HomeMy WebLinkAbout20042171.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - SIGNAL BEHAVIORAL HEALTH NETWORK
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 Signal
Behavioral Health Network, commencing July 1,2004, and ending May 31,2005,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 Signal
Behavioral Health Network 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 28th day of July, A.D., 2004, July 1, 2004.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
r EL
EXCUSED
Robert D. Masden, Chair
1861 Ia rk to the Board
•
/
V Pt William H. rke, Pro-Tem
-Deputy Clerk to the Board
M. . eile
AP ED A RM:
David E. Long
ounty Attor y
EXCUSED
// Glenn Vaad
Date of signature: �//V,7
2004-2171
SS0031
(n ; SS( . lc 5) id-oy
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DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO.80632
Webslte:www.co weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O MEMORANDUM
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COLORA1Q Robert D. Masden, Chair Date: July 26, 2004
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services n Q W 10
RE: Child Protection Agreement for Services between the Weld County
Department of Social Services and Signal Behavioral Health
Network
Enclosed for Board approval is a Child Protection Agreement for Services between the
Weld County Department of Social Services (Department) and Signal Behavioral Health
Network (Signal). This Agreement was reviewed at the Board's Work Session of May 3,
2004.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is from July 1, 2004 through May 31, 2005.
2. The source of funding is Core Services.
3. Signal is agrees to provide drug and alcohol treatment services for child welfare
clients through its provider, Island Grove Regional Treatment Center and at fee
charges set by Signal.
4. The Department agrees to reimburse Signal for drug and alcohol treatment
services at maximum funding level of$52,398 including a 5% administrative fee.
If you have any questions, please telephone me at extension 6510.
2004-2171
RECEIVED BY
Contract Number.PY 04-05-CPS-30 J U L 2 6 2004
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES.EL l l uN i Y �•,`i�T.
AND SIGNAL BEHAVIORAL HEALTH NETWORK JJVV �!Nof f;Cp1f1! r-P
OF ,.S
This Agreement,made and entered into the day of May 2004,by and between the Board of Weld
County Commissioners,sifting as the Board of Social Services,on behalf of the Weld County Department of Social
Services,hereinafter referred to as"Social Services,"and Signal Behavioral Health Network,referred to as"Signal".
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 Colorado Core Services substance
abuse treatment funding to Social Services for outpatient and residential core services for families,children,and
adolescents;and
WHEREAS,Social Services requires the services of a substance abuse treatment provider to assist Social
Services to deliver substance abuse treatment services to child welfare clients,and Signal is willing and able to
provide such services;and
WHEREAS,Signal is a Colorado non-profit corporation organized for the purpose of managing and
coordinating high quality,cost efficient, integrated chemical dependency and related behavioral health care services
in the State of Colorado.
NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
0
�Z00`f
This Agreement shall become effective on 4,upon proper execution of this Agreement and shall
expire May 31,2005.
2. Scope of Services
Signal network providers shall provide services 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,"Exhibit C,"Core Services
Fee Schedule,"and Exhibit E,"Standards of Responsibility for Core Services",copies of which
are attached hereto and incorporated herein by reference.
"Payment Schedule"shall establish the maximum reimbursement,which will be paid from
Colorado Core Services substance abuse treatment funding during the duration of this Agreement.
Signal,in accordance with federal HIPPA regulations,has adopted the standard transaction code
set for all treatment services on or before October 16,2003.
B. Signal 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 as mutually agreed
upon by Social Services and Signal. Requests to modify criteria must be provided with 30 days
advance notice. Signal 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. Signal shall make available,on its web site,monthly reports in accordance with the billing criteria
established by Social Services no later than the twenty-fifth(25)calendar day of the month
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Contract Number.PY 04-05-CPS-30
following the month of service.
Failure to make available monthly billings and/or monthly client reports in accordance with the
terms of this agreement may result in Signal's forfeiture of all rights to be reimbursed for such
expenses. In the event of a forfeiture of reimbursement,Signal may appeal such circumstance to
the Director of Social Services,after all remedies described in Item 11,A of the Agreement are
exhausted. The Director of Social Services shall render a decision. The decision of the Director
of Social Services maybe appealed to the Board of County Commissioners according to the
provisions of Item 11 of the Agreement.
D. Payments of costs incurred pursuant to this Agreement is expressly contingent upon the
availability of Colorado Core Services substance abuse treatment funding to Social Services.
E. 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,"Scope of Services"and Exhibit C,"Core Services
Fee Schedule". Work performed prior to the execution of this Contract shall not be reimbursed or
considered part of this Agreement.
F. Signal shall provide training and technical support,as necessary,for Social Services staff in
accessing Signal's data and billing reports and on the use of the child welfare referral system.
4. Financial Management
At all times from the effective date of this Contract until completion of this Contract, Signal 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 the Child Welfare Services and Family and Children's Program 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. Signal shall provide proper monthly invoices and verification of services performed for costs incurred
in the performance of the agreement.
B. Social Services may withhold any payment if Signal has failed to comply with the Financial
Management Requirements,program objectives,contractual terms,or reporting requirements. In
the event of a forfeiture of reimbursements, Signal may appeal such circumstance to the Director
of Social Services,after all remedies described in Item 11,A of the Agreement are exhausted. The
Director of Social Services shall render a decision. The decision of the Director of Social Services
may be appealed to the Board of County Commissioners according to the provisions of Item 11 of
the Agreement.
6. Assurances
Signal 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, Signal 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. Signal acknowledges that the following laws are included:
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Contract Number.PY 04-05-CPS-30
Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d—1 et.seq.and its implementing
regulation,45 C.F.R.Part 80 et.seq.;and
Section 504 of the Rehabilitation Act of 1973,29 U.S.C. Section 794,and its implementing
regulations,45 C.F.R.Part 84;and
the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et.seq.and
its implementation regulations,45 C.F.R.Part 91;and
Title VII of the Civil Rights Act of 1964;and
the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
the Education Amendments of 1972;and
Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
and all regulations applicable to these laws prohibiting discrimination because of race,color,national
origin,and sex,religion and handicap,including Acquired Immune Deficiency Syndrome(AIDS)or AIDS
related conditions,covered under Section 504 of the Rehabilitation Act of 1973,as amended,cited above.
If necessary,Signal and Social Services will resist in judicial proceedings any efforts to obtain access to
client records except as permitted by 42 CFR Part 2. Social Services and Signal shall sign a Qualified
Service Organization Agreement in compliance with 42 CFR Part 2,and attached hereto as Exhibit F.
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
Signal 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
Signal and Social Services agree that monitoring and evaluation of the performance of this Agreement shall
be conducted by Signal and Social Services. The results of the monitoring and evaluation shall be provided
to the Board of Weld County Commissioners and Signal.
Signal shall permit Social Services,and any other duly authorized agent or governmental agency,to
monitor all activities conducted by Signal 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
A. Signal and Social Services shall exhaust all remedies as provided in Exhibit E,"Standards of
Responsibility for Core Services",prior to the remedy provided in Item 11,B,of this Agreement.
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Contract Number.PY 04-05-CPS-30
B. The Director of Social Services or designee may exercise the following remedial actions should
s/he find Signal 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 Signal. These remedial actions are as follows:
1) Withhold payment of Signal until the necessary services or corrections in performance are
satisfactorily completed;and
2) Deny payment or recover reimbursement for those services or deliverables,which have
not been performed and which due to circumstances caused by Signal 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;and
3) Incorrect payment to Signal due to omission,error,fraud,and/or defalcation shall be
recovered from Signal by deduction from subsequent payments under this Agreement or
other agreements between Social Services and Signal,or by Social Services as a debt due to
Social Services or otherwise as provided by law.
C. Signal may appeal the decision of the Director of Social Services or designee,as provided in Item 11,
B,of the Agreement,by submitting,within thirty(30)calendar days of the Director's action,and basis
of such appeal to the Board of County Commissioners.
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 Signal:
Bill Wendt Chief Executive Officer,Signal
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: Signal
Judy A.Griego,Director Bill.Wendt,CEO
P.O.Box A 1391 Speer Blvd.,Suite 300
Greeley,CO 80632 Denver,CO 80204
14. Litigation
Signal shall promptly notify Social Services in the event that Signal learns of any actual litigation in which
it is a party defendant in a case that involves services provided under this Agreement. Signal,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.
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15. Termination
This Agreement may be terminated at any lime by either party given thirty(30)days written notice and is
subject to the availability of funding,subject to the provisions of Item 10 and Item 15. Signal reserves the right
to suspend services to clients if funding is no longer available. Social Services acknowledges financial
responsibility for clients authorized under the terms of the Agreement.
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.
�a _ IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year
ILei t abo� written.
1 1861tS 'yfl1erk
to the Board COUNTY OF WELD COLORADO,BY AND THROUGH
m� ♦ ! THE BOARD OF COUNTY COMMISSIONERS,SITTING
AS THE BOARD OF SOCIAL SERVICES FOR THE
- f WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
uty C er to the Board
By: The
William H. Jerke, Chair Pro—Tem
oV As JUL2 b LUU4
ttomey
APPROVED AS TO SUBSTAN SIGNAL AUTHOR! D PRE VE:
By: By
Ju .Gri g ,Director, eld Co ty Scott hoe ce,Board President
ent ocial Sery es Signal Behavioral Health Network
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gOo9 -917
Contract Number.PY 04-05-CPS-30
EXHIBIT A
SCOPE OF SERVICES
A. Assessments
1) Alcohol and Drug Differential Assessment(3-Hours)
Assessment will evaluate alcohol/drug involvement as well as mental health status,history of mental
health issues,sexual history,legal history,and certain standard tests(ASAP,ASAM PPC-2,ASI,
SOCRATE,AODUI,Drinking History Questionnaire,Family Environment Scale)may be given.
Signal will provide two collateral contacts as part of the Assessment.
A Baseline Urinalysis Testing(7-Panel)will be part of the assessment.Summary of assessment with
recommendations sent to referral agency. Tests determine what drugs are present in client.
The 7-Panel baseline urinalysis test for alcohol and drugs screens for the following:
THC Cutoff Level:50 ng/ml
Amphetamines Cutoff Level: 1000 bg/ml
Cocaine Cutoff Level:300 ng/ml
Barbiturates Cutoff Level:200 ng/ml
Benzodiazepines Cutoff Level:200 ng/ml
Opiates Cutoff Level: 200 ng/ml
Creatinine >20 mgDL is normal
The 3-Panel baseline urinalysis test screens for: Amphetamines,THC,and Cocaine.
2) Co-Occurring Alcohol and Drug with Domestic Violence Assessment(3-Hours)
Summary of assessment with recommendations sent to referring agency. The following areas will be
assessed:
Criminal History Profile of Client's Violent
Behaviors
Potential for Violence Mental Health Status
Client's Medical History Substance Abuse History
SuicidaUPsychological/Cultural Millon Test,if needed
History
3) Substance Abuse Forensic Evaluation(3 hours,as staff expertise permits)
A forensic evaluation is specifically geared toward the substance-abusing offender. It involves
additional testing to determine the crimogenic aspect of the person to be taken into consideration
when developing treatment recommendations. Testing will be comprised of CVI,ASUS,SASSI,
Millon Clinical Multiaxial Inventory(MCMI-III),a clinical interview,and a behavioral profile. The
testing is cross-referenced with the clinical interview,and in relation to collateral data.
B. Treatment Options
1) Co-Occurring Alcohol and Drug with Domestic Violence Group Therapy(average length of
treatment,24 to 36 weeks): Groups for both men and women are offered. The group addresses
anger management,healthy relationships,male and female roles,and boundaries. As needed,a
Millon Test may be given,a standardized psychological test which measures functioning level in
22 personality disorders and clinical syndromes for adults(8th grade reading level: > 18;available
in Spanish).
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Contract Number.PY 04-05-CPS-30
2) Family Therapy(average length of treatment,8 to 16 sessions): Involves two or more family
members and provides therapeutic intervention to improve family communications,functioning,
and relationships. Length of participation is dependent on client goals and progress toward
meeting goals.
3) Individual Counseling(average length of treatment,6 to 12 sessions): Primary client is seen
on an individual basis. Length of participation is dependent on client goals and progress toward
goals.
4) Substance Abuse Therapy(average length of treatment,12 to 20 sessions): A group to
enhance positive coping skills by focusing on their lifestyle dealing with use and abuse of
chemicals.
5) Adult Intensive Outpatient(average length of treatment,4 to 12 weeks): An intensive
outpatient group therapy track that offers groups every evening,Monday through Friday,with a
family program component. This program will include medical aspects of addiction and adult
relapse education components focusing on understanding the relapse process as well as group
process(focuses on individual issues relating to their abuse of alcohol). The program length and
participation level will be individualized based on the presenting issues and other factors.
6) Women's Group(average length of treatment,12-20 session): A gender-specific group
addressing issues affecting women and their relationships,such as family violence,co-
dependency,self-esteem and stress management.
7) Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent
Cannabis Users(MET/CBT5 average length of treatment 5-8 weeks): The MET/CBT5 is a
brief treatment approach for cannabis abusing adolescents. Treatment consists of two individual
motivational enhancement therapy sessions(MET)Sessions, followed by participation in three
group cognitive behavioral therapy (CBT)sessions. The assessment includes a psychosocial
history and data from the Global Assessment of Individual Needs(CAIN),and a personalized
feedback report.
C. Special Program Option
1) Special Connections(through pregnancy and up to one year postpartum): A gender-specific
program that focuses on healthy babies,appropriate child care,prenatal care,birth control,
developmental stages of the baby,parenting skills,relationship issues,and other issues as
identified by the counselor. Services include group and individual therapy,case management and
family health education.
D. Miscellaneous Service Options
1) Fast Track Adolescent Program: The Fast Track Adolescent Program is an Intensive Outpatient
Program with supportive housing services if clinically necessary. The targeted population ranges
from 13 to 17 years of age who demonstrate substance abuse problems. The goal is to have these
adolescents discover positive alternatives to their current use behavior. The program consists of a
comprehensive differential assessment compiling personal and collateral information as well as
data obtained from the Addiction Severity Index(ASI), Substance Abuse Subtle Screening
Inventory(SASSI)and the Adolescent Self-Assessment Profile(ASAP)instruments. This data is
utilized to develop an individualized treatment plan. Clients receive a minimum of three
individual sessions with the focus on achieving their treatment goals and attend three groups per
week and three per day if in residential with the primary focus on education and motivational
topics. Family therapy is encouraged as a part of the client's treatment. A discharge planning
session will be implemented focusing on appropriate referrals addressing the needs and motivation
of the adolescent and family. To refer to the Fast Track Program, Social Services will contact
Program Manager of Youth Services at(970)356-6664,extension 16. If she/he is not on duty,
inform the staff person that Social Services is referring a Fast Track adolescent and give the
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youth's caseworker's name so that the Fast Track staff can contact the caseworker when they
return to duty.
2) On-Site Staff Services: The scope of the services offered to the local Social Services agency by
ADAD approved staff placed on site by the licensed ADAD program may include performing
alcohol and drug assessments,brief therapy(under 8 hours),case consultation,case management,
and in-house training on pertinent alcohol/drug issues as requested and training evaluation of care
givers. In addition to this,on-site staff may accompany Social Services staff on follow-up visits to
perform a behavioral health screening for the purpose of identifying clients who could benefit
from further assessments for alcohol/drug interventions or mental health interventions.
3) Extended Detoxify Stay: This is an option when case management goals require that the person
be in a stable environment until they can be referred to the next level of care.
4) Enhanced Services: Enhanced services as approved services that are requested by Social
Services for specific cases,which fall outside of the definitions,listed above in the description of
the ADAD menu of services. Enhanced services may be services not described on the menu,
services not included in the definition or due to lack of economy of scale,or rural location,or
result in additional costs to Signal. In order for Signal to provide enhanced service,the cost would
be outside of the approved rates. Any additional fees would be negotiated on a case-by-case basis.
Signal can arrange for services outside of the approved definitions,but Social Services will be
charged an additional fee that would be negotiated on a case-by-case basis by the designated
representative listed in the contract.
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EXHIBIT B
PAYMENT SCHEDULE
Funding and Method of Payment
Social Services agrees to reimburse to Signal in consideration for the work and services performed,a total
amount not to exceed Fifty-two Thousand,Three Hundred Ninety-eight Dollars($52,398.00)under Core
Services Funding. Of this total amount,Social Services agrees to pay an administrative fee not to exceed
Two Thousand,Four Hundred Ninety-Five Dollars and Fourteen Cents($2,495.14)or five percent of the
service fees,salaries,and other authorized costs that are actually incurred in the delivery of the treatment
services authorized in this Agreement.
Expenses incurred by Signal,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 Colorado Core Services substance abuse treatment funding,whether
in whole or in part,is subject to and contingent upon the continuing availability of Colorado Core Services
substance abuse treatment funding 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
Social Services agrees to pay for services according to Exhibit A,"Scope of Services",and according to the
fees described in Exhibit C,"Core Services Fee Schedule".
Social Services referrals will not be sent to collections by Signal for default of co-pay/fees. Services will
be performed regardless of client's refusal or inability to pay co-pay.
The Sliding Fee Schedule will only be applied to those services as noted in Exhibit C,"Core Services Fee
Schedule",all other fees will be charged directly to Social Services.
Signal will collect any applicable sliding scale co-pays and credit Social Services for any payments
received on the monthly billing statements.
3. Submittal of Vouchers
Signal shall prepare and submit monthly the itemized voucher according to the criteria listed under Exhibit
E,"Standards of Responsibility for Core Services,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,"Scope of
Services",and Exhibit C,"Core Services Fee Schedule".
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EXHIBIT C
CORE SERVICES FEE SCHEDULE
1. General Core Services Fee Schedule
Service
Description Code Weld County
Provider 5.0% AFS/Core Units
Rate Rate
Alcohol (ethanol), breath 82075 $2.00 $0.10 $2.10 Each
Alcohol and/or drug screening; laboratory H0003 $12.00 $0.60 $12.60 Each
analysis of specimens for presence of
alcohol and/or drugs(UA)
Alcohol and/or drug services; acute H0011 $152.00 $7.60 $159.60 Day(s)
detoxification (residential addiction
program inpatient)(Detox)
Alcohol and/or drug services; group H0005 $6.75 $0.34 $7.09 15 Minutes
counseling by a clinician
Alcohol and/or other drug testing, H0048:HF $50.00 $2.50 $52.50 Each
collection and handling only, specimens
other than blood: Substance abuse
program (Drug Patch Monitoring)
Alcohol and/or substance abuse services: T1006 $25.00 $1.25 $26.25 15 Minutes
family/couple counseling
Behavioral health screening to determine H0002 $140.00 $7.00 $147.00 Each
eligibility for admission to treatment
program (Evaluation)
Behavioral health screening to determine H0002:TN $200.00 $10.00 $210.00 Each
eligibility for admission to treatment
program: Rural/out of service area (Off-
Site Evaluation)
Behavioral health; long term residential H0019 $93.00 $4.65 $97.65 Day(s)
(non-medical, non-acute care in a
residential treatment program where stay
is typically longer than 30 Day(s)s),
without room and board, per diem
(Transitional Residential)
Drug confirmation, each procedure 80102 $35.00 $1.75 $36.75 Each
Individual behavioral health counseling H0004 $15.00 $0.75 $15.75 15 Minutes
and therapy, per 15 min
Medical testimony 99075 $18.75 $0.94 $19.69 15 Minutes
Office or other outpatient visit for the 99214 $60.00 $3.00 $63.00 Each
evaluation and management of a new
patient, which requires these three key
components: a detailed history; a detailed
examination; and medical decision making
of low complexity. (Antabuse Physical,
new patient)
Office or other outpatient visit for the 99203 $60.00 $3.00 $63.00 Each
evaluation and management of an
established patient, which requires at least
two of these three key components: a
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Contract Number.PY 04-05-CPS-30
detailed history; a detailed examination;
medical decision making of moderate
complexity. (Antabuse Physical,
established patient)
On-site Staff Services N/A $55.00 $2.75 $57.75 Each
Oral medication administration, direct H0033 $2.00 $0.10 $2.10 Each
observation(Antabuse Monitoring)
Vapor inhalations evaluation 94664 $40.00 $2.00 $42.00 Each
Out of Region One Services
Alcohol and/or drug services; methadone H0020 $415.00 $20.75 $435.75 Month
administration and/or service(provision of
the drug by a licensed program)
Behavioral health day treatment, per hour: H2012:HB $6.90 $0.35 $7.25 Hour(s)
Adult program, non-geriatric(Day Tx--
Adult)
Behavioral health day treatment, per hour: H2012:HA $9.87 $0.49 $10.36 Hour(s)
Child/adolescent program (Day Tx--
Adolescent)
Behavioral health; long term residential H0019:HD $175.00 $8.75 $183.75 Day(s)
(non-medical, non-acute care in a
residential treatment program where stay
is typically longer than 30 days), without
room and board, per diem:
Pregnant/parenting women's program
(New Directions for Family)
Behavioral health; short-term residential H0018:HB $170.00 $8.50 $178.50 Day(s)
(non hospital residential treatment
program)without room and board, per
diem:Adult program, non-geriatric
(Intensive Residential--Adult)
Behavioral health; short-term residential H0018:HA $228.00 $11.40 $239.40 Day(s)
(non hospital residential treatment
program)without room and board, per
diem: Child/adolescent program (Intensive
Residential —Adolescent)
Therapeutic behavioral services, per diem: H2020:HB $59.00 $2.95 $61.95 Day(s)
Adult program, non-geriatric(Therapeutic
Community--Adult w/out Infant)
Therapeutic behavioral services, per diem: H2020:HA $125.00 $6.25 $131.25 Day(s)
Child/adolescent program (Therapeutic
Community—Adolescent)
Therapeutic behavioral services, per diem: H2020:HD $99.50 $4.98 $104.48 Day(s)
Pregnant/parenting women's program
(Therapeutic Community --Adult w/
Infant)
2. Special Core Services Fee Schedule
On-Site Staff Services Child Welfare Section: Minimum of 15 hours per week,maximum
of 28 hours. Social Services will pay for 15 hours per week.
Weld County will not be billed for hours that the staff person is
not on site(due to illness,vacation,educational leave etc.)during
the 15-hour minimum.
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Contract Number.PY 04-05-CPS-30
Assessments All assessments will be paid for through the Social Services
CORE service contract. Signal contract provider will deliver the
completed evaluation to Social Services within two weeks of the
client's evaluation meeting with the staff person. All assessments
shall include documentation of at least two collateral contacts to
confirm/refute client self-reported information.
Residential Youth residential services may be billed to core,as negotiated on a
case-by-case basis.
Adult Treatment Adult treatment,case management and after care(45-60 days).
Services
Ongoing Treatment Ongoing treatment services will be assigned to funding streams
according to usage,as negotiated on a case-by-case basis.
Youth Services Youth in Conflict(YIC)cases may be eligible for services through
Core Service dollars,as negotiated on a case-by-case basis.
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Contract Number.PY 04-05-CPS-30
EXHIBIT D
ASSURANCES
1. Signal 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 Signal or its employees,
volunteers,or agents while performing duties as described in this Agreement. Signal shall indemnify,
defend,and hold harmless Weld County,the Board of County Commissioners of Weld County, its
employees,volunteers,and agents. Signal 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,Signal 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 created 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. Signal 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. Signal 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 Signal.
9. All such records,documents,communications,and other materials shall be the property of Social Services
and shall be maintained by Signal,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.
10. Signal 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.
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Contract Number.PY 04-05-CPS-30
11. This Contract shall be binding upon the parties hereto,their successors,heirs,legal representatives,and
assigns. Signal or Social Services may not assign any of its rights nor obligations hereunder without the
prior written consent of both parties.
12. Signal certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of Signal,
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. Signal assures that it will fully comply with all other applicable federal and state laws. Signal understands
that the source of funds to be used under this Contract is: Colorado Core Services substance abuse
treatment funds.
14. Signal 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 Signal with Social Services when
Signal 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 Signal to gain from knowledge of
these opposing interests. It is only necessary that Signal know that the two relationships are in opposition.
During the term of the Contract,Signal 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,
Signal 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 Signal.
16. Signal shall protect the confidentiality of all applicant records and other materials that are maintained in
accordance with this Contract. Except for purposes directly connected to the administration of Child
Protection,no information about or obtained from any applicant/recipient in possession of Signal shall be
disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in
accordance with Signal written policies governing access to, duplication and dissemination of,all such
information. Signal shall advise its employees,agents,and sub-providers of Signal,if any,that they are
subject to these confidentiality requirements. Signal shall provide its employees,agents,and sub-providers
of Signal,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,
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Contract Number.PY 04-05-CPS-30
(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 Signal in the course of providing services under this Contract will be accorded at least the same
precautions as are employed by Signal for similar information in the course of its own business.
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Contract Number.PY 04-05-CPS-30
EXHIBIT E
STANDARDS OF RESPONSIBILITY FOR CORE SERVICES
1. Signal and Social Services agree to develop a case management plan(aka substance abuse treatment plan)
on each referred family within 30 days of the date Signal received the referral.The case management plan
will be monitored and modified monthly to measure progress toward goals. Copies of the case management
plan must be sent to the caseworker,program area supervisor,and Ms. Elaine Furister,CPS/CAP,Core
Services Specialist,at Weld County Department of Social Services,P.O.Box A,315 13 N 11 Avenue,
Greeley,Colorado, 80632. The case management plan will include,at a minimum,goals,timelines,and
measurement of success.
2. Signal and Social Services agree to resolve level of care conflicts at the Signal/County level through
cooperation. Social Services and Signal shall attempt to resolve all levels of care conflicts and disputes at
the lowest level possible within each organization. Should Social Services and/or Signal fail to agree upon
the level of care offered by Signal,they may appeal the case directly to the County Director,or designee,
and the Signal Chief Executive Officer. Both Signal and Social Services will have an opportunity to
provide consultation and documentation regarding the appeal.Appeals are to be resolved within 72
working hours,unless good cause justifies an extension.
3. Signal agrees that payments for levels of care are not authorized for reimbursement by Social Services until
a referral from Social Services is provided to Signal prior to services rendered by Signal.
4. Signal agrees not to accept any referral from Social Services unless the referral contains all information
required on the form and necessary for reimbursement by Social Services and authorized for
reimbursement according to Exhibit E,Item 20. If Signal accepts the referral without all data fields
required on the referral form or authorization,Signal may assume fiscal responsibility for the services
provided under the incomplete referral. Inaccurate information listed on the referral form by Social
Services will be excluded as a fiscal responsibility for Signal.
5. Signal agrees to provide a monthly client progress report within twenty-five(25)calendar days
immediately after the month of service.The monthly progress report must be attached to the monthly
billing for payment to be honored. Failure to submit such monthly reports will result in delays or forfeiture
of payment. It is expected,at a minimum,that these reports will reflect:
A. Presenting problem(s)of the client/family;and
B. Specific services provided;and
C. Extent of client(s)participation and commitment to program;and
D. Client(s)progress to date;and
E. Anticipated discharge date.
6. Signal agrees to provide a final discharge summary of client outcomes to Social Services within thirty(30)
calendar days after the completion date.
7. Signal agrees to report expenditures and case disbursement at agreed upon times.
8. Signal agrees to provide completed billing forms or reports monthly to Ms.Elaine Furister,CPS/CAP,Core
Services Specialist,that are consistent with Trails,and county,administration and reporting requirements,
within twenty-five(25)calendar days of the month following service in order to receive payment.
9. Signal agrees to assume fiscal responsibility for expenses incurred by Signal that do not meet the
requirements of Exhibit E of this Agreement.Those expenses incurred by Signal outside of the scope of
Exhibit E requirements are not eligible Social Services expenditures and shall not be reimbursed by Social
Services.
10. Signal agrees to the definition of a complete and timely billing form for purposes of submitting an original
bill under Exhibit E,8.A complete and timely billing form must include the following elements.
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Contract Number.PY 04-05-CPS-30
A. The billing must be an original billing signed by the provider and/or designee.
B. The billing must include all forms designed for Core Services reimbursement and approved by
Social Services;Core Services Authorization of Funds,Project Report,Update Report,and original
signed client verification forms for therapy and group services.Additionally,Signal agrees to
provide Social Services monitoring results(UA,BA,patch,tox trap)by faxing said results to Social
Services at 970.346.7698 no later than 72 hours after the day of service.
C. The Department will determine billed services not eligible for payment by identifying conflicts in
the following:
1. Details provided in client referrals and renewals,including approved hours of service,begin
and end dates of service,client name,and Case ID.
2. Details in supporting documentation provided by the Provider and submitted with the
original bill,including,but not limited to,original signed client verifications,receipt of
monitoring results,time of service and 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, 11 C, 1,2,and 3,will supersede all requests from Signal for review of billing
errors. Items submitted for billing will be processed according to the criteria established by the
above documentation.
The Department will make obvious corrections to minor errors in the bill in order to expedite
processing the claims for payment. Minor errors include missing or transposed digits in Household
Numbers,TRAILS Case ID,or other Department-generated information.
D. An Administrative fee may be assessed to all fees reimbursed through County only funding. Such
fees include,but are not limited to,those service fees previously billed and determined by the
Department to be not eligible for payment.
12. Signal 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.
13. Signal,or their authorized designee,will meet with the Social Services designated supervisor quarterly
(more if needed)to review program usage and effectiveness to discuss necessary improvements to better
serve families or increase referrals.
14. Signal will be available to Social Services staff to explain program,time lines of response to referrals and
answer questions to enhance program.
15. Signal,or their authorized designee,will be available for the Families,Youth and Children(FYC)
Commission review and attendance at the FYC meetings.
16. Regarding all forms referenced herein in the Agreement,Signal shall replicate these forms in format,
content and according to the specifications of Social Services or as mutually agreed upon by Signal and
Social Services. Signal agrees to modify these treatment authorization forms according to Social Services
specifications and requirements.
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Contract Number.PY 04-05-CPS-30
17. Social Services will be responsible for electronically authorizing services to various Signal providers and
initially designating if Core funds shall be used for payment. Social Services shall assure that the
authorizations will have all information required for reimbursement from the county.
18. Social Services agrees to provide Signal with the name of a primary contact who will be responsible for
interacting with Signal's data system.
19. Social Services agrees to provide a TRAILS Remittance Advice and a Signal Remittance Advice(Exhibit
G)to Signal within 5 business days of the monthly TRAILS Core Main Payroll date.
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Contract Number.PY 04-05-CPS-30
5310.213 (2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
1. WELD COUNTY 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.
Child's Name on TRAILS TRAILS Case ID Number
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.PY 04-05-CPS-30
WELD COUNTY CORE SERVICES PROGRAM MONTHLY REQUEST FOR REIMBURSEMENT
Remit to: Elaine Furister,CPS,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 Actual Maximum Hours Rate per Monthly Social Payments Services
Entry Date Exit Date Hrs/Service Sessions/Service Unit Total Services Denied/Delayed Payable
Period Period Only-
Comments
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.PY 04-05-CPS-30
WELD COUNTY CORE SERVICES PROGRAM PROJECT REPORT
Remit to: Elaine Furister, CPS,Core Service Specialist
Weld County Department of Social Services
Program Month of Service P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Telephone: 970.352.1551,Ext. 6295
FAX: 970.346.7698
#Households Referred #of Households Enrolled #of Households Served #of Households Monthly Expenditure Expenditures to Date
During Month During Month During Month Discharged During Month
Termination Reason Codes: SEP-Successfully Ended Program;M-Moved;UL-Unable to Locate;RCCF-Entered a Residential Facility;FCR-Foster Care Review;OT-Explain,TM-
Transferred to Another Program More Restrictive;FC-Entered Foster Care;NT-Terminated;Unable to Work with Client;RH-Returning to Relative
Child's Name Direct Date Service Termination Client Caseworker Provider Initial Case Monthly Funding Total Cost Social
Service Ended Reasons Survey Survey Survey Management Progress Source of Program Services
Date Plan(Date) Report to Date Use
Funding Source: M-Medicaid;CI-Client Insurance;O-Other
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Contract Number.PY 04-05-CPS-30
WELD COUNTY CORE SERVICES PROGRAM RE-BILL 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
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:970352.1551,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/ Unit Total Documentation Payable or
(Example: Re-billed Attached Not payable
11111-02) (Include reason if not payable)
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 1 of 1
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Contract Number. PY 04-05-CPS-30
EXHIBIT F
SIGNAL BEHAVIORAL HEALTH NETWORK
QUALIFIED SERVICE ORGANIZATION AGREEMENT
Signal Behavioral Health Network(MSO)and Weld County Department of Social Services(Social Services)hereby enter
into a Qualified Service Organization Agreement whereby the MSO agrees to accept and serve Counties' clients
substance abuse treatment needs. In light of the relationship between County and the MSO,County requires client
identifying information and data and information related to the services furnished to the clients. County and MSO will
have this relationship from June 1,2004-June 30,2005,thus the QSOA will be in effect during this period of time.
Furthermore,the County:
1. Acknowledges that in receiving,storing,processing,or otherwise dealing with any information from
the MSO about the clients in the MSO's program,it is fully bound by the provisions of the federal regulations governing
Confidentiality of Alcohol and Drug Abuse Patient Records,42 CFR Part 2;and
2. Agrees to undertake in resisting judicial proceedings in any effort to obtain access to information
pertaining to clients otherwise thanas expressly provided for in the federal confidentiality regulations,42 CFR Part 2.
Executed this A ts day of <..)U52004.
AIL
William W.Wendt,CEO Judy riego,Direct r
Signal Behavioral Health Network Weldiounty Dep ment of Social Services
RECEIVED BY
JUL 2 6 2004
WELD GOON i v DEPT.
OF SOr9Al. SFPV CE9
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