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HomeMy WebLinkAboutC08-257DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ROUTING NO. 09 FLA 00663 APPROVED TASK ORDER CONTRACT -WAIVER #154 This Task Order Contract is issued pursuant to Master Contract made on 01/23/2007, with routing number 08 FAA 00016 STATE• State of Colorado for the use & benefit of the Department of Public Health and Environment Prevention Services Division WHS/FP 4300 Cherry Creek Drive South Denver, Colorado 80246 CONTRACTOR: Board of County Commissioners of Eagle County 500 Broadway Eagle, CO 81631-0850 for the use and benefit of the Eagle County Health & Human Services 551 Broadway Eagle, CO 81631 TASI{ ORDER bIAllE DAT& 08/15/08 CONTRACTOR ENTITY T\"PE: Colorado Political Subdivision PO/SC ENCUMBRANCE NUMBER: PO FLA FPP0900663 TERM: , This Task Order shall be effective upon approval by the State Controller, or designee, or on 10/20/2008, whichever is later. The Task Order shall end on 06/30/2009. BILLING STATEbIENTS RECEIVED. Monthly STATUTORY AUTHORITY. N/A PRICE STRUCTURE• Cost Reimbursement PROCUREMENT METHOD: Exempt BID/RFP/LIST PRICE AGREEMENT NUMBER: Not Applicable L.S\G SPECIFIED VENDOR STATUTE. CONTRACT PRICE NOT TO EXCEED: $32,398.00 FEDERAL FLtNDING DOLLARS: $ STATE FUNDING DOLL.ARS• $32,398.00 MAXLMUbf AbSOUNT AVAILABLE PER PISCAL YEAR: FY09: $32,398.00 Not Applicable STATE REPRESENTATIVE. Judith Crotser Department of Public Health and Environment Prevention - WHSJFP 4300 Cherry Creek Drive South Denver, CO 80246 CONTRACTOR REPRESENTATIVE• Jill Hunsaker Eagle County Health & Human Services P. O. Box 660 Eagle, CO 81631 SCOPE OF WORK: The contractor will provide a comprehensive family planning program with an emphasis on increasing the total number of men and women accessing services and increasing utilization of long acting reversible methods of contraception (LARC) among existing clients. Page 1 of 4 ExHIBITS• The following exhibits are hereby incorporated: Exhibit A - Additional Provisions (and its attachments if any - e.g., A-1, A-2, etc.) Exhibit B - Statement of Work and Budget (and its attachments if any - e.g., B-1, B-2, etc.) Exhibit C - Limited Amendment Template for Task Orders Exhibit D - Sample Funding Letter GENERAL PROVISIONS The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made more specific in some instances in exhlbits to this Task Order Contract. To the extent that other provisions of this Task Order Contract provide more specificity than these general clauses, the more specific provision shall control. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall be performed according to the standards, terms and conditions set forth in the Master Contract. 2. In accordance with section 24-30-202(1), C.R.S., as amended, this Task Order Contract is not valid until it has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not authorized to, and shall not; commence performance under this Task Order Contract until this Task Order Contract has been approved by the State Controller or delegee. 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 Contract. If the State Controller approves this Task Order Contract on or before its proposed effective date, then the Contractor shall commence performance under this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order Contract after its proposed effective date, then the Contractor shall only commence performance under this Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through and including the date specified on page one of this Task Order Contract, unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract. Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of the terms and conditions of this Task Order Contract. 3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits and/or attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 5) the Page2of4 Additional Provisions -_Exhibit A, and its attachments if included, to this Task Order Contract; 4) the Scope/Statement of Work -Exhibit B, and its attachments if included, to this Task Order Contract; 6) other exhibits/attachments to this Task Order Contract in their order of appearance. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit B". The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this Task Order Contract's Statement of Work through a "Limited Amendment for Task Orders" that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as Exhibit C. 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. Upon proper execution and approval, this Limited Amendment shall become a formal amendment to this Task Order Contract. This contract is subject to such modifications as may be required by changes in Federal or State law, or their implementing regulations. Any such required modification shall automatically be incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein. 6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work - Exhibit B, establishes or creates standards of performance greater than those set forth in the 1ZFP, then the Contractor shall also meet those standards of performance under this Task Order Contract. Page 3 of 4 IN WI'T'NESS WHEREOF, the State has executed this Task Order Contract as of the day first above written. * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect and accept personal responsibility for any and all damages the State may incur for any errors in such representation. CONTRACTOR: Board of County Commissioners of Eagle County for the use and benefit of the Eagle County Health & Human Services Legal Name of Contracting Entity STATE OF COLORADO: BILL BITTER, JR. GOVERNOR By For Executive Director Signature of Authorized Officer QP~1-2~' ~. '(Zuv~~1o h . C~hct ~ r mou-~ Print Name & Title of Authorized Officer Department of Public Health and Environment Department Program Approval: 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 and/or services provided. STATE CONTROLLER: David J. McDermott, CPA By Date Page4of4 EXHIBIT A ADDITIONAL PROVISIONS To Contract Dated 08/15/2008 -Contract Routing Number 09 FLA 00663 These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above. 1. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this contract does not constitute a Business Associate relationship under HIPAA. 2. The contractor shall be compensated for services provided in accordance with Attachment A-1 hereto. In consideration of those services satisfactorily and timely performed by the Contractor under this contract the State shall cause to be paid to the Contractor a sum not to exceed thirty two thousand three hundred and ninety eight dollars ($32,398.00). 3. To receive compensation under this Contract, the Contractor shall submit a signed Family Planning Initiative Reimbursement Statement monthly. The Reimbursement Statement to be used is attached hereto as Attachment A-2 and incorporated herein by this reference. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B and in accordance with the allocable expenses outlined in Attachment A-1. Reimbursement Statements shall: 1) reference this Contract by its contract routing number, which number is located on page one of this Contract; 2) state the applicable performance dates; 3) state the names of payees; 4) include a brief description of the services performed during the relevant performance dates; 5) describe the incurred expenditures if reimbursement is allowed and requested; and, 6) show the total requested payment. Payment during the initial, and any renewal or extension, term of this Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Contract. Reimbursement Statements shall be sent to: Serafin Diaz Division of Prevention Services Family Planning Intiative Colorado Department of Public Health and Environment PSD-CHFC-A4 4300 Cherry Creek Drive South Denver, CO 80246 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 performance 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 later than sixty (60) calendar days from the effective expiration or termination date of this Contract. 4. The State may require forms attached to this contract and incorporated herein by reference by updated during the term of this contract. The Contractor will be informed of the new forms as they are developed. Forms may be sent to contractors or will be available on the Family Planning Administrative Manual website: dal www.cdphe.state.ro.uslagJw~rnensJfar~lan.htrnl. 5. The Contractor is not authorized to make transfers of funds from one line item in its Budget to another line item in its Budget without prior, expressed, written consent of the State. Transfer of funds may require the Contractor to enter into an amendment to the Original Task Order Contract with the State, which requires State Controller or delegate approval before the transfer can be made. 6. 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). To be attached to CDPHE Page 1 of 2 Revised: 4/1/04 Version 1.0 (4/04) contract template EXHIBIT A 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 Gaze, 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 Women Infant and Children (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 Contract, 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. 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. To be attached to CDPHE Page 2 of 2 Revised: 4JU04 Version 1.0 (4/04) contract template Exhibit A Attachment A-1 Contract Reimbursement Statement Guidelines Contract Reimbursement Statements are to be billed monthly, no later than by the 10'" of the following month. 1. Contraceptive Methods (Methods) are limited to Intrauterine Devices (IUD) Mirena and Paraguard, contraceptive implants and contraceptive rings. Methods may be billed for the purchase amount and up to 10% for shipping and handling expenses. Shipping and handling expenses are limited to the costs of ordering, maintaining inventory and stocking fees. 2. Tubal Ligations and Vasectomies shall be billed monthly for the number of procedures completed at the actual reimbursement cost to the provider. The maximum allowable reimbursement cost per procedure is $2,500.00 for each tubal ligation and $625.00 for each vasectomy (actual costs may be less). A referral cost of $100.00 for each tubal ligation and $50.00 for each vasectomy is also allowed. Reimbursement Statement Example: 2.TUBAL LIGATION Number of Actual cost per procedure + referral: $2,600.00 procedures: 1 ($2,500.00 actual procedure cost + $100.00 referral) 3.VASECTOMY Number of Actual cost per procedure + referral: $675.00 procedures: 1 ($625.00 actual procedure cost + $50.00 referral) 3. A maximum of $2,000.00 for training expenses is allowable. Training is limited to Family Planning Program staff. Training is limited to reproductive health related conferences; those related to Long Acting Reversible Contraception (LARC) are preferred. Training expenses are limited to the cost of registration, car and air travel, meals and hotels. 1 of 1 TO: SeraGn Diaz REIMBURSEMENT STATEMENT FROM: Colorado Department of Public Health and Environment Agency Name Prevention Services Division 4300 Cherry Creek Drive South, PSD - CHFC - A4 Denver, Colorado 80246-1530 PHONE: (303) 692-2391 FAX: (303) 753-9249 TYPE OF Colorado Family Planning PROGRAM: Initiative (CFPI) FEDERAL ID NUMBER: FROM: TO: Exhibit A Attachment A-2 INVOICE NUMBER CONTRACT/PO# Contact Name and Phone Number Address ,,{~ra~K.,'ab~~, r. ~ ~. ::?,zd, &: Y,x• -'t' ~`.' ~,~:"~' ) 5-?~:i ; ; ~-~nx~.~,~"er.•ii~~;r';~z ~R ~ ~,~ ,.., l x `~r br ..«4_, z~ f ~ z &e+@ 1 _ - ::~. n;~, _v "~~ sr ~ .m.~"t '~, ~ ~;'~~s s. ~g,~s° ..aR#LcPi~~~X1~~aE~ ` '~~jj~~. ~ P' 9~ .i,... ~ ~ ~ .3'e. ~~ : it~ ~~ ~ ~~~~ ~~ . . ~ R W#~ j 1. METHODS l.a. SHIPPING AND HANDLING (10%) 2.TUBAL LIGATION Number of procedures: Actual cost per procedure + referral cost: 3.VASECTOMY Number of procedures: Actual cost per procedure + referral cost: 4.TRAINING G~~A~i`D TOTAL NOTE: Incomplete statements will be returned. Please only submit SIGNED copies via email, fax or mail. 1 DATE OF EXPENDITURE: Exhibit A Attachment A-2 TO BE SIGNED BY CONTRACTORNENDOR I/We affirm the claimed expenses comply with the budget provisions of the contract and are reasonable and necessary, that all relevant progress or other reports have been timely filed, and all contract milestones andJor tasks related to the billing period have been achieved SIGNATURE TO BE SIGNED BY CDPHE PROGRAM DIRECTOR/DESIGNATED STAFF TITLE DATE I affirm that I or my staff have reviewed the contractor's invoice and supporting documentation (as required), progress reports and other communications with the contractor, and believe to the best of my knowledge, that the contractor is in compliance with all contract provisions DATE SIGNATURE TITLE TO BE SIGNED BY CDPHE DIVISION CHIEF FISCAL OFFICER OR DESIGNEE I certify that the claimed expenses have been reviewed by me for compliance with requirements of the funding source and State of Colorado Fiscal Rules, and are charged to the appropriate funding source. SIGNATURE TITLE DATE EXHIBIT B STATEMENT OF WORK To Contract Dated 08/15/2008 -Contract Routing Number 09 FLA 00663 These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above. 1) The Contractor, in accordance with the terms and conditions of this contract, shall perform and complete, in a timely and satisfactory manner, all activities described in this approved Statement of Work and incorporated in accordance with the associated Budget, which is attached hereto as Exhibit B Attachment B-1. 2) The Contractor shall continue to conduct a comprehensive family planning program ("the program"). This program shall comply with section 1001 of the federal Act and all applicable federal regulations, as amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations. (Federal funding from HHS, CFDA #93.217 FP Services). The program shall offer the following under the Title X family planning program: A. Outreach services and/or other program efforts designed to improve client recruitment. B. Nursing and medical services, which shall include a comprehensive health and social history and physical examination administered in accordance with all applicable Title X regulations and, all applicable nursing-medical policies or procedures which have been, or may be, established by the State's Women's Health Unit (WHU). C. Contraceptive information, education, and supplies regarding all family planning methods. D. Education and counseling services regarding family planning, family planning methods, child spacing, infertility, sterilization, nutrition, sexually transmitted diseases, Human immunodeficiency virus (HIV)J Acquired immunodeficieny syndrome (AIDS), adolescent counseling and other related health issues, as outlined in the Nursing and Administrative Manual. E. Follow-up and/or referral services, as appropriate. 3) All money received by the Contractor from the State under the Colorado Family Planning Initiative (CFPI) shall be used by the Contractor to provide contraceptive services in accordance with Attachment B-1. The Contractor shall make its program available to men and women in their reproductive years and shall offer the following services under the CFPI: ' A. Utilize CFPI funding to purchase long acting reversible methods of contraception and contraceptive rings. These are limited to Intrauterine Devices (ND) Mirena and Paraguard, contraceptive implants and contraceptive rings. B. Utilize CFPI funding to provide the referral process and cover the actual costs of tubal ligation and vasectomy procedures. C. Utilize CFPI funding for Family Planning staff to attend reproductive health related training with preference to those related to long acting reversible methods of contraception. D. Provide comprehensive family planning services to increase the total number of family planning clients receiving services (fertile clients receiving contraceptive services). 4) The services provided by the Contractor to the clients it serves shall be performed pursuant to law in accordance with prevailing medical standard of care for the same or similar medical, nursing and professional services. The services provided shall also comply with applicable Title X regulations, WHU To be attached to CDPHE Page 1 of 3 Revised: 4/1/04 Version 1.0 (4/04) contract template EXHIBIT B nursing-medical policies and procedures, and any applicable fiscal or administrative policies of the State or Federal government. Contractor acknowledges that it has received copies of the preceding policies and regulations as of the effective date of this Contract. 5) The Contractor shall provide the State's family planning program consultants and administrators with reasonable access to its operations to perform: periodic site reviews, data reviews, fiscal reviews or other evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be based on established standards and policies of the State or the Federal government. The Contractor shall cooperate during all periodic site visits, data reviews, fiscal reviews or other evaluations conducted by the State. 6) If necessary, the Contractor shall comply with all recommendations made by the State's family planning program consultants and/or administrators after a periodic site visit, data review, fiscal review or other evaluations that are necessary to bring its program into compliance with all applicable federal and state laws, policies and regulations. The Contractor shall be in full compliance with a recommendation, if any, within three (3) months of the date a recommendation is made by the State. If the Contractor cannot obtain full compliance within this three (3) month period, then on or before the expiration date of that three (3) month period the Contractor shall present sufficient written evidence to the State: to show that continuing progress is being made towards full compliance; and, the date when full compliance shall occur. In no event, however, shall full compliance with a recommendation occur any later than six (6) months after the date that a recommendation was initially made by the State. Notwithstanding the foregoing provisions, the State may disregard these cure periods and immediately terminate the contract without liability if it has solely determined that Contractor's noncompliance places the health, safety or welfare of persons receiving services in jeopardy. 7) On a monthly basis, the Contractor shall collect and provide to the State, by the fifteenth calendar day of the following month, all pertinent data regarding all services offered, and all family planning clients served, by its program during the preceding month, submitted through the IRIS data system. This data shall be verified on a monthly basis to help assure accuracy. 8) Within thirty (30) calendar days of receipt of a written request from the State, the Contractor shall submit nursing-medical chart audits to the State. 9) The Contractor shall only use program income generated from client fee collections and donations for family planning purposes that further the objectives of the legislation under which this Contract is entered into. In accordance with Title X guidelines, the Contractor shall not charge for any Title X required services provided to clients who are at or below 100% of the official poverty line as defined by the Office of Management and Budget (OMB). A copy of this guideline has been provided to the Contractor by the State as of the effective date of this Contract. If the State receives new poverty guidelines from the OMB during the term of this Contract, then the State shall immediately forward those new poverty guidelines to the Contractor. The Contractor shall use these new poverty guidelines, if any, upon receipt thereof from the State. 10) The Contractor's charges for services to clients who are above 100% of poverty level shall be based on a sliding fee scale that takes into account a client's family size and/or individual income. These charges and the sliding fee scale shall be made available to all clients of the Contractor, the general public, and the State. This most current version of this document is available on the Family Planning website: (http://www.cdphe.state.co.us/pp/womens/FederalPovertyGuidelines.html. Charges shall be based upon the Contractor's actual costs to provide these services as determined by a cost analysis. The Contractor and the State shall review these costs annually. The Contractor shall insure that all clients understand that they will not be denied services because of an inability to pay any of the Contractor's sliding fee charges. t 31 The Contractor shall either use a cytology laboratory chosen by the State or, a laboratory proposed by the Contractor and approved by the State. To be attached to CDPHE Page 2 of 3 Revised: 4/1/04 Version 1.0 (4/04) contract template EXHIBIT B 12) During the term of this Contract, the Contractor agrees to provide the State with the semi-annual Family Planning Expenditure/Revenue Reports. The Expenditure/Revenue Report (ERR) is located on pages 19-21 in the Financial Management Section of the Family Planning Administrative Manual, this information can also be accessed online on the CDPHE Family Planning website at htt~mm~~rvu.c~l ~t~e.4tate.«.usi ~ ~-~~~t,i>>~r>.s;f'a:~5 ~laii.html. The first report is for the months of October to December will be due no later than February 7. January through June and will be due no later than August 7. 13) The, Contractor shall protect the confidentiality of all client records and other materials that are obtained, created, or maintained by the Contractor under this contract. Except for purposes directly related to the administration of this contract, no information about, or obtained from, any client shall be disclosed by the Contractor in any form that would identify that client without the prior written consent of that client. As of the acceptance date of this contract by the Contractor, the Contractor shall have written policies governing the access to and, the duplication and dissemination of, all such information. The Contractor shall advise its directors, officers, employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. 14) Maintenance of Effort (MOE) Colorado Family Planning Initiative funding is expected to provide new funding for providing services to additional family planning clients and increasing the total number of clients utilizing efficacious methods of contraception. This is a temporary funding source, and therefore shall not be used to supplant other traditional funding sources. Therefore, the contractor shall show Maintenance of Effort (MOE) for revenue provided by local government as documented on the required family planning program Expenditure Revenue Reports (ERR), for the three years previous to any year in which funding from the Colorado Family Planning Initiative is received. This revenue, provided by local government (county and city grants and contracts) shall be equal to, or in excess of, 90% of the average of the last 3 year's Expenditure Revenue Reports. Definition: Maintenance of Effort (MOE) - A measure intended to preserve funding for the base program. This ensures that fiscal resources are not supplanted and that new funding creates an expansion in the program. MOE shall be determined by averaging the revenue provided by local government in the last 3 years' Expenditure/Revenue Reports (ERR) for the entity's family planning program, and then multiplying by ninety percent (90%). The result is the minimum amount that the entity must spend in order to illustrate MOE. In an instance where there is not three years' data, MOE shall be 90% of previous two years' local government revenues from the ERR, or 95% of the last year's results, as applicable. In the case of an anomaly where local government revenue level from the previous three years' ERR varies more than 30% in any two of the three years, an explanation of the variance must be provided by the Contractor. The Family Planning Director shall use this information to decide if the anomaly should be eliminated from the calculation of the MOE level. In any year in which the Contractor will not attain MOE, according to the formula described in the definition the Contractor shall notify the Family Panning Director. Should MOE not be obtained, in special hardship cases, a Maintenance of Effort Waiver to this clause may be requested from the CDPHE Family Planning Director, in conjunction with the Women's Health Director, attached hereto as Attachment B-2. Should a Maintenance of Effort Waiver not be granted, the Colorado Family Planning Initiative funding maybe reduced. 15) Funding adjustments maybe made during the term of this contract. The State makes funding adjustments on this contract using a Funding Letter substantially equivalent to Exhibit D and bearing the approval of the State Controller or his designee; the funding letter shall not be deemed valid until the State Controller or his designee has approved it. To be attached to CDPHE Page 3 of 3 Revised: 4/1/04 Version 1.0 (4104) contract template Exhibit B Attachment B-1 Colorado Family Planning Initiative Budget Eagle County Department of Health & Human Services October 20, 2008 to June 30, 2009 r• ~ ~ ~• ~. Methods: limited to Intrauterine Devices (IUD) Mirena and Paraguard, contraceptive implants and contraceptive rings. Methods may be billed for the purchase amount and up to 10% for shipping and handling expenses. $8,248.00 Tubal Ligations & Vasectomies: The maximum allowable reimbursement cost per procedure $2,500.00 for each tubal ligation and $625.00 for each vasectomy. A referral cost of $100.00 for each tubal ligation and $50.00 for each vasectomy is also allowed in addition to the actual cost for the procedure. $22,150.00 Training: Training related to reproductive health, those related to Long Acting Reversible Contraception (LARC) preferred. Training expenses are limited to the cost of registration, car and air travel, meals and hotels. $2,000.00 Total $32,398.00 lofl Exhibit B Attachment B-2 Colorado Family Planning Initiative Request for Waiver of Maintenance of Effort Maintenance of Effort (MOE) - A measure intended to preserve funding for the base program. This ensures that fiscal resources are not supplanted and that new funding creates an expansion in the program. MOE shall be determined usually by averaging the revenue provided by local government in the last 3 years' Expenditure/Revenue Reports (ERR) for the entity's family planning program, and then multiplying by ninety percent (90%). The result is the minimum amount that the entity must spend in order to illustrate MOE. Agency Name: Agency Address: Name of Requestor of Waiver: Title: Address (if not the same as agency): Phone Number: Email Address: Date of request: Average amount of annual revenue provided by the local government over the past 3 years' Expenditure/Revenue Reports (ERR) for the entity's family planning program. $ /year Please indicate 3-year time period used Amount of anticipated amount annual revenue to be provided by local government for the entity's family planning program. $ /year. Please explain the reason for and the duration of the expected decrease of local government support to the entity's family planning program: Email to cdohe.ps~EOme~~:,he~~(cl~~~i state.co.u:;, subject line: CFPI Waiver Request; or fax to 303-691-6957 Attention: Family Planning Director. lofl EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER **_***** °: ..1~.~'1`: il,l. l°`t)ltll ~ ~ ,- ~~ 1~~'1+;:I1®;{; °~ D LIMITED AMENDMENT FOR TASK ORDERS #* 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. (legal 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 entered into a Master Contract, dated ******** ** ****, with contract routing number ** *** ***** "the Master Contract"). Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated ******** ** ****, with contract encumbrance number PO *** ********** and contract routing number ** *** *****, ~i~a~c~°t ~~c t°$sl€~~~•~,s~ il' a-~z~ic~~~~ affi~~~c~atl~~~~•a~t~~l, £°I~~~r~;~e is~°c~rf~~, r£°ea~ P~ ~i~3 t~.;o ~ ~;et~n p~°t>rc°w~d E: as amended by] ;itacl~~~l~ =al 1~~°~~6e~ca~ :2ti£tlif,~[ii;Tit{°~p. ='°s>it!",„'t psi"e~~,: i~'p. d"£Ilt.'13~i~(S~ ilnt i~ii"it" t £1ttil€!k; I9~iIi1~)£',t-~, ~~€i~i£ € °gl~' r->~2~~~~iaat; it i~~~' ;P~~is gtt~~£:~t£s~3~Rr~~f~), ~It~~~~~zt t~r~lcs°{~~. ~°c°st~°~~a9is} ltaa~° I~~=~°a~ ~~ ~; ~:,~~cil: collectively referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: §~~~°i~.=1} ci~sc~°i~~~' r~lta~t tl~ta (~~~~~g :-c-`.'~° ~~~~r t=, ;~~~ ~ao~i~.~° _?~~° t1~°i~;l~t •1`aslc t3~•il£:a° ~sc,?~;5~£', C`t4>~+~a,^ t~ItG (- x'15.°, i•r~~d)tb(f`•°; ~B~ti6° i4~~CSiSIt'• '3IIf~ t~t~t'~ a~i£' {6I~;a't" f~~t`£=~° '~;'<~€)tii €~a3a' The State promises to =a ~;c~ca°~=: •=st~ aa4~c ~9£~lc4e i~zc t}tl£~r~ increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the ~`t~;x• a~- ::s~ :5~~c t~ci5.-t~' tic g:~ ~,~ t~~ increased/decreased work under the Original Task Order Contract. Page 1 of 5 The State promises to pay the Contractor the sum of ********** Dollars, ($*.**1 in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Contract for the renewal term of **** years/months, ending on ******** ** ****. The State promises to ~' 1£€)€~~~." €~Fa€.= ma:a£1 €l~°~=°icY tl€~ ,ati€£€° increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**1 for the renewal term of **** [clat)a)sc €)ax£~ : n£4 ~-I~ait€; alac~ $s<=; b ~ ~ years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the ~ . ==~~€o°+t* ;P;a€a and £!~ :~~~~~ ~I,c° ~adl€€; r; increased/decreased work described herein. The State hereby exercises a "no cost" change to the (£°lar)€~~~ ~l€1sc: ta.at ;alal~:~ :t€,d tlx'i£°tc; =la~~:~~ _ _€:_~ ~~'--°+`t :;p~~io budget, specifications within the Statement of Work, project management/manager identification, notice address or notification personnel, or performance period within the ~~ la€~~.~:-~ a)ai£~ <aa,a. ~l£:a.°t€; ~~€c €)tl€ca• current term of the Original Task Order Contract or renewal term of the Original Task Order Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: Consideration for this Limited Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the Original Task Order Contract, contract routing number ** *** *****, i€as£.~a° t€~ €)166)y~'~Ia~; d~aat;~£a4ae ~1€',t°l', t~"9®°C'~'t43t1S iit2£C'll£CS~~ =i~~'~}q C~1lsaY9~(' Cb~"£;L"Y(y}' t't',T~~.~S'stl{§}' `'9ai~ )..' l~c°~°a~ a°€~rc4~£°€l~ as amended by iaac~rate ball l~rc°~ °Y,;as :aa€~c=racl€~a~rat{~)q £ 1`€:aa=~;~~ era°£lta-s'-j, a-~aaa~sz=al{s} Arad tla€:la° a°a)a~ti€a~ ;a£aa~atgz,~a°~, i-a~;c°€°t the taEl€tr~~i€);; ~~€aa€1 il' pre~i€€tas ~araat€a~~araeart{s}, c.a~a~;.~ zaa°s,Iw°a°is)g €°c3rt£:~>- .~' w) a~a~-£° i)€.=a.aa l~r€~cc~~~~im cttl~ca•~r~~~y €i£Ylet£x b`€°€allccti~ tl~•"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. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: ~l'leeast° €:it€a€a~€° ~"aac° ;k~ lac !~€)E€a~~ira~ t~>~-a.~~ tal~iiaara~ mtNaa. ~1~3s:tc ttac~ ~rf~€a €€latir€ras €a~at ~cl£~ct£°€ A. a~ °~~° dais pGaa°:x=,~~~apl ~~"laer- €ta~aa;:,.~ t€> tl~a 1`taa~"~~:a;; ie~cfl ~,f'te }t°~:~s~a.a i`sa~l: :~, =>~-a" ~'m:~sstt°a)tt €)cc€~a° ~l£aa'i~a= tllc £°aaa°a'rrat tia°~aa ttt ~la~° i~a°i~;ia~a:rl ~1`~a~~~ t~~ ~4~°a- a' ~aaaa)~:£c:li This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of ********* ** Page 2 of 5 EXHIBIT C ****, through and including ********* ** ****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is ~~~It~rrAC' free ~tt~d ~1t~D~°~~= t~~:= t~tltct°~ increased/decreased by ********** Dollars, ($*.**) for an amended total financial obligation of the State of ********** DOLLARS, $( *.**). ~~~~ tt t6te `rrl[ts~~~~t~ i£'IItF ~t'e il' tart al~t> =~::rl~t~ ~gt ~~=rtr ~ittr<il~arca The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". tclxxtc= €l~e I'tr1€r~s ~:- r~tt~ttc~~ ~~ t~tr9 *rplrir° i`,1~° ~~~ , :a~r~° ~~tt~atattt~~ The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. Jl.~~° ~'s3s part°-t~;a°s~tlr ~~l~tt~tt tl~c _~t°~~;it~a:l .1.:~1: ~~~°a.l~:a~ {'t-ttt°~rct dill 1>c t°~°~a~.,g,:s ~~~~° drta$~~tart° t 5 ,~t~r This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order 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, $( *.**) for an amended total financial obligation of the State of ********** DOLLARS, ($*.**). lt.~lete tl~c ttrtsr~sitlt; ~~rrt~tic,~.. i ncrt al~picbibica ire ~'c~€ar =~a~rt~ttittn~ The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". s tel~te tfte t~tt~lt>~~irtg ° =•=.tt€:ttc;e il- ct++t gct~lrl~~;rlrlc> ~;t ~t,t° ~~ttt:stitr[t] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. ~l~~c ilt~ l~~~ra~;t°atp <;$:~ta tltc°~°c are `°tttt ~~trds ~°~rata~;ey"' tc~ ~,c lt:t~l~;t°~, ,tt ~1~~°~°~tt~<t,=.~;~ts ~~'r~~rtta tltt? cry°~~;ta~:a[ ~tatt~:a~ettt trt ~'frt°l~o <~lr~~~~tl~!c ~:=l~tt°~rs:l rcr~ ~°~xc~a~s at •: =trrt~ac~, tat° l~~'r g°~t°t~~~att~°c~ leer°i=~~. This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment ~ °t€rtr@~ ~ tto~c~ them ~tppl;, ~rtt~l il~°lc~tt~ t[tr)s~ ttt=~t tlt~~t~t modifies the Budget in ~i~i~:t~tif4 ~asc;ita";;~ its ~,,~~gt°:t~°i~, modifies the Statement of Work in ldertti~r ltr~°~=.ti€rtr get ,°arr~tt°Et~°t ~, modifies the project management/manager identification in ;;g~~~1til~ lt,c<tt~t~t~ itt ~~=~t~traci~, modifies the notice address or notification personnel in it9t .a~~~ l4rc°~~t~tar~ =t~ =_s€~t,?~~-~rt~, modifies the period of performance in y~t~-$ttf;~ !==~t~t~tt~~ mr~ ~t~;t~a-~~~l ofthe Original Task Order Contract. The revised !~°£~trr>~r° tl~tr~€~ that atpp~ .~~~cl ~le~~°tc; r':€a~~= :bs~t ~~r~tt'i~ Budget, Statement of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated by this reference and identified as. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Limited Amendment is **/**/****, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Page 3 of 5 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Limited Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Limited Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens 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 4 of 5 EXHIBIT C IN WITNESS WHEREOF, the parties hereto have executed this Limited Amendment on the day first above written. * Persons signing for Contractor hereby swear and afI•inn that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect and accept personal responsibility for any and all damages the State may incur for any errors in such representation. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (a political subdivision of the State of Colorado) Bill Ritter, Jr. Governor By: Name: Title: By: For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment 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 David J. McDermott, CPA By: Date: Page 5 of 5 Exhibit D SAMPLE FUNDING LETTER Date: State Fiscal Year: TO: (contractor's name here) SUBJECT: Funding Letter No. In accordance with Exhibit B, Paragraph 13 of contract routing number ,between the State of Colorado Department of Public Health and Envrionment, (division) and (contractor's name) 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 (~. amount of chance) 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 Ritter, Jr., Governor By: Date: For the Executive Director Colorado Department of Public Health and Environment By: For Date: (Division) 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 David ]. McDermott, CPA By: Date: Page 1 of 1