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Home My WebLink About20032721.tiff RESOLUTION RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES FOR DRUG AND ALCOHOL TESTING AND AUTHORIZE CHAIR TO SIGN - MAYFIELD DRUG SCREENING 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 for Drug and Alcohol Testing 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 Mayfield Drug Screening, commencing September 1, 2003, and ending February 28, 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 for Drug and Alcohol Testing 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 Mayfield Drug Screening 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 24th day of September, A.D., 2003, nunc pro tunc September 1, 2003. BOARD OF COUNTY COMMISSIONERS n / �J WE�OUNTY, COLORAD ATTEST: g ��'/��/' ,�J ccnn+�)II l �(/�/w`av/( vid o , Ch Y Weld County Clerk to the Board /' Robert D. M en, Pro-Tem BY: _t:- -� �� Deputy Clerk to the Board M. J. ile A ED AS oC . /? —t William H. Jerke County Attor y EXCUSED Glenn Vaad Date of signature: i /5/03 2003-2721 SS0030 4O, —S—)(: ©-11e) Contract Number 03-CPS-29 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES AND MAYFIELD DRUG SCREENING This Agreement,made and entered into the_day of August 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 Mayfield Drug Screening,hereinafter referred to as "Mayfield." WITNESSETH WHEREAS,required approval, clearance,and coordination have been accomplished from and with appropriate agencies; and WHEREAS,the Colorado Department of Human Services has provided Child Welfare Regular Administration funding to Social Services for immediate referrals for monitored sobriety services for families, children,and adolescents;and WHEREAS,Social Services requires the services of a substance abuse testing and screening provider to assist the County to deliver services for referrals for monitored sobriety to child welfare clients,and Mayfield is willing and able to provide such services; and WHEREAS,Mayfield is a Colorado non-profit organization organized for the purpose of alcohol and drug test screening. NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on September 1,2003,upon proper execution of this Agreement and shall expire February 28,2004,unless sooner terminated as provided herein. 2. Snnpe of Servines Services shall be provided by Mayfield network providers to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"a copy of which is attached by reference. 3. Payment a. Payment shall be made on the basis of Exhibit B, "Payment Schedule,"and Exhibit C, "Fee Schedule,"copies of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement,which will be paid from Child Welfare Regular Administration funds during the duration of this Agreement. Mayfield,in accordance with federal HIPAA regulations,will be adopting the standard transaction code set for all treatment services on or before October 16, 2003. Even though this compliance will change the service labels and groupings,the net fees associated with those services will not change. b. Mayfield 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. Mayfield shall submit all itemized monthly billings to Social Services no later Page 1 of 16 Contract Number 03-CPS-29 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. 4. Financial Manag-.ment At all times from the effective date of this Contract until completion of this Contract,Mayfield 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 Methnd Unless otherwise provided in the Scope of Services and Payment Schedule: a. Mayfield 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 Mayfield has failed to comply with the Financial Management Requirements,program objectives,contractual terms, or reporting requirements. In the event of a forfeiture of reimbursements,Mayfield may appeal such circumstance to the Director of Social Services. The decision of the Director of Social Services shall be final. 6. Accnranres Mayfield shall abide by all assurances as set forth in the attached Exhibit D,which is attached hereto and incorporated herein by reference. 7. flnmpliance with Applicable Taws At all times during the performance of this contract,Mayfield 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. Mayfield acknowledges that the following laws are included: Tide 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 Tide 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; Page 2 of 16 Contract Number 03-CPS-29 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,Mayfield and Social Services will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 CFR Part 2. Included is 45 C.F.R.Part 74 Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies,equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all federal and/or state financial assistance. Any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S.Department of Health and Human Services, Office for Civil Rights. 8. Certifications Mayfield 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 F,valnation Mayfield and Social Services agree that monitoring and evaluation of the performance of this Agreement shall be conducted by Mayfield and Social Services. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners and Mayfield. Mayfield shall permit Social Services,and any other duly authorized agent or governmental agency,to monitor all activities conducted by Mayfield 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 Mayfield 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 Mayfield. These remedial actions are as follows: a. Withhold payment to Mayfield 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 Mayfield 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; Page 3 of 16 Contract Number 03-CPS-29 c. Incorrect payment to Mayfield due to omission,error,fraud,and/or defalcation shall be recovered from Mayfield by deduction from subsequent payments under this Agreement or other agreements between Social Services and Mayfield,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 Rnmansik Social Services Administrator Name Title For Mayfield: J aura Mayfield Executive Director,Mayfield 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: Mayfield Judy A Gringo Director Torn Allbrandt,Executive Director 2 O Box A 170 West Olive ('rreeley,CO 20647 Fort Collins CO 20571 14. Litigation Mayfield shall promptly notify Social Services in the event that Mayfield learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Mayfield, 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. Mayfield 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. Page 4 of 16 Contract Number 03-CPS-29 TNESS'WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year first �v�ST: WELD COUNTY—Leg" BOARD OF COUNTY 1861 fC .ERK TO THE BOARD COMMISSIONERS WELD Ce COUN , O O ® Y 2� By. E4 2003 eputy Clerk Davi .Long,Chair AP E AS MAYFIELD l 'Y� BY I County Atto ey Lora Allbrandt,Executive ctor WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: • D e tor Page 5 of 16 Contract Number 03-CPS-29 EXHIBIT A SCOPE OF SERVICES Special Conditions: A. Mayfield will conduct monitored sobriety for Social Services' clients at the Weld County Department of Social Services,Annex building in Greeley and the South County Office in Del Camino. B. Mayfield will confirm any positive and negative monitored sobriety results within 24 hours through a phone call and a fax to the Social Services caseworker. C. Mayfield will use the Instant Drug Screen(drugs plus adulteration check)and the Saliva Test (alcohol only)with Social Service clients. D. Mayfield will provide a qualified monitored sobriety collector on site three days a week at the Department of Social Services from 3:00 p.m.-7:00 p.m.,or as modified by Social Services. Page 6 of 16 Contract Number 03-CPS-29 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment Social Services agrees to reimburse to Mayfield in consideration for the work and services performed,a total amount not to exceed Thirty Thousand Dollars($30,000.00)under Child Welfare Regular Administration funding. Expenses incurred by Mayfield,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 Mayfield for default of co-pay/fees. Services will be performed regardless of client's refusal or inability to pay co-pay. Mayfield 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 Mayfield 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 7 of 16 Contract Number 03-CPS-29 EXHIBIT C COLLECTION FEES Six Panel Instant UA Drug Screen, (screens for THC, Cocaine, Meth/Amphetamines, Opiates, and Benzodiazepines) $ 12.00 Saliva Test(alcohol only) $ 1.50 Any positive result will be rescreened by GC/MS confirmation $ 12.00 Mayfield will provide court testimony at no charge to Social Services $ 0.00 Page 8 of 16 Contract Number 03-CPS-29 EXHIBIT D ASSURANCES 1. Mayfield 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 Mayfield-contracted providers or its employees,volunteers, or agents while performing duties as described in this Agreement. Mayfield shall indemnify,defend,and hold harmless Weld County,the Board of County Commissioners of Weld County,its employees,volunteers,and agents. Mayfield 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,Mayfield 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. Mayfield 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. Mayfield 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 Mayfield. 9. All such records,documents,communications,and other materials shall be the property of Social Services and shall be maintained by Mayfield,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. Mayfield 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 Page 9 of 16 Contract Number 03-CPS-29 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,theft successors,heirs,legal representatives,and assigns. Mayfield or Social Services may not assign any of its rights or obligations hereunder without the prior written consent of both parties. 12. Mayfield certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of Mayfield,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. Mayfield assures that it will fully comply with all other applicable federal and state laws. Mayfield understands that the source of funds to be used under this Contract is Child Welfare Regular Administration funds. 14. Mayfield 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 nereccary 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,Mayfield 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,Mayfield 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 Mayfield. 16. Mayfield 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 Mayfield shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in Page 10 of 16 Contract Number 03-CPS-29 accordance with Mayfield written policies governing access to,duplication and dissemination of,all such information. Mayfield shall advise its employees,agents,and subcontractor, if any,that they are subject to these confidentiality requirements. Mayfield 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(I)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 Mayfield in the course of providing services under this Contract will be accorded at least the same precautions as are employed by Mayfield for similar information in the course of its own business. Page 11 of 16 Contract Number 03-CPS-29 EXHIBIT E CHILD WELFARE REGULAR ADMINISTRATION FUNDS Standards of Responsibility. Mayfield agrees to: 1. Provide a written report to the Social Services caseworker within 24 hours of providing services to the client; 2. When a monitored sobriety result is positive Mayfield agrees to leave a voice mail message to the referring caseworker within 24 hours of providing the service. 3. Report expenditures and case disbursement at agreed upon times. 4. Submit monthly-completed billing forms to Ms.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. 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. The provider shall 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 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 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. Page 12 of 16 Contract Number 03-CPS-29 3). Requests for payment must be date stamped by Social Services by the 25th day of the month following the service month.Requests for payment received after the 25th of the month following service will not be honored. 4). Re-bills for services must include only those items Mayfield 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 meet with Social Services FPP Supervisor quarterly(more if needed)to review program usage and effectiveness to discuss necessary improvements to better serve families or increase referrals; 9. Be available to meet with the Social Services staff to explain program,time lines of response to referrals and answer questions to enhance program. 10. Be available for the Families,Youth and Children Commission review and attendance at the FYC meetings. Page 13 of 16 Contract Number 03-CPS-29 5310.213 (2/79) COLORADO STATE DEPARTMENT OF SOCIAL SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES 1. WET D COT iNTY 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. Page 14 of 16 Contract Number 03-CPS-29 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 HII# Referral it 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 15 of 16 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 1DI#&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 ifs 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 16 of 16 DEPARTMENT OF SOCIAL SERVICES PO BOX A 'irckt GREELEY,CO 80632 WEBSITE:: , ; www.co.weid.co.us Administration and Public Assistance(970)352-1551 C Child Support(970)352-6933 COLORADO • MEMORANDUM TO: David E. Long, Chair Date: September 22, 2003 Board of County Commissioners n FR: Judy A. Griego, Director, Social Services uo1(1 a O RE: Child Protection Agreement for Services Between Weld County Department of Social Services and Mayfield Drug Screening Enclosed for Board approval is a Child Protection Agreement for Services between the Weld County Department of Social Services and Mayfield Drug Screening. The Agreement was reviewed at a Work Session with the Board on August 18, 2003. The major provisions of the Agreement are as follows: 1. The term of the Agreement will be September 1, 2003 through February 28, 2004, under a six-month trail period. 2. The Department agrees to reimburse Mayfield a maximum of$30,000 for drug and alcohol testing at rates provided in the Agreement. 3. Mayfield agrees to provide drug and alcohol testing for adults and juveniles who are involved in Dependency&Neglect or Youth In Conflict cases at the physical locations of our Greeley Annex facility and the Southwest County facility. If you have any questions, please telephone me at extension 6510. 2003-2721 Hello