HomeMy WebLinkAbout20042371.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN -YOUTH EMANCIPATION AND SERVICES, INC.
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 Youth
Emancipation and Services, Inc.,commencing July 1,2004, and ending June 30,2005, 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 Youth
Emancipation and Services, Inc. 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 11th day of August, A.D., 2004, nunc pro tunc July 1, 2004.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
14)112a11-14491 a 11\1\1 --
Robert D. Masden, Chair
erk to the Board
1861
i}.. William H. rke, Pro-Tem
p erk to the Board
M. J. G=ile
ED M:
David E. Long
ounty orrey en
G eh Vaa.
Date of signature: Fd, ,9
2004-2371
SS0031
cf0.1.6
�� DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website:www.co.weld.co.us
' Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO
MEMORANDUM
TO: Robert D. Masden, Chair Date: August 4, 2004
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services !<t .\l_'r ','j Cwt,
J '
RE: Child Protection Agreement for Services Between the Weld County
Department of Social Services and Youth Emancipation& Services, Inc.
Enclosed for Board approval is a Child Protection Agreement for Services between the Weld
County Department of Social Services(Department) and Youth Emancipation& Services,Inc.
This Agreement was discussed and reviewed at the Board's Work Session of July 12, 2004.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is July 1, 2004 through June 30, 2005.
2. Youth Emancipation& Services, Inc.,will provide anger management therapy through
individual, group, and family settings for primarily adolescents according to the fee
schedule provided in the Agreement.
3. The total funding available under the Agreement is $2,500 from Child Welfare funding.
If you have any questions,please telephone me at extension 6510.
20p4_2371
Contract Number: 04-CPS-36
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND YOUTH EMANCIPATION&SERVICES,INC.
This Agreement,made and entered into the,//-day of&. 72004,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 Youth Emancipation&Services, Inc.,hereinafter referred
to as "GRIFFIN HOUSE".
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 anger management and family conflict management services for
families, children,and adolescents; and
WHEREAS, Social Services requires the services of a therapeutic provider to assist the County to deliver
anger management and family conflict resolution services to youth in the child welfare system,and GRIFFIN
HOUSE is willing and able to provide such services;and
WHEREAS,GRIFFIN HOUSE is a Colorado non-profit corporation organized for the purpose of
managing and coordinating high quality,cost efficient, therapeutic services in the State of Colorado.
NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
This Agreement shall become effective on July 1,2004,upon proper execution of this Agreement and shall
expire June 30, 2005,unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by GRIFFIN HOUSE 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,"a copy of which is 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.
b. GRIFFIN HOUSE 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. GRIFFIN HOUSE 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 is expressly contingent upon the availability
of Child Welfare Regular Administration funds to Social Services.
•
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,c,9OOy-643 7/
Contract Number: 04-CPS-36
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 Manag-.ment
At all times from the effective date of this Contract until completion of this Contract,GRIFFIN HOUSE
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. GRIFFIN HOUSE 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 GRIFFIN HOUSE has failed to comply with the
Financial Management Requirements,program objectives, contractual terms,or reporting
requirements. In the event of a forfeiture of reimbursements,GRIFFIN HOUSE may appeal such
circumstance to the Director of Social Services. The decision of the Director of Social Services
shall be final.
6. Assurances
GRIFFIN HOUSE shall abide by all assurances as set forth in the attached Exhibit C,which is attached hereto
and incorporated herein by reference.
7. Compliance with Applicable I aws
At all times during the performance of this contract,GRIFFIN HOUSE 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. GRIFFIN HOUSE acknowledges that the following laws are included:
Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d—1 et.seq.and its implementing
regulation,45 C.F.R.Part 80 eL 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 eL seq.and
its implementation regulations,45 C.F.R.Part 91;and
Title VII of the Civil Rights Act of 1964;and
- the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
the Education Amendments of 1972;and
Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
and all regulations applicable to these laws prohibiting discrimination because of race, color,
National origin,and sex,religion and handicap, including Acquired Immune Deficiency Syndrome(AIDS)
or AIDS related conditions,covered under Section 504 of the Rehabilitation Act of 1973,as amended, cited
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Contract Number: 04-CPS-36
above. If necessary,GRIFFIN HOUSE 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 fmancial 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
GRIFFIN HOUSE 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
GRIFFIN HOUSE and Social Services agree that monitoring and evaluation of the performance of this
Agreement shall be conducted by GRIFFIN HOUSE and Social Services. The results of the monitoring and
evaluation shall be provided to the Board of Weld County Commissioners and GRIFFIN HOUSE.
GRIFFIN HOUSE shall permit Social Services,and any other duly authorized agent or governmental
agency,to monitor all activities conducted by GRIFFIN HOUSE 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 fmd
GRIFFIN HOUSE 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
GRIFFIN HOUSE. These remedial actions are as follows:
a. Withhold payment to GRIFFIN HOUSE until the necessary services or corrections in performance
are satisfactorily completed;
b. Deny payment or recover reimbursement for those services or deliverables,which have not been
performed and which due to circumstances caused by GRIFFIN HOUSE 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 GRIFFIN HOUSE due to omission,error,fraud,and/or defalcation shall be
recovered from GRIFFIN HOUSE by deduction from subsequent payments under this Agreement or
other agreements between Social Services and GRIFFIN HOUSE,or by Social Services as a debt due
to Social Services or otherwise as provided by law.
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Contract Number: 04-CPS-36
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 GRIFFIN HOUSE:
Tames P Nelson Executive Director
Name Title
13. Notice
All notices required to be given by the parties hereunder shall be given by certified or registered mail to the
individuals at the addresses set forth below. Either party may from time to time designate in writing a
substitute person(s)or address to whom such notices shall be sent:
To: Social Services To: GRIFFIN HOUSE
Judy A Griegn Director Tames P Nelson
P O Box A 3400 1 fim Street,Bldg fi Su ite MM
Greeley,CO R0617 Greeley,CO 50614
14. I.itigation
GRIFFIN HOUSE shall promptly notify Social Services in the event that GRIFFIN HOUSE learns of any
actual litigation in which it is a party defendant in a case that involves services provided under this
Agreement. GRIFFIN HOUSE,within five(5)calendar days after being served with a summons,complaint,
or other pleading which has been filed in any federal or state court or administrative agency,shall deliver
copies of such document(s)to the Social Services Director. The term"litigation" includes an assignment
for the benefit of creditors, and filings in bankruptcy,reorganization and/or foreclosure.
15. Termination
This Agreement may be terminated at any time by either party given thirty(30)days written notice and is
subject to the availability of funding. GRIFFIN HOUSE reserves the right to suspend services to clients if
funding is no longer available.
16. Entire Agreement
This Agreement,together with all attachments hereto,constitutes the entire understanding between the
parties with respect to the subject matter hereof,and may not be changed or modified except as stated in
Paragraph 10 herein.
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Contract Number: 04-CPS-36
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year
first above written.
MM4r
BOARD OF COUNTY
•"i%�S'OARD COMMISSIONERS WELD
h
1861 itit9 COUNTY,COLORADO
•
B �ui� • Y•v
®p u����sqq ' lerk Robert D.Masden,Chair AUG 11 2004
tLd g� ..
AS TO GRIFFIN HO
BY . At--al/AC--
County Attorney I s P.Nelson,Executive Director
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: •
D' for
Page 5 of 15
cN?CeSi $
Contract Number: 04-CPS-36
EXHIBIT A
SCOPE OF SERVICES
Group Therapy/Support(iroupc
1. Anger Management and Conflict Resolution Groups will concentrate on discovering the
underlying feelings antecedent to anger outbursts,the irrational thoughts and fears that
contribute to the intensity of anger,and will retain individuals and families in the
understanding and diffusing of their personal anger cycles.
2. A licensed master's level therapist who has experience in group therapy with this
challenging yet rewarding population will facilitate groups.
Family Conflict Management
1. Family Conflict Management will teach dispute resolution skills to reduce stress and
foster an atmosphere of cooperation rather than contention when internal conflicts arise
that reduces the family's ability to work together to achieve common goals and interests.
The degree of conflict within the family will be measured using an assessment devise at
the initiation of services and at the termination of services.
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Contract Number: 04-CPS-36
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse GRIFFIN HOUSE in consideration for the work and services
performed,a total amount not to exceed Two Thousand Five Hundred Dollars($2,500)under Child
Welfare Regular Administration funding.
Expenses incurred by GRIFFIN HOUSE,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
Individual,Group,and Family Therapy $45.00/hour
Boy's and Girl's Groups,Anger Management $29.00/hour
Social Services referrals will ant be sent to collections by GRIFFIN HOUSE 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
GRIFFIN HOUSE shall prepare and submit monthly the itemized voucher according to the criteria listed
under"Standards of Responsibility" in Exhibit D, 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.
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Contract Number: 04-CPS-36
EXHIBIT C
ASSURANCES
1. GRIFFIN HOUSE 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 GRIFFIN HOUSE-
contracted Griffin Houses or its employees,volunteers, or agents while performing duties as described in
this Agreement. GRIFFIN HOUSE shall indemnify, defend,and hold harmless Weld County,the Board of
County Commissioners of Weld County, its employees,volunteers, and agents. GRIFFIN HOUSE 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,GRIFFIN HOUSE 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. GRIFFIN HOUSE 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. GRIFFIN HOUSE 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
GRIFFIN HOUSE.
9. All such records,documents, communications,and other materials shall be the property of Social Services
and shall be maintained by GRIFFIN HOUSE,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
fmding.
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Contract Number: 04-CPS-36
10. GRIFFIN HOUSE 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. GRIFFIN HOUSE or Social Services may not assign any of its rights or obligations hereunder
without the prior written consent of both parties.
12. GRIFFIN HOUSE certifies that federal appropriated funds have not been paid or will be paid,by or on
behalf of GRIFFIN HOUSE,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. GRIFFIN HOUSE assures that it will fully comply with all other applicable federal and state laws.
GRIFFIN HOUSE understands that the source of funds to be used under this Contract is Child Welfare
Regular Administration funds.
14. GRIFFIN HOUSE 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,GRIFFIN HOUSE 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, GRIFFIN HOUSE 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 GRIFFIN HOUSE.
16. GRIFFIN HOUSE 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
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Contract Number: 04-CPS-36
administration of Child Protection,no information about or obtained from any applicant/recipient in
possession of GRIFFIN HOUSE shall be disclosed in a form identifiable with the applicant/recipient or a
minor's parent or guardian unless in accordance with GRIFFIN HOUSE written policies governing access
to,duplication and dissemination of,all such information. GRIFFIN HOUSE shall advise its employees,
agents, and subcontractor, if any,that they are subject to these confidentiality requirements. GRIFFIN
HOUSE 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 GRIFFIN HOUSE in the course of providing services under this Contract will be accorded at least the
same precautions as are employed by GRIFFIN HOUSE for similar information in the course of its own
business.
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Contract Number: 04-CPS-36
EXHIBIT D
CHILD WELFARE SERVICES
GRIFFIN HOUSE agrees to:
1. Provide a written report to the Social Services caseworker within 25 calendar days of the month following
service.
2. Report to Social Services a monthly brief report on the status of the program as prescribed by Social
Services.
3. Report expenditures and case disbursement at agreed upon times.
4. Submit monthly-completed billing forms to Ms.Elaine Furister, CPS/CAP,Core Services Specialist,within
twenty-five(25)calendar days of the month following service in order to receive payment.Failure to submit
in a timely and complete manner shall result in forfeiture of payment.
5. Submit 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. Submit an original Request for Reimbursement in complete form to re-bill for services previously denied by
Social Services. If in the resolution process,the provider will not re-bill for payment unless the provider
can justify payment by documentation. Social Services will not consider payments that were originally
reviewed as deficient in documentation without new documentation to justify payment. Social Services shall
receive the Request for Reimbursement no later than five business days from receipt of a certified letter
from Social Services documenting such denials of payment.
7. Work with family to prepare to pay for services beyond established time frame.
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 Administration funding
reimbursement and approved by the Department of Social Services including Colorado State
Department of Social Services Authorization for Contractual Services form and Weld County
Monthly Request for Reimbursement under Child Welfare Regular Administration Funding.
c. A re-bill must include all forms designed for re-billing of Requests for Reimbursement under
Child Welfare Regular Administration funds,and approved by the Department of Social
Services.This includes a signed original Authorization for Contractual Services and Weld
County Program Re-bill under Child Welfare Regular Administration funds and Additional
Request for Reimbursement form.
I. Authorization for Contractual Services forms must be submitted completely filled in
with an original signature from the provider and/or designee.
2. 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.
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Contract Number: 04-CPS-36
3. Requests for payment must be date stamped by the Department of 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.
4. Re-bills for services must include only those items Island Grove can justify with
documentation and include a signed original Authorization for Contractual Services
form and Weld County Program Re-bill under Child Welfare Regular Administration
funds and Additional Request for Reimbursement form.The Weld County Rebill
under Child Welfare Regular Administration funding form must include the client's
name;household number and suffix number,if applicable;month of billed service,
re-bill amount,the approved entry date and exit dates,the actual units re-billed,the
rate per unit,and the re-bill total for the line item.
8. Will develop and utilize evaluation tools(pre and post assessment test instruments)to
collect necessary data in cooperation with Social Services staff to monitor effectiveness of
program.
9. 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.
10. Be available to meet with Social Services staff to explain program,time lines of response
to referrals and answer questions to enhance program.
11. Be available for the Families,Youth and Children Commission review and attendance at
the FYC meetings.
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Contract Number: 04-CPS-36
5310.213(2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
1. WEI D COITNTY DATE:
2.
Name of Provider
3.
Address
4.
City, State, Zip
THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED:
5.
Name of Client Household# Cat. Cat.Grp.
6.
Description Sv. Code
7.APPROVAL:
Caseworker Date Co.Director or Supervisor
8.TO BE COMPLETED BY PROVIDER
DATE OF SERVICE
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 COUNTY
DEPARTMENT OF SOCIAL SERVICES INDICATED.
Provider Signature Date
Prepare in Triplicate,Original and One copy to Provider,One Copy for Pending File.
Completed Provider's Forms-Original to County Finance Office-Copy to Case Record.
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Contract Number: 04-CPS-36
WELD COUNTY MONTHLY REQUEST FOR REIMBURSEMENT UNDER CHILD WELARE REGULAR ADMINISTRATION FUNDING
Remit to: Elaine Furister, CPS/CAP, Core Services Specialist
Name of Program Month of Service Weld County Department of Social Services
Notice to Providers:List all clients currently enrolled in your program. P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Enter 0 if no services were provided during billing month Telephone: 970.352.1551,extension 6295
FAX: 970.346.7698
Client Name HH# Referral# Approved Approved Date of Actual Rate per Total Payment Social Services Payments Services
(If Entry Exit Date Service Hrs/Units Unit Requested Only-Comments Denied/Delayed Payable
_applicable) Date
Social Service Codes: CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMH-Exceeds Maximum Hours;EMS-Exceeds Maximum Sessions;
NP-Not Payable;
PD-Payment Delayed; SPD; Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification; ICMP-Initial Case Management Plan Needed;
PR-Progress Report Needed
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Contract Number: 04-CPS-36
WELD COUNTY RE-BILL UNDER CHILD WELFARE REGULAR ADMINISTRATION FUNDS AND ADDITIONAL REQUEST FOR REIMBURSEMENT
Remit to:Elaine Furister,CPS/CAP,Core Services Specialist
Name of Program Month of Service Weld County Department of Social Services
P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Telephone:970.352.1551,extension 6295 FAX:970.346.7698
Client Name HH#&Client Referral# Month of Re-bill Approved Approved Actual Rate per Re-bill Certified Letter and (DSS Only)
Suffix Service amount Entry Date Exit Date Hrs/Units Unit Total Documentation Payable or
(Example: Re-billed Attached Not payable
11111-02) (Include reason if n
Social Service Codes:CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMH-Exceeds Maximum Hours;EMS-Exceeds Maximum Sessions;NP-Not Payable;
PD-Payment Delayed;SPD;Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;PR-Progress Report Needed
Page 15 of 15
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