The URL can be used to link to this page

Browse Search

Home My WebLink About20061583.tiff RESOLUTION RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE CHAIR TO SIGN - ROCKY MOUNTAIN OFFENDER MANAGEMENT SYSTEMS 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 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 Rocky Mountain Offender Management Systems, commencing June 1, 2006, and ending May 31, 2007, 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 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 Rocky Mountain Offender Management Systems 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 14th day of June, A.D., 2006, nunc pro tunc June 1, 2006. � �:OARD OF COUNTY COMMISSIONERS �� ► ��"4 �r LD OUN GLORADO ATTEST: "' / 4�■ / 1 . eile, Chair Weld County Clerk to the Bo*,,r 7 u 2≥ I N David . Long, Pro-Tem V BY: / De y Cler o the oard 'w W • m H. Jerke APPR S TO FO W. J)IVA -n Robert D. Ma den / ney AA,/ �l Glenn Vaad Date of signature: o, 101.o/etc 2006-1583 SS0033 eQ ;. SS 0?-/ /-o67 i;≥\ DEPARTMENT OFGREELEY, CO. 80632 Website:www.caweld.co.us VIIDe 4 Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 COLORADO MEMORANDUM TO: M.J. Geile, Chair Date: June 8, 2006 Board of County Commissioners FR: Judy A. Griego, Director, Social Services,fr RE: Child Protection Agreement for Services between the Weld County Department of Social Services and Rocky Mountain Offender Management Systems, A Colorado Limited Liability Company Enclosed for Board approval is a Child Protection Agreement for Services between the Weld County Department of Social Services (Department) and Rocky Mountain Offender Management Systems (Contractor) . This Agreement was reviewed at the Board's Work Session held on May 24,2006. The major provisions of the contract are as follows: 1. The term of the contract is June 1, 2006 through May 31, 2007. 2. The source of funding is Child Welfare Administration funding. 3. The Contractor will provide monitored sobriety for adults and youth involved in the child welfare system. 4. The Department will reimburse the Contractor according to their fee schedule and at a maximum reimbursement level of$30,000. If you have any questions,please telephone me at extension 6510. • 2006-1583 06-07-CORE-66 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES AND ROCKY MOUNTAIN OFENDER MANAGEMENT SYSTEMS,A COLORADO LIMITED LIABILITY COMPANY This Agreement,made and entered into the 1sT day of June 2006,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 Rocky Mountain Offender Management Systems, a Colorado Limited Liability Company,hereinafter referred to as"RMOM." 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 Child Welfare Regular Administration funding to Social Services for immediate referrals for monitored sobriety services for families, children, and adolescents; and WHEREAS, Social Services requires the services of a substance abuse testing and screening provider to assist the County to deliver services for referrals for monitored sobriety to child welfare clients,and RMOM is willing and able to provide such services;and WHEREAS, RMOM is a Colorado organization organized for the purpose of alcohol and drug test screening. NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June I, 2006, upon proper execution of this Agreement and shall expire May 31, 2007,unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by RMOM network providers 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,"and Exhibit C,"Fee Schedule,"copies of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement,which will be paid from Child Welfare Regular Administration funds during the duration of this Agreement. RMOM, in accordance with federal HIPAA regulations,has adopted the standard transaction code set for all treatment services on or before October 16,2003. Even though this compliance has changed the service labels and groupings, the net fees associated with those services have not changed. 1 06-07-CORE-66 b. RMOM 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. RMOM 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 Child Welfare Regular Administration 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. 4. Financial Management At all times from the effective date of this Contract until completion of this Contract, RMOM 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 Child Welfare Regular Administration 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. RMOM 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 RMOM has failed to comply with the Financial Management Requirements,program objectives, contractual terms, or reporting requirements. In the event of a forfeiture of reimbursements,RMOM may appeal such circumstance to the Director of Social Services. The decision of the Director of Social Services shall be final. 6. Assurances RMOM shall abide by all assurances as set forth in the attached Exhibit D,which is attached hereto and incorporated herein by reference. 7. Compliance with Applicable Laws At all times during the performance of this contract,RMOM 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. RMOM acknowledges that the following laws are included: Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d—I 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 2 06-07-CORE-66 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,RMOM and Social Services will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 CFR Part 2. 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 RMOM 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 RMOM and Social Services agree that monitoring and evaluation of the performance of this Agreement shall be conducted by RMOM and Social Services. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners and RMOM. RMOM shall permit Social Services,and any other duly authorized agent or governmental agency,to monitor all activities conducted by RMOM 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 RMOM 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 RMOM. These remedial actions are as follows: a. Withhold payment to RMOM until the necessary services or corrections in performance are satisfactorily completed; 3 06-07-CORE-66 b. Deny payment or recover reimbursement for those services or deliverables,which have not been performed and which due to circumstances caused by RMOM 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 RMOM due to omission,error,fraud,and/or defalcation shall be recovered from RMOM by deduction from subsequent payments under this Agreement or other agreements between Social Services and RMOM,or by Social Services as a debt due to Social Services or otherwise as provided by law. 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 RMOM: Daniel A. Beeck General Manager 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: RMOM Judy A.Griego,Director Daniel A.Beeck,General Manager P.O.Box A 8787 Tumpike Drive,#200 Greeley,CO 80632 Westminster,CO 80031 14. Litigation RMOM shall promptly notify Social Services in the event that RMOM learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. RMOM, 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 finding. RMOM reserves the right to suspend services to clients if funding is no longer available. 4 06-07 CORE 66 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. IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year first above written. ATTEST: ,. / /';' ' WELD COUNTY s+ ,, ^. a 4 OF COUNTY CLERK TO THE BOARD ri , O ISSIONERS WELD v* vs ? Y361 N. ,COLORA De tyCler�� ?FFyy M.J. de, hair JUN 1 4 2006 APPROVED AS TO FORM: ®�� CKY MOUNTAIN OFFENSE MANAGEMENT SYSTEMS BY SJA oun orney Daniel A. Beeck WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Ju A.Grie , Director 5 ate 6- /S,,3 06-07-CORE-66 EXHIBIT A SCOPE OF SERVICES Special Conditions: A. RMOM will conduct monitored sobriety for Social Services' clients at their offices at 800 8th Avenue, Suite 100,Greeley, CO 80631. B. RMOM will confirm any positive, negative or missed monitored sobriety results within 72 hours through a phone call,test result,email and/or a fax to the Social Services caseworker. C. RMOM will automatically perform a GCMS test on each positive UA test result. Said results will be forwarded to the caseworker. D. RMOM will submit a copy of the valid Core Services Referral and the client sign in sheet(if applicable)with each monthly billing to the Core Caseworker at Social Services. E. RMOM will provide the caseworkers with the test results within 7 days of the test date via facsimile at(970)353-5215. 6 06-07-CORE-66 EXHIBIT B PAYMENT SCHEDULE Funding and Method of Payment Social Services agrees to reimburse RMOM in consideration for the work and services performed,a total amount not to exceed Thirty Thousand Dollars($30,000.00)under Child Welfare Regular Administration funding. Expenses incurred by RMOM, 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 Child Welfare Regular Administration funds,whether in whole or in part, is subject to and contingent upon the continuing availability of Child Welfare Regular Administration 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—as shown on the attached Exhibit C"Fee Schedule." Social Services referrals will not be sent to collections by RMOM for default of co-pay/fees. Services will be performed regardless of client's refusal or inability to pay co-pay. 3. Submittal of Vouchers RMOM shall prepare and submit monthly the itemized voucher according to the criteria listed under "Standards of Responsibility"in Exhibit E, and 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 06-07-CORE-66 EXHIBIT C FEES FOR SERVICES Description of Services Charge Standard Laboratory Test- Tests for: ALC, AMP/METH, BENZ, COC, OPI,PCP, THC $12.00 Breathalyzer Screening (n/c w/UA) $1.00 GCMS Confirmation screening test was POS $12.50 RMOM- Court Testimony $75.00 per hour 8 06-07-CORE-66 EXHIBIT D ASSURANCES RMOM 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 RMOM-contracted providers or its employees,volunteers,or agents while performing duties as described in this Agreement. RMOM shall indemnify,defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees,volunteers,and agents. RMOM 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,RMOM 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. RMOM 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. RMOM 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 RMOM. 9. All such records,documents,communications,and other materials shall be the property of Social Services and shall be maintained by RMOM,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. 9 06-07-CORE-66 10. RMOM 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. RMOM or Social Services may not assign any of its rights or obligations hereunder without the prior written consent of both parties. 12. RMOM certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of RMOM,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. RMOM assures that it will fully comply with all other applicable federal and state laws. RMOM understands that the source of funds to be used under this Contract is Child Welfare Regular Administration funds. 14. RMOM 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, RMOM 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, RMOM 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 RMOM. 10 06-07-CORE-66 16. RMOM shall protect the confidentiality of all applicant records and other materials that are 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 RMOM shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with RMOM written policies governing access to,duplication and dissemination of, all such information. RMOM shall advise its employees,agents,and subcontractor, if any,that they are subject to these confidentiality requirements. RMOM 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 RMOM in the course of providing services under this Contract will be accorded at least the same precautions as are employed by RMOM for 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. 11 06-07-CORE-66 EXHIBIT E CHILD WELFARE REGULAR ADMINISTRATION FUNDS Standards of Responsibility: RMOM agrees to: Provide a written report to the Social Services caseworker within 24 hours of providing services to the client; 2. When a monitored sobriety result is positive RMOM agrees to leave a voice mail message to the referring caseworker within 24 hours of providing the service. 3. Report expenditures and case disbursement at agreed upon times. 4. Submit monthly-completed billing forms to Ms.Andrea Shay,Core Services caseworker,within twenty- five(25)calendar days of the month following service in order to receive payment. Billing forms will not be accepted by the Department for processing after the 25th day following the service month. 5. In the event no service fees are incurred during the service month, an Authorization for Contractual Services stating no services were provided for that service month shall be submitted within twenty-five (25)calendar days following the month of service. 6. A complete and timely billing form is identified by and must include the following elements. a. The billing must be an original billing signed by the provider and/or designee. b. The billing must include all forms designed for Child Welfare Regular Administration funds reimbursement and approved by Social Services including Colorado State Department of Social Services Authorization for Contractual Services,and Weld County Monthly Request for Reimbursement under Child Welfare Regular Administration funding. c. The Department will determine billed services not eligible for payment by identifying conflicts in the following: 1. Details provided in client referrals, including types of service,approved hours and/or units of service,begin and end dates of service,client name, or other client identifying information. 2. Details in supporting documentation provided by RMOM and submitted with the original bill, including,but not limited to,original signed client verifications,receipt of monitoring results,times of service,units or hours of service provided,and names of clients receiving the services. 3. Details provided in the current approved contract and Notification of Financial Assistance, including,but not limited to unit of service,cost per unit of service, and special conditions and/or revisions to said contract. The above items,6d, 1, 2, and 3,will supersede all requests from RMOM for review of billing errors. Items submitted for billing will be processed according to the criteria established by the above documentation. 12 06-07-CORE-66 7. Work with family to prepare to pay for services beyond established time frame. a) Authorization for Contractual Services forms must be submitted completely filled in with an original signature from the provider and/or designee. b) Request for Reimbursement forms must include the client's full name;Weld County household number, suffix number, and referral number, if applicable; units provided,service date, unit rate, and total billed for the service date. c) Requests for payment must be date stamped by Social Services by the 25th day of the month following the service month. Requests for payment received after the 25th of the month following service will not be honored. 8. Will meet with Social Services FPP Supervisor quarterly(more if needed)to review program usage and effectiveness to discuss necessary improvements to better serve families or increase referrals; 9. Be available to meet with the Social Services staff to explain program, time lines of response to referrals and answer questions to enhance program. 10. Be available for the Families,Youth and Children Commission review and attendance at the FYC meetings,if requested. 13 06-07-CORE-66 EXHIBIT F BILLING PROCEDURES Billings are to be submitted by the 10th day of the month following the month of service. The forms below will be submitted with original signatures. For monitored sobriety,proof of services rendered shall be a sign-in sheet with client signatures or the test result. Submit these forms,along with a copy of the referral page showing the valid dates of the referral for service,with each invoice. Utilize the three forms below to submit monthly invoices. 14 06-07-CORE-66 WELD COUNTY AUTHORIZATION FOR CONTRACTUAL SERVICES Date: Provider: Billing Contact: Phone #: 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: Approvals: Core Caseworker Date Director Date AMOUNT PAYABLE: $ ANY CHANGES LISTED BELOW: Client/ID/HH# Billed Amt Denied Paid Reason 15 0 s m T co 4 t 0 r. G V 0 O U T z w 0 W v C 2 m 7_ .rd C JA ci N O b , W L_ F Q G R O w U 2g d v V w t V ,rO t Y 0 y 0 o. v « Ej d 'V C N 0. a2 O O• t ° u c .2 • U h z t v a_ .E St v O - >.--i' 4 nv n o �r�Dp '7 'O .0 T a y .4 Vl L a r c o c 6o lA N O m s a -o w da U o. O U Oo > ° ' w z a VV h s w .E m ce .2 -- OU A ¢ x Y o z o 15 u v 0• Sr c c y 0 p o „�, o E v w o co CI s e = > 0 O• -C a X • ` G < •OW C p a .v. ,,, o 0 -0 > O o7° o. � E aw 73E « ; E 73 b , t i V a t v z O o O` o a d U ✓ O , o x X O E o z 'z v � E z" c C E / } / ft° \ \ \k ( /ET H ° / .55. / ° c0 < _ 0 \ Lw- CO / A § ; \k _ z / \ � � Z. </ .ti ,Y1 E % S } / ° § ( iz z� \ \ - ` � Po 2 tu \ ` � � ! ` \ \\ / \ A \ \ / C \ ! ; B § o ; L) 2 \ ) 0) . � \ ) r , = # e 2 ! cc) a � & : ; _ ! / zi / \ \ \ G \ \ \ �73 \ � 121 \ 0.0 cr : - § � w . e = I \ ! ) / ; y @ § ° � } ^ ` \ \ \ it � Z _ < 0 C © * 2 ` / \ ] - CO } j 52 0. r= t< c § \ E. ) \ ) _ : 2 / at on — ) § V, 0 ® / ! \ 0CC 0 j2 ) ! ) / ^ \ E ` \ = 3 ( -o / ; Hello