HomeMy WebLinkAbout20072084.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SEX ABUSE INTERVENTION
PROGRAM SERVICES AND AUTHORIZE CHAIR TO SIGN - SAVIO HOUSE
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 Child Protection Agreement for Sex Abuse
Intervention Program Services between the County of Weld,State of Colorado,by and through the
Board of County Commissioners of Weld County,on behalf of the Department of Social Services,
and Savio House, commencing June 1, 2007, and ending May 31, 2008, with further terms and
conditions being as stated in said agreement, and
WHEREAS,after review,the Board deems it advisable to approve said agreement,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,ex-officio Board of Social Services,that the Child Protection Agreement for Sex
Abuse Intervention Program Services between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County,on behalf of the Department of Social
Services, and Savio House be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said agreement.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 23rd day of July, A.D., 2007, nunc pro tunc June 1, 2007.
BOARD`` ELD COUNTY, COMMISSIONERS
COLORADO
ATTEST: is USED
d E. Long, Chair
Weld County Clerk to the Bob
USED
BY: eq��r��.{ it illiam HAerk Pro-Tem
De Cle to the Boar
Willia F. Garcia
APP D AS TO F SIA
Robert
",�D.I Masden, Acting
/Chair Pro-Tem
�orney ' '`
un :0. dckor pt d, r
p ougla ademacher
Date of signature: a 1101
2007-2084
SS0034
SC cY-67-07
DEPARTMENT OF SOCIAL SERVICES
re t itsiiH3/4..... ,
P.O. BOX A
GREELEY, CO. 80632
Website: www.co.weld.co.us
Ilk
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
COLORADO
MEMORANDUM
TO: David E. Long, Chair Date: July 23, 2007
Board of County Commissioners
FR: Judy A. Griego, Director, Social Service 4A 6( �w
RE: Child Protection Agreement for Services b twe_enn the Weld County
Department of Social Services and Savio House
Enclosed for Board approval is a Child Protection Agreement for Services between the
Weld County Department of Social Services (Department) and Savio House. This
Agreement was reviewed at the Board's Work Session held on July 23, 2007.
The major provisions of the contract are as follows:
1. The term of the contract is June 1,2007 through May 31, 2008.
2. The source of funding is Core Services funding.
3. Savio House will provide Sex Abuse Intervention(SAI)Program services. The SAI
Program works with youth(14 to 21 years of age)with problem sexual behaviors in their
families to stop sexually abuse behavior and prevent its recurrence through monitoring,
education and therapeutic intervention provided in the community.
4. The Department will reimburse North Range $1,833 per month, pro-rated for any partial
month of services.
If you have any questions, please telephone me at extension 6510.
2007-2084
Contract No:07-08 CORE 99 RF�Fi
ken
CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY
DEPARTMENT HOUSE OF SOCIAL SERVICES ✓U(I B
ANDI8O,
This Agreement,made and entered into the 1 day of June 2007,by and between the Board of Weld County
Commissioners,sitting as the Board of Social Services,on behalf of the Weld County Department of Social
Services,hereinafter referred to as"Social Services,"and Savio House,hereinafter referred to as"Contractor".
WITNESSETH
WHEREAS,required approval,clearance,and coordination have been accomplished from and with
appropriate agencies;and
WHEREAS,the Colorado Department of Human Services has provided Core Services funding to Social
Services for outpatient therapy for sexual abuse victims and their family members.
NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
This Agreement shall become effective on June 1,2007,upon proper execution of this Agreement and shall
expire May 31,2008,unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by the Contractor to any person(s)eligible for child protection services in
compliance with Exhibit A"Scope of Services,"a copy of which is attached by reference.
3. Payment
a. Payment shall be made on the basis of Exhibit B,"Payment Schedule,"of which are attached
hereto and incorporated herein by reference.
"Payment Schedule"shall establish the maximum reimbursement,which will be paid from Core
Service funding during the duration of this Agreement.
b. The Contractor shall submit an itemized monthly bill to Social Services for all costs incurred and
services provided pursuant to Exhibit A of this Agreement in accordance with criteria established
by Social Services. The Contractor shall submit all itemized monthly billings to Social Services no
later than the twenty-fifth(25)day of the month following the month the cost was incurred.
c. Payments of costs incurred pursuant to this Agreement are expressly contingent upon the
availability of Core Service funds to Social Services.
d. Social Services shall not be billed for,and reimbursement shall not be made for time involved in
activities outside of those defined in Exhibit A. Work performed prior to the execution of this
Contract shall not be reimbursed or considered part of this Agreement.
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Contract No: 07-08 CORE 99
4. Financial Management
At all times from the effective date of this Contract until completion of this Contract,the Contractor shall
comply with the administrative requirements,cost principles and other requirements set forth in the
Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds
expended under Core Service funding must conform to the Single Audit Act of 1984 and OMB Circular A-
133.
5. Payment Method
Unless otherwise provided in the Scope of Services and Payment Schedule:
a. The Contractor shall provide proper monthly invoices and itemization of services performed for
costs incurred in the performance of the agreement.
b. Social Services may withhold any payment if the Contractor has failed to comply with the
Financial Management Requirements,program objectives,contractual terms,or reporting
requirements. In the event of a forfeiture of reimbursements,the Contractor may appeal such
circumstance to the Director of Social Services. The decision of the Director of Social Services
shall be final.
6. Assurances
The Contractor shall abide by all assurances as set forth in the attached Exhibit C,which is attached hereto
and incorporated herein by reference.
7. Compliance with Applicable Laws
At all times during the performance of this contract,the Contractor shall strictly adhere to all applicable
federal and state laws,orders,and all applicable standards,regulations,interpretations or guidelines issued
pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records,
papers,documents,tapes and any other materials that have been or may hereafter be established which
relate to the Contract. The Contractor acknowledges that the following laws are included:
Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d—1 et. seq.and its implementing
regulation,45 C.F.R.Part 80 et.seq.;and
Section 504 of the Rehabilitation Act of 1973,29 U.S.C. Section 794,and
its implementing regulations,45 C.F.R.Part 84;and
the Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et.seq.and
its implementation regulations,45 C.F.R.Part 91;and
Title VII of the Civil Rights Act of 1964;and
the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
the Education Amendments of 1972;and
Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
and all regulations applicable to these laws prohibiting discrimination because of race,color,
National origin,and sex,religion and handicap, including Acquired Immune Deficiency Syndrome(AIDS)
or AIDS related conditions,covered under Section 504 of the Rehabilitation Act of 1973,as amended,cited
above. If necessary,the Contractor and Social Services will resist in judicial proceedings any efforts to
obtain access to client records except as permitted by 42 CFR Part 2.
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Contract No: 07-08 CORE 99
Included is 45 C.F.R.Part 74 Appendix G 9,which requires that affirmative steps be taken to assure that
small and minority businesses are utilized,when possible,as sources of supplies,equipment,construction
and services. This assurance is given in consideration of and for the purpose of obtaining any and all
federal and/or state financial assistance.
Any person who feels that s/he has been discriminated against has the right to file a complaint either with
the Colorado Department of Human Services or with the U.S.Department of Health and Human Services,
Office for Civil Rights.
8. Certifications
The Contractor certifies that,at the time of entering into this Contract,it has currently in effect all necessary
licenses,approvals,insurance,etc.required to properly provide the services and/or supplies covered by this
contract.
9. Monitoring and Evaluation
The Contractor and Social Services agree that monitoring and evaluation of the performance of this
Agreement shall be conducted by the Contractor and Social Services. The results of the monitoring and
evaluation shall be provided to the Board of Weld County Commissioners and the Contractor.
The Contractor shall permit Social Services,and any other duly authorized agent or governmental agency,
to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. As the
monitoring agency may in its sole discretion deem necessary or appropriate,such program data,special
analyses,on-site checking,formal audit examinations,or any other reasonable procedures. All such
monitoring shall be performed in a manner that will not unduly interfere with agreement work.
10. Modification of Agreement
All modifications to this agreement shall be in writing and signed by both parties.
11. Remedies
The Director of Social Services or designee may exercise the following remedial actions should s/he find
the Contractor 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
Contractor. These remedial actions are as follows:
a. Withhold payment to the Contractor 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 Contractor 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. Incorrect payment to the Contractor due to omission,error,fraud,and/or defalcation shall be
recovered from the Contractor by deduction from subsequent payments under this Agreement or
other agreements between Social Services and the Contractor,or by Social Services as a debt due to
Social Services or otherwise as provided by law.
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Contract No: 07-08 CORE 99
12. Representatives
For the purpose of this Agreement,the individuals identified below are hereby designated representatives of
the respective parties. Either party may from time to time designate in writing a new or substitute
representative(s):
For Social Services:
Gloria Romansik Social Services Administrator
Name Title
For Savio:
William S. Hildenbrand Executive Director
Name Title
13. Notice
All notices required to be given by the parties hereunder shall be given by certified or registered mail to the
individuals at the addresses set forth below. Either party may from time to time designate in writing a
substitute person(s)or address to whom such notices shall be sent:
To: Social Services To: Savio House
Judy A.Griego,Director William S. Hildenbrand,Executive Director
P.O.Box A 325 King Street
Greeley,CO 80632 Denver,Colorado 80219
14. Litigation
The Contractor shall promptly notify Social Services in the event that the Contractor learns of any actual
litigation in which it is a party defendant in a case that involves services provided under this Agreement.
The Contractor,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,reorganization and/or foreclosure.
15. Termination
This Agreement may be terminated at any time by either party given thirty(30)days written notice and is
subject to the availability of funding. The Contractor reserves the right to suspend services to clients if
funding is no longer available.
16. Entire Agreement
This Agreement,together with all attachments hereto,constitutes the entire understanding between the
parties with respect to the subject matter hereof,and may not be changed or modified except as stated in
Paragraph 10 herein.
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Contract No:07-08 CORE 99
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year first
above written.
LI�i
ATTEST:
WELD CO ��V I OF COUNTY
CLERK TOT '. B ISSIONERS WELD
� tit /� • ,�LRRAD(�°�) ^�I1/1/I
By: � :. 'l"' C r B;�I
(l- %1 �r
D tltyClerk Robert D. Masden, Acting Chair Pro-Tern
07/23/2007
AP"OV'D O i. • • CONTRACTOR:
BY s GY/1 Z%
P.untyAttorney William S.Hildenbrand
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICE
By:
D. ctor
5
07092-R689
Contract No: 07-08 CORE 99
EXHIBIT A
SCOPE OF SERVICES
1. Program Description:
Savio provides community based services to youth at risk and their families. The Sex Abuse Intervention
(SAI)program works with youth with problem sexual behaviors in their families to stop sexually abuse
behavior and prevent its recurrence through monitoring,education and therapeutic intervention provided in
the community. The program utilizes a high level of supervision and involvement and emphasizes
community safety and client accountability at all times which assists in shortening placement stays and
helps clients successfully and safely transition to their homes and families.
All Savio SAI therapists receive training and supervision according to the Colorado Sex Offender
Management Board(SOMB) Standards and all staff follow SOMB training and supervision guidelines.
2. Target Population:
Adolescent males and females,fourteen to twenty years of age,who have committed a sexual offense,both
adjudicated and non-adjudicated sexually reactive youth and youth with boundary issues and/or harassment
behaviors. The program targets youth who have identified caretakers who are willing to participate in the
SAI program and provide the necessary monitoring and supervision. Savio also serves emancipating youth
with problem sexual behaviors focusing on identifying high-risk situations,safety planning and relapse
prevention,community and family support as youth re-integrate into the community and develop
independent living skills.
3. Scope of Service:
• Savio will provide individual offense specific therapy,family therapy and informed supervision
training if needed. This will include face-to-face contacts,either in-home or in-community services,on
an average of 2-3 times per week minimally. Services also involve working with all systems involved
with the youth to provide intensive supervision to increase the youth's accountability and develop pro-
social behaviors while maintaining containment.
• Additional Services: Savio will provide polygraphs and clarification when necessary and appropriate.
6
Contract No: 07-08 CORE 99
EXHIBIT B
PAYMENT SCHEDULE
Funding and Method of Payment
Social Services agrees to reimburse the Contractor in consideration for the work and services performed
under Core Service funding.
Expenses incurred by the Contractor,in association with said project prior to the term of this agreement,are
not eligible Social Services expenditures and shall not be reimbursed by Social Services.
Payment pursuant to this Contract,if Core Service funds,whether in whole or in part,is subject to and
contingent upon the continuing availability of Core Service funds for the purposes hereof. In the event that
said funds,or any part thereof,become unavailable as determined by Social Services, Social Services may
immediately terminate this Contract or amend it accordingly.
2. Fees for Services
Services will be provided at a cost of$1833.00 per month,pro-rated for any partial month of service.
3. Submittal of Vouchers
The Contractor shall prepare and submit monthly the itemized voucher per Exhibit D—Billing Procedures,
and will certify that the services authorized were provided on the date indicated and the charges made were
pursuant to the terms and conditions of Exhibit A.
7
Contract No: 07-08 CORE 99
EXHIBIT C
ASSURANCES
The Contractor agrees it is an independent contractor and that its officers and employees do not become
employees of Weld County,nor are they entitled to any employee benefits as Weld County employees,as
the result of the execution of this Agreement.
2. Weld County,the Board of County Commissioners of Weld County,its officers and employees,shall not be
held liable for injuries or damages caused by any negligent acts or omissions of the Contractor-contracted
the Contractor or its employees,volunteers,or agents while performing duties as described in this
Agreement. The Contractor shall indemnify,defend,and hold harmless Weld County,the Board of County
Commissioners of Weld County,its employees,volunteers,and agents. The Contractor shall provide
adequate liability and worker's compensation insurance for all its employees,volunteers,and agents
engaged in the performance of the Agreement upon request,the Contractor shall provide Social Services
with the acceptable evidence that such coverage is in effect.
3. No portion of this Contract shall be deemed to constitute a waiver of any immunities the parties or their
officers or employees may possess,not shall any portion of this Agreement be deemed to have treated a
duty of care with respect to any persons not a party of this Agreement.
4. No portion of this Contract shall be deemed to create an obligation on the part of the County of Weld,State
of Colorado,to expend funds not otherwise appropriated in each succeeding year.
5. If any section,subsections,paragraph,sentence,clause,or phrase of this Contract is for any reason held or
decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The
parties hereto declare that they would have entered into this Contract and each and every section,
subsection,paragraph, sentence,clause,and phrase thereof irrespective of the fact that any one or more
sections, subsections,paragraphs,sentences,clauses,or phrases might be declared to be unconstitutional or
invalid.
6. No officer,member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest,direct or indirect,in the approved Agreement or the proceeds thereof.
7. The Contractor assures that they will comply with the Title VI of the Civil Rights Act of 1986 and that no
person shall,on the grounds of race,creed,color, sex,or national origin,be excluded from participation in,
be denied the benefits of,or be otherwise subjected to discrimination under this approved Contract.
8. The Contractor assures that sufficient,auditable,and otherwise adequate records that will provide accurate,
current, separate,and complete disclosure of the status of the funds received under the Contract are
maintained for three(3)years or the completion and resolution of an audit. Such records shall be sufficient
to allow authorized local,Federal,and State auditors,and representatives to audit and monitor the
Contractor.
9. All such records,documents,communications,and other materials shall be the property of Social Services
and shall be maintained by the Contractor,in a central location and custodian,in behalf of Social Services,
for a period of four(4)years from the date of final payment under this Contract,or for such further period
as may be necessary to resolve any matters which may be pending,or until an audit has been completed
with the following qualifications: If an audit by or on behalf of the federal and/or state government has
begun but is not completed at the end of the four(4)year period,or if audit findings have not been resolved
after a four(4)year period,the materials shall be retained until the resolution of the audit finding.
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Contract No: 07-08 CORE 99
10. The Contractor assures that authorized local, federal,and state auditors and representatives shall,during
business hours,have access to inspect any copy records,and shall be allowed to monitor and review
through on-site visits,all contract activities, supported with funds under this Contract to ensure compliance
with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the
performance of the Agreement shall be conducted by appropriate funding sources. The results of the
monitoring and evaluation activities shall be provided to the appropriate and interested parties.
11. This Contract shall be binding upon the parties hereto,their successors,heirs,legal representatives,and
assigns. The Contractor or Social Services may not assign any of its rights or obligations hereunder without
the prior written consent of both parties.
12. The Contractor certifies that federal appropriated funds have not been paid or will be paid,by or on behalf
of the Contractor,to any person for influencing or attempting to influence an officer or employee of an
agency,a Member of Congress,an officer or employee of Congress,or an employee of a Member of
Congress in connection with the awarding of any Federal contract,the making of any federal grant,the
making of any federal loan,the entering into of any cooperative agreement,and the extension,continuation,
renewal,amendment,or modification of any Federal contract,loan,grant,or cooperative agreement.
13. The Contractor assures that it will fully comply with all other applicable federal and state laws. The
Contractor understands that the source of funds to be used under this Contract is Core Service funds.
14. The Contractor assures and certifies that it and its principals:
a. Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transaction by a federal department of agency.
b. Have not,within a three-year period of preceding this Agreement,been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining,attempting to obtain,or performing a public(federal,state,or local)transaction or
contract under a public transaction;violation of federal or state antitrust statutes or commission of
embezzlement,theft,forgery,bribery,falsification or destruction of records,making false
statements,or receiving stolen property;
c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(federal,state,or local)with commission of any of the offenses enumerated in paragraph 11(b)of
this certification;and
d. Have not,within a three-year period preceding this Contract,had one or more public transactions
(federal,state,and local)terminated for cause or default.
15. The Appearance of Conflict of Interest applies to the relationship of a contractor with Social Services when
the contractor also maintains a relationship with a third party and the two relationships are in opposition. In
order to create the appearance of a conflict of interest,it is not necessary for the contractor to gain from
knowledge of these opposing interests. It is only necessary that the contractor know that the two
relationships are in opposition.During the term of the Contract,the Contractor shall not enter any third
party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing
appearance of a conflict of interest situation,the Contractor shall submit to Social Services,a full disclosure
statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly
submit a disclosure statement required by this paragraph shall constitute grounds for Social Services'
termination,for cause,of its contract with the Contractor.
16. The Contractor shall protect the confidentiality of all applicant records and other materials that are
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Contract No: 07-08 CORE 99
maintained in accordance with this Contract. Except for purposes directly connected with the
administration of Child Protection,no information about or obtained from any applicant/recipient in
possession of the Contractor shall be disclosed in a form identifiable with the applicant/recipient or a
minor's parent or guardian unless in accordance with the Contractor written policies governing access to,
duplication and dissemination of,all such information. The Contractor shall advise its employees,agents,
and subcontractor, if any,that they are subject to these confidentiality requirements. The Contractor shall
provide its employees,agents,and subcontractors,if any,with a copy or written explanation of these
confidentiality requirements before access to confidential data is permitted.
17. Proprietary information for the purposes of this contract is information relating to a party's research,
development,trade secrets,business affairs,internal operations and management procedures and those of its
customers,clients or affiliates,but does not include information(1)lawfully obtained from third parties,(2)
that which is in the public domain,or(3)that which is developed independently. Neither party shall use or
disclose directly or indirectly without prior written authorization any proprietary information concerning the
other party obtained as a result of this Contract. Any proprietary information removed from the State's site
by the Contractor in the course of providing services under this Contract will be accorded at least the same
precautions as are employed by the Contractor or similar information in the course of its own business.
18. The Contractor certifies it will abide by Colorado Revised Statue(C.R.S.)26-6-104,requiring criminal
background record checks for all employees,contractors,and sub-contractors.
19. Contractor certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-
101, et seq. Contractor shall not knowingly employ or contract with an illegal alien to perform work under
this Contract or enter into a contract with a subcontractor that fails to certify to Contractor that the
subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this
Contract. Contractor represents, warrants, and agrees that it (a) has verified that it does not employ any
illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by
the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply
with the requirements of C.R.S. 8-17.5-102(2)(b). Contractor shall comply with all reasonable requests
made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and
Employment. If Contractor fails to comply with any requirement of this provision or C.R.S. 8-17.5-101, et
seq., Social Services may terminate this Contract for breach and Contractor shall be liable for actual and
consequential damages to Social Services.
Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if Contractor
receives federal or state funds under this Contract, Contractor must confirm that any individual natural
person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-
76.5-103(4) if such individual applies for public benefits provided under this Contract. If Contractor
operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it (a) is a citizen of
the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall
produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce
one of the forms of identification required by C.R.S.24-76.5-103 prior to the effective date of this Contract.
10
Contract No: 07-08 CORE 99
EXHIBIT D
BILLING PROCEDURES
1. All billings are to be submitted by the 10`he day of the 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.
2. Billings must be submitted with the attached required forms, Authorization for
Contractual Services, Request for Reimbursement and Client Verification Form. The
forms must be submitted with original signatures.
3. For monitored sobriety, proof of services rendered shall be a sign-in sheet with client
signatures or the test result.
I1
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
Program Year 2007-08
TO BE COMPLETED BY PROVIDER:
Date:
Provider: Billing Contact:
Phone Number:
Address:
Description of Services:
Service Month / Year: Charges: $
I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE
INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE
CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF SOCIAL
SERVICES.
Printed Name of Signer Provider Signature Date
(Original signature REQUIRED—NO FAXES)
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
FOR COUNTY USE ONLY:
AMOUNT AUTHORIZED FOR PAYMENT: $
Approvals:
/
Core & Service Contract Coordinator Date
/
Director Date
Comments:
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