HomeMy WebLinkAbout951238.tiffRESOLUTION
RE: APPROVE FAMILY PLANNING PROGRAM CONTRACT 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 the Family Planning Program Contract
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Health Department, and the
Colorado Department of Public Health and Environment, beginning July 1, 1995, and ending June
30, 1996, with 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 County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Weld County Health Department, and the Colorado Department of Public Health and Environment
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 19th day of June, A.D., 1995.
BOARD OF COUNTY COMMISSIONERS
ATTEST:
adh
Weld Coupt leek to the Board
BY:
DeplytliCIO e. Board
/-
APPROVED AS TO FORM
COUNTY, CQLOI DO
Dale K. Hall, Chairman
BarbarazJ Kirkmeyer, Pry-Tem
eorge E.4axter
Constance L. Harbert
W. H. Webster
Cyc : /kJ Est & 6)
951238
HL0021
Department or Agency Number
FAA
Contract Routing Number
96020
CONTRACT
THIS CONTRACT, Made this 1st day of July 1995, by and
between the State of Colorado for the use and benefit of the
Department of Public Health and Environment, 4300 Cherry Creek
Drive South, Denver, Colorado 80222-1530 hereinafter referred to
as the State, and Weld County Health Department, 1517 16th Avenue
Court, Greeley, Colorado 80631-4597 hereinafter referred to as the
Contractor.
WHEREAS, the 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 FAA FPP96020; and
WHEREAS, required approval, clearance and coordination has
been accomplished from and with appropriate agencies; and
WHEREAS, 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. 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.
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:
Page 1 of 9
951238
a) Outreach services and/or other program effort for patient\
recruitment.
b) Nursing and medical services which shall include a
comprehensive health and social history; and physical
examination, in accordance with Title X (42 CFR, Subpart
A, Part 59) as authorized under Sectiori 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.
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 Family Planning Program for review
and approval prior to employment.)
1 . 1
4. The contractor agrees to render acceptable services as
determined by the 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, and all fiscal and
administrative policies of. the Family Planning Program. 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 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.
Page 2 of 9
951238
6. The State will pay Seventy-six thousand nine hundred sixty-
eight dollars ($76,968) ($56,495 Title X dollars and $20,473
State dollars) to provide contraceptive services to approximately
2000 family planning patients, and One thousand three hundred
fifty dollars ($1,350) to provide cryosurgery services and/or pap
smear screening services to 18 patients. In consideration of
said services by the Contractor and conditioned upon affirmation by
the 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 Seventy-eight thousand three
hundred eighteen dollars ($78,318) as follows:
a) 1) The Contractor is entitled to bill for 1/6 of the
Title X contraceptive services amount (specified
above) at the end of each month July through
December and for 1/6 of the state contraceptive
services amount (specified above) at the end of
each month January thru June on a signed Contract
Reimbursement Statement (copy attached and by
reference made part hereof as Attachment A).
Payments of monthly reimbursement requests are
contingent upon contractor complying with all terms
of this contract.
2) Contractor will be reimbursed cryosurgery amounts
as expended. Monthly billings must include a copy
of the Cervical Follow-up Information form, (copy
attached and by reference made part hereof as
Attachment B), for each patient served and total
numbers of each service provided shall be submitted
on the Contract Reimbursement Statement.
b) A quarterly expenditure report (copy attached 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 and amounts 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.
Page 3 of 9
951238
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 100% of the poverty level. Patients above 100% of
poverty level will be charged based on a schedule of
discounts which has been provided to the contractor.
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.
7. 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 Contract Change Letter (Sample
attached and by this reference made a part hereof as
Attachment D) 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 Contract Change
Letter.
Page 4 of 9
951238
8. Because khe appropriation of funds is a legislative 1
function, funding availability after the current state fiscal
year is contingent upon an annual appropriation of funds by
the legislature, and in the event no appropriation is made,
this contract may be cancelled arid terminated with no penalty
to.the State. The state fiscal year is July 1 through June
30.
9. 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 maybe 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.
10. Copies of all materials, manuals, policies and procedures
referenced herein have been provided to the contractor and are
hereby made part of this contract.
11. This contract is effective beginning July 1, 1995 and
continuing through June 30, 1996 and is renewable annually at
the State's option, for 3 additional one year periods' by
Contract Renewal letter, in the form attached hereto as
Attachment E. Dollar amounts and patient numbers for any
renewal period are subject to change from prior contract
period based on actual funding appropriations and legislative
approval for each state fiscal year.
Page 5 of 9
951238
)DORADO DEPARTMENT OF HEALTH - hereinafter, under the General Provisions referred to as
"Health".
GENERAL PROVISIONS -- page 1 of 2 pages
The contractor shall perform its duties hereunder as an independent contractor and
)t as an employee. Neither the contractor nor any agent or employee of [he contractor
-tall be or shall be deemed to be an agent or employee of the state. sontrprovide Contractor sand shall
iv when due all required employment taxes and income tax withholding,
-ep in force worker's compensation (and show proof of such insurance) and- unemployment
,mpensation insurance in the amounts required by law. Contractor will be solely
asponsible for its acts and the acts of its agents, employees, servants and
abcontractors during the performance of this contract.
•
Contractor authorizes Health, or its agents, to perform audits and to make
nspections for the purpose of evaluating performance under this contract_
Either party shall have the right to terminate this agreement by giving the other
arty thirty days notice by registered mail, return receipt requested. If notice is so
iven, this agreement shall terminate on the expiration of the thirty days, and the
iability' of the parties hereunder for the further performance of the terms of this
greement shall thereupon cease, but the parties shall not be relieved of the duty to
erform their obligations up to the date of termination.
This agreement is intended as the complete integration of all understandings
etween the parties. No prior or contemporaneous addition, deletion, or other amendment
ereto shall have any force or effect whatsoever, unless embodied herein in writing. No
ubsequent novation, renewal, addition, deletion, or ocher amendment hereto shall have
ny force or effect unless embodied in a written contract executed and approved pursuant
o the State Fiscal Rules.
If this contract involves the expenditure of federal funds, this
urccontract
ct tie
ontingent upon continued availability of, federal' funds for payment pursuant
erns of this agreement. Contractor also agrees to fulfill the requirements of:
a) Office of Management and Budget Circulars A-87, A21 or A-122, and A-102 or
-110, whichever is applicable;
b) the Hatch Act (5 USC 1501-1508) and Public Law 95-454 Section 4728. These
statutes state that federal funds cannot be used for partisan political purposes of any
:ind by any person or organization involved in the administration of federally -assisted
irograms;
c) the Davis -Bacon Act (40 Stat. 1494, Mar. 3, 1921, Chap. 411, 40 USC
:76A -276A-5). This act requires that all laborers and and mechanics employed by
:ontractors or sub -contractors to work on construction projects financed by federal
assistance must be paid wages not less than those established for the locality of the
'roject by the Secretary of Labor;
d) 42 USC 6101 et seq, 42 USC 2000d, 29 USC 794. These acts require that no
,erson shall.: on the grounds of race, color, national origin, age, or handicap, be
,xcluded from:participation in or be subjected to discrimination in any program or
activity funded, in whole or in part, by federal funds; and
Pa4e -6 of 9
ev. 06/01/92
Pages
951238
GENERAL PROVISIONS_ ,Page2:of 2, pages
e) the Americans with Disabilities Act (Public Law 101-336; 42 USC 12101, 12102,
12111 - 12117, 121 - 12134, 12141 - 12150, 12161 - 12165, 12181 - 12189, 12201 - 12213
and 47 USC 225 and 47 USC 611.
f) if the contractor is acquiring real property and displacing households or
businesses in the performance of this contract, the contractor is in compliance with the
Iniform Relocation Assistance and Reap_ Property Acquisition Policies Act, as amended
(Public Law 91-646, as amended and Public Law 100-17, 101 Stat. 246 - 256);
g) when applicable, the contractor 'is in compliance with the provisions of the
'Uniform Administrative Requirements for Grants and Cooperative Agreements to State and
Local Governments (Common Rule).
6. By signing and submitting this contract the contractor states that:
a) the contractor is in compliance with the requirements of the Drug -Free
Workplace Act (Public Law 100-690 Title V, Subtitle D, 41 USC 701 et seq.);
b) the contractor is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered transactions by any federal
department or agency; and
7. To be considered for payment, billings for payment pursuant to this contract must he riod for ch t is finalCebillingshlon60theycontract tmust ebe receivedLby Health within being
das after within 60daysrequested
after the end
of the contract term.
8. If applicable, Local Match is to be submitted on the monthly payment statements, in
the column provided, as required by the funding source.
9. If Contractor receives $25,000.00 or more per year in federal funds in the
aggregate from Health. Contractor agrees to have an annual audit, by an independent
cerUIf$'ed public accountant, which meets the requirements of Office of Management and
Budget''Circular A-128 or A-133, whichever applies. 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, A-21
or A-122. Contractor agrees to furnish one copy of the audit reports to the Health
Department Accounting Office within 30 days o€ 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 and financial statements for a period of three
years after the date of issuance of the auditreport. This contract contain
--
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. Contractor agrees to not use federal funds to satisfy o federal rledcot ari
sagency.
and
matching requirements unless approved in writing by the app p
Page 7 of 9 Pages
Rev. 06/01/92
951238
SPECIAL PROVISIONS
ONTROLLER'S APPROVAL
L 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
'revision is applicable to any contact involving the payment of money by the State
ONO AVAILABILITY
2. Financial obligations of the State of Colorado payable after the current fiscal year arc contingent upon funds for that parpuaobeing appropriated, budgeted,
d otherwise made available
OND REQUIREMENT.
3. If this contract involves the payment of mote than fifty thousand dollars for the construction, erection. repair. maintenance. or improvement of any building.
.ad, bridge, viaduct. cannel excavation of other public work for this State. the contractor shall. before entering upon the performance of any such work included
, this contract. duly execute sad deliver to the State official who will sign the contract, a good and suffeient bond or other acceptable surety to be approved by
Lid official is a penal aunt 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
army conditioned upon the faithful performance of the contract sad in addition. sham provide that if the contractor or kis subcontractors fail to duly pay for any
bor, materials, seam hire. sustenance, pravism°s. provendor or other supplies used or consumed by such contractor or his subcontractor in performance of the work
mtactod to be done or fails to pay any person who supplies rental machinery. tools, or equipment in the prosecution of the work the surety will pay the same in
h mount not exceeding the sum specified in the bond. together with interest at the rate of eight per cent per annum. Unless such bond is executed. delivered and
ld., no claim in favor of the contactor arising under such contact shall be audited, allowed or paid. A certified or cashier's cheek or a bank money order payable
the Treasurer of the State of Colorado may be accepted is lieu of a bond. This provision is in compliance with CRS 38-26.106.
WDEMNIFICATION
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.
images. liability and court awards including costs. expenses, and attorney fees incurred as a result of any act or omission by the contractor, or its employees.
tents, subcontractors, or assignees pursuant to the terms of this contract.
LSCRIMINAT ION 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
isaimination and unfair employment practices (CRS 24-34-402). and as required by Executive Order, Equal Opportunity and Affirmative Action, dated April 16.
)75. Phrasal thereto. the following provisions shall be contained in all State contracts or sub -Contracts.
During the performance of this contract, the contractor agrees as follows:
(a) 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 ■ffun ative action to insure that applicants arc employed, and that
employees are treated during employment. without regard to the above mentioned chaauaistics- Spell action shall include. but not be limited to the following:
employment upgradfmg. demotion. or transfer, recruitment or recruitment advatisings; lay-offs 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 provided by the contracting officer setting forth provisions of this non-discrimination clause.
(b) The contractor will. in all solicitations or advertisements for employees placed by or on behalf of the contactor, 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.
(e) The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or
understanding. notice to be provided by the contractingofficer. 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.
(d) The contractor and labor unions will furnish all information and reports required by Executive Order. Equal Opportunity and Affirmative Action of April
16. 1975. and by the ruts, regulations and Orders of the Governor, or pursuant thereto, and will permit access to his books. records, and accounts by the I
contracting agency and theoffice of the Governor or his designee for purposes of investigation to ascertain compliance with such rules, regulations and orders.
(e) A labororgattiatioa will not exclude any individual otherwise qualified front full membership rights in such taboroiganizatioa orexpel 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 eke, creed. color.
sex, national origin, or ancestry. '
(f) 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
discriminatory or obstruct or prevent any person from complying with the provisions of this contract or any order issued thereunder, or attempt. either directly
or indirectly, to commit any act defused in this contract to be discriminatory.
,nn 6 -AC -028
cvised 1193
15-5341-1022
page 8 of 9 pages
951238
the event -of the contractor's non-compliance with thc non-discrimination clauses of this contract or with any of such rules. regulations,
or orders,
r ay be declared or
unrcaec with) prbe canceled. terminatd or suspendd in whole Or in part and the ocedures, authorizede in Executive cOrder. Equal Opportunity and AffirmaivenActon of April 16. ineligible1975 and ithe rules. a¢g Contracts in
promulgated in accordance therewith. and such other sanctions as may be imposed and remedies as may be invoked as provided in Executive Order.
Opportunity and Affirmative Action of April 16. 1975. or by rules, regulations. or orders promulgated in accordance therewith. or as otherwise
led by law.
Opportunity and Affirmative and
Acsub of April 16. 1chas so that e xeby
to contractor will include the provisions of paragraphs (a) through (h) in every sub -contract and subcontractor purchase order unless exempted y
ill
ding
regulations, c orct orders issued pursuant r.o ThExecutive Order, Equal Opfro ) sub-contracting
ting or p event the contractor
fling upon cash subcontractor or vendor. The contractor will take such action with respect to any subtontncting or purchase order as the contracting
y may direct. as a means of enforcing such provisions- including sanctions for non-compliance: provided, ith e such o.
lved in.
or is r is thre atd with. igh
ten itiati w Bathos to oprotect tor or rve s of tae State of Colonection by the contracting agency. the contractor
les ed ened with. thquest
:ADO LABOR PREFERENCE
visions of CRS S-17-101 & 102 for preference of Colorado labor arc applicable to this contract if public worts within the State are undertaken hereunder and
ccd in whole or in pan by State funds.
:n a 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
r 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 determined by
requirements of Federal law, this subsection shall be suspended. but only to the extent necessary to prevent denial of the moneys or to
er responsible for awarding the bid that compliance with this subsection .06 may cause denial of federal funds which would otherwise be available or would
c be inconsistent with
e thc inconsistency with Federal requirements (CRS 8-19-101 and 102)
(AL
for in eation by any n.exexecution,
body or e or which
: laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation. cxcctnion, and enforcement of this w. Any provision this contract whether or not incorporated s shall herein by reference null f provides
wise in conflict with said laws. ales, and regulations shall be considered null and void. Nothing contained in any provision incorporated herein by reference
alid or or available in any action at law whether tarpons
to erwise. this or special
and void by the operationhof thisvprow provision will notein invalidate the remainder of this contract to he extent complaint.
. or otherwise. Any provision
is capable of execution.
all times during the performance of this contract, the Contractor shall strictly adhere to all applicable federal and state laws. rules. and regulations ha have
may hereafter be established.
e signatories aver that they are familiar withCRS 18-8-301, et. seq.. (Bribery and Corrupt Influences) and CRS 18-8-401. et. sq.. (Abuse of Public Office).
: no violation of such provisions is present. described herein:
any personal or beneficial intern! whatsoever in the service or property
he signatories aver that to their knowledge. no state employee has
'NESS WHEREOF, the panics hereto have executed this Contract on the day frnt above'written.
nor
egal Name)
STATE OF COWRA
1� r ROY RO
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DALE K. HALL (6/19/95) /
WELD COUNTY BOARD OF COMMISSIONERS
CHAIRMAN
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attachment B
• COLORADO OLPAN I Mtn( 'Jr alIn -----
COLORADO WOMEN'S CANCER CONT..JL INITIATIVE
4300 Cherry Creek DA''e Snirth
Denver. CO 80222-1530
(303) 692-2S31
(PLEASE MESS FIRMLY) CERVICAL FOLLOW-UP INFORMATION
A. GENERAL INFORMATION
Name el Provider or CAgency:
Patient Name:
Date of Blatt / / SSN:
Address`
• Initial Pap Result
-
ri..cc* Cede tm.me.draPLO(
• Date Pap Report Received: / I
- • -
• Appointment Date and Time: . ..
• Date Patient Contacted: / I
Date / / and TimeAM PM
* Required for FPP / PPRM Subsidized Clinics
B. DIAGNOSTIC EVALUATION
Please Indicate the procedures you have completed or planned for this patient A final diagnosis must be kdicated for a
women except for those lost to follow-up. If this patient Is lost to follow-up, complete Section E
1. Repeat Pape
❑ Completed: __/,_ I
Result • Reimbursement
■ Planned: ___/___/__
requested:
4. Colposcopy with Directed Biopsy
11 Completeck Jam_ ■
• Ranbursement requested:
Planned:
V
•
N
.
___/_/___
IlaCCPCSaisTablecabalpapeat
Y
N
2. Colposcopy without Biopsy •
❑ Completed: / / ❑ Planned: I [_
S. tEE?
• Reimbursement requested:
Y
Ill
❑ meted: �[— 0 Planned: -�-i
3. Endocenrical Curettage Result O Pos O Neg
6. Othec
❑ Completed: I / ❑ Planned: I I
❑ Completed: I I ❑ Planned_._
C. DIAGNOSIS : Diagnosis must be based on results of diagnostic procedures (check as that apply)
1. Normal / Benign Reaction 6. Invasive Cervical Carcinoma :
2. HPV / Cordylom(a / Atypia ❑ Stage I ❑ Stage 8 ❑ Stage in ❑ Stage h/ ❑ Unknown
❑ 3.1N I (Low grade SIL/ Mild Dysplada)
SiL/ Mod Dysplasia) ❑ 7. Other:
❑ 4. CIN II (Ffigh grade
❑ S. CIN 18 / CIS (Mgt grade SIL /Severe Dyspiaaa)
D. TREATMENT / FOLLOW-UP
Please Indicate the procedures you have completed a planned for this patient. If you do not plan any treatment. or this
patient is lost to follow-up, complete Section E.
1. Medication (to treat infection found on Pap or exam)
❑ Administered on: .11_1_
❑ Planned: / /
& Hysterectomy
❑ Completed: _L / ❑Planned: ____L_L__
•
2. Cryosurgery
I / ❑ Planned:
7.
Radiation Therapy
■ meted: I I
■ Planned: ___/__ (_
❑ Completed: _Li__
a LEER
❑Completed: ____L_L_
Snaffled: I I
a Chemotherapy
❑Catpieted: ___L-1_.
■ Mame& —/_.1.-
9. Other (specify):
4. Cone Biopsy
❑ Completed: _._/____L— ❑ Planned: _(__
❑ Completed: __LI ❑ Planned: --/-.-1--
S. Laser Ablation
❑ Completed: / / ❑ Planned: __id_
Coflkleiiis::
. .... .. .... .... �. -'�'.
_
E. Follow-up evaluation has NOT been completed or planned for the following reason(s):
❑ Procedure(s) planned, date(s) indicated above ■ Patient scheduled but O Patient moved
faded to show O Patient deceased
❑ Not medically eindicated O Patient refused -
❑ Patientreferred* ❑ Financial barriers
'Gamma mat O but tailed to schedule (3 tries including regular mail)
Krom-y Patient notified
Isommian a.a ode A on as Como
Yes
II
No Date: / /
F. PAP RECOMMENDATIONS Return for Annual Pap?
OR
Repeat Pap?
Return for Re at
a
Yes
❑
No Date: / /
G. PROVIDER SIGNATURE:
ern. rmni nrunnn- AGENGI` -�J-I
unUITC- nnnmpo m VFI t OW- WHC r rP(`n PINK- A(;FN(:Y r(:nMPI _
38
Attachment C
COLORADO DEPARTMENT OF HEALTH — FAMILY PLANNING PROGRAM
SCAR QUARTERLY EXPENDITURE REPORT
PERSONNEL COSTS
PERSONNEL
FRINGE
SUBTOTAL (A)
OPERATING COSTS
TRAVEL
SUPPLIES(PURCHASED)
CONTRACTUAL
OTHER
SUBTOTAL (8)
MEDICAL
LAB
PHARM.
OTHER
HEALTH
COMM.
HEALTH
ADM
BLDG.
PATIENT
RECORD
TOTAL
EXPENDITURE
TOTAL DIRECT COSTS
(TOTAL OF (A) + (8))
______
INDIRECTCOSTS (C)
TOTAL PAID EXPENSES
(TOTAL A + B + C)
DONATED SERVICES (D)
(In —kind)
DEPRECIATION` (E)
TOTAL PROGRAM COST
(A+B+C+D+E)
SQUARE FOOTAGE
Jly—Sep Report Only
*DEPRECIATION
If you are listing a capital equipment Item (items costing $1000 or more per unit with a useful life of
2 or more years). Complete the following using the formula Purchased cost divided by life years =
depreciation per year, divided by 4 quarters = depreciation amount per quarter.
PURCHASE USEFUL#
ITEM COST LIFE YEARS
_
AGENCY:
COMPLETED BY:
DATE;
REPORTING PERIOD:
See back of form for funding and source information
951238
STATE OF COLORADO
Roy Romer, Governor
Patti Shwayder, Acting Executive Director
Dedicated to protecting and improving the health and environment of the people of Co/orado
4300 Cherry Creek Dr. S.
Denver, Colorado 80222-1530
Phone (303) 692-2000
Date
TO
Laboratory Building
4210 E. 11th Avenue
Denver, Colorado 80220-3716
(303) 691-4700
Attachment "D"
CONTRACT CHANGE LETTER #_
STATE FISCAL YEAR
Colorado Department
of Public Health
and Environment
Pursuant to Paragraph 7 of the Family Planning Contract, Contract # FPP ,
[as amended], covering the period July 1, 199_ to June 30 199_. the Coloraaddo
Department of Public Health and Environemnt hereby notifies
the maximum amount of reimbursement from the Family Planning Program is hereby
increased/decreased by Dollars ($ ) to a new total of
Dollars ($ ) (Page 3, Paragraph 6). These funds are $ Title
X dollars, $ State and Waxman dollars.
The number of comprehensive
increased/decreased by
Colposcopy, biopsy and/or
increased/decreased by
Cryosurgery services and/o
increased/decreased by
This contract change letter is intended to be effective , but in
no event shall it be deemed valid until it is approved by the State Controller
or his designee.
Please sign and return all copies of this notification to the Family Planning
Program. A fully executed copy will be returned to you.
family planning patients to be served is to be
patients to a new total of patients;
pap smear screening services are to be
to a new total of
r pap smear screening
to a new total of
services are to be
Sincerely,
Lee Thielen
Assistant Director
Colorado Department of Health
Program Approval
Contractor
By
Title
APPROVED:
State Controller, Clifford W. Hall
By
Ray Campbell
CDH FPP 3/94 Colorado Department of Health
951238
STATE OF COLORADO
Roy Romer, Governor
Path Shwayder, Acting Executive Director
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr. S.
Denver, Colorado 80222-1530
Phone (303) 692-2000
DATE
TO:
Laboratory Building
4210 E. 11th Avenue
Denver, Colorado 60220-3716
(303) 691-4700
Attachment "E"
CONTRACT RENEWAL LETTER
Colorado Department
of Public Health
and Environment
The Colorado Department of Public Health and Environemnt hereby notifies
that pursuant to paragraph 11 of contract number
FPP , the state will exercise its option to renew this contract for an
additional one year period beginning July 1, 199_ through June 30, 199_.
Paragraph 6 of the contract is deleted and replaced with the following
(Paragraphs 6a through 6g remain unchanged):
The State will pay Dollars ($ ) ($ Title X dollars and
$ State and Waxman dollars) to provide contraceptive services to
approximately _comprehensive family planning patients; Dollars ($
to provide colposcopy, biopsy, and/or pap smear services to _ patients;
and Dollars ($ ) to provide cryosurgery and/or pap smear screening
services to _ patients. In consideration of said services by the Contractor
and conditioned upon affirmation by the Family Planning Program that services
were rendered in accordance with this contract, the state will
cause ) tobe paid
to the Contractor a sum not to exceed Dollars
This contract renewal letter is intended to be effective July 1, 199_, but in no
event shall it be deemed valid until it is approved by the State Controller or
his designee.
Please sign and return all copies of this notification. A fully executed copy
will be returned to you.
Sincerely,
Lee Thielen
Assistant Director
Colorado Department of Health
Contractor
By
Title
APPROVED
Program Approval State Controller, Clifford W. Hall
By
Ray Campbell, Controller,
CDHFPP 1/94 Colorado Department of Health
951238
4K it:t mEmoRAnDum
WIDalellall,Chairman�Pc.
To Board of County Commissioners Date June 15, 1995
COLORADO �- _ f.�_
x'14 A✓
From
Subject:
John Pickle, Director, Health Department
Family Planning Contract
Enclosed for Board approval is a contract between the Weld County Health Department and the
Colorado Department of Public Health and Environment for our Family Planning Program for
the period July 1, 1995 through June 30, 1996. This contract is renewable annually at the State's
option for three additional one year periods by a Contract Renewal Letter.
The Health Department will be reimbursed up to $76, 968 to provide contraceptive services to
approximately 2,000 family planning clients and $1,350 to provide cryosurgery services and/or
pap smear screening services to 18 patients. These amounts equal a total contract amount of
$78,318 which is $7,466 less than last year's contract.
Family Planning is one of the tools we use in working with the teen pregnancy issue. I
recommend your approval of this contract.
Enclosure
951238
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