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2004-126-RES AUTHORIZING EXECUTION OF CONTRACT FOR PUBLIC HEALTH SERVICES TDH DOCUMENT NO. 7560022067 A-2005 (ATTACHMENT NO 01) CONTRACT CHANGE NOTICE NO. 01 (ATTACHMENT NO 01A) RESOLUTION NO. 2004-126 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PARIS, PARIS, TEXAS, APPROVING AND AUTHORIZING THE EXECUTION OF A CONTRACT FOR PUBLIC HEALTH SERVICES, TDH DOCUMENT NO. 7560022067A-2005 (ATTACHMENT NO. 01); APPROVING AND AUTHORIZING THE EXECUTION OF CONTRACT CHANGE NOTICE NO. 01 (ATTACHMENT NO. 01A); 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 Public Health Services, TDH Document No. 7560022067A-2005 (Attachment No. 01), 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; and, WHEREAS, it is further deemed appropriate that the form of Contract Change Notice No. 01 (Attachment No. OIA), attached hereto as Exhibit B, 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 forms of the Contract for Public Health Services, TDH Document No. 7560022067A-2005 (Attachment No. 01), attached hereto as Exhibit A, and Contract Change Notice No. 01 (Attachment No. 01A), attached hereto as Exhibit B, be, and the same are 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 Public Health Services and Contract Change Notice No. 01, under the terms and conditions and in the forms shown in Exhibits A and B, respectively, attached hereto. Section 4. That this resolution shall be effective from and after its date of passage. PASSED AND APPROVED this 12th day of Jul , ~,\ '\'\ { \" - '-. l __.:;:,.,,, ;"", "- ( '.....t--- ATTEST: f)4~ ~ Sherian Dixon, Assistant City Clerk APPROVED AS TO FORM: "', :::ONTRACT FOR PUBLIC HEALTH SERVICES I Contract Issued by: (RECEIVING AGENCY) DEPARTMENT OF STATE HEALTH SERVICES 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-3199 DSHS DOCUMENT NO. 7560022067 A2005 WW Legal Authority to Contract: Chapters 12 and 121, Health and Safety Code. Venue: The provisions of this Contract shall be interpreted in accordance with Texas law. Venue for any court disputes shall be in Travis County. Texas. I 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) PA YEE 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 PAYEE AGENCY Fiscal Year Ending Month: September i PAYEE BUSINESS INFORMATION FOR STATISTICAL REPORTING: r 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. Please check the categories that apply to your business. 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 COVER PAGE 2 - Details of Attachment(s) COVER PAGE 3 - Authorized Signatures GENERAL PROVISIONS - 6/2004 A IT ACHMENT(S) EXHIBITS, IF APPLICABLE Cover Page 1 EXHIBIT 1l L~TAILS OF ATTACHME~-lS Au! DSHS Program ID! Term Financial Assistance Direct Total Amount Amd DSHS Purchase Assistance (DSHS Share) No. Order Number Begin End Source of Amount Funds* 01 ACFH/FEE 09/01/04 08/31/05 20,000.00 0.00 20,000.00 038765000 02 ACFH/FEE-FP 09101/04 08/31/05 10,781.00 0.00 10,781.00 038767000 DSHS Document No.7560022067A2005 Totals $ 30,781.00 $ 0.00 $ 30,781.00 . *Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS. r 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: RECEIVING AGENCY NAME: DEPARTMENT OF STATE HEALTH SERVICES By: ~ (Signature of person authorized to sign contracts) Bob Burnette, Director Procurement and Contracting Services Division (Name and Title) Date: DSHS Document No: 7560022067 A2005 Cover Page 3 GENERAL PROVISIONS FOR DEPARTMENT OF STATE HEALTH SERVICES SUBRECIPIENT GRANT CONTRACTS ARTl"LE.. 1. - PREAMBLE 1 - TERM 3 - FUNDlNG 4 - AMENDMENTS 5 - APPLICABLE LAWS AND STANDARDS 6 - DEBARMENT AND SUSPENSIONS 7 - ASSURANCES 8 CHILD ABUSE REPORTING REQUIREMENTS 9 - INTELLECTUAL PROPERTY . 10.- mSTORlCALLYUNDERUTll..IZEDBUSINl3SSES It - CONFLICTOF INTEREST . 12 - CERTIFICATION OF SOFfWARE, HARDW1\R.E,FIRMWARE,ANf)MICRO CODE PRODUCTS . . 13 - STANDARDS FOR FINANCIAL AND PROGRAMMATIC MANAGEMENT 14 - BONDING AND LIABILITY lNSURANCE . 15 - TERMS AND CONDITIONS OF PAYMENT 16. - PROGRAM lNCOME 17 .. - CONTRACTS. WITH SUBRECIPIENTS .. ..... . ... .. ..-.. 18 - CONTRACTS FORPROCUREMENT 19 - REPORTS 20 - INSPECTIONS 21 - RECORDSRETENTION 22 - CONFIDENTIALITY OF PROTECfEDHEALTH INFORMATION 23 -. HOLD HARMLESS 14 SANCTIONS .....15 - SANCTION REVIEW ..Z6 - . BREACH OF CONTRACT. CLAIM 27 - TERMINATION 28 - VOID CONTRACT 29 - SEVERABILITY ..30 - SURVIVAL OF TERMS 31 - CONSTRUCTIONOFAMBIGUlTIES. 32 - NO WAIVER OF SOVEREIGN IMMUNl1'Y Paper Publications Number: 29-11835, Revised June 2004 (F ee-for-Service) GENERAL PROVISIONS 6/2004 ARTICLE 3. Fundinl! This contract is contingent upon the continued availability of funding. If ftmds become unavailable through lack of appropriations, budget cuts, transfer of ftmds between programs or agencies, amendment of the appropriations act, health and human services agency consolidations, or any. other disruption of current appropriations, provisions of the Termination Article shall apply. ARTICLE 4. Amendments Amendments to this contract must be in writing and signed by individuals with authority to bind the parties. Unifonn Grants Management Standards and RECEIVING AGENCY procedures authorize limited changes to a contract attachment with prior written approval from RECEIVING AGENCY. PERFORMING AGENCY must submit request in format prescribed by RECEIVING AGENCY Program. .RECEIVING AGENCY will consider the request l(lIld document approval or disapproval in writing. PERFORMING AGENCY is responsible for ensming that any modification to a contract Attachment becomes a part of the contract file. RECEIVING AGENCY may not waive any term, covenant, or condition of this contract unless by amendment executed in compliance with this Article. PERFORMING AGENCY shall not perform and RECEIVING AGENCY will not pay for the performance of different or additional services, work, or products except pursuant to an amendment that is executed in compliance with this Article. PERFORMING AGENCY shall plan expenditures so that any necessary budget revisions or amendments are executed no later than ninety (90) days prior to the expiration of the Attachment term. PERFORMING AGENCY shall provide a written justification for any budget revisions and/or amendments. If a budget revision or amendment is requested during the last quarter of the Attachment term, the written justification shall include a reason for the delay. Revision or amendment requests may be granted at the discretion of RECEIVING AGENCY. ARTICLE S. ADDlicable Laws and Standards This contract shall be interpreted under and in accordance with the laws of the State of Texas and enabling state rules. Where applicable, federal statutes and regulations, including federal grant requirements applicable to funding sources, shall apply to this contract. The principles in the Uniform Grant Management Standards (UGMS) as amended by revised federal circulars and incorporated in UGMS by the Governor's Budget and Planning Office shall be used as a guide in the pricing of fixed price arrangements where costs are used in determining the appropriate price. PERFORMING AGENCY shall not use funds granted under this contract to pay any person for influencing or attempting to influence an officer or employee of any agency, federal or state, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in cormection with the awarding of any contract or grant or the extension, continuation, renewal, amendment, or modification of any contract or grant (31 USC ~1352, as amended, and UGMS). If at any time this contract exceeds $100,000 of federal funds, PERFORMING AGENCY shall file with RECEIVING AGENCY a declaration containing the name of any registrant under the Lobbying Disclosure Act of 1995 who has made lobbying contacts on behalf of PERFORMING AGENCY in connection with that contract or grant, a certification that none of the funds provided by RECENING AGENCY have been or will be used for payment to lobbyists, and disclosure of the names of any and all registered lobbyists with whom PERFORMING AGENCY has an agreement. PERFORMING AGENCY shall require any person who requests or receives a subgrant or subcontract to file the same declaration, certification, and disclosure with RECEIVING AGENCY. PERFORMING AGENCY shall file the declaration, certification, and disclosure at the time of application for the contract or grant; upon (Fee-for-Service) GENERAL PROVISIONS 612004 Page 2 . The Drug Abuse Office and Treatment Act of 1972, 21 USC ~~1101 et seq., as amended, relating to nondiscrimination on the basis of drug abuse; . The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, 42 USC ~290dd (b)(l), as amended, relating to the nondiscrimination on the basis of alcohol abuse or alcoholism; . Public Health Service Act of 1912, ~~523 and 527, 42 USC ~290dd-2, as amended, relating to confidentiality of alcohol and drug abuse patient records; . Title vm of the Civil Rights Act of 1968, 42 USC ~~3601 et seq., as amended, relating to nondiscrimination in the sale, rental or financing of housing; . The requirements of any other nondiscrimination statute(s); and Collectively, such requirements obligate RECEIVING AGENCY to provide services without discrimination on the basis of race, color, national origin, religion, age, sex or disability. PERFORMING AGENCY shall carry out the terms of this contract in a manner which will assist RECEIVING AGENCY in complying with such obligations to the fullest extent of PERFORMING AGENCY'S ability. PERFORMING AGENCY agrees to comply with all or part of the following, as applicable: A. Texas Labor Code, Chapter 21, which requires that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin, or age. B. Immigration Reform and Control Act of 1986, 8 USC ~1324a, as amended, regarding employment verification and retention of verification forms for any individual(s) hired on or after November 6, 1986, who will perform any labor or services under this contract. C. Pro-Children Act of 1994, 20 USC ~~6081-6084, regarding the provision of a smoke-free workplace and promoting the non-use of all tobacco products. D. The National Research Service Award Act of 1971, 42 USC ~~289a-l et seq., as amended, and 6601 (p.L. 93-348 and P.L. 103-43), as amended, regarding the protection of human subjects involved in research, development, and related activities supported by any applicable award of federal assistance, as implemented by 45 CFR Part 46, Protection of Human Subjects. E. The Clinical Laboratory Improvement Amendments of 1988, 42 USC ~263a, as amended, which establish federal requirements for the regulation and certification of clinical laboratories. F. The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens, 29 CFR ~1910.1030, which set safety standards for those workers and facilities in the private sector who may handle blood borne pathogens, or Title 25 Texas Administrative Code (T AC), Chapter 96, which affects facilities in the public sector. G. Laboratory Animal Welfare Act of 1966, 7 USC ~~2131 et seq. (p.L. 89-544), as amended, pertaining to the care, handling, and treatment of warm-blooded animals held for research, teaching, or other activities supported by this award of assistance. H. Texas Government Code, Chapter 469, as amended, pertaining to standards which eliminate architectural barriers for persons with disabilities. I. Health and Safety Code, Chapter 165, relating to the rights of mothers to breast-feed and the promotion of breast-feeding. RECEIVING AGENCY will support PERFORMING AGENCY in complying by providing promotional material and information that encourages breast-feeding to (Fee-for-Service) GENERAL PROVISIONS 6/2004 Page 4 PERFORMING AGENCY shall comply with the flood insurance purchase requirements of 102(a) of the Flood Disaster Protection Act of 1973,42 USC ~~4001-4003, as amended. Section 102(a) requires the purchase of flood insurance in communities where the insurance is available as a condition for the receipt of any federal financial assistance for construction or acquisition proposed for use in any area that has been identified by the Secretary of the U.S. Department of Housing and Urban Development as an area having special flood hazards. As required by Texas Family Code, ~231.006, a child support obligor who is more than thirty (30) days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least twenty-five percent (25%) is not eligible to receive payments from state funds under a contract to provide property, materials, or services or receive a state-funded grant or loan. If applicable, PERFORMING AGENCY agrees to comply with these provisions, certifies that it is not ineligible to receive the payments specified in this contract, and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. Pursuant to Government Code ~ 403.055, Receiving Agency will not approve and the State Comptroller will not issue payment to Perfonning Agency if Performing Agency is indebted to the state for any reason, including a tax delinquency. If PERFORMING AGENCY provides medical, dental, psychological or surgical treatment to a minor under this contract, either directly or through contracts with subrecipients, the treatment of a minor shall be provided only if consent to treatment is obtained pursuant to Chapter 32 of the Texas Family Code relating to consent to treatment of a child by a non-parent or child. If requirements of federal law relating to consent directly conflict with Chapter 32 of the Family Code, federal law shall supersede state law. If PERFORMING AGENCY provides immunizations, PERFORMING AGENCY shall comply with all immunization reporting guidelines and requirements set forth in the Health and Safety Code, Chapter 161, Subchapter A. This requirement shall also apply to subrecipients or subcontractors of PERFORMING AGENCY, if any. PERFORMING AGENCY shall comply with the requirements of the Texas Workers' Compensation Act, Labor Code, Chapters 401-406, and rules promulgated there under found at 28 Texas Administrative Code (TAC), Part 2, which cover compensation for employees' injuries. When incorporated into an Attachment, standard assurances contained in the application package, if any, become terms or conditions for receipt of RECEIVING AGENCY funds. PERFORMING AGENCY and its subrecipients shall maintain an appropriate contract administration system to ensure that all terms, conditions, and specifications are met. PERFORMING AGENCY shall comply with all federal tax laws and is solely responsible for filing all reqUired state and federal tax forms. PERFORMING AGENCY assures it shall not transfer, assign or sell its interest in this contract without the written consent of RECEIVING AGENCY. ARTICLE 8. Child Abuse ReDorti.n2 Reauirements [PERFORMING AGENCY is required to comply with this article only as related to services provided under the following Attachments: Human Immunodeficiency Virus and Sexually Transmitted Diseases (all direct client care services for lllV and other sexually transmitted diseases funded under the Ryan White CARE Act Title II or general revenue), Title V Family Planning (ACFH/FEE-FP, Title X Family Planning (BWHffITLE X), Title XX Family Planning (BWH/ITLXX), Primary Health Care (ACFH/PHC), Title V Maternal and Child Health (ACFH/FEE), Special Supplemental Nutrition Program for Women, Infants, and Children (BNS/WIC-CARD, (Fee-for-Service) - GENERAL PROVISIONS 6/2004 Page 6 ARTICLE 11. Conflict of Interest PERFORMING AGENCY does not have nor will it acquire any interest that would conflict in any manner with the performance of its obligations under this contract. Potential conflicts of interest include an existing business or personal relationship between PERFORMING AGENCY, its principal, or any affiliate or subrecipient with RECEIVING AGENCY, its board members, officers or employees, or any other entity or person involved in any way in any project that is the subject of this contract. ARTICLE 12. Certification of Software. Hardware. Firmware and Micro Code Produds PERFORMING AGENCY certifies that any supplied or supported software, hardware, firmware, and micro code products used individually or together as a system to comply with RECEIVING AGENCY contract requirements shall operate "accurately" in the manner in which they were intended when given a "valid date" containing century, year, month, and day. For purposes of this Article, "supplied or supported software, hardware, firmware, and micro code products" does not include software supported by RECEIVING AGENCY or an agency of the federal government. PERFORMING AGENCY is responsible for installing and implementing any versions of any software provided by RECEIVING AGENCY or an agency of the federal government which is used in performance of this contract. For purposes of this Article, A) "accurately" is defined to include the following: I) calculations shall be correctly performed using four-digit year processing; 2) functionality-on-line, batch including entry, inquiry, maintenance and updates shall support four-digit year processing; 3) interfaces and reports shall support four-digit year processing; 4) processing with a four-digit year shall occur without human intervention; 5) correct results in forward and backward date calculation spanning century boundaries shall be provided; 6) correct leap year calculations shall be performed; and 7) processing correct results in forward and backward date calculation spanning century boundaries shall occur; B) "date integrity" shall mean all manipulations of time-related data (dates, durations, days of week, etc.) shall produce desired results for all valid date values within the application domain; C) "explicit century" shall mean date elements in interfaces and data storage permit specifying century to eliminate date ambiguity; D) "extraordinary actions" shall be defined to mean any action outside the normal documented processing steps identified in the product's reference documentation; E) "general integrity" shall mean no value for current date shall cause interruptions in desired operation; F) "implicit century" shall mean for any data element without century, the correct century is unambiguous for all manipulations involving that document; (Fee-for-Service) GENERM. PROVISIONS 6/2004 Page 8 hislher duties or to account properly for all monies and property received by virtue of hislher position or employment. PERFORMING AGENCY shall also maintain liability insurance coverage, referred to in Texas Government Code, Section 2259.102, as "director and officer liability coverage," where PERFORMING AGENCY is a legal entity that is required to have directors and/or officers. This provision applies to entities that are organized as non-profit corporations under the Texas Non-Profit Corporation Act; for-profit corporations organized under the Texas Business Corporations Act; and any other legal entity that is required under Texas law to have directors and/or officers. PERFORMING AGENCY shall maintain liability insurance coverage in an amount not less than the total value of this contract Attachment and that is sufficient to protect the interests of RECEIVING AGENCY in the event an actionable act or omission by a director or officer of PERFORMING AGENCY damages RECEIVING AGENCY'S interests. ARTICLE 15. Terms and Conditions ofPavment For services satisfactorily performed pursuant to this contract, RECEIVING AGENCY will pay PERFORMING AGENCY for allowable costs. Payments are contingent on a signed contract and will not exceed the total of each Attachrnent(s). PERFORMING AGENCY is entitled to payment only if the service, work, and/or product has been authorized and satisfactorily performed. If those conditions are met, RECEIVING AGENCY will make payment in accordance with the Texas prompt payment law (Texas Government Code, Chapter 225 I). PERFORMING AGENCY is entitled to exercise remedies for nonpayment in accordance with Texas Government Code, Chapter 2251, Subchapter D. PERFORMING AGENCY shall submit requests for payment on a State of Texas Purchase Voucher (fDH Form B-13) or any other form designated by RECEIVING AGENCY. PERFORMING AGENCY shall submit vouchers monthly for payment within thirty (30) days following the end of the month covered by the bill. PERFORMING AGENCY shall submit a payment request as a final close-out bill not later than ninety (90) days following the end of the applicable Attachment term(s) for goods received and services rendered during the Attachment term. Requests received in RECEIVING AGENCY'S offices more than ninety (90) days following the end of the applicable Attachment term will not be paid. If necessary to meet this deadline, PERFORMING AGENCY may submit payment request by facsimile transmission. Consideration of requests for an exception will be made on a case-by-case basis and only for an extenuating circumstance such as a catastrophic event, natural disaster, or criminal activity that substantially interferes with normal business operations, or causes damage or destruction of the place of business and/or records. A written statement describing the extenuating circumstance and the last request for payment must be submitted for review and approval to the RECEIVING AGENCY Program sponsoring the Attachment. PERFORMING AGENCY shall disburse program income, rebates, refunds, contract settlements, audit recoveries and interest earned on such funds before requesting cash payments including advance payments from RECEIVING AGENCY. Funding from this contract shall not be used to supplant [i.e., use in place of funds dedicated, appropriated or expended for activities funded through the Attachment(s)] state or local ftmds, but PERFORMING AGENCY shall use the funds from this contract to increase state or local funds currently available for a particular activity. PERFORMING AGENCY shall make a good faith effort to maintain its current level of support. PERFORMING AGENCY may be required to submit documentation substantiating that a reduction in local funding, if any, resulted for reasons other than receipt or expected receipt of funding under the Attachment(s). RECEIVING AGENCY shall determine whether costs submitted by PERFORMING AGENCY are allowable and payable. If RECEIVING AGENCY has paid funds to PERFORMING AGENCY for unallowable or ineligible costs, PERFORMING AGENCY shall return the funds to RECEIVING AGENCY within thirty (30) days of written notice. {Fee-for-Service} GENERAL PROVISIONS 6/2004 Page 10 PERFORMING AGENCY is responsible to RECEIVING AGENCY for the performance of any subrecipient. PERFORMING AGENCY shall monitor both financial and programmatic performance and maintain pertinent records that will be available for inspection by RECEIVING AGENCY. PERFORMING AGENCY shall ensure that: . Subrecipients are fully aware of the requirements imposed upon them by state/federal statutes and regulations including prompt payment of any subcontractors pursuant to Texas Government Code, Chapter 2251, Subchapter D; . Subrecipients comply with all financial management requirements as defined by RECEIVING AGENCY, UGMS and the applicable OMB circulars; . Subrecipients complete required audits; . An adequate tracking system is maintained to ensure timely receipt of any subrecipient's required audit reports and the resolution of any findings and questioned costs cited by these reports; and, that . RECEIVING AGENCY is immediately notified in writing of alleged. or actual misuse or misappropriation of contract funds by subrecipients. ARTICLE 18. Contracts for Procurement PERFORMING AGENCY may enter into contracts for procurement of goods and services unless restricted or otherwise prohibited in specific Attachment(s). PERFORMING AGENCY agrees that it shall be responsible to RECEIVING AGENCY for the performance of any subcontracted activity. Contracts for procurement of goods and services shall be in writing and contain the following provisions: . Adminis1rative, contractual, or legal remedies in instances where contractors violate or breach contract terms, and provide for such sanctions and penalties as may be appropriate (c~1racts other than small purchases). . Remedies for prompt payment of any subcontractor pursuant to Texas Government Code, Chapter 2251, Subchapter D. . Termination for cause and for convenience by PERFORMING AGENCY including the manner by which it will be effected and the basis for settlement (all contracts in excess of $10,000). . Compliance with the Copeland "Anti-Kickback" Act (18 USC ~874) as supplemented in Department of Labor regulations (29 CPR Part 3) (all contracts and subgrants for construction or repair). . Compliance with ~~103 and 107 of the Contract Work Hours and Safety Standards Act (40 USC ~~327- 330) as supplemented by Department of Labor regulations (29 CFR Part 5) (construction contracts awarded by grantees and subgrantees in excess of $2,000, and in excess of $2,500 for other contracts which involve the employment of mechanics or laborers). . Notice of RECEIVING AGENCY requirements and regulations pertaining to reporting. . Notice of RECEIVING AGENCY requirements and regulations pertaining to trademarks, service marks, copyrights, and patent rights with respect to any discovery or invention which arises or is developed in the course of or under such contract. . RECEIVING AGENCY requirements and regulations pertaining to copyrights and rights in data. . Access by RECEIVING AGENCY, the federal grantor agency, the Comptroller General of the United States, the State of Texas or any of their duly authorized representatives to any books, documents, papers, and records of the contractor which are directly pertinent to that specific contract for the pmpose of making audit, examination, excerpts, and transcriptions. . Retention of all required records for the required retention period after RECEIVING AGENCY makes final payments and all other pending matters are closed. (Fee-for-Service) GENERAL PROVISIONS 612004 Page 12 that is the subject of litigation or an audit until the litigation is ended or all questions pertaining to the audit are resolved. Legal requirements for PERFORMING AGENCY may extend beyond the retention schedules established herein. ARTICLE 22. Confidentiality of Protected Health Information PERFORMING AGENCY is required to comply with state and federal laws relating to the privacy and confidentiality of patient and client records that contain protected health information, or other information made confidential by law. PERFORMING AGENCY is required to disclose protected health information of patients or clients provided services funded through this contract to RECEIVING AGENCY upon request, or as otherwise required in other contract provisions. . RECEIVING AGENCY is authorized to request, collect and receive protected health information under this contract, without the consent of the individual to whom the protected health information relates, for funding, payment and administration of the grant program. RECEIVING AGENCY is also authorized to request, collect and receive protected health information under this contract, without the consent of the individual to whom the protected health information relates, under exceptions to state confidentiality laws and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIP AA) and the Privacy Standards adopted to implement HIP AA at 45 CFR Parts 160 and 164, at ~164.512, and Occupations Code, Chapter 159, at ~~159.003 and 159.004. PERFORMING AGENCY muSt maintain patient and client records in compliance with state laws relating to the secmity and retention of medical or patient records. RECEIVING AGENCY may require PERFORMING AGENCY to transfer original or copies of patient and client records to another entity, without the consent or authorization of the patient or client, upon termination of this contract, or if the care and treatment of the individual patient or client is transferred to another entity. If providing direct client care, services, or programs, PERFORMING AGENCY shall implement RECEIVING AGENCY'S policies based on the model HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) workplace guidelines, and PERFORMING AGENCY shall educate employees and clients concerning HIV and its related conditions, including AIDS, in accordance with the Health and Safety Code, ~~85.l12-114. ARTICLE 23. Hold Harmless PERFORMING AGENCY, as an independent contractor, agrees to hold RECEIVING AGENCY and/or the federal government harmless and to indemnify them from any and all liability, suits, claims, losses, damages and judgments, and to pay all costs, fees, and damages to the extent that such costs, fees, and damages arise from performance or nonperformance of PERFORMING AGENCY under this contract. ARTICLE 24. Sanctions RECEIVING AGENCY may impose sanctions for any breach of this contract, and will monitor PERFORMING AGENCY for both programmatic and fmancial compliance. HHSC may impose or recommend imposition of sanctions to RECEIVING AGENCY for any breach of this contract and will monitor PERFORMING AGENCY for financial compliance. RECEIVING AGENCY may, at its own discretion, impose one or more sanctions for each item of noncompliance and will determine sanctions on a case-by-case basis. A state or federal statute, (Fee-for-Service) GENERAL PROVISIONS 6/2004 . Page 14 N. Demand repayment from PERFORMING AGENCY; O. Reduce the funding amount for failure to achieve or maintain the proposed level of service, to expend funds appropriately and at a rate which will make full use of the award, or to provide services as set out in. the Attachment( s); and P. Impose other remedies provided by law. RECENING AGENCY will formally notify PERFORMING AGENCY in writing when a sanction is imposed (with the exception of accelerated monitoring, which may be unannounced), stating the nature of the sanction(s), the reasons for imposing them, the corrective actions which shall be taken before they will be removed and the time allowed for completing the corrective actions, and the method, if any, of requesting reconsideration of the sanctions imposed. PERFORMING AGENCY is required to file, within fifteen (15) days of receipt of notice, a written response to RECEIVING AGENCY'S program/division that sent the notice, acknowledging receipt of such notice and stating how PERFORMING AGENCY shall correct the noncompliance or demonstrating in writing that the findings on which the sanctions are based are either invalid or do not warrant the sanction(s). If RECENING AGENCY determines that a sanction is warranted, and unless the sanction is subject to review (see Sanction Review Article), RECEIVING AGENCY'S decision is final and PERFORMING AGENCY shall take corrective action. In an emergency, RECENING AGENCY may immediately terminate or suspend all or part of this contract, temporarily or permanently withhold cash payments, deny contract renewal or future contract awards, or delay contract execution by delivering written notice to PERFORMING AGENCY, by any verifiable method, stating the reason for the emergency action. An "emergency" is defined as the following: · PERFORMING AGENCY is noncompliant and the noncompliance has a direct adverse impact on the public or client health or safety. The direct adverse impact may be programmatic or financial, impacting health or safety by failing to provide services, providing inadequate services, providing unnecessary services, or utilizing resources so that the public or clients do not receive the benefits contemplated by the scope of work or performance measures; · PERFORMING AGENCY fails to achieve a performance measure; · PERFORMING AGENCY is paid or requesting payment for expenditures which are not in accordance with applicable federal or state laws and regulations or the provisions of this contract; or · PERFORMING AGENCY is expending ftmds inappropriately. Whether PERFORMING AGENCY'S conduct or inaction is an emergency will be determined by RECEIVING AGENCY on a case-by-case basis and will be based upon the egregious nature of the noncompliance or conduct. ARTICLE 25. Sanction Review PERFORMING AGENCY may request a review of the imposition of the following sanctions: termination of all or part of this contract, suspension of all or part of this contract, permanent withholding of cash payments, reduction of funding or other amendment resulting from noncompliance, and denial of contract renewal or future contract awards. PERFORMING AGENCY shall make the request for review in writing to RECENING AGENCY within fifteen (15) days from the date of notification by providing written notice of the dispute to the person who signed the notification. (Fee-for-Service) GENERAL PROVISIONS 612004 Page 16 representative of RECEIVING AGENCY relating to this contract shall be considered a waiver of sovereign immunity to suit. Neither the occurrence of an event nor the pendency of a claim constitute grounds for the suspension of performance by PERFORMING AGENCY, in whole or in part. ARTICLE 27. Termination Each Attachment shall terminate upon its expiration date unless extended by written amendment in accordance with the Amendments Article. Prior to completion of the Attachment term, all or a part of this contract may be terminated with or without cause as set out below. A. Termination is the permanent withdrawal of PERFORMING AGENCY'S authority to obligate previously awarded funds before that authority would otherwise expire or the voluntary relinquishment by PERFORMING AGENCY of the authority to obligate previously awarded funds. PERFORMING AGENCY costs resulting from obligations incurred by PERFORMING AGENCY after termination of an award are not allowable unless expressly authorized by the notice of termination. Termination does not include: (1) withdrawal of funds awarded on the basis of the PERFORMING AGENCY'S underestimate of the unobligated balance in a prior period; (2) withdrawal of the unobligated balance as of the expiration of an Attachment; (3) refusal to extend an Attachment or award additional funds, to make a competing or noncompeting continuation, renewal, extension, or supplemental award; or (4) voiding of a contract upon determination that the award was obtained fraudulently, or was otherwise illegal or invalid from inception. B. Termination without cause. (1) Either party may terminate this contract with at least ninety (90) days prior written notice to the other party. (2) The parties may terminate this contract by mutual agreement. (3) Either party may terminate this contract with at least thirty (30) days prior written notice to the other party in the event state and/or federal funding for this contract is terminated, limited, suspended, withdrawn, or discontinued. (4) RECEIVING AGENCY may terminate this contract when, in the sole determination of RECEIVING AGENCY, termination is in the best interest of the State of Texas. C. Termination for cause. (1) Either party may terminate for material breach of this contract with at least thirty (30) days written notice to the other party. (2) RECEIVING AGENCY may terminate this contract, in whole or in part, for breach of contract or for any other conduct that jeopardizes the contract objectives, by giving at least thirty (30) days written notice to PERFORMING AGENCY. Such' conduct may include one or more of the following: (a) A court of competent jurisdiction fmds that PERFORMING AGENCY has failed to adhere to any laws, ordinances, rules, regulations or orders of any public authority having jurisdiction; (b) PERFORMING AGENCY fails to communicate with RECEIVING AGENCY or fails to allow its employees or those of its subrecipients to communicate with RECEIVING AGENCY as necessary to the performance of this contract; (c) PERFORMING AGENCY breaches a standard of confidentiality with respect to the services provided under this contract; (Fee-for-Service) GENERAL PROVISIONS 612004 Page 18 period. Upon termination of all or part of this contract, RECEIVING AGENCY and PERFORMING AGENCY will be discharged from any finther obligation created tmder the applicable terms of this contract except for the equitable settlement of the respective accrued interests or obligations incurred prior to termination. Termination does not, however, constitute a waiver of any remedies for breach of this contract. In addition, the obligations of PERFORMING AGENCY to retain records and maintain confidentiality of information shall survive this contract. ARTICLE 28. Void Contract RECEIVING AGENCY may hold this contract void upon determination that the award was obtained fraudulently or was otherwise illegal or invalid from its inception. ARTICLE 29. Severability If any provision of.this contract is construed to be illegal or invalid, the illegal or invalid provision will be deemed stricken and deleted to the same extent and effect as if never incorporated, but all other provisions will continue. ARTICLE 30. Survival of Terms Termination or expiration of this contract for any reason shall not release either party from any liabilities or obligations set forth in this contract that (a) the parties have expressly agreed shall survive any such termination or expiration, or (b) remain to be performed or by their nature would be intended to be applicable following any such termination or expiration. ARTICLE 31. Construction. of Ambi21lities The parties expressly agree that they have each independently read and understood this contract. Any ambiguities in this contract shall not be construed against the drafters. ARTICLE 32. No Waiver of Sovereim Immunitv THE PARTIES EXPRESSLY AGREE THAT NO PROVISION OF THIS CONTRACT IS IN ANY WAY INTENDED TO CONSTITUTE A WAIVER BY RECEIVING AGENCY OR THE STATE OF TEXAS OF ANY IMMUNITIES FROM SUIT OR FROM LIABILITY THAT RECEIVING AGENCY OR THE STATE OF TEXAS MAY HAVE BY OPERATION OF LAW. (Fee-for-Service) GENERAL PROVISIONS 612004 Page 20 DOCUMENT NO. 7560022067 A-2005 ATTACHMENT NO. 01 PURCHASE ORDER NO. 038765000 PERFORMING AGENCY: PARIS-LAMAR COUNTY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: ASSOCIATE COMMISSIONER FOR FAMILY HEALTH TERM: September 0 I, 2004 THR U: August 31, 2005 SECTION I. 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 T AC S 1.91 (Local Health Departments only). The following documents are incorporated by reference and made a part of this contract Attachment. These include: r · RECEIVING AGENCY 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 FY2005; and · RECEIVING AGENCY'S Texas Department of Health (TDH) Standards for Public Health Clinic Services, revised January 31, 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 Public Health Regional Director or designee, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to A IT ACHMENT - Page 1 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, 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 Attashment 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 270 (TDH Form GC-lO), is due no later than ninety (90) days after the end of the Attachment term. This report shall be marked "Final". BILLING REQUIRE:MENTS 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 TDH 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 ATTACHMENT - Page 2 denied eligibility by the Texas Department of Human Services. 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 subject 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 Jess 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. ELIGIBILITY All individuals considered for Title V eligibility must be screened and determined eligible using a TDH 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 A IT ACHMENT - Page 3 Departments shall comply with RECEIVING AGENCY fee collection policies detailed in 25 TAC ~ 1.91. General Provisions, Program Income Article, is revised to include: All revenues directly generated by a Contract 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. 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 (TDH 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 PERJ;ORMING AGENCY. 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. ~ 1320a-7(b)(1)-(3); A IT ACHMENT - Page 4 · Has had a civil monetary penalty assessed under 42 U.S.C. ~ 1320a and/or 42 U.S.c. ~ 1320a-8; or, · Has been excluded from participation in a program under 42 U.S.C. ~ 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. r A IT ACHMENT - Page 5 DOCUMENT NO. 7560022067 A-2005 ATTACHMENT NO. 02 PERFORMING AGENCY: PARIS-LAMAR COUNTY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: ASSOCIATE COMMISSIONER FOR FAMILY HEALTH TERM: September 01, 2004 THRU: August 31,2005 SECTION I. SCOPE OF WORK: PERFORMING AGENCY shall provide or assure the provision of family planning services 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: . RECEIVING AGENCY Family Planning Standards and Rules, 25 T AC Chapter 56; . Sterilization, 42 CFR Part 50, Subpart B; and . 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 Title V FY2005 Competitive Request For Proposal (RFP); . PERFORMING AGENCY'S FY2005 Component II, Attachment B application and any revisions; . Title V Policy and Procedures Manual, revised for FY2005; and . RECEIVING AGENCY'S Texas Department of Health (TDH) Standards for Public Health Clinic Services, revised January 31, 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 Public Health Regional Director or designee, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to PERFORMING AGENCY. RECEIVING AGENCY personnel may, from time to time, provide technical assistance and training to PERFORMING AGENCY. PERFORMING AGENCY sha1l A TT ACHMENT - Page 1 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 through twenty-one (21) years of age 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, 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 family planning 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 fpr 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. BILLING REQUIREMENTS PERFORMING AGENCY shall bill RECEIVING AGENCY for allowable services provided to Title V eligible clients. Requests for payment shall be submitted to the Health and Human Services Commission's claims administrator in a manner compatible with the Compass 21 billing system by the 120th day after the date on which services were provided or the date of any third party insurance Explanation of Benefits form. Appeals must be submitted within 180 days of rejection, and all requests for payment shall be submitted within 90 days of the end of the Attachment term. Claims shall be submitted using an approved claim format which follows the RECEIVING AGENCY Family Planning Division billing specifications which may be obtained from RECEIVING AGENCY Family Planning Division. A TT ACHMENT - Page 2 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. ELIGIBILITY All individuals considered for Title V eligibility must be screened and determined eligible using a TDH 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 AGENGY under this Attachment. A co-payment assessment may not exceed 25% of the amount RECEIVING AGENCY pays PERFORMING AGENCY for the provision of a given service. 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 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 ~ 1.91. General Provisions, Program Income Article, is revised to include: All revenues directly generated by a Contract 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. PERFORMING AGENCY shall identify and report all program income annually using Form 270 Request for Advance or Reimbursement (TDH Form GC-IO). 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 A TT ACHMENT - Page 3 demonstrated only by submission of acceptable family planning claims 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: · A Request for Advance or Reimbursement Form 270 (TDH Form GC-IO), 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. 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 US.C. S 1320a-7(b)(l)-(3); · Has had a civil monetary penalty assessed under 42 US.c. S 1320a and/or 42 U.S.C. S 1320a-8; or, · Has been excluded from participation in a program under 42 US.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. A TT ACHMENT - Page 4 STERILIZA TION PERFORMING AGENCY shall comply with all federal regulations applying to sterilization procedures. Prior to receiving a sterilization, a client shall sign a copy of the U.S. Department of Health and Human Services (DHHS) sterilization consent form. The original of this form, with all required signatures (including the physician's), shall be kept in the client's medical records. 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 $10,781.00. r A TT ACHMENT - Page 5 . CONTRACT FOR PUBLIC HEALTH SERVICES Contract Issued by: (RECEIVING AGENCY) DEPARTMENT OF STATE HEALTH SERVICES 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-3199 DSHS DOCUMENT NO 7560022067 A2005 IV Legal Authority to Contract: Chapters 12 and 121, Health and Safety Code. Venue: 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) 17560022067001 PAYEE AGENCY Fiscal Year Ending Month: September PA YEE BUSINESS INFORMATION FOR S1;ATISTlCAL 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 COVER PAGE 2 - Details of Attachment(s) COVER PAGE 3 - Authorized Signatures GENERAL PROVISIONS - 6/ 2004 A IT ACHMENT(S) EXHIBITS, IF APPLICABLE Cover Page 1 EXHIBIT .a. DETAILS OF ATTACHMENT~ Attf DSHS Program ill/ Term Financial Assistance Direct Total Amount Amd DSHS Purchase Assistance (DSHS Share) No. Order Number Begin End Source of Amount Funds * 01 ACFHlFEE 09/01/04 08/31/05 20,000.00 0.00 20,000.00 038765000 02 ACFHlFEE-FP 09/01/04 08/31/05 10,781.00 0.00 10,781.00 038767000 DSHS Document No.7560022067 A2005 Totals $ 30,781.00 $ 0.00 $ 30,781.00 . I I I *Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS. r 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: By: Date: RECEIVING AGENCY NAME: DEPARTMENT OF STATE HEALTH SERVICES By: (Signature of person authorized to sign contracts) Bob Burnette, Director Procurement and Contractin Services Division (Name and Title) DSHS Document No: 7560022067 A2005 Cover Page 3 DOCUMENT NO. 7560022067 A-2005 ATTACHMENT NO. 01 PURCHASE ORDER NO. 038765000 PERFORMING AGENCY: PARIS-LAMAR COUNTY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: ASSOCIATE COMMISSIONER FOR FAMILY HEALTH TERM: September 01, 2004 THRU: August 31,2005 SECTION I. 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 ~ 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 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 FY2005; and · RECEIVING AGENCY'S Texas Department of Health (TDH) Standards for Public Health Clinic Services, revised January 31,2004. 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 Public Health Regional Director or designee, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to ATTACHMENT - Page 1 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, 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 AGEN'CY 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 270 (TDH Form GC-lO), is due no later than ninety (90) days after the end of the Attachment term. This report shall be marked "Final". BilLING REQUIREMENTS 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 TDH 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 A IT ACHMENT - Page 2 denied eligibility by the Texas Department of Human Services. 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 subject 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. ELIGIBILITY All individuals considered for Title V eligibility must be screened and determined eligible using a TDH 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 A IT ACHMENT - Page 3 Departments shall comply with RECEIVING AGENCY fee collection policies detailed in 25 TAC ~ 1.91. General Provisions, Program Income Article, is revised to include: All revenues directly generated by a Contract 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. 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 (TDH 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. 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. ~ 1320a-7(b)(1)-(3); A IT ACHMENT - Page 4 · Has had a civil monetary penalty assessed under 42 U.S.c. ~ 1320a and/or 42 U.S.c. ~ 1320a~8; or, · Has been excluded from participation in a program under 42 U.S.c. ~ 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. I' A IT ACHMENT - Page 5 DOCUMENT NO. 7560022067 A-2005 ATIACHMENT NO. 02 PERFORMING AGENCY: PARIS-LAMAR COUNTY HEALTH DEPART!vffiNT RECEIVING AGENCY PROGRAM: ASSOCIATE COMMISSIONER FOR FAMILY HEALTH TERM: September 01,2004 THRU: August 31,2005 SECTION I. SCOPE OF WORK: PERFORMING AGENCY shall provide or assure the provision of family planning services 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: · RECEIVING AGENCY Family Planning Standards and Rules, 25 T AC Chapter 56; · Sterilization, 42 CPR Part 50, Subpart B; and · Fees for Clinical Health Services, 25 T AC ~ 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 Title V FY2005 Competitive Request For Proposal (RFP); · PERFORMING AGENCY'S FY2005 Component II, Attachment B application and any revisions; · Title V Policy and Procedures Manual, revised for FY2005; and · RECEIVING . AGENCY'S Texas Department of Health (TDH) Standards for Public Health Clinic Services, revised January 31,2004. 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 Public Health Regional Director or designee, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to PERFORMING AGENCY. RECEIVING AGENCY personnel may, from time to time, provide technical assistance and training to PERFORMING AGENCY. PERFORMING AGENCY shall A TT ACHMENT - Page 1 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 through twenty-one (21) years of age 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, 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 family planning 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 t~rmination. 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. BILLING REQUIREMENTS PERFORMING AGENCY shall bill RECEIVING AGENCY for allowable services provided to Title V eligible clients. Requests for payment shall be submitted to the Health and Human Services Commission's claims administrator in a manner compatible with the Compass 21 billing system by the 120th day after the date on which services were provided or the date of any third party insurance Explanation of Benefits form. Appeals must be submitted within 180 days of rejection, and all requests for payment shall be submitted within 90 days of the end of the Attachment term. Claims shall be submitted using an approved claim format which follows the RECEIVING AGENCY Family Planning Division billing specifications which may be obtained from RECEIVING AGENCY Family Planning Division. A TT ACHMENT - Page 2 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. ELIGIBILITY All individuals considered for Title V eligibility must be screened and determined eligible using a TDH 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-payment assessment may not exceed 25% of the amount RECEIVING AGENCY pays PERFORMING AGENCY for the provision of a given service. 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 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 ~ 1.91. General Provisions, Program Income Article, is revised to include: All revenues directly generated by a Contract 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. PERFORMING AGENCY shall identify and report all program income annually using Form 270 Request for Advance or Reimbursement (TDH Fonn GC-IO). 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 A TT ACHMENT - Page 3 demonstrated only by submission of acceptable family planning claims 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: · A Request for Advance or Reimbursement Form 270 (TDH 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. 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 US.C. S 1320a-7(b)(1)-(3); · Has had a civil monetary penalty assessed under 42 US.c. S 1320a and/or 42 D.S.C. S 1320a-8; or, · Has been excluded from participation in a program under 42 US.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. A TT ACHMENT - Page 4 STERILIZATION PERFORMING AGENCY shall comply with all federal regulations applying to sterilization procedures. Prior to receiving a sterilization, a client shall sign a copy of the U.S. Department of Health and Human Services (DHHS) sterilization consent form. The original of this form, with all required signatures (including the physician's), shall be kept in the client's medical records. SECTION m. 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 $10,781.00. t ATTACHMENT - Page 5