2005-115-RES AUTHORIZING DSHS DOCUMENT NO 7560022067-A2006 (ATTACHMENT NO 1-PURCHASE ORDER NO 0000309628)
RESOLUTION NO. ~005-115
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PARIS,
PARIS, TEXAS, APPROVING AND AUTHORIZING THE EXECUTION OF
DSHS DOCUMENT NO. 7560022067-A2006 (ATTACHMENT NO. 1-
PURCHASE ORDER NO. 0000309628) FOR COMMUNITY HEALTH
SERVICES; MAKING OTHER FINDINGS AND PROVISIONS RELATED
TO THE SUBJECT; AND PROVIDING AN EFFECTIVE DATE.
WHEREAS, the State of Texas is a funding partner with the County of Lamar and the
City of Paris for the Paris-Lamar County Health Department; and,
WHEREAS, the Contract for Community Health Services, DSHS Document No.
7560022067-A2006, (ATTACHMENT NO. 1- PURCHASE ORDER NO. 0000309628) is the
conduit through which the state funds are received; and,
WHEREAS, it is appropriate that the form of said Contract attached hereto as Exhibit
A, be approved, and that the City Manager be authorized to execute the same on behalf of the
City of Paris, which is the authorized contracting entity for the performing agency, the Paris-
Lamar County Health Department; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, PARIS,
TEXAS:
Section 1. That the findings set out in the preamble to this resolution are hereby in all
things approved.
Section 2. That the form of the Contract for Community Health Services, DSHS
Document No. 7560022067-A2006 (ATTACHMENT NO. 1- PURCHASE ORDER NO.
0000309628) attached hereto as Exhibit A, be, and the same is hereby, approved.
Section 3. That the City Manager be, and he is hereby, authorized and directed to
execute, on behalf of the City of Paris, which is the authorized contracting entity for the
performing agency, the Paris-Lamar County Health Department, the Contract for Community
Health Services, DSHS Document No. 760022067-A2006 (ATTACHMENT NO. 1-
PURCHASE ORDER NO. 0000309628), under the terms and conditions and in the form shown
in Exhibit A, attached hereto.
Section 4. That this resolution shall be effective from and after its date of passage.
PASSED AND APPROVED this 19th day
ATTEST:
~~Q ~ Qllin
. ice Ellis, City Clerk
APPROVED AS TO FORM:
~
CONTRACT FOR PUBLIC HEALTH SERVICES
Contract Issued by: DEPARTMENT OF STATE HEALTH SERVICES KR
(RECEIVING AGENCY) 1100 WEST 49TH STREET
AUSTiN, TEXAS 78756-3199
Legal Authority to Contract: Chapters 12 and 121, Health and Safety Code.
Veoue: The provisions of this Contract shall be interpreted in accordance with Texas law. Venue for any court disputes shall be in Travis County.
Texas.
PERFORMING AGENCY NAME: PARIS-LAMAR COUNTY HEALTH DEPARTMENT
MAILING ADDRESS: PO BOX 938 PARIS TX 75460-0938
STREET ADDRESS: 740 6TH ST SW PARIS TX 75460-8530
NAME OF AUTHORIZED
CONTRACTING ENTITY: CITY OF PARIS
(If different from PERFORMING AGENCY)
PAYEE DATA (If not the same as PERFORMING AGENCY or AUTHORIZED CONTRACTING ENTITY; must be on file with the Texas State
Comptroller's Office.):
NAME: PARIS-LAMAR COUNTY HEALTH DEPARTMENT
ADDRESS: PO BOX 938 PARIS TX 75460-0938
(City, State, Zip)
State of Texas Vendor Identification No. (14 digits) PAYEE AGENCY Fiscal
17560022067001 Year Ending Month: September
PAYEE BUSINESS INFORMATION FOR STATISTICAL REPORTING: Please check the categories that apply to your business.
- Small Business _ A corporation, sole proprietorship, or other legal entity formed for the purpose of making a profit which is
independently owned and operated and has fewer than 100 employees or has less than $1,000,000 in annual gross receipts.
- Historically Underutilized Business (HUB) - A corporation, sole proprietorship, or joint venture formed for the purpose of making a
profit in which at least 51 % of all classes of the shares of stock or other equitable securities are owned by one or more persons who
have been historically underutilized (socially disadvantaged) because of their identification as members of certain groups: Black
American, Hispanic American, Asian Pacific American, Native American, and Women. The HUB must be certified by Texas
Building and Procurement Commission or another entity.
- For Profit Organization
SUMMARY OF CONTRACT DOCUMENTATION:
COVER PAGE 1 - Receiving and Performing Agency Data GENERAL PROVISIONS - 6/ 2004
COVER PAGE 2 - Details of Attachment(s) A IT ACHMENT(S)
COVER PAGE 3 - Authorized Signatures EXHffiITS, IF APPLICABLE
DSHS DOCUMENT NO 756oo22067A2006
Cover Page 1
',::::.."
DETAILS OF ATTACHMENTS
An! DSHS Program 10/ Term Financial Assistance Direct Total Amount
Amd DSHS Purchase Assistance (DSHS Share)
No. Order Number Begin End Source of Amount
Funds*
01 CHS/FEE 09/01/05 08/31/06 State 93.994 20,000.00 0.00 20,000.00
0000309628
DSHS Document No.7560022067A2006 Totals $ 20,000.00 $ 0.00 $ 20,000.00
,
*Federal funds are indicated by a number from the Catal<g of Federal Domestic Assistance (CFDA), if applicable. REFER TO
BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS.
Cover Page 2
EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN.
CITY OF PARIS
Authorized Contracting Entity (type above if different
from PERFORMING AGENCY) for and in behalf of:
PERFORMING AGENCY NAME:
PARIS-LAMAR COUNTY HEALTH
DEPARTMENT
By:
(Signature of person authorized to sign contracts)
(Name and Title)
Date:
RECOMMENDED:
By:
(P RF RMING AGENCY Director, if different
from person authorized to sign contract)
RECEIVING AGENCY NAME:
DEPARTMENT OF STATE HEALTH
SERVICES
By:
(Signature of person authorized to sign contracts)
Bob Burnette, Director
Client Services Contracting Unit
(Name and Title)
Date:
DSHS Document No: 7560022067A2006
Cover Page 3
i
GENERAL PROVISIONS FOR
DEPARTMENT OF STATE HEALm SERVICES SUBRECIPIENT GRANT CONTRACTS
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, .,.....;..,' ..:..::.........:;:.'
. TABLEOFOON1Elft'8 .
A1tTICLE 1 - PREAMBLE
Z - TERM
3 - FUNDING .
4- AMEND~S .:' .. .
5 .. APPLlCABIB LA WS'AND S'1'ANDAtmS . .
6 - DBB~ AND SUSPENSIONS
7 - ASSURANCES .
8 CHlLDABUSERBPORTJNG lUiQ~
. 9 - INTlllLBCTUAL ;ry... .' ... .,../
~t. ~:a'~1.$E8Ti~,;.. . .. .,\
12 . CERllt'1<':: ON 01.801".. WARE. HAlIDWARE. FIRMWARE, AND MICRO
CODBPROOUcrS '.. .' .",. .
13 _ STANDARDS FOR FINANCIAL AND PROGRAMMATIC MANAGEMENT
14 - BONDING AND LIABILITY INSURANCE
15 - TERMsANDCONDmoNSOFPAYMBNT
16 . PROGRAM INCOME
17 . CONTRACTS WITH SUBRECIPlENTS
18 - CONTRACTS FOR PROCUREMENT
19 - REPORTS
20 - INSPEcTIoNS
21 . RECORDS RETENTION
22 _ CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION
23 - HOLD HARMLESS
24 . SANCTIONS
2S - SANCTION REVIEW
.26 . BREACH OF/CONTRACT CLAIM
27 ~ TERMlNATION
28 . VOID CONTRACT
29 - SEVERABILITY
30 . SURVIVALOFTERMS
.31 ~ CONSTRUcrION OF AMBIGmIIES .
32 . NO W AlVER OF SOVEREIGN lMMUN1TY
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Paper Publications Number: 29-11835, Revised June 2004
(Fee-for-Service)
GENERAL PROVISIONS 612004
Any alterlltlon to this docnment coDstltntes a collnter-off.,. and mnll b. approved In writing by the Department of Stale Health
Services.
GENERAL PROVISIONS FOR
DEPARTMENT OF STATE REALm SERVICES SUBRECIPIENT GRANT CONTRACTS
ARTICLE 1. Preamble
PERFORMING AGENCY and RECENING AGENCY (the parties) agree to make and enter into this grant
contract (contract), to faithfully perfonn the duties prescribed by this contract, and to uphold and abide by its
terms and provisions. This contract consists of:
. RECENING and PERFORMING AGENCY identifying data,
. Details of Attachment(s),
. authorized signatures,
. General Provisions, and
. Attachment(s).
Attachments may include the following elements as applicable:
. detailed Scope(s) of Work,
. Special Provisions,
. budget(s), and
. exhibit(s).
This contract represents the complete and entire understanding and agreement of the . parties. No prior
agreement or understanding, oral or otherwise, of the parties or their agents will be valid or enforceable unless
embodied in this contract. The terms "shall" and "will" are used interchangeably in this contract.
The person or persons signing and executing this contract on behalf of PERFORMING AGENCY, or
representing themselves as signing and executing this contract on behalf of PERFORMING AGENCY, warrant
and gwirantee that he, she, or they have been duly authorized by PERFORMING AGENCY to execute this
contract for PERFORMING AGENCY and to validly and legally bind PERFORMING AGENCY to all of its
terms, perfonnances, and provisions.
PERFORMING AGENCY assures compliance with this contract, including these General Provisions unless
otherwise specified in any Special Provisions of the Attachment(s) to this document. lfthe General Provisions
are revised or replaced during the term of this contract and PERFORMING AGENCY does not consent to
comply with the modified General Provisions, PERFORMING AGENCY may exercise its termination options
in accordance with the General Provisions, Termination Article.
ARTICLE 2. Term
The term (time period) of this contract shall be governed by the term(s) of the Attachment(s). No commibnent
of contract funds is permitted prior to the first day or subsequent to the last day of the term. The term may be
renewed, extended or shortened by amendment(s).
(Fee-for-Servil:e)
GENERAL PROVISIONS 6/2004
Page I
,
execution of a contract or grant unless PERFORMING AGENCY previously filed a declaration, certification, or
disclosure fonn in connection with the award; and at the end of each calendar quarter in which there occurs any
event that materially affects the accuracy of the information contained in any declaration, certification, or
disclosure previously filed. RECEIVING AGENCY wiU supply the certification form to PERFORMING
AGENCY upon request.
ARTICLE 6. Debarment and Snsnenslon
PERFORMING AGENCY certifies by execution of this contract to the following:
. It is not ineligtble for participation in federal or state assistance programs under Executive Order 12549,
Debarment and Suspension, Feb.J8, 1986,51 Fed. Reg. 6370;
. Neither it nor its principals are presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this transaction by any federal department or
agency;
. It has not knowingly failed to pay a single substantial debt or a number of outstanding debts to a federal
. or state agency; and,
. It is not subject to an outstanding judgment in a suit against PERFORMING AGENCY for coUection of
the balance of a debt.
Where PERFORMING AGENCY is unable to certify to any of the statements in this Article, PERFORMING
AGENCY shall attach an explanation. If PERFORMING AGENCY'S status with respect to the items certified
above changes during the contract, PERFORMING AGENCY shall notify RECEIVING AGENCY
immediately.
PERFORMING AGENCY shall not contract with a subrecipient nor procure goods or services from a
subcontractor, at any tier, which is debarred or suspended or is otherwise excluded from or ineligible for
participation in federal assistance programs under Executive Order 12549.
ARTICLE 7. Assnrances
PERFORMING AGENCY shall establish safeguards to prohibit employees from using their positions for a
purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal
gain.
To the extent such provisions are applicable to PERFORMING AGENCY, PERFORMING AGENCY agrees to
fuUy comply with the foUowing:
. Title VI of the Civil Rights Act of 1964, 42 USC ~~2000d et seq., as amended (p.L. 88-352), which
prohibits discrimination on the basis of race, color or national origin, and includes the provision for
effective comnnmication and equal access to programs, services and activities to persons with Limited
English Proficiency;
. Title IX of the Education Amendments of 1972,20 USC ~~1681-1683, and 1685-1686, as amended,
which prohibits discrimination on the basis of sex;
. Section 504 of the Rehabilitation Act of 1973, 29 USC ~ 794( a), which prohibits discrimination on the
basis of disabilities and the Americans with Disabilities Act of 1990,42 USC ~~12101 et seq., including
the provision for effective communication and equal access to programs, services and activities to
persons with sensory and speech impairments;
. The Age Discrimination Act of 1975, 42 USC ~~6101-6107, as amended, which prohibits
discrimination on the basis of age;
(Fu-for-Service)
GENERAL PROVISIONS 612004
Page 3
program participants who are pregnant women or mothers with infants. Promotional material may
be requested from RECEIVING AGENCY by calling (512) 458-7796.
J. Environmental standards,pursuant to the following:
(1) Institution of environmental quality control measures under the National Environmental
Policy Act of 1969, 42 USC ~~4321-4347 and Executive Order 11514 (35 Fed. Reg. 4247),
"Protection and Enhancement of Environmental Quality."
(2) Notification of violating facilities pursuant to Executive Order 11738 (40 CPR Part 32),
"Providing for Administration of the Clean Air Act and Federal Water Pollution Control
Act with Respect to Federal Contracts, Grants, or Loans."
(3) Protection ofwet1ands pursuant to Executive Order 11990,42 Fed. Reg. 26961.
(4) Evaluation of flood hazards in floodplains in accordance with Executive Order 11988, 42
Fed. Reg. 26951.
(5) Assurance of project consistency with the approved State Management program developed
under the Coastal Zone Management Act of 1972, 16 USC ~~1451 etseq., as amended.
(6) Conformity of federal actions to state clean air implementation plans under the Clean Air
Act of 1955, as amended, 42 USC ~F401 et seq.
(7) Protection of underground sources of drinking water under the Safe Drinking Water Act of
1974,42 USC ~~300f-300j. as amended.
(8) Protection of endangered species under the Endangered Species Act of 1973, 16 USC
~~1531 et seq., as amended.
K. Hatch Political Activity Act, 5 USC 997321-26, which limits the political activity of employees
whose principal employment activities are funded in whole or in part with federal funds.
1. The Fair Labor Standards Act, 29 USC 99201 et seq., and the Intergovernmental Personnel Act of
1970,42 USC ~94701 et seq., as applicable, concerning minimum wage and maximum hours.
M. General Appropriations Act, Regular Session, 78th Legislature, 2003, Article 99-6.13, page IX-
35, "Limitation on Grants to Units of Local Government." For the purpose of 99-6.13, "unit of
local government" shall mean a council of goyernments, a regional planning commission, or a
similar regional planning agency created under Chapter 391, Local Government Code; a local
workforce development board; or an MHMR community center.
N. Texas Government Code, Chapter 573, relating to nepotism.
O. Texas Government Code, Chapter 552, relating to open records and public infonnation.
P. Texas Government Code, Chapter 551, relating to open meetings.
Q. Texas Occupations Code, Chapter 1701, as amended, and all rules adopted by the Texas
Commission on Law Enforcement Officer Standards and Education pursuant to Chapter 1701, as
amended, relating to regulated law enforcement agencies.
PERFORMING AGENCY shall ensure that the facilities under its ownership, lease or supervision which will be
utilized in the accomplishment of the project are not listed on the Environmental Protection Agency's (EPA) list
of Violating Facilities and shall notify the Federal grantor agency of the receipt of any communication from the
Director of the EP A Office of Federal Activities indicating that a facility to be used in the project is under
consideration for listing by the EPA (Executive Order 11738).
(Fee1or-Serviu)
GENERAL PROVISIONS 612004
Page S
and the Services Delivery Integration project (SDUFFS).] PERFORMING AGENCY and each of its
subrecipiei1ts shall make a good faith effort to comply with child abuse reporting guidelines and requirements in
Chapter 261 of the Texas Family Code relating to investigations of reports of child abuse and neglect.
PERFORMING AGENCY and each of its subrecipients shall develop, implement and enforce a written policy
that includes at a minimum the TDH Child Abuse Screening, Documenting, and Reporting Policy for
ContractorslProviders and train all staff on reporting requirements. PERFORMING AGENCY and its
subrecipients shall use the Checklist for 'IDH Monitoring as required by RECEIVING AGENCY. (The policy
and checklist are available at each of the above-referenced programs' websites.)
ARTICLE 9. Intellectual Prooertv
Texas Health and Safety Code ~12.020, as amended, authorizes RECENING AGENCY to protect intellectua1
property developed as a result of this contract.
"Intellectual property" means created property that may be protected under copyright, patent, or
trademark/service mark law.
"Work made for hire" is a copyrightable work prepared for RECENING AGENCY use, or a work specially
ordered or commissioned through a contract for RECENING AGENCY use. RECENING AGENCY owns
works made for hire unless it agrees otherwise by contract.
If federal or state funds are used to finance activities supported by this Contract that result in the production of
origina1 material, the federal or state awarding agency reserves a royalty-free, nonexclusive, and irrevocable
license to reproduce, publish, or otherwise use, and to authorize others to use, for federal or state government
pwposes (1) the copyright in any work developed under a grant, subgrant, or contract under a grant or subgrant;
and (2) any rights of copyright to which a PERFORMING AGENCY or its subrecipient purchases ownership
with grant support. PERFORMING AGENCY shall place an acknowledgment of federal or state awarding
agency grant support and a disclaimer, as appropriate, on any publication written or published with such support
and, if feasible, on any publication reporting the results of or describing a grant-supported activity. An
acknowledgment shall be to the effect that "'This publication was made possible by grant number _ from
(federal or state awardinl! al!encv)" or "The project described was supported by grant number from
(federal or state awardinl! al!encv)" and "Its contents are solely the responsibility of the authors and do not
necessarily represent the official views of the (federal or state awardinl! al!encv)."
In the event the terms of a federal or state grant award the copyright to PERFORMING AGENCY,
RECENING AGENCY reserves a royalty-free, nonexclusive, worldwide and irrevocable license to reproduce,
publish or otherwise use, and to authorize others to use, for RECENING AGENCY, public health, and state
governmental noncommercial pwposes (I) the copyright, trademark, service mark, and/or patent on an
invention, discovery, or improvement to any process, machine, manufacture, or composition of matter; products;
technology; scientific information; trade secrets; and computer software, in any work developed under a grant,
subgrant, or contract under a grant or subgrant; and (2) any rights of copyright, service or trade marks or patents
to which a grantee, subgrantee or a PERFORMING AGENCY purchases ownership with grant support.
If the results of the contract performance are subject to copyright law, the PERFORMING AGENCY cannot
publish those results without prior review and approval ofRECENING AGENCY.
ARTICLE 10. mltoTicallv Underutlllzed Businesses
If PERFORMING AGENCY subcontracts a portion of this contract, PERFORMING AGENCY agrees to make
a good faith effort to subcontract with HUBs during the performance of its Attachment(s) with RECENING
AGENCY and win report HUB subcontract, or activity on a quarterly basis to RECENING AGENCY,
(Fee-for-Serv/ee)
GENERAL PROVISIONS 612004
Page 7
G) "product" or "products" shallbe defined to include, but is not limited to, any supplied or
supported hardware, software, firmware and/or micro code;
H) "valid date" shall contain a two-digit month, a two-digit day and a four-digit year.
PERFORMING AGENCY and its subrecipient(s) shall obtain a warranty from any vendorllicensor from which
it obtains product(s) that product(s) delivered and installed under the contractllicense shall accurately process
valid date data when used in accordance with the product documentation provided by the contractorllicensor and
require no extraordinary actions on the part of PERFORMING AGENCY, its personnel, or its subrecipient(s).
Products wder the contractllicense shall possess general integrity, date integrity, explicit and implicit century
capabilities. If the contractllicense requires that specific products shall perform as a system in accordance with
the foregoing warranty,then the warranty shall apply to those listed products as a system. The duration of this
warranty and the remedies available to PERFORMING AGENCY or its subrecipient(s) for breach of the
warranty shall be defined in, and subject to, the terms and conditions of the contractor's standard commercial
warranty or warranties contained in the contractllicense; provided, that notwithstanding any provision to the
contrary in such commercial warranty or warranties, the remedies available to PERFORMING AGENCY or its
subrecipient(s) shall include repair or replacement of any supplied product if its noncompliance is discovered
and made known to the contractorllicensor in writing within ninety (90) days after fina1 acceptance. Nothing in
the warranty shall be considered to limit any rights or remedies PERFORMING AGENCY or its subrecipient(s)
may otherwise have wder the contractllicense.
RECEIVING AGENCY will not hold PERFORMING AGENCY responsible if the information coming to
PERFORMING AGENCY'S product/software from RECEIVING AGENCY is inaccmate or corrupt.
ARTICLE 13. Standards for Fmanclal and Prol!l'ammatic Mana!!ement
PERFORMING AGENCY shall bill all third party payers for services provided under the Attachment(s) before
submitting any request for payment to RECEIVING AGENCY. A third party payer is any person or entity who
has the legal responsibility for paying all or part of the services provided, including, commercial health or
liability insurance carriers, Medicaid, or other federal, state, local and private fimding sources. Third party
billing functions shall be provided by PERFORMING AGENCY at no cost to the client. PERFORMING
AGENCY or its subrecipient shall become a Medicaid provider if performing approved Texas Medicaid services
authorized by the Attacbment(s).
PERFORMING AGENCY, if designated a 50l(c)(3) organization as defmed in the Internal Revenue Service
Code or a for-profit organization, and its governing board, shall bear full responsibility for the integrity of the
fiscal and programmatic management of the organization. Such responsibility shall include: accowtability for
all funds and materials received from RECEIVING AGENCY; compliance with RECEIVING AGENCY rules,
policies, procedures, and applicable federal and state laws and regulations; and correction of fiscal and program
deficiencies identified through self-evaluation and RECEIVING AGENCY'S monitoring processes. Further,
PERFORMING AGENCY'S governing board shall ensure separation of powers, duties, and functions of board
members and staff. Ignorance of any contract provisions or other requirements contained or referenced in this
contract shall not constitute a defense or basis for waiving or appealing such provisions or requirements.
ARTICLE 14. Bondln!! and Liability Insurance
PERFORMING AGENCY is required to carry a fidelity bond or insurance coverage equal to the amount of
funding provided under the Attacbment(s) up to $100,000 that covers each employee of PERFORMING
AGENCY handling funds under this contract, including person(s) authorizing payment of such funds. The
fidelity bond or insurance shall provide for indenmification of losses occasioned by: 1) any fraudulent or
dishonest act or acts committed by any of PERFORMING AGENCY'S employees, either individually or in
concert with others, and/or 2) failure of PERFORMING AGENCY or any of its employees to perform faithfully
(Feejor-Service)
GENERAL PROVISIONS 612004
Page 9
RECEIVlNG AGENCY may withhold all or part of any payments to PERFORMING AGENCY to offset
payment for any ineligible expenditures that PERFORMING AGENCY has not paid to RECEIVlNG
AGENCY, or if ftnancial status report(s) required under the Reports Article are not submitted by the date(s) due.
RECENING AGENCY may take repayment from funds available under any Attachment, active or expired, in
amounts necessary to fulfill PERFORMING AGENCY repayment obligations.
ARTICLE 16. PrOl!l'am Income
PERFORMING AGENCY may, or if PERFORMING AGENCY is a local health department shall, develop a
fee-for-service system and a schedule of fees for personal health services in accordance with the provisions of
Health and Safety Code, ~ 12.031; the Texas Board of Health rules covering Fees for Clinical Health Services,
25 TAC ~1.91; and other applicable laws. No patient shall be denied a service due to inability to pay..
All revenues directly generated by an Attachment(s) supported activity or earned only as a result of the
Attachment(s) during the term of the Attachment(s)are considered program income. Program income shall be
used by l'ERFORMING AGENCY to further the program objectives of the state/federal statute under which the
Attachment(s) was/were made, and it shall be spent on the same project in which it was generated.
PERFORMING AGENCY shall identify and report this income utilizing the forms and time frames specified in
the Reports Article of these provisions or the Special Provisions of the Attachment.
PERFORMING AGENCY shall use program income to provide additional client services. Any program
income not used to provide additional client services shall be deducted from PERFORMING AGENCY'S total
final billing to RECEIVING AGENCY at the end of the Attachment(s) tenn(s).
RECEIVlNG AGENCY may base future funding levels, in part, upon PERFORMING AGENCY'S proftciency
in identifying, billing, collecting, and reporting program income, and in utilizing it for the purposes and
conditions of the applicable Attachment(s).
ARTICLE 17. Contracts with Subrecioients
PERFORMING AGENCY may enter into contracts with subrecipients unless restricted or otherwise prohibited
in specific Attachment(s). Prior to entering into an agreement equaling $25,000 or twenty-five percent (25%) of
an Attachment, whichever is greater, PERFORMING AGENCY shall obtain written approval from
RECEIVlNG AGENCY.
Contracts with subrecipients shall be in writing and include the following:
. Name and address of all parties;
. A detailed description of the services to be provided;
. Measurable method and rate of payment and total amount of the contract;
. Clearly defined and executable termination clause;
. Beginning and ending dates which coincide with the dates of the applicable Attachment(s) or cover a
tenn within the beginning and ending dates of the applicable Attachment(s);
. Records retention requirements consistent with UGMS;
. Access to inspect the work and the premises on which any of the work is performed, in accordance with
the Inspections Article contained in this contract;
. All clauses required by state/federal statutes, executive orders, and their implementing regulations; and
. Where applicable, federal statutes and regulations, including federal grant requirements applicable to
funding sources, Uniform Grant Management Standards issued by the Governor's Office, applicable
Office of Management and Budget Circulars, and applicable Code of Federal Regulations.
(Fee-for-Servlce)
GENERAL PROVISIONS 612004
Page 11
. . Compliance with all applicable standards, orders, or requirements issued under ~306 of the Clean Air
Act (42 use ~7401), ~S08 of the Clean Water Act (33 USC ~1368), Executive Order 11738, and
Environmental Protection Agency regulations (40 CFR Part 15) (contracts, subcontracts, and subgrants
of amounts in excess of51oo,000).
. Mandatory standards and policies relating to efficiency which are contained in the state energy plan
issued in compliance with the Energy Policy and Conservation Act (p. L. 94-163), 42 USC ~~6201 et
seq., as amended.
ARTICLE 19. Reuorts
PERFORMING AGENCY shall submit the financial, program, and progress reports required by RECEIVING
AGENCY in the format agreed to by the parties. PERFORMING AGENCY shall provide RECEIVING
AGENCY and/or HHSC other reports including financial reports determined necessary to accomplish the
objectives of this contract and to monitor compliance. If PERFORMING AGENCY is legally prohibited from
providing such reports, it shall immediately notify RECEIVING AGENCY and/or HHSC.
ARTICLE 20. Insuections
RECEIVING AGENCY, Health and Human Services Commission (HHSC), and, when federal funds are
involved, any authorized representative(s) of the federal government ha.ve the right, at all reasonable times, to
inspect or otherwise evaluate the work (including reviews of client or patient records and discussions with staff)
performed by PERFORMING AGENCY and its subrecipient(s), if any, and the premises on which the work is
being performed. PERFORMING AGENCY and its subrecipient(s) shall participate in inspections and provide
reasonable access, facilities, and assistance to the representatives. All inspections and evaluations will be
conducted in such a manner as will not unduly interfere with the work.
PERFORMING AGENCY (and any parent, affiliate or subsidiary organization, if such a relationship exists) and
its subrecipient(s), if any, shall give RECENlNG AGENCY, HHSC, the federal government, and the Texas
State Auditor, or any of their duly authorized representatives, access to any pertinent books, documents, papers,
and client or patient records, if any, for the purpose of making audit, examination, excerpts, and transcripts of
transactions related to this contract. RECENlNG AGENCY and HHSC will have the right to audit billings
both before and after payment. Payments will not foreclose the right of RECEIVING AGENCY and HHSC to
recover excessive or illegal payments.
Any deficiencies identified by RECEIVING AGENCY and/or HHSC upon examination of PERFORMING
AGENCY'S records will be conveyed in writing to PERFORMING AGENCY. PERFORMING AGENCY'S
resolution of fmdings will be conveyed in writing within thirty (30) days of receipt of the report of the
deficiencies. PERFORMING AGENCY'S resolution of findings will be sent to the agency(ies) referenced in
the cover letter of the report. A RECENlNG AGENCY and/or HHSC determination of either an inadequate or
inappropriate resolution of the findings may result in sanctions which will remain in effect until RECEIVING
AGENCY and HHSC determines the deficiencies are properly remedied.
ARTICLE 21. Records Retention
PERFORMING AGENCY and its subrecipients and subcontractors shall retain medical records in accordance
with 22 Texas Administrative Code (TAC), Part 9, ~165.l(b)(c) or other applicable statutes and regulations
governing medical information. PERFORMING AGENCY shall retain and preserve all other records, including
financial records, which are generated or collected by PERFORMING AGENCY or its subrecipients or
subcontractors under the provisions of this contract, for a period of four (4) years after the termination of the
Attachment(s). If an Attachment is funded through Medicaid, the federal retention period, if more than four (4)
years, shall apply. PERFORMING AGENCY and its subrecipients shall retain all records for an Attachment
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GENERAL PROVISIONS 612004
Page 13
rule, regulation, or federal guideline will prevail over the provisions of this Article unless the statute, rule,
regulation, or guideline can be read together with the provision(s) of this Article to give effect to both.
RECEIVING AGENCY may:
. A. Terminate all or a part of this contract. See the Termination Article in these provisions.
B. Suspend all or part of this contract. Suspension is, depending on the context, either (1) the temporary
withdrawal of PERFORMING AGENCY'S authority to obligate funds pending corrective action by
PERFORMING AGENCY or its subrecipient(s) or pending a decision to terminate or amend the
contract, or (2) an action taken by a suspending official in accordance with agency regulations
implementing Executive Order 12549 to immediately exclude a person from participating in contract
transactions for a period, pending completion of an investigation and such legal or debarment
proceedings as may ensue. PERFORMING AGENCY costs resulting from obligations incurred by
PERFORMING AGENCY during a suspension are not allowable unless expressly authorized by the
notice of suspension;
C. Disallow (deny both use of funds and matching credit for) altor part of the activities or action not in
compliance;
D. Temporarily withhold cash payments. Temporarily withholding cash payments means the temporary
withholding of advances or reimbursements to PERFORMING AGENCY or its subrecipient(s) for
proper charges or obligations incurred, pending resolution of issues of noncompliance with contract
conditions or indebtedness to the United States or to the State of Texas;
E. Permanently withhold cash payments. Pennanent withholding of cash payment means that
RECEIVlNG AGENCY retains funds billed by PERFORMING AGENCY or its subrecipient(s) for a)
unallowable, undocumented, disputed, inaccurate, improper, or erroneous billings; b) failure to
comply with contract provisions; or c) indebtedness to the United States or to the State of Texas;
F. Deny contract renewal or future contract awards to a PERFORMING AGENCY;
G.' Delay contract execution with PERFORMING AGENCY while other imposed or proposed sanctions
are pending resolution;
H. Place PERFORMING AGENCY on probation. Probation means that PERFORMING AGENCY will
be placed on accelerated monitoring for a period not to exceed six (6) months at which time items of
noncompliance shall be resolved or substantial improvement shown by PERFORMING AGENCY;
I. Conduct accelerated monitoring of PERFORMING AGENCY. Accelerated monitoring means more
frequent or more extensive monitoring will be performed by RECENING AGENCY than would
routinely be accomplished;
J. Require PERFORMING AGENCY to obtain technical or managerial assistance;
K. Disallow requests for payments by disapproving costs or fees submitted for payment or
reimbursement by PERFORMING AGENCY;
1. Establish additional prior approvals for expenditure of funds by PERFORMING AGENCY;
M. Require additional, more detailed, financial and/or programmatic reports to be submitted by
PERFORMING AGENCY;
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GENERAL PROVISIONS 6/2004
Pag<: 15
PERFORMING AGENCY'S notice shall contain the following: (I) a copy of the letter from RECEIVING
AGENCY notifying PERFORMING AGENCY of the sanction; (2) a specific description of each act that is the
basis for the dispute; (3) the grounds upon which PERFORMING AGENCY bases the complaint; (4) an
identification of the issue or issues to be resolved; (5) a precise statement of the relevant facts; (6) any
documentation in support of PERFORMING AGENCY'S position; and (7) a statement and authorities in
support of PERFORMING AGENCY'S position.
Evidence that PERFORMING AGENCY properly notified RECEIVING AGENCY consists of any of the
following documents: (I) signature on delivery card; (2) confirmation of a facsimile to the correct telephone
number; or (3) signed acknowledgment of delivery.
RECEIVING AGENCY'S representative will schedule a meeting or a conference call to attempt to resolve the
issues in dispute. If the dispute is resolved, any resolution will be in writing and will be signed by all parties. If
the dispute is not resolved, RECEIVING AGENCY'S representative will notify PERFORMING AGENCY in
writing. RECEIVING AGENCY will appoint a reviewer(s), who will review the infonnation, who may permit
or require additional information and who may grant, deny, or modify all relief requested in the written notice of
dispute. The reviewer( s)' s decision will be in writing and will contain a discussion of the reason for the decision
and the remedial action, if any. The reviewer( s) will send copies of the decision to all parties by any verifiable
means. The decision of the reviewer(s) is final and is the final action of RECEIVING AGENCY for purposes of
further proceedings.
A state statute or rule or a federal statute, regulation or guideline will prevail over the provisions of this Article
unless the statute, rule, regulation or guideline can be read together with the provision or provisions of this
Article to give effect to both.
ARTICLE 26. Breach of Contract Claim
The process for a breach of contract claim provided for in Chapter 2260 of Texas Government Code and
implemented in the rules at 25 TAC ~~1.431-I.447 shall be used by RECEIVING AGENCY and
PERFORMING AGENCY to attempt to resolve any claim for breach of contract made by PERFORMING
AGENCY. (This process is not applicable for governmental entities.)
A. PERFORMING AGENCY'S claims for breach of this contract that the parties can not resolve in the
ordinary course of business shall be submitted to the negotiation process provided in Chapter 2260,
subchapter B, Texas Government Code. To initiate the process, PERFORMING AGENCY shall
submit written notice, as required by subchapter B, to RECEIVING AGENCY'S Office of General
Counsel. Said notice shall specifically state that the provisions of Chapter 2260, subchapter B, are
being invoked. A copy of the notice shall also be given to all other representatives of RECEIVING
AGENCY and PERFORMING AGENCY otherwise entitled to notice under this contract.
Compliance by PERFORMING AGENCY with subchapter B is a condition precedent to the filing of
a contested case proceeding under Chapter 2260, subchapter C, Texas Government Code.
B. The contested case process provided in Chapter 2260, subchapter C, Texas Government Code is
PERFORMING AGENCY'S sole and exclusive process for seeking a remedy for any and all alleged
breaches of contract by RECEIVING AGENCY if the parties are unable to resolve their disputes
under subparagraph A. of this paragraph.
C. Compliance with the contested case process provided in subchapter C is a condition precedent to
seeking consent to sue from the Legislature under Chapter 107 of the Civil Practices and Remedies
Code. Neither the execution of this contract by RECEIVING AGENCY nor any other conduct of any
{Fee-for-Service}
GENERAL PROVISIONS 612004
Page 17
.'!"
(d) RECENING AGENCY determines that PERFORMING AGENCY is without the
persormel or resources to perform under this contract;
(e) RECENING AGENCY determines that PERFORMING AGENCY, its agent or
another representative offered or gave a gratuity (e.g., an entertainment or gift) to an
official or employee of RECENING AGENCY for the purpose of obtaining a contract
or favorable treatment;
(f) PERFORMING AGENCY'S management system does not meet the UGMS
management standards; or
(g) PERFORMING AGENCY appears to be financially unstable. Indicators of financial
instability may include one or more of the following:
(i) PERFORMING AGENCY fails to make payments;
(ii) PERFORMING AGENCY makes an assignment for the benefit of its creditors;
(iii) PERFORMING AGENCY admits in writing. its inability to pay its debts
generally as they become due;
(iv) If judgment for the payment of money in excess of $50,000 (which is not
covered by insurance) is rendered by any court or governmental body against
PERFORMING AGENCY, and PERFORMING AGENCY does not (a)
discharge the judgment or (b) provide for its discharge in accordance with its
terms, or (c) procure a stay of execution within thirty (30) days from the date of
entry thereof, and within the thirty (30) day period or a longer period during
which execution of the judgment shall have been stayed, appeal therefrom and
cause the execution thereof to be stayed during such appeal while providing such
reserves therefore as may be required under generally accepted accounting
principles;
(v) A writ or warrant of attachment or any similar process shall be issued by any
court against all or any material portion of the property of PERFORMING
AGENCY, and such writ or warrant of attachment or any similar process is not
released or bonded within thirty (30) days after its entry;
(vi) PERFORMING AGENCY is adjudicated bankrupt or insolvent;
(vii) PERFORMING AGENCY files a case under the Federal Bankruptcy Code or is
seeking relief under any provision of any bankruptcy, reorganization,
arrangement, insolvency, readjustment of debt, dissolution, receivership or
liquidation law of any jurisdiction, whether now or hereafter in effect, or
consents to the filing of any case or petition against it under any such law;
(viii) Any property or portion of the property of PERFORMING AGENCY is
sequestered by court order and the order remains in effect for more than thirty
(30) days after PERFORMING AGENCY obtains knowledge thereof;
(ix) A petition is filed against PERFORMING AGENCY under any state
reorganization, arrangement, insolvency, readjustment of debt, dissolution,
liquidation, or receivership law of any jurisdiction, whether now or hereafter in
effect, and such petition is not dismissed within thirty (30) days; or
(x) PERFORMING AGENCY consents to the appointment of a receiver, trustee, or
liquidator of PERFORMING AGENCY or ofall or any part of its property.
D. Emergency termination. In emergency circumstances, RECENING AGENCY may terminate this
contract immediately upon notice to PERFORMING AGENCY by any verifiable means.
"Emergency" is defined in the Sanctions Article.
Either party may deliver written notice of intent to terminate by any verifiable method. If either party gives
notice of its intent to tenninate all or a part of this contract, RECENING AGENCY and PERFORMING
AGENCY will attempt to resolve any issues related to the anticipated termination in good faith during the notice
{Fee-for-Service}
GENERAL PROVISIONS 612004
Page 19
DOCUMENT NO. 7560022067 A-2006
ATTACHMENT NO. 01
PURCHASE ORDER NO. 0000309628
PERFORMING AGENCY: PARIS-LAMAR COUNTY HEALTH DEPARTMENT
RECEIVING AGENCY PROGRAM: COMMUNITY HEALTH SERVICES SECTION
TERM: September 01,2005 THRU: August 31, 2006
SECTION 1. SCOPE OF WORK:
PERFORMING AGENCY shall provide or assure the provision of prenatal, preventive, and
primary child health, dysplasia, and dental services (for children and adolescents) for Title V
eligible clients. PERFORMING AGENCY shall provide services approved in the
PERFORMING AGENCY'S application or shall have an established referral relationship with a
qualified provider of each approved service, which it does not provide.
PERFORMING AGENCY shall comply with all applicable federal and state laws, rules,
regulations, standards and guidelines in effect on the beginning date of this contract Attachment
unless amended, including but not limited to:
. Fees for Clinical Health Services, 25 TAC S 1.91 (Local Health Departments only).
The following documents are incorporated by reference and made a part of this contract
Attachment. These include:
. RECEIVING AGENCY'S FY2006 Title V Fee-For-Service Maternal & Child Health
Services Renewal Application and any revisions;
. PERFORMING AGENCY'S FY2006 Application and any revisions;
. RECEIVING AGENCY'S Title V FY2005 Competitive Request For Proposal (RFP);
. PERFORMING AGENCY'S FY2005 Component II, Attachment A application and any
reVISIOns;
. Title V Policy and Procedures Manual, revised for FY2006; and
. RECEIVING AGENCY'S Department of State Health Services Standards for Public
Health Clinic Services, revised August 2004.
Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING
AGENCY shall inform RECEIVING AGENCY Program, in writing, if it shall not continue
performance under this Attachment in compliance with the amended standard(s) or guideline(s).
RECEIVING AGENCY may terminate the Attachment immediately or within a reasonable
period of time as determined by RECEIVING AGENCY.
RECEIVING AGENCY'S Health Service Regional Director or designee, as coordinator of
regional services, will assist RECEIVING AGENCY staff in providing direction to
ATTACHMENT-Page t
PERFORMING AGENCY. RECEIVING AGENCY personnel may, from time to time, provide
technical assistance and training to PERFORMING AGENCY. PERFORMING AGENCY shall
cooperate with RECEIVING AGENCY staff to attain the goals of unified community health
assessment, policy development, coordinated services, and quality assurance and to prevent
unnecessary duplication of services.
PERFORMANCE MEASURES
The following performance measure(s) will be used to assess, in part, the PERFORMING
AGENCY'S effectiveness in providing the services described in this contract Attachment,
without waiving the enforceability of any of the other terms of the contract.
At least 25% of the total amount of this Attachment shall be for services provided to Title V
eligible individuals ages one (1) through twenty-one (21) by PERFORMING AGENCY.
PERFORMING AGENCY shall provide services to clients who receive services in the following
county(ies)/area: Lamar.
SECTION II. SPECIAL PROVISIONS:
General Provisions, Child Abuse Reporting Requirements Article, first sentence, is replaced in
its entirety:
PERFORMING AGENCY is required to comply with this article only as related to
services provided under the following Attachnlents: Human Immunodeficiency Virus and
Sexually Transmitted Diseases (all direct client care services for HIV and other sexually
transmitted diseases funded under the Ryan White CARE Act Title II or general
revenue), Title V Family Planning (CHS/FEE-FP), Title X Family Planning (CHS/TITLE
X), Title XX Family Planning (CHS/TTLXX), Primary Health Care (CHS/PHC), Title V
Maternal and Child Health (CHS/FEE), Special Supplemental Nutrition Program for
Women, Infants, and Children (NSS/WIC-CARD), and the Services Delivery Integration
project (SDVFFS).
General Provisions, Terms and Conditions of Payment Article, is revised to include:
PERFORMING AGENCY'S contract amount under this Attachment is a ceiling against
which it may bill, on a fee-for-service basis, for the provision of allowable services to
Title V eligible clients. Only allowable services provided to Title V eligible clients may
be billed against this ceiling. The current schedule of allowable services and rates, as well
as Title V eligibility requirements, may be modified at the sole discretion of
RECEIVING AGENCY with thirty (30) days written notice to PERFORMING
AGENCY. The notice will provide PERFORMING AGENCY with an opportunity to
terminate this Attachment should the modification include a reduction in rates.
PERFORMING AGENCY shall have thirty (30) days from receipt of this notice to
exercise the option for termination. If the PERFORMING AGENCY does not exercise
the option during the thirty (30) day time period, PERFORMING AGENCY shall be
deemed to have waived the option. A Request for "Advance or Reimbursement", Form
A TT ACHMENT - Page 2
270 (Form GC-lO), is due no later than ninety (90) days after the end of the Attachment
term. This report shall be marked "Final".
PERFORMING AGENCY shall notify RECEIVING AGENCY immediately in the event
of any significant change affecting the PERFORMING AGENCY'S identity, ownership
or control, name change, governing board membership, vendor identification, medical or
program director, changes in hours of operation, clinic site information regarding closure,
relocation, change of address, and openings of new clinic sites. Failure to disclose the
required information or inaccurate disclosure by the PERFORMING AGENCY may be
treated as a material breach of this contract and may be grounds for termination.
BILLING REOUIREMENTS
PERFORMING AGENCY shall bill RECEIVING AGENCY on a monthly basis for
allowable services provided to Title V eligible clients. Bills for all allowable services
shall be submitted as aggregate activity reports with a DSHS Monthly Reimbursement
Request and shall not refer to or identify individual clients. PERFORMING AGENCY
shall bill within thirty (30) days after the end of the month which services were provided
or within sixty (60) days in cases of potentially Medicaid eligible individuals who are
denied eligibility by the Health and Human Services Commission. All bills shall be
submitted within ninety (90) days of the end of the Attachment term.
In billing RECEIVING AGENCY, PERFORMING AGENCY shall certify that all billed
services have been provided only to individuals who have been determined to be eligible
for Title V services. RECEIVING AGENCY will pay PERFORMING AGENCY for all
acceptable vouchers submitted up to PERFORMING AGENCY'S contract ceiling
amount. Billing vouchers submitted outside of the time frames indicated above shall be
subj ect to disallowance.
BILLING ACTIVITY
RECEIVING AGENCY shall distribute funds in a way that will maximize the delivery of
authorized services to eligible clients. RECEIVING AGENCY will monitor
PERFORMING AGENCY'S billing activity. If utilization is below that projected in
PERFORMING AGENCY'S contract ceiling amount, shown in SECTION III. BUDGET,
PERFORMING AGENCY'S ceiling may be subject to a decrease for the remainder of the
contract Attachment period. PERFORMING AGENCY may be subject to contract
ceiling amount decreases if PERFORMING AGENCY'S billing activity is less than
projected.
RECEIVING AGENCY may pay for additional services as specified in this Attachment
if provided by PERFORMING AGENCY during the term of this Attachment (but not
otherwise paid during the term of this Attachment) if is in the best interest of the State
and the RECEIVING AGENCY Program to do so, and funds are available. If
PERFORMING AGENCY exceeds the ceiling amount of the Attachment,
PERFORMING AGENCY shall continue to bill RECEIVING AGENCY for the services
provided. RECEIVING AGENCY may pay for these additional services if funds become
available at a later date.
ATTACHMENT - Page 3
ELIGffiILITY
All individuals considered for Title V eligibility must be screened and determined
eligible using a DSHS or Title V program approved screening tool as updated in the
spring of each year when federal poverty levels and eligibility determination forms are
revised.
CO-PAY
PERFORMING AGENCY may assess a co-pay from clients provided services by
RECEIVING AGENCY under this Attachment. A co-pay shall not be assessed from
such clients if their family income is at or below 100% of the most recently defined
federal poverty level. A co-pay assessment may not exceed 25% of the amount
RECEIVING AGENCY pays PERFORMING AGENCY for the provision of a given
service. A client shall not be denied services due to inability to pay. Local Health
Departments shall comply with RECEIVING AGENCY fee collection policies detailed
in 25 TAC S 1.91.
General Provisions, Program Income Article, is revised to include:
All revenues directly generated by a Contract Attachment(s) supported activity or eamed
only as a result of the Attachment(s) during the term of the Attachment(s) are considered
program income. PERFORMING AGENCY shall identify and report all program
income monthly.
Program Income may be retained by PERFORMING AGENCY so long as it is used to
provide services specified in the scope of work detailed in this Attachment. This shall be
demonstrated only by submission of acceptable billing vouchers for services provided to
Title V eligible clients which exceeds PERFORMING AGENCY'S Attachment amount
by the total program income amount.
General Provisions, Reports Article, is revised to include:
PERFORMING AGENCY shall submit:
. Title V MCH Monthly Aggregate Activity Report, in conjunction with each
monthly billing request. Each report shall detail the total unduplicated number of
clients seen for the first time within a service category type during the contract
period by age, and race/ethnicity. Billing requests will not be processed for
payment by RECEIVING AGENCY unless accompanied by a complete
corresponding aggregate report;
. A Request for Advance or Reimbursement Form 270 (Form GC-lO), no later than
ninety (90) days after the end of the attachment term; and,
. Other reports as deemed necessary by RECEIVING AGENCY upon reasonable
notice to PERFORMING AGENCY.
ATTACHMENT - Page 4
In addition to the site visits authorized by the Inspections Article of the General Provisions,
PERFORMING AGENCY shall allow RECEIVING AGENCY to conduct on-site quality
assurance reviews as deemed necessary by RECEIVING AGENCY. Unsatisfactory review
findings may result in implementation of General Provisions, Sanctions Article.
PERFORMING AGENCY certifies that neither the PERFORMING AGENCY nor any
individual who has a direct or indirect ownership or controlling interest of 5% or more of the
PERFORMING AGENCY nor any PERFORMING AGENCY officer, director, agent or
managing employee (e.g. general manager, business manager, administrator, director, or like
individual who exercises operational or managerial control over PERFORMING AGENCY or
who directly or indirectly conducts the day-to-day business of the PERFORMING AGENCY), is
an entity or individual who:
. Has been convicted of any offense under 42 U.S.C. S l320a-7(b)(I)-(3);
.' Has had a civil monetary penalty assessed under 42 U.S.C. S 1320a and/or 42 U.S.C. S
1320a-8; or,
. Has been excluded from participation in a program under 42 U.S.C. S 1395 et seq.; or
under a State health care program.
If the foregoing statement is not true, PERFORMING AGENCY shall submit a
disclosure/ownership form to RECEIVING AGENCY. PERFORMING AGENCY shall
immediately notify the RECEIVING AGENCY in writing, in the event that the foregoing
statement changes during the term of this Attachment. A false statement regarding
PERFORMING AGENCY'S status will be treated as a material misrepresentation.
PHARMACY
If PERFORMING AGENCY is dispensing and/or providing prescribed medications, e.g., birth
control pills, antibiotics, etc., on site, it shall have, at a minimum, a Class D pharmacy license as
provided by the Texas Pharmacy Act, Occupations Code, Chapter 560, or shall dispense and/or
provide such medications in compliance with other pharmacy statutes with prior approval from
RECEIVING AGENCY.
SECTION III. BUDGET:
PERFORMING AGENCY shall adhere to the current schedule of allowable services and rates as
referenced in SECTION II. SPECIAL PROVISIONS, as amended and approved by the
RECEIVING AGENCY.
Total payments will not exceed $20,000.00.
ATTACHMENT - Page 5