HomeMy WebLinkAbout20011475.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR ADDITIONAL FAMILY
SERVICES AND AUTHORIZE CHAIR TO SIGN -COMPASS BEHAVIORAL HEALTH
SYSTEMS, 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
Additional Family 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 Compass Behavior Health Systems, LLC, commencing July 1, 2001, and ending
June 30, 2002, 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 Additional Family 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 Compass Behavior Health Systems, 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 4th day of June, A.D., 2001.
BOARD OF COUNTY COMMISSIONERS
L,�` WELD C' NTY, COLORADO
ATTEST: gay / / .,tlt •
61 i it ..- J. eile, Ch it
Weld County Clerk to the'joa . , . "�p , 4 ` ��j Glenn Vaad, Pwo
BY: iT l' f�,,1 t' J Eti
Deputy Clerk to the Board " 17-1-.-r—r'
Wi 'a ' H. Jeke
R ED A ORM:
David . Long
i
ounttyatt(rney
Robert D. Masden
2001-1475
SS0028
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
_ GREELEY,CO 130632
1 WEBSITE:www.co.weld.co.us
{ Administration and Public Assistance(970)352-1551.
111 D eir
Child Support(970)352 6933
COLORAD MEMORANDUM
TO: M.J. Geile, Chair Date: May 28, 2001
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services
RE: Child Protection Agreement for Additional Family Services
Between the Weld County Department of Social Services and
Compass Behavioral Health Systems, LLC
Enclosed for Board approval is a Child Protection Agreement for Additional Family
Services between the Weld County Department of Social Services and Compass
Behavioral Health Systems, LLC.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is from July 1, 2001 through June 30, 2002.
2. This Agreement is a non-financial agreement between the parties. The Colorado
Department of Social Services has provided funding to Compass through Island
Grove Regional Treatment Center to provide alcohol and drug services to
families, children, and adolescents who are eligible due to imminent risk of out-
of-home placement. Compass has initially allocated $99,674.67 to serve eligible
Weld County residents from its regional allocation for Sub-State Planning Area 1.
This area includes Weld, Larimer, Logan, Sedgwick, Phillips, Morgan,
Washington, Yuma, Elbert, Lincoln, Kit Carson and Cheyenne.
3. Island Grove Regional Treatment Center will provide assessments, treatment
options, special program services, on-site staff services, and other related services
for families and adolescents.
If you have any questions, please telephone me at extension 6510.
2001-1475
CHILD PROTECTION AGREEMENT FOR AFS (Additional Family Services)
BETWEEN WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND COMPASS BEHAVIORAL HEALTH SYSTEMS, LLC
This Agreement is made and entered into the 1st day of July, 2001, by and between the
Weld County Department of Social Services, hereinafter referred to as "Social Services," and
Compass Behavioral Health Systems, LLC, hereinafter referred to as "Compass."
WITNESSETH
WHEREAS, required approval, clearance and coordination have been accomplished from
and with appropriate agencies; and
WHEREAS, the Child Welfare Settlement Agreement required, among other things,
Social Services to obtain alcohol and drug CORE services for eligible clients who are at
imminent risk for out-of-home placement in the category of alcohol and drug services; and
WHEREAS, the Colorado Department of Human Services has provided Family Issues
Cash Fund resources to Social Services for alcohol and drug CORE services for families,
children, and adolescents; and
WHEREAS, the Colorado Department of Human Services, Alcohol and Drug Abuse
Division has provided match funds to Signal Behavioral Health Network, Inc., (Signal) to provide
AFS alcohol and drug services to families, children and adolescents who are eligible due to
imminent risk for out-of-home placement; and
WHEREAS, Signal Behavioral Health Network, Inc., (Signal) has contracted with
Compass Behavioral Health Systems, LLC (Compass) to manage and coordinate AFS alcohol
and drug services either directly or through their Participating Providers to eligible families,
children and adolescents in Sub-State Planning Area 1 which includes Weld, Larimer, Logan,
Sedgwick, Phillips, Morgan, Washington, Yuma, Elbert, Lincoln, Kit Carson and Cheyenne
Counties.
NOW, THEREFORE, in consideration of the promises, the parties hereto covenant and
agree as follows:
1 . Term
This Agreement shall become effective on July 1, 2001, upon proper execution of this
Agreement and shall expire on June 30, 2002.
2. Scope of Services
Services shall be provided by Compass directly or through their Participating Providers to
any person(s) eligible for child protection services or youth in conflict services in compliance
with Exhibit A "Scope of Services," a copy of which is attached by reference.
Not all services on the "Scope of Services" attachment are available in each County and
accessibility of the full menu of services is dependent on number of referrals and cost
effectiveness of the service that is requested for that area.
Page 1
Priorities for use of the allocated funds are based on the presenting needs of the eligible
families, children and adolescents requesting services and for which approval for utilization of
the funds has been received by the local Department of Social Services, Compass designated
providers and when necessary Signal.
Social Service Directors can request that Compass/Signal screen and approve additional
qualified providers in their service areas in order to meet established time lines and provide
approved services when the current provider network is unable to meet their needs in a timely
fashion. Social Service Directors may actively participate in recruiting potential provider
candidates and recommending those qualified providers to Compass/Signal. Compass/Signal
will actively assist qualified providers in meeting the screening and required qualifications for
the approval process. Island Grove Regional Treatment Center, Inc. will be the primary provider
for Weld County referrals.
Exhibit B outlines proposed minimum/maximum requirements for on site staffing
services, and outlines initial agreements for funding services from the CORE services dollars
and the ADAD AFS dollars.
3. Payment
Payment shall be made based on Exhibit C, "Region One AFS Service Fee Schedule," a
copy of which is attached and incorporated by reference.
All parties agree to bill according to the attached schedule for approved services. This
contract identifies funding from Compass to create a funding pool from which CORE service
plans were designed. Compass/Signal funds are regionally based, not county based. However,
each county will receive an allocated amount at the beginning of this contract. The initial
allocation will be reviewed by Compass managers on a quarterly basis and may be re-allocated
to areas that are utilizing the funds in order to insure that funds are spent on needed services
for eligible child welfare referrals during the contract period.
In order for Compass to access funds through the Signal contract, families must remain
open on the Colorado Trails system for the entire duration of treatment. The Social Service
agencies agree to maintain eligible clients on the Colorado Trails system until they have been
discharged from treatment.
Compass will submit an itemized statement (Exhibit D) itemizing services provided to
DSS clients, which were paid for through Compass AFS contract funds. This statement will be
forwarded minimally on a quarterly basis for the purpose of informing DSS of services provided
to their referrals from the AFS funding stream.
Services delivered are expressly contingent upon the availability of funds.
The County Plans may allow client co-pay/fees to be assessed on a sliding fee schedule
and collected by the Provider. Services will be performed regardless of the client's refusal or
inability to pay the assessed co-pay. Social Services is responsible for the full payment in the
absence of any collected co-pays. Social Services referrals will not be sent to collections for
default of co-pay.
Page 2
The sliding fee schedule will only be applied to those services as noted on the fee
schedule (Exhibit C) and approved by Social Services; all other fees will be charged directly to
Social Services. Social Services may request a waiver on any referral and no co-pay will be
assessed.
The Provider will collect any applicable co-pays and credit Social Services for any
payments received during that billing period on the monthly billing statement. As applicable,
co-pays will only be collected during the active treatment enrollment period.
4. Funding
Funding for the purpose of funding eligible child welfare clients through ADAD AFS
resources is allocated based on agreements between Compass/Signal and approved providers
located in Sub-State Planning Area 1 .
For the purpose of this contract, Compass/Signal shall initially allocate $99,674.67 from
designated ADAD AFS funds to serve eligible Weld County clients. Based on utilization within
Area 1, Compass/Signal's initial allocation may be increased or decreased based on regional use
patterns.
5. Monitoring and Evaluation
Social Services and Compass/Signal agree that monitoring and evaluation of the
performance of this Agreement shall be conducted through Compass/Signal and Social
Services. Any concerns regarding services should be reported to the direct provider first and if
no satisfactory resolution is reached, Social Services will contact BJ Dean, Managing Partner of
Compass. The final level of appeal can be taken to Bill Wendt, Executive Director, Signal
Behavioral Health Network. The decision of Signal's Executive Director is final.
6. Modification of Agreement
All modifications to this Agreement shall be in writing and signed by all parties.
7. Representatives
For the purpose of this Agreement, the individuals identified below are 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:
Name: Dave Aldridge
Title: Social Services Manager
For Compass:
Name: BJ Dean
Title: Managing Partner, Compass Behavioral Health Systems, LLC
Page 3
8. Termination
This Agreement may be terminated at any time by either party giving 30 days written
notice and is subject to the availability of funding.
9. 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 6 herein.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month and year first above written.
Jt
WELD COUNT EPARTMENT OF SOCIAL SERVICES ' I1� SIG?
By (1 vcat) ATTEST: .�'; co
M. J. Geile (06/04/2001) By: rig
Typed Name Deputy Clerk to the Boa!el
Chair, Weld County Board of Commissioners N
Title
COMPASS BEHAVIORAL HEALTH SYSTEMS, LLC
By ti----
BJ ean, MA, CAC III
Managing Partner
SIGNAL
1.12;4114 BEHAVIORAL HEALTH NETWORK
By (/.J W"t
Bill Wendt
Executive Director
O:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001-02\DSS AFS agmt.doc
5/25/2001
Page 4
EXHIBIT A
SCOPE OF SERVICES
Alcohol and Drug Differential Assessment (2-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, SOCRATES, AODUI, Drinking History
Questionnaire, Family Environment Scale) may be given. Baseline Urinalysis Testing (7-Panel) is included. Summary of
assessment with recommendations sent to referral agency.
The 7-Panel baseline urinalysis test for alcohol and drugs screens for the following:
Tests determine what drugs are present in client.
THC Cutoff Level: 50 ng/ml Amphetamines Cutoff Level: 1000 ng/ml
Cocaine Cutoff Level: 300 ng/ml Barbiturates Cutoff Level: 200 ng/ml
Benzodiazepines Cutoff Level: 200 ng/ml Opiates Cutoff Level: 300 ng/ml
Alcohol .05/100 3-Panel THC, Cocaine, Amphetamines
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:
O Criminal History 0 Profile of Client's Violent Behaviors
O Mental Health Status 0 Client's Potential for Violence
O Medical History 0 Substance Abuse History (see above)
O Suicidal/Psychological/Cultural History 0 Milton Test, if needed
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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, boundaries, and the role alcohol and drugs play in these topics. 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 (8' grade reading level; >18; available in Spanish).
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 dependent on client's goals and progress toward meeting goals.
Individual Counseling (average length of treatment, 6 to 12 sessions)
Primary client is seen on an individual basis. Length of participation dependent on client goals and progress toward goals.
Biofeedback Sessions (average length of treatment, 4 to 8 sessions)
The client will be monitored individually through sensitive computerized biofeedback instruments. The goal of biofeedback is
self-regulation—learning how to regulate both mental and pitlical processes for health and improved functioning.
Biofeedback is used to reduce stress and to demonstrate control over mental and physical impulses and develop deep
relaxation techniques.
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.
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.
Women's Group (average length of treatment, 12-20 sessions)
A gender-specific group addressing issues affecting women and their relationships, such as family violence, co-dependency,
self-esteem and stress management.
Adolescent Domestic Violence Group Therapy(average length of treatment, 15-18 weeks)
Group treatment addresses anger management, gender roles, taking responsibility, and maintenance self control plan. The
assessment will include a Domestic Violence Inventory-J uvenile Version (DVI-J), the Adolescent Self-Assessment Profile II
(ASAP II), and a baseline urinalysis drug screening.
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 (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
(GAIN), and a personalized feedback report.
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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.
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Case Aide
This position will assist in family visits to determine how the family is functioning together while in the home, and to improve
the family's ability to access resources in the community. The case aide can take direction from the primary therapist
assigned to the family or the Social Services caseworker. Duties to be performed by the case aide include, but are not
limited to, providing transportation to therapy, doctors appointments and court, supervised visits, child care while family is in
treatment, run errands such as filling prescriptions, shopping, and assisting in living skill development, assist the family in
developing other service links and miscellaneous functions to facilitate the stabilization of the family. (Case Aide tasks will
be mutually agreed upon between counselor and caseworker and identified in the "Services Plan".)
Fast Track Adolescent Program
The Fast Track Adolescent Program is an Intensive Outpatient Program with residential 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 (SASS!) 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.
Referral Process to Fast Track Program:
Contact Youth Services Program Manager at (970) 356-6664 extension 16. If the Program Manager is not on duty,
inform the staff person that Social Services is referring a Fast Track adolescent and give the youth's case worker's
name so that the Fast Track staff can contact the case worker when they return to duty.
On-Site Staff Services
The scope of the services offered to the local Social Service 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 Service 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.
Enhanced Services
Enhanced services are approved services that are requested by Social Services for specific cases that 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 Compass. In order for Compass to provide the enhanced service, the cost would be outside of the
approved rates. Any additional fees would be negotiated on a case-by-case basis.
An example of a service outside of the approved definitions would be a request for a system evaluation. This would include
collateral contacts as appropriate with schools, parents, primary care giver, probation, and other significant persons in the
identified client's life. The information gathered from the collateral contacts would be included in the assessment findings
and treatment recommendations. If additional service is needed in order to meet a request by a local department such as
parenting skills assessment, additional fees may be added to the basic assessment fee. Psychological exams and
psychiatric testing are not included in the definition of the alcohol and drug evaluation. Normally this type of assessment
would be done with mental health dollars and not alcohol and drug (ADAD) funding. Other services such as home based
services, which have a designated core service funding source, should be paid for out of those funds. Compass could
supplement the home-based services with in-home family alcohol and drug services as appropriate.
Compass providers can arrange for services outside of the approved definitions but the Social Service Department
requesting the specialized service will be charged an additional fee that would be negotiated on a case by case basis by the
designated representative listed in the contract. If the additional cost is recommended to be reimbursed with the ADAD
funds, the cost must be approved by Compass/Signal.
Another example of enhanced services which may be provided with higher fees may be intensive outpatient services, or the
use of a floater* or approved subcontractor for a specific task. The additional cost would be negotiated with the respective
Social Services Department.
Floater - a temporarily assigned staff or subcontractor to perform a time specified alcohol or drug
related approved task.
O:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001-02\AFS Scope sery Exh AAoc
5/24/2001
EXHIBIT B
Weld County Guidelines
On -Site Staff Services:
Child Welfare Section: Minimum of 15 hours per week, maximum of 28 - Weld County
will pay for 15 hours per week from Core service dollars regardless of utilization of on-site
staff person by Social Services. Compass will bill the additional on-site staff time to the
AFS contract on an "as used" basis. 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.
Case Aide/Case Management:
Youth in Conflict Section: Minimum of 16 hours per week, a maximum of 24. Compass
will bill the minimum weekly amount to the ADAD AFS contract regardless of utilization
of the on site case aide/case management by Social Services. Any hours above the 16
per week would also be billed to the ADAD AFS contract on an "as used" basis.
Compass will not bill ADAD for hours that the staff person is not on site (due to illness,
vacation, educational leave etc.) during the 16-hour minimum.
Residential
Residential Services for eligible adult persons and Youth Residential Services may be billed
to CORE or AFS dollars or a combination of funding streams.
Assessments
All Assessments will be paid for through the Social Services CORE Service contract.
Ongoing Treatment
On-going treatment services will be assigned to funding streams according to usage.
Youth Services
If Weld County does not approve Youth in Conflict (YIC) cases eligible for services
through CORE Service dollars, then all on-going YIC adolescent services will be paid for
from the ADAD MS funding stream.
0:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001-02\AFS Sery Exh B.tloc
5/24/2001
EXHIBIT C
Region I
AFS
Fee Schedule
2001-02
Assessments
Alcohol and Drug Differential Assessment $150.00
(includes baseline Urinalysis Test)
Co-Occurring Alcohol and Drug with Domestic Violence $150.00
Vocational"Assessment $175.00
Treatment Options
Co-Occurring Alcohol and Drug with Domestic Violence
Group Therapy ($30 per group) $ 15.00/hour
Co-Pay/Sliding Fee
Family Therapy ($80 session maximum) $ 80.00/hour
Co-Pay/Sliding Fee
Intensive Family Therapy ($90 session maximum) $ 90.00/hour
Co-Pay/Sliding Fee
Individual Counseling $ 60.00/hour
Co-Pay/Sliding Fee
Substance Abuse Group Therapy ($30 per group) $ 15.00/hour
Co-Pay/Sliding Fee
Adult Intensive Outpatient Group ($50 per group) $ 25.00/hour
Co-Pay/Sliding Fee
Women's Services
Differential Assessment $150.00
Individual Counseling $ 60.00/hour
Co-Pay/Sliding Fee
Group Counseling ($30 per group) $ 15.00/hour
Co-Pay/Sliding Fee
Health Education Services $ 15.00/hour
Special Connections - Treatment for pregnant women and postpartum women (Medicaid
reimbursement eligible)
• If on Medicaid, Island Grove will bill Medicaid directly.
• If not on Medicaid, fees are as stated above in Women's Services
Youth Services
Adolescent Detox $185.00 per/day
Adolescent IUD (Fast Track) $ 50.00/hour
Adolescent Residential Support Services KW $115.00/day
Assessment $150.00
Family Counseling $ 80.00/hour
Co-Pay/Sliding Fee
Individual Counseling $ 60.00/hour
Outpatient Group Counseling ($30 per group) $ 15.00/hour
Miscellaneous Services
Case Aide/Case Management Services $ 35.00/hour
Expert Testimony (4 hour maximum) $ 75.00/hour
Case Consultation $ 40.00/hour
(Interdisciplinary Assessment Process)
On-Site Staff Services $ 55.00/hour
Enhanced Services (negotiated on a case by case basis)
Residential Services
Adult Residential Services (Island Grove) $115.00/day
Co-Pay/Sliding Fee
Out-of-Area Adolescent and Adult Residential Services (negotiated on individual basis)
Methadone (negotiated on individual basis)
Other Services
Breathalyser Testing $ 2.00/test
Urinalysis Testing (7-Panel) $ 25.00/test
(3-Panel) $ 15.00/test
Monitored Antabuse $ 2.00/monitor
(If client is not currently enrolled in weekly counseling program(s) of Island Grove Center)
Patch Monitoring $ 40.00/patch
O:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001.02\Fee schedule Bch C 01.02.doc
5/24/2001
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONI'RACTUAL CASE SERVICES
1. WELD County DATE:
2. Compass Behavioral Health Systems
1140'M'Street
Greeley,CO 80631
THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED:
5. SEE ATTACHED LIST
(Name of Client) Household No. (CAT.) (CAT.GRP.)
6. SERVICE:
(Description) (SV.CODE)
7. APPROVAL:
/ / / /
(Caseworker) (Date) (Co.Director or Supervisor) (Date)
8. TO BE COMPLETED BY PROVIDER
Month 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.
Accountant
Typed Name_.
PREPARE IN TRIPLICATE,ORIGINAL AND ONE COPY TO PROVIDER,ONE COPY FOR PENDING FILE.
COMPLETED PROVIDERS FORMS-ORIGINAL TO COUNTY FINANCE OFFICE-COPY TO CASE RECORD
0 VGHuyt000MPASS\FORMSOSSUuthContCsays 01-02 DOC
SOCIAL SERVICES
AFS SERVICES / 200
2001-02
REMIT TO: COMPASS BEHAVIORAL HEALTH SYSTEMS FROM: I CERTIFY THAT THE FOLLOWING SERVICES WERE PROVIDED IN ACCORDANCE WITH THE
1140 M STREET Provider Name- Dept. ABOVE CONTRACT AND AM SUBMITTING STATEMENTS REGARDING TIME SPENT FOR THE
GREELEY, CO 80631 SAME.
Mailing Address
BILLING FOR MONTH OF:
City County
COUNTY OF: SIGNATURE TITLE DATE
SERVICE DESCRIPTION OF SERVICES NO.OF RATE PER TOTAL FEE :.
DATES UNITS.. UNIT
A. MANAGEMENT FEE ASSESSMENT
B. ON-SITE STAFF SERVICES
SERVICE CLIENT NAME HOUSEHOLD REFERRAL APPROVED APPROVED COUN- AFS NO.OF RATE TOTAL FEE
DATES. NUMBER NUMBER ENTRY EXIT SELO/t SERVICES UNITS PER UNIT COMMENTS,ETC
DATE DATE - ID (BELOW) BILLED. _.
PAGE OF PAGE TOTAL $
TOTAL DUE FOR BILLING MONTH: $
ASSESSMENTS(AID,SWS,YOUTH) (.A) CASE AIDE/CASE MANAGEMENT SERVICES (CM) URINALYSIS TEST-7 PANEL (UA7)
GROUP SESSIONS(A/D,SWS,YOUTH) (GS) VOCATIONAL ASSESSMENT (VA) URINALYSIS TEST-3 PANEL (UA3)
FAMILY SESSIONS(AID',.YOUTH) (FS) INDIVIDUAL SESSIONS(A/D.SWS,YOUTH) (IS) BREATHALYSER TESTING (SAC) . .
INTENSIVE FAMILY SESSIONS (In) INTENSIVE OP SESSIONS(ADULT/YOUTH) (TOP) MONITORED ANTABUSE (MA)
ADOLESCENT DETOX (ADT) TRANSITIONAL RESIDENTIAL SERV. (ADULT) (TRT) PATCH MONITORING (PM)
HEALTH EDUCATION SERVICES (HES) ADOLESCENT RES SUP SVS(YOUTH) (ARS)
CASE CONSULTATION (CC) EXPERT TESTIMONY (ET) ..
O:\Kathryn\COMPASS\CONTHACT\NE Counties Contracts&Exh\2001-02\AFS Sys billing.DOC
SOCIAL SERVICES
UA SERVICES
2001-02
REMIT TO: ISLAND GROVE TREATMENT CENTER FROM: I CERTIFY THAT THE FOLLOWING SERVICES WERE PROVIDED IN ACCORDANCE WITH THE
1 140 M STREET Provider Name- Dept. ABOVE CONTRACT AND AM SUBMITTING STATEMENTS REGARDING TIME SPENT FOR THE
GREELEY, CO 80631 SAME.
Mailing Address
BILLING FOR MONTH OF:
City County
COUNTY OF: SIGNATURE TITLE DATE
SERVICE DESCRIPTION OF SERVICES NO.OF. RATE PER TOTAL FEE
DATES UNITS UNIT
A. MANAGEMENT FEE ASSESSMENT
B. ON-SITE STAFF SERVICES
SERVICE CLIENT NAME HOUSEHOLD REFERRAL APPROVED APPROVED COON- CORE ?la OF RATE TOTAL FEE
DATES NUMBER NUMBER ENTRY EXIT SELOR SERVICES UNITS PER UNIT COMMENTS,ETC
-. -. DATE DATE ID (BELOW) BILLED --.. -
-... PAGE OF PAGE TOTAL -. $
TOTAL DUE FOR BILLING MONTH: $
ASSESSMENTS(A/D,SWS.YOUTH) (A I - CASE AIDE/CASE MANAGEMENT SERVICES (CM) URINALYSIS TEST-7 PANEL (UA7).
GROUP SESSIONS(A/D,SWS,YOUTH) (GS) VOCATIONAL ASSESSMENT (VA) URINALYSIS TEST-3 PANEL (UA3)
FAMILY SESSIONS(A/D, YOUTH) (FS) INDIVIDUAL SESSIONS(A/D,SWS,YOUTH) (IS) BREATHALYSER TESTING (RAC)
INTENSIVE FAMILY SESSIONS OFT) INTENSIVE OP SESSIONS(ADULT/YOUTH) (LOP) MONITORED ANTABUSE (MA)
ADOLESCENT DETOX (ADT) TRANSITIONAL RESIDENTIAL SERV. (ADULT) (TRT) PATCH MONITORING (PM)
HEALTH EDUCATION SERVICES (HES) ADOLESCENT RES SUP SVS(YOUTH) (ARS)
CASE CONSULTATION (CC) EXPERT.TESTIMONY (ET) --.
O:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001-02\UA SVS.doc
SOCIAL SERVICES
PATCH MONITORING SERVICES
2001-02
REMIT TO: ISLAND GROVE TREATMENT CENTER FROM: I CERTIFY THAT THE FOLLOWING SERVICES WERE PROVIDED IN ACCORDANCE WITH THE
1140 M STREET Provider Name-Dept. ABOVE CONTRACT AND AM SUBMITTING STATEMENTS REGARDING TIME SPENT FOR THE
GREELEY, CO 80631 SAME.
Mailing Address
BILLING FOR MONTH OF:
City County
COUNTY OF: SIGNATURE TITLE DATE
SERVICE DESCRIPTION OF SERVICES NO.OF RATE PER TOTAL PEE
DATES UNITS UNIT
A. MANAGEMENT FEE ASSESSMENT
B. ON-SITE STAFF SERVICES
SERVICE CLIENT NAME HOUSEHOLD REFERRAL APPROVED APPROVED COON- CORE NO.OF RATE TOTAL FEE
DATES NUMBER NUMBER ENTRY EXIT SELOR SERVICES UNITS PER.UNIT COMMENTS,ETC
DATE DATE ID (BELOW) BILLED /
PAGE_ OF PAGE TOTAL_.. $
TOTAL DUE FOR BILLING MONTH: $
ASSESSMENTS(A/D,SINS, YOUTH) (A) CASE AIDE/CASE MANAGEMENT SERVICES ((CM) URINALYSIS TEST-7 PANEL (UA7).
GROUP SESSIONS(A/D,SWS,YOUTH) (GS) VOCATIONAL ASSESSMENT (VA) URINALYSIS TEST- 3 PANEL (UA3)
FAMILY SESSIONS(A/D,YOUTH) IFS) INDIVIDUAL SESSIONS(A/D,SWS,YOUTH) (IS) BREATHALYSER TESTING (BAC)
INTENSIVE FAMILY SESSIONS (WTI INTENSIVE OP SESSIONS(ADULT/YOUTH) (IOP) MONITORED ANTABUSE (MA)
ADOLESCENT DETOX (ADT) TRANSITIONAL RESIDENTIAL SERV. (ADULT) (TAT) PATCH MONITORING (PM)
HEALTH EDUCATION SERVICES (HES) ADOLESCENT RES SUP SVS(YOUTH) (ARS)
CASE CONSULTATION (CC) EXPERT TESTIMONY (Er) _.
O:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001-02\Patch Svs.DOC
SOCIAL SERVICES
BAC SERVICES
2001-02
REMIT TO: ISLAND GROVE TREATMENT CENTER FROM: I CERTIFY THAT THE FOLLOWING SERVICES WERE PROVIDED IN ACCORDANCE WITH THE
1 140 M STREET Provider Name- Dept. ABOVE CONTRACT AND AM SUBMITTING STATEMENTS REGARDING TIME SPENT FOR THE
GREELEY, CO 80631 SAME.
Mailing Address
BILLING FOR MONTH OF:
City County
COUNTY OF: SIGNATURE TITLE DATE
SERVICE DESCRIPTION OF SERVICES NO.OF RATE PER TOTAL FEE
DATES. . UNITS UNIT
A. MANAGEMENT FEE ASSESSMENT
B. ON-SITE STAFF SERVICES
SERVICE. . CLIENT NAME HOUSEHOLD REFERRAL APPROVED APPROVED COON-. CORE NO.OF RATE TOTAL FEE
DATES NUMBER NUMBER ENTRY EXIT SELOR SERVICES UNITS PER UNIT COMMENTS,ETC
DATE DATE ID (BELOW). . BILLED
PAGE OF_ PAGE TOTAL
TOTAL DUE FOR BILLING MONTH: S
ASSESSMENTS(A/D,SWS,YOUTH) I A) CASE AIDE/CASE MANAGEMENT SERVICES (CM) '.URINALYSIS TEST-7 PANEL (UA7)
GROUP SESSIONS(A/O,SWS,YOUTH) (OS) VOCATIONAL ASSESSMENT (VA) URINALYSIS TEST- 3 PANEL (UAS)
FAMILY SESSIONS IA/D,YOUTH) (ES) '. INDIVIDUAL SESSIONS(AID,SWS,YOUTH) (IS) BREATHALYSER TESTING (BAC)
INTENSIVE FAMILY SESSIONS OFT) INTENSIVE OP SESSIONS(ADULT/YOUTH) OOP) MONITORED ANTABUSE (MA)
ADOLESCENT DETOX (ADT) TRANSITIONAL RESIDENTIAL SERV. (ADULT) (TRY) PATCH MONITORING (PM)
HEALTH EDUCATION SERVICES (HES) ADOLESCENT RES SUP SVS(YOUTH) (ARS)
CASE CONSULTATION (CC) EXPERT TESTIMONY (ET)
O:\Kathryn\COMPASS\CONTRACT\NE Counties Contracts&Exh\2001-02\BAC Svs.doc 5/24/2001
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