the individual/family. G. New concerns are added as necessary with each encounter. (Concerns) H Progress notes are entered to document progress on the care coordination plan. See also Section JlI Client Records. (Client Encounter). Page 7 of ] ] B. Customer Satisfaction Surveys: State Hep 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. I. HCP Regional or county offices sends family the "Customer Satisfaction Survey" provided by State HCP office. 2. Survey is sent out when family goes on "inactive status" and/or at end Of 12- month service period. 3. Regional and county office staff instructs family to complete survey and return to State HCP office. 4. State HCP office compiles and shares survey data and results C. 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; 2. Results of the previous year's quality improvement activities 3. A work plan describing the planned activities on what? D. 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 formal mechanism for providing feedback regarding the HCP administrative processes, as well as assuring consistency and fair treatment in policy implementation. A primary function of the grievance process is to provide Hep management feedback regarding policies. The process is an integral part of Quality Assurance and includes annual review of logs and other records, to identify patterns of dissatisfaction and recommend policy changes. Appeals and Grievances may address issues including but not limited to: I. Quality of care coordination services provided by HCP 2. Timeliness of care coordination services 3. Dissatisfaction with a Care Coordinator or HCP staff 4. Accessibility of HCP Care Coordinator or HCP staff 5. 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 This activity is administered through the Quality Assurance Committee. The assigned State HCP staff person is responsible for the day-lo-day operation of this process, including accepting the complaints, researching and documenting the issues, coordinating follow-up and calling the QA Committee as needed 9 of] ] Contact Information Brain Injury Association of Colorado (BIAC) Address: 4200 W. Conejos Place, Suite 524 Denver, CO 80204 Phone: 303-355-9969 800-955-2443 FAX: 303-355-9968 Website: www.biacolorado.org HCP TBI Referral Manager Name: Rasa Eglite Address: Health Care Program for Children with Special Needs (HCP) Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South PSD - HCP - A4 Denver, CO 80426-] 530 Phone: 303-692-24] ] 800-886- 7 689 (ext. 24] ]) FAX: 303-753-9249 E-mail: rasa.egl ite@state.co.us Page] ] of]] Attachment A-1O HEAL TH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) SUGGESTED CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEED ACTIVITIES As of October I, 2003 The following suggested strategies are offered as guidance to local public health agencies in defining 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 of local communities. Local public health staff are currently doing many of the following activities. The CDPHE Health Care Program for Children with Special Needs (HCP) and Public Health Nursing consultant staff will provide technical assistance, as needed in assisting local public health agencies to define which of these - or other activities- . are most appropriate for addressing the needs of children with chronic illnesses and disabilities. l. Direct Services 1.1 Seek out funding resources and work with specialty providers to establish alternative funding sources for families. 1.2 Work with health providers so that they appropriately refer families to state and local resources that can fund or discount specialty medical care services. I.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.) of new families to help them determine their need for information, referral and/or care coordination using a standard tool such as the "Family Status Profile" form. 2.2. Assist families 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 families 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 family to assure the family was able to make the suggested contacts. 2.4. Determine the status of primary care and immunizations 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 family and medical home when it has been determined that a family would benefit from care coordination. This includes a statement of the family's strengths and needs as identified by the family and strategies for enhancing the child's Page I of 5 2.18. Identify existing primary health care and specialty providers and support resources including translation, transportation and respite care. 3. Population-based Services 3.1. Promote public health services available to children, i.e., HCP, WIC, EPSDT, and Immunization, by using local media, posters and attendance at health fairs, etc. 3.2 Develop and maintain liaisons with the local community resources to maintain open communication, to promote the services ofHCP and other services available to children with special needs, and to establish a network for working together to eliminate gaps or duplication of services and supports. 3.3. Assure 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 staff is knowledgeable in the eligibility criteria and referral procedures for Medicaid, SSI, Children's Medical Waiver 200, Children's Home Care Based Services Waiver (Katie Becken - Model 200 Waiver), and EPSDT. Assure that EPSDT case managers are knowledgeable about HCP services. 3.5. Assure that training opportunities are provided to staff on cultural competency and family-centered care. 3.6. Establish or maintain interagency collaboration through periodic meetings with representatives of the local human services agencies, the Community Center Board, the mental health agency and special education services from the school district to understand their services, to learn about their eligibility criteria, and to provide them with information about HCP and other resources within the local community. 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 WIC, with other efforts 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 number 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 actual case loads. 42. Know and analyze the numbers of children enrolled on HCP for care coordination only. Page 3 of 5 4.10. Assure that there is community parent representation from families who have children with special needs in the community service system efforts. (For example, attending meetings, contacting representatives, providing input into quality and quantity of local services.) 4.11. Participate actively in a community interagency council (ICe) by meeting regularly for the purpose 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 for children with special needs, to identify barriers and gaps in the service delivery system, to develop collaborative plans for removing the barriers and gaps including writing community-based grants for improvement of local systems. Last Revised June 17,2003 Page 5 of 5 Attachment A-II HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) CLINIC SUPPORT FEE SCHEDULE Effective October], 2005 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 families have access to specialty care. To this end, a Clinic Support Fee helps to provide vital support to the loca] infrastructure necessary to operate the HCP Specialty Clinics. The sliding fee schedule affects families with or without insurance, including CHP+. Medicaid clients do not pay a clinic support fee. This policy does not apply to the statewide Diagnostic and Evaluation (D&E) Clinic System. I. Pediatric Audiology/Otology, Pediatric, Pediatric Orthopedic, Pediatric Cardiology, Pediatric Neurology, and Pediatric Rehabilitation Clinics A. Families, except those on Medicaid, will be assessed a clinic support fee. B. Clients will be charged a clinic support fee according to their Federal Poverty Level (FPL) as follows: I. No charge for families at or below] 00% FPL 2. $5 fee per visit for a rating of 10] -] 33%FPL 3. $] 0 fee per visit for a rating of ] 34 to ] 85% FPL 4. $30 fee per visit for a rating of I 86 to 2] ] % FPL 5. $50 fee per visit for a rating of2]2 to 399% FPL 6. $75 fee per visit for a rating of 400 to 450% FPL 7. $ I 00 fee per visit for a rating greater than 450% FPL C. 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 D. Each child that has an individual appointment time will be charged a clinic support fee. E.G., The family with two children that have two separate appointment slots would be charged two fees. E. The fees collected are to support HCP clinic activities such as: clinic supplies, clinic equipment, clinic furniture or parent/professional stipends. A record of fees collected and how they are dispersed is to be kept by the clinic coordinator and the Team Leader. ]1. Pediatric Clinics Children attending an HCP Pediatric Clinic: A. Upon referral rrom the child's PCP requesting a diagnostic evaluation and/or continuing consultation rrom the pediatrician, the child may be seen in the HCP Pediatric Clinic. B. Families not on Medicaid will be charged a clinic support fee. (HCP is providing access for these families, but not paying for services to children.) C. Family pays all labs and x-rays ordered out of clinic. Revised April 2005 Page I of ] EXHIBIT B HIP AA BUSINESS ASSOCIATE Memorandum of Understanding The parties to this Business Associate Memorandum of Understanding ("MOU") are the Colorado Department of Public Health and Environment ("State" or "Department") and the Board of County Commissioners of Eal!le County ("Contractor," or "Associate"). This MOU is effective as of October 1,2005 or the compliance date ofthe Privacy Rule (defined below), whichever first occurs (the "MOU Effective Date"). RECITALS 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 if the 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 of the 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 subsequent encumbering and payment in Fund Number 100, Organizational Unit Code 6810, Appropriation Code 609, Program Code(s) 9017, Function Code(s) FL WT and Object Code 5120, and Grant Budget Line Code(s) OF6P under Contract encumbrance number PO FLA HCP06000001 for Traumatic Brain Injury (TBI) Services. All required approvals, clearances, and coordination have been accomplished from and with all appropriate agencies. Colorado MOU ~ Subcontracting Covered Functions Rev. 3/04 Page] of] 0 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 of this 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 B-1. 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 1 64.502(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 B-1. 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 ofImproper 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 J 0 1. 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 of the U.S. Department of Health and Human Services (the "Secretary"), in a time and maImer 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 of the 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. 1. 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 ofthis MOU and shall continue to ~aintain 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 MOU. Colorado MOU - Subcontracting Covered Functions Rev. 3/04 Page 5 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 MOU 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 othr 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 of this 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 MOU, 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 MOU, for any reason, Associate shall return or destroy all Protected Information that Associate or its agents or subcontractors still maintain in any form, and shall retain no copies of such Protected Information. If Associate elects to destroy the PHI, Associate shall 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(e), 5(d) and 5(e) of this MOU 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 MOU - Subcontracting Covered Functions Rev. 3/04 Page 7 of ] 0 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 compl ies 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 J 0 A TT ACHMENT B-1 This Attachment sets forth additional terms to the HIP AA Business Associate MOD dated October 1, 2005, 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 MOD. 1. Additional Permitted Uses. In addition to those purposes set forth in Section 5(a) of the MOD, Associate may use Protected Information as follows: The Associate may disclose aggregate reports that conform to HIP AA de-identification definitions contained in HIPAA 9 164.514 (b) (1) or (2). 2. Additional Permitted Disclosures. In addition to those purposes set forth in Section 5(b) of the MOD, 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 S 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 MOD shall be deemed to occur as follows, and Associate's obligations under the MOD 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-injured child. This information may be in paper or electronic format. 5. Additional Restrictions on Dse 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 form to be used is attached as Attachment B-l-1 to the MOD. Colorado MOU Subcontracting Covered Functions Rev. 3/04 Page] of 1 ATTACHMENT B-l-l 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 information?) 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 PSD-HCP-A4 Traumatic Brain Injury Surveillance Project 4300 Cherry Creek Drive South PSD-IE-A4 Denver, ,0 80246-1530 4300 Cherry Creek Drive South Denver, CO 80246- I 530 SPECIFIC IDENTIFYING INFORMATION BEING REQUESTED: PATIENT DATE OF BIRTH GENDER (Circle): M F RACE (Optional) PERSON AUTHORIZED TO SIGN FOR PATIENT RELATIONSHIP TO PATIENT ADDRESS (If different from DATE OF HOSPITALIZATION FOR TBl: HOSPITAL NAME: PURPOSE FOR DISCLOSURE: (What is the information to be used for?) Public health analysis. The Injury Epidemiology Program will group this infonnation to describe children who received services, compare this group to all children hospitalized with TBI, and estimate the need for TBl 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 auth.orization 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 confinning that it accurately reflects my wishes. Patient Signature Date(fime Person authorized to sign for patient DatefTime Address Relationship to Patient Phone City State HCP Staff Signaturerritle (if signed in person) Date/Time Page I of2 EXHIBIT C TASK ORDER CHANGE ORDER LETTER (Datej Task Order Change Order Letter Number:::, Contract Routing Number ** *** ***** State Fiscal Year 20** - 20**, *************** Pro2ram This Task Order Change Order Letter is issued pursuant to paragraph *. *. of the Master Contract identified as contract routing number ** *** ***** and paragraph *. *. of the Task Order identified as contract routing number ** *** ***** and contract encumbrance number ** *** **********. This Task Order Change Order Letter is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and ILEGAL NAME OF CONTRACTORl. The Task Order has been amende? by Task Order Option to Renew Letter :::, contract routing number ** *** *****, and/or Task Order Change Order Letter :::, contract routing number ~ ~,ifany. The Task Order, as amended, if applicable, is referred to as the "Original Task Order". This Task Order Change Order Letter is for the current term of********* **, ****, through ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is increased/decreased by ********** Dollars, ($*. **) for' an amended total financial obligation of the State of ********** DOLLARS, ($*.**). The revised specifications to the original Scope of Work and the revised Budget are incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment *" and "Attachment *". The first sentence in paragraph *. *. of the Original Task Order is modified accordingly. All other terms and conditions of the Original Task Order are reaffirmed. This change to the Task Order shall be effective upon approval by the State controller, or designee, or on ********* **, ****, whichever is later. Please sign, date, and return all ::: originals of this Task Order Change Order Letter by ********* **, ****, to the attention of: ************ ************, Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, Mail Code ***-***-**, Denver, Colorado 80246. One original of this Task Order Change Order Letter will be returned to you when fully approved. (LEGAL NAME OF CONTRACTOR} STATE OF COLORADO (a political subdivision of the state of Colorado) BiIJ Owens, Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT PROGRAM APPROVAL: (Seal - Required) By: A TTEST (required): By: 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 andlor services provided. ST A TE CONTROLLER: Leslie M. Shenefelt By: Date: Revised: 11/5/04 Page 1 of 1 EXHIBIT D T ASK ORDER OPTION TO RENEW LETTER (Date) Task Order Option to Renew Letter Number =, Contract Routing Number ** *** ***** State Fiscal Year 20** - 20** *************** Pro2:ram This Task Order Option to Renew Letter is issued pursuant to paragraph *. *. of the Master Contract identified by contract routing number ** *** ***** and paragraph ~ of the Task Order identified by contract routing number ** *** ***** and contract encumbrance number ** *** **********. This Task Order Option to Renew Letter is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and (LEGAL NAME OF CONTRACTORl. The Task Order has been amended by Task Order C~ange Order Letter =, contract routing number ** *** *****, and/or Task Order Option to Renew Letter =, contract routing number ~ .:::.:.:.:, ifany. The Task Order, as amended, ifapplicable, is referred to as the "Original Task Order". This Task Order Option to Renew Letter is for the renewal term of********* **, ****, through ********* **, ****. The maximum amount payable by the State for the work to be perfonned by the Contractor during this renewal term is ********** Dollars, ~ for an amended total financial obligation of the State of ********** DOLLARS, This is.an increase/decrease of ($*. **) of the amount payable from the previous tenn. The Budget for this renewal term is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment *". The first sentence in paragraph *. *. of the Original Task Order is modified accordingly. All other terms and conditions of the Original Task Order are reaffinned. This Task Order Option to Renew Letter is effective upon approval by the State Controller, or designee, or on ********* **, ****, whichever is later. Please sign, date, and return all = originals of this Task Order Option to Renew Letter by ********* ** , ****, to the attention of: ************ ************, Colorado Department of Public Health and Environment, Mail Code ***-***-**,4300 Cherry Creek Drive South, Denver, Colorado 80246. One original of this Task Order Option to Renew Letter will be returned to you when fully approved. ILEGAL NAME OF CONTRACTOR) STATE OF COLORADO (a political subdivision of the state of Colorado) Bill Owens, Governor By: By: Name: For the Executive Director Title: DEP ARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT PROGRAM APPROVAL: (Seal - required) By: A TTEST (required): By: 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. ]f performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and/or services provided. ST A TE CONTROLLER: Leslie M. Shenefelt By: Date: Revised: 1115/04 Page] of ]