HomeMy WebLinkAbout20113240.tiff RESOLUTION
RE: APPROVE STATEMENT OF WORK FOR COLORADO IMMUNIZATION
PROGRAM (CIP) OUTREACH PROJECT 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 a Statement of Work for the Colorado
Immunization Program (CIP) Outreach Project from 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, to the Colorado Department of Public Health and
Environment, commencing January 1, 2012, and ending August 31, 2012, with further terms
and conditions being as stated in said Statement of Work, and
WHEREAS, after review, the Board deems it advisable to approve said Statement of
Work, 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 the Statement of Work for the Colorado Immunization Program
(CIP) Outreach Project from 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, to 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 Statement of Work.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 19th day of December, A.D., 2011.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: JgF• y , ci7
Barbara Kirkmeyer, Chair
Weld County Clerk to the Board (/—"
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I � I / 4\Sean P. C• • ay, Pro-Tem
BY: o Yu 7
Deputy Clerk to the Boar , ,; :' �L� //
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Douglas F;ademacher
Date of signature: /-/a' /�
I o r'[ - o To ' a C ✓ . i\ L_ 2011-3240
1 a . (DO 1 1 1 - a3 HL0038
Memorandum
TO: Barbara Kirkmeyer, Chair
Board of County Commissioners
CFROM: Mark E. Wallace, MD, MPH, Director
• Department of Public Health and
COLORADO Environment `,3\L'h)e.LCd )
DATE: December 2, 2011
SUBJECT: Colorado Immunization Program (CIP)
Affordable Care Act(ACA)
Reimbursement Immunization Opportunity
(RIZO) Pilot Project
School-Located Vaccination clinics (SLV)
Enclosed for Board review and approval is the 2011-12 Immunization ACA RIZO Project Scope
of Work(SOW) between the Colorado Department of Public Health and Environment, Colorado
Immunization Program, and the Weld County Department of Public Health and Environment.
The funding period is from January 1, 2012 to August 31, 2012 for $31,853.00. Statement of
work involves continued participation in the RIZO program to develop the capacity for billing
health insurance for services provided to health plan members by local public health agencies
(LPHA) and to work with the Weld County schools to increase immunization awareness for
children and to use third-party billing to enhance the sustainability of school-located vaccination
clinics (SLV). This will include collecting data to determine if reimbursement for administration
fees and vaccine costs to third-party payers (Medicaid, Medicare, CHP+, and private insurance)
is cost effective, increasing our capacity to bill third-party payers electronically, training staff in
billing processes for third-party payers, creating partnerships with the school nurses to have SLV
clinics and help increase immunization rates in Weld County. We will act as a Mentor to other
counties as a resource for third-party billing.
2011-3240
//Z GD3d'
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1 8 6 I - 2 0 I I 1555 North 17th Avenue
Greeley, CO 80631 Public Health
-� Web: http://weldhealth.orq
Health Records
eic Health 8 Clinical Services
er Environmental Health Communication,&Planning
Emergency Preparedness
W E L DEC O U N T Y Vital e 304. ale-Services Tele 97s Education. . 0 Pl47ning 8 Response
Fate:970.3046412 Fsx. 970.3046416 Fa 970.304.6411 Fa 970.3046452 Fa 970.304.6469
Fax: 9]0.3046412 Fax: 970.304.6416 Fax: 970.304 6411 Fax. 970.304 6452 Fax: 970.304.6469
Our vision Together with the communities we serve,we are working to make Weld County the healthiest place to live,learn,work and play.
Colorado Department of Public Health and Environment
Colorado Immunization Program
Affordable Care Act (ACA)
Reimbursement Immunization Opportunity (RIZO)
Statement of Work
Agency Name: Weld County Department of Public Health and Environment (WCDPHE)
Project name: 2011-12 Immunization ACA RIZO
Funding period: January I, 2012 through August 31, 2012
Project Description: The Colorado Immunization Program at the Colorado Department of Public Health and
Environment has funding available to develop the capacity for local public health agencies (LPHA) to bill
public and/or private health insurance plans for services provided to health plan members.
The RIZO program will involve the following:
• Collect and analyze patient data as requested by the Colorado Immunization Program to determine
if reimbursement for the administration fee and vaccine cost is a cost effective/sustainable process.
• Fund the development and/or improvement of LPHA infrastructure and processes that lead to
successful third-party (public and/or private) billing mechanisms for the immunization of insured
patients.
• Third-party billing will include billing of the vaccine administration fees, and potentially the
vaccine cost for private-stock vaccines only.
• An option for LPHA to use third-party billing processes to enhance the sustainability of school-
located vaccination clinics (SLV).
Project goal: Develop the capacity of LPHA to bill public and private health insurance plans for services
provided to health plan members.
•
Definitions:
ACA Affordable Care Act
CDPHE Colorado Department of Public Health and Environment
CIP Colorado Immunization Program
IZ Immunization
LPHA Local public health agency
RIZO Reimbursement Immunization Opportunity
1. Performance Requirements/Deliverables:
WCDPHE agrees to provide the following:
Goal #1 By 8/31/12, Increase immunization rates in children attending Weld County schools by
10% to 15%. Schedule a minimum of 1 clinic for each school in Lochbuie, Hudson,
Pierce, Frederick, Erie, Keenesburg, Ault, and Kersey during the 2011-2012 school
year to administer immunizations.
Objective 1-1 By 01/31/12, WCDPHE Immunization nurse will partner and strategize with outlying
schools by speaking with school nurses about improving immunization rates for their
students and scheduling school based clinics throughout Weld County schools, as
indicated in Goal #1. This will be achieved by:
a) By 01/11/12, WCDPHE Immunization nurse will contact school nurses during the
2011-2012 school year to meet in January 2012 to schedule immunization clinics
throughout the year.
b) The minimum number of school based clinics to be scheduled for the 2011-2012
school year will be 9-18 (2 clinics at each of the 9 school locations noted above).
c) Clinics will be scheduled for February 2012, March 2012, April 2012, May 2012,
and August 2012. 4-5 schools will be attended to each month, starting with series 1
of HPV4 in February 2012 and series 2 of HPV4 scheduled in April 2012.
d) The second set of 4 schools will be scheduled with series 1 of HPV4 in March 2012
and series 2 of HPV4 in May 2012.
e) May clinics will be scheduled accordingly to those schools unable to participate
earlier in the year, in addition to the second set of schools scheduled for HPV4 #2.
0 5 schools will be attended to in August 2012 within District 6.
Objective 1-2 By 01/31/12, WCDPHE Immunization program will create partnerships and
collaboration with school nurses within Weld County school districts to help increase
immunization rates. This will be achieved by:
a) By 01/09/12, Immunization nurse will contact each school to coordinate a meeting
in person or via teleconference in January 2012.
b) By 03/12/12, Immunization nurse will contact each school to coordinate a meeting
in person or via teleconference in May 2012.
c) By 01/31/12, immunization nurse will attend meeting and discuss plan for SLV
clinics throughout the school year 2011-2012.
d) Discussion items would include new recommendations and requirements for
students as well as third party billing information that is needed from parents.
Goal #2 Increase awareness about the importance of immunizations by providing a pamphlet to
outlying schools discussed in Goal #1 per school year for nurses to educate families
with children behind on immunizations as well as teachers.
Objective 2-1 By 01/31/12, a pamphlet regarding new research and immunization recommendations
will be created and disbursed to outlying schools as discussed in Goal #1 for school
nurses to distribute to parents and teachers. This will be achieved by:
a) By 01/15/12, information from the CDC website and ACIP recommendations will
be collected.
b) By 01/31/12, information retrieved from the websites indicated above will be
combined into a pamphlet to provide to schools. This Pamphlet will include
information about any upcoming SLV clinics as well as the Weld County
Department of Public Health and Environment clinic hours.
c) By 02/29/12, a Pamphlet will be distributed to school nurses in outlying schools for
distribution to parents and teachers for the 2011-2012 school year in January 2012
and February 2012 when clinics are scheduled.
Objective 2-2 Immunization recall systems will be conducted throughout the year (February 2012,
May 2012, and August 2012) to contact those students and individuals who are unable
to attend scheduled SLV clinics and who are behind on immunizations. This will be
achieved by:
a) Data will be obtained through the CIIS every 3 months (February 2012, May 2012,
and August 2012) to capture those children behind on shots within Weld County.
b) Data collected will be submitted to Televox every 3 months (February 2012, May
2012, and August 2012) our recall organization we are contracted with.
c) A Televox recall will be scheduled every 3 months (February 2012, May 2012, and
August 2012) to contact those children who are behind on shots and will notify
them to come to the Weld County Department of Public Health and Environment
for immunizations or their PCP.
d) By 08/15/12, a Televox recall will be scheduled during the summer months when
school is not in session to schedule those students needing to complete their TIPV4
series.
Goal #3 To increase WCDPHE's capacity to bill health insurance plans electronically for
immunization services provided to health plan members.
Objective 3-1 By 6/1/12, bill Immunization Services to Medicaid, Medicare, CHP, and Private
insurance Health Care Financing Administration (HCFA) claims electronically with
Electronic Data Interchange (EDI) through our EMR/PM system. This will be
achieved by:
a) By 02/01/12, coordinate with EMR/PM system technical support to program the
existing system to process our Public Health insurance claims electronically.
b) By 02/01/12, meet with technical support to assess what changes and requirements
are needed to send claims electronically.
c) By 03/01/12, technical support will make changes to the EMR/PM system to
populate correct information on HCFA claim forms.
d) By 03/01/12, process test claims through system and EDI.
e) By 03/01/12, test system in processing claims independently and accurately from
both Public Health facility and Community Health Center.
Objective 3-2 By 3/1/12, verify codes, fees, and billing fields are correct in the EMR/PM system.
This will be achieved by:
a) By 02/01/12, verify CPT and ICD-9 codes in the EMR/PM system to insure the
correct codes transfer to claim forms.
b) By 02/15/12, verify all needed billing fields (such as: signature on file, patient
demographics, insurance information,provider information, clinic information,
place of service) populate on claim form and make any changes or corrections as
needed.
c) By 01/15/12, verify fee schedules.
d) By 02/15/12, verify insurance companies' information is entered correctly.
Goal #4 By 6/1/12, continue to train and update billing technicians (2), financial screeners (5),
and agency health care workers (27) on billing processes to insure correct information
is put in the system.
*An upgrade to our EMR/PM system was implemented in May 2011. This upgrade
may present additional training needs.
Objective 4-1 By 3/1/12, Insurance technician will train 2 billing technicians on correct coding and
information needed on HCFA claims for submission. This will be achieved by:
a) By 03/01/12, train to verify correct CPT codes and ICD-9 codes are on claims.
b) By 03/01/12, train to verify claim form is completed with required and accurate
information. Familiarize technicians with private insurance companies'
requirements.
c) By 04/01/12, train to process claims electronically.
d) By 04/01/12, train to process denials and resubmissions of claims electronically.
Objective 4-2 By 3/1/12, Insurance technician will train financial screeners. This will be achieved by:
a) By 03/01/12, train on screening patients with insurance as what to ask for and put in
the PM system.
b) By 03/01/12, create a script for calling insurance companies' to verify benefit
coverage and deductibles.
c) By 01/31/12, provide fee schedule for financial screeners to refer to when giving
cost estimate to patient.
d) By 01/31/12, review information needed in PM system.
Objective 4-3 By 08/31/12, Insurance technician will keep agency health care workers updated on
procedure and diagnosis coding. This will be achieved by:
a) Continue to review administration fees and vaccine fees at monthly Immunization
staff meetings.
b) Continue to review procedure and diagnosis coding for services performed in the
agency health care workers chart in the EMR, to insure procedure code matches
correct diagnosis code as this will transfer to claim form. This will be reviewed
during monthly Immunization staff meetings.
c) Train one-on-one as necessary.
Goal #5 To work with agency health care workers (27) and financial screeners (5) on collecting
insurance information from patients with third party insurance in our clinic and school
located clinics for submitting claims for immunization services provided by WCDPHE.
Focusing more on private insurance.
Objective 5-1 By 01/31/12, coordinate with school staff and agency health care workers to create an
efficient way to collect third party payer information from parent/guardian for
submission of claims for immunization services provided for their child/children in the
school located clinics. This will be achieved by:
a) By 01/31/12, meet with school staff to discuss methods to collect third payer
information from parent/guardian before school located clinic date.
b) By 01/31/12, create form for collecting third payer information to be filled out by
parent/guardian or school staff before school located clinic date.
Objective 5-2 By 03/01/12, train financial screeners (5) to enter complete insurance information in
patient management system. This will be achieved by:
a) By 03/01/12, financial screeners will enter complete insurance information in
patient management system. Training will take place during monthly office staff
meetings. The EMR/PM system will be brought up on overhead screen and the
steps for completing insurance information practiced, encouraging input and
questions from staff. One- on-one training will be provided as needed.
b) By 03/01/12, financial screeners will verify insurance information or get missing
information from parent/guardian if needed.
RIZO Mentor Responsibilities:
1) be a resource to other agencies that are in the preliminary or early stages of third-party billing.
This could include providing guidance on the basics, such as how to pursue a contract with a
specific payer or how to process a claim. As the mentor pursues its RIZO goals and gathers more
learnings, it is expected that that any relevant knowledge is also passed down to mentees.
2) guide and assist RIZO mentees in all areas requested. Continued willingness to perform these
tasks will result in full mentor payment.
3) identify the appropriate internal subject matter expert(s) for RIZO mentoring and provide this
information to the CIP within one month after the start of the project.
4) participate in and/or facilitate conference calls as requested by CIP and RIZO mentees.
5) maintain availability via phone and email to respond to inquiries from other RIZO contractors
within 1-3 business days.
6) occasional travel requests or daytrips, as needed, to assist in training or possible face-to-face
workgroup sessions. Travel may be negotiated directly between mentor and mentee, based on
agreed-upon need. Travel expenses do not need to be reported to CIP, but the RIZO Project
Manager will be notified of any travel planned as part of RIZO mentoring duties.
7) invoice for the $7500 in mentor funds during the period of January - March 2012.
8) no required documentation of time spent on mentoring activities, but mentees may be asked to
report on the level of responsiveness demonstrated by WCDPHE.
Project activities will follow the timeline listed here:
Description of the planned activities Additional
comments
January Pamphlets with vaccine information and research data would be created during this
2012 month. We will continue to train staff and prepare our system to electronically bill
third party payers, as stated in RIZO goals. We will work with our insurance
technician to revise our consent and clerical forms used within the Health Department
to include third-party billing information needed to submit claims.
School nurses would be contacted and the Weld County immunization nurses would
meet with school nurses to provide education and schedule 1-3 clinics for the 2011-
2012 school year. Discuss forms to collect third party billing information. An
informational pamphlet will be developed and distributed to the school nurses and
teachers at this time.
Research private insurance companies' for requirements needed on claim submissions.
Meet with IT staff to implement appropriate changes in system. Process test claims
electronically with EDI. Make note of any denied claims and reasons, follow-up with
resubmission of claims, and training of billing technicians. Follow-up meetings with
financial screeners, billing technicians and agency health care workers to address any
concerns or changes with billing process. Process test claims with EDI.
Feb 2012 Weld County Health Department immunization nurses would attend scheduled school
clinics and would provide immunizations. Utilize billing information from clinic
forms to bill third party payers. Revise forms as needed to ensure more complete
information.
Process claims electronically. Follow-up with billing technicians and financial
screeners regarding any concerns or changes to billing process. Make note of any
denied claims and reasons, follow-up with resubmission of claims, and training of
billing technicians. Conduct meetings with agency health care workers to address any
concerns or changes with billing process, and review progress.
Mar 2012 Weld County Health Department immunization nurses would attend scheduled school
clinics and would provide immunizations. Utilize billing information from clinic
forms to bill third party payers. Revise forms as needed to ensure more complete
information.
Process claims electronically. Review insurance response time and accepted claims
processed. Make note of any denied claims and reasons,follow-up with resubmission
of claims, and training of billing technicians.
Apr 2012 Weld County Health Department immunization nurses would attend scheduled school
clinics and would provide immunizations. Utilize billing information from clinic
forms to bill third party payers.
Process claims electronically. Review insurance response time and accepted claims
processed. Conduct meetings with financial screeners,billing technicians and agency
health care workers to address any concerns or changes with billing process, and
review progress. Make note of any denied claims and reasons, follow-up with
resubmission of claims, and training of billing technicians.
May 2012 Weld County Health Department immunization nurses would attend scheduled school
clinics and would provide immunizations. Utilize billing information from clinic
forms to bill third party payers.
Process claims electronically. Review insurance response time and accepted claims
processed. Make note of any denied claims and reasons, follow-up with resubmission
of claims, and training of billing technicians.
June 2012 Contributions throughout the year would be reviewed to evaluate how the clinics went
and if partnerships were created. A recall would be scheduled to contact those
students needing to complete their HPV4 series.
Process claims electronically. Review insurance response time and accepted claims
processed. Follow-up meetings with financial screeners, billing technicians and agency
health care workers to address any concerns or changes with billing process, and
review progress.
July 2012 Data regarding children's immunization rates would be calculated to determine if we
met our goal of improving by 10%-15%of compliance. A recall would be scheduled
to contact those students needing to complete their HPV4 series
Process claims electronically. Review insurance response time and accepted claims
processed.Follow-up meetings with financial screeners, billing technicians and agency
health care workers to address any concerns or changes with billing process, and
review progress.
Aug 2012 Weld County immunization nurses would attend scheduled school clinics within
District 6 Greeley Middle Schools and would provide immunizations during back-to-
school activities. Utilize billing information from clinic forms to bill third party
payers.
Process claims electronically. Review insurance response time and accepted claims
processed. Follow-up meetings with financial screeners,billing technicians and agency
health care workers to address any concerns or changes with billing process, and
review progress.
CDPHE CIP agrees to provide the following:
• Timely response to all inquiries
• RIZO technical assistance and expert knowledge
• CDPHE CIP contractual/fiscal technical assistance
• Address barriers, as needed, in an efficient manner
2. Monitoring: •
a) Work is not to begin on the proposed project until the grantee receives an approved contract or
purchase order from the CIP.
b) Monthly online progress reports are due the last working day of each month for that month's
activities. The link to the online monthly report is:
http://fs9.fonnsite.com/ColoradoIMMprogram/ACA RIZO Monthly Report/index.html
c) RIZO projects will collect, track and report monthly the following data as applicable:
• Number of claims submitted to each payer, broken out by dollars submitted and paid
• Number of claims paid, partially paid, and denied, as well as those with no response
• Most frequently received denial reasons
• 3-6 months of initial data collection on patients immunized to identify billing opportunities
specific to the agency's jurisdiction (3-6 months is based on quality of data submitted as
assessed by CIP)
• SLV data collection template for each SLV clinic collecting the following information:
i. School name and school population
ii. Grade span of students
iii. Date of clinic
iv. Vaccines given
v. Count of students vaccinated, as compared to count of students eligible for
vaccination
vi. Patient specific data (vaccines administered, source of vaccine (public or private
stock), payer details, claim submitted)
• Status of project-specific milestones as documented on the application timeline
• Ongoing project overview
• Status of implemented activities
• Difficulties/barriers encountered
• Future planned project activities
d) A final, comprehensive RIZO Project evaluation report will be due to the CIP by September 30,
2012. The report will contain the following at a minimum:
• Active Payers: List of payers the agency now bills for immunization services
• Outcomes: Describe the final outcome of each objective and if the objective was achieved on
time. If delayed, please explain.
• Learnings: List all lessons learned (positive and negative)
• Project barriers.
• Cost Analysis: Quantified assessment of revenue increase vs. personnel time spent
processing claims (do not include time spent in ramp-up, contracting, or training)
• Sustainability: Explain if billing is sustainable based on the results of this project and what
the agency intends to do with immunization billing in the future.
• SLV specific:
i. utilization rate (# students vaccinated/#students eligible for vaccination)
ii. summary of techniques used to educate parents about the importance of providing
health plan insurance information
e) Additional follow-up contact will be made by the RIZO Project Manager and CIP Contract
Manager as necessary.
3. Personnel:
a) Agency information:
Agency name Weld County Department of Public Health and
Environment
Agency mailing address 1555 N. 17th Ave.
Phone number 970-304-6420 Ext. 2308
Fax number 970-304-6416
Agency DUNS # 075757955
Agency FEIN # 846000813
b) Agency Project contact persons:
Name Samantha Orozco-RN, BSN, Wendy Paris
Phone number 970-304-6420 Ext. 2308 or 2116
Email address sorozco(nico.weld.co.us or wparis@co.weld.co.us
c) CIP RIZO Project Manager:
Name Jodi Maturo
Phone number 303-692-2753
Email address Jodi.maturo@state.co.us
d) CIP SLV Project Manager:
Name Margaret Huffman
Phone number 303-692-2332
Email address Margaret.huffman@state.co.us
e) CIP Contract Manager:
Name Teri Lindsey
Phone number 303-692-2732
Email address Teri.lindsey@state.co.us
4. Payment:
a) WCDPHE will receive$31,853.00 for this RIZO Project as detailed below.
Expenses Describe in detail Proposed Local Total
funding In-kind Budget
Personnel RN and OT FTE's $19,459.58 $19,459.58
Personnel RN $24.16/hour, 8 hours per week=
$193.28, for 35 weeks=$6,764.80
38.93%Fringe=$2,633.54
RN total=$9,398.34
OT$13.59 per hour, 4 hours per week=$54.36,
for 35 weeks= $1,902.60
38.93%Fringe=$740.68
OT total=$2,643.28
Total Staff: $8,667.40+$3,374.22=$12,041.62
RIZO Staff
.11 FTE Insurance Tech, .06 FTE Billing Tech,
.05 FTE Financial Screener -Total$7,417.96
Travel Off-site clinic travel $375.00 $375.00
Marketing Advertising to schools,pamphlets&flyers $345.00 $345.00
Incentives Stickers,juice, snacks $100.00 _ $100.00
Operating Clinic supplies—needles, syringes, alcohol pads, $250.00 $250.00
Expenses band aids, cotton balls.
Office supplies Paper, printing, ink, computer airtime charges, $247.62 $247.62
general office supplies
Indirect 13.39% $2,875.80 $2,875.80
Other IT Support time-Costs include—Electronic $ 700.00 $ 700.00
claims and remittance from EMR/PM system
per FTE provider per month, cost per claim sent
by Vendor.
RIZO Mentor activities $7,500.00 $7,500.00
Total $31,853.00 $31,853.00
b) Funds are 100% Federal Dollars.
c) Invoices for payment shall be submitted quarterly.
d) The attached invoice shall be used for payment and submitted to:
Teri Lindsey
teri.lindseya,state.co.us
Phone: 303-692-2732
Fax: 303-691-6118
5. Remedies:
Throughout the funding period, the CIP will conduct ongoing project monitoring and provide technical
assistance as needed. In the event that project performance does not meet the agency's stated goals, a
follow-up work plan will be created and additional technical assistance will be provided. In an extreme
situation, and in consultation with the agency, the CIP reserves the right to reduce or withhold quarterly
payments due to poor project performance.
Statement of Work Acceptance:
I Barbara Kirkmeyer on behalf of the Board of Weld County Commissioners
hereby acknowledge that the requirements of the above-named Immunization statement of work have been
reviewed, and are accepted and agreed to. I further acknowledge that I have the necessary authority to sign this
acceptance on behalf of the entity mentioned above.
Signature
Chair
Title
DEC 19 2011
Date
ACA RIZO PROJECT
INVOICE
Agency Name:
Your Invoice No. (if applicable):
Today's Date: Billing Period:
TO: Teri Lindsey
Colorado Department of Public Health & Environment / Immunization Program
4300 Cherry Creek Drive South, DCEED-IMM-A3
Denver, CO 80246-1530 / Phone: 303-692-2732 / Fax: 303-691-6118
EXPENSES DESCRIPTION AMOUNT
Personnel
Travel
Marketing
Incentives
Equipment
Office Supplies
Indirect
Other
TOTAL DUE $
Name of agency staff authorized to complete this invoice:
Agency Address:
City:
State: Colorado
Zip Code:
Agency Tax ID #:
Purchase Order #:
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