HomeMy WebLinkAbout20140585.tiff RESOLUTION
RE: APPROVE GRANT CONTINUATION APPLICATION FOR FISCAL YEARS 2014AND 2015
FOR NURSE HOME VISITOR PROGRAM AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with a Grant Continuation Application for Fiscal
Years 2014 and 2015, for the Nurse Home Visitor Program, commencing July 1, 2014, and ending
June 30, 2015, from the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment,to the Colorado Department of Public Health and Environment,with further terms and
conditions being as stated in said application, and
WHEREAS,after review,the Board deems it advisable to approve said application,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 Grant Continuation Application for Fiscal Years 2014 and 2015 for the
Nurse Home Visitor Program from the County of Weld, State of Colorado, by and through the Board
of County Commissioners of Weld County, on behalf of the Weld County Department of Public
Health and Environment, to the Colorado Department of Public Health and Environment be, and
hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 3rd day of March, A.D., 2014.
BOARD OF COUNTY COMMISSIONERS
\A LD COUNTY OLORADO
ATTEST: CCam�(( �.n \ -Kcal
C1 �`� 'Ft,uglas Rademacher, Chair
Weld County Clerk to the Boar., v
1 41'•� L-"USED
• 4 •ara Kirkmeyer, Pro-Tem
BY: IL 1 'fte) . L l/.w. Ael `ie
Dep . Clerk to the Boar. %Tr `Y J USED
‘74% r Van P. Conway
APPROVED A RM: � 2as
Mike Fre n
urt y Attorney
William F. Garcia
Date of signature: 3.10'14
FFL, Aux,
eug 3 .1i-lc/ 2014-0585
3'3 HL0044
X1861 Memorandum
� TO: Douglas Rademacher, Chair
Cc-U T Y Board of County Commissioners
�� FROM: Mark E. Wallace, MD, MPH,
Executive Director
Department of Public Health & Environment
DATE: February 24, 2014
SUBJECT: FY14-15 Continuation Application
Weld County Nurse Home Visitor Program
Enclosed for Board review and approval is the FY2014-15 NHVP Continuation Application
between the Colorado Department of Human Services (CDHS) and the Weld County Board of
County Commissioners on behalf of the Weld County Department of Public Health and
Environment's Nurse Home Visitor Program (WCDPHE/NHVP).
With the approval of this continuation application, Weld County will be requesting total funding
of$810,555 for this one-year contract to cover activities performed beginning July 1, 2014, and
ending June 30, 2015. The contract is funded by the Colorado State Tobacco Settlement Funds
and Medicaid reimbursements. The grant will fund 8 FTE including 1 FTE Office Technician, 6
FTE Public Health Nurse II and .75 FTE Public Health Nurse Ill, Supervisor.
At no cost to the client, specially trained registered nurses provide bi-monthly home visits to
low-income, first time mothers residing in Weld County beginning in pregnancy and continuing
until the client's child reaches the age of two years. Clients are educated and encouraged to
develop positive maternal/child health practices, and understanding of infant/toddler
developmental needs, effective parenting and maternal economic self-sufficiency.
I recommend approval of this FY2014-15 Nurse Home Visitor Program (NHVP) Continuation
Application for contract renewal.
2014-0585
Form 1
COVER SHEET
Name of Agency: Weld County Department of Public Health and Environment
Address/City/Zip: 1555 North 17th Avenue, Greeley CO 80631
2 . For the period of July 1, 2014, through June 30, 2015, please indicate:
Total funding request: $ $810,555 (TOTAL amount required whether covered by NHVP funds, Medicaid or other dollars)
County(ies) to be served : Weld
Funded Caseload : 150
Total FTE to be funded : 7.75
Total number of nurse home visitors to be funded : 6
3 . NFP Supervisor: Barbara Francisco, RN
Position/Title: NFP Supervisor, PHN Ill
Telephone: 970-304-6420 x2186
Email : bfrancisco@co .weld .co. us
4. Name of person completing budget forms: Tanya Geiser
Position/Title : Director, Administrative Services
Telephone : 970-304-6412 x2122
Email : tgeiser@co.weld .co.us
5 . Name/Signature of Authorized Signer: Douglas Rademach , 41 . ovo C. 4Aft---
(Must be an individual with authoyty to sign grant application)
Position/Title: Chair, Weld County Board of County Commissioners
Telephone : 304-6410 Email : please contact Tanya Geiser
6. Contact Information of Agency Contract Administrator for FY2013-14 contract:
Name: Tanya Geiser
(Must be the individual authorized to receive a state contract)
Email : tgeiser@co.weld .co . us Telephone : 970-304-6412 X2122
Physical Address for Contract Delivery: 1555 North 17th Avenue, Greeley CO 80631
Form 2
Fiscal Management Report
Complete items 1 and 2 below.
1. Related to FY2012-13 (July 1,2012 through June 30,2013):
A B C(=B/A)
CDPHE NHVP funding FY2012 13 FY2012-13 FY2012-13
(do not include Medicaid or Final Budget Final Expenditures billed %of budget expended*
Other Sources) r (after mid-year budget to CDPHE($)
revision) ($)
$665,075.00 $663,153.31 99.71%
*If the percentage of your budget expended is less than 97.0%, please provide a detailed explanation of why your
organization under-spent the budget.
A B C (=B/A)
Medicaid Total Medicaid Final Medicaid %of reimbursements
Reimbursements for Expenditures for the received**
Claims with dates of period 7/1/2012
payments between 6/30/2013($)
7/1/2012-6/30/2013
($)
$44,998.00 $44,998.00 100%
Notes: This figure should This figure should be in
match reports from the your accounting system
Department of Health AND should match the
Care Policy and total cumulative shown on
Financing. Flora the cost reimbursement
Martinez emailed this statements for the period
figure on 9/23/13. 7/1/2012-6/30/2013
**If the percentage of your reimbursements received is less than 97.0%, please provide a detailed explanation of
why your organization under-spent the budget.
2. Related to FY2013-14 Mid-year(July 1, 2013 through December 31,2013):
A B C(=B/A)
CDHS NHVP Funding Budget for FY 2013-14 Expenditures 7/1/2013— %budget expended***
($) 12/31/13
CDHS NHVP Funding $730,958 $317,001.21 42.71%
(do not include Medicaid or
Other Sources)
Medicaid Medicaid Estimate for Total Medicaid %of reimbursements:,
FY2013-14($) Reimbursements for Claims received***
with dates of payments
between 7/1/2013
12/31/2013($)
Medicaid $50.000 $16,529.36 33%
***50% of the contract period has elapsed. If % of budget expended or % of reimbursements is less than 40% of
your NHVP Funding or Medicaid Estimate, please explain.
Open NHV position since 6/21/2013. Fewer Medicaid qualified clients. Have reviewed Targeted Case Management
billable activities with NHVs.
Form 3
NHVP FY2014-15 Proposed Budget
FOR TIIE PERIOD: July 1,2014-June 30,2015
APPLICANT: Weld County Department of Public Health&Environment
FUNDED CASELOAD: 150
COUNTIES SERVED: Weld
Enter whole amounts only/Do not create new formulas
TOTAL CDHS F014-15
July 1,2013 to June 30,2014 CONTRACT BUDGET TOTAL AGENCY F014-15
(B+C) NHVP BUDGET(A+B+C)
' A.Other , -•._ 4 CONS (B+C)Medicaid: - --
T,Sources of '"I '-� - , luridoeg Estimate&CDHS (At B+C)
Funding •Ty �fI�YP) i• Funding(N60P)
PERSONNEL C0575(Deng Expenses) Base Salary Fringe Total N Effort
(Annual) Benefits (All Funding �
Sources)
Personnel Services(Title and Name) 3893%
Nurse Home Vistor-Arm Ingram 5.52,383 $20,393 $72,776 1.00' $72,776 $72,776F_ - $72,776
Nurse Home Vistor-Ariane Rowe-Denning_ $66,426 $25,860 $9'285 1.00 $92,286 $92,2sql - - $92,286
Nurse Home Vistor-Dana Garvey $50,442 $23,141 -$82,583 1.00 . • .. $82,583- $82,683 582,583
Nurse Home Vistor-.Geraktne Horton ' $66,109_ .$25,735: ;$91,845 1.00 $91,845 -$91:845 $91,845
Nurse Home Visitor-Joel Woodward ' . _ $57,780 .$22,494 .580,274 1.00 $80,274 $80,274 . $841,274
Nurse Home Visitor-Kathleen Hagihara $61,277 $23;855 $85,132 1.00 _ - $85,132 $85,132 $85,132
Office Tedvgdan-VACANT $33,533 $13,054 $46,587 1.00 $46,587 - $46,587 $46,5971
-$upervisor-Barbara Fnncisoo $66,912 $26,049 $92,961 0.75 $44,409 $25,312, $69,721, , $69,721
• — $0 _$0
CommulttsHeakh Manager-Kathy Sinitic-Shclion.. . . . $6$,586 . . $26,701- .$95,287_; 0.05, • . . .. $4,764. $4,764 $4764
t„tr
So' 5D.
. v.
.. ..r ..
.
. So - SO
- .... 1.TOTALPERSONBlEL0 a.. $44,409 ,.a.. .$581559 C. $625,968 '' $625,968
OPERATING(Detail Expenses)
Office Operating Expenses(i.e.supplies,pens,etc.)(including allocations for such,if any) _ I ____....___I $800 • .[;.. . 5800 _._ - $000
Client Su Materials _ -'— _ _ —._,_•_._-_ $5,300 -: $5,300 $5,300'
Support r
Printing&Publications (including allocations for such,if any) ._— _._ $2,�'•.':' $2000 S2,000
Postal&Shipping Services(including allocations for such,if arty) •_ -_ _$1,350 .-$1,350 :$$1,350,
Communications(i.e.long distance,cellular,airards and network service)(Including allocations for such,If any) $5,4001` '$5,100, $5,400
Medical/Program Supplies _. _ p _ ,:.:.
Outside Services 50 $0
Required model materials(Le.Keys to Care Giving,Beginning Rhythms,etc.) SSG - $500 $500 `$500
-_- _ -- $0 . , --S°
'i.: SO , 0
.... = 2.TOTALOPERATING -'x10 ..$o::.: ' $18,350 .
Training and Technical Assistance Fee e Total Cost
Nurse Initial Education Tuition Per NHV $4,069 1 54,069_ $4,069 r
Supervisor Initial Education Tuition Per Sup $4,803 $0 r
Administrator Orientation Per Administrator $480 $5 _ SO SO
Supervisor Expansion/Replacement Fee 12,764 So _.,-. r SO
Nurse Education Materials(New Supervisor/RN ONLY) Per NHY&Sup $517 — $0 t
DANCE Education Per NHV&sup 5595 1 $595; $595
DANCE Licensing Per NI-IV&Sup 555 1 i $55 • $55
Program Support Fee Per Sup $7,046 1 $7,046_. $7,046 $7,0461 $7,046
Professional Development Per Nurse $600 7 $4,200_.. . $4,200 $4,200 $4,200
Nurse Consultation 1st Supervisor $2,534 1- $2,534 $ 34 $2,534 .. $2,534
Nurse Consultation Per add.Supervisor $1,520 So So $o
_ $0 "I $0
3.TOTALTRAININGend TECHNICAL ASSISTANCE ••'jo $o . $1$499 $18,499. $18,499
Form 3
NHVP FY2014-1.5 Proposed Budget
FOR THE PERIOD: July 1,2014-June 30,2015
APPLICANT: Weld County Department of Public Health&Environment
FUNDED CASELOAD: 150
COUNTIES SERVED: Weld
Enter whole amounts only/Do not create new formulas
TOTAL CDHS FY;4.15
TOTAL AGENCY FYI4-15
Leib/1,2013 t0 June 30,2614 CONTRACT MIDGET NHVP BUDGET(A+B+C)
(M+C7
A.Other •
Cl M•elc,,d
'
Sources of aE �[ t �x,f � Esii tc5Cn lt5
Funding T �f2,T;,ftf, ,,('? ' Funding(rJ SAP)
E•of•ment I-
Computers w/Software 52,530 OO - 52,500
._
Cellular Phones
$0.
•
.• .�.'•;:',''._:f•t.:.E-'.S : .4.TOTAL EQUIPMENT:. •' - "$0 - $2,500' —$2,5001 w
TRAVEL Detail En•" see
VisitOutreachMilea:e $2E,C $28,000. '"";[1'`'r$•.'-r DOj
NFPTraininp and Meetrg Travel(Supervisors,Nurses) -._-_ SOLI $4•
Other Travel
-- - -- - •
I
-- - - SO 0
Sn $a
i5: ;; .w, ::'..' - ,..:' -.. . S.TOTALTRAV$L •C: s-. - '$28,400
;J'ti .e:..•. :.., 5a ,:.$28.400 _. : �:.. 28,400
OTHER COSTS(Detail Other Pro:ram Costs)
Maternal Mental Health Consultant-Kate Brockman _ _ $12001 $3,200 $1,200
Electronic Medical Record Data Base&Associated ITCosts/Data Processin:Ch :es _ 525,0001 $25,000 -$25,000
SO _-_•' $o
.r, $0 $0
s ,r,'=�: '. ' i,r ht'c., '6.SOTAL OTHER COSTS - $D . •,.S2g20IBI 526,200
OTALOIRECPPRDGRAM'Co5TS Adding},etcate-oriesl-fi ". '_•r;ti.(t;N K ""'�.� 6.: 544409 j . ::$675308 • $719911 — $719,917_
ADMINSTRATIVE COSTS Detail AdministrativeCOsts OR Indirect ita ipble _
Administrative Personnel Seruires(i.e. g,acctin admfn,HR) _ • A"t(¢' $0
••mMstrative Su•piles i.e.not• •:ram supplies)
•ccxun• i.e audit,bank expenses,liability) "" 1 - -$o -- __.$0
Su y orting Costs i.e.miles:e,recruitment) _ $0 so
Board of Health -� .:$0 $0
Other Admedstrative Costs i.e.Pasta:e,Occu•an ,Computer ---I • -$0 $0
—` -- - • `
_— $0� SO
OR - • $0 • - So
Indirect Rate at 12.59%for 2014 this is also an estimate for 2015;that will than and we r•• est that we be able to bill $0 $5 •1 "' } $90,638
our new 2015CDPHEn-:abated rate in 20151 .0 i ..10 So
^$D r So
$6 3a
— -- :_ So "So
- $o • So
— so $o
t." TDTAL:'MIMSTItATIVE COSTS L. -• .:' $5 91 --590,639 $90,638
TOTAL PROGRAM C0575(04ec1P-oQram+Adm,nlstrattve Costs) ',, -;e, „„ .., •- -••'• •^; -• .'-.. ..-•`-''t100: . .-..p'555 $BJA,SSS I $810,555
rf
5,eci "OTHER SOURCES..'Oil •••ir -fidIttifle Oilann&.abovl:."..:`_r i' . •
Total Other Sources $OAO
FY14-15 Non-Competitive Continuation Budget Proposal Narrative
FY2014-15 BUDGET NARRATIVE
Budget Period:July 1,2014—June 30,2015
PERSONNEL:$ 625,968
(Do not complete this section unless needed to provide information ore calculation not included in the Budget template)
Increases due to expected COLA of 1.5%-3%for 2015.Also salary increases for 2014-2015.
•
•
OPERATING EXPENSES:$ 18,350
All costs should be itemized within this category by major types(Office Supplies;Client Support Materials;Printing&Publications;Postal&
Shipping;Communications;Medical Supplies;Outside Services).The basis for cost computations should be shown(ie:"x"dollars per month for
Office Supplies;"y"dollars per person for Training Materials;Communications—Cell Phone long distance at"Z"dollars per month times#staff,
etc.).
Office Operating Expenses:$66.66 per month $800 divided by 12 months=$66.66 Client Support Materials:$5,300 divided by 12 months=$441.66 divided by 150
clients=$2.95. Printing and Publications:$2,000 divided by 12 months=$166.66 Postal&Shipping:$1,350 divided by 12 months=$112.50 Communication:$5400
divided by 12 months=$450 I This includes cell phone plan that includes unlimited texting and air cards for 6 laptop computers Medical/Program Supplies:$3,000 divided by
12 months=$350 Required model materials:$50 one time purchase
EQUIPMENT:$2,500
All costs should be itemized within this category by major types,as above(Computers,Cell Phones,Tablets,etc.).
$2,500 replacement of 2 desktop computers.$2,500 divided by 2 computers=$1,250
•
TRAINING AND TECHNICAL ASSISTANCE:$ 18,499
(Do not complete this section unless needed to provide information or o calculation not included in the Budget template)
TRAVEL:$ $28,400
All costs should be itemized with this category by major types(Visit Outreach Mileage,Training and Meeting Travel,etc.).The basis for cost
computations should be shown(4 nurse home visitors X average 500 miles/month/nurse x 12 months=x).
Visit Outreach Mileage:$28,000 6 NHVs+1 Supervisor%average of 600 miles/month/nurse%12 months=50,400 miles=$27,720(Includes lodging casts for NPF
Symposium and other training opportunities). NW Training&Meeting Travel:$400 One time charge for travel to Vail for 4 vehicles for NFP Mandatory Symposium.
OTHER:$ 26,200
All costs should be itemized within this category by major types(e.g.,Contractual Staff)
$1,200 divided by 12 months=$100 for Mental Health Consultant to participate and offer guidance and insight during one case conference per month @$100 per
consultation. $25,000 divided by 12 months=$2,083.333 for computer and data processing expenses related to maintenance and support of the computer network
(referred to in this application as"IT"),which includes,but is not limited to,maintainance&upgrades to the Electronic Medical Record data base,EMR licenses,operation and
tech support.
ADMINISTRATIVE COSTS or INDIRECT:$ 90,638
Administrative Costs: itemize details for each direct administrative cost using the categories listed on the budget
Indirect Rate:itemize details used to calculate the indirect rate
Current negotiated rate of 12.59%plus additonal estimate of indirect rate for 2015
Form 4
FY2014-15 Colorado Nurse Home Visitor Program (NHVP)
ASSURANCE of INTENTION to MEET PROGRAM REQUIREMENTS
NHVP contractors seeking continuation funding must assure that they intend to meet the Program
Requirements, as described in the Rules Concerning the Nurse Home Visitor Program adopted by the Colorado
Board of Health by initialing each of the outlined areas below and by signing this assurance page. Once the
Colorado Board of Human Services approves Rules for the Nurse Home Visitor Program,you will be sent a new
Assurance to sign and submit.
X Annual Plan
X Training Requirements
X Visit Protocols
X Program Management Information Systems
X Reporting and Evaluation System
X Staffing Requirements including to hire nurses as stated in Definitions(11) and (13) of the
Rules
Concerning the Colorado Nurse Home Visitor Program and to obtain and retain
documentation demonstrating all nurses have a current license.
X Eligibility of Clients including securing and maintaining proof of income for each mother
participating in the program.
Name of Agency: Weld County Department of Public Health and Environment
Name of Authorized Signer: Douglas Rademacher
Signature of Authorized Signer: st vilq_alita
Date: MAR 0 3 2094
Form 5
P12014-15 Colorado Nurse Home Visitor Program(NHVP)
ASSURANCE of INTENTION to be an ACTIVE MEDICAID PROVIDER
The Center for Medicaid and Medicare Services (CMS) has approved Medicaid reimbursement for Targeted
Case Management (TCM) services provided by NHVP sites. Targeted Case Management services are defined
by CMS as "services which will assist individuals eligible under the Colorado State Plan in gaining access to
needed medical, social, educational, and other services." Nurse home visitors provide targeted case
management through 1) assessment of the needs for health, mental health, social service, educational,
housing, child care and related services to women and children; 2) development of care plans to obtain the
needed services; 3) referral to resources to obtain the needed services, including medical providers who
provide care to a first-time pregnant woman and her first child; and,4) routine monitoring and follow-up visits
with the women where progress in obtaining the needed services is monitored, problem-solving assistance is
provided and the care plans are revised to reflect the woman's and child's current needs."
The Colorado Department of Human Services and the Colorado Department of Health Care Policy and
Financing have created a Medicaid Management Information System that allows for electronic billing of TCM
services under the NHVP. All NHVP sites are required to be active Medicaid providers, if not already, and must
bill Medicaid for TCM services as allowed. A portion of the annual funding for each NHVP site is derived from
Medicaid reimbursements.
NHVP applicants seeking funding must assure that they intend to meet the Medicaid requirements by initialing
each of the outlined areas below and by signing this assurance page. The entity will:
X Be an active Medicaid Provider on or before July 1, 2014 through June 30, 2015.
X Enroll all NHVP nurses in Medicaid as providers.
X Have a Medicaid consulting physician.
X Submit TCM claims as established by Medicaid billing rules and requirements,
including timely filing of claims.
X Ensure that all Medicaid-eligible participants are identified and receive assistance with
enrollment and referrals to other programs, including the Early and Periodic Screening,
Diagnosis and Treatment (EPSDT).
Name of Agency: Weld County Department of Public Health and Environment
Name of Authorized Signer: Douglas Rademancher
Signature of Authorized Signer:X ( �' 2itP.i
Date: MAR 0 3 2014
,�iy rs8s
Form 6
FY2014-15 Colorado Nurse Home Visitor Program (NHVP)
ASSURANCE of INTENTION to Follow CASELOAD GUIDELINES
The 2006 NHVP audit conducted by the Office of the State Auditor included a recommendation to the CDPHE to work with
the State Board of Health and the NHVP management partners to address program costs through caseload standards and
attrition rates. More specifically,the Department should:
(a) Determine why local sites are not achieving and maintaining caseload standards and develop strategies to help
increase participation.
(b) Establish guidelines for reducing caseloads and funding when sites do not meet caseload standards.
(c) Provide attrition analyses to the local sites and develop specific strategies to reduce the level of addressable
attrition at each local site.
It is understood that sites will not always reach 100% of their funded caseload due to factors such as (1) nurse turnover,
(2) new nurses learning the NFP model, (3) caseload build-up over 7-9 months, and (4) sites developing adequate referral
networks. Instead, a statewide baseline of an 85% active caseload of the total number of participants funded to be
served within a given fiscal year has been set. Active clients are defined in the NFP Efforts to Outcomes (ETOTM) software
as those that have not been discharged from the NFP program and have had a completed nurse visit within 90 days. The
CDPHE and the NHVP management partners will review site-specific active caseload trends covering a three-year period
(current year and two years prior) to assess for legitimate caseload size variances and to arrive at site-specific funding
recommendations based on a reasonable expected active caseload size. Please acknowledge review of this material by
signing below.
Sites are expected to track their active caseload numbers using ETO reports and will be expected to report any caseload
variations. Sites will be alerted to any issues they need to address to ensure they are meeting active caseload
expectations.
The NHVP mid-year budget adjustment process will be enhanced to consider year-to-date expenditures based on active
caseload size. If a site has cost savings as a result of a lower active caseload, those dollars may be redistributed to
another grantee site.
For sites indicating an active caseload deficiency (consistently below baseline over the three-year trend period), a
Performance Improvement Plan will be required, including specific strategies and time lines for meeting active caseload
expectations.
If a site does not meet the Performance Improvement Plan active caseload size expectation, a recommendation may be
made to the State Board of Health to reduce the active caseload number and funding in the site's contract to be
commensurate with the site's consistent performance.
The CDPHE contract will include active caseload size expectations as well as this plan as a means to formalize these
requirements and to hold all parties accountable for maximum caseload and funding efficiency.
The CDPHE and NHVP management team will develop a detailed caseload maintenance process and time line to guide
and assist the sites in effectively managing caseload size, including implementation of proven strategies to retain clients
or to recruit new participants to the program.
Name of Agency: Weld County Department of Public and Environment
Name of Authorized Signer: Douglas Rademacher,Weld County Commissioners Chair Person
Signature of Authorized Signer. ( \ ld 1se-
Date: MAR 0 3 2014
Form 7
SUBMISSION CHECKLIST
Name of Agency:Weld County Department of Public Health and Envrivonment
X Form 1:Cover Sheet.
X Form 2: Fiscal Management Report
X Form 3: FY14-15 Proposed Budget and Budget Narrative(both worksheets)
X Form 4: Assurance of Intention to Meet Program Requirements
X Form 5: Assurance of Intention to be an Active Medicaid Provider
X Form 6: Assurance of Intention to Follow Caseload Guidelines
X Form 7:Submission Checklist
ASSEMBLY AND SUBMISSION:
• Scanned PDF file of Forms 1—7 in the order listed above; use the following naming convention for the
PDF document:
Agency Name_NHVP FY15 Non-Competitive Continuation Budget Proposal
• Excel File with Proposed Budget and Budget Narrative(Form 3, 1 workbook with 2 worksheets)
• Emailed to: Nancy Jennings, Home Visiting Operations Coordinator
Nancy.iennings@state.co.us
• Due Date: Received by CDHS on or before Friday,February 28,2014 by 4:00 p.m.
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