07-L(1) Health ContractDRAFT
F:ALICE\RFSWORK\CURRENT\hEALTH Contract2005
July 7, 2004
RESOLUTION NO.
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. Ol); APPROVING AND
AUTHORIZING THE EXECUTION OF CONTRACT CHANGE NOTICE
NO. Ol (ATTACHMENT NO. OlA); 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. OlA), 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 COLTNCIL 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. OlA), 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 July, 2004.
Curtis Fendley, Mayor
ATTEST:
Sherian Dixon, Assistant City Clerk
APPROVED AS TO FORM:
Larry W. Schenk, City Attorney
~ F
y s
~
-ONTRACT FOR PUBLIC HEALTH SERVICES
DSHS DncuMF.1vT tv() 75()00??067a')005
Contract Issued by: DEPARTMENT OF STATE HEALTH SERVICES W W
(RECEIVING AGENCY) 1100 WEST 49T" STREET
AUSTIN, TEXAS 78756-3199
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 Counry
,
Texas.
PERFORMING AGENCY NAME: PARIS-LAMAR COUNTY HEALTH DEPARTMENT
I
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)
I
State of Texas Vendor ldentification 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.
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.
_ Historically Underutilized Business (HUB) - A corporation, sole proprietorship, or joint venture formed for the purpose of making a
profit in which at least 5 1 % 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 ano[her 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) ATTACHMENT(S)
COVER PAGE 3- Authorized Signatures EXHIBITS, IF APPLICABLE
cover Page 1 EXHIBIT A
DETAILS OF ATTACHMENTS
Atd
DSHS Program ID/
Term
Financial Assistance
Direct
Total Amount
A
d
DSHS P
h
m
urc
ase
Assistance
(DSHS Share)
No.
Order Number
Begin
End
Source of
Amount
Funds*
ACFH/FEE
O1
038765000
09/O1/04
O8/31/O5
20,000.00
0.00
20,000.00
ACFH/FEE-FP
02
038767000
09/O1/04
08/31/O5
10,781.00
0.00
10,781.00
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.
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
B y:
(Signature of person authorized to sign contracts)
(Name and Title)
Date:
RECOMMENDED:
By:
kERF_dRM11q(5 A C irector, if different
from person authorized t sign contract),
RECEIVING AGENCY NAME:
DEPARTMENT OF STATE HEALTH
SERVICES
By:
(Signature of person authorized to sign contracts)
Bob Burnette, Director
Procurement and ContractinQ Services Division
(Name and Title)
Date:
DSHS Document No: 7560022067A2005
A
Cover Page 3
GENERAL PROVISIONS FOR
DEPARTMENT OF STATE HEALTH SERVICES SUBRECIPIENT GRANT CONTRACTS
TABLE OF CONTENTS _
ARITCLE ' 1 =
PREAMBLE
;2 -
TERM
3 -
FUNDIl*1'G'
4 -
AMENDMENTS.
5 -
"APPLZCABLE LAWS AND ST.ANDARDS '
b -
DEBARMENT AND SUSPEI*1SIONS
' ? -
ASSURANCFS
-
$ -
CHII,D ABLTSE REPORTING REQUIREMENTS
9 -
INTELLECTUAL PROPERTY '
1Q -
HIS'FORICALLY UNDERUTILtZED BUSIl'4ESSBS'
11 •
CONFLICT 0F INTEREST . '
12 -
CERTIFICATION OF SOFTWARE, HARDWARE, FIRM[WARE, AND MICRO
CODE PRODUCTS
13 -
STANDARDS FOR FINANCIAL AND PROGR.AMMATIC MANAGEIVIENT
14 -
BONDING AND LIABILITY ]NSURANCE
15
- TERIVIS AND CONDTTIQNS OF PAYMENT
16
PROGRAM Il*iCOME
17
- CONTRAGTS WITH SUBRECIPIENTS
i8
= CONTRAC'TS FOR PROCUREMEN'I'
.19
- REPORTS ,
20
- INSPECTIONS' '
Zl
- RECORDS RETENTION
22
- CONFIDENTIALTTY OF PROTECTED HEALTH INFORIVIATION
23
HOLD HARMLES5
' 24
- SANCTIONS
' 25
- SANCTIQN REVIEW
' Zd
- BREACH t3F CONTRACT CLAIM
27
- TERMINATION
VOID CONTRACT
>Z9
- SEVERABII,ITY
' 30
- SURVNAL OF TERMS,
31
- ' CONSTRUCTION OF AIVIBIGUrrMS
32
- NO WANER OF SOVEREIGN IlMMITNiTY
Paper Publications Number: 29-11835, Revised June 2004
(Fee for-Service) ' GENERAL PROVISIONS 6/2004
ARTICLE 3. Fnndin
This contract is contingent upon the continued availability of funding. If funds become unavailable through lack
of appropriations, budget cuts, transfer of funds 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 sha.ll apply.
pR'TICLE 4. Amendments
Amendments to this contract must be in writing and signed by individuals with authority to bind the parties.
Uniform Cmants Management Standards and RECEIVING AGENCY procedures authorize limited changes to a
contcact attachment with prior written approval from RECEIVING AGENCY. PERFORMIIJG AGENCY must
submit request in format prescribed by RECEIVING AGENCY Program. RECEIVING AGENCY will
consider the request and document approval or disapproval in writing. PERFORMIlNG AGENCY is responsible
for ensuring that any modification to a contract Attachment becomes a part of the contract file.
RECEIVING AGENCY may not waive any tercn, covenant, or condition of this contract unless by amendment
executed in compliance with this Article. PERFORMIlNG 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 quartcr of the Attachment term, the written justification sha11 include
a reason for the delay. Revision or amendment requests may be granted at the discretion of RECENING
AGENCY.
ARTICLE 5. Analicable 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 applica.ble, 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 Govemor'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.
PERFORMIlNG AGENCY shall not use funds granted under tlus contract to pay any person for influencing or
attempting to influcnce 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 ar 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
PERFORMMG AGENCY in connection with that contract or grant, a certification that none of the funds
provided by RECEIVING 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 agrecment.
PERFORIvSMG AGENCY shall require any person who requests or receives a subgrant or subcontract to file
the same declararion, 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-jor-Service) - GENERAL PROVISIONS 612004 Page 2
• Thc 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)(1), as amended, relating to the nondiscrimination on the basis of alcohol
abuse or alcoholism; `
• Public Health Sezvice Act of 1912, §§523 and 527, 42 USC §290dd-2, as amended, relating to
confidentiality of alcohol and drug abuse patient records;
• Tide VIII 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 RECENING 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 RECENING 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 foz 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 Reseazch Service Award Act of 1971, 42 USC §§289a-1 et seq., as amended, and
6601 (P.L. 93-348 and P.L. 10343), as amended, regarding the protection of human subjects
involved in reseazch, 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, ar Title 25 Texas Administrative Code (TAC), 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 barriets 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. RECENING AGENCY will support PERFORMING AGENCY in
complying by providing promotional material and information that encourages breast-feeding to
(Feefor-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
Secretazy af the U.S. Department of Housing and Urban Development as en 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, ar services or receive a state-funded
grant or loan. ff applicable, PERFORMING AGENCY agrees to comply with these provisions, certifies that it
is not ineligible to receive the payments specified in this contract, and aclrnowledges 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 Sta.te Comptroller will not
issue paymcnt to Performing 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 treatinent 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 PERFORMNG
AGENCY, if any.
PERFORMING AGENCY shall comply with the requirements of the Texas Warkers' 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 te-ins or conditions for receipt of RECENING 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 RECENING AGENCY.
ARTICLE 8. Child Abuse Reaortins Repuirements
[PERFORMING AGENCY is required to comply with this article only as related to services provided under the
following Attachments: Human Immunodeficiency Yirus and Sexually Transmined 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 Y Family Planning (ACFH/FEE-FP, Title X Family Planning (BWH/TI7ZE Jg, Title XX
Family Planning (BWH17TLU9, 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
ART'ICLE 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. Certtfication of Software, Hardware. Firmware and Micro Code Products
PERFORMING AGENCY certiSes that any supplied or supported soflware, 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 cenauy, yeaz, month, and day.
For purposes of this Article, "supplied or supported soflware, hardware, firmwaze, and micro code products"
dces not include softwaze supported by RECENING AGENCY or an agency of the federal govemment.
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:
1) calculations shall be correctly performed using four-digit yeaz 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 backwazd date calculation spanning century boundaries shall
be provided;
6) correct leap y,ear calculations shall be performed; and
'n processing correct results in forward and backward date calculation spanning century
boundaries shall occur;
g) "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) "gcncral integrity" shall mean no value for current date shall cause interruptions in desired
operarion;
F) "implicit century" shall mean for any data element without century, the conect century is
unambiguous for all manipulations involving that document;
(Fee for-Servtce) GENERAL PROVISIONS 612004 - Pag° 8
hisJher duties or to account properly for all monies and property received by virtue of his/her position or
employment.
PERFORMIlNG AGENCY shall also maintain liability insurance coverage, referred to in Texas Govemment
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 RECENING
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 of Pavment
For services satisfactorily performed pursuant to this contract, RECENING AGENCY will pay PERFORMIING
AGENCY for allowable costs. Payments are contingent an a signed contract and will not exceed the total of
each Attachment(s). PERFORMING AGENCY is entifled to payment only if the service, work, and/or product
has been authorized and satisfactorily performed. If those condirions are met, RECENING AGENCY will
make payment in accordance with the Texas prompt payment law (Texas Government Code, Chapter 2251).
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 ('TDH Form
B-13) or any other form designated by RECENING 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 RECENING AGENCY'S offices more than ninety (90) days following
the end of the applicable Attactunent 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 ar 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 RECENING
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 payrnents from
RECEIVING AGENCY. Funding from this conttact 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 funds, but PERFORMING AGENCY
shall use the funds from this contract to increase state or local funds currently available for a particular acrivity.
PERFORMING AGENCY shall make a good faith effort to maintain its cutrent 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).
RECENING AGENCY shall determine whether costs submitted by PERFORMING AGENCY are allowable
and payable. If RECENING AGENCY has paid funds to PERFORDING AGENCY for unallowable or
ineligible costs, PERFORMING AGENCY shall retiun the funds to RECENING AGENCY within thirty (30)
days of written notice. .
(Fee for-Service) GENERAL PROVISIONS 6/2004 Pege 10
PERFORMING AGENCY is responsible to RECEIVING AGENCY for the performance of any subrecipient.
PERFORMIIJG AGENCY shall monitor both financial and programmatic performance and maintain pertinent
records that will be available for inspection by RECENING AGENCY.
PERFORMMG 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 RECENING
AGENCY, UGMS and the applicable OMB circulars;
• Subrecipients complete required audits;
• An adequate tcacking 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
• RECENING AGENCY is immediately notified in writing of alleged - or actual misuse or
misappropriation of contract funds by subrecipients.
ARTICLE 18. Contracts for Procnrement
PERFORMING AGENCY may enter into contracts for procurement of goods and services unless restricted or
othcrwise prohibited in specific Attachment(s). PERFORMING AGENCY agrees that it shall be responsible to
RECENING AGENCY for the performance of any subcontracted activity.
Contracts for procurement of goods and services shall be in writing and contain the following provisions:
• Administrative, contractual, or legal remedies in instances where contractors violate or breach contract
tercns, and provide for such sanctions and penalties as may be appropriate (coniracts other than small
purchases).
• Remedies for prompt payment of any subcontractor pursuant to Texas Government Code, Chapter 2251,
Subchapter D.
• Tennination 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 CFR 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 inechanics or laborers).
• Notice of RECENING AGENCY requirements and regulations pertaining to reporting.
• Notice of RECENING 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.
• RECENING AGENCY requirements and regulations pertaining to copyrights and rights in data.
• Access by RECENING 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 purpose
of maldng audit, examination, excerpts, and transcriptions.
• Retenrion of all required records for the required retention period after RECENING AGENCY makes
final payments and all other pending matters are closed.
(Fee for-Service) GENERAL PROVISIONS 6/2004 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 (HIPAA) and the Privacy Standards adopted to implement HIPAA at 45 CFR Parts 160 and
164, at §164.512, and Occupations Code, Chapter 159, at §§159.003 and 159.004.
PERFORMIlNG AGENCY must maintain patient and client records in compliance with state laws relating to the
security and retention of inedical or patient records. RECEIVING AGENCY may require PERFORMIIVG
AGENCY to transfer original or copies of patient and client recards 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.
ff providing direct client care, services, or programs, PERFORMIlNG AGENCY shall implement RECEIVING
AGENCY'S policies based on the model HN/AIDS (human immunodeficiency virus/acquired
immunodeficiency syndrome) workplace guidelines, and PERFORMING AGENCY shall educate employees
and clients conceming HN and its related conditions, including AIDS, in accardance with the Health and Safety
Code, §§85.112-114.
ARTICLE 23. Hold Harmless
PERFORMING AGENCY, as an independent contractor, agrees to hold RECEIVING AGENCY and/or the
federal govemment 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. •
ARTIC'LE 24. Sanctions
RECEIVING AGENCY may impose sanctions for any breach of this contract, and will monitor PERFORMNG
AGENCY for both programmatic and financial complia.nce. HHSC may impose or recommend unposition of
sanctions to RECEIVING AGENCY for any breach of this contract and will monitor PERFORIIING AGENCY
for financial compliance. RECENING 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 612004 • Page 14
N. Demand repaymcnt from PERFORMING AGENCY;
0. 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.
RECEIVING AGENCY will formally notify PERFORMING AGENCY in writing when a sanction is imposed
(with the exccption of accelerated monitoring, which may be unannouncod), 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. PERFORMIING AGENCY is required to file, within fifteen (15) days of receipt of notice, a
written response to RECENING AGENCY'S program/division that sent the notice, aclrnowledging receipt of
such notice and stating how PERFORMING AGENCY shall correct the noncompliance ar demonstrating in
writing that the findings on which the sanctions are based are either invalid ar do not wairant the sanction(s). If
RECENING AGENCY determines that a sanction is warranted, and unless the sanction is subject to review
(see Sanction Review Article), RECENING 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 emcrgency 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;
• PERFORMNG 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 regularions or the provisions of this contract; or
• PERFORMING AGENCY is expending funds inappropriately.
Whether PERFORMING AGENCY'S conduct or inaction is an emergency will be deteimined by RECENING
AGENCY on a case-by-case basis and will be based upon the egtegious nature of the noncompliance or
conduct.
ARTIC'LE 25. Sanction Review
PERFORMIlNG 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
fifteen (15) days from the
signed the notification.
shall make the request for review in writing to RECENING AGENCY within
date of notification by providing written notice of ttie dispute to the person who
(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 Arkicle. 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 withdrawai of PERFORMING AGENCY'S authority to obligate
previously awarded fimds before that authority would otherwise expire or the voluntary
relinquishment by PERFORMING AGENCY of the authority to obligaxe previously awarded funds.
PERFORMING AGENCY costs resulting from obligations incurred by PERFORiVIIING AGENCY
after tennination of an award are not allowable unless expressly authorized by the notice of
termination. Temunation 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 expira.tion of an Attachment; (3) refusal to extend an
Attachment or award additional funds, to make a competing or noncompeting continuation, renewal,
extension, or supplemental awazd; or (4) voiding of a contract upon detemrination 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 pariy.
(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/ar federal funding for this contract is temunated, limited,
suspended, withdrawn, or discontinued.
(4) RECENING AGENCY may terminate this contract when, in the sole detercnination of
RECENING 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) RECENING AGENCY may terminate this contract, in whole or in part, for breach of contract
or for any other conduct that jeopazdizes the contract objectives, by giving at least thirty (30)
days written notice to PERFORMIlNG AGENCY. Such conduct may include one or more of
the following:
(a) A court of competent jurisdiction fmds that PERFORNSING 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 perfonnance 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 6/2004 Page 18
period. Upon tetmination of all or part of this contract, RECEIVING AGENCY and PERFORMING AGENCY
will be discharged from any further obligation created under the applicable tcrms of this contract except for the
equitable settlemeat of the respecdve 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 confidcntiality of information shall survive this
contract.
ARTICLE 28. Void Contract
RECEIVING AGENCY may hold this contract void upon determination that the award was obtained
fraudulentty or was otherwise illegal or invalid from its inception.
ARTICLE 29. Severabilitv
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 incorporatsd, but all other provisions will
continue.
ARTICI,E 30. Survivai of Terms
Termination or expiration of this contract for any reason shall not release either party from any liabilities or
obligations set farth in this contract that (a) the parties have expressly agreed shall survive any such termination
or expiration, or (b) rernain to be performed or by their nature would be intended to be applicable following any
such tennination ar expiration.
ARTICLE 31. Constraction of AmbiQnities
,
The parties expressly agree that they have each independently read and understood this contract. Any
ambiguities in this conhact shall not be construed against the drafters.
ARTICI,E 32. No Waiver of Sovereian Immnnitv
THE PARTIES EXPRESSLY AGREE THA►T NO PROVISION OF TffiS CONTRACT IS IN ANY
WAY INTENDED TO CONSTITUTE A WAiVER BY RECEIVING AGENCY OR TSE STATE OF
TEXAS OF ANY S FROM SUTT OR FROM LIABILITY THAT RECEIVING AGENCY
OR THE STATE OF TEXAS MAY HAVE BY OPERATION OF LAW.
(F~-I~T Seryke) GENERAL PROV.ISIONS 6/2004 Page 20
DOCUMENT NO. 7560022067A-2005
ATTACHVIENT 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:
r
~ RECENING 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
ATTACHVIENT - 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 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 shali be
deemed to have waived the option. A Request for "Advance or Reimbursement", Form
270 (TDH Form GC-10), is due no later than ninety (90) days after the end of the
Attachment term. This report shall be marked "Final".
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 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
ATTACHVIENT - Page 2
denied eligibility by the Texas Department of Human Services. All bills shal] 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°Io of the most recently defined
federal poverty level. A co-pay assessment may not exceed 25°Io 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. Loca] Health
ATTACHVIENT - 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-10), 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);
ATTACHVIENT - 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
ATTACHVVIENT - Page 5
DOCUMENT NO. 7560022067A-2005
ATTACHVIENT 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 TAC Chapter 56;
• Sterilization, 42 CFR Part 50, Subpart B; and
• 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 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
ATTACHMENT - 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 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 REOUIREMENTS
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.
ATTACHMENT - 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
RECENING 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 Form
GG 10):
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
ATTACHMENT - 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-10), 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°Io 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);
• 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 itom 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
RECENING AGENCY.
ATTACHMENT - 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 III. BUDGET:
PERFORMING AGENCY shall adhere to the current schedule of allowable services and rates as
referenced in SECTION H. SPECIAL PROVISIONS, as amended and approved by the
RECEIVING AGENCY.
Total payments will not exceed $10,781.00.
i-
ATTACHMENT - Page 5
~ F
x >
~
CONTRACT FOR PIJRLiC HF.Ai.TH cF.uvir-Fc
li3n3 liv1_,UMt1v TNU. 7560022067A2005
Contract Issued by: DEPARTMENT OF STATE HEALTH SERVICES
JV
(RECEIVING AGENCY) 1100 WEST 49T" STREET
AUSTIN, TEXAS 78756-3199
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 Count
y,
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 ldentification 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 entiry 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 °lo 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) ATTACHMENT(S)
COVER PAGE 3- Authorized Signatures EXHIBITS, IF APPLICABLE
Cover Page 1 EXHIBIT B
DETAILS OF ATTACHMENTS
Att/
DSHS Program ID/
Term
Financial Assistance
Direct
Total Amount
Amd
DSHS Purchase
No.
Order Number
Begin
End
Source of
Amount
Assistance
(DSHS Share)
Funds*
01
ACFH/FEE
038765000
09/01/04
08/31/05
20,000.00
0.00
20,000.00
02
ACFH/FEE-FP
038767000
09/01/04
08/31/05
10,781.00
0.00
10,781.00
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.
Cover Page 2
EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOVG'N.
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
B y:
Date:
(Signature of person authorized to sign contracts)
(Name and Title)
RECOMMENDED:
By: A(PRF0RjM1N__GfAGE CY irector, if different
from person authorized to sign contract) r
RECEIVING AGENCY NAME:
DEPARTMENT OF STATE HEALTH
SERVICES
By: _
(Sign,ature of person authorized to sign contracts)
Bob Burnette, Director
Procuremen and Contractin Services Division
(Name and Title)
Date:
DSHS Document No: 7560022067A2005
Cover Page 3
DOCUMENT NO. 7560022067A-2005
ATTACHVIENT 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:
• RECENING AGENCY Title V FY2005 Competitive Re'quest For Proposal (RFP);
• PERFORMING AGENCY'S FY2005 Component II, Atkachment 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) Qr guideline(s), PERFORMING
AGENCY shall inform RECEIVING AGENCY Program, in uvriting, 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
ATTACHVIENT - 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 RECENING 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 prbvision of allowable services to
Title V eligible clients. Only allowable services providerl to Title V eligible clients may
be billed against this ceiling. The current schedule of allawable 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
ternunate 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 PERFORMIlNG 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-10), is due no later than ninety (90) days after the end of the
Attachment term. This report shall be marked "Final".
BII.LING REOUIREMENTS
PERFORMING AGENCY shall bill RECEIVING AGENCY on a monthly basis for
allowable services provided to Title V eligible clients. $ills for all allowable services
shall be submitted as aggregate activity reports with aTDH Monthly Reimbursement
Request and shall not refer to or identify individual clients. PERFORMING AGENCY
shall bill within thirty (30) days after the end of the month which services were provided
or within sixty (60) days in cases of potentially Medicaid eligible individuals who are
ATTACHVVIENT - Page 2
denied eligibility by the Texas Department of Human Services. All bills shall be
submitted within ninety (90) days of the end of the Attachment term.
In billing RECEIVING AGENCY, PERFORMING AGENCY shall certify that all billed
services have been provided only to individuals who ha~re been determined to be eligible
for Title V services. RECENING AGENCY will pay P'ERFORMING AGENCY for all
acceptable vouchers submitted up to PERFORMING AGENCY'S contract ceiling
amount. Billing vouchers submitted outside of the time frames indicated above shall be
subject to disallowance.
BILLING ACTIVITY
RECEIVING AGENCY shall distribute funds in a way that will maximize the delivery of
authorized services to eligible clients. RECEIVING AGENCY will monitor
PERFORMING AGENCY'S billing activity. If utiliza$ion 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. PERFORM]NG 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 telm 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
PERFORMIIVG 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 detiermination forms are revised.
CO-PAY
PERFORMING AGENCY may assess a co-pay from !i clients provided services by
RECENING AGENCY under this Attachment. A co-pay shall not be assessed from
such clients if their family income is at or below 100%I 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
ATTACHVIENT - 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 vpuchers 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 cakegory 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 GG10), no later
than ninety (90) days after the end of the attachmeiftt term; and,
• Other reports as deemed necessary by RECEIVIPriG 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 AGFNCY. Unsatisfactory review
findings may result in implementation of General Provisions, Sanfitions Article.
PERFORMING AGENCY certifies that neither the PERFq'RMING 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);
ATTACHVIENT - 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 Sfate health care program. '
If the foregoing statement is not true, PERFORMINC AGENCY shall submit a
disclosure/ownership form to RECEIVING AGENCY. P$RFORMING AGENCY shall
immediately notify the RECENING 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 rl1isrepresentation.
PHARMACY
If PERFORMING AGENCY is dispensing and/or providing proscribed 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, Chapqer 560, or shall dispense and/or
provide such medications in compliance with other pharmacy sxatutes with prior approval from
RECENING 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
RECENING AGENCY. '
Total payments will not exceed $20,000.00.
F
ATTACHVIENT - Page 5
DOCUMENT NO. 7560022067A-q005
ATTACHIVIENT NO. 02 j
PERFORMING AGENCY: PARIS-LAMAR COUNTY HEALTH DEPARTMENT
RECEIVING AGENCY PROGRAM: ASSOCIATE COMMIS$IONER FOR FAMILY
HEALTH '
TERM: September 01, 2004 THRU: August 31, 2005
SECTION I. SCOPE OF WORK:
PERFORMING AGENCY shall provide or assure the provisiorp 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 establ$shed referral relationship with a
qualified provider of each approved service, which it does not provide.
PERFORMIlVG AGENCY shall comply with all applicable' federal and state laws, rules,
regulations, standards and guidelines in effect on the beginning idate of this contract Attachment
unless amended, including but not limited to: '
• RECEIVING AGENCY Family Planning Standards and Rules, 25 TAC Chapter 56;
• Sterilization, 42 CFR Part 50, Subpart B; and '
• Fees for Clinical Health Services, 25 TAC § 1.91 (Local Health Departments only).
The following documents are incorporated by reference andi' made a part of this contract
Attachment. These include:
• RECEIVING AGENCY Title V FY2005 Competitive Request For Proposal (RFP);
• PERFORNIING AGENCY'S FY2005 Component II, Attachment B application and any
revisions; '
• Title V Policy and Procedures Manual, revised for FY20015; and
• RECENING AGENCY'S Texas Department of Health (TDH) Standards for Pubiic
Health Clinic Services, revised January 31, 2004. '
Within thirty (30) days of receipt of an amended standard(s) dr guideline(s), PERFORMING
AGENCY shall inform RECEIVING AGENCY Program, in ~pvriting, if it shall not continue
performance under this Attachment in compliance with the amer)'ded 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 qr 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 sha11
ATTACHMENT - Page 1
cooperate with RECEIVING AGENCY staff to attain the goaJs 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 fior services provided to Title V
eligible individuals through twenty-one (21) years of age by PERi'FORMING 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 RECENING 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 modlification include a reduction in
rates. PERFORMING AGENCY shall have thirty (30) da+ys 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. '
BILLING REOUIREMENTS
PERFORMING AGENCY shall bill RECEIVING AGf-NCY for allowable services
provided to Title V eligible clients. Requests for pay~ ent shall be submitted to the
Health and Human Services Commission's claims adminilstrator in a manner compatible
with the Compass 21 billing system by the 120th day a~er the date on which services
were provided or the date of any third party insurance , xplanation 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 Att chment term. Claims shall be
submitted using an approved claim format which followls the RECEIVING AGENCY
Family Planning Division billing specifications which may be obtained from
RECENING AGENCY Family Planning Division.
ATTACHMENT - Page 2
BII.LING ACTIVITY
RECENING AGENCY shall distribute funds in a way 1
authorized services to eligible clients. RECEIV:
PERFORMING AGENCY'S billing activity. If utiliL
PERFORMING AGENCY'S contract ceiling amount, sr
PERFORMING AGENCY'S ceiling may be subject to a
contract Attachment period. PERFORMING AGEN,
ceiling amount decreases if PERFORMING AGENC
projected.
RECENING AGENCY may pay for additional service
if provided by PERFORMING AGENCY during the I
otherwise paid during the term of this Attachment) if i
and the RECEIVING AGENCY Program to do s
PERFORMING AGENCY exceeds the ceiling
PERFORMING AGENCY shall continue to bill RECEI
provided. RECEIVING AGENCY may pay for these ac
available at a later date.
ELIGIBILITY
at will maximize the delivery of
1G AGENCY will monitor
ion is below that projected in
wn in SECTION III. BUDGET,
lecrease for the remainder of the
Y may be subject to contract
'S billing activity is less than
as specified in this Attachment
rm of this Attachment (but not
in the best interest of the State
and funds are available. If
mount of the Attachment,
'ING AGENCY for the services
itional services if funds become
All individuals considered for Title V eligibility mu t be screened and determined
eligible using a TDH or Title V program approved scree~ing tool as updated in the spring
of each year when federal poverty levels and eligibility d~termination forms are revised.
CO-PAY
PERFORMING AGENCY may, assess a co-pay frort~l clients provided services by
RECEIVING AGENCY under this Attachment. A cc}-payment assessment may not
exceed 25% of the amount RECEIVING AGENCY paysl PERFORMING AGENCY for
the provision of a given service. A co-pay shall not be aslsessed from such clients if their
family income is at or below 100°l0 of the most recently Oefined 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 polici~s detailed in 25 TAC § 1.91.
General Provisions, Program Income Article, is revised to
All revenues directly generated by a Contract Attachmen (s) supported activity or earned
only as a result of the Attachment(s) during the term of t e Attachment(s) are considered
program income. PERFORMING AGENCY shall id ntify and report all program
income annually using Form 270 Request for Advance 6r Reimbursement (TDH Form
GG10).
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
ATTACHMENT - Page 3
demonstrated only by submission of acceptable fam~ly planning claims for services
provided to Title V eligible clients which exceeos PERFORMING AGENCY'S
Attachment amount by the total program income amounlt.
General Provisions, Reports Article, is revised to include:
PERFORMING AGENCY shall submit: '
• A Request for Advance or Reimbursement Fotm 270 (TDH Form GG10), no
later than ninety (90) days after the end of the attachment term; and,
• Other reports as deemed necessary by RECEIVIING AGENCY upon reasonable
notice to PERFORMING AGENCY. '
In addition to the site visits authorized by the Inspections A icle of the General Provisions,
PERFORMING AGENCY shall allow RECEIVING AGE CY to conduct on-site quality
assurance reviews as deemed necessary by RECEIVING A ENCY. Unsatisfactory review
findings may result in implementation of General Provisions, Sa'pctions Article.
I
PERFORMING AGENCY certifies that neither the PERFORMING AGENCY nor any
individual who has a direct or indirect ownership or controlling interest of 5°Io or more of the
PERFORMING AGENCY nor any PERFORMING AGEN~Y officer, director, agent or
managing employee (e.g, general manager, business manager,~ administrator, director, or like
individual who exercises operational or managerial control ov~r PERFORMING AGENCY or
who directly or indirectly conducts the day-to-day business of th~ PERFORMING AGENCY), is
an entity or individual who:
• Has been convicted of any offense under 42 U.S.C. § 132pa-7(b)(1)-(3);
~ Has had a civil monetary penalty assessed under 42 U.S.C. § 1320a andlor 42 U.S.C. §
1320a-8; or, I~ Has been excluded from ParticiPation in a Program und r 42 U.S.C. 1395 et se
~ § q.; or
under a State health care program. ,
If the foregoing statement is not true, PERFORMINGI 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 mrisrepresentation.
PHARMACY '
If PERFORMING AGENCY is dis ensin
p g and/or providing pre cnbed 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, Chapt r 560, or shall dispense and/or
provide such medications in compliance with other pharmacy statutes with prior approval from
RECENING AGENCY.
ATTACHMENT - Page 4
STERILIZATION
PERFORMING AGENCY shall comply with all federal re
procedures.
lations applying to sterilization
Prior to receiving a sterilization, a client shall sign a copy of th U.S. Department of Health and
Human Services (DHHS) sterilization consent form. The origi al 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 H. SPECIAL PROVISIONS, as 4mended and approved by the
RECEIVING AGENCY.
i
Total payments will not exceed $10,781.00. '
r.
ATTACHIVIENT - Page 5