HomeMy WebLinkAbout20082636.tiff MEMORANDUM
♦ a DATE: September 25, 2008
' 1�� TO: William H. Jerke, Chair, Board of County Commissioners
W� O FROM: Judy A. Griego, Director, Human Sery ep•
� �
COLORADO RE: Addendum to the Individual Provider Contract for
Foster Care Services between the Weld County Department
of Human Services and John and Donna Downey to be
Placed on the Consent Agenda
Enclosed for Board approval is an Addendum to the Individual Provider Contract for Foster
Care Services between the Weld County Department of Human Services and John and Donna
Downey. This was presented at the Board's September 8, 2008, Work Session. This
Agreement can be placed on the Consent Agenda.
Please see attached Memorandum for the major provisions of this Agreement. The term for
this Agreement is July 1, 2008 through June 30, 2009.
If you have questions please give me a call at extension 6510.
/Vie CO 79
CI cr rtc 6iS& 2008-2636
19 2`1f-0-tig Vie : tlR OR k8
Liu
a DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREEL wwH w
CO. 80632
Website: .co. eld.co.
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
•
COLORADO
MEMORANDUM
TO: Judy Griego — Director
FROM: Lesley Cobb - Child Welfare Rate Negotiator
DATE: August 29, 2008
SUBJECT: Work session request for approval of the Weld
Addendum to the Individual Provider Contract for
Foster Care Services.
Attached please find the Weld Addendum to the Individual Provider
Contract for Foster Care Services for the following provider:
2008-2009 CONTRACTS FOR
FOSTER CARE SERVICES
Nailla�
. ., . .lI' 1&M a a ale 7
1 Downey, John and Donna 1551054 3826 W. 8th Street Greeley CO 80634
This contract has not been presented under the consent agenda, as it is a
new provider and I am requesting that it be put on the next work session in
order to be signed and approved by the Board of County Commissioners.
If you have any questions please call me at Ext. 6441.
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Downey,John and Donna
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this rj day of 2008, are added to the referenced
Agreement. Except as modified hereby, all terms f the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1551054. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TR[ AILS CASE ID jDOB
M F I I
WORKER COMPLETING ASSESSMENT JIIH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑l)One round trip a week 01%)2 round trips a week
O2)3-4 round trips a week. ❑2%:) 5 round trips a week O3)6 round trips a week
❑3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required 01)Once a month 01%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular
special education plan?
❑Basic Maint.)No educational requirements Dl)Less than a %2 hour per day 01%) V how a day
❑2) 1 hour a day O2 %) 1'/-2 hours per day O3)2'h-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/s) 11 to 14 hours per week
❑3)Constant basis during awake hours O3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedi
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County Addendum to the CW£
•
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
a ) ,
= S,
,.. .._ ...
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting ❑ 0 0 ❑
Stealing
❑ 0 ❑ 0
Self-injurious Behavior
❑ 0 ❑ ❑
Substance Abuse
❑ 0 ❑ 0
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ ❑
Enuresis/Encopresis
❑ 0 0 ❑
Runaway
❑ 0 ❑ ❑
Sexual Offenses
❑ 0 0 ❑
5 Weld County Addendum to the CWS
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..l to this child.
1m5Z TMC��. �{
_ .. . _.. ., t a $'
•
• wI ( tct.,� f.T
s . tat
Inappropriate Sexual Behavior
❑ O ❑ O
Disruptive Behavior
❑ O O O
Delinquent Behavior
❑ O ❑ O
Depressive-like Behavior
❑ O O O
Medical Needs
(If condition is rated"severe",please complete O O O O
the Medically fragile NBC)
Emancipation
❑ O O ❑
Eating Problems
❑ O ❑ O
Boundary Issues
❑ O O O
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ O O
Involvement with Child's Family
❑ O O O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 O 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
• NEEDS BASED CARE
RATE TABLE
(Exhibit C)
; Age 0-10...$16.32($496) fi' Basic Maint $4.93 day/$150mo ` Level 0 $0 r-
Count Age 11-14."$18'05 ., f Therapy not needed or provided
y r ($549) No crisis intervention,Minimal CPA by Level 0...$0
Basic • 0Age 15-21...$19.27
Maint ' ≤' 9 (None)
($586) involvement,one face-to-face visit another source,i.e.mental health.
w1 +$.66 Respite Care
($20) with child per month.
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
+$.66 Respite Care Minimal crisis intervention as needed ;s Regularly scheduled therapy,
1 4 one face-to-face visit per month with Level 1 ...$2.99
($20.39 day/$620 mo) child, up to 4 hours/month.
2-3 contacts per month
:,' $23.01
1 1/2 +$,66 Respite Care Level 1 1/2.........$9.86 day/$300 mo ------------ _--
g ($23.67 day/$720 mo)
$26.30 Level 2................$11.51 day/$350 mo . Level 2 $9.86/$300 mo -. .H
2 +$.66 Respite Care Occasional crisis intervention as needed,
Weekly scheduled therapy, - Level 2..$4.47
`j ($26.96 day/$820 mo) 'Pi. two face-to-face visits with child, 5-8 hours a month with 4 hours of
Q 2-3 contacts per month group therapy.
$29.59 yg
2 1/2 :cif; +$,66 Respite Care - Level 2 1/2 $13.15 day/$400 mo , ------------
v;*. ($30.25 day/$920 mo) , ,r
$32.88 .;;i: Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo .
+$.66 Respite Care Ongoing crisis intervention as needed Regularly scheduled weekly .'
3 ;a multiple sessions,can include Level 3..$6.02
,'3 weekly face-to-face visits with child more
($33.54day/$1020 mo) and intensive coordination of ` than 1 person,i.e.family therapy,
multiple services. for 9-12 hours/monthly.
$36.16
3 1/2 " +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo ----.....------- ------
I ($36.82 day/$1,120 mo)
$39.45 '-•.! Level 4 $18.08 day/$550 mo . Level 4.........$14.79/$450 mo ,
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
4 multiple sessions,can include
RTC which includes high level of case more
Drop Level 4....Neg.
Down � ($40.77 day/$1220 mo) management and CPA involvement with than 1 person,i.e.family therapy.
F.;
child and provider and 2-3 face-to-face for 9-12 hours/monthly.
t. contacts .er week minimum. _
Assess $26.96 day/$820 mo -,.
Rate ;-0 (Includes Respite) }1!) $11.51 day/$350 mo --------------------
'A s
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 month
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Iiatie /u
Weld County Clerk to the Board
WELD COUNTY BOARD OF
N•
k< SOCIAL SERVICES, ON BEHALF
(' � '-\\ OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
}_ f SERVICES
By: • c By:
Deputy Cl to the Board Chair Signature
William H. Jerke, Chair
09/29/2008
PROVIDER: i
«NAME» 2 I \r 1.r , \11" \-1\YArtA«MAILING ADDRESS» 3no i414
«CITY STATE ZIP»Gre4 Co 80Ot'
n
XBy: Z .
\ (Signat e)
WOF LD A E CARTMENT
OF SOCIAL SERVICES
Lc
By:
(Direc or Sign )
8 Weld County Addendum to the CWS-7A
MEMORANDUM
a
fs14 DATE: September 25, 2008
W I
William H. Jerke, Chair, Board of County Commissioners
�•FROM: Judy A. Griego, Director, Human Servic s Department
COLORADO RE: Addendum to the Out-of-Home Placem gre ifibn r
Foster Care Services between the Wel ounty ep ent
of Human Services and Larry and Katherine Risner-Vivanco
to be Placed on the Consent Agenda
Enclosed for Board approval is an Addendum to the Out-of-Home Placement Agreement for
Foster Care Services between the Weld County Department of Human Services and Larry and
Katherine Risner-Vivanco. This was presented at the Board's September 8, 2008, Work
Session. This Agreement can be placed on the Consent Agenda.
Please see attached Memorandum for the major provisions of this Agreement. The term for
this Agreement is July 1, 2008 through June 30, 2009.
If you have questions please give me a call at extension 6510.
C O ao
rs citd DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREELEY,
CO. 80632
Website eld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
I
O
•
COLORADO
MEMORANDUM
TO: Judy Griego — Director
FROM: Lesley Cobb - Child Welfare Rate Negotiator
DATE: August 28, 2008
SUBJECT: Work session request for approval of Weld
Addendum to the Agreements to Purchase Out-of-
home Placement Services (SS-23A) for Foster Care
Services.
Attached please find the Weld Addendum to the Agreement to Purchase
Out-of-home Placement Services (SS-23A) for the following provider:
2008-2009 CONTRACT FOR
FOSTER CARE SERVICES
• D rT t,.
a a a
Risner-Vivanco, Larry
1 and Katherine 1552270 1104 N 3rd St Johnstown, CO 80534
This contract has not been presented under the consent agenda, as it is a
new provider and I am requesting that they be put on the next work
session in order to be signed and approved by the Board of County
Commissioners. If you have any questions please call me at Ext. 6441.
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of/Ca-Aster Care ?'
Services and Foster Care Facility Agreement (the "Agreement")' twe,en
1.Larry Dean Risner and Katherine Laura Vivanco 11: '
Sp 11
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this day o 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of e Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1552270. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
- ' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County C t
1 � WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: /02444,et .l �� -. 41,2' � By: 'A � �
Deputy rk to the Board Chair Signature
William H, Jerke r Chair
09/29/2008
PROVIDER:
Larry Risner& Katherine Vivanco
1104 N. 3rd St.
Johnstown, CO 80234
BA �.
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Dir ctor Signatp e)
8 Weld County Addendum to the CWS-7A
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