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Weld County General Hospital
SIXTEENTH STREET AT SEVENTEENTH AVENUE
GREELEY, COLORADO 80631
BOARD OF TRUSTEES BOARD OF TRUSTEES
SHELDON D.BROOKS,PRESIDENT ROBERT S.DAVIS
PAUL L.GOOD,VICE-PRESIDENT November 15, 1972 VICTOR R.KLEIN
REX C.EATON,JR.,SECRETARY HARRY MYERS
HIROSHI TATEYAMA
Mr, Barton Buss
Chief Accounting Officer
Weld County Colorado
Greeley, Colorado
Dear Barton:
Enclosed please find copies of the agreements with the Department of Health
Education and Welfare (Medicare) and the Colorado State Board of Social Ser-
vices (Medicaid). To the best of my knowledge these are the only contracts
we have governmental entities.
Ve tr .y yours,
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Richar• H. Stenner
Administrator
RHS:rtb
Enclosures
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Nov 1 619723
GREELEy, COLD.
730472
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z l� HEALTH INSURANCE BENEFITS AGREEMENT
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� (Agreement with Provider of Services Pursuant to
0 a:. 4.4
1 Section 1866 of the Social Security Act)
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For the purpose of establishing eligibility for payment under Title XVIII of the
Social Security Act, Weld County General Hospital , Greeley, Colorado
hereinafter referred to as the provider of services, hereby agrees:
(A) not to charge, except to the extent permitted by section 1866(a)(2) of such Act
and regulations issued thereunder, any individual or any other person for items and serv-
ices with respect to which the provider of services is precluded by reason of section
1866(a)(1) from charging such individual or such other person;
(B) to return any moneys incorrectly collected from such individual or such person,
or to make such other disposition as may be specified in regulations.
This agreement, upon submission by the provider of services of acceptable assur-
ance of compliance with the requirements of Title VI of the Civil Rights Act of 1964, and
, upon acceptance for filing, by the Secretary of Health, Education, and Welfare, shall be
binding on such provider of services and the Secretary. The agreement may be terminated
by either party in accordance with the provisions of section 1866(b)(1) and (2) of the Social
Security Act and regulations thereunder. In the event of such termination, the obligations
of the Secretary to make payment to the provider of services pursuant to this agreement
shall be abrogated to the extent specified in section 1866(b)(3), (4) and (5) of such Act
and regulations thereunder.
This agreement shall become effective when accepted for filing by the Secretary or
• his delegate.
Accepted for Secretary of
F o rovider of Services by: He h, Education, and Welfare by:
_ . _ `.. —)1 c .
Name Name
George N. Stout Martha A. McSteen .
_Administrator- -Regional Repreeentative, Health Insurance
Title
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_Ap 11_25} 26_6_ Agri.l-25,-1956
Date Date
FORM SSA-1561 to-ee> _
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t
(b/72) .
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COLORADO MEDICAL ASSISTANCE PROGRAM ("MEDICAID")
APPLICATION FOR PARTICIPATION - HOSPITAL
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WELD COUNTY.GENERAL.HOSPETAL ("the Applicant"),
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hereby makes application for participation in the Colorado
Medical Assistance Program ("Program") to the Colorado Department •
of Social Services ("Department"), pursuant to provisions of .
Title XIX of the Social Security Act, and Article 12, Chapter
119, C.R.S. 1963, as amended, under which law the Department
is the sole administering agency, and rules of the Department
as promulgated by the Colorado State Board of Social Services.
The Applicant has been granted license number 27 •
to operate a hospital by the Colorado Department of Health for
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the period from Jan. 1, 1972 to Dec. 31, 1972.
The Applicant desires to participate in the Program as
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a provider of necessary hospital services to recipients of
Program benefits.
The Applicant agrees, if approved as a participating
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provider:
1. To provide necessary hospital services within the
scope of its authority as vested by the aforesaid license.
2. To abide by all the provisions o£ Title XIX of the -
Social Security Act and Article 12, Chapter 119, C.R.S. 1963, as -
• amended, and all pertinent rules of the Department. Mailing of
a copy of such Department rules to the Applicant shall constitute
due notice and knowledge by the Applicant of such rules. Mailing
. to the Applicant of new, amended, or revised Department rules
shall constitute due notice and knowledge thereof.
3. To submit billings for authorized hospital services.
in accordance with the form, manner, and in the amount as is
provided by Department rules, any subsequent amendments thereto,
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HED-11-U (6-22)
Page 2 •
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' and this Application for Participation, and agrees to provide
such hospital services on the basis of being compensated there—
_' „ for in accordance with this Application for Participation and
Department rules. In the event the Applicant should receive
payment for necessary hospital services in an amount in excess •
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of that authorized by Department rules, whether "a result of •
Applicant's or Departments error, the Applicant agrees to
permit the Department the option and discretion either to
'deduct such excessive payments from future payments, 'or to
recover such excessive payments in accordance with ruled of
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the Department, or to require Applicant to make repayment to
Department of said excess payment within sixty (60) days of •
written demand by Department or to recover such excessive
payments by other legal means.• -
4. To.not submit bills or otherwise attempt to collect
• payments from recipients, relatives of recipients, or recipients'
.estates for any hospital services.provided to recipients which
are benefits reimbursable under the Program in accordance with
the law and rules of the Department.
5. To provide the Department with at least sixty (60) •
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days prior notice in .the event of termination of participation
in the Program, including cessation of business, election to
no longer participate, or all transfers of the assets, ownership,'
administration or operation of said business. Provided,however, -
this provision shall not apply in the case where amendments,
-revisions or additions to the rules of .the -Department are
determined to be unacceptable to the Applicant and for such
reason the Applicant elects to discontinue participation in
the Program. In such event, the Applicant shall forthwith
notify the Department in writing of its intent to discontinue
and the Applicant and the Department shall forthwith negotiate
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(6-72)
Page 7 "� h 1
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the termination date. In no event shall such negotiated termi—
nation date exceed a sixty (60) day period from the effective
date of the rule, amendment, revision, or addition. ,
6. To provide acceptable assurance of compliance with
the applicable requirements of Title VI of the Civil Rights '
Act of 1964.
7. To give full cooperation to the Department and its
duly authorized agents in the administration of the Program.
Furthermore, the Applicant agrees to maintain records as required
by federal and state law and Department rules and to provide
access to such records as may be provided for in the rules of
the Department and as may be requested in accordance with such
rules.
8. To accept as payment in full without retroactive
adjustment a prospective per diem rate of $ 77.69 , based upon •
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reasonable cost, in accordance with the procedures set forth
in the rules of the Department. This provision in no way
relieves the Applicant of the responsibility to obtain payment
from legally responsible persons or entities as required by law '
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and Department rules.
9. To submit with.this Application written evidence
of the authority of the authorized agent for the applicant. This
may be copies of the corporate by-laws, resolutions, minutes of
• meetings, orother sufficient. evidence. Such authority must not
only empower the authorized agent to legally bind the applicant
to all of the terms and conditions contiined in this Application,
but also must delegate such authorized agent to represent the
applicant in all future dealings with.the Department and to be
• responsible for the applicant's compliance with federal and
• state laws and Department rules.
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MED-11-6 (hat) p`--,-
Page 4.
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10. To submit with this Application a current list of '
'.e• the names and-addresses of the officers and directors of the
corporation or.in lieu thereof, a copy of the latest corporate
annual report filed with the Secretary of State.
None of the foregoing specifics in this Application
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shall limit the responsibility of the Applicant to abide by _
applicable current Title XIX and Colorado Medical Assistance
Act, Article 12, Chapter 119, C.R.S. 1963, as amended, provi-
aions and current Department rules as they may be amended or
subsequently enacted by the Colorado State Board of Social
Services.
The name of the Applicant as listed with the Secretary
of State for the State of Colorado is Weld County General Hospital;
(and the corporation does business in the State of Colorado under
the trade name of same ). Articles of Incor-
poration were first filed 1n the State of Colorado on the 31 day
of _ March , 1944 .
This Application for Participation in the Colorado Medical
Assistance Program is made this 30 day of August , 1972. , _
by We ' t
ldCounty
p(name of Applicant.)
# Formed by Resolution of the Board of County Commissioners March 31,
1944 under provisions of CRS 66-7-1.
ATTEST: Signature: r= 1/C:'
Sheldon D. Brooks, President -
Board of Trustees
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FOR COMPLETION BY THE COLORADO DEPARTMENT OF SOCIAL SERVICES:
The Applicant having agreed to all of the covenants and
conditions herein contained, is hereby certified to be a partic-
' ipating provider in the Colorado Medical Assistance Program for
the period extending from Sept. 5 , 1972 , to Dec. 31 , 19 72 .
The Department agrees to make payments to the Applicant in accord-
. - ante with the law and Department rules which govern the Program,
providing that the Applicant complies with tha law and rules of
the Program and the terms and conditions herein at it pro- •ective
reimbursement per diem rate of $77.69 /
COLORADO. + P LENT Or SO ilpAL SERVICES
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Date: September 5. 1972 By
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