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Home My WebLink About20161446.tiff � 4k 1LD4 857 CONTRACT AGREEMENT AMENDMENT BETWEEN • ' THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES • AND HEART-CENTERED COUNSELING, P.C. (Core) rh This Agreement Amendment, made and entered into 4/ day of CSC , 2016, by and between the Board of Weld County Commissioners,on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department",and Heart-Centered Counseling, P.C., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2016-1446, approved on April 27, 2016. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement,which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: • The Original Agreement ended on May 31, 2016. • The Original Agreement was renewed for the term of June 1, 2016-May 31, 2017. The Agreement Amendment is identified by the Weld County Clerk to the Board of County Commissioners as document No. 2016-1446, approved on August 8, 2016. • The Amendment(s),together with the Original Agreement,constitutes the entire understanding between the parties. The following change is hereby made to the Contract Documents: 1. Term This agreement shall become effective on April 1, 2016, upon proper execution of this Agreement and shall expire May 31, 2017, unless sooner terminated as provided herein. 2. Exhibit C-Scope of Services Contractor will conduct various Neuropsych testing for Community Centered Board (CCB) and/or Supplemental Security Income (551) qualification,or other needs as identified by the Department. C Oltde D it-ZI-1L 7 3. Exhibit D, Paragraph 2— Fees for Services $120.00/Hour (Psy.D. - Neuropsych Testing) • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day, month,and year first above written. COUNTY: ATTEST: ...4011401.1CI• �— BOARD OF COUNTY COMMISSIONERS Weld my Clerk to the Board WELD COUNTY,COLORADO By: Deputy CI k to h La Sean P. Conway, Pro—Tern N16 1861 NTRA R: Q� ;1Heart-Centered Counseling, P.C. 320 West Olive Street Fort Collins, Colorado 80521 (970) 498-0709 By: Carl R. Nassar, Ph.D., Director Date: GZb/ -- /'4" u, to CONTRACT AGREEMENT AMENDMENT BETWEEN I! �� rTHE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HEART-CENTERED COUNSELING, P.C. (Core) This Agreement Amendment, made and entered into ?r4day o 2016, by and between the Board of Weld County Commissioners, on behalf of the Weld Cou Department of Human Services, hereinafter referred to as the "Department", and Heart-Centered Counseling, P.C., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2016-1446, approved on April 27, 2016. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement ended on May 31, 2016. • The Amendment(s), together with the Original Agreement, constitutes the entire understanding between the parties. The following change is hereby made to the Contract Documents: 1. Term This agreement shall become effective on April 1, 2016, upon proper execution of this Agreement and shall expire May 31, 2017, unless sooner terminated as provided herein. 2. None • All other terms and conditions of the Original Agreement remain unchanged. cam: - 1-. Wg7 g- Ivy r- r /40. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: di,/ 4.do74, BOARD OF COUNTY COMMISSIONERS Weld C•un Clerk to the Board WELD COUNTY, COLORADO By: .. 1 � - ► Mike Freeman,Chair Deputy CI-I k to the ::•F�r1- ,. 14 �`�~ a,� AUG 082016 1F"r NTRACTOR: `��j� \ / Heart-Centered Counseling, P.C. rr'01 320 West Olive Street Fort Collins, Colorado 80521 (970) 498-0709 By: Carl R. Nassar, Ph.D., Director Date: /et /7G ot.04 - /44714 AcoR1$ CERTIFICATE OF LIABILITY INSURANCE DATE M/DD/YYYY) `--� 03/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER _CONTACT Affinity Insurance Services Inc Affinity Insurance Services, Inc PHONE _ JA/C,No,Eztl: 888-288-3534 I FAX 159E County Line Rd 1 847-953-0890 E-MAIL (A/C,No): Hatboro, PA 19040 ADDRESS: Firms@hpso.com INSURER(S)AFFORDING COVERAGE NAIC p INSURER A: American Casualty Company of Reading 20427 INSURED Heart-Centered Counseling, PC INSURERB: - 320 W Olive St INSURER C_: _INSURER D: ---- - - -- - - --- -_-._ Fort Collins CO 80521 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. T I --- -- - -.--LTR I, - -- - I- - I INSD WVD - POLICY EFF POLICY EXP - - - --- --"- INSR -- ADDL SUER TYPE OF INSURANCE POLICY NUMBER (MMIDD/YYYY) LIMITS COMMERCIAL ERAL LIABILITY ��- X � ) EACH OCCURRENCE -. . $1,000,000 DAMAGE TO RENTED � PREMISES IEa occurrence) l$ General Liability 622028318 01/01/2016 01/01/2017 MED EXP(Any one person) $ GE PERSONAL 8 ADV INJURY $ N'L AGGREGATE LIMIT APPLIES PER: I ' GENERAL AGGREGATE I $3,000,000 PRO- , JECT POLICY LOC PRODUCTS-COMP/OP AGG $ _ L. _�., OTHER. �._- _ _._.I$ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ (Ea accident) - _, ANY AUTO 1 ! i BODILY INJURY(Per person) I$ 1 ALL OWNED � .-. --- --- -.. AUTOS _� .1 BODILY INJURY Per accident)I $ SCHEDULED ( HIRED AUTOS AUTOS NON-OWNED I 1'. PROPERTY DAMAGE $ -- -- - - (Per accdent) _ UMBRELLA LIAR 5 I OCCUR EACH OCCURRENCE Imo$ EXCESS LIAB CLAIMS-MADE - --_ -- AGGREGATE I $ DED I l IN$ 1 -- - -- - WORKERS COMPENSATIONLOYERS'LIABILITY Y/N PER I 1 0TH- AOFFICER/MEMBEROORIO EXCLUDED'?R/E N/A ELI STATUTE : ER ANY PROPRIETOR/PARTNER/EXECUTIVE EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE F$ If yes,describe under �- _.- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ Professional Liability I X 622028318 01/01/2016 I01/01/2017 $1,000,000 per claim$3,000,000 aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The listed certificate holder Weld DHS is added to the professional and general liability as an additional insured as of 04/01/2016. CERTIFICATE HOLDER CANCELLATION The County of Weld DHS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1150 o Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Greeley CO 80631 AUTHORIZED REPRESENTATIVE Affinity Insurance Services @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD RESOLUTION RE: APPROVE AGREEMENT FOR CHILD PROTECTION SERVICES AND AUTHORIZE CHAIR TO SIGN - HEART-CENTERED COUNSELING, P.C. 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 an Agreement for Child Protection Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Heart-Centered Counseling, P.C., commencing April 1, 2016, and ending May 31, 2016, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Agreement for Child Protection Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Heart-Centered Counseling, P.C., be and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 27th day of April, A.D., 2016, nunc pro tunc April 1, 2016. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: J s •-L'LLo;r4 rittSL.31t42 _ Mike Freeman, Chair Weld County Clerk to the Board Sean P. Conway, Piro--Tem BY:. �� ` GG/� C Deputy Clerk to the Board : % a► . Cozad /A V AS T• 1f w!' '•''- :ara Kirkmeye aunty orney �` +✓ /� �/` O'LQ. � Steve Moreno Date of signature: /IVl . OSP ( 2016-1446 HR0087 MEMORANDUM 86�44 r DATE: April $, 2016 TO: Board of County Commissioners—Pass-Around { p FR: Judy A. Griego, Director, Human Services U — G (7U NY y RE: Weld County Department of Human Services' Child Protection Agreement for Services with Heart-Centered Counseling P.C. Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement for Services with Heart-Centered Counseling P.C. The boiler plate agreement form was approved March 9, 2015, by the Board of County Commissioners. The major provisions for this Agreement are as follows: No. Contractor Location/Term Service/Funding Rates 1 Fort Collins,CO 80521 Mental Health Services $85.00/Hour (Master's Level), $93.00/Hour(Ph.D.Level),$95.00/Hour April I, 2016, upon proper Core (Assessment/Evaluation), $60.00/Hour execution of this Agreement (Court Facilitation, Court Staffing, and shall expire May 31, Family Team Meeting (FTM) or Team 2016 Decision Making Meeting(TDM)) I do not recommend a Work Session. I recommend approval of this Agreement. Approve Request 13OCC ,enda Work Session Sean Conway Steve Moreno f Barbara Kirkmeyer Mike Freeman Julie Cozad ., 2016-1446 4e.06 Pass-Around Memorandum; April 8, 2016- Contract ID #s 413 Page 1 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HEART-CENTERED COUNSELING, P.C. (CORE) This Agreement, made and entered into the 'day of March,2016, by and between the Board of Weld County Commissioners,on behalf of the Weld County Department of Human Services, hereinafter referred to as the"Department'and«Contractor», hereinafter referred to as the"Contractor" The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Contractor's Proposal, Exhibit B, Scope of Services, and Exhibit C, Payment Schedule. Each of these documents is attached hereto and incorporated herein by this reference. WITNESSETH WHEREAS,required approval, clearance, and coordination have been accomplished from and with appropriate agencies;and WHEREAS,the Colorado Department of Human Services has provided Core Services funding to the Department for Mental Health Services. NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on April 1, 2016, upon proper execution of this Agreement and shall expire May 31, 2016, unless sooner terminated as provided herein. The agreement is for a period of three years. However,the agreement must be renewed by both parties, in writing,on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s)eligible for services in compliance with Exhibit A,Contractor's Proposal and Exhibit B,Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Department's Resource Manager,Child Welfare Contract and Services Coordinator,or through a Team Decision Making(TDM)meeting or Family Team Meeting(FTM). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit an itemized complete billing statement by the 7` of the month, following the month of service, utilizing billing forms required by the Department. d. Contractor agrees to submit a monthly report with the billing statement by the 7t"of the month „/ following the month of service for each client receiving ongoing services. One-time services will be 1 ''// verified through receipt of the completed product(ex. psychological evaluation, substance abuse evaluation). Verification of Monitored Sobriety Services will be the test result. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical,emotional,educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. 4. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid(if Contractor is a Medicaid eligible provider)or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. b. Payment shall be made in accordance with Exhibit A,Contractor's Proposal, Exhibit B,Scope of Services,and Exhibit C, Payment Schedule, attached hereto and incorporated herein by reference,so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to,and contingent upon,the continuing availability of said funds for the purposes hereof. d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives,contractual terms,or reporting requirements. In the event of forfeiture of reimbursement,Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements,cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMG Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A,Contractor's Proposal, Exhibit B,Scope of Services,and Exhibit C, Payment Schedule: a. If services are funded through Core Services, Contractor agrees to accept reimbursement 4� through ACH direct deposit one time per month. b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit an ACH Form for Colorado Providers,which will be provided by the Department. Contractor is solely responsible to submit the ACH Form to the State of Colorado per the directions on the form. Failure to complete and submit this form in a timely and accurate manner may result in a delay of payment. 2 c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement,Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents,tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-1 et.seq.and its implementing regulation,45 C.F.R. Part 80 et. seq.;and - all provisions of the Civil Rights Act of 1986 so that no person shall,on the grounds of race, creed,color, sex, or national origin, be excluded from participation in,be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794,and its implementing regulations,45 C.F.R. Part 84;and - the Age Discrimination Act of 1975,42 U.S.C.Section 6101 et.seq. and its implementation regulations,45 C.F.R. Part 91;and - Title VII of the Civil Rights Act of 1964; and - the Age Discrimination in Employment Act of 1967;and - the Equal Pay Act of 1963;and - the Education Amendments of 1972;and - Immigration Reform and Control Act of 1986, P.L. 99-603,42 C.F.R. Part 2; and - all regulations applicable to these laws prohibiting discrimination because of race,color, national origin, sex, religion, and handicap,including Acquired Immune Deficiency Syndrome (AIDS)or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973,as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute(C.R.S.)26-6-104, requiring criminal background record checks for all employees, contractors and sub-contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services,Office for Civil Rights. 3 c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is Core Services. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment,declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public(Federal, State or Local)transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state or local) with commission of any of the offenses enumerated in this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions(federal, state, or local)terminated for cause or default. e. Public Contracts for Services C.R.S. §8-17.5-101. Contract Professional certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this contract. Contract Professional will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E-Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5-102(5)(c). Contract Professional shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contract Professional that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contract Professional shall not use E-Verify Program or State of Colorado program procedures to undertake pre-employment screening or job applicants while this Agreement is being performed. If Contract Professional obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contract Professional shall notify the subcontractor and County within three (3) days that Contract Professional has actual knowledge that a subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contract Professional shall not terminate the contract if within three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. Contract Professional shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. 48-17.5-102(5), by the Colorado Department of Labor and Employment. if Contract Professional participates in the State of Colorado program, Contract Professional shall, within twenty days after hiring a new employee to perform work under the contract,affirm that Contract Professional has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contract Professional shall deliver to County,a written notarized affirmation that it has examined the legal work status of such employee, and shall comply with all of the other requirements of the State of Colorado program. If Contract Professional fails to comply with any requirement of this provision or of C.R.S. §8-17.5.101 et seq„ County, may terminate this Agreement for breach, and if so terminated,Contract Professional shall be liable tor acrilai and cr n;equent ai damage . 4 f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contract Professional receives federal or state funds under the contract, Contract Professional must confirm that any individual natural person eighteen (18)years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contract Professional operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a)is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24-76.5-101,et seq.,and(c)shall produce one of the forms of identification required by C.R.S. § 24-76.5-103 prior to the effective date of the contract. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan(PIP)will be implemented for the state to erhanc services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 3(d)of this Agreement. 9. Insurance Requirements Contractor and Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances(including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteers,and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect within seven (7)days of the date of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable tO r^ Contractor's business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, State of Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible the insurance provider. a. General Requirements:Contractors/Contract Professionals must secure, at or before the time of execution of any agreement or commencement of any work, the following insurance covering all operations,goods or services provided pursuant to this request. Contractors/Contract Professionals shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as"A"VIII or better. Each policy shall contain a valid provision or endorsement stating ✓✓ "Should any of the above-described policies by canceled or should any coverage be reduced 5 before the expiration date thereof, the issuing company shall send written notice County Director of General Services by certified mail, return receipt requested Such, .tir notice shall be sent thirty(30) days prior to such cancellation or reduction unless due to non- payment of premiums for which notice shall be sent ten(10)days prior. If any policy is in excess of a deductible or self-insured retention, County must be notified by the Contractor/Contract Professional. Contractor/Contract Professional shall be responsible for the payment of any deductible or self-insured retention. County reserves the right to require Contract , Professional to provide a bond, at no cost to County, in the amount of the deductic' insured retention to guarantee payment of claims. The insurance coverages specified in tc;s Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor/Contract Professional.Contractor/Contract Professional shall ma.ntR r a! its own expense, any additional kinds or amounts of insurance that 't } cover its obligations and liabilities under this Agreement. b. Types of Insurance: Contractor/Contract Professional shall obtain, and ma„-,:, :. times during the term of any Agreement, insurance in the following kinds and amounts, Workers'Compensation Insurance as requ;rec h „ ._ Liability Insurance covering all of Contractor's Cortr,,c, within the course and scope of their employment. If Contractor is an indep.,,,I, Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. Commercial General Liability Insurance written on ISO occurrence torn- 01 10/93 or equivalent, covering premises operations, fire damage, independent Contractors, products and completed operations, blanket contractual liability, personal injury,and advertising liability with minimum limits as follows: - $1,000,000 each occurrence; - $2,000,000 general aggregate; - 550,000 any one fire; and - $500,000 errors and omissions. iii. Automobile Liability: Contractor/Contract Profes�io=�a � 51,000,000 for bodily injury per person, $1,000,000 for boo , , _ and $1,000,000 for property damage applicable to all vehicles cpera- � . property and elsewhere. iv. Additional Provisions: Policies for all general liability. liquor liability and pollution liability must provide the follor.' rig If any aggregate limit is reduce by twenty-five percent(25%)or more by paid or reserved claims, Contractor shall notify County within ten (10)days and reinstate the aggregates required; Unlimited defense costs in excess of policy limits, Contractual liability covering the indemnification provisions or this Agreement, A severability of interests provision; Waiver of exclusion for lawsuits by one insured against another; A provision that coverage is primary;and A provision that coverage is non-contributory to 6 self-insurance provided by County. v. For all general liability, excess/umbrella liability, liquor liability, pollut:on 'iab:!:t, and professional liability policies, if the policy is a claims-made policy the date must be on or before the contract date or the first date when any gooa, o ,- were provided to County,whichever is earlier. c. Contractors/Contract Professionals shall secure and deliver to County's Res Administrator("Administrator") at or before the time of execution of th,, aF e keep in force at all times during the term of the Agreement as the -- herein provided, a commercial general liability insurance policy, includinb t ,bi c . property damage, in form and company acceptable to and approved by said Administrator. covering all operations hereunder set forth in the related Bid or Request for Proposal. d. Proof of Insurance: Contractor/Contract Profession,t! s ,; w _, . information to its insurance agent or broker, and shall have its agent or c cxer Contractor/Contract Professional's required insurance. County reserves the right to require Contractor/Contract Professional to provide a certificate of insurance, a policy,or other proof of insurance as required by the County's Risk Administrator in his sole discretion. e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal ;ab l ry liquor liability, and inland marine, Contractor/Contract Professional's insurer shall name County as an additional insured as follows f. Waiver of Subrogation: For all coverages, Contractor/Contract Professional's insurer shall waive subrogation rights against County. B. Subcontractors: All subcontractors, subcontractors, independent contractors, sup vendors, suppliers or other entities providing goods or services required by this Agreement snail be subject to all of the requirements herein and shall procure and maintain the same coverages required of Contractor/Contract Professional.Contractor/Contract Professi.^na' r, such subcontractors, independent contractors, sub-vendors supplier, under its policies or shall ensure that all subcontractors maintain the req Contractor/Contract Professional agrees to provide proof of insurance for all such s,:bcontractors, independent contractors, sub-vendors suppliers or other entities upon request by the County. A provider of Professional Services(as defined in the Bid or RFP)shall provide the following coverage: Professional Liability: Contract Professional shall maintain limits of S1,000,000 fc, $2,000,000 aggregate limit for all claims. 10. Certification Contractor certifies that,at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Trainin Contractor may be required to attend training that the request of the Department spec:f . tc provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 7 12. Subpoenas Contractor will,on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement Contractor receives a subpoena via e-mail but will only accept personal service,the Contract contact the Weld County Attorney's Office immediately at 970-352-1551, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners,the Department and the Contractor. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses,on-site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: - Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. Deny payment or recover reimbursement for those services or deliverables,which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. - Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under th . Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 8 16. Representatives For the purpose of this Agreement,the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s). For Department: For Contractor: Heather Walker, Administrator Carl R. Nassar, Ph.D., Director 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s)or address to whom such notices shall be sent. For Department: For Contractor: Judy A.Griego, Director Carl R. Nassar, Ph.D.. Director P.O. Box A 320 West Olive Street Greeley, CO 80632 Fort Collins,CO 80521 (970) 352-1551 (970)498-0709 18. Litigation Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five(5)calendar days after being served with a summons,complaint, or other pleading which has been filed in any Federal or State court or administrative agency,shall deliver copies of such document(s) to the Director of Human Services, The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year,as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department,or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental 9 Immunity Act of§§24-10-101 et. seq.,as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties/Conflict of Interest No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department when the Contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement,Contractor shall not enter into any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract,the making of any Federal grant,the making of any Federal loan, the entering into of any cooperative agreement, and the extension,continuation, renewal, amendment,or modification of an Federal contract, loan,grant,or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall,during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on-site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request,for a period of seven (7)years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period,the materials shall be retained until the resolution of the audit finding. 10 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, No information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minors parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcontractor, if arty,that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested, 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information(1) lawfully obtained from third parties, (2)that which is in the public domain,or (3)that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contract Professional agrees that it is an independent Contract Professional and that Contract Professional's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contract Professional shall perform its duties hereunder as an independent Contract Professional. Contract Professional shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contract Professional, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contract Professional or any of its agents or employees. Unemployment insurance benefits will be available to Contract Professional and its employees and agents only if such coverage is made available by Contract Professional or a third party. Contract Professional shall pay when due all applicable employment taxes and income taxes and local head taxes(if applicable) incurred pursuant to this Agreement. Contract Professional shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contract Professional shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers'compensation and unemployment compensation insurance in the amounts required by law and provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, 11 legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence and judgment provided by highly competent individuals and entities that perform services of a similar nature to those described in this Agreement including Exhibits A, B, and C. 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to Department originals of all tests and results, reports, etc.,generated during completion of this work. Acceptance by Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest.C.R.S. §§24-18201 et seq. and §24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests, During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflict with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board,committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contract Professional's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 12 34. Choice of Law/Jurisdiction Colorado law,and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution,and enforcement of this Agreement.Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contract Professional agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contract Professional acknowledges that County has entered into this Agreement in reliance upon the particular reputation and expertise of Contract Professional. Contract Professional shall not enter into any subcontractor agreements for the completion of this project without County's prior written consent,which may be withheld in County's sole discretion. 36, Attorneys Fees/Legal Costs In the event of a dispute between County and Contract Professional, concerning this Agreement,the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. 37. Ownership All work and information obtained by Contract Professional under this Agreement or individual work order shall become or remain (as applicable), the property of County. In addition, all reports, documents, data, plans, drawings, records and computer files generated by Contract Professional in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the County.Contract Professional shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of County. 38, Interruptions Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 39. Severability If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. 13 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. C COUNTY: ATTEST: d...i c{C4/ �/• x,-114 � BOARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board WELD COUNTY,COLORADO By I ` Il- L �I!.�'�i` 11 `tJ Deputy Cler;to the Bo Mike Freeman,Chair APR 2.7 2016 t1.616024g Heart-Centered Counseling, P.C. 320 West Olive Street Fort Collins, CO 80521 (970)498-0709 Carl R. Nassar, Ph.D., Director Date: 3 / 2 ? //‘ 14 To whom it may concern: Heart-Centered counseling is seeking to partner with Weld County DHS to offer professional counseling services. Heart-Centered counseling is one of Larimer and Weld County's largest outpatient mental health centers. With twenty eight (28) therapists and over five hundred (500) different clients seen each week, Heart-Centered Counseling is the largest provider of out-patient mental heath care after only SummitStone and NorthRange community mental health centers. Heart-Centered Counseling has three office locations, one in Weld County (located in the city of Greeley) and two in Larimer County (located in Loveland and Fort Collins). Our Greeley location consists - currently - of 12 therapists located in 6 offices. (Our Loveland location has 3 offices, and our Fort Collins location has 13 offices.) Heart-Centered Counseling makes the following commitments to the communities it serves: 1. Immediate Availability: We understand that when individuals or referring agencies call for Mental Health support, the need is almost always immediate. For this reason, whenever a client needs to be seen quickly, we get 90% of our clients scheduled for next day appointments, and 95% scheduled within a week. 2. Acceptance of Medicaid, Medicare, and all Commercial Insurances: We accept all major insurances, including Medicaid, Medicare, and private commercial insurance plans such as those offered through BC/BS, United. Cigna, and so on. 3. Coverage for all areas of Mental Health: We work with children as young as 2 and as old as 17; with adults of all ages, including the elderly: with couples; and with families. We offer support for the full gamut of mental health issues, ranging from trauma, to substance abuse, to anxiety and depression, to eating disorders, to you-name-it. And we have therapists that deliver a full gamut of healing modalities, including EMDR. 4. Experienced Care: A large percentage of our therapists have over 10 years of experience, and many have over 30. We pride ourselves in offering experienced clinical care, and have an in-house training program to ensure our therapists remain both experienced and engaged. 5. Coordination of Care: We provide a weekly report on any new referrals, letting you find out what happened when we reached your client to schedule an appointment. We also offer monthly treatment updates which share information such as frequency of visits and improvement in therapy. We currently partner with UCHealth Family Practices and Internal Medicine Practices, being their preferred mental health referral source, as well as working closely with Banner, Family Physicians of Greeley, and Associates in Family Medicine. We also work closely with both Poudre and Thompson School Districts. and are currently building a relationship with District 6. Finally, we work closely with Larimer County DHS, and look forward to building a similar success story with Weld County's wonderful DHS team. Warmly, Carl R Nassar Director, Heart-Centered Counseling Scope of Services, Rate Schedule & Insurance Requirements Scope of Services Location Services offered are outpatient mental health, and in Weld County these take place at our Greeley office located at 1770 W 25th Ave. Days/Hours Our offices see clients as early as 7:30a and as late as 730p on all five weekdays. Some weekend availability is offered, usually on Saturday mornings from 9a to 1 p. Services Offered at above location, during above hours Outpatient Psychotherapy - billed with CPT code 90837 -Young Children -Adolescents -Adults (young. middle-aged, and elderly) -Couples -Families Assessment -Diagnostic psychological assessment -ADHD assessment -Learning Disability assessment -Autism assessment -Substance abuse evaluations -Child custody evaluations -neuropsych evaluations Rate Schedule Outpatient Psychotherapy - CPT 90837 - Master's Level practitioner $85. Ph.D Level practitioner $93 Assessment - $95 per hour. Duration of any assessment can be discussed on a case-by-case basis prior to the start of any work. Compliance with Weld County's Insurance Requirements Our professional and general liability policies can easily become fully compliant with all the requirements outlined by Weld County. Please let us know when your team feels ready to move ahead together, and we'll update a few policy details, and then provide your team with a copy of our insurance policies for final review. From: ar' 'vasar To: Toer voter Subject: Re Rate tor Staffing Date: Tuesday, March 22, 2016 12:27:29 PM Iii Tobi. Thank you tier asking. I totally missed on including this information. So, in short, the request rate for participation in staffings is $60 an hour. Again. please let me know if that's something you're not comfortable with. Warmly. Carl On filar 22. 2016. at 8:03 AM. l obi Vegter <.yel;tcrta a,cu.wellco.us> wrote: Good morning. Carl. I apologize as I know this is likely a repeat question but unfortunately-. I am not finding the necessary information among the information provided. nor in my notes from our initial meeting. Does [ICC charge for participation in stattings (TDMs. 1 1\Is. etc.)'.' If so. what is the hourly rate fur that participation? Thank you. Regards. Tobi Vegter Child Welfare Contract and Services Coordinator Weld County Department of Human Services Division of Child Welfare Resource Unit (9701 352-1551. cxi. 6392 (9 0) 301-?6-'6 Well/ (y"0/ 346-'66- (Fax) <image00 3.jpe., Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged. confidential or otherwise protected from disclosure. If you have reccked this communication in error. please immediately notify sender by return e-mail and destroy the communication. Any disclosure. copying. distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. EXHIBIT B SCOPE OF SERVICES 1. Contractor will provide outpatient Mental Health Services to individuals and families as referred by the Department, under this agreement. 2. Contractor will serve male and female,adults and children,age two or older,with a variety of mental health issues including, but not limited to,trauma,anxiety and depression, and substance abuse issues. 3. Contractor will ensure that all services are provided by experienced and qualified mental health professionals with the appropriate licensing and credentialing. For the purposes of this agreement,all mental professionals providing services will hold, at a minimum,a Master's Degree and will be actively licensed with the State of Colorado and in good standing. 4. Contractor will offer services at 1770 West 25th Avenue, in Greeley. Appointments will be available 7:30 a.m.-7:30 p.m., Monday thru Friday,and 9:00 a.m.-1 p.m. on Saturdays. 5. Services available under this agreement include: • Outpatient Psychotherapy • Diagnostic Psychological Assessment • ADHD Assessment • Learning Disability Assessment • Autism Assessment • Substance Abuse Evaluations • Neuropsych Evaluations 6. Contractor will bill Medicaid for all Medicaid-eligible services. 7. Contractor agrees to receive referrals through electronic mail. 8. Contractor will make at least three(3)attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral(excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If after three(3)attempts the client does not respond the Contractor will notify the caseworker and the Child Welfare Contract and Services Coordinator immediately. 9. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to,any physical, emotional,educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 11. Contractor,at a minimum,will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. Contractor is expected to co 12. Contractor agrees any change to an existing referral must be pre-approved through the Child Welfare 16 Contract and Services Coordinator, a Department-facilitated Team Decision Making(TDM)or Family Team Meeting(FTM), or by court order, A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 13. Contractor understands that the Department will not reimburse Contractor for "no shows" beyond two (2)consecutive "no shows". It is the responsibility of the Contractor to communicate "no shows" to the Department in a timely manner to determine continuation of services. 14. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. Contractor is responsible for obtaining the meeting Facilitator's signature on the Client Verification Form at the time of the staffing/meeting in order to be reimbursed. The Department will reimburse for actual participation in the meeting only so long as the meeting is at least one hour in length, the Contractor obtains the Facilitator's signature, and participation in the meeting is deemed appropriate and necessary by the Department. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. 17 EXHIBIT C PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate(s) specified in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2016, Expenses incurred by the Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Contractor will bill Medicaid for all Medicaid-eligible services. If referred client is not eligible for Medicaid or the service is not covered by Medicaid, Contractor will assess the following fees under Core Services funding: $85.00/Hour(Master's Level) 593.00/Hour(Ph.D. Level) $95.00/Hour (Assessment/Evaluation) $60.00/Hour (Court Facilitation, Court Staffing, Family Team Meeting(FTM)or Team Decision Making Meeting(TDM)) Contractor may not attempt to collect co-pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. Contractor will collect any applicable sliding scale co-pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers Contractor shall prepare and submit monthly an itemized voucher, and signed monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges made were pursuant to the terms and conditions of Paragraph 3. Contractor shall submit all monthly billings and applicable reports to the Department by the 7" day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. 18 a. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d)of this =� Agreement. b. For one-time services, proof of services rendered shall be receipt of the completed product. c. For Monitored Sobriety services, proof of services rendered shall be the test result. 19 Ac RD® CERTIFICATE OF LIABILITY INSURANCE DATE M/DD/YYYY) `.,�� 03/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Affinity Insurance Services Inc Affinity Insurance Services, Inc PHONE 159 E County Line Rd FAX �C No,Ext): 1-888-288-3534 (A/C,Not 1-847-953-0890 E-MAIL Hatboro, PA 19040 ADDRESS: Firms@hpso.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: American Casualty Company of Reading 20427 INSURED Heart-Centered Counseling, PC INSURER B: INSURER C; 320 W Olive St INSURER D: Fort Collins CO 80521 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I R TYPE OF INSURANCE ADDLISUBR: POLICY EFF POLICY EXP LT INSD I LTR INSD WVD' POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY X EACH OCCURRENCE $1,000,000 I DAMAGE TO RENTED -- _. -1 CLAIMS-MADE Xn OCCUR PREMISES(Ea occurrence) $ A General Liability MED EXP(Any one person) $ 622028318 01/01/2016_ 01/01/2017 PERSONAL&ADV INJURY $ , GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $3,000,000 r PRO- I POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (EaALL SCHEDULED ! BODILY L INANY AUTO JURY AUTOS OWNED AUTOS INJURY(Per person) $ J BODILY INJURY(Per accident)' $ - $ 1 NON-OWNED PROPERTY DAMAGE t HIRED AUTOS ' AUTOS (Per accident) $ 1 I $ UMBRELLA LIAB ' OCCUR EACH OCCURRENCE $ EXCESS LIAB - '.CLAIMS-MA ICI AGGREGATE ' $ T DED I 1 RETENTION$ $ WORKERS COMPENSATION I PER OTH- ANDEMPLOYERS'LIABILITY I STATUTE -__ ' ER 'OFFICER/MEMBER EXCLUDED? Y/" ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. .N/A EACH ACCIDENT }$ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE' $ If yes,describe under - — - ---- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional Liability X 622028318 01/01/2016 01/01/2017 I$1,000,000 per claim$3,000,000 aggregate I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The listed certificate holder Weld DHS is added to the professional and general liability as an additional insured as of 04/01/2016. CERTIFICATE HOLDER CANCELLATION The County of Weld DHS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1150 o Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Greeley CO 80631 AUTHORIZED REPRESENTATIVE Affinity Insurance Services ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD - (Policy Provisions w� u u v U u D, 4 IC INFORMATION PAGE WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: TRUMBULL INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 19666 THE '""' Company Code: H HARTFORD N N N 0 Suffix CARS RENEWAL POLICY NUMBER: 76 WEG 1O8418 00 Previous Policy Number: NEW 14141414 HOUSING CODE: 76 0 1. Named Insured and Mailing Address: HEART CENTERED COUNSELING PC (No.. Street, Town, State. Zip Code) w N 0 320 W OLIVE ST FEIN Number: 452668894 FORT COLLINS, CO 80521 State Identification Number(s): UIN: anis The Named Insured is: CORPORATION Business of Named Insured: MEDICAL OFFICE - OTHER Other workplaces not shown above: 320 W OLIVE ST FORT COLLINS CO 80521 ,.... 2. Policy Period: From 01/11/16 To 01/11/17 maim 12:01 a.m., Standard time at the insured's mailing address. mos Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY PO BOX 33015 SAN ANTONIO, TX 78265 Producer's Code: 250873 Issuing Office: THE HARTFORD 3600 WISEMAN BLVD. wigSAN AN'I'ONIO TX 78251 i (877) 287-1316 MUM Total Estimated Annual Premium: $3, 662 NOM Deposit Premium: Policy Minimum Premium: $324 CO (INCLUDES INCREASED LIMIT MIN. PREM. ) MI Audit Period: ANNUAL Installment Term: = The policy is not binding unless countersigned by our authorized representative. mer Countersigned by 01/14/16 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 01/14/16 Policy Expiration Date: 01/11/17 ORIGINAL INFORMATION PAGE (Continued) 7 f Policy Number: 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation i_aw of the states listed here: CO B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed r t The limits of our liability under Part Two are Bodily injury by Accident $1, 000, 000 each accident Bodily injury by Disease $1, 000, 000 policy limit Bodily injury by Disease $1, 000, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3 .A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 00 04 21D WC 00 04 22B WC 99 03 02B WC 00 04 14 WC 00 04 "_9 WC 05 04 02 WC 99 00 69 WC 99 03 58B WC 66 02 81C WC 66 03 06 4. The premium for this policy will be determined by our Manuals of Rules, Classifications. Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8832 889, 100 .38 3 , 3`'9 PHYSICIAN & CLERICAL INCREASED LIMITS PART TWO (9812) 1.10 PERCENT 37 TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848) 83 COLORADO GROUP DISCOUNT (5%) (9722) -175 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 3 ,324 EXPENSE CONSTANT (0900) `6O TERRORISM (9740) 889,100 .010 89 CATASTROPHE (9741) 889, 100 .010 89 TOTAL ESTIMATED ANNUAL PREMIUM 3,662 Total Estimated Annual Premium: $3, 662 Deposit Premium: Policy Minimum Premium: $324 CO (INCLUDES INCREASED LIMIT MIN. PREM. Interstate/Intrastate Identification Number: NAICS: 621399 Labor Contractors Policy Number: SIC: 8049 UIN: NO. OF EMP: 00001.7 Form WC 00 00 01 A (1) Printed in U S.A. Page 2 Process Date: 01/14/16 Policy Expiration Date: 01/11/17 Hello