HomeMy WebLinkAbout910775.tiff , -- �.
RESOLUTION
RE: APPROVE FAMILY PLANNING PROGRAM CONTRACT BETWEEN WELD COUNTY HEALTH
DEPARTMENT AND COLORADO DEPARTMETN OF HEALTH AND AUTHORIZE CHAIRMAN TO
SIGN
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 Family Planning Program
Contract between the Weld County Health Department and the Colorado Department
of Health, commencing July 1, 1991, and ending June 30, 1992, with the further
terms and conditions being as stated in said Contract, and
WHEREAS, after review, the Board deems it advisable to approve said
Contract, 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, that the Family Planning Program Contract between the Weld
County Health Department and the Colorado Department of Health be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said Contract.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 5th day of August, A.D. , 1991, nunc pro tune
July 1, 1991.
�� BOARD OF COUNTY COMMISSIONERS
ATTEST: WELD COUNTY, COLORADO
Weld County Clerk to the Board
/� Gordon . c t rman
B l_.�- -a )/ Ll e L Y / C� i x "r_c_ .--2--,---,___- �-
Deputy Ca€rk to the Board Geor a Kennedy, Pro-Teem ' L
APPROVED A O FORM: �ijrade £ZG -
07 _4...40,0 Constance L. Harbert
if 271-C
County Attorney C. W. Kirby
r
W. H. Webster
910775
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4210 East 11th Avenue Ptarmigan Ptarmigan�"o�
c3a» 32a1�Y9 _ ,.: ROY ROMER
Denver, Colorado 80220.3718 Governor
Phone(303) 320.8333 ?Ira N.mnd BIM(Ilinidlnetionvar
(309) 366•%59
1 !!� Grand Junction Otda JOEL KAHN
COLORADO
OL OR M (303) 248.7198 Interim Executive Director
LVI�t]W Pueblo Office
DEPARTMENT (719) 643.8441
OFAHEALTH
DATE ?'--42-f/
FROM ACCOUNTING
APPROVED COPY OF AGREEIMNT FAA FPP 92- 06d
FOR YOUR FILES
GWEN TINSLEY
raj
Fmn 6-AC-0U IR S/a51 DEPARTMENT OR AGENCY NUMBER
260000 -- FAA
CONTRA ' INnrER
CONTRACT
THIS CONTRACT, made this 1St thy of July 199 1 . by and between the
State of Colorado for the use and benefit of the Department of 't HEALTH
4210 E. 11th Avenue, Denver, Colorado 80220
hereinafter refereed to as the State,and '= WELD COUNTY HEALTH DEPARTMENT, 1517 16th Avenue Court,
Greeley. Colorado 80631-4597
hereinafter refened to as the contractor,
WHEREAS, authority exists in the Law and Funds have been budgeted, appropriated and otherwise made
available and a sufficient unencumbered balance thereof remains available for payment in Fund Number 100
APPR code 625 , Contract Encumbrance Number FAAFPP920014 ; and
WHEREAS, required approval, clearance and coordination has been accomplished from and with appropriate
agencies;and
WHEREAS,3 the State has formulated a comprehensive State Plan relative to
the Family Planning Program; and
WHEREAS, said comprehensive State Plan allocates funds to be utilized to
implement the Family Planning Program in order to provide these health care
services to the people of Colorado; and
WHEREAS, the Contractor is considered by the State to be an appropriate
agency to fulfill the requirements of the program as herein set forth.
NOW THEREFORE, it is hereby agreed that for and in consideration of their
mutual promises to each other, hereinafter stated, the parties hereto agree as
follows:
1.4 The Contractor will conduct a comprehensive family planning program
in Weld County which will comply with all applicable regulations
and subsequent amendments as described in Title X (42 CFR, Subpart A, Part
59) as authorized under Section 1001 of the Public Health Service Act,
published in the Federal Register on June 30, 1980, a copy of which has
been made available to the Contractor.
2. The Contractor will make this family planning program available to men
and women in their reproductive years and will offer the following
components as applicable:
a) Outreach services and/or other program effort for patient
recruitment.
Page 1 of 8 pages
91.07'75
b) Nursing and -"Meal services which shall inc1 -=e a comprehensive
health and :. .vial history and physical exami .cion, in accordance
with Title X (42 CFR, Subpart A, Part 59) as authorized under Section
1001 of the Public Health Service Act, published in the Federal
Register on June 30, 1980, and the Nursing-Medical Policies and
Procedures established by the Colorado Department of Health Family
Planning Program, copies of which have been made available to the
Contractor.
c) Contraceptive information, education, and supplies regarding all
family planning methods.
d) Education and counseling regarding family planning, family
planning methods, child spacing, infertility, sterilization,
nutrition, sexually transmitted diseases, HIV/AIDS, and related
health issues.
e) Follow-up and/or referrals, as appropriate.
3. The Contractor will, on or after the date of this contract, employ only
individuals under this contract who meet the minimum qualifications as set up
by the State Nursing Section and Family Planning Program for each position.
(If there is any reason to question whether or not an applicant may meet these
minimum qualifications for education or experience, it is necessary to submit
the application to the State Family Planning Program for review and approval
prior to employment. )
4. The contractor agrees to render acceptable services as determined by the
State Family Planning Program. This includes compliance with applicable
Nursing-Medical Policies and Procedures established by the Colorado Department
of Health Family Planning Program, Title X (42 CFR, Subpart A, Part 59) as
authorized under Section 1001 of the Public Health Service Act, published in
the Federal Register on June 30, 1980, copies of which have been made
available to the Contractor, and all fiscal and administrative policies of the
Colorado Department of Health Family Planning Program. These have been made
available to the Contractor. Program medical/nursing performance will be
reviewed on site visits and by audits pursuant to the medical/nursing
standards and judged acceptable or not. The nursing consultant and
administrators assigned by the State Family Planning Program shall have the
authority for periodic evaluation of the delegate family planning program
based on standards and policies established by the Family Planning Program.
The Contractor agrees to cooperate in any evaluation and program
recommendations directed by the State.
5. The State will continue payment for family planning services so long as
the Contractor submits acceptable data as determined by the State using the
Family Planning Data System Clinic Visit Log and Patient Visit Sample which
are attached and by this reference made part hereof as Attachment A. Data on
all visits will be collected on log sheets; additional information will be
sampled periodically. Both will be done in accordance with the instructions
in the data manual and in time periods stated therein. (Manuals have been
made available to the Contractor. ) Changes in the order of the log items may
be negotiated individually between the State and the Contractor. Any agreed
upon changes will be verified in writing by the State, Family Planning Program.
Page 2 of 8
•
6. The State wi__ pay $94,749 (Ninety-four thous__.d seven hundred forty-nine
dollars) to provide contraceptive services to approximately 1675 comprehensive
family planning patients, $5,893 (Five thousand eight hundred ninety-three
dollars) to provide colposcopy and biopsy services to 33 patients, and $1,458
(One thousand four hundred fifty-eight dollars) to provide cryosurgery
services to 19 patients (for fiscal year 1992) . Dollar amounts and patient
numbers for fiscal year 1993 are subject to change based on differences
between estimated and actual funding appropriations and legislative approval
and will be set forth in a letter to be signed by the State and the Contractor
and approved by the State Controller. In consideration of said services by
the Contractor and conditioned upon affirmation by the State Family Planning
Program that services were rendered in accordance with this contract, the
state will cause to be paid to the Contractor a sum not to exceed $102.100
(ONE HUNDRED TWO THOUSAND ONE HUNDRED DOLLARS) , as follows:
a) 1) The Contractor is entitled to bill for 1/12 of the contraceptive
services amount at the end of each of the first two months of
each quarter, based on the State fiscal year. The submission of
a signed reimbursement statement (copy attached and by reference
made part hereof as Attachment B) is necessary for monthly
payment. The Contractor must submit a quarterly expenditure
report and a signed reimbursement statement (Attachment B) at
the end of each quarter; OR
2) The Contractor is entitled to bill 1/12 of the contraceptive
services amount for each of the first two months of the contract
term (July and August) . An advance for the next month may be
requested throughout the year and will be granted by the state
upon receipt of a statement of actual expenditures for the
oldest month still outstanding (i.e. , July and August have been
advanced. To receive a September advance, actual expenditures
must be submitted for July. To receive an October advance the
actual expenditures must be submitted for August.) This process
may be repeated until an advance is made for the month of May.
June reimbursement will be made only upon receipt of a statement
of actual expenditures for the month and shall be contingent
upon receipt of statements of actual expenditures for all months
previously advanced. Total reimbursements shall not exceed the
total contract allocation. The submission of a signed "Request
for Advance" statement (copy attached and by reference made part
hereof as Attachment D) is necessary for the advance.
3) The Contractor is entitled to bill up to 1/4 of the colposcopy,
biopsy and cryosurgery amounts in advance for the first quarter
of the fiscal year. Further quarterly advances will be granted
by the state upon receipt of a statement of actual expenditures
for the previous quarter. The submission of a Dysplasia
Treatment Advance/Reimbursement Request (copy attached and by
reference made part hereof as Attachment F) is necessary for
payment.
Page 3 of 8
b) A quarte_�y expenditure report (copy att..Led and by reference made
part hereof as Attachment C) must be submitted by the 30th of the
following month and must show total actual costs incurred for family
planning contraceptive services during that quarter; must state the
source of funding; and the July - Sept. quarterly report must include
results of a time study giving percentages of staff time allotted to
Bureau of Common Reporting Requirements (BCRR) cost centers and
information on square footage.
c) Recommendations made by the Family Planning Nursing Consultant to
bring the program into compliance with the Nursing-Medical Policies
and Procedures and the Title X Guidelines (Part 59) following site
visits or data reviews must be met within a three-month period, or
evidence must be shown that progress is being made toward meeting
said recommendations.
d) Recommendations made by the Family Planning administrative staff to
bring the program into compliance with the Title X Guidelines and
State policies and standards following site visits or data reviews
must be met within a three-month period, or evidence must be shown
that progress is being made toward meeting such recommendations.
e) Nursing-medical chart audits will be submitted to the
family planning nursing consultant upon request.
f) Program income generated from patient fee collections and
donations must be used by the program only for family planning
purposes which further the objectives of the legislation under which
this contract is made. In accordance with Title X guidelines (Part
59) no charges shall be made for services provided to patients at or
below 1008 of the poverty level. Patients above 1008 of poverty
level will be charged based on a schedule of discounts which is
attached and by this reference made part hereof as Attachment E.
g) The Contractor must use the cytology laboratory chosen by the State,
or a laboratory approved by the State as outlined in the
Nursing-Medical Policies and Procedures and the Administrative
Policies and Procedures. Follow-up information on all abnormal pap
smears will be submitted according to policies and procedures
outlined in these manuals, copies of which have been made available
to the Contractor.
h) Equipment and supplies may be purchased with the family planning funds
awarded in this contract. No line item billing is required from the
Contractor. The Contractor will return equipment and supplies
purchased through this contract to the State if so requested. An
inventory number will be assigned to this equipment by the State and
the Contractor shall affix the number to the equipment items and
confirm this in writing to the State. Permission must be requested
in writing from the State to purchase a piece of equipment in excess '
of $1000.00.
Page 4 of 8
91V775
7. Payment hsuant to this contract will be de as earned, in whole or
in part from available State funds encumbered in an amount not to exceed
TWO MILLION, THREE HUNDRED FIFTY FOUR THOUSAND, EIGHT HUNDRED SIXTY FOUR
DOLLARS ($2,354,864) for the purchase of family planning services. It is
further understood and agreed that the maximum amount of State funds
available for Fiscal Year 1991-1992 for the purchase of family planning
services is in the amount of TWO MILLION, THREE HUNDRED FIFTY FOUR
THOUSAND, EIGHT HUNDRED SIXTY FOUR DOLLARS ($2,354,864) or such lesser
amount as may be mandated by executive order or legislative action. The
liability of the State, at any time, shall be limited to the unencumbered
amount remaining in such funds.
8. Changes in reimbursement amounts for the above-named services in
consideration of increased or decreased levels of utilization from the
levels funded in the original contract shall be made with approval of the
Contractor, the State (Family Planning Program) and the State Controller
as evidenced by a mutually signed Letter of Approval which shall include
the following:
a) Identification of contract by contract number and
number of the affected paragraph;
b) Type of services increased or decreased;
c) Amount of increase or decrease in funding and
patients to be served;
d) Effective date of the funding change;
e) Authorized signatures of the State, the Contractor
and the State Controller. It is understood that no change
except funding amounts and resulting changes in utilization
shall be made through the Letter of Approval.
9. Because the appropriation of funds is a legislative function, funding
availability after State fiscal year 1992 is contingent upon an annual
appropriation of funds by the legislature, and in the event no
appropriation is made, this contract may be cancelled and terminated with
no penalty to the State.
10. Contractor agrees to provide services to all program participants and
employees in a smoke-free environment. Smoking may not be permitted in
waiting areas, examination rooms, formal sessions providing education,
therapy, or similar services. Designated smoking areas dmay be established
for staff, program participants, family members, and visitors. These
designated areas should be well ventilated in order that the waiting area
and the service delivery environment remains smoke free.
11. The term of this contract is beginning July 1, 1991 and continuing
through June 30, 1993.
Page 5 of 8
91.077S
COLORADO DEPARTMENT OF HEAL__. - hereinafter, under the Gene. . Provisions referred to as
"Health".
GENERAL PROVISIONS
1. The parties of this contract intend that the relationship between them contemplated
by this contract is that of employer—independent contractor. No agent, employee or
servant of Contractor shall be or shall be deemed to be an employee, agent or servant of
Health. Contractor will be solely and entirely responsible for its acts and the acts of
its agents, employees, servants and subcontractors during the performance of this
contract.
2. At all times during the performance of this contract, the Contractor shall strictly
adhere to all applicable federal and state laws that have been or may hereafter be
established.
3. Contractor authorizes Health to perform audits and to make inspections for the
purpose of evaluating performance under this contract.
4. Either party shall have the right to terminate this agreement by giving the other
party thirty days notice by registered mail, return receipt requested. If notice is so
given, this agreement shall terminate on the expiration of the thirty days, and the
liability of the parties hereunder for the further performance of the terms of this
agreement shall thereupon cease, but the parties shall not be relieved of the duty to
perform their obligations up to the date of termination.
5. This agreement is intended as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion, or other amendment
hereto shall have any force or effect whatsoever, unless embodied herein in writing. No
subsequent novation, renewal, addition, deletion, or other amendment hereto shall have
any force. or effect unless embodied in a written contract executed and approved pursuant
to the State Fiscal Rules.
6. If this contract involves the expenditure of federal funds, this contract is
contingent upon continued availability of federal funds for payment pursuant to the
terms of this agreement. Contractor also agrees to fulfill the requirements of Office
of Management and Budget Circulars A-87 and A-102 or A-110, whichever is applicable.
7. To be cynsidered for payment, billings for reimbursement pursuant to this contract
must be received within 60 days after the period for which reimbursement is being
requested and final billings on the contract must be received by the State Health
Department within 60 days after the end of the contract term.
8. If applicable, Local Match is to be submitted on the monthly reimbursement
statements, in the column provided, as required by the funding source.
9. If Contractor receives $25,000.00 or more per year in Federal funds in the
aggregate from Health, Contractor agrees to have an annual audit, by an independent
certified public accountant, which meets the requirements of Office of Management and
Budget Circular A-128. If Contractor is required to submit an annual indirect cost
proposal to Health for review and approval, Contractor's auditor will audit the proposal
in accordance with the requirements of OMB Circular A-87. Contractor agrees to furnish
one copy of the audit reports to the Health Department Accounting Office within 30 days
of their issuance, but not later than nine months after the end of Contractor's fiscal
year. Contractor agrees to' take appropriate corrective action within six months of the
report's issuance in instances of noncompliance with Federal laws and regulations.
Contractor agrees to permit Health or its agents to have access to its records and
financial statements as necessary, and further agrees to retain such records ane
financial statements for a period of three years after the date of issuance of the audit
report. This contract does contain Federal funds as of the date it is signed.
This requirement is in addition to any other audit requirements contained in other
paragraphs within this contract.
10. If applicable, Contractor agrees to not use Federal funds to satisfy Federal cost
sharing and matching requirements unless approved in writing by the appropriate Federal
Agency.
Page 6 of 8 Pages
Rev. 06/06/88
Form 6-AC-02B
SPECIAL PROVISIONS
CONTROLLER'S APPROVAL
I. This contract shall not be deemed valid until it shall have been approved by the Controller of the State of Colorado or such assistant as he may designate.This
provision is applicable to any contract involving the payment of money by the State.
FUND AVAILABILITY
2. Financial obligations of the State payable after the current fiscal year are contingent upon funds for that purpose being appropriated,budgeted and otherwise
made available.
BOND REQUIREMENT
3. If this contract involves the payment of more than fifty thousand dollars for the concoction,erection,repair,maintenance,or improvement of any building,
road,bridge,viaduct,tunnel,excavation or other public works for this State,the contractor shall,before entering the performance of any such work included in this
contract,duly execute and deliver to and file with the official whose signature appears below for the State,a good and sufficient bond or other acceptable surety to be
approved by said official in a penal sum not less than one-half of the total amount payable by the terms of this contract Such bond shall be duly executed by a
qualified corporate surety,conditioned for the due and faithful performance of the contract,and in addition,shall provide that if the contractor or his subcontractors
fail to duly pay for any labor,materials,team hire,sustenance,provisions,provender or other supplies used or consumed by such contractor or his subcontractor in
performance of the work contracted to be done,the surety will pay the same in an amount not exceeding the sum specified in the bond,together with interest at the
rate of eight per cent per annum.Unless such bond,when so required,is executed,delivered and filed,no claim in favor of the contractor arising under this contract
shall be audited,allowed or paid.A certified or cashier's check or a bank money order payable to the Treasurer of the State of Colorado may be accepted in lieu of a
bond. This provision is in compliance with 38-26-106 CRS, as amended.
INDEMNIFICATION
4. To the extent authorized by law,the contractor shall indemnify,save and hold harmless the State,its employees and agents,against any and all claims,
damages,liability and court awards including costs,expenses,and attorney fees incurred as a result of any act or omission by the convector,or its employees,
agents, subcontractors,or assignees pursuant to the terms of this contract.
DISCRIMINATION AND AFFIRMATIVE ACTION
5. The contractor agrees to comply with the letter and spirit of the Colorado Antidiscrimination Act of 1957,as amended,and other applicable law respecting
discrimination and unfair employment practices(24-34-402.CRS 1982 Replacement Vol.),and as required by Executive Order,Equal Opportunity and Affirma-
tive Action,dated April 16, 1975. Pursuant thereto, the following provisions shall be contained in all State contracts or sub-contracts.
During the performance of this convect,the contrattor agrees as follows:
(1) The contractor will not discriminate against any employee or applicant for employment because of race,creed,color,national origin,sex,marital status,
religion,ancestry,mental or physical handicap,or age.The contractor will take affirmative action to insure that applicants are employed,and that employees are
veated during employlnent,without regard to the above mentioned characteristics.Such action shall include,but not be limited to the following:employment,
upgrading,demotion,or transfer,recruitment or recruitment advertising;layoffs or terminations;rates of pay or other forms of compensation;and selection for
training,including apprenticeship.The contractor agrees to post in conspicuous places,available to employees and applicants for employment,notices to be pro-
vided by the contracting officer setting forth provisions of this non-discrimination clause.
12) The convector will,in all solicitations or advertisements for employees placed by or on behalf of the contractor,state that all qualified applicants will receive
consideration for employment without regard to race,creed, color, national origin,sex, marital status, religion, ancestry, mental or physical handicap,or
age.
(3) The contractor will send to each labor union or representative of workers with which he has collective bargaining agreement or other contract or understand-
ing,notice to be provided by the contracting officer,advising the labor union or workers'representative of the contractor's commitment under the Executive
Order, Equal Opportunity and Affirmative Action,dated April 16, 1975, and of the rules,regulations,and relevant Orders of the Governor.
(4) The contractor and labor unions will furnish all information and reports required by Executive Order,Equal Opportunity and Affarnative Action of April 16,
1975,and by the rules,regulations and Orders of the Governor,or pursuant thereto,and will permit access to his books,records,and accounts by the contracting
agency and the office of the Governor or his designee for purposes of investigation to ascertain compliance with such rules,regulations and orders.
(5) A labor organization will not exclude any individual otherwise qualified from full membership rights in such labor organization,or expel any such individual
from membership in such labor organization or discriminate against any of its members in the full enjoyment of work opportunity,because of race,creed,color,
sex, national origin,or ancestry.
(6) A labor organization,or the employees or members thereof will not aid,abet,incite,compel or coerce the doing of any act defined in this contract to be dis-
criminatory or obstruct or prevent any person from complying with the provisions of this convect or any order issued thereunder;or attempt either directly or
indirectly, to commit any act defined in this contract to be discriminatory.
395-53-01-1022
Revised 1/88 page 7 of g pages
{ Dc-10-2306a-88ll- 7174
•
Form 6-AC-02C
(7) In the event of the contractor's non-compliance with the non-discrimination clauses of this contractor or with any of such rules,regulations,or orders,this
contract may be cancelled,terminated or suspended in whole or in part and the contractor may be declared ineligible for further State contracts in accordance
with procedures,authorized in Executive Order,Equal Opportunity and Affirmative Action of April 16, 1975 and the rules,regulations,or orders promulgated
in accordance therewith,and such other sanctions as may be imposed and remedies as may be invoked as provided in Executive Order,Equal Opportunity and
Affirmative Action of April 16, 1975, or by rules, regulations, or orders promulgated in accordance therewith, or as otherwise provided by law.
(8) The contractor will include the provisions of paragraph(1)through(8)in every subcontract and subcontractor purchase order unless exempted by rules,
regulations,or orders issued pursuant to Executive Order,Equal Opportunity and Affirmative Action of April 16, 1975,so that such provisions will be binding
upon each subcontractor or vendor.The contractor will take such action with respect to any subcontracting or purchase order as the contracting agency may
direct,as a means of enforcing such provisions,including sanctions for non-compliance;provided,however,that in the event the contractor becomes involved
in,or is threatened with,litigation with the subcontractor or vendor as a result of such direction by the contracting agency,the contractor may request the State
of Colorado to enter into such litigation to protect the interest of the State of Colorado.
COLORADO LABOR PREFERENCE
6a. Provisions of 8-17-101&102,CRS for preference of Colorado labor are applicable to this contract if public works within the State are undertaken hereun-
der and are financed in whole or in part by State funds.
b. When construction contract for a public project is to be awarded to a bidder,a resident bidder shall be allowed a preference against a non-resident bidder
from a state or foreign country equal to the preference given or required by the state or foreign country in which the non-resident bidder is a resident.If it is deter-
mined by the officer responsible for awarding the bid that compliance with this subsection.06 may cause denial of federal funds which would otherwise be avail-
able or would otherwise be inconsistent with requirements of federal law,this subsection shall be suspended,but only to the extent necessary to prevent denial of
the moneys or to eliminate the inconsistency with federal requirements (section 8-19-101 and 102, CRS).
GENERAL
7. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation,execution and enforcement of this
contract.Any provision of this contract whether or not incorporated herein by reference which provides for arbitration by any extra-judicial body or person or
which is otherwise in conflict with said laws,rules and regulations shall be considered null and void.Nothing contained in any provision incorporated herein by
reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by
way of complaint,defense or otherwise.Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to
the extent that the contract is capable of execution.
8. At all times during the performance of this Contract,the Contractor shall strictly adhere to all applicable federal and state laws,rules and regulations that
have been or may hereafter be established
9. The signatories hereto aver that they are familiar with 18-8-301,et seq.,(Bribery and Corrupt Influences)and 18-8-401,et.seq.,(Abuse of Public Office),
CRS 1978 Replacement Vol., and that no violation of such provisions is present.
I0. The signatories aver that to their knowledge, no state employee has a personal or beneficial interest whatsoever in the service or property
described herein:
IN WITNESS WHEREOF, the parties hereto have executed this Contract on the day first above written.
Contractor.
(Full Legal Name) Weld County Board of Commissioners
— STATE OF COLORADO
By REc GOVERN
OR
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COLORADO DEPARTMENT OF HEALTH ATTACHMENT A-2
Family Planning Data System
PATIENT VISIT SAMPLE
III f Iao veer
l
1. Date of Visit
2. Service Site Number ' Mitt i
3. Patient Number
4. County of Residence Code
5. Pregnancy History
Number of times pregnant MOM
Number of live births MEM
6. Ethnicity/Race (Check one)
Anglo in1 American Indian MEM
Black MINIn Oriental MEM
Hispanie MEM Other nsi
Unknown I♦MO
7. Someone' Agricultural Worker (Check one)
Seasonal MEM Neither eta
Migrant MIMI Unknown Mn
6. Purpose of Visit (Check one)
Initial Medical MEI Other New Visit 111111.31
Annual Medical IllEi7 Other Revisit M ■]
9. Medical Services Provided (Check all which apply)
Complete Initial Pregnancy Testing H
or Annual Medical A Diaphragm Fit J
Hct/Rgb B Contraceptive Revisit E,
Other Blood Test C Vaginal Infection M
Blood Pressure D G.C. Culture N
Pap Smear Here B Rubella Immunisation P
IUD Insertion F Rubella Titer R
IUD Removal G Other Medical S
10. Type of Counseling (Cheek all which apply)
Initial or Annual Pre-conceptual E
Visit Counseling f A Problem Pregnancy F
Contraceptive I B Sterilisation (pre) G
Infertility ( C Adolescent R
Nutrition I D Other J
11. Contraceptive Method at the End of This Visit (Check all which apply)
Orel A Contraceptive Sponge F
IUD B Natural/Fart. Aware G
Dimphragn C Cervical Cap H
Condom D None J
Foes/Jelly/Cream E Condom/Spermicide E
12. Provider of Encounter (Check all which apply)
Doctor WIWI Nurse =Ma
Nurse Practitioner/ MMI] Other Health MEC
Midlevel Practitioner
13. Referrals Elsewhere (Check all which apply)
Infertility A Sterilisation C
Prenatal Care B Other D
None E
FPDS t2 (5-64)
(Revised 1/69)
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ATTACHMENT C
COLORADO DEPARTMENT OF HEALTH - FAMILY PLANNING PROGRAM
BCRR QUARTERLY EXPENDITURE REPORT
OTHER COMMUNITY PATIENT TOTAL
MEDICAL LAB PHARMACY HEALTH HEALTH ADM BLDG. RECORDS EXPENDITURES
=v = =zees==== :s===e=as
PERSONNEL COSTS
PERSONNEL
FRINGE
SUBTOTAL (A) _
OPERATING COSTS
TRAVEL
SUPPLIES (PURCHASED)
CONTRACTUAL
OTHER
SUBTOTAL (B)
TOTAL DIRECT COSTS
(TOTAL OF (A) + (B))
INDIRECT COSTS (C)
TOTAL PAID EXPENSES 1
(TOTAL A + B + C)
DONATED SERVICES (D)
(In-kind)
DEPRECIATION' (E)
TOTAL PROGRAM COSTS
(A • B • C + D • E)
SQUARE FOOTAGE
Jly-Sep Report Only
==== ====ss=== ____
*DEPRECIATION
If you are listing a capital equipment item (items costing SS00 or more per unit with a useful life of
2 or more years). Complete the following using the formula. Purchased cost divided by life years a
depreciation per year, divided by 4 quarters • depreciation amount per quarter.
PURCHASE USEFUL ><
ITEM COST LIFE YEARS
____ =see
AGENCY:
COMPLETED BY:
REPORTING PERIOD:
Revised 5/90 UM FPP
91.C775
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VII.009
COLORADO DridITMENT OF HEALTH FAMILY PLANNT-' PROGRAM
•
ADJUSTED TOTAL GROSS INCOME AND FAMILY SIZE CODES - 1991
Attachment E
FAMILY
SIZE ANNUAL INCOME MONTHLY INCOME WEEKLY INCOME CODE
Less than 6621 Less than 553 Less than 128 1
1 6621-9930 553-828 128-191 2
9931-13240 829-1104 192-255 3
More than 13240 More than 1104 More than 255 4
Less than 8881 Less than 741 Less than 172 1
2 8881-13320 741-1110 172-257 2
13321-17760 1111-1480 258-342 3
More than 17760 More than 1480 More than 342 4
Less than 11141 Less than 928 Less than 215 1
3 11141-16710 929-1393 215-321 2
16711-22280 1394-1857 322-428 3
More than 22280 More than 1857 _ More than 428 4
' Less than 13401 Less than 1118 I Less than 259 1
4 13401-20100 1118-1676 j 259-387 2
20101-26800 1677-2234 388-516 3
More than 26800 More than 2234 More than 516 4
Less than 15661 Less than 1306 Less than 302 1
5 15661-23490 1306-1958 302-452 2
23491-31320 1959-2610 453-602 3
More than 31320 More than 2610 More than 602 4
Less than 17921 Less than 1494 Less than 346 1
6 17921-26880 1494-2240 346-518 2
26881-35840 2241-2987 519-690 3
More than 35840 More than 2987 More than 690 4
Less than 20181 Less than 1683 Less than 389 1
7 20181-30270 1683-2523 389-582 2
' 30271-40360 2524-3364 583-776 3
More than 40360 More than 3364 More than 776 4
Less than 22441 Less than 1871 Less than 433 1
8 22441-33660 1871-2805 433-648 2
33661-44880 2806-3740 649-864 3
More than 44880 More than 3740 More than 864 4
Use Codes 1 to 4 with Sliding Fee Scale prices to determine amount patients
pay for services and supplies.
Code 1: Below 1008 poverty as defined by 1991 guidelines.
Code 2: Between 1018 and 1508 poverty as defined by 1991 guidelines.
Code 3: Between 1518 and 2008 poverty as defined by 1991 guidelines.
Code 4: Above 2008 poverty as defined by 1991 guidelines.
NOTE: For family units with more than 8 members, add $2260 for each
additional member.
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+� MEMORAnDum
Gordon E. Lacy, Chairman
To Board of County Commissioners odLe July 30, 1991
+ L/
COLORADO From Jeannie K. Tacker, Business Manager, Health Department
Subject: Family Planning Contract
Enclosed for Board approval is a contract between the Weld County Health
Department (WCHD) and the Colorado Department of Health for our Family
Planning Program.
The WCHD will be reimbursed $94,749 to provide contraceptive services to
approximately 1,675 comprehensive family planning patients, $5,893 to provide
colposcopy and biopsy services to 33 patients, and $1,458 to provide
cryosurgery services to 19 patients for a total reimbursement of $102,100.
This amount is an increase of $8,180 for family planning services from the
prior year's contract.
The Weld County Health Department is responsible for conducting a
comprehensive family planning program in compliance with Title X and Colorado
Department of Health regulations.
The term of the contract shall be from July 1, 1991 through June 30, 1993.
Funding for fiscal year 1993 is subject to change based upon state funding
appropriations.
If you have any questions, please feel free to contact me.
JKT/ja
Enclosure
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