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Home My WebLink About20120828.tiff RESOLUTION RE: APPROVE AMENDMENT#1 TO TASK ORDER CONTRACT FOR WOMEN'S WELLNESS CONNECTION PROGRAM AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS,the Board has been presented with Amendment# 1 to Task Order Contract for the Women's Wellness Connection Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, commencing April 1, 2012, and ending March 31, 2013, with further terms and conditions being as stated in said amendment, and WHEREAS,after review,the Board deems it advisable to approve said amendment,a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that Amendment # 1 to Task Order Contract for the Women's Wellness Connection Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said amendment. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 26th day of March, A.D., 2012. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: Sean P. w , Chair /vim Weld County Clerk to the Boar illaam F. Ga ia, Pro-Tem BY: l Deputy CI c to the Boar ra Kirkmeyer' APP ED A RM: `) , C David E. Long • tfu Attorney EXCUSED 11 / Douglas Rademacher Date of signature: 1 -/0 -1 4 OnC }-o 0-t 2012-0828 312-611L. _\--1-1 a HL0039 Memorandum 3,_ TO: Sean P. Conway, Chair o�• Board of County Commissioners G O U__N T Y FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and Environment DATE: 3-19-2012 SUBJECT: Women's Wellness Connection/Komen Amendment#1 Enclosed for Board review and approval is Amendment#1 to the original Task Order Contract between the Colorado Department of Public Health and Environment and Weld County Board of County Commissioners for the Department of Public Health and Environment's Women's Wellness Connection (WWC) program. This is a supplemental amendment that accesses the private funds of Susan G Komen to expand eligibility for women not covered under the state and federally funded WWC program. Weld County has an existing agreement with the Women's Wellness Connection to serve low- income, uninsured and underserved women eligible for breast and cervical cancer screening. . The Komen funding provides low-income, uninsured and underserved women clinical breast exams and referrals for mammography that are not currently eligible for WWC services, to detect breast cancer at the earliest stages. No additional staff will be added to provide these services. Weld County's model of incorporating WWC and Komen services into our current Family Planning program is a model for the state. These services are available at both our North and South County sites. The original funding amount of this contract was $45,055.00. On 3-15-12 Weld County was notified that there was an overall reduction of funds resulting in a decreased amount of funding to Weld County in the amount of$1,287.00. This results in total funding for this contract to be $43,768.00. The funds are from the Susan G Komen for the Cure Denver Metropolitan Affiliate. The term of this Contract is April 1, 2012 through and including March 31, 2013. I recommend your approval of this contract. Enclosures 2012-0828 STATE OF COLORADO John W. Hickenlooper,Governor -— Christopher E. Urbina, MD,MPH �;oF cLOR Executive Director and Chief Medical Officer tee; Ta Dedicated to protecting and improving the health and environment of the people of Colorado . *) 4300 Cherry Creek Dr.S. Laboratory Services Division s Denver,Colorado 80246-1530 8100 Lowry Blvd. \!a�g� Phone(303)692-2000 Denver,Colorado 80230-6928 Colorado Department Located in Glendale,Colorado (303)692-3090 of Public Health http://www.cdphe.state.co.us and Environment 04/09/12 Weld County Public Health 1555 North 17th Avenue Greeley, CO 80631 Dear Ms. Drew, This cover letter serves as notification of your FULLY EXECUTED Colorado Department of Public Health & Environment(CDPHE)Amendment For task Order#1 listed below: PO FLA PPG1241166 Contractor Name: Board of County Commissioners of Weld County Amendment For task Order#1 Number: 12 FLA 41166 Original Contract Number: 11 FLA 29348 Division: Prevention Services Division Program Name: Women Wellness Connection-Susan G. Komen for the Cure Partnership Project Reason for Contract: Increased funding The Amendment For task Order#1listed above has been fully executed and you may begin work on April 4, 2012. An original hard copy of the Amendment For task Order#1 will be mailed to you soon. Please contact me with questions or concerns. My contact information is listed below. Sine l , L-H nevie owden Contract oordinator Prevention Services Division Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80246-1530 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PSD-WWC DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 12-41166 AMENDMENT FOR TASK ORDERS#1 This Amendment is made this 16th day of February,2012,by and between the State of Colorado,acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as the"State"; and, Board of County Commissioners of Weld County, (a political subdivision of the state of Colorado)for the use and benefit of the Weld County Department of Public Health and Environment whose address or principal place of business is 915 10th Street,Greeley,Colorado 80631,hereinafter referred to as the"Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated January 23,2007,with contract routing number 08 FAA 00052. Pursuant to the terms and conditions of the Master Contract,the parties entered into a Task Order Contract,dated March 1,2011,with contract encumbrance number PO FLA PPG1129348, and contract routing number 11 FLA 29348,as amended by Grant Funding Change Letter# 1,Contract Routing# 12 FLA 38399 collectively,referred to herein as the"Original Task Order Contract, whereby the Contractor was to provide to the State the following: Contractor shall perform cancer screenings for the Susan G. Komen and Denver Affiliate Grant. The State promises to increase the amount of funds to be paid to the Contractor by Forty-Three Thousand,Seven Hundred Sixty-Eight Dollars,($43,768.00)for the renewal term of 12 months,ending on March 31,2013,in exchange for the promise of the Contractor to perform the increased work described herein. NOW THEREFORE, in consideration of their mutual promises to each other, stated below,the parties hereto agree as follows: I. Consideration for this Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order Contract,contract routing number 11 FLA 29348,as amended by Grant Funding Change Letter# 1, Contract Routing# 12 FLA 38399 collectively, referred to herein as the Original Contract,which is by this reference incorporated herein. All terms,conditions, and provisions thereof, unless specifically modified herein,are to apply to this Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: Page 1 of 5 Rev 3/16/2010 A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number 11 FLA 29348. This Amendment is for the renewal term of April 1, 2012,through and including March 31,2013. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is Forty-Three Thousand, Seven Hundred and Sixty-Eight Dollars,($43,768.001 for an amended total financial obligation of the State of NINETY THOUSAND,FOUR HUNDRED SIXTY-THREE DOLLARS, ($90,463.00). This is an increase of Forty-Three Thousand,Seven Hundred and Sixty-Eight Dollars, ($43,768.001 of the amount payable from the previous term. The revised specifications to the original Statement of Work, if any, for this renewal term are incorporated herein by this reference and identified as"Exhibit D"and the revised Additional Provisions is incorporated herein by this reference and identified as"Exhibit C". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Amendment is April 1,2012,or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance,or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Task Order Contract,the terms and provisions of this Amendment shall in all respects supersede,govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 2 of 5 Rev 3/16/2010 This page left intentionally blank. Page 3 of 5 Rev 3/16/2010 IN WITNESS WHEREOF,the parties hereto have executed this Amendment on the day first above written. * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: STATE: Board of County Commissioners of Weld County STATE OF COLORADO for the use and benefit of the Weld County John W. Hickenlooper,Governor Department of Public Health and Environment (a political subdivision of the state of Colorado qmocia , By: Signature of Authorized Offi MAR 2 6 701? For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Sean P. Conway Print Name of Authorized Officer Chair Print Title of Authorized Officer PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts.This Contract is not valid until signed and dated below by the State Controller or delegate.Contractor is not authorized to begin performance until such time.If Contractor begins performing prior thereto,the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER David J.McDermott,CPA By: Date: i/4",ei< OJZ Page 4 of 5 Rev 3/16/2010 o1Dy, ece cQ This page left intentionally blank. Page 5 of 5 Rev 3/16/2010 EXHIBIT C ADDITIONAL PROVISIONS To Task Order Contract Dated 02/16/2012-Contract Routing Number 12 FLA 41166 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. These provisions are effective for the renewal term beginning 4/1/2012. 1. The list of acronyms attached hereto as Attachment C-1 may be referenced to in Exhibit C,Exhibit D, and all and any attachments thereof in this Task Order Contract. 2. This Task Order Contract contains 100%private funds. 3. To receive compensation under this Task Order Contract, the Contractor shall provide cancer screening services to women during the term of this Task Order Contract.The Contractor shall also provide Women's Wellness Connection approved diagnostic services to women that meet the criteria in accordance with the Statement of Work attached hereto as Exhibit D and incorporated herein. The Contractor shall be paid in accordance with rates as outlined in this Task Order Contract. To be considered for payment, all Women's Wellness Connection services must be entered into eCaST within thirty(30)days of service being performed. Cases that exceed sixty(60)calendar days in screening length and negatively affect the program's Core Performance Indicators may or may not be reimbursed at the discretion of the State. 4. Time Limit for Acceptance of Deliverables. a. Evaluation Period. The State shall have thirty(30)calendar days from the date a deliverable is delivered to the State by the Contractor to evaluate that deliverable,except for those deliverables that have a different time negotiated by the State and the Contractor. b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design specifications for that particular deliverable,or is otherwise deficient,then the State shall notify the Contractor of the failure or deficiencies,in writing,within thirty(30)calendar days of: 1) the date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or deficiency at the time of delivery; or 2)the date the State becomes aware of the failure or deficiency. The above time frame shall apply to all deliverables except for those deliverables that have a different time negotiated by the State and the Contractor in writing pursuant to the State's fiscal rules. c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed deliverable,the Contractor shall have a reasonable period of time,not to exceed ten(10) calendar days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within ten (10)calendar days,the Contractor shall be in default of its obligations under this Task Order Contract and the State,at its option, may elect to terminate this Task Order Contract or the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract. 5. Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination. The State has determined that this Task Order Contract does not constitute a Business Associate relationship under HIPAA. 6. Contractor must notify the State within thirty(30)days of a change of the Project Director or Principal Investigator responsible for the performance of services provided under this Task Order Contract. To be attached to CDPHE Page 1 of 2 Revised: 12/19/06 Task Order v1.0(11/05)contract template EXHIBIT C 7. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9,Rights in Data, Documents and Computer Software or Other Intellectual Property,unless otherwise provided for, all data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this Task Order Contract shall remain the sole property of the State, whether in individual,aggregate, identified or de-identified form or any other form required by the State. To facilitate follow-up,research,surveillance and evaluation,any such data collected,used or acquired shall be made available in any form required by the State, to the State and any other entity designated by the State. Any such data collected,used or acquired shall be used solely for the purposes of this Task Order Contract. The Contractor and its subcontractors agree not to release,divulge,publish,transfer,sell,or otherwise make known any such data to unauthorized persons without the express prior written consent of the State or as otherwise required by law.This includes a prior written request by the Contractor to the State for submission of abstracts or reports to conferences,which utilize data collected under this Task Order Contract. Notwithstanding the foregoing,the Contractor shall be entitled to retain a set of any such data collected or work papers necessary to perform its duties under this Task Order Contract and in accordance with professional standards. 8. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9,Rights in Data, Documents and Computer Software or Other Intellectual Property,or Section 23.i,General Provisions, Media or Public Announcements,the State of Colorado,specifically the Department of Public Health and Environment,shall be the owner of all printed materials,graphic representations,educational materials,audio-visual products,or any other media, in whatever form,created under this Task Order Contract. This requirement applies,but is not limited to,any brochure,flyer,presentation, billboard,radio spot,website,banner advertisement. The State reserves the right to require logos,or other wording on any material,representation,product or other media form created under this Task Order Contract. Any material,representation,product or other media form that will use the State's or logo or information must be approved by the State prior to production and distribution. A minimum of ten(10)business days is required for the review and approval process. 9. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding Change Letter substantially equivalent to Attachment C-2. The Grant Funding Change Letter is not valid until it has been approved by the State Controller or designee. 10. Notwithstanding anything in this Task Order to the contrary,the parties understand and agree that all terms and conditions of this Task Order which may require continued performance, compliance, or effect beyond the termination date of this Task Order and shall survive such termination date and shall be enforceable by the State as provided herein in the event of failure to perform or comply by the Contractor. 11. The State of Colorado,specifically the Colorado Department of Public Health and Environment, shall be the owner of all equipment as defined by Federal Accounting Standards Advisory Board(FASAB) Generally Accepted Accounting Principles(GAAP)purchased under this Task Order Contract. At the end of the term of this Task Order Contract,the State shall approve the disposition of all equipment. 12. The Contractor shall not use funds provided under this Task Order Contract for the purpose of lobbying as defined in Colorado Revised Statutes(C.R. S.)24-6-30I(3.5)(a). To be attached to CDPHE Page 2 of 2 Revised: 12/19/06 Task Order v1.0(11/05)contract template Attachment C-1 Commonly Used Acronyms and Abbreviations That May Be Referenced In the Scope of Work: ACS American Cancer Society ACNS Alamosa County Nursing Service ACF Administration for Children and Families ADA Americans with Disabilities Act ADAD Alcohol and Drug Abuse Division AHA American Heart Association AIDS Acquired Immune Deficiency Syndrome ALA American Lung Association ALA(C) American Lung Association(of Colorado) AMCHP Association of Maternal Child Health Programs ANR Americans for Non-Smokers'Rights ARC Addiction Recovery Centers ARRA American Recovery and Reinvestment Act ASC Adams State College ASSIST American Stop Smoking Intervention Study ASTHO Association of State and Territorial Health Office B&G Boys&Girls BACCHUS BACCHUS Peer Education Network BAG Build a Generation BBLHC Boulder Broomfield Latino Health Coalition BC Boulder County BCCP Breast and Cervical Cancer Program BCHD Bent County Health Dept BCPH Boulder County Public Health BCPHA Baca County Public Health Agency BCDSS Baca County Dept Social Services BCTEPP Bent County Tobacco Education Prevention Partnership BGC Boys&Girls Club BGCMD Boys&Girls of Metro Denver BHS Broomfield High School BMTF Baby&Me Tobacco Free BOCES Board of Cooperative Educational Services BOH Board of Health BRFSS Behavioral Risk Factor Surveillance System BVBAG Buena Vista Build a Generation BVSD Boulder Valley School District Bx Biopsy C Choice CAD Coronary Artery Disease CASB Colorado Association of School Board CB Community-based System CBE Clinical Breast Exam CBO Community-based Organization CC Clear Creek CC Custer County CC Community Coordination/Coordinator CCAP Larimer County Child Care Assistance Program CCC Colorado Cancer Coalition CCCHE Colorado Community Coalition for health Equity CCGC Colorado Clinical Guidelines Collaborative CCMC Colorado Clinical Managed Care Network CCMC Commission for Case Manager Certification CCPD Cancer,Cardiovascular,and Pulmonary Disease CCIAA Colorado Clean Indoor Air Act CCTCI Colorado Chew Tobacco Collaborative Initiative Page 1 of 6 Attachment C-1 CCTEPP Custer County Tobacco Education Prevention Partnership CDC Centers for Disease Control and Prevention CDE Colorado Department of Education CDPHE Colorado Department of Public Health and Environment CEC Career Education Center CEO Chief Executive Officer CFDA Catalog of Federal Domestic Assistance CFFC Colorado Foundation for Families and Children CHIN Community Health Information Network CICP Colorado Indigent Care Program CJD Colorado Judicial Department CM Case Management CMC Colorado Mountain College CMS Contract Management System CMS Creative Media Solutions CNCC Colorado Northwestern Community College CNS County Nursing Service CO Colorado COD Colorado Donated Dental Services Program COPAN Colorado Physical Activity and Nutrition Program COV Colorado Van Program CPCF Colorado Parent and Child Foundation CPHA Colorado Public Ilealth Association CPT Current Procedural Technology CRUE Culturally Responsive Urban Education CSAP Colorado Student Assessment Program CSH Coordinated School Health CSU Colorado State University CSU-P Colorado State University-Pueblo's CTC Connect to Care CTEPA Colorado Tobacco Education and Prevention Alliance CTFK Campaign for Tobacco-Free Kids CTRP Colorado Tobacco Research Program CTP Crossroads Turning Point CU University of Colorado,Boulder CWCCI Colorado Women's Cancer Control Initiative CY Contract Year DAISI Denver At-home Intervention Service Initiative DASH Division of Adolescent&School Health (CDC) DCMH Delta County Memorial Hospital DH Denver Health DHHA Denver Health and Hospital Authority DHS Department of Human Services Df IHS Unites States Department of Health and Human Services DOR Department of Revenue DOS Delta Opportunity School DSS Department of Social Services E&I Education and Information EAP Employee Assistance Program EBHV Evidence-Based Home Visiting to Prevent Child Maltreatment Grant Program ECC Early childhood council ECC Electrocardiogram ECCLC Early Childhood Council of Larimer County ECLC Early Childhood Leadership Council/Commission E.D. Executive Director EHS Early Head Start EMR Electronic Medical Record EMT Emergency Medical Technicians Page 2 of 6 Attachment C-1 EPA Environmental Protection Agency EPE Epidemiology Planning and Evaluation ESL English as a Second Language ETS Environmental Tobacco Smoke(a.k.a,secondhand smoke) FIRC Family and Intercultural Resource Center FICA The Federal Insurance Contribution Act FDA Food and Drug Administration FNA Final Needle Aspiration PPP Family Planning Program FPL Federal Poverty Level FRCC Front Range Community College FTE Full Time Equivalent FTP File Transfer Protocol FY Fiscal Year FYI Family Youth Initiatives GASO Great American Smokeout GED General Education Development GASP CO Group to Alleviate Smoking Pollution of Colorado Get R!EAL(GR) Resist! Expose Advertising Lies(Youth Empowerment Program) GLBT Gay,Lesbian,Bisexual,and Transgender GYN Gynecological HCP Health Care Program For Children with Special Needs HCYS Huerfano County Youth Services HHS Health and Human Services HIPPA Health Insurance Portability and Accountability Act of 1996 HIPPY Home Instruction for Parents of Preschool Youngster HIT Health Improvement Team HIV Human Immunodeficiency Virus HPV Human Papillomamavirus HR Human Resources hr hour HRSA Health Resources and Services Administration HSL High School Leadership ID Identification IIK Invest in Kids ISHT Interagency School Health Team IT Information Technology JAC Juvenile Assessment Center KIS Keeping in STEPP KMH Keefe Memorial Hospital KPC Kevin Patrick Caleum LAHCDHD Las Animas Iuerfano Counties District Health Department LBW Low Birth Weight LC Learning Community LGBT Lesbian,Gay,Bisexual,Transgender LEM Latinas en Movimiento LHA Local Health Agency I.HD Local Health Department LLC Limited Liability Company LRCC Latino Regional Community Coalition LRPC Latino a Research and Policy Center LST Life Skills Training LSTPEN Latino Statewide Tobacco Prevention and Education Netw LWB Live Well Broomfield MCHA Montezuma Housing Authority MCHD Montezuma County Health Department MCHS Montezuma-Cortez High School MCPN Metro Community Provider Network Page 3 of 6 Attachment C-1 MCRC Media Campaign Resource Center—CDC MD Medical Doctor MHCBBC Mental Health Center Serving Boulder and Broomfield Counties MIECHV Maternal,Infant and Early Childhood Home Visiting Program MO Month MOB Medical Office Building MOtJ Memorandum of Understanding MPA Master of Public Administration in Health and Human Services MPH Master of Public Health MRI Magnetic Resonance Imaging Scan MS Master of Science MSA Master Settlement Agreement MUH Multi-user Housing MYAT Multi-Disciplinary Youth Assessment Team N/A Not Applicable NACCHO National Association of County and City Health Officials NACR Native American Cancer Research NAQC North American Quitline Consortium NASBE National Association of State Board of Education NCHD Northeast Colorado Health Department NCI National Cancer Institute NE North East NFP Nurse-Family Partnership NFPNSO Nurse-Family Partnership National Service Office NHVP Nurse Home Visitor Program NIDA National Institute on Drug Abuse NIH National Institute of Health NJH National Jewish Medical and Research Center N-O-T Not-on-Tobacco,(ALA's Youth Smoking Cessation Program) NP Nurse Practitioner NPP Nurturing Parenting Program NRT Nicotine Replacement Therapy NSBA National School Boards Association OSH Office on Smoking or Health (CDC) OTC Over the Counter PA Physician's Assistant PAC Prevention Awareness Crew PACT Partners Assessing Chew Tobacco • PAT Parents as Teachers PCCHD Pueblo City-County Health Department PPC Personal Care Providers PE Presumptive Eligibility PEN Parent Engagement Nctwork PVCHC Peak Vista Community Health Center PHN Public Health Nurse PIO Public Information Officer PM Peer Mentor PMC Parkview Medical Center PMR Planning Management Region PN Patient Navigator PO Purchase Order PPC Policy Partner Committee PPFC Pikes Peak Family Connections PPN Prevention Policy Network • PRA Policy Resource Alliance PRAMS Pregnancy Risk Assessment and Monitoring Survey PRIDE Pure Respect Initiative Direct Education PSA Public Service Announcement Page 4 of 6 Attachment C-1 PSD Prevention Service Division PTEPP Pueblo Tobacco Education and Prevention Partnership PVC Prairie View Clinic QI Quarter One Q2 Quarter Two Q3 Quarter Three Q4 Quarter Four QI Quality Improvement QOL Quality of Life RDAC Regional Disparities Advisory Council RFA Request for Applications RFP Request For Proposals RIE Reach,Implementation and Effectiveness RIHEL Regional Institute for Health and Environment RMC Rocky Mountain Center for Health Promotion&Education RMRH Rocky Mountain Rural Health RMYC Rocky Mountain Youth Corps RN Registered Nurse Rx Perscription RY Reconnecting Youth SafeCare SAMIISA Substance Abuse Mental Health Services Administration SB School-based System SBAG Salida Build A Generation SBHC School-Based Health Centers SCYC School Community Youth Coalition SCRFIC Southern Colorado Regional Health Collaborative SD Service Delivery SECH Southeast Colorado Hospital SEMHS Southeast Mental Health Services SES Socio-Economic Status SEW School Employee Wellness SGR Surgeon General's Report SHAC Smoke-free I lousing Action Committee SHI School Health Index SHS Secondhand Smoke SIDS Sudden Infant Death Syndrome SLV San Luis Valley SMART Staying Motivated at Reducing Temptations SMART OUTCOME OBJECTIVE Specific,Measurable,Achievable,Realistic,Time-Bound SRO School Resource Officer STD Sexually Transmitted Disease STEPP State Tobacco Education and Prevention Partnership STW Straight-to-Work SVVSD St.Vrain Valley School District SWOT Strengths,Weaknesses,Opportunities,Threats SYNAR Synar Regulation TA Technical Assistance TABS Tobacco Attitudes and Behavior Survey TAG Technical Advisory Group(for evaluation&TPEG) TANF Temporary Aid to Needy Families TARP Tobacco Advocacy and Resource Partnership TBD To Be Determine TCP Tobacco Control Partners TDAC Tobacco Disparities Advisory Council TDG Tobacco Disparities Grant TDS Tobacco Disparities Subcommittee TEACH Teaching Equity to Advance Community Health Page 5 of 6 Attachment C-1 TEFAP The Emergency Food Assistance Program TEPP Tobacco Education Prevention Partnership TFCCI Tobacco-Free Colorado Communities Initiative TFLC Tobacco Free Larimer County TFS Tobacco-Free Schools TFS Law Tobacco-Free Schools Law TGYS Tony Grampsas Youth Services Title V Title V of the Social Security Act TND Project Toward No Drug Abuse TPEG Tobacco Program Evaluation Group TPI Tobacco Prevention Initiative TRC Tobacco Education and Prevention and Cessation Program Review Committee TRI Tobacco Rapid Improvement Activity TRIA Tobacco Rapid Improvement Assessment TTI Tony Grampsas Tobacco Initiative UCD University of Colorado—Denver UCDHSC Heath Sciences Center at UCD(sometimes abr. UCHSC) UCDHSC University of Colorado at Denver and Health Sciences Center US United States of America USSTC US Smokeless Tobacco Company VP Vice President Well COA Wellness Councils of America WHU Women's Health Unit WIC Women,Infants,Children WWC Women's Wellness Connection Y@C Youth at Crossroads YE Youth Empowerment YPH Youth Partnership for Health Yr Year YRBS Youth Risk Behavior Survey YSAP Youth Substance Abuse Prevention Coalition YTS Youth Tobacco Survey YVMC Yampa Valley Medical Center 5 A's Ask,Advise,Assess,Assist,Arrange 2A's R Ask,Advise,Refer • Page 6 of 6 Attachment C-2 GRANT FUNDING CHANGE LETTER Date: State Fiscal Year: Grant Funding Change Letter# CMS Routing# TO: Insert Grantee's name In accordance with Section of the Original Contract routing number , [insert the following language here if previous amendment(s), renewal(s) have been processed] as amended by [include all previous amendment(s), renewal(s) and their routing numbers], [insert the following word here if previous amendment(s), renewal(s) have been processed] between the State of Colorado, Department of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of original contract>and ending on Insert ending date <insert ending date of current contract amendment>, the undersigned commits the following funds to the Grant: The amount of grant funds available and specified in Section of<insert contract amendment number and routing number> is ❑ increased or❑ decreased by $amount of change to a new total funds available of$ <insert new cumulative total>for the following reason: . Section is hereby modified accordingly. This Grant Funding Change Letter does not constitute an order for services under this Grant. The effective date of hereof is upon approval of the State Controller or , whichever is later. STATE OF COLORADO John W. Hickenlooper,GOVERNOR Department of Public Health and Environment PROGRAM APPROVAL: By: Lisa Ellis,Purchasing&Contracts Unit Director By: Date: ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER CRS§24-30-202 requires the State Controller to approve all State Grants.This Grant is not valid until signed and dated below by the State Controller or delegate.Grantee is not authorized to begin performance until such time.If Grantee begins performing prior thereto,the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER David J. McDermott,CPA By: Date: Pane 1 of 1 EXHIBIT D STATEMENT OF WORK To Task Order Contract Dated 02/16/2012-Contract Routing Number 12 FLA 41166 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. The Contractor,in accordance with the terms and conditions of this Task Order Contract,shall perform and complete,in a timely and satisfactory manner,all activities described in the approved Work Plan/Scope of Work that is attached hereto as Attachment D-I and incorporated herein To be attached to CDPHE Page 1 of 1 Revised:4/1/04 Version 1.0(4/04)contract template Attachment D-1 STATEMENT OF WORK Project Period: April 1, 2012 through March 31, 2013. Background: In partnership with Susan G. Komen for the Cure Denver Metropolitan Affiliate and Aspen Affiliate, the Women's Wellness Connection (WWC) program provides low-income, uninsured, uninsured and underserved clients in Colorado access to timely, high-quality screening and diagnostic services to detect breast cancer at the earliest stages. Services are currently available through eight agencies including, Summit Community Care Clinic, Tri- County Health Department, Weld County Department of Public Health and Environment, Denver Health Mobile Clinic, Yuma District Hospital, La Clinica Tepeyac, Jefferson County Public Health, and Grand River Hospital District. Direct Beneficiaries: Direct beneficiaries are men and women residing in Colorado who arc uninsured or underinsured and at or below 250% of the Federal Poverty Level. Project Goals: I. Deliver breast cancer screening services within the Contractor's existing network of Subcontractors. 2. Provide quality services to clients receiving screenings. 3. Promote a seamless system of breast cancer screening and diagnostic services for Komen/WWC clients. Definitions: Breast Cancer Screen — Standard testing performed to determine the presence or non-presence of breast cancer. Standard screening tests include a clinical breast exam (CBE) and a mammogram. Core Performance Indicators—Measures of clinical quality of care and penetration of screenings in certain target populations. Indicators are set by the WWC and Komen programs. Contractor—Agency responsible for signing and administering this contract. Page 1 of 12 Attachment D-1 Definitive Diagnosis—The final point in cancer screening care where it is determined whether a client has or does not have breast cancer. This information is usually obtained after diagnostic services have been rendered. Department—The Colorado Department of Public Health and Environment Diagnostic Testing — Further testing used when a definitive diagnosis is unable to be determined by the results of prior screening tests. eCaST—An electronic database system the WWC program uses to track clients and administer payment to Contractors for services performed. Network — Any provider site that works under the Contractor name and receives fiscal and administrative assistance to do business. Program—Women's Wellness Connection program Subcontractor — An entity in the community that provides services for the Contractor that the Contractor cannot perform onsite. Agreements are made between the Contractor and the Subcontractor directly; WWC is not involved in these negotiations or agreements. Deliverables: Under this arrangement, the Contractor shall provide and perform the following: 1. Administration: a. The Contractor must submit an updated list of contact information(Attachment D-1-A) to WWC by June 29, 2012. The WWC program will request this completed document in early June 2012 from WWC Coordinators directly, the attachment is a draft; please do not send this completed attachment with the contract. i. All staff changes during the contract year must be reported to the WWC within fifteen (15) calendar days. b. Security access to eCaST must be renewed by completing the renewal form (Attachment D-1-B) by June 29, 2012. The WWC program will request this completed document in Page 2 of 12 Attachment D-1 early June 2012 from WWC Coordinators directly. The Attachment D-1-B is a draft; please do not send this completed attachment with the contract. c. The Contractor must maintain a network of Subcontractors (as needed or required to perform breast cancer screening and diagnostic services) and submit an updated list of these Subcontractors (Attachment D-1-C) to the WWC by June 29, 2012. The WWC program will request this completed document in early June 2012 from WWC Coordinators directly. The attachment is a draft; please do not send this completed attachment with the contract. i All Subcontractor changes during the contract year must be reported to the WWC within fifteen (15) calendar days. 2. Network: Ensure breast cancer screening services for eligible clients are performed by the Contractor or through a subcontracted network of providers until a definitive diagnosis has been achieved. a. Subcontractors: Service performed by Subcontractors shall: 1. Be performed in an outpatient setting to the extent possible. 2. Not exceed the Medicare reimbursement rate as established in the annual Current Procedural Technology (CPT) code list(Attachment D-1-D). Rates on this CPT code list will remain in effect for the length of the contract. The WWC Program typically revises this list annually and the Contractor is responsible for communicating rate changes to Subcontractors when they occur. 3. Specify that only services related to breast cancer screenings on the CPT code list will be performed and charged to the Contractor. 4. Not be charged to eligible clients unless services are performed that are not on the CPT code list. If services outside of the CPT code list are required, arrangements for completing and paying for services should be specified in the Subcontractor agreement. Clients may be charged for services outside the CPT code list,but should be notified before services are rendered and be told Page 3 of 12 Attachment D-1 how much they will cost. 5. Be agreed upon in writing through the use of a signed contract or memorandum of understanding which includes the service period. b. The Contractor must identify and support a WWC/Komen Coordinator. This person should be the same person who serves as the WWC Coordinator. The role of the coordinator will be the point of contact between the Contractor and WWC and will be considered the lead for the program at the Contractor level. It is expected that the coordinator will promote and distribute the communication of updates,policy changes, trainings, Core Performance Indicator reports, etc. throughout the Contractor and to necessary staff. i It is expected that the coordinator will be responsible for clinical quality performance at the Contractor level (as demonstrated in the Core Performance Indicator report) and update eCaST data as needed to keep the agency in compliance. c. The Contractor must identify and support a WWC/Komen Data Coordinator. The role of the data coordinator is to ensure that all information about clients screened under the WWC/Komen Program is entered into cCaST. It is expected that the data coordinator will maintain data in eCaST that is up to date and meets Core Performance Indicators. iii The WWC/Komen Data Coordinator is responsible for ensuring all data clean-up requests, both ad hoc and formal projects, arc completed with specified deadlines. iv The WWC/Komen Coordinator role and WWC/Komen Data Coordinator role may be filled by the same person at the agency. 3. Enrollment: The Contractor must ensure that clients screened under the WWC/Komen program meet WWC/Komen program eligibility requirements: a. WWC/Komen Program Eligibility Requirements (Attachment D-1-E). Eligibility guidelines may be updated during the period this scope of work is in effect. When new eligibility guidelines are adopted for implementation by Page 4 of 12 Attachment D-1 WWC, the Contractor will be notified and responsible for implementing necessary changes to the Contractor workflow by a date determined by WWC. Contractors should provide eligibility screenings, referrals and medical services in Spanish or other languages as requested by clients served. b. Document lawful presence status in eCaST for each client in eCaST (see section 8 eCaST System). 4. Billing and Reimbursement: a. The Contractor shall only request reimbursement from the WWC/Komen Partnership Project for a case that meets eligibility, timeliness, performance, and data requirements. Cases out of compliance with any of these requirements may be deemed ineligible for payment by the WWC Program. b. Reimbursement will be provided at the end of the case when a definitive diagnosis has been achieved, and all data has been entered in eCaST. c. Reimbursement is determined by the outcome of the case. Payment will be determined based on the highest level of care provided to the client(Attachment D-1-F). Cases that exceed sixty (60) days in length from screening to definitive diagnosis and negatively affect the program's Core Performance Indicators may or may not be reimbursed at the discretion of the WWC Program. i Cases that are closed out in eCaST as "lost to follow-up" or"refused" will be paid at the highest level achieved. iii It is expected that if a Contractor starts cancer screening services for a client, the same Contractor will be responsible for closing the case and reaching the point of definitive cancer diagnosis. In cases where more than one WWC/Komen contracting agency is involved with the same woman, the Contractor who closes the case will receive all of the WWC or Komen funds at the highest level achieved. iv Rates for the reimbursement process may be revised or updated during the period this scope of work is in effect. When changes are adopted for implementation by WWC, the Contractor will be notified at least sixty (60) days prior. d. It is expected that reimbursement will cover costs associated with: Page 5 of 12 Attachment D-1 Enrollment of women into the WWC/Komen Program; ii Cancer screening services, including a clinical breast exam and mammogram; i Case management of abnormal findings; iv Diagnostic services to the point of a definitive diagnosis, as necessary; v Entry of all information into eCaST; vi Administrative procedures to place women with a positive diagnosis of breast cancer into the Breast and Cervical Cancer Medicaid Program if eligible; and vii Administrative procedures to enroll clients diagnosed with breast cancer that are not eligible for Breast and Cervical Cancer Medicaid into treatment services through Komen or other community-based efforts. e. Data entered into eCaST is the basis for calculating reimbursement for each woman screened. Data for any WWC/Komen procedure must be entered into eCaST within thirty (30) days of service being performed. Cases entered after this thirty(30) day period may or may not be paid at the discretion of the WWC. ii The Contractor shall review Report 22S -Incomplete Cases Not Yet Paid to identify women who are pending services, or who may have missing essential information prior to the fourteenth (141h) of each month. 1. It is the responsibility of the Contractor to ensure its network of provider sites has entered all required data elements prior to the WWC billing cycle on the fourteenth (14th) of each month. 2. Essential data elements missing from a client's electronic record may make him/her ineligible for payment. 3. Procedures entered into eCaST must be charged to the correct program (Komen or WWC) in order to be paid. The Contractor shall follow the Komen/WWC Funding Diagram (Attachment D-1-F) to determine which program to charge each service to. f. One Komen reimbursement check for all completed screenings that have met data quality standards and occurred in the prior thirty (30) days will be sent to the Contractor each month. The Contractor will work with WWC Program staff directly on non-payment of Page 6 of 12 Attachment D-1 clients screened. If WWC staff is unable to rectify reimbursement,the Contractor will work with the WWC fiscal officer to the point of satisfaction by both parties. ii Contractors will each be given a funding cap of$43.768.00 (this varies by Contractor) for direct care screening services. WWC will notify Contractors on a monthly basis regarding how funds are being expended and assist with making decisions to stop, slow down or make changes to accommodate this funding cap. Contractors should run on a monthly basis eCaST Report 24S - Supplemental Count of Women Paid for an unduplicated count of Komen clients paid and Report 72S - Service Delivery Grant Payment Supplemental to keep track of Komen fund expenditure. g. WWC may reimburse the Contractor for above and beyond costs outside of the level reimbursement system with Komen funds. Any procedures provided outside of the approved procedures on the CPT code list (Attachment B-1-D) must be pre-approved by a WWC staff member and must be charged to the WWC/Komen program at current Medicare rates. Procedures must also be entered into eCaST. • 5. Service Delivery: - a. The Contractor shall follow and utilize all policies and guidelines according to the 2010- 2011 WWC Provider Toolkit, https://docs.google.com/viewer?a=v&pid=explorer&chromertiue&srcid=0B9UrHzcBK K4hOTZ1NmI3YmYtZGY3MS00NzU3LWlyZTQtY2Y4YzhmZTIXMzU0&hl=en US, and Komen screening guidelines, (httn://ww5.komen.org/BreastCancer/GeneralRecommendations.htme, as the standard of care when performing services related to breast cancer screening. i. The Provider Toolkit may be updated during the period this scope of work is in effect. When new documents/policy/guidelines or toolkit directives are adopted for implementation by WWC agencies,the Contractor will be notified and responsible for implementing necessary changes by a date determined by the WWC. b. The Contractor shall implement the breast cancer screening algorithms as approved by the program as clinical guidelines for breast cancer screenings. c. The Contractor may utilize the WWC Nurse Consultant for clinical consultation services Page 7 of 12 Attachment D-1 on any client. 6. Performance Standards: a. The Contractor will meet or exceed established Centers for Disease Control and Prevention (CDC) Clinical Core Performance Indicators for abnormal breast cases (Attachment B-1-G). Contractors will be provided with quarterly updates on their performance from WWC. 1. Contractors not meeting Core Performance Indicators may be placed under a performance improvement plan. a. This performance improvement plan will have expectations set by the WWC with time frames for completion. b. Contractors are responsible for developing and implementing a quality improvement plan to meet expectations. c. Unmet expectations may result is cancellation or limitation of the contract. 2. Contractors exceeding indicators will be recognized for good performance. 7. Site Visits: a. The WWC/Komen program will perform site visits to select Contractors on an annual basis. The purpose of a site visit is to provide, promote and ensure quality breast cancer screenings in Colorado at local agencies by focusing on administrative and management functions and clinical oversight. b. Selection of Contractors to visit is based on the following: Core Performance Indicators; ii eCaST data reports, specifically Report 17 - Missing Data and Report 84S — Breast Diagnostic Follow up; iii Technical assistance needs; iv Adherence to this Statement of Work; v Participation in trainings, conference calls and webinars; and vi Ability to refer positively diagnosed clients to Medicaid (or other) treatment in a Page 8 of 12 Attachment D-1 timely manner when eligible. c. Site visits will include: Completion of the WWC prep tool https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B0i5- XFhANOXOWY3ZjliMjQtZjliMi00N?MzLWE0MGMtMjQwNzklZjO0Y2Vi& h1=en US; • ii Chart audit; iii Review of Subcontractor agreement(s); iv Review of program administration and program management; v Review of clinical services and case management activities; and vi Implementation of a corrective action plan for agencies not meeting two or more Core Performance Indicators for a period of six (6)months or more prior to the site visit. d. WWC will provide a final report to the Contractor within thirty(30)days of the visit. e. Site visit evaluations may be used as part of,but will not be a substitute for,the quarterly Contract Management System (CMS) evaluations. 8. eCaST System: a. WWC will provide training on the data system to the Contractor, its administration staff, fiscal staff and provider site staff as needed or requested by the Contractor. Any changes to staff that are responsible for data entry of Komen/WWC information must be reported to the Department within fifteen (15)days. ii New provider site staff must be trained by WWC on eCaST within thirty(30) days of hire. b. Forms used to collect eligibility and enrollment information will be electronically furnished by WWC. For Komen only funded clients, Contractors may use their own forms or forms jointly created with the WWC and the Contractor to obtain required information for data entry into eCaST. c. Every client must be screened for lawful presence status. For those who are undocumented: Leave the checkbox titled"Verified Legal Presence"in eCaST blank. Page 9 of 12 Attachment D-1 i The Contractor may use their own address for undocumented clients in eCaST. iii Name, birth date, income and insurance status need to be accurately reported in eCaST. For those who meet lawful presence requirements: Check the checkbox titled"Verified Legal Presence in eCaST." ii If the patient is eligible for WWC, follow WWC requirements for lawful presence verification. 9. Communication: a. When corresponding with the WWC, Contractors must use all privacy and security measures to protect the client's personal health information. Accepted forms of communication include: 1. WWC/Komen identification number used in all email conversations 2. Mail or fax clearly marked"Confidential" 3. Health Insurance Portability and Accountability Act(HIPAA) compliant files transmitted via secure File Transfer Protocol (FTP) sites or encrypted emails. i If a Contractor intends to use data from eCaST for publications, conference presentations, and/or research projects, the Contractor must notify the WWC program. b. At least one representative from the Contractor and/or its network provider sites should attend meetings hosted by WWC staff to ensure compliance with this contract. WWC will attend conference calls and meetings as needed and upon special request of the Contractor. ii WWC will provide Contractor with a "monthly data snapshot" which includes data on numbers screened, spending, average costs, patient demographics, abnormal rates etc. to assist Contractors with managing their programs effectively. 10. Medicaid Treatment for WWC Clients Diagnosed with Cancer a. The Contractor will refer WWC eligible women with a positive diagnosis of breast cancer to Medicaid. Contractor personnel must follow the STEP Enrollment Process (Attachment D- Page 10 of 12 Attachment D-1 1-H). This document may also be found by navigating to Medicaid BCCP, Step List at https://dots.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0 B0i 5- XFbANOXYzJkYzM2MzEtNjY4YS00YzFmLW I4NDgtNmMOYmUwZjczZW I x&h1=cn US. ii Contractor will fax initial completed paperwork(WWC Personal History form, WWC Rules Form, Lawful Presence affidavit and pathology report confirming the diagnosis)to WWC within five (5) business days of cancer diagnosis. iii Women referred to Medicaid must be completely entered into eCaST within twenty-four(24)hours of diagnosis. iv Contractor will fax final completed paperwork(Medicaid application signature page and presumptive eligible form)to WWC within five (5)business days of receiving approval for presumptive eligibility. v Contractors will ensure applications are submitted to local Social Service agencies within thirty(30)business days after diagnosis. b. Documents used in the process of enrolling women into Medicaid for treatment may be updated during the period this scope of work is in effect. When new documents are adopted for implementation by WWC, the Contractor will be notified and responsible for implementing necessary changes by a date determined by the WWC. Updated documents may also be located by navigating to Medicaid BCCP, Step List at https://docs.googie.com vicwcr?a=v&pid=explorcr&chrome=true&weld=0B0i5- XFbANOXYzJkYzM2MzEtNjY4YS00YzFmLW14NDgtNm MOYmUwrZjezZWIx&h1=e n US c. For clients diagnosed with breast cancer that are not eligible for Medicaid, Contractors arc required to enroll clients in treatment services through Komen or other community- based efforts as close to the client's home address as possible. 11. Contract Management System(CMS)Evaluations a. Effective July 1, 2009,pursuant to C.R.S. §§ 24-102-205,24-102-206, 24-103.5-101 and 24-105-102 requiring monitoring of Contractor performance, the Colorado Department of Public Health and Environment (CDPHE)has adopted the contract management best Page 11 of 12 Attachment D-1 practice of evaluating Contractor performance. Evaluations will occur on a quarterly basis throughout the contract period. All evaluations will be based on documentation of performance maintained in CDPHE program and contract files. The following categories will be used to evaluate performance: Quality, Timeliness, Budget/Price, Business Relations and Deliverables/Requirements specific to each contract. Please see the notification memo for further information (Attachment D-1-I). 12. Reporting to the Susan G. Komen for the Cure Denver Metropolitan Affiliate a. Contractors will not be required to submit reports directly to Komen. b. WWC will submit monthly reports, mid-year and end of year reports to Komen on the Contractor's behalf. c. Contractors will provide feedback as needed in order for WWC to complete these reports on the Contractor's behalf. Page 12 of 12 Attachment 0-1-A Contractor Contact Information The WWC program will request this completed document in early June 2012 from WWC Coordinators directly, This attachment is a draft; please do not send this completed attachment with the contract. Contractors cannot begin work under this contract until this form is received by the WWC. Page 1 of 3 Attachment D-1-A Agency Contacts Verification Fiscal Year 2011-2012 Agency# **************************** Legal Name **************************** Phone: ######-#### Fax: ######-#### Physical Address Mailing Address ******************** ******************** ******************** ******************** Agency Director ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** Clinical Liaison ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** Contract Administrator ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** eCaST Coordinator ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** Fiscal Manager ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** Payment Coordinator ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** Page 2 of 3 Attachment D-1-A Agency Contacts Verification Fiscal Year 2011-2012 Signature Authority ❑ ******************** Phone: ******************** Fax: **a:***************** Email: ******************** WWC Coordinator ❑ ******************** Phone: ******************** Fax: ******************** Email: ******************** Page 3 of 3 Attachment D-1-B Contractor eCaST Annual Security Renewal Forni The WWC program will request this completed document in early June 2012 from WWC Coordinators directly. This attachment is a draft; please do not send this completed attachment with the contract. Contractors cannot begin work under this contract until this form is received by the WWC. Page 1 oft STATE OF COLO Att 1 John W. Hickenlooper,Governor Christopher E. Urbina,MD,MPH oe c0Zo� Executive Director and Chief Medical Officer �QA xIIo\1 Dedicated to protecting and improving the health and environment of the people of Colorado , ,k o-' o' 4300 Cherry Creek Dr. S. Laboratory Services Division 't ravb x/ Denver,Colorado 80246-1530 8100 Lowry Blvd. ----- Phone(303)692-2000 Denver,Colorado 80230-6928 Colorado Department Located in Glendale,Colorado (303)692-3090 of Public Health http://www.cdphe.state.co.us and Environment WOMEN'S WELLNESS connection WWC/eCaST Coordinator: Fax: Aec t'y: Re: Secure External User Id Annual Renewal From: Amanda Howard, Data Coordinator Phone: (303) 692-2436 Date: In accordance with the Colorado Department of Public Health and Environment Policy Manual's Access Control policy, all authorized state database users are required to periodically renew their security access forms. The names of the staff at your agency that currently have eCaST access are listed below. Please have each staff member sign and date where indicated to continue accessing eCaST. A program manager's signature is also required where indicated. Be advised that a missing signature on this form will indicate that the employee no longer requires eCaST access in which case his or her access will be terminated immediately. Please complete and return this form by 06/29/2012, to the contact shown below. Thank you in advance for your prompt attention. Employee Name Employee Signature Date Program Manager or Supervisor Print Name Signature . Date Contact: Amanda Howard, fax 303-758-3268. If you have any questions or comments, please contact Amanda at 303-692-2436 or amanda.howard(a)state.co.us, or the data manager, Christen Lara, at 303-692-2531 or christen.lara(i.state.eo.us. Page 2 of 2 Attachment D-1-C Contractor List of Current Subcontractors The WWC program will request this completed document in early June 2012 from WWC Coordinators directly. This attachment is a draft; please do not send this completed attachment with the contract. Contractors cannot begin work under this contract until this form is received by the WWC. Page 1 of 2 Attachment D-1-C WWC Subcontractor Verification - Fiscal Year 2012-2013 Please fill this out for each subcontractor NOT listed for your agency. New Subcontractor Name: Corporate Information: Mailing Address: City: State: Zip: County: Contact: Phone: Clinic Information: Mailing Address: City: State: Zip: Contact: __ Phone: All sites using this subcontractor: New Subcontractor Name: Corporate Information: Mailing Address: City: State: Zip: County: • Contact: Phone: Clinic Information: Mailing Address: City: State: Zip: Contact: Phone: All sites using this subcontractor: Page 2 of 2 Attachment D-1-D 2012-2013 Women's Wellness Connection CPT Code List Listed below are allowable procedures and the corresponding CPT codes for use in the Women's Wellness Connection program under these general conditions: * Screening services should include CBE, pelvic exam, mammogram, and a Pap smear. * Reimbursement for treatment services is not allowed. * Several codes carry technical and professional components. If these components are to billed separately, then bill should be coded to reflect this status through the inclusion of a modifier(e.g., 77057-TC, 77057-26). * Anesthesia codes should not be charged unless an anesthesiologist or nurse anesthetist is in attendance. * Providers should not be billed under code 99070 -supplies and materials not usually provided. These procedures or items should be billed for with specific HCPC codes and should only be included if they are not usually provided with the procedure being billed for. These rates are based on information found on the Centers for Medicare& Medicaid Services website,http:/'www.cros.gov/apps/physician-fee-schedule/license-agf•eement.aspx Bolded items require WWC pre-approval 2011 Prof Tech CPT code Description CO (26) (TC) Rates OFFICE VISITS Outpatient office visit, detailed history, including clinical breast c 99203 exam (CBE)and pelvic exam (if only one service is provided, $101.63 rate for each is half or$50.82) co Repeat Clinical Breast Exam(Office Consultation; expanded 99242 history, exam, straightforward decision-making; 30 minutes) $ Pricing for this code was found on https://catalog.ama- 86.38 .6 assn.org/Catalog/cpt/cpt_searchisp Surgical consultation (Office Consultation;detailed history, 99243 exam, decision-making of low complexity; 40 minutes) ' Pricing for this code was found on https://catalog.ama- $117.94 assn.org/Catalog/cpt/cpt search.Jsp BREAST SCREENING &DIAGNOSTIC PROCEDURES 76098 Radiological examination, surgical specimen $ $ $ 19.16 &06 11.10 76645 Ultrasound, breast(s), unilateral or bilateral, B-scan and/or $ $ $ real time with image documentation 95.85 26.82 69.02 0 76942 Ultrasonic guidance for needle placement, imaging $ supervision and interpretation $197.14 33.27 $163.87 Stereotactic localization guidance for breast biopsy or needle $ $ 77031 placement $160.33 79.12 81.22 77032 Mammographic guidance for needle placement, breast $ $ $ 55.62 27.59 28.03 Page 1 of 4 Attachment D-1-D 2011 Prof Tech CPT code Description CO Rates (26) (TC) 77053 Ductogram,single duct $ $ $ 67.62 17.57 50.05 77054 Ductogram, multiple duct $ $ $ 91.52 22.49 69.02 770E5 :A:_:::mmo ,r:,:p:'y, Diagnostic Follow-up, Unilateral $ $ $ 86.04 34.63 51.41 0 77056 Mammography, Diagnostic Follow-up, Bilateral $110.02 43.04 66.99 O 77057 Screening Mammogram, Bilateral (2 view film study of each $ $ $ breast, analog) 80.62 34.63 45.99 G0204 • Diagnostic Mammogram, Digital $ $166.93 42.70 $124.24 G0206 Diagnostic Mammogram, Digital, Unilateral $ $ $132.11 34.63 97.48 G0202 Screening Mammogram, Bilateral, Digital $ $139.56 34.63 $104.93 10021 Fine needle aspiration without imaging guidance $140.25 10022 Fine needle aspiration with imaging guidance $135.15 19000 Drainage of breast lesion, cyst aspiration $107.58 1,7_, J1 rainage of breast lesion, each additional cyst, used with $ 19000 26.05 19100 Breast biopsy, percutaneous, needle core, not using imaging guidance, stereotactic core biopsy $139.58 19101 Breast biopsy, open, incisional, stereotactic core biopsy $317.62 19102 Breast biopsy, percutaneous, needle core, using imaging guidance; for placement of localization clip use 19295 $210.44 22 Breast biopsy, percutaneous, stereotactic automated vacuum 19103 assisted or rotating biopsy device, using imaging Uy p y g g guidance $541.45 19120 Excision/removal of breast lesion $457.41 19125 Excision/removal of breast lesion identified by preoperative placement of radiological marker;open; single lesion $507.58 Excision/removal of breast lesion identified by preoperative 19126 placement of radiological marker, open; each additional lesion $154.98 separately identified by a preoperative radiological marker 19290 Preoperative placement of needle localization wire, breast $158.01 19291 Preoperative placement of needle localization wire, breast; $ each additional lesion 67.06 19295 Image guided placement, metallic localization clip, $ percutaneous, during breast biopsy 90.02 Page 2 of 4 Attachment D-1-D 2011 Prof Tech CPT code Description CO (26) (TC) Rates 88172 Cytopathology, evaluation of fine needle aspirate; immediate $ $ $ cytohistologic study to determine adequacy of specimen(s) 50.37 29.79 20.58 0 88173 Cytopathology, evaluation of fine needle aspirate, $ $ interpretation and report $136.92 67.90 69.02 88305 Surpathology, $ $gical gross and microscopic examination $105.60 36.24 69.36 88307 Surgical pathology, gross and microscopic examination; $ requiring microscopic evaluation of surgical margins $225.35 79.10 $146.26 Anesthesia for procedures on the integumentary system, anterior trunk, not otherwise specified. Must be administered by anesthesiologist or nurse anesthetist. Billed for in units, $ a) 00400 base rate of 3 units for the procedures always applies 20.58 (3x$20.58 = $61.74) plus time ($20.58 per 15 minute interval, if time goes 1 minute into next 15 minute interval, that counts as 1 unit) Pre-operative testing; CBC, urinalysis, pregnancy test, etc. These procedures should be medically necessary for the O 99070 planned surgical procedure. Pre-operative tests should be billed for with specific HCPC codes. CERVICAL SCREENING & DIAGNOSTIC PROCEDURES 88141 Cytopathology(conventional Pap test), cervical or vaginal, $ any reporting system, requiring interpretation by physician 28.59 Cytopathology(liquid-based Pap test)cervical or vaginal, $ 88142 collected in preservative fluid, automated thin layer 28.51 preparation; manual screening under physician supervision Cytopathology(conventional Pap test), slides cervical or $ 88164 vaginal reported in Bethesda System, manual screening 14.87 under physician supervision 0 88331 Pathology consultation during surgery, first tissue block, with $ $ $ L frozen section(s), single specimen 91.08 59.32 31.76 88332 Pathology consultation during surgery, first tissue block, with $ $ $ frozen section(s), each additional specimen 40.21 29.11 11.10 88305 Surgical pathology, gross and microscopic examination $ $ $105.60 36.24 69.36 Papillomavirus, Human, Amplified Probe (Hybrid Capture II from Digene-HPV Test(High Risk Typing only) or $ 87621 Cervista HPV HR)(Requires WWC pre-approval unless 49.39 provided as a reflex test after an ASCUS or LSIL in menopausal women) 57452 Colposcopy of the cervix, without biopsy $106.91 57454 Colposcopy of the cervix, with biopsy and endocervical curettage $151.23 m 57455 Colposcopy of the cervix, with biopsy $140.77 rn 57456 Colposcopy of the cervix, with endocervical curettage $133.13 57460 Biopsy of cervix with scope LEEP (WWC pre-approval not required if performed after an HSIL Pap test) $287.98 Page 3 of 4 Attachment D-1-D 2011 Prof Tech CPT code Description CO (26) (TC) Rates 57461 Conization of cervix with scope LEEP $323.72 Biopsy of cervix, single or multiple, or local excision of lesion, 57500 with or without fulg;.ra"on (scdarate procedure) Use this $128.89 code for cervical pot,o removal 57505 Endocervical curettage (not done as part of a dilation and curettage) $100.43 Conization of cervix, with or without fulguration,with or m 57520 without dilation and curettage, with or without repair; $301.71 cold knife or laser 57522 Conization of the cervix or LOOP $260.07 Endometrial sampling (biopsy)with or without 58100 endocervical sampling (biopsy), without cervical dilation, $108.10 any method (separate procedure) Endometrial sampling (biopsy) performed in conjunction with $ 58110 colposcopy(No WWC pre-approval required if performed after 47.53 an AGUS Pap test) Supplies and materials (except spectacles), provided by the physician over and above those usually included with the 99070 office visit or other s..rvices rendered (list drugs, trays, O supplies, or materials provided). Supplies and materials should be billed for with specific HCPC codes. PROCEDURES SPECIFICALLY NOT ALLOWED Any Treatment of breast cancer, cervical intraepithelial neoplasia and cervical cancer. Any HPV testing for screening purposes Any Computer Aided Detection (CAD)in breast cancer screening or diagnostics Any Magnetic Resonance Imaging(MRI)in breast cancer screening or diagnostics Page 4 of 4 Attachment D-1-E Women's Wellness Connection/Komen Program Eligibility Requirements To qualify for the Women's Wellness Connection Program, women must: • Bc 40 - 64 years of age (mammograms are provided to women 50-64 years of age unless they are currently experience breast cancer symptoms) • Be at or below 250%of the Federal Poverty Level (see table) Persons in family 250% of DHHS FEDERAL POVERTY (Household)* GUIDELINES (FPL)** Size*** Monthly Annual 1 $2,269 $27,225 2 $3,065 $36,775 3 $3,860 $46,325 4 $4,656 $55,875 5 55,452 $65,425 6 $6,248 $74,975 7 $7,044 $84,525 8 $7,840 $94,075 more than 8 $7,840+add $796 $94,075+add $9,550 for each person for each person *As defined by the Bureau of the Census for statistical purposes, a household consists of all the persons who occupy a housing unit (house or apartment), whether they are related to each other or not. If a family and an unrelated individual, or two unrelated individuals, are living in the same housing unit, they would constitute two family units,but only one household. **DHHS Federal Poverty Guidelines change annually by January. *** Size of Family Unit supported by Total Gross Household Income. Gross income is money made by individual BEFORE taxes. Source: Federal Register/Vol. 76, No. 13/January 20, 2011: http://wwt ede'rcrlregister.goviarsicles/2011,O1/20!2011-1237./arrritral-tpdate-o%the-hhs poverty- euidel ine.1 • Lack health insurance, have health insurance that does not cover screening exams, or have a high deductible/co-pay significant enough to delay or refuse screening • Be lawfully present in the United States. Common forms of ID include: o Colorado Driver's License o Colorado ID card o US Passport • o Permanent Resident Card(1-551) o Other forms of ID arc also acceptable,please see: http://www.colorado.gov/cs Satellite/Revenue-Main/XR M/12 16289012125 Page 1 of 2 Attachment D-1-E • Have not had a mammogram for 12 months or more unless currently experiencing symptoms* • Have not had a Pap test for 12 months (if using conventional Pap smears) or 22 months (if using liquid based technology) or more unless currently experience symptoms. Women are eligible for a pelvic exam every year* *Breast auu cervical cancer screenings may be provided separately if clinically appropriate To qualify for Komen only paid services, clients must: • Be at or below 250% of the Federal Poverty Level (see table) Persons in family 250% of DHHS FEDERAL POVERTY (Household)* GUIDELINES (FPL)** Size *** Monthly Annual 1 $2,269 $27,225 2 $3,065 $36,775 3 $3,860 $46,325 4 $4,656 $55,875 5 $5,452 $65,425 6 $6,248 $74,975 7 $7,044 $84,525 8 $7,840 $94,075 more than 8 $7,840 + add $796 $94,075+ add $9,550 for each person for each person *As defined by the Bureau of the Census for statistical purposes, a household consists of all the persons who occupy a housing unit (house or apartment), whether they are related to each other or not. If a family and an unrelated individual, or two unrelated individuals, are living in the same housing unit, they would constitute two family units, but only one household. **DHHS Federal Poverty Guidelines change annually by January. *** Size of Family Unit supported by Total Gross Household Income. Gross income is money made by individual BEFORE taxes. Source: Federal Register/Vol. 76, No. 13/January 20, 2011: htip:/'uwwlederalreg>ister.go /articles/2011/01/20/2011-1237/annual-thdate-o%Nae-hhs- poverty-guidelines • Lack health insurance, have health insurance that does not cover screening exams, or have a high deductible/co-pay significant enough to delay or refuse screening Page 2 of 2 L. 0 a) a) E U ��++ y Q •ZI U G U ,�' �" •U ) Vi 0 fir••+ O et •� 0 cn '5 E 0 U ~ — hY rr•• P i GcVcs yam. 0 0 to o — c.) oo c� 0" U U Co 'O 0 c� L. oQ'^" 'CJ Ctl oU... �+' N _co az sue. 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G J T•0. • O L m U p 0 c3 v T C v co O O W > U U .4-14) U Z J a G O Q p U (n Q e�1 U u 'a t) (n • • • V1 • • • .U. .� < cd ›s' r C3 Cl) 60 U y ^' L .r v v v o v 4' G ta• O a WI 0.0 H .a = w E y bct7 y A (/) U 6 O fir • Attachment D-1-G Example of Core Performance Indicators Report from eCaST '`'' Colorado Department of Public Health and Environment WOMEN'S WELLNESS SOS- Core Indicator Report Supplemental connection REPORT P8RAIYE1 RS [h_tes'roar 04'01/2011 to C3r31,20'2 Agency: Agency Standard Stale Sta4narel Program Performance Indicators Standard Count Population Percent Met? Count Population Percent Met? Breast Cancer Clegat en Waders Annum;snreerer1g msuaa Win corhre re.. `rl.'Ya n•more 4 1: r s 1, r .. tilOw•1lp T,rne!rem scree^ar.1 la I ormus,Xdays 7`.%n o, 3 23 70 rr. r C. 'or 33 lomnl=Coning results 12:21,20,1 3 13 34P11 Rem1-005•Con L dcaa er:+rr1 SupOr nen:d Peer 1,,:n • Page 1 of 1 Attachment D-1-H COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT WOMEN'S WELLNESS Cancer Prevention&Control Breast & Cervical Cancer Program (BCCP) Medicaid Enrollment Step List Clients enrolled in Wor - is Wellness Connection (WWC) who have been diagnosed with breast or cervical cancel or pre-cancer may be eligible for treatment through Medicaid's BCCP. Only currently enrolled clients are eligible and must have had their screening and/or diagnostic evaluation paid through WWC. Undocumented clients are NOT eligible for this program. This process should begin within five business days after a breast or cervical diagnosis occurs. Failure to follow these steps may result in loss of eligibility. For any questions regarding this process, please call 303-692-2436. STEP 1 Confirm eligibility for BCCP and complete eCaST data entry The provider site must confirm that the client was eligible for WWC and that her diagnosis was made using WWC funds. BCCP eligibility criteria include: • 40-64 years of age • At or below the 250% Federal Poverty Level • Meets identity and citizenship verification criteria as stated in the Colorado Department of Revenue "Rules for Evidence of Lawful Presence" at http://www.colorado.gov/cs/Satellite/Revenue-Main/XRM/1216289012112. • Does not have health insurance or has health insurance that will not cover breast or cervical cancer treatment. The BCCP enrollment process cannot proceed until all data is entered into STOP eCaST. All information should be completed in eCaST within 24 hours of the diagnosis. STEP 2 Determine whether the diagnosis is eligible for BCCP The list of eligible diagnoses can be found online at: http://www.cohealthsource.orq/programs/women's-wellness-connection/provider- information.aspx. If your pathology report has a diagnosis that is NOT on this list, please call 303- 692-2323 before deciding not to proceed. Page 1 of 4 Attachment D-1-H COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT WOMEN'S WELLNESS Cancer Prevention&Control Breast & Cervical Cancer Program (BCCP) Medicaid Enrollment Step List STEP 3 Obtain approval from WWC Fax ONLY the following to 303-758-3268. 1. Personal History Form (must be complete) 2. WWC Rules Form 3. Signed lawful presence affidavit 4. Pathology report(s) (Please only send the report that confirms the diagnosis) Ldp Eligibility must be confirmed by WWC staff BEFORE you call the PE hotline. A WWC staff person will notify you within three (3) business days of receipt to confirm eligibility of the client. STEP 4 Obtain Presumptive Eligibility (PE) number from BCCP Do not attempt to get the PE number for the client until you have received approval from WWC. Clients should not be scheduled for surgery, radiological testing or treatment until you have received the PE number for the client. • Call the PE hotline, 303-866-5204, to enroll the client in Presumptive Eligibility (PE). Please note that the date of eligibility will be the date the definitive diagnosis was made, not the date of the call to the hotline. The definitive date of diagnosis is the date the biopsy was taken. • The PE hotline operator will give you a PE number over the phone. Please note that PE cards are being replaced with an approval letter mailed by Medicaid to the client only. The letter will be generated automatically when the hotline attendant enters the PE information (usually within 24 hours). The PE number for the client issued to you by the PE hotline operator should be documented in the client's medical chart. This number can be used by the Medicaid provider to check the Medicaid status of the client. • Please be sure to complete the box in the left lower corner of the PE form with the information received from the PE hotline attendant. See Supplement Information to WWC BCCP Step List. o http://www,cohealthsource.orq/media/182782/pe%20enelish%2020 10.pdf (English) o http://www.cohealthsource.orWmedia/182785/pe/020spanish°/0202 010.pdf (Spanish) Page 2 of 4 Attachment D-1-H COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT WOMEN'S WELLNESS Cancer Prevention&Control Breast & Cervical Cancer Program (BCCP) Medicaid Enrollment Step List STEP 5 Fun-idly enroll ir. `Medicaid To assist the client to get treatment benefits under BCCP, you should assist her in completing a full Medicaid application available at your local County Human/Social Services agency, or on the web: • http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=applicat ion%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251640911 378&ssbinary=true (English) • http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=applicat ion%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251652374 979&ssbinary=true (Spanish) Clients should bring proof of income and legal presence. After you help the client complete this application in your office: • Please fax copies of the following forms to 303-758-3268 within five (5) business days of receiving the PE number: 1. The signature page of the full application — this is the last page 2. The completed PE form • Submit the completed, full application to your County Department of Human/Social Services office within 30 business days after the diagnosis. For a listing of these offices, see: http://www.cohealthsource.orq/media/182788/bccp%2omain%20county% 20contacts.pdf o If you submit the full Medicaid application by fax, please use the "Fax Cover Sheet for Medicaid Applications." This will alert the staff at your county Human/Social Service office that this is a BCCP Medicaid application and correctly facilitate processing. This can be found at: http://www.cohealthsource.orq/media/182791/faxcoversheetformedi caidapp.pdf • Keep a copy of the fax confirmation sheet, the person's name that the application was sent to and original Medicaid application in the client's chart. If this step is not completed correctly, the client will be dropped from Medicaid once her PE period is over (usually 45 days). Page 3 of 4 Attachmento-t-H COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT WOMEN'S WELLNESS Cancer Prevention&Control Breast & Cervical Cancer Program (BCCP) Medicaid Enrollment Step List STEP 6 Enter treatment start date in eCaST Enter the treatment start date in eCaST as soon as it is available. The treatment start date is defined as the date that an actual cancer treatment intervention occurred. Examples include mastectomy, lumpectomy, and chemotherapy or radiation treatment. Surgical consults, patient navigator referrals or breast needle biopsies do not count as a treatment. Page 4 of 4 Attachment D-1-I Contract Management System Notification MEMORANDUM Effective July 1, 2009, pursuant to C.R.S. §§ 24-102-205, 24-102-206, 24-103.5-101 and 24- 105-102 requiring monitoring of Contractor performance, the Colorado Department of Public Health and Environment (CDPHE) has adopted the contract management best practice of evaluating Contractor performance. Evaluations will occur on a quarterly basis throughout the contract period. An evaluation of the entire contract period will occur when the contract expires. The evaluation that rice us at the end of the contract period is referred to as the final evaluation. For those contracts that meet the requirements of C.R.S. §§ 24-102-205, 24-102-206, 24-103.5- 101, and 24-105-102, the final evaluation rating will be posted to the public website maintained by the Office of the State Controller. This website is a searchable database of all personal services contracts valued at $100,000 or more entered into after July 1, 2009. The following link provides access to the website http://contractsweb.state.co.us This evaluation process has been incorporated into the Department's routine contract oversight (or monitoring) practices. All evaluations will be based on documentation of performance maintained in CDPHE program and contract files. The following categories will be used to evaluate performance: Quality, Timeliness, Budget/Price, Business Relations and Deliverables/Requirements specific to each contract. The evaluation will result in an overall rating of either"Standard, Above Standard or Below Standard" for the evaluation period. A -Standard" rating is defined as satisfactory. CDPHE documentation must demonstrate consistency in meeting standards, requirements and expectations as defined in the contract. An "Above Standard"rating is defined as exceeding the standards, requirements and expectations as defined in the contract. CDPHE documentation must demonstrate consistent and exceptional performance or superior achievement beyond the requirements of the contract. A "Below Standard" rating is defined as less than satisfactory. CDPHE documentation must demonstrate performance does not consistently meet the standards, requirements and expectations as defined in the contract. The quarterly and final evaluation form used by CDPHE staff will be emailed to you by your program contact. The evaluation form will include a list of the documents reviewed. Please note that the instructions contained in the evaluation form are for Department use. The email will request a confirmation of receipt of the evaluation within a specific period of time. Your comments concerning the evaluation results or the Department's performance under the contract arc welcome and encouraged. If you have questions about the evaluation process, please contact Deb Polk, Contract Performance Manager for the Colorado Department of Public Health and Environment at 303- 692-2136 or email at deb.polk( state.co.us • Deb Polk, Contract Performance Manager Colorado Department of Public Health and Environment Page 1 of 1 . 8 6 . o Memorandum TO: Office of Clerk to the Board to the Weld W County Commissioners WELD--COUNTY FROM: Administration Division-Department of Public Health and Environment DATE: APRII 12, e9,012- SUBJECT: Wo rat rv'S tMISS COnryec fi oN Attached to this memo is the finalized contract that the Health Department has received. Please sign and date below indicating you have received the finalized contract and return this signed memo to the Administration Division of the Health Department. Please send the confirmation receipt to my attention. Thank you for your assistance with the processing of this document. ATTN: 0 \MO WN WLtlnZss ipnnectioNl • F CA) e... �av� N22 �t'� Tro3ecT Contract Name: So So NI G . I\OMtJ 2 OC ' J Resolution Number: a D t 2 - 0% 23 Finalized Contract Received By: 1 bvAT. 3is n kin Date Received: IA - J Enclosure Hello