HomeMy WebLinkAbout20240543.tiffCVaCftt8L(D4
AGREEMENT AMENDMENT BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND TIPPETS DENTISTRY
This Agreement Amendment made and entered into 3�d day of
2024 by and between the Board of Weld County Commissioners, on behalf of the W d
County Department of Human Services, hereinafter referred to as the "Department", and
Tippets Dentistry, hereinafter referred to as the "Contractor".
WHEREAS the parties entered into an Agreement for Case Management Agency
Services. (the "Original Agreement") identified by the Weld County Clerk to the Board of
County Commissioners as document No. 2024-0543, approved on March 4, 2024.
WHEREAS the parties hereby agree to amend the term of the Original Agreement in
accordance with the terms of the Original Agreement and any previously adopted
amendment, which is incorporated by reference herein, as well as the terms provided herein.
/3/Z4
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and
agree as follows:
• The Original Agreement will end on June 30. 2024.
• This Amendment, together with the Original Agreement, constitutes the entire
understanding between the parties. The following additional changes are hereby
made to the current Agreement effective July 1, 2024:
1. Paragraph IV, is hereby amended as follows:
a. The term of this Agreement shall be from July 1, 2024, through June 30
2025, and may be extended upon written agreement of both parties.
d. In order to comply with HCPF State General Funds reporting requirements,
no invoices received from the VENDOR after July 3, 2025, for Fiscal Year
July 1, 2024 through June 30, 2025 will be accepted or paid by CMA, the
date of July 3, 2025 is subject to change pending Fiscal Year 24-25
holiday schedule.
• All other terms and conditions of the Original Agreement remain unchanged.
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IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
COUNTY:
ATTEST: 0;ei BOARD OF COUNTY COMMISSIONERS
to the Boar WEI,A.l≤OUNTY, COLORADO
Deputy CI
Perry L. ck, Chair Pro-Tem
ONTRACTOR:
JUL 0 3 2024
Tippets Dentistry
257 Johnstown Center Drive, Unit 108
Johnstown, Colorado 80534
eL
By: Dr Jeffrey 5 T,ppets Ju 27, 2024 1 t�DT,
Dr. Jeffrey S. Tippets, Owner
Date:
Jun 27, 2024
ao4ii_ off 43
SIGNATURE REQUESTED: Weld/Tippets
Dentistry Amendment #1
Final Audit Report
2024-06-27
Created: 2024-06-27
By: Sara Adams (sadams@weld.gov)
Status: Signed
Transaction ID: CBJCHBCAABAAdWwgzRJSWXaVgDeJlox_I95NHuncJM5M
"SIGNATURE REQUESTED: Weld/Tippets Dentistry Amendme
nt #1" History
5 Document created by Sara Adams (sadams@weld.gov)
2024-06-27 - 3:49:29 PM GMT- IP address: 204.133.39.9
Document emailed to office@tippetsdentistry.com for signature
2024-06-27 - 3:50:20 PM GMT
t Email viewed by office@tippetsdentistry.com
2024-06-27 - 9:56:25 PM GMT- IP address: 69.131.130.94
60, Signer office@tippetsdentistry.com entered name at signing as Dr. Jeffrey S Tippets
2024-06-27 - 9:57:26 PM GMT- IP address: 69.131.130.94
d Document e -signed by Dr. Jeffrey S Tippets (office@tippetsdentistry.com)
Signature Date: 2024-06-27 - 9:57:28 PM GMT - Time Source: server- IP address: 69.131.130.94
Agreement completed.
2024-06-27 - 9:57:28 PM GMT
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DENTISTS PROFESSIONAL LIABILITY
OF COLORADO
DENTISTS PROFESSIONAL LIABILITY TRUST OF COLORADO
PROFESSIONAL LIABILITY COVERAGE AGREEMENT
DECLARATIONS PAGE
This Declarations Page summarizes the essential elements of the Professional Liability Coverage Agreement
("Policy"). It attaches to and becomes a part of the Policy. Please read carefully and completely review the Policy
terms and conditions.which follow.
Item 1 POLICY NUMBER: TRU1003152-4
Item 2 PARTICIPANT'S NAME AND ADDRESS:
Jeffrey S. Tippets, DDS
1395 Barn Owl Ct.
Windsor, CO 80550
Item 3 PARTICIPANT'S FORM OF BUSINESS:
Item 4 ANNUAL POLICY PERIOD (CLAIMS MADE FORM):
This insurance does not apply to injuries, claims or dental incidents which occur before the Retroactive
Date, if any, stated below
Initial Date: 07/05/2004
Effective Date: 07/05/2024
Expiration Date: 07/05/2025
Retroactive Date: 07/05/2004
12:01 a.m. Standard Time
12:01 a.m. Standard Time
12:01 a.m. Standard Time
12:01 a.m. Standard Time
Item 5 LIMITS OF LIABILITY:
In consideration of the Participant's payment of the required contributions set forth herein, in reliance
upon the statements and representations made by the Participant in the Application and the
Supplemental Application for coverage, and subject to the terms and conditions of the Trust
Agreement, the Trust agrees to provide the Participant with professional liability coverage for the policy
period set forth in Item 4. above, subject to the limits of liability shown below, and expressly subject to
all the terms and conditions of the Policy.
$2,000,000 Each Claim
$6,000,000 Annual Aggregate
Item 6 ANNUAL CONTRIBUTION: $1,957
Item 7 EXTENDED REPORTING PERIOD ENDORSEMENT CONTRIBUTION:
The additional contribution required for an Extended Reporting Period Endorsement at the end of this
policy period is: $3,914
DEC -CL (08/20)
Page 1 of 2
Item 8 ENDORSEMENTS ATTACHED AND MADE PART OF THIS POLICY:
DISC (08/20) CA (08/20) ENTY (08/20) IMPL (08/20)
STBD (08/20)
Item 9 These Declarations, together with the Application and Supplemental Application, the Coverage
Agreement, and all forms and endorsements made part thereof, complete the abovenumberedpolicy.
COUNTERSIGNED: 06/27/2024 BY:
C0,414._ Lk_
DEC -CL (08/20) Page 2_.of 2
Contract Form
Entity Information
Entity Name *
TIPPETS DENTISTRY
Entity ID*
@00033334
Contract Name * Contract ID
TIPPETS DENTISTRY - CMA SERVICES AGREEMENT 8464
AMENDMENT #1
Contract Status
CTB REVIEW
Contract Lead *
SADAMS
O New Entity?
Parent Contract ID
20240543
Requires Board Approval
YES
Contract Lead Email Department Project #
sadams@weld.gov;cobbx
xlk@weld.gov
Contract Description *
(CONSENT) TIPPETS DENTISTRY - CMA SERVICES AGREEMENT AMENDMENT #1 TO EXTEND TERMS TO 07/01 /24
TO 06/30/2025
Contract Description 2
NO PA NEEDED
Contract Type * Department Requested BOCC Agenda Due Date
AMENDMENT HUMAN SERVICES Date* 06/29/2024
07/03/2024
Amount*
$0.00
Renewable*
NO
Automatic Renewal
Grant
IGA
Department Email
CM-
HumanServices@weldgov.
com
Department Head Email
CM-HumanServices-
DeptHead@weldgov.com
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY@WEL
DGOV.COM
Will a work session with BOCC be required?*
NO
Does Contract require Purchasing Dept. to be
included?
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts
are not in OnBase
Contract Dates
Effective Date
Termination Notice Period
Contact Information
Review Date
04/30/2025
Committed Delivery Date
Renewal Date
Expiration Date"
06/30/2025
Contact Info
Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2
Purchasing
Purchasing Approver Purchasing Approved Date
CONSENT 06/28/2024
Approval Process
Department Head Finance Approver Legal Counsel
JAMIE ULRICH CONSENT CONSENT
DH Approved Date Finance Approved Date Legal Counsel Approved Date
06/28/2024 06/28/2024 06/28/2024
Final Approval
BOCC Approved Tyler Ref #
AG 070324
BOCC Signed Date Originator
SADAMS
BOCC Agenda Date
07/03/2024
Conkva Ci- 1N:1 '7881
Case Management Agency (CMA)
Service Agreement Terms and Conditions
This Service Agreement (SA) is made this day Ma /C,V) 441 'MN) , by and between
Weld County Department of Human Services, hereinafter referred to as "CMA", having its
principal place of business at 315 North 11th Avenue, Greeley, Colorado 80631, and Tippets
Dentistry, hereinafter referred to as the "VENDOR," whose business address is 257 Johnstown
Center Drive, Unit 108, Johnstown, Colorado 80534. NOW THEREFORE, in consideration of the
promises and covenants contained herein, the parties agree as follows:
I. Work and Payment
The VENDOR should not commence services under this Agreement until Services have been
approved in the individual's Service Plan. Services to be provided are detailed in the Individual's
State Supported Living Services (SLS) or OBRA Service Plan which dictates the type of service as
well as timing and frequency of service to be performed. Rates paid for State SLS and OBRA
services can be found on the State Health Care Policy and Financing Website
https://hcpf.colorado.gov/provider-rates-fee-schedule see State General Fund Programs Direct
Service Rates Fee Schedule. The VENDOR shall include in their monthly invoice the date and
duration of services performed.
Specific work performance expectations that are deemed appropriate and necessary in order to
receive compensation for the work must meet specified State Regulations. Services covered in
this agreement are listed in Exhibit B, Scope of Services and Rates. The VENDOR affirms the
following requirements are met, as defined by the State of Colorado:
The service to be delivered shall meet all applicable state licensing requirements for the
performance of the support or service being provided.
Certificate: The service to be delivered shall meet all applicable state certification
requirements for the performance of the support or service being provided and program
approval.
Electronic Visit Verification (EVV) is not a requirement for billing State SLS / OBRA services.
More information can be found on the HCPF website https://hcpf.colorado.gov/electronic-visit-
verification-program-manual#coEWX
II. Intent of the Parties:
It is the expressed intent of the parties that the Contractor is a VENDOR and not the agent,
employee, or servant of CMA and that:
a. The VENDOR does not have the express or implied authority to act for CMA or to bind CMA
to any agreements, liability, or understanding except as expressly set forth herein.
b. The VENDOR shall be accountable to CMA for the ultimate results of its actions but shall not
be subject to direction and control of CMA herein.
c. Neither the VENDOR nor any agent or employee of the VENDOR shall be or shall be deemed
to be an agent or employee of CMA.
ee. 07,6%,-p)
2024-0543
3/4/24
d. The VENDOR shall pay when due all required employment taxes and Income Tax
Withholdings, including all Federal and State Income Tax and Local Tax on any monies paid
pursuant to this service authorization.
e. The VENDOR acknowledges that the VENDOR and its employees are not entitled to
unemployment insurance benefits unless the VENDOR, or a Third Party provides such
coverage, and that CMA does not pay for or otherwise provide such coverage.
f. The VENDOR shall provide and keep in force Worker's Compensation and show proof of
such insurance; and unemployment compensation insurance in the amounts required by
law and shall be solely and entirely responsible for the acts of the VENDOR, its employees,
and agents. The VENDOR shall furnish CMA with written certification of the existence of
such coverage prior to the finalization of service authorization provisions.
Ill. VENDOR Responsibilities:
a. COMPLIANCE WITH THE LAW: The VENDOR agrees to perform its duties and obligations
hereunder in strict conformity with relevant federal law, all pertinent federal regulations
promulgated pursuant to federal law, the Home and Community -Based Services for Persons
with Developmental Disabilities Act; 10 Code of Colorado Regulations (CCR) 2505-10 8.500;
10 CCR 2505-10 8.600 Colorado Revised Statute (CRS); Title 25.5 Article 10 et seq., relevant
State law, and all pertinent regulations of the Colorado Department of Human Services,
Colorado Department of Health Care Policy and Financing, and Colorado Department of
Public Health and Environment, as they currently exist or may hereafter be amended.
b. LICENSES AND CERTIFICATIONS: The VENDOR represents and warrants to CMA that it and
its employees have the requisite training, skills, experience, qualifications, all necessary
provider numbers, licenses, certifications, approvals, etc. required to properly provide the
services or goods covered by this authorization.
c. RECORDS: The VENDOR shall maintain a complete file of all records, communications,
documents, and other written materials that pertain to the operation of programs or the
delivery of services under this SA and shall maintain such records for a period of six (6) years
after the date of termination of this SA as per State requirements, or for such further period
as may be necessary to resolve any matters which may be pending. All files shall be kept at
the VENDOR's place of business, and the VENDOR shall furnish copies of such files, or
portions thereof, as requested by CMA or its designee.
d. INSPECTIONS AND PERFORMANCE MONITORING: The VENDOR shall permit CMA, the State
of Colorado, the Colorado Department of Health Care Policy and Financing, the U.S.
Department of Health and Human Services, and any other duly authorized agent or
governmental agency (including the Medicaid Fraud Control Unit) to monitor all activities
authorized under this SA. Such monitoring may consist of internal evaluation procedures,
examination of data, formal audit, on -site checking, or any other reasonable procedure. Any
amounts which have been paid by CMA, and which are found to be improper in accordance
with the terms of this SA shall be immediately returned to CMA or may be withheld from
future payments. Services rendered through State SLS are subject to inspection and
recovery by the Department pursuant to 10 C.C.R. 2505-10 Section 8.076.
e. ASSIGNMENT/DELEGATION/SUBCONTRACTORS: The VENDOR shall not assign, delegate,
nor subcontract services in this SA without the express prior written consent of CMA.
f. INSURANCE:
i. The VENDOR agrees that it will keep in force an insurance policy or policies, issued by
a company authorized to do business in Colorado, in the kinds and minimum amounts
specified below unless specifically waived herein. In the event of cancellation of any
such coverage, the VENDOR shall immediately notify CMA of such cancellation.
ii. The VENDOR shall have CMA and State of Colorado Health Care Policy and Financing
listed as "Additional Insured" on VENDOR's insurance policies.
iii. Standard Worker's Compensation and Employers' Liability as required by State
statute, including occupational disease, covering all employees on or off the work site
acting within the course and scope of their employment.
iv. General, Personal Injury, Professional, Automobile Liability (including bodily injury,
personal injury, and property damage) minimum coverages:
v. Occurrence basis policy: combined single limit of $1,000,000 or Claims -Made policy:
combined single limit of $1,000,000; plus, an endorsement, certificate, or other
evidence that extends coverage two years beyond the performance period of the
service authorization.
vi. Annual Aggregate Limit policy: Not less than $1,000,000 plus an agreement that the IC
will purchase additional insurance to replenish the limit to $1,000,000 if claims reduce
the annual aggregate below $1,000,000.
vii. The insurance shall include provisions preventing cancellation without thirty (30)
calendar days prior written notice to CMA by certified mail.
viii. The VENDOR shall provide certificates of adequate insurance coverage to CMA within
ten (10) days of receipt of this service authorization.
IV. Payment for Services and Term:
a. This contract shall be for a term commencing March 1, 2024 through June 30, 2024 and
may be extended upon written agreement of both parties.
b. Monthly Invoicing: The VENDOR shall invoice CMA within four (4) working days of the end
of the month in which the services were performed, except at the end of the fiscal year
when invoices are due two (2) working days from the end of the fiscal year. Invoices
received within this time frame will be paid Net 30 unless otherwise noted on the invoice.
Invoices may be sent via email to wccmabilling@weld.gov
c. Vendor must include the following detail on invoices in order to be paid for services:
i. Name of individual in services
ii. Dates of Service
iii. For services paid in 15 -minute increments, invoice must show the amount of time
services were provided in hours or 15 -minute increment
iv. Rate per 15 -minute increment or Rate per hour (per Medicaid fee schedule)
v. Total Amount Due
vi. "No shows" are not billable to Medicaid and will not be reimbursed. Do not include
"No shows" in your billing ("No shows" include family cancelling or provider
cancelling)
d. In order to comply with HCPF State General Funds reporting requirements, no invoices
received from the VENDOR after July 3, 2024, for Fiscal Year July 1, 2023 thru June 30, 2024
will be accepted or paid by CMA, the date of July 3, 2024 is subject to change pending Fiscal
Year 23-24 holiday schedule.
e. Services may be increased or decreased during the term of this agreement by either party
due to increased or decreased State funding levels or adjustments to service levels, with the
agreement by both parties.
f. In the event that overpayments are made by CMA due to the VENDOR's omission, error,
fraud, or defalcation; or in the event that the State or Federal government seeks to recover
from CMA any sums of money based upon a claim on behalf of the VENDOR after said funds
have been paid to the VENDOR, the VENDOR shall immediately reimburse such funds to
CMA as allowed by law. The parties understand and agree that CMA shall have the right to
offset against payments due to the VENDOR hereunder, or by other legal means recover
any debts owed by the VENDOR to CMA or to the State.
V. General Terms and Conditions:
a. TERMINATION: Except as otherwise agreed in Section I, if the VENDOR refuses or fails to
perform any of the provisions of this SA in a timely manner, CMA may notify the VENDOR in
writing of nonperformance and may terminate VENDOR's right to proceed with the SA. In
addition, either party shall have the right to terminate this SA, without cause, by giving the
other party 30 days written notice. If notice is so given, this SA shall terminate on the
expiration of the thirty (30) days, and the liability of the parties hereunder for further
performance of the terms of this agreement shall thereupon cease, but the parties shall not
be released from the duty to perform their obligations up to the date of termination.
b. COMPLETE SERVICE AUTHORIZATION: This SA contains the entire agreement of the parties.
c. INDEMNIFICATION: To the extent authorized by law, the VENDOR shall indemnify, save, and
hold harmless CMA, 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 VENDOR or its employees, agents, subcontractors, or assignees pursuant
to the terms of this SA.
d. NON-DISCRIMINATION: The VENDOR agrees to comply with the letter and spirit of all
applicable State and federal laws respecting discrimination and unfair employment
practices.
e. CONFIDENTIALITY OF RECORDS: The VENDOR shall protect the confidentiality of all records
containing personal identifying information that are maintained in accordance with this SA.
No such information shall be released except for program administration purposes or with
the subject individual's prior written consent.
f. CONFLICT OF INTEREST: The VENDOR shall fully disclose to CMA any relationship(s) it has
with a third party where such relationship is in opposition or conflict to its relationship with
CMA under this SA.
g. Health Insurance Portability & Accountability Act of 1996 ("HIPAA"). Federal law governing
the privacy of certain health information requires a "Business Associate" service
authorization between CMA and the VENDOR. 45 CFR Section 164.504(e). Attached and
incorporated herein by reference as Exhibit A is a HIPAA Business Associate Addendum for
HIPAA compliance.
h. BACKGROUND CHECKS: As per C.R.S. 27-90-111, the VENDOR shall conduct background
(criminal record) and reference checks prior to hiring staff and volunteers or contracting
with other providers. The VENDOR shall not employ, contract with, or accept volunteer
services from individuals who would have unsupervised contact with or access to persons
receiving services under this service authorization, or their property and who have been
convicted of abuse, neglect, or mistreatment of a child, adult or person receiving services,
or of a misdemeanor or felony involving physical harm or violence to another individual, or
distribution of controlled substances.
i. CONTRACTS FOR SERVICE — ILLEGAL ALIENS: The VENDOR shall not knowingly employ or
contract with illegal aliens to perform work under this service authorization or enter into a
contract with a subcontractor that fails to certify to VENDOR that the subcontractor
knowingly does not employ or contract with illegal aliens to perform work under this
service authorization. The VENDOR, if a natural person eighteen (18) years of age or older,
hereby swears or affirms under penalty of perjury that he or she (i) is a citizen or otherwise
lawfully present in the United States pursuant to federal law, (ii) shall comply with the
provisions of CRS 24-76.5-101 et seq. and (iii) shall produce identification required by CRS
24-76.5-103 prior to the effective date of this service authorization.
j. If there is a dispute, VENDORs are to follow Section 25.5-10-212 CRS,
k. The VENDOR agrees to abide by the following CMA policies and procedures located on the
CMA website at https://www.weld.gov/Government/Departments/Human-Services/Area-
Agency-on-Aging-AAA
i. Critical Incidents
ii. Mistreatment
iii. Human Rights Committee (HRC)
I. FEDERAL FALSE CLAIMS ACT 31 US Code 3729: The VENDOR, its employees, subcontractors,
and agents shall comply with the Federal False Claims Act. Violations of the False Claims Act
such as false claims or attempts to defraud health care programs should be promptly
reported, investigated, and remedied, as appropriate and required by law. Detailed
information regarding the False Claims Act and CMA's policy can be found on the CMA
website.
The parties have caused their duly authorized representatives to sign this Service Authorization
Agreement stated above:
CMA:
ATTEST: BOARD OF COUNTY COMMISSIONERS
WELD CO U N 1L9 -L8
BY:
evin D. Ross, Chair MAR 0 4 2024
DOR:
pets Dentistry
57 Johnstown Center Drive, Unit 108
Johnstown, Colorado 80534
Je fte Tie ets
By:Jeffrey ippets eb 26,'2 413:14 MST)
Dr. Jeffrey S. Tippets, Owner
Date: Feb 26, 2024
Exhibit A
CMA
HIPAA BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement ("Agreement") is part of federal and state
requirements of CMA For purposes of this Agreement, CMA is referred to as "Covered Entity"
or "CE" and VENDOR is referred to as the "Business Associate" or "Associate." The Associate
performs, or assists in the performance, of a function or activity, or provides services of a type
for CMA that makes the Associate a "Business Associate" for purposes of the HIPAA privacy
regulations.
The CE may disclose protected health information to the Associate in conjunction with the
function, activity, or services performed or provided by the Associate. The CE and the
Associate desire to enter into an agreement as required by the HIPAA privacy regulations to
provide satisfactory assurance to CMA that the Associate will appropriately safeguard that
protected health information (PHI).
RECITALS
A. CE and Associate intend to protect the privacy and provide for the security of PHI
disclosed to Associate pursuant to this Agreement in compliance with the Health
Insurance Portability and Accountability Act of 1996, 42 U.S.C. §1320d — 1320d-8
("HIPAA"), as amended by the American Recovery and Reinvestment Act of 2009
("ARRA")/HITECH Act (P.L. 111-005), and its implementing regulations promulgated by
the U.S. Department of Health and Human Services, 45 C.F.R. Parts 160, 162 and 164
(the "HIPAA Rules") and other applicable laws, as amended.
B. As part of the HIPAA Rules, the CE is required to enter into an agreement containing
specific requirements with Associate prior to the disclosure of PHI, as set forth in, but
not limited to, Title 45, Sections 160.103, 164.502(e) and 164.504(e) of the Code of
Federal Regulations ("C.F.R.") and contained in this Agreement.
The parties agree as follows:
1. Term. Except as otherwise provided for herein, this Agreement will continue in full
force and effect through the term of any function, activity, or services performed or provided
by the Associate.
2. Definitions.
a. Except as otherwise defined herein, capitalized terms in this Agreement shall
have the definitions set forth in the HIPAA Rules at 45 C.F.R. Parts 160, 162 and 164, as
amended. In the event of any conflict between the mandatory provisions of the HIPAA Rules
and the provisions of this Agreement, the HIPAA Rules shall control.
b. "Protected Health Information" or "PHI" means any information, whether oral
or recorded in any form or medium: (i) that relates to the past, present, or future physical or
mental condition of an individual; the provision of health care to an individual; or the past,
present, or future payment for the provision of health care to an individual; and (ii) that
identifies the individual or with respect to which there is a reasonable basis to believe the
information can be used to identify the individual and shall have the meaning given to such
term under the HIPAA Rules, including, but not limited to, 45 C.F.R. Section 164.501.
c. "Protected Information" shall mean PHI provided by CE to Associate or created,
received, maintained, or transmitted by Associate on CE's behalf. To the extent Associate is a
covered entity under HIPAA and creates or obtains its own PHI for treatment, payment, and
health care operations, Protected Information under this Agreement does not include any PHI
created or obtained by Associate as a covered entity and Associate shall follow its own policies
and procedures for accounting, access and amendment of Associate's PHI.
3. Obligations of Associate.
a. Permitted Uses. Associate shall not use Protected Information except for the
purpose of performing Associate's obligations as permitted under this Agreement. Further,
Associate shall not use Protected Information in any manner that would constitute a violation
of the HIPAA Rules if so used by CE, except that Associate may use Protected Information: (i)
for the proper management and administration of Associate; (ii) to carry out the legal
responsibilities of Associate; or (iii) for Data Aggregation purposes for the Health Care
Operations of CE. Associate agrees to defend and indemnify the CE against third party claims
arising from Associate's breach of this Agreement.
b. Permitted Disclosures. Associate shall not disclose Protected Information in
any manner that would constitute a violation of the HIPAA Rules if disclosed by CE, except that
Associate may disclose Protected Information: (i) in a manner permitted pursuant to this
Agreement; (ii) for the proper management and administration of Associate; (iii) as required
by law; (iv) for Data Aggregation purposes for the Health Care Operations of CE; or (v) to report
violations of law to appropriate federal or state authorities, consistent with 45 C.F.R. Section
164.502(j)(1).
c. Appropriate Safeguards. Associate shall implement appropriate safeguards as
are necessary to prevent the use or disclosure of Protected Information other than as
permitted by this Agreement. Associate shall comply with the requirements of the HIPAA
Security Rule at 45 C.F.R. Sections 164.308, 164.310, 164.312, and 164.316. Associate shall
maintain a comprehensive written information privacy and security program that includes
administrative, technical, and physical safeguards appropriate to the size and complexity of
the Associate's operations and the nature and scope of its activities. Associate shall review,
modify, and update documentation of its safeguards as needed to ensure continued provision
of reasonable and appropriate protection of Protected Information.
d. Reporting of Improper Use or Disclosure. Associate shall report to CE in
writing any use or disclosure of Protected Information other than as provided for by this
Agreement within five (5) business days of becoming aware of such use or disclosure.
e. Accounting Rights. Associate and its agents shall make available to CE, within
ten (10) business days of notice by CE, the information required to provide an accounting of
disclosures to enable CE to fulfill its obligations under the HIPAA Rules, including, but not
limited to, 45 C.F.R. Section 164.528. In the event that the request for an accounting is
delivered directly to Associate or its agents, Associate shall within five (5) business days of the
receipt of the request, forward it to CE in writing. It shall be CE's responsibility to prepare and
deliver any such accounting requested. Associate shall not disclose any Protected Information
except as set forth in Section 2(b) of this Agreement.
f. Governmental Access to Records. Associate shall keep records and make its
internal practices, books and records relating to the use and disclosure of Protected
Information available to the Secretary of the U.S. Department of Health and Human Services
(the "Secretary,") in a time and manner designated by the Secretary, for purposes of
determining CE's or Associate's compliance with the HIPAA Rules. Associate shall provide to
CE a copy of any Protected Information that Associate provides to the Secretary concurrently
with providing such Protected Information to the Secretary when the Secretary is investigating
CE. Associate shall cooperate with the Secretary if the Secretary undertakes an investigation
or compliance review of Associate's policies, procedures or practices to determine whether
Associate is complying with the HIPAA Rules, and permit access by the Secretary during normal
business hours to its facilities, books, records, accounts, and other sources of information,
including Protected Information, that are pertinent to ascertaining compliance.
g. Minimum Necessary. Associate (and its agents) shall only request, use, and
disclose the minimum amount of Protected Information necessary to accomplish the purpose
of the request, use, or disclosure, in accordance with the Minimum Necessary requirements
of the HIPAA Rules, including, but not limited to, 45 C.F.R. Sections 164.502(b) and 164.514(d).
h. Data Ownership. Associate acknowledges that Associate has no ownership
rights with respect to the Protected Information.
i. Retention of Protected Information. Except upon termination of all functions,
activities, or services performed or provided by the Associate, Associate or agents shall retain
all Protected Information and shall continue to maintain the information for a period of six (6)
years.
j. Notification of Breach. During the term of this Agreement, Associate shall
notify CE within five (5) business days of any suspected or actual breach of security, intrusion
or unauthorized use or disclosure of Protected Information and/or any actual or suspected
use or disclosure of data in violation of any applicable federal or state laws or regulations.
Associate shall not initiate notification to affected individuals per the HIPAA Rules without
prior notification and approval of CE. Information provided to CE shall include the
identification of each individual whose unsecured PHI has been, or is reasonably believed to
have been accessed, acquired or disclosed during the breach. Associate shall take (i) prompt
corrective action to cure any such deficiencies and (ii) any action pertaining to such
unauthorized disclosure required by applicable federal and state laws and regulations.
k. Safeguards During Transmission. Associate shall be responsible for using
appropriate safeguards, including encryption of PHI, to maintain and ensure the
confidentiality, integrity and security of Protected Information transmitted to CE pursuant to
the Agreement, in accordance with the standards and requirements of the HIPAA Rules.
I. Restrictions and Confidential Communications. Associate will not respond
directly to an individual's requests to restrict the use or disclosure of Protected Information
or to send all communication of Protected Information to an alternate address. Associate will
refer such requests to the CE so that the CE can coordinate and prepare a timely response to
the requesting individual and provide direction to Associate.
4. Obligations of CE.
a. Safeguards During Transmission. CE shall be responsible for using appropriate
safeguards, including encryption of PHI, to maintain and ensure the confidentiality, integrity
and security of Protected Information transmitted pursuant to this Agreement, in accordance
with the standards and requirements of the HIPAA Rules.
b. Notice of Changes. CE maintains a copy of its Notice of Privacy Practices on its
website. CE shall provide Associate with any changes in, or revocation of, permission to use or
disclose Protected Information, to the extent that it may affect Associate's permitted or
required uses or disclosures. To the extent that it may affect Associate's permitted use or
disclosure of PHI, CE shall notify Associate of any restriction on the use or disclosure of
Protected Information that CE has agreed to in accordance with 45 C.F.R. Section 164.522.
5. Reasonable Steps to Cure Breach.
a. If CE knows of a pattern of activity or practice of Associate that constitutes a
material breach or violation of the Associate's obligations under the provisions of this
Agreement or another arrangement, then CE shall take reasonable steps to cure such breach
or end such violation. If Associate knows of a pattern of activity or practice of an agent that
constitutes a material breach or violation of agent's obligations under the written agreement
between Associate and the agent, Associate shall take reasonable steps to cure such breach
or end such violation, if feasible.
6. Disposition of the PHI upon Termination or Expiration.
a. Upon termination or expiration of any agreement for services between the
Parties, the Associate will either return or destroy, at CE's sole discretion and in accordance
with any instructions by CE, all PHI in the possession or control of the Associate and its agents.
However, I the Associate determines that neither the return nor destruction of the PHI is
feasible, the Associate may retain the PHI provided that the Associate complies with those
reasonable restrictions imposed by the CE.
7. Disclaimer. CE makes no warranty or representation that compliance by Associate with
this Agreement or the HIPAA Rules will be adequate or satisfactory for Associate's own
purposes. Associate is solely responsible for all decisions made by Associate regarding the
safeguarding of PHI.
8. Assistance in Litigation or Administrative Proceedings. Associate shall make itself and
any employees or agents assisting Associate in the performance of its obligations under the
Agreement, available to CE, at no cost to CE, up to a maximum of thirty (30) hours, to testify
as witnesses or otherwise, in the event of litigation or administrative proceedings being
commenced against CE, its directors, officers, or employees based upon a claimed violation of
the HIPAA Rules or other laws relating to security and privacy or PHI, in which the actions of
Associate are at issue, except where Associate or its employee or agent is a named adverse
party.
9. Interpretation and Order of Precedence. The provisions of this Agreement shall be
interpreted as broadly as necessary to implement and comply with the HIPAA Rules. The
parties agree that any ambiguity in this Agreement shall be resolved in favor of a meaning that
complies and is consistent with the HIPAA Rules.
10. Survival of Certain Agreement Terms. Notwithstanding anything herein to the
contrary, Associate's obligations under this Agreement shall survive termination of this
Agreement and shall be enforceable by CE as provided herein in the event of such failure to
perform or comply by the Associate.
11. Representatives and Notice. For the purpose of the Agreement, the individuals
identified on Page 1 of 4 Pages of this agreement shall be the representatives of the respective
parties. All required notices shall be hand delivered or given by certified or registered mail to
the representatives at the addresses listed at the top of this form.
Exhibit B
Scope of Services and Rates
1. Scope of Services
a. Services to be provided are detailed in the Individual's State Supported Living
Services (SLS) or OBRA Service Plan which dictates the type of service as well as
timing and frequency of service to be performed.
b. Approved VENDOR State SLS and OBRA services provided under this agreement:
® 02999: State SLS - Dental
❑ H1010: CES — Parent Education
❑ H2019: State SLS — Behavioral Consultation
❑ H2019: DD — Behavioral Counseling Individual
❑ H2019: SLS — Behavioral Counseling Individual
❑ H2019: OBRA — Counseling Individual
❑ H2019: State SLS— Counseling Services Individual
❑ H2021: State SLS - Mentorship
❑ H2023: State SLS - Supp Employment -Job Development
❑ S5130: SLS — Homemaker Basic
❑ S5130: State SLS — Homemaker Basic
❑ S5130: State SLS — Homemaker Enhanced
❑ S5150: State SLS — Respite Individual per 15 minutes
❑ S5151: State SLS— Respite Individual Per Day
❑ S5161: State SLS — Personal Emergency
❑ S5161: SLS — Personal Emergency Response Services
❑ S5165: CES — Home Accessibility Adaptations
❑ S5199: CES—Adapted Therapeutic Recreational Fees
❑ S8940: CES — Hippotherapy - Individual
❑ S8940: SLS — Hippotherapy - Individual
❑ T1019: State SLS - Personal Care
❑ T1999: CES — Adapted Therapeutic Recreational Equipment
❑ T2003: State SLS—Transportation Mileage
❑ T2003: State SLS—Transportation Mileage nonday
❑ T2003: SLS— Transportation Mileage Band 1
❑ T2004: State SLS — Transportation Other
❑ T2004: DD —Transportation — Other (Public Conveyance)
❑ T2004: SLS — Transportation — Other (Public Conveyance)
❑ T2019: State SLS—Supportive Employment Individual
❑ T2019: State SLS — Supportive Employment Group
❑ T2021: State SLS — Day Habilitation Supp Comm Connect
❑ T2021: State SLS — Day Habilitation Specialized Flab
❑ T2024: State — Behavioral Assessment
❑ T2028: DD — Specialized Medical Supplies — Disposable
❑ T2028: SLS - Specialized Medical Supplies - Disposable
❑ 12029: CES — Specialized Medical Equipment
❑ T2029: DD — Specialized Medical Equipment
❑ T2029: SLS—Specialized Medical Equipment
❑ T2035: CES — Assistive Technology
❑ V2799: DD — Vision Services
❑ V2799: SLS — Vision Services
❑ V2799: State SLS — Vision Services
❑ 97124: CES — Message Therapy
❑ 10000: State SLS — Acquiring Pest Abatement
2. Provider Rates and Fee Schedule
a. Rates paid for State SLS and OBRA services can be found on the State Health Care
Policy and Financing Website https://hcpf.colorado.gov/provider-rates-fee-
schedule, see State General Fund Programs Direct Service Rates Fee Schedule.
Terms
1. Home and Community Based Service (HCBS) Provider Agency Billing
a. Claims for HCBS services are payable only if submitted in accordance with the
following procedures:
i. VENDOR shall verify Member eligibility prior to delivering services;
ii. VENDOR shall verify a Prior Authorization Request (PAR) has been
approved for the services in question, prior to service provision and
claim submission;
iii. Claims shall be submitted to the Fiscal Agent in accordance with
Department billing manuals and policies, outlined in 10 C.C.R. 2505-10
Section 8.043;
iv. Claims shall only be submitted for services the VENDOR is enrolled to
provide, including correct HCBS specialties;
v. Claims shall only be submitted for services provided in accordance
with all applicable federal and state statutes, regulations, and other
authorities;
vi. Submitted claims shall include all data elements required to complete
the National Uniform Claim Committee Form 1500 (CMS 1500).
b. Payment shall not exceed rate shown in the Health First Colorado Fee
Schedule in effect on the date services are provided.
c. Pursuant to § 25.5-4-301, C.R.S., VENDOR shall not collect copayments or seek
reimbursement from eligible Members for covered services.
2. Personnel
a. Employee and Contractor records
i. The VENDOR shall maintain records documenting the qualifications and
training of employees and Contractors who provide services to Members.
ii. The VENDOR shall maintain a personnel record for each employee or
Contractor. The record shall contain:
■ Documentation of employee/Contractor qualifications.
Documentation of trainings completed.
Documentation of supervision and performance evaluation or
contractor
management.
Documentation that the employee/Contractor was informed of all
policies and procedures required by Section 8.7409.
• Documentation of the employee's/Contractor's job description.
• Documentation of a criminal background check and a CAPs check.
3. License/Certification
a. The VENDOR shall meet the enrollment requirements for each service it
provides prior to providing services. The VENDOR shall ensure each employee
or independent Contractor maintains the necessary and appropriate license
and/or Certification to render services. The VENDOR shall maintain
documentation of current and valid individual license(s) and Certification(s) in
the personnel record.
4. Medication Administration
a. All employees and Contractors, not otherwise authorized by law to administer
medication, who assist and/or monitor Members in the administration of
medications or the filling of medication reminder boxes shall have passed a
"Qualified medication administration person" or "QMAP" competency
evaluation offered by an approved training entity, and shall be listed on the
Department's list of persons who have passed the requisite competency
evaluation as defined in 6 CCR 1011-1, Chapter 24. Each facility shall ensure
the qualifications of the QMAP employee or Contractor per 6 CCR 1011-1,
Chapter 24, Section 3.
5. Trainings
a. The VENDOR shall have an organized program of orientation and training of
sufficient scope for employees and Contractors to carry out their duties and
responsibilities efficiently, effectively, and competently. Training shall be
provided prior to employees or Contractors having unsupervised contact with
Members. The training program shall, at a minimum, provide for and include:
i. Training related to person -centered practices, the role of the Person -
Centered
Support Plan, and the concept of dignity of risk;
ii. Training related to health, safety, and services and supports to be
provided related to the specific needs and diagnoses of Members served;
iii. Training specific to the individual(s) for whom the employees or
Contractors will be providing services and supports which includes
medical or behavioral protocols, supervision, dietary and Activities of Daily
Living (ADL) needs, and Provider agencies' internal policies and
procedures.
6. Rendering Services According to the Person -Centered Support Plan
a. The VENDOR shall maintain, on file, copies of the current Person -Centered
Support Plan for all Members they serve. Staff providing direct care to
Members shall have access to or a copy of the support plan Person -Centered
Support Plan and shall render services as required in the support plan Person -
Centered Support Plan.
b. The VENDOR shall render services according to the agreed upon Person -
Centered Support Plan and coordinate with other provider agencies, when
applicable. Members receiving services shall be included in developing the
Person -Centered Support Plan and have the freedom to choose a willing
service vendor.
c. The VENDOR shall not condition a Member's receipt of any service on the
Member's agreement to receive other services from the service vendor.
d. The VENDOR shall not discontinue or refuse to provide agreed upon services
to a Member unless documented efforts have been made to resolve the
situation that triggers such discontinuation or refusal to provide services.
7. Incident Reporting
a. The VENDOR shall complete the timely reporting, recording, and reviewing of
Incidents which shall include, but not be limited to:
• Death of Member receiving services;
Hospitalization of Member receiving services;
Medical emergencies, above and beyond first aid, involving Member
receiving services;
Allegations of MANE;
Injury to Member or illness of Member;
• Damage or theft of Member's personal property;
• Errors in medication administration;
• Lost or missing person receiving services;
Criminal activity; and
Incidents or reports of actions by Member receiving services that are
unusual and require review.
b. The VENDOR shall submit a verbal or written report of every Incident to the
HCBS Member's Case Management Agency Case Manager within 24 hours of
discovery of the actual or alleged Incident. The report shall include:
• Name of person reporting;
• Name of Member who was involved in the Incident;
• Member's Medicaid identification number;
• Name of persons involved or witnessing the Incident;
.
Incident type;
Date, time, and duration of Incident;
Location of Incident;
Persons involved;
Description of Incident;
Description of action taken;
Whether the Incident was observed directly or reported to the
provider;
Name of person notified;
Follow-up action taken or where to find documentation of further
follow-up;
Name of the person responsible for follow up; and
Resolution, if applicable.
c. If any of the above information is not available and reported to the Case
Management Agency Case Manager within 24 hours of the Incident, the
VENDOR must submit follow up information as soon as it is obtained.
d. Additional follow up information may also be requested by the Case Manager,
or the Department. The VENDOR is required to submit all follow up
information within the timeframe specified by the Case Management Agency.
e. VENDOR shall review and analyze information from Incident reports to
identify trends and problematic practices which may be occurring in specific
services and shall take appropriate corrective action to address problematic
practices identified.
SIGNATURE REQUESTED: Weld/Tippets
Dentistry CMA Service Agreement 2024 (f)
Final Audit Report
2024-02-26
Created: 2024-02-21
By: Sara Adams (sadams@weid.gov)
Status: Signed
Transaction ID: CBJCHBCAABAAOd-w8CQ9mSgcbhW7CT41_uCgUkUmWjFH
"SIGNATURE REQUESTED: Weld/Tippets Dentistry CMA Servi
ce Agreement 2024 (f)" History
t Document created by Sara Adams (sadams@weld.gov)
2024-02-21 - 8:29:14 PM GMT
ET, Document emailed to office@tippetsdentistry.com for signature
2024-02-21 - 8:29:44 PM GMT
,n Email viewed by office@tippetsdentistry.com
2024-02-22 - 11:39:55 PM GMT
,i°J Email viewed by office@tippetsdentistry.com
2024-02-26 - 7:55:31 PM GMT
4 Signer office@tippetsdentistry.com entered name at signing as Jeffrey Tippets
2024-02-26 - 8:14:26 PM GMT
4 Document e -signed by Jeffrey Tippets (office@tippetsdentistry.com)
Signature Date: 2024-02-26 - 8:14:28 PM GMT - Time Source: server
Agreement completed.
2024-02-26 - 8:14:28 PM GMT
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Contract Form
Entity Information
Entity Name
TIPPETS DENTISTRY
Entity ID*
@00033334
O New Entity?
Contract Name* Contract ID
TIPPETS DENTISTRY CASE MANAGEMENT AGENCY 7881
(CMA) SERVICES AGREEMENT
Contract Status
CTB REVIEW
Contract Lead *
SADAMS
Contract Lead Email
sadams@weld.gov;cobbx
xlk@weld.gov
Parent Contract ID
Requires Board Approval
YES
Department Project #
Contract Description*
(CONSENT) TIPPETS DENTISTRY CASE MANAGEMENT AGENCY (CMA) SERVICES AGREEMENT
Contract Description 2
PA ROUTED THROUGH BOCC ON 2/6/2024 AND WAS APPROVED ON 2/12/2024, KNOWN TO CTB AS TYLER#
2024-0326
Contract Type*
AGREEMENT
Amount*
$0.00
Renewable"
NO
Automatic Renewal
Grant
IGA
Department Requested BOCC Agenda Due Date
HUMAN SERVICES Date* 02/24/2024
02/28/2024
Department Email
CM-
HumanServices@weldgov.
com
Department Head Email
CM-HumanServices-
DeptHead@weldgov.com
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY@WEL
DGOV.COM
Will a work session with BOCC be required?*
NO
Does Contract require Purchasing Dept. to be
included?
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts
are not in OnBase
Contract Dates
Effective Date
Termination Notice Period
Contact Information
Review Date"
04/30/2024
Committed Delivery Date
Renewal Date
Expiration Date*
06/30/2024
Contact Info
Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2
Purchasing
Purchasing Approver Purchasing Approved Date
CONSENT 02/26/2024
Approval Process
Department Head Finance Approver Legal Counsel
JAMIE ULRICH CONSENT CONSENT
DH Approved Date Finance Approved Date Legal Counsel Approved Date
02/26/2024 02/26/2024 02/26/2024
Final Approval
BOCC Approved Tyler Ref #
AG 030424
BOCC Signed Date Originator
SADAMS
BOCC Agenda Date
03/04/2024
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