HomeMy WebLinkAbout20031865.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - STILLWATER SERVICES, LLC
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 Stillwater
Services, LLC, commencing July 1, 2003, and ending June 30, 2004, 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 Stillwater
Services, LLC, 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 21st day of July, A.D., 2003, nunc pro tunc July 1, 2003.
BOARD OF COUNTY COMMISSIONERS
�/ ,�_ WEL OUN T , COLO DO
ATTEST: L4' I d
David E. Long, Chair
�z it Clerk to the Board
♦ EXCUSED
Robert D. M den, Pro-Tem
1861 to the Board
. J. eile TOS-0 It William H. Jer e
ounty Attor ey EXCUSED
Glenn Vaad
Date of signature: 5?-13'-.O?
2003-1865
SS0030
Oc c;
Contract Number. 03-CPS-29
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND STILLWATER SERVICES,LLC
This Agreement,made and entered into the // day of Ju/7 2003,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 Stillwater Services, LLC,hereinafter referred to as
"Stillwater."
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 services for families, children, and adolescents; and
WHEREAS, Social Services requires the services of a individual and family service provider to assist the
County to deliver anger management services to child welfare clients,and Stillwater is willing and able to provide
such services;and
WHEREAS,Stillwater is a Colorado for-profit Limited Liability 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. Tenn
This Agreement shall become effective on July 1,2003,upon proper execution of this Agreement and shall
expire June 30, 2004,unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by Stillwater 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.
b. Stillwater 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. Stillwater 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.
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.
Page 1 of 15
Contract Number. 03-CPS-29
4. Financial Management
At all times from the effective date of this Contract until completion of this Contract, Stillwater 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. Stillwater shall provide proper monthly-itemized invoices for costs incurred in the performance of the
agreement.
b. Social Services may withhold any payment if Stillwater has failed to comply with the Financial
Management Requirements,program objectives, contractual terms,or reporting requirements. In the
event of a forfeiture of reimbursements, Stillwater may appeal such circumstance to the Director of
Social Services. The decision of the Director of Social Services shall be final.
6. Assurances
Stillwater 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, Stillwater 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. Stillwater acknowledges that the following laws are included:
Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-1 et seq and its implementing
regulation,45 C.F.R.Part 80 et seq•and
Section 504 of the Rehabilitation Act of 1973,29 U.S.C. Section 794,and its implementing
regulations,45 C.F.R.Part 84;and
- the Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et seq.and its implementation
regulations,45 C.F.R.Part 91;and
Title VII of the Civil Rights Act of 1964;and
the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
- the Education Amendments of 1972;and
Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
and all regulations applicable to these laws prohibiting discrimination because of race, color,national
origin,and sex,religion and handicap, including Acquired Immune Deficiency Syndrome(AIDS)or AIDS
related conditions, covered under Section 504 of the Rehabilitation Act of 1973,as amended, cited above.
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.
Page 2 of 15
Contract Number. 03-CPS-29
8. Certifications
Stillwater 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
Stillwater and Social Services agree that monitoring and evaluation of the performance of this Agreement
shall be conducted by Stillwater and Social Services. The results of the monitoring and evaluation shall be
provided to the Board of Weld County Commissioners and Stillwater.
Stillwater shall permit Social Services,and any other duly authorized agent or governmental agency,to
monitor all activities conducted by Stillwater 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
Stillwater 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 Stillwater.
These remedial actions are as follows:
a. Withhold payment to Stillwater 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 Stillwater 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 Stillwater due to omission,error,fraud,and/or defalcation shall be recovered from
Stillwater by deduction from subsequent payments under this Agreement or other agreements between
Social Services and Stillwater,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 Stillwater:
Shari Simmons or Nathan Ruxman Member,Stillwater
Name Title
Page 3 of 15
Contract Number. 03-CPS-29
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: Stillwater
May A ('.riego,Director Shari Simmnnc nr Nathan Bnxman
p O Box A PO Box 11605R
Greeley,CO 80619 Greeley,CO 50614
14. Litigation
Stillwater shall promptly notify Social Services in the event that Stillwater learns of any actual litigation in
which it is a party defendant in a case that involves services provided under this Agreement. Stillwater,
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. Stillwater reserves the right to suspend services to clients if funding is no
longer available.
16. Fntire 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: a. ., �,/��Ctw► �•
WELD CO ,rwp !'•OARD OF COUNTY COMMISSIONERS
CLERK TO THE BOARD Viol (Il _�/ :1/42 ELD C TY,COLORADO
By: g :y:
D-.uty Clerk y David E.Long,Chair L 1 2003
APPRO ' D AS . S '. : STILLWATER
• . Lc.si.v 7-'4-03
o ,�•homey Shari S' ons,Member
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES f �/
By: 1 By: /�(/// J/ciw-- friA 7-/rn3
Dr c or Nathan Buxn6n Member
Page4of15 l3- /'(psi
Contract Number. 03-CPS-29
EXHIBIT A
SCOPE OF SERVICES
Assessments
Upon request by Social Services, Stillwater will conduct an extensive assessment to determine whether a
youth meets the criteria for an anger management course. During this assessment, a youth's history,legal
record,current coping strategies,and support system will be addressed. Upon completion of the
assessment,a copy of each evaluation and its coinciding recommendations will be delivered to the
requesting caseworker at the Department. If determined that a youth may benefit from anger management
coaching, a recommendation will be made to Social Services that the youth attend a 12-week Anger
Management Course offered by Stillwater.
Treatment
Stillwater offers a 12-week Anger Management Course that serves both as a support and education group.
Classes are one night a week and last 1 '/2 hours. The class material is based on several adolescent-focused
curriculums,including the RETHINK model and The Angry Self Curriculum For Youth. A multi-modality
approach that incorporates audio,visual,role-plays, and bookwork is utilized in each session. Sessions are
more effective with a minimum of three students in attendance. During these sessions, gift certificates,pop,
and community service hours will be offered for youth attendance,participation, and homework completion.
Page 5 of 15
Contract Number. 03-CPS-29
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to Stillwater in consideration for the work and Services performed, a
total amount not to exceed Two Thousand Five Hundred Dollars($2,500.00)under Child Welfare Regular
Administration funding.
Expenses incurred by Stillwater, 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 nut be sent to collections by Stillwater 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
Stillwater 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.
Page 6 of 15
Contract Number. 03-CPS-29
EXHIBIT C
FEE SCHEDULE
Child Welfare Regular Administration Funds
Fee Schedule-2003-2004
Anger Management Assessments $100.00
Anger Management Support/Education Groups $240.00/Course or$20.00/Class
Page 7 of 15
Contract Number. 03-CPS-29
EXHIBIT D
ASSURANCES
1. Stillwater 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 Stillwater-contracted
providers or its employees,volunteers,or agents while performing duties as described in this Agreement.
Stillwater shall indemnify,defend, and hold harmless Weld County,the Board of County Commissioners of
Weld County, its employees, volunteers,and agents. Stillwater 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, Stillwater 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. Stillwater 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. Stillwater 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 Stillwater.
9. All such records, documents,communications,and other materials shall be the property of Social Services
and shall be maintained by Stillwater,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. Stillwater 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.
Page 8 of 15
Contract Number. 03-CPS-29
11. This Contract shall be binding upon the parties hereto,their successors,heirs,legal representatives,and
assigns. Stillwater or Social Services may not assign any of its rights or obligations hereunder without the
prior written consent of both parties.
12. Stillwater certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of
Stillwater, 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. Stillwater assures that it will fully comply with all other applicable federal and state laws. Stillwater
understands that the source of funds to be used under this Contract is Child Welfare Regular Administration
funds.
14. Stillwater 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, Stillwater 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, Stillwater 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 Stillwater.
16. Stillwater 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 Stillwater shall
be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in
accordance with Stillwater written policies governing access to,duplication and dissemination of,all such
information. Stillwater shall advise its employees,agents, and subcontractor, if any,that they are subject to
these confidentiality requirements. Stillwater 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.
Page 9 of 15
Contract Number. 03-CPS-29
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 Stillwater in the course of providing services under this Contract will be accorded at least the same
precautions as are employed by Stillwater for similar information in the course of its own business.
Page 10 of 15
Contract Number. 03-CPS-29
EXHIBIT E
CHILD WELFARE SERVICES
Stillwater agrees to:
1. Provide a written report to the Social Services caseworker within 24 hours of providing services to the
client;
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
the Department. If in the resolution process,the provider will not re-bill for payment unless the provider can
justify payment by documentation.The Department will not consider payments that were originally
reviewed as deficient in documentation without new documentation to justify payment.The Department
shall receive the Request for Reimbursement no later than five business days from receipt of a certified
letter from the Department documenting such denials of payment.
7. Work with family to prepare to pay for services beyond established time frame.
8. 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.
1) 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.
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.
Page 11 of 15
Contract Number. 03-CPS-29
4) Re-bills for services must include only those items Stillwater 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.
9. Will develop and utilize evaluation tools(pre and post assessment test instruments)to collect necessary data
in cooperation with the Departments staff to monitor the effectiveness of the program;
10. Will meet the Department FPP Supervisor quarterly(more if needed)to review program usage and
effectiveness to discuss necessary improvements to better serve families or increase referrals;
11. Be available to meet with the Departments staff to explain program,time lines of response to referrals and
answer questions to enhance program;
12. Be available for the Families, Youth and Children Commission review and attendance at the FYC meetings.
Page 12 of 15
Contract Number. 03-CPS-29
5310.213 (2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
1. WELD COT TNTY 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 Date
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.
Page 13 of 15
Contract Number. 03-CPS-29
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
Page 14 of 15
Contract Number. 03-CPS-29
WELD COUNTY RE-BILL UNDER CHILD WELFARE REGULAR ADMINISTRATION FUNDS AND ADDITIONAL REQUEST FOR REIMBURSEMENT
Remit to:Elaine Punster,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 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 15 of 15
DEPARTMENT OF SOCIAL. SERVICES
PO BOX A
GREELEY,CO 80632
VI
DC WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
COLORADO
MEMORANDUM
TO: David E. Long, Chair Date: July 16, 2003
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services ,k,tiakA Ct (!W.C110
RE: Child Protection Agreement for Services Between the Weld
County Department of Social Services and City of Evans jl aka,
Enclosed for Board approval is a Child Protection Agreement for Services between the
Weld County Department of Social Services (Department) and Stillwater Services. The
Agreement was discussed and reviewed at the Board's Work Session of June 23, 2003.
The major provisions of the Agreement are:
1. The term of the Agreement is July 1, 2003 through June 30, 2004.
2. Stillwater Services will provide an adolescent-focused anger management
assessment and treatment services for youth involved with the Youth In Conflict
system.
3. The Department agrees to reimburse Stillwater Services a maximum of$2,500.
Stillwater Services' rates are $100 per youth for assessment and $240 per youth
per course or $20.00 per class per youth.
4. The source of funding is Child Welfare Administration funding.
If you have any questions, please telephone me at extension 6510.
2003-1865
Hello