HomeMy WebLinkAbout20072779.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR TRAUMATIC BRAIN INJURY 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 a Task Order Contract for the Traumatic
Brain Injury 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 October 1, 2007, and ending September 30, 2008,with further terms and conditions
being as stated in said task order contract, and
WHEREAS,after review,the Board deems it advisable to approve said task order contract,
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 Task Order Contract for the Traumatic Brain Injury 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 task order contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 29th day of August, A.D., 2007.
BOARD OF COUNTY COMMISSIONERS
I I L WELD COUNTY, COLORADO
_ATTEST: % '��,��. �; CUSED
1861 _fast vid E. Long, Chair
Weld County Clerk to the '=r.
♦� ��
Van r% William . Pro-Tem
De= tyCI r totheBo
-
William F. Garcia
M:/: EXCUSED
' / Robert D. Masden
nty'ttorney
Dougla Rademac er
Date of signature: lI to 47
2007-2779
HL0034
(' /fL 690-LA 09- /3-0-7
Memorandum
TO: David E. Long, Chair
Board of County Commissioners
Ind FROM: Mark E. Wallace, MD, MPH
C Director, onmeDepar t frtf Pkab+l5ic He l�
and Environment 1�"°�, 5
COLORADO DATE: August 23, 2007
SUBJECT: TBI Program Task Order Contract
Enclosed for Board review and approval is a task order contract between the Weld County Board
of Commissioners on behalf of the Department of Public Health and Environment(WCDPHE)
and the State of Colorado through the Colorado Department of Public Health and Environment
(CDPHE) for the TBI (Traumatic Brain Injury) Program.
Weld County will receive an amount not to exceed $103,200 for providing care coordination for
families who have children with traumatic brain injury(TBI) and are enrolled in the TBI Trust
Fund Program during the time period October 1, 2007 through September 30, 2008.
Reimbursement will be based upon an initial payment of$320 for the month in which the State
approves the Care Coordinator Plan for the family with an additional $80 to be paid for each
month the family receives care coordination services during this initial term of the contract. This
contract is funded entirely by the State of Colorado. The funding for this program was
previously included in the Maternal and Child Health task order contract. I recommend your
approval.
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2007-2779
DEPARTMENT MENI'OE PUBLIC I IP:Al II I AND ENV IRONMENI'
ROUTING NO.08 FLA 00502
APPROVED TASK ORDER CONTRACT-WAIVER#154
This Task Order Contract is issued pursuant to Master Contract made on 12/18/2006,with routing number 08 FAA 00052
SI ATIi: CONTRACTOR
State of Colorado for the use&benefit of the Board of County Commissioners of Weld County
Department of Public Health and 915 10th Street, Greeley,Colorado 80632-0758
Environment for the use and benefit of the
Prevention Services Division Weld County Department of Public Health and
MCH Environment, 1555 North 17th Avenue
4300 Cherry Creek Drive South Greeley,Colorado 80631
Denver,Colorado 80246
TASK ORDER MADE DATE: CONTRACTOR ENTITY I'IY TYPE:
08/01/2007 Colorado Political Subdivision
PO/SC I(NCUMBRANCE,NUMBER: CONTRACTOR FEN OR SO(:I AE,SECURITY NUMBER:
PO FLA PSD0800502 84-6000813 B
I ERAt: BILLING SIATEMIIN'I'S RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 10/01/2007 whichever is later. The STATUTORY AUl]IORTIY:
Task Order shall end on 06/30/2008. CRS 26-1-304
PRICE(STRUCTURE: CONTRACT PRICE NOT TO EXCEED:
Fixed Price $103,200.00
PROCURI:MI(N'T MP:I)IOD: FEDERAL FUNDING DOLLARS: $0.00
Exempt STATE FUNDING IX)LLARS: $103,200.00
BID/REP/EAST PRICE AGREEMENT NUMBER MAXIMUM AMOUNT AVAILABLE PER EISCAI.YEAR:
Not Applicable FY 08: $103,200.00
• FY 09: $0.00
I AVC SIBTI 11:D VIiNDOR STATUTE:
Not Applicable
S T A ll(RI:PRI N:NTATI V E: CONTRACTOR RI/PRESENTATIVE:
Kathy Watters Judy Nero
Department of Public Health and Environment Weld County Department of Public Health and
Prevention Services Division Environment
Traumatic Brain Injury Trust Fund Program 1555 North 17th Avenue
4300 Cherry Creek Drive South Greeley,Colorado 80631
Denver,CO 80246
SCOPE OF WORK:
Working in partnership with the State and other local agencies to provide care coordination for families who have
children with Traumatic Brain Injury(TBI)and are enrolled in the TBI Trust Fund Program.
Page 1 of 4
I XIIIa1'IS.
The following exhibits are hereby incorporated:
Exhibit A - Additional Provisions (and its attachments if any—e.g.,A-1,A-2,etc.)
Exhibit B - Statement of Work and Budget(and its attachments if any—e.g.,B-1,B-2,etc.)
Exhibit C- Limited Amendment Template for Task Orders
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses,the more specific provision shall control.
1. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including,but not limited to,Exhibit One thereto. The total term of this Task Order Contract,including
any renewals or extensions,may not exceed five(5)years.The parties intend and agree that all work shall
be performed according to the standards,terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(1),C.R.S.,as amended,this Task Order Contract is not valid until it
has been approved by the State Controller,or an authorized delegee thereof. The Contractor is not
authorized to,and shall not;commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or,any costs or expenses,incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date,then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date,then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract,unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated,all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract(including its exhibits
and/or attachments),or between this Task Order Contract and its exhibits and/or attachments,such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: 1)the
Special Provisions of the Master Contract;2)the Master Contract(other than the Special Provisions)and its
exhibits and attachments in the order specified in the Master Contract;3)this Task Order Contract;5)the
Page 2 of 4
Additional Provisions-_Exhibit A,and its attachments if included,to this Task Order Contract;4) the
Scope/Statement of Work-Exhibit B,and its attachments if included,to this Task Order Contract;6)other
exhibits/attachments to this Task Order Contract in their order of appearance.
4. The Contractor,in accordance with the terms and conditions of the Master Contract and this Task Order
Contract,shall perform and complete,in a timely and satisfactory manner,all work items described in the
Statement of Work and Budget,which are incorporated herein by this reference,made a part hereof and
attached hereto as"Exhibit B".
5. The State,with the concurrence of the Contractor,may,among other things,prospectively renew or extend
the term of this Task Order Contract,subject to the limitations set forth in the Master Contract,increase or
decrease the amount payable under this Task Order Contract,or add to,delete from,and/or modify this
Task Order Contract's Statement of Work through a"Limited Amendment for Task Orders"that is
substantially similar to the sample form Limited Amendment that is incorporated herein by this reference
and identified as Exhibit C. To be effective,this Limited Amendment must be signed by the State and the
Contractor,and be approved by the State Controller or an authorized delegate thereof. Upon proper
execution and approval,this Limited Amendment shall become a formal amendment to this Task Order
Contract. This contract is subject to such modifications as may be required by changes in Federal or State
law,or their implementing regulations. Any such required modification shall automatically be incorporated
into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein.
6. The conditions,provisions,and terms of any RFP attached hereto,if applicable,establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal, if attached hereto,or any attachments or exhibits thereto,or the Scope/Statement of Work
Exhibit B,establishes or creates standards of performance greater than those set forth in the RFP,then the
Contractor shall also meet those standards of performance under this Task Order Contract.
Page 3 of 4
IN WITNESS WHEREOF, the State has executed this Task Order Contract as of the day first above
written.
CONTRACTOR: STATE OF COLORADO:
Board of County Commissioners of Weld BILL RITTER,JR. GOVERNOR
County for the use and benefit of the ..9._. —
\Veld County Department of Public I Iealrh and
Environment
Legal Name of Contracting Entity _/�Q
By ��
For Executive Director
84-6000813 Department of Public Health and Environment
Social Security Number or FEIN
1 <-. ' Department Program Approval:
Signature of Authorized Officer 1"
William H. Jerke, Chair Pro—Tem By
PrintName&Title of Authorized Officer
08/29/2007
GOVERNMENTAL ENTITIES: /// ����
(An attestation and sea a e r� i�� t\� I
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,O 5 r :,l (i.:..
Attest(Seal)By �/�Q�ZP..�j � ' '
(Town/City/County Clerk Equivalent) �' �.,. �'1. ��ern Ri;,s al here)
if
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State
Controller,or such assistant as he may delegate,has signed it. The contractor is not authorized to begin performance until
the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be
obligated to pay for the goods and/or services provided.
STATE CONTROLLER:
Leslie M.Shenefelt
r
By "� I��1
Date ' ' ) 1 •
WELD COUNTY DEPARTMENT OF
PUS CCU I�E?�TAIDCRO TS
Page 4 of 4 BY: �/�!`Cj.�.l"/�`(// w�/'.�
Mark E. Wallace, MD, MPH•Director
07077- d77
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 08/01/2007-Contract Routing Number 08 FLA 00502
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order
Contract specified above.
1. Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination.
The State and the Contractor have determined that Contractor is a business associate under
HIPAA. The Contractor hereby agrees to,and has an affirmative duty to,execute the State's
current HIPAA Business Associate Agreement,which is attached hereto as Attachment A-1,and
incorporated herein by this reference. This Business Associate Agreement shall be fully and
properly executed by Contractor and retumed to the State at the time Contractor signs the Task
Order Contract of which this exhibit is a part.
2. The Colorado Department of Human Services,through Denver Options,Inc.and under the
provisions of C.R.S.26-1-304,is authorized to purchase services for children with traumatic train
injuries through the Children's TBI Trust Fund grant. Denver Options contracts with the Health
Care Program for Children with Special Needs (HCP)to purchase care coordination services for
children under the age of 21 with a traumatic brain injury who have been determined eligible for
program services through the Brain Injury Association of Colorado.
If the underlying award authorizes the State to pay all allowable and allocable expenses of a
contractor as of the effective date of that award,then the State shall reimburse the Contractor for
any allowable and allocable expenses of the Contractor that have been incurred by the Contractor
since the proposed effective date of this Task Order Contract. If the underlying Award does not
authorize the State to pay all allowable and allocable expenses of a contractor as of the effective
date of that Award,then the State shall only reimburse the Contractor for those allowable and
allocable expenses of the Contractor that are incurred by the Contractor on or after the effective
date of this Task Order Contract,with such effective date being the later of the date specified in
this Task Order Contract or the date the Task Order Contract is signed by the State Controller or
delegee.
3. Payment pursuant to this Contract shall be made as earned,in whole or in part,from available cash
funds exempt in an amount not to exceed$103.200.00 for the purchase of statewide Traumatic
Brain Injury(TBI)Trust Fund Program services. The Contractor expressly acknowledges that the
maximum amount of funds available statewide for each state Colorado fiscal year for these TBI
services from all contractors is the amount,which is encumbered in the blanket encumbrance. The
liability of the State,at any time,for payments to the Contractor,and all other contractors,shall be
limited to the remaining unencumbered balance of these funds. If the total funds appropriated for
the purposes of this Contract are reduced during the term of this Contract,then the State, in its sole
discretion,may proportionately reduce the funding for this Contract and all other contracts or,
terminate this Contract and all other contracts. The liability of the State,at any such time,for such
payments shall be limited to the unexpended amount remaining of such funds.
4. To receive compensation under this Task Order Contract,for the period of October 1,2007
through June 30,2008,the Contractor shall submit a signed monthly Invoice/Cost Reimbursement
Statement in a format acceptable to the State. Reimbursement will be based upon one initial
payment of$320.00 for the month in which the State approves the Care Coordinator Plan with an
additional$80.00 to be paid each month of the initial term of this Task Order during which a
client receives care coordination services. The total cumulative reimbursements may not exceed
the total financial obligation of the State. Expenditures shall be in accordance with the Statement
of Work attached hereto as Exhibit B and incorporated herein. .
Page 1 of 4
EXHIBIT A
The monthly payment schedule for the contract term is as follows:
October 2007 only:
Continuing clients receiving services in October 2007: $140.00
Clients with new care plans approved in October 2007: $320.00
November 2007 through June 2008:
First month of services(month in which initial care plan is approved by HCP): $320.00
Continuing clients for months 2 through 12 of their enrollment period: $80.00
5. The contractor shall participate in activities in conjunction with the State to ensure that the
program planning,evaluation and monitoring requirements as described in this Task Order and
Exhibits and Attachments are met. Activities include,but are not limited to,participation in site
visits and meetings as requested by the State at the Contractor's location.
6. The Contractor agrees to perform its duties and obligations hereunder in conformity with relevant
federal law,pertinent federal regulations promulgated pursuant to federal law,relevant State law,
and all pertinent regulations of the Colorado Department of Human Services and Colorado
Department of Public Health and Environment,as they currently exist or may hereafter be
amended. The Contractor and its agents shall strictly adhere to all applicable federal,state laws,
Executive Orders,and implementing regulations as they currently exist and may hereafter be
amended. Without limitation,these federal laws and regulations include:
a. Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et.seq.and its
implementing regulation,45 C.F.R.Part 91;
b. Age Discrimination in Employment Act of 1967,29 U.S.C.621 et seq.;
c. Americans with Disabilities Act of 1990(ADA),42 U.S.C. 12101 et seq.;
d. Drug Free Workplace Act of 1988,41 U.S.C.701 et.seq.•
e. Equal Pay Act of 1963,29 U.S.C.206;
f. Immigration Reform and Control Act of 1986,8 U.S.C. 13246;
g. Pro-Children Act of 1994,20 U.S.C.6081 et.seq.
h. Section 504 of the Rehabilitation Act of 1973,29 U.S.C. 794,as amended,and
implementing regulation 45 C.F.R.Part 84;
i. 9)Title VI&VII of the Civil Rights Act of 1964,42 U.S.C.2000d;and Title
VII of the Civil Rights Act of 1964,42 U.S.C.2000(d)&(e);
j. 10)The Personal Responsibility and Work Opportunity Reconciliation Act of
1996,42 USC 604a,PL 104-193. See also State Executive Order D 015 00;
k. 11)Title IX of the Education Amendments of 1972,20 U.S.C. 1681 et seq.:
I. 12)The"Uniform Administrative Requirements for Grants and Cooperative
Agreements to State and Local Governments(Common rule),at 45 CFR,Part
92;
m. 13)Office of Management and Budget Circulars A-87,A-21,or A-122,and A-
102 or A-110,whichever is applicable;
Page 2 of 4
EXHIBIT A
n. 14)The Hatch Act(5 USC 1501-1508)and Civil Service Reform Act,Public
Law 95-454 Section 4728);
o. 15)Departments of Labor,Health,and Human Services,and Education and
Related Agencies Appropriations Act, 1990,PL 101-166,Section 511;and,
p. 16)45 CFR Subtitle A,Department of Health and Human Services regulations.
q. 17)The Single Audit Action Amendments of 1996,31 USC 7501,Public Law
104-156,OMB Circular A-133,and 45 CFR 74.26.
7. The Contractor agrees to implement a non-discrimination policy that ensures that it does not
discriminate on the basis of handicap in admission,or access to,treatment or employment in its
programs,services,benefits,or activities in accordance with the provisions of Section 504 of the
Rehabilitation Act of 1973,(PL 93-112)as applicable.
The Contractor also shall comply with any and all laws and regulations prohibiting discrimination
in the specific program(s)which is/are the subject of this contract. In consideration of and for the
purposes of obtaining any and all federal and/or state financial assistance,the Contractor makes
the following assurances,upon which Denver Options relies:
a. The Contractor will not discriminate against any person on the basis of race,color,
national origin,age,sex,religion and handicap,including Acquired Immune
Deficiency Syndrome(AIDS)or AIDS related conditions,in the performance of
work under this contract.
b. At all times during the performance of this contract,no qualified individual with a
disability shall,by reason of such disability,be excluded from participation in,or
denied benefits of the service,programs,or activities performed by the Contractor or
be subjected to any discrimination by the Contractor.
c. Any person who feels that s/he has been discriminated against relating to the services
provided under this contract has the right to assert a claim with the Colorado
Department of Human Services,the Colorado Civil Rights Commission,and/or the
U.S.Commission on Civil Rights.
8. The Contractor shall protect the confidentiality of all applicant or recipient records and other
materials that are maintained in accordance with this Task Order. Except for purposes directly
connected with the administration of this Task Order,no information about or obtained from,any
applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient
without the prior written consent of the applicant or recipient,or the parent or legal guardian of a
minor applicant or recipient with the exception of information protected by Colorado statute as it
applies to confidentiality for adolescent services in which case the adolescent minor and not the
parent or legal guardian must provide consent or,as otherwise properly ordered by a court of
competent jurisdiction. The Contractor shall have written policies governing the access to,and
duplication and dissemination of,all such information. The Contractor shall advise its employees,
agents,servants,and subcontractors, if any,that they are subject to these confidentiality
requirements.
9. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of
1964 are carried out. That Act states that"no person in the United States shall on the ground of
race,color,or national origin,be excluded from participation in,be denied the benefits of,or be
subjected to discrimination under any program or activity receiving Federal financial assistance."
The Office of Civil Rights has concluded that it is the responsibility of any program which is a
Page 3 of 4
EXHIBIT A
recipient of funds from the Department of Health and Human Services to ensure that clients who
do not speak or understand English well,be provided interpretation services to ensure that the
service provider and the client can communicate effectively. The Contractor shall have policies
and procedures to ensure that interpretation services are available for clients with Limited English
Proficiency and will advise such clients that an interpreter will be provided for them. If a client
has their own interpreter,they shall be advised that the Contractor will provide an interpreter if the
client so chooses.
10. The services or activities under this Task Order may be carried out by the Contractor itself,or
through subcontracts with other providers or,through collaborative partnerships with other
community partners. The State authorizes the Contractor to subcontract some,or all,of the
services that are to be performed under this Task Order. However,a subcontractor is subject to all
of the terms and conditions of this Task Order. Additionally,the Contractor remains ultimately
responsible for the timely and satisfactory completion of all work performed by any
subcontractor(s)under this Task Order. If the Contractor desires to subcontract some,or all,of the
services that are to be performed under this Task Order,the Contractor shall obtain the prior,
express,written consent of the State before entering into any subcontract.
11. Notwithstanding anything in this contract to the contrary,the parties understand and agree that all
terms and conditions of this contract which may require continued performance,compliance,or
effect beyond the termination date of the contract 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.
Page 4 of 4
Attachment A-1
HIPAA BUSINESS ASSOCIATE ADDENDUM
This Business Associate Addendum("Addendum") is a part of the Contract dated October 1,
2007 between the Department of Public Health and Environment and Weld County Department
of Public Health and Environment, contract number 08 FLA 00502. For purposes of this
Addendum, the State is referred to as"Covered Entity"or"CE"and the Contractor is referred to
as"Associate". Unless the context clearly requires a distinction between the Contract document
and this Addendum, all references herein to "the Contract"or"this Contract" include this
Addendum.
RECITALS
A. CE wishes to disclose certain information to Associate pursuant to the terms of the
Contract, some of which may constitute Protected Health Information("PHI") (defined
below).
B. CE and Associate intend to protect the privacy and provide for the security of PHI
disclosed to Associate pursuant to this Contract in compliance with the Health Insurance
Portability and Accountability Act of 1996,42 U.S.C. § 1320d— 1320d-8 ("HIPAA") and
its implementing regulations promulgated by the U.S. Department of Health and Human
Services, 45 C.F.R. Parts 160 and 164(the"Privacy Rule") and other applicable laws, as
amended.
C. As part of the HIPAA regulations, the Privacy Rule requires CE to enter into a contract
containing specific requirements with Associate prior to the disclosure of PHI, as set
forth in, but not limited to, Title 45, Sections 160.103, 164.502(e)and 164.504(e) of the
Code of Federal Regulations("C.F.R.") and contained in this Addendum.
The parties agree as follows:
1. Definitions.
a. Except as otherwise defined herein, capitalized terms in this Addendum shall have
the definitions set forth in the HIPAA Privacy Rule at 45 C.F.R. Parts 160 and 164,as amended.
In the event of any conflict between the mandatory provisions of the Privacy Rule and the
provisions of this Contract, the Privacy Rule shall control. Where the provisions of this Contract
differ from those mandated by the Privacy Rule, but are nonetheless permitted by the Privacy
Rule, the provisions of this Contract shall control.
b. "Protected Health Information"or"PHI"means any information, whether oral or
recorded in any form or medium: (i)that relates to the past,present or future physical or mental
condition of an individual; the provision of health care to an individual; or the past, present or
future payment for the provision of health care to an individual; and (ii) that identifies the
individual or with respect to which there is a reasonable basis to believe the information can be
Page 1 of 10
Colorado Model BA Provision and
Addendum For New or Amended Contracts
Rev. 10/03
used to identify the individual, and shall have the meaning given to such term under the Privacy
Rule, including,but not limited to, 45 C.F.R. Section 164.501.
c. "Protected Information" shall mean PHI provided by CE to Associate or created
or received by Associate on CE's behalf. To the extent Associate is a covered entity under
HIPAA and creates or obtains its own PHI for treatment,payment and health care operations,
Protected Information under this Contract does not include any PHI created or obtained by
Associate as a covered entity and Associate shall follow its own policies and procedures for
accounting, access and amendment of Associate's PHI.
2. Obligations of Associate.
a. Permitted Uses. Associate shall not use Protected Information except for the
purpose of performing Associate's obligations under this Contract and as permitted under this
Addendum. Further, Associate shall not use Protected Information in any manner that would
constitute a violation of the Privacy Rule if so used by CE, except that Associate may use
Protected Information: (i) for the proper management and administration of Associate; (ii)to
carry out the legal responsibilities of Associate; or(iii) for Data Aggregation purposes for the
Health Care Operations of CE. Additional provisions, if any, governing permitted uses of
Protected Information are set forth in Attachment 1 to this Addendum.
b. Permitted Disclosures. Associate shall not disclose Protected Information in any
manner that would constitute a violation of the Privacy Rule if disclosed by CE, except that
Associate may disclose Protected Information: (i) in a manner permitted pursuant to this
Contract; (ii) for the proper management and administration of Associate; (iii) as required by
law; (iv) for Data Aggregation purposes for the Health Care Operations of CE; or(v) to report
violations of law to appropriate federal or state authorities, consistent with 45 C.F.R. Section
164.502(j)(1). To the extent that Associate discloses Protected Information to a third party,
Associate must obtain,prior to making any such disclosure: (i) reasonable assurances from such
third party that such Protected Information will be held confidential as provided pursuant to this
Addendum and only disclosed as required by law or for the purposes for which it was disclosed
to such third party; and(ii) an agreement from such third party to notify Associate within two
business days of any breaches of confidentiality of the Protected Information, to the extent it has
obtained knowledge of such breach. Additional provisions, if any, governing permitted
disclosures of Protected Information are set forth in Attachment 1.
c. Appropriate Safeguards. Associate shall implement appropriate safeguards as are
necessary to prevent the use or disclosure of Protected Information other than as permitted by
this Contract. Associate shall maintain a comprehensive written information privacy and
security program that includes administrative, technical and physical safeguards appropriate to
the size and complexity of the Associate's operations and the nature and scope of its activities.
Page 2 of 10
Colorado Model BA Provision and
Addendum For New or Amended Contracts
Rev. 10/03
d. Reporting of Improper Use or Disclosure. Associate shall report to CE in writing
any use or disclosure of Protected Information other than as provided for by this Contract within
five(5) business days of becoming aware of such use or disclosure.
e. Associate's Agents. If Associate uses one or more subcontractors or agents to
provide services under the Contract, and such subcontractors or agents receive or have access to
Protected Information, each subcontractor or agent shall sign an agreement with Associate
containing substantially the same provisions as this Addendum and further identifying CE as a
third party beneficiary with rights of enforcement and indemnification from such subcontractors
or agents in the event of any violation of such subcontractor or agent agreement. Associate shall
implement and maintain sanctions against agents and subcontractors that violate such restrictions
and conditions and shall mitigate the effects of any such violation.
f. Access to Protected Information. Associate shall make Protected Information
maintained by Associate or its agents or subcontractors in Designated Record Sets available to
CE for inspection and copying within ten(10)business days of a request by CE to enable CE to
fulfill its obligations to permit individual access to PHI under the Privacy Rule, including, but
not limited to, 45 C.F.R. Section 164.524.
g. Amendment of PHI. Within ten business(10)days of receipt of a request from
CE for an amendment of Protected Information or a record about an individual contained in a
Designated Record Set, Associate or its agents or subcontractors shall make such Protected
Information available to CE for amendment and incorporate any such amendment to enable CE
to fulfill its obligations with respect to requests by individuals to amend their PHI under the
Privacy Rule, including,but not limited to, 45 C.F.R. Section 164.526. If any individual requests
an amendment of Protected Information directly from Associate or its agents or subcontractors,
Associate must notify CE in writing within five (5)business days of receipt of the request. Any
denial of amendment of Protected Information maintained by Associate or its agents or
subcontractors shall be the responsibility of CE.
h. Accounting Rights. Within ten(10)business days of notice by CE of a request
for an accounting of disclosures of Protected Information, Associate and its agents or
subcontractors shall make available to CE the information required to provide an accounting of
disclosures to enable CE to fulfill its obligations under the Privacy Rule, including,but not
limited to, 45 C.F.R. Section 164.528. As set forth in, and as limited by,45 C.F.R. Section
164.528, Associate shall not provide an accounting to CE of disclosures: (i) to carry out
treatment, payment or health care operations, as set forth in 45 C.F.R. Section 164.506; (ii) to
individuals of Protected Information about them as set forth in 45 C.F.R. Section 164.502; (iii)
pursuant to an authorization as provided in 45 C.F.R. Section 164.508; (iv) to persons involved
in the individual's care or other notification purposes as set forth in 45 C.F.R. Section 164.510;
(v) for national security or intelligence purposes as set forth in 45 C.F.R. Section 164.512(k)(2);
(vi) to correctional institutions or law enforcement officials as set forth in 45 C.F.R. Section
164.512(k)(5); (vii) incident to a use or disclosure otherwise permitted by the Privacy Rule; (viii)
as part of a limited data set under 45 C.F.R. Section 164.514(e); or(ix) disclosures prior to April
14, 2003. Associate agrees to implement a process that allows for an accounting to be collected
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and maintained by Associate and its agents or subcontractors for at least six (6)years prior to the
request,but not before the compliance date of the Privacy Rule. At a minimum, such
information shall include: (i) the date of disclosure; (ii) the name of the entity or person who
received Protected Information and, if known, the address of the entity or person; (iii) a brief
description of Protected Information disclosed; and(iv) a brief statement of purpose of the
disclosure that reasonably informs the individual of the basis for the disclosure,or a copy of the
individual's authorization, or a copy of the written request for disclosure. In the event that the
request for an accounting is delivered directly to Associate or its agents or subcontractors,
Associate shall within five(5)business days of the receipt of the request forward it to CE in
writing. It shall be CE's responsibility to prepare and deliver any such accounting requested.
Associate shall not disclose any Protected Information except as set forth in Section 2(b)of this
Addendum.
i. Governmental Access to Records. Associate shall make its internal practices,
books and records relating to the use and disclosure of Protected Information available to the
Secretary of the U.S. Department of Health and Human Services(the"Secretary"), in a time and
manner designated by the Secretary, for purposes of determining CE's compliance with the
Privacy Rule. Associate shall provide to CE a copy of any Protected Information that Associate
provides to the Secretary concurrently with providing such Protected Information to the
Secretary.
j. Minimum Necessary. Associate(and its agents or subcontractors) shall only
request, use and disclose the minimum amount of Protected Information necessary to accomplish
the purpose of the request,use or disclosure, in accordance with the Minimum Necessary
requirements of the Privacy Rule including, but not limited to 45 C.F.R. Sections 164.502(b) and
164.514(d).
k. Data Ownership. Associate acknowledges that Associate has no ownership rights
with respect to the Protected Information.
1. Retention of Protected Information. Except upon termination of the Contract as
provided in Section 4(d) of this Addendum, Associate and its subcontractors or agents shall
retain all Protected Information throughout the term of this Contract and shall continue to
maintain the information required under Section 2(h)of this Addendum for a period of six (6)
years.
m. Associate's Insurance. Associate shall maintain casualty and liability insurance
to cover loss of PHI data and claims based upon alleged violations of privacy rights through
improper use or disclosure of PHI. All such policies shall meet or exceed the minimum
insurance requirements of the Contract(e.g., occurrence basis, combined single dollar limits,
annual aggregate dollar limits,additional insured status and notice of cancellation).
n. Notification of Breach. During the term of this Contract, Associate shall notify
CE within two business days of any suspected or actual breach of security, intrusion or
unauthorized use or disclosure of PHI and/or any actual or suspected use or disclosure of data in
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violation of any applicable federal or state laws or regulations. Associate shall take(i)prompt
corrective action to cure any such deficiencies and(ii) any action pertaining to such unauthorized
disclosure required by applicable federal and state laws and regulations.
o. Audits,Inspection and Enforcement. Within ten(10)business days of a written
request by CE, Associate and its agents or subcontractors shall allow CE to conduct a reasonable
inspection of the facilities, systems,books, records, agreements,policies and procedures relating
to the use or disclosure of Protected Information pursuant to this Addendum for the purpose of
determining whether Associate has complied with this Addendum; provided, however,that: (i)
Associate and CE shall mutually agree in advance upon the scope, timing and location of such an
inspection; (ii) CE shall protect the confidentiality of all confidential and proprietary information
of Associate to which CE has access during the course of such inspection; and(iii) CE shall
execute a nondisclosure agreement,upon terms mutually agreed upon by the parties, if requested
by Associate. The fact that CE inspects, or fails to inspect, or has the right to inspect,
Associate's facilities, systems,books, records, agreements,policies and procedures does not
relieve Associate of its responsibility to comply with this Addendum,nor does CE's (i) failure to
detect or(ii) detection, but failure to notify Associate or require Associate's remediation of any
unsatisfactory practices, constitute acceptance of such practice or a waiver of CE's enforcement
rights under the Contract.
p. Safeguards During Transmission. Associate shall be responsible for using
appropriate safeguards to maintain and ensure the confidentiality,privacy and security of
Protected Information transmitted to CE pursuant to the Contract, in accordance with the
standards and requirements of the Privacy Rule,until such Protected Information is received by
CE, and in accordance with any specifications set forth in Attachment 1.
q. Restrictions and Confidential Communications. Within ten (10) business days of
notice by CE of a restriction upon uses or disclosures or request for confidential communications
pursuant to 45 C.F.R. 164.522, Associate will restrict the use or disclosure of an individual's
Protected Information, provided Associate has agreed to such a restriction. Associate will not
respond directly to an individual's requests to restrict the use or disclosure of Protected
Information or to send all communication of Protect Information to an alternate address.
Associate will refer such requests to the CE so that the CE can coordinate and prepare a timely
response to the requesting individual and provide direction to Associate.
3. Obligations of CE.
a. Safeguards During Transmission. CE shall be responsible for using appropriate
safeguards to maintain and ensure the confidentiality,privacy and security of PHI transmitted to
Associate pursuant to this Contract, in accordance with the standards and requirements of the
Privacy Rule,until such PHI is received by Associate, and in accordance with any specifications
set forth in Attachment 1.
b. Notice of Changes. CE shall provide Associate with a copy of its notice of
privacy practices produced in accordance with 45 C.F.R. Section 164.520, as well as any
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subsequent changes or limitation(s)to such notice, to the extent such changes or limitations may
effect Associate's use or disclosure of Protected Information. CE shall provide Associate with
any changes in, or revocation of,permission to use or disclose Protected Information, to the
extent it may affect Associate's permitted or required uses or disclosures. To the extent that it
may affect Associate's permitted use or disclosure of PHI, CE shall notify Associate of any
restriction on the use or disclosure of Protected Information that CE has agreed to in accordance
with 45 C.F.R. Section 164.522. CE may effectuate any and all such notices of non-private
information via posting on CE's web site. Associate shall review CE's designated web site for
notice of changes to CE's HIPAA privacy policies and practices on the last day of each calendar
quarter.
4. Termination.
a. Material Breach. In addition to any other provisions in the Contract regarding
breach, a breach by Associate of any provision of this Addendum, as determined by CE, shall
constitute a material breach of this Contract and shall provide grounds for immediate termination
of this Contract by CE pursuant to the provisions of the Contract covering termination for cause,
if any. If the Contract contains no express provisions regarding termination for cause, the
following terms and conditions shall apply:
(1) Default. If Associate refuses or fails to timely perform any of the
provisions of this Contract, CE may notify Associate in writing of the non-performance, and if
not promptly corrected within the time specified, CE may terminate this Contract. Associate
shall continue performance of this Contract to the extent it is not terminated and shall be liable
for excess costs incurred in procuring similar goods or services elsewhere.
(2) Associate's Duties. Notwithstanding termination of this Contract,and
subject to any directions from CE, Associate shall take timely,reasonable and necessary action
to protect and preserve property in the possession of Associate in which CE has an interest.
(3) Compensation. Payment for completed supplies delivered and accepted
by CE shall be at the Contract price. In the event of a material breach under paragraph 4a, CE
may withhold amounts due Associate as CE deems necessary to protect CE against loss from
third party claims of improper use or disclosure and to reimburse CE for the excess costs
incurred in procuring similar goods and services elsewhere.
(4) Erroneous Termination for Default. If after such termination it is
determined, for any reason, that Associate was not in default, or that Associate's action/inaction
was excusable, such termination shall be treated as a termination for convenience, and the rights
and obligations of the parties shall be the same as if this Contract had been terminated for
convenience, as described in this Contract.
b. Reasonable Steps to Cure Breach. If CE knows of a pattern of activity or practice
of Associate that constitutes a material breach or violation of the Associate's obligations under
the provisions of this Addendum or another arrangement and does not terminate this Contract
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pursuant to Section 4(a), then CE shall take reasonable steps to cure such breach or end such
violation, as applicable. If CE's efforts to cure such breach or end such violation are
unsuccessful, CE shall either(i) terminate the Contract, if feasible or(ii) if termination of this
Contract is not feasible, CE shall report Associate's breach or violation to the Secretary of the
Department of Health and Human Services.
c. Judicial or Administrative Proceedings. Either party may terminate the
Contract, effective immediately, if(i) the other party is named as a defendant in a criminal
proceeding for a violation of HIPAA, the HIPAA Regulations or other security or privacy laws
or(ii) a finding or stipulation that the other party has violated any standard or requirement of
HIPAA, the HIPAA Regulations or other security or privacy laws is made in any administrative
or civil proceeding in which the party has been joined.
d. Effect of Termination.
(1) Except as provided in paragraph(2)of this subsection, upon termination
of this Contract, for any reason, Associate shall return or destroy all Protected Information that
Associate or its agents or subcontractors still maintain in any form, and shall retain no copies of
such Protected Information. If Associate elects to destroy the PHI, Associate shall certify in
writing to CE that such PHI has been destroyed.
(2) If Associate believes that returning or destroying the Protected
Information is not feasible,Associate shall promptly provide CE notice of the conditions making
return or destruction infeasible. Upon mutual agreement of CE and Associate that return or
destruction of Protected Information is infeasible, Associate shall continue to extend the
protections of Sections 2(a), 2(b), 2(c), 2(d) and 2(e)of this Addendum to such information, and
shall limit further use of such PHI to those purposes that make the return or destruction of such
PHI infeasible.
5. Injunctive Relief. CE shall have the right to injunctive and other equitable and legal
relief against Associate or any of its subcontractors or agents in the event of any use or
disclosure of Protected Information in violation of this Contract or applicable law.
Associate acknowledges and agrees that in the event of such impermissible use or
disclosure of CE:
a. Will suffer real, immediate, and irreparable injury which will be prevented by
injunctive relief;
b. That CE has no plain, speedy, and adequate remedy at law;
c. That the granting of a preliminary injunction will promote the public interest in
privacy rather than disserve the public interest;
d. That the balance of equities always favors the injunction in such cases;
e. That the injunction will preserve the status quo pending a trial on the merits; and
f. That CE shall not be required to demonstrate a reasonable probability of success on
the merits in order to obtain injunctive relief.
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6. No Waiver of Immunity. No term or condition of this Contract shall be construed or
interpreted as a waiver, express or implied, of any of the immunities, rights,benefits, protection,
or other provisions of the Colorado Governmental Immunity Act, CRS 24-10-101 et seq. or the
Federal Tort Claims Act, 28 U.S.C. 2671 et seq. as applicable, as now in effect or hereafter
amended.
7. Limitation of Liability. Any limitation of Associate's liability in the Contract shall be
inapplicable to the terms and conditions of this Addendum.
8. Disclaimer. CE makes no warranty or representation that compliance by Associate with
this Contract, HIPAA or the HIPAA Regulations will be adequate or satisfactory for Associate's
own purposes. Associate is solely responsible for all decisions made by Associate regarding the
safeguarding of PHI.
9. Certification. To the extent that CE determines an examination is necessary in order to
comply with CE's legal obligations pursuant to HIPAA relating to certification of its security
practices, CE or its authorized agents or contractors, may, at CE's expense, examine Associate's
facilities, systems, procedures and records as may be necessary for such agents or contractors to
certify to CE the extent to which Associate's security safeguards comply with HIPAA, the
HIPAA Regulations or this Addendum.
10. Amendment.
a. Amendment to Comply with Law. The parties acknowledge that state and federal
laws relating to data security and privacy are rapidly evolving and that amendment of this
Addendum may be required to provide for procedures to ensure compliance with such
developments. The parties specifically agree to take such action as is necessary to implement the
standards and requirements of HIPAA, the Privacy Rule, the Final HIPAA Security regulations
at 68 Fed. Reg. 8334 (Feb20, 2003),45 C.F.R. § 164.314 and other applicable laws relating to
the security or privacy of PHI. The parties understand and agree that CE must receive
satisfactory written assurance from Associate that Associate will adequately safeguard all
Protected Information. Upon the request of either party, the other party agrees to promptly enter
into negotiations concerning the terms of an amendment to this Addendum embodying written
assurances consistent with the standards and requirements of HIPAA, the Privacy Rule or other
applicable laws. CE may terminate this Contract upon thirty(30)days written notice in the event
(i) Associate does not promptly enter into negotiations to amend this Contract when requested by
CE pursuant to this Section or(ii) Associate does not enter into an amendment to this Contract
providing assurances regarding the safeguarding of PHI that CE, in its sole discretion, deems
sufficient to satisfy the standards and requirements of HIPAA and the Privacy Rule.
b. Amendment of Attachment 1. Attachment 1 may be modified or amended by
mutual agreement of the parties in writing from time to time without formal amendment of this
Addendum.
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11. Assistance in Litigation or Administrative Proceedings. Associate shall make itself, and
any subcontractors, employees or agents assisting Associate in the performance of its obligations
under the Contract, available to CE, at no cost to CE up to a maximum of 30 hours, to testify as
witnesses, or otherwise, in the event of litigation or administrative proceedings being
commenced against CE, its directors,officers or employees based upon a claimed violation of
HIPAA, the Privacy Rule or other laws relating to security and privacy or PHI, except where
Associate or its subcontractor, employee or agent is a named adverse party.
12. No Third Party Beneficiaries. Nothing express or implied in this Contract is intended to
confer, nor shall anything herein confer,upon any person other than CE, Associate and their
respective successors or assigns,any rights, remedies, obligations or liabilities whatsoever.
13. Interpretation and Order of Precedence. The provisions of this Addendum shall prevail
over any provisions in the Contract that may conflict or appear inconsistent with any provision in
this Addendum. Together, the Contract and this Addendum shall be interpreted as broadly as
necessary to implement and comply with HIPAA and the Privacy Rule. The parties agree that
any ambiguity in this Contract shall be resolved in favor of a meaning that complies and is
consistent with HIPAA and the Privacy Rule. This Contract supercedes and replaces any
previous separately executed HIPAA addendum between the parties.
14. Survival of Certain Contract Terms. Notwithstanding anything herein to the contrary,
Associate's obligations under Section 4(d) ("Effect of Termination") and Section 12 ("No Third
Party Beneficiaries") shall survive termination of this Contract and shall be enforceable by CE as
provided herein in the event of such failure to perform or comply by the Associate. This
Addendum shall remain in effect during the term of the Contract including any extensions.
15. Representatives and Notice.
a. Representatives. For the purpose of the Contract,the individuals identified
elsewhere in this Contract shall be the representatives of the respective parties. If no
representatives are identified in the Contract, the individuals listed below are hereby designated
as the parties' respective representatives for purposes of this Contract. Either party may from
time to time designate in writing new or substitute representatives.
b. Notices. All required notices shall be in writing and shall be hand delivered or
given by certified or registered mail to the representatives at the addresses set forth below.
State/Covered Entity Representative:
Name: Kathy Watters
Title: Children with Special Health Care Needs Unit Director
Department and Division: CDPHE/PSD/HCP
Address: 4300 Cherry Creek Drive South
PSD HCP A4
Denver, Colorado 80246
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Contractor/Business Associate Representative:
Name: Judy Nero
Title: Admin Director
Department and Division: Weld County Department of Public Health and Environment
Address: 1555 North 17th Avenue
Greeley, Colorado 80631
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Attachment A-1
ATTACHMENT 1
This Attachment sets forth additional terms to the HIPAA Business Associate
Addendum, which is part of the Contract dated 08/01/2007 between Colorado Department of
Public and Environment and Weld County Department of Public Health and Environment,
contract number 08 FLA 00502 ("Contract") and is effective as of 10/01/2007 (the"Attachment
Effective Date"). This Attachment may be amended from time to time as provided in Section
10(b)of the Addendum.
1. Additional Permitted Uses. In addition to those purposes set forth in Section 2(a) of the
Addendum, Associate may use Protected Information as follows:
None, except as otherwise directed in writing by CE or by Denver Options.
2. Additional Permitted Disclosures. In addition to those purposes set forth in Section 2(b)
of the Addendum, Associate may disclose Protected Information as follows:
a. The Associate may disclose aggregate reports that conform to HIPAA de-
identification definitions contained in HIPAA & 164.514 (b) (1)or(2).
b. Upon receipt of signed authorizations,the HCP Program may disclosepatient
information to the Traumatic Train Injury Surveillance project for analysis for public health
purposes
3. Subcontractor(s). The parties acknowledge that the following subcontractors or agents of
Associate shall receive Protected Information in the course of assisting Associate in the
performance of its obligations under this Contract:
HCP local offices. including organized health departments, county nursing
services and Imagine!
4. Receipt. Associate's receipt of Protected Information pursuant to this Contract shall be
deemed to occur as follows, and Associate's obligations under the Addendum shall commence
with respect to such PHI upon such receipt:
Delivery of copies of eligibility applications, including ICD-9 diagnoses and any
other information that can be used in the treatment of the traumatic brain iniured child.
This information may be in paper of electronic format.
5. Additional Restrictions on Use of Data. CE is a Business Associate of certain other
Covered Entities and,pursuant to such obligations of CE,Associate shall comply with the
following restrictions on the use and disclosure of Protected Information:
As may be directed in writing by the State or Denver Options.
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6. Additional Terms. [This section may include specifications for disclosure format,
method of transmission, use of an intermediary, use of digital signatures or PKI, authentication,
additional security of privacy specifications, de-identification or re-identification of data and
other additional terms.]
None
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Exhibit B
STATEMENT OF WORK
Board of County Commissioners of Weld County
To Task Order Contract Dated 08/01/2007-Contract Routing Number 08 FLA 00502
1. Under this Task Order,a local public health agency,such as the Contractor,shall provide care coordination
for families who have children with Traumatic Brain Injury(TBI)and are enrolled with the TBI Trust Fund
Program. Care coordination services are defined and described in the Health Care Program for Children
with Special Needs(HCP)Policies and Procedures Manual available on the HCP website:
www.hcpcolorado.org The Manual are periodically updated and the contractor will be notified by email
when updates/revisions are made. The contractor is responsible for complying with any updates/revisions.
The HCP Policies and Procedures Manual are incorporated and made part hereof by reference.
2. The Contractor Care Coordinator shall use the"HCP Policy and Procedures for Care Coordination Services
for Children and Youth with Traumatic Brain Injury"in the HCP Policies and Procedure Manual,which is
available on the HCP website: www.hcpcolorado.org This manual is to be used for the implementation
and documentation of TBI Trust Fund Program services.
3. The Contractor shall provide technical assistance and consultation to the Care Coordinators in Weld
County.
4. The Contractor shall make care coordination plans available to the state or other duly authorized agent or
governmental agency for audits and/or inspection at any reasonable time during the term of this contract
and for a period of three(3)years following the termination of this contract to assure compliance with its
terms,and/or to evaluate the Contractor's performance.
5. The Contractor shall perform and complete,in a timely and satisfactory manner,all activities and services
related to this Task Order in accordance with the HCP Policies and Procedures Manual.
6. The Contractor shall work collaboratively with the State for consultation,technical assistance,oversight
and training on documentation in the Health Care Program for Children with Special Needs/Clinical Health
Information Record of Patients(HCP/CHIRP)database and to ensure that all HCP/CHIRP database users
follow the HCP/CHIRP database policies and procedures as outlined in the HCP Policy and Procedure
Manual and CHIRP User Guide which are made available on the HCP web site:www.hcocolorado.org
7. The Contractor shall follow the HCP/CHIRP Security policy and procedures outlined in the CHIRP User
Guide,HCP Policies and Procedure Manual,and Data Security Use and Confidentiality Agreement signed
by each user.
8. The Contractor shall follow the policies and procedures in the HCP Policies and Procedures Manual which
is available on the HCP web site: www.hcpcolorado.org
9. The Contractor shall attend regional teleconferences,meetings,and/or videoconference meetings,as
appropriate,that the state may organize to address priority TBI needs,promote learning groups,and
increase skills as Care Coordinators
10. The Contractor shall provide all requested records regarding recipients for whom services were provided
under this Task Order.
11. The Contractor shall participate in activities in conjunction with the State to ensure that the program
planning,evaluation and monitoring requirements as described in this Task Order and Exhibits are met.
Activities include,but are not limited to,participation in site visits and meetings as requested by the State
at the Contractor's location.
Page 1 of 1
EXHIBIT C
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
(ADD PROGRAM NAME HERE)
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
ELIMINATE ALL INFORMATION APPEARING IN RED
LIMITED AMENDMENT FOR TASK ORDERS#*
This Limited Amendment is made this**** day of*********,200*,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, LEGAL NAME
OF ENTITY, (legal type of entity), whose address or principal place of business is Street
Address,City, State& Zip Code,hereinafter referred to as the"Contractor".
FACTUAL RECITALS
The parties entered into a Master Contract, dated******** **, ****, with contract routing
number** *** *****"the Master Contract").
Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order
Contract,dated ******** ** ****, with contract encumbrance number PO *** **********
and contract routing number** *** *****. 'insert the following if previous amendment(s),
change order(s), renewal(s) have been processed: as amended by] ]include all previous
amendment(s), change order(s), renewal(s) and their routing numbers], (insert the
following if previous amendment(s), change order(s), renew al(s) have been processed:
collectively] referred to herein as the"Original Task Order Contract, whereby the Contractor was
to provide to the State the following:
]Briefly describe what the Contractor was to do under the Original Task Order
Contract— indent this paragraph!
[Please choose one of the following four options and delete the other three options not
selected
The State promises to ]choose one and delete the other] increase/decrease the amount of funds
to be paid to the Contractor by **********Dollars, ($*.**) during the current term of the
Original Task Order Contract in exchange for the promise of the Contractor to perform the
(choose one and delete the other] increased/decreased work under the Original Task Order
Contract.
Page 1 of 5
The State promises to pay the Contractor the sum of********** Dollars, ($*.**) in exchange
for the promise of the Contractor to continue to perform the work identified in the Original Task
Order Contract for the renewal term of**** years/months, ending on******** **, ****.
The State promises to [choose one and delete the other) increase/decrease the amount of funds
to be paid to the Contractor by **********Dollars, ($*.**) for the renewal term of****
[choose one and delete the other' years/months, ending on******** **, ****, in exchange
for the promise of the Contractor to perform the [choose one and delete the other]
increased/decreased work described herein.
The State hereby exercises a"no cost"change to the (choose those that apply and delete those
that don't apply[ budget, specifications within the Statement of Work,project
management/manager identification, notice address or notification personnel,or
performance period within the ]choose one and delete the other[ current term of the
Original Task Order Contract or renewal term of the Original Task Order Contract.
NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the
parties hereto agree as follows:
1. Consideration for this Limited Amendment to the Original Task Order Contract consists
of the payments and services that shall be made pursuant to this Limited Amendment,
and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to
the Original Task Order Contract,contract routing number** *** *****, [insert the
following language here if previous amendment(s), change order(s), renewal(s) have
been processed[ as amended by [include all previous amendment(s), change
order(s), renewal(s) and their routing numbers], [insert the following word if
previous amendment(s), change order(s), renewal(s) have been processed,otherwise
delete"collectively"'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 Limited 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:
[Please choose one of the following three options and delete the two options not
selected[
A. (Use this paragraph when changes to the funding level of the Original Task
Order Contract occur during the current term of the Original Task Order
Contract) This Limited Amendment is issued pursuant to paragraph 5 of the
Original Task Order Contract identified by contract routing number** ***
*****. This Limited Amendment is for the current term of********* **
Page 2 of 5
EXHIBIT C
****, through and including ********* ** ****. The maximum amount
payable by the State for the work to be performed by the Contractor during this
current term is (choose one and delete the other' increased/decreased by
********** Dollars, ($*.**) for an amended total financial obligation of the
State of********** DOLLARS, ($*.**). 'Delete the following sentence if not
applicable in your situation' The revised Statement of Work is incorporated
herein by this reference and identified as"Attachment*". 'Delete the following
sentence if not applicable in your situation' The revised Budget is incorporated
herein by this reference and identified as"Attachment*". The Original Task
Order Contract is modified accordingly. All other terms and conditions of the
Original Task Order Contract are reaffirmed.
A. 'Use this paragraph when the Original Task Order Contract will he renewed
for another term' This Limited Amendment is issued pursuant to paragraph 5 of
the Original Task Order Contract identified by contract routing number** ***
*****. This Limited Amendment is for the renewal term of********* **
****, through and including ********* ** ****. The maximum amount
payable by the State for the work to be performed by the Contractor during this
renewal term is********** Dollars, ($*.**) for an amended total financial
obligation of the State of**********DOLLARS. ($*.**). 'Delete the
following sentence if not applicable in your situation' The revised Statement of
Work is incorporated herein by this reference and identified as"Attachment *".
'Delete the following sentence if not applicable in your situation' The revised
Budget is incorporated herein by this reference and identified as"Attachment *".
The Original Task Order Contract is modified accordingly. All other terms and
conditions of the Original Task Order Contract are reaffirmed.
A. Rise this paragraph when there are"no cost changes"to the Budget, the
specifications within the original Statement of Work, allowable contract
provisions as noted,or performance period.' This Limited Amendment is
issued pursuant to paragraph 5 of the Original Task Order Contract identified by
contract routing number** *** *****. This Limited Amendment 'choose those
that apply and delete those that don't' modifies the Budget in 'identify
location in contract', modifies the Statement of Work in 'identify location in
contract', modifies the project management/manager identification in
'identify location in contract',modifies the notice address or notification
personnel in 'identify location in contract',modifies the period of
performance in 'identify location in contract' of the Original Task Order
Contract. The revised 'choose those that apply and delete those that don't'
Budget, Statement of Work,project management/manager identification,
notice address or notification personnel,or period of performance is
incorporated by this reference and identified as. All other terms and conditions of
the Original Task Order Contract are reaffirmed.
4. The effective date of this Limited Amendment is **/**/****,or upon approval of the
State Controller,or an authorized delegate thereof, whichever is later.
Page 3 of 5
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 Limited Amendment and any of the terms and provisions of the Original Task Order
Contract, the terms and provisions of this Limited 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 4 of 5
EXHIBIT C
IN WITNESS WHEREOF, the parties hereto have executed this Limited Amendment on the
day first above written.
CONTRACTOR: STATE:
[LEGAL NAME OF CONTRACTOR] O
(a political subdivision of the State of Colorado o ernor
By:
Name: D For the Executive Director
Title: DEPA OF PUBLIC
ENVIRONMENT
OM APPROVAL:
Because the Con ov
entity, an attestat D e By:
(Seal,required)
By:
City,City and County, County,
Special District,or Town Clerk or Equivalent
Delete inapplicable language.]
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 24-30-202 requires that the State Controller approve all state contracts. This limited
amendment is not valid until the State Controller,or such assistant as he may delegate, has
signed it. The contractor is not authorized to begin performance until the contract is
signed and dated below. If performance begins prior to the date below,the State of
Colorado may not be obligated to pay for goods and/or services provided.
STATE CONTROLLER
Leslie M. Shenefelt
By:
Date:
Page 5 of 5
STATE OF COLORADO
Bill Ritter,Jr.,Governor
James B.Martin,Executive Director coca
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory Services Division t*
Denver,Colorado 80246-1530 8100 Lowry Blvd. � ` �
Phone(303)692-2000 Denver,Colorado 80230-6928 a76
TDD Line(303)691-7700 (303)692-3090
Located in Glendale,Colorado Colorado Department
of Public Health
http://www.cdphe.state.co.us and Environment
Prevention Services Division
Center for Healthy Families and Communities
Children with Special Health Care Needs Unit
Telephone:(303)692-2370;FAX:(303)753-9249
November 2,2007
Ms.Judy Nero
Weld County Department of Public Health and Environment
1555 North 17th Avenue
Greeley,Colorado 80631
Re: Health Care Program for Children with Special Needs
TBI Task Order Contract Routing#00502
Dear Ms.Nero:
Enclosed please find a fully executed copy of the above referenced TBI Task Order for your files. This Task Order covers
the period from October 22,2007 through and including September 30,2008.
If you have any question regarding this Task Order,please contact Charla Low,HCP Fiscal Officer or Kathy Watters,
CSHCN Unit Director.Charla can be reached at 303-692-2423 or charla.low(ndstate.co.us and Kathy can be reached at 303-
692-2418 or Kathy.waters(dstate.co.us.
Sincerely,
tda H.Diaz
HCP Contract Coordinator
303-692-2384
placida.diazgstate.co.us
Enclosure:Task Order
cc: file
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