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111•1111 ARIZONA DEPARTMENT OF HEALTH SERVICES 11 IF C.Pe ,18. March 16, 2018 Dear Colleague: The Arizona Department of Health Services' (ADHS) Tuberculosis (TB) Control Program has Walmart vouchers available in a new denomination of $25. These were purchased to assist local TB programs address some of the challenges associated with completion of therapy for TB and latent TB infection (LIB° cases, and for compliance of TB related services (including food or supplies needed by patients). Funding for these vouchers is made available through the American Lung Association of Arizona. Additional information that is needed is attached to this letter and outlined below. 1. Incentive Program Incentive Request • A formal request of incentives is needed to participate in the incentive program. 2. Incentive Program Monthly Report • Aggregate listing the number of incentives distributed during the month and the number of patients receiving the incentives submitted to ADHS by the 1 5t of every month. • Incentive Program Tracking Log I. Used to document and monitor recipients and serial numbers of vouchers. Please contact Mary Gullion via email at Mary.Gullion@azdhs.gov or by phone at 602-364-4750 to let us know if you can use these as incentives for completion of therapy and compliance of TB related services among patients receiving TB treatment in your jurisdiction. I hope the vouchers combined with directly observed therapy will help your program achieve better rates of completion of therapy. I can be reached at (602) 364-3375 or Kristen.Herrick@azdhs.gov if you have any questions. Sincerely, )( 4A-dd14/u . Tr/ 7 lAt40' " Kristen Herrick, TB Program Manager Arizona Department of Health Services Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P I 602-542-1025 F I 602-542-1062 W I azhealth.gov Health and Wellness for all Arizonans lin g ARIZONA DEPARTMENT I OF HEALTH SERVICES FL PREPAREDNESS TUBERCULOSIS CONTROL— INCENTIVE PROGRAM — INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364-3267 or email Mary.Gullion@azdhs.gov . If you have any questions regarding this form, please call (602) 364-4750. Walmart Total number of $25.00 vouchers requested 240 Total value ($) of vouchers requested $6,000 Initials of program The vouchers will be used solely as incentives for clients receiving anti-TB treatment. representative: Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. AB Initials of program The program will keep a record (tracking log) of every voucher dispensed and record representative: the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. AB Initials of program The program will submit a monthly report to ADHS listing the number of vouchers representative: distributed, the number of patients who received vouchers, and number of vouchers distributed YTD. AB Comments: Program Representative Contact Name, phone#, email t_11/40-SC0 triOD • 3f-ia • 0674 Director or DON Contact Name, phane#, email 1 Angelito Bravo, 602-372-1013, AngelitoBravo©mail.maricopa.gov Katherine Mason IJIgilally 0010. 2016.03.30 Big n Rd by 0129,31 15a Lherine .0007 Mason 03/30/2018 Signature of PrograiD-Repres'efititive • c ejA ALA" C jit Date tt—A ketkfl kA- G Angelito Bravo Dina [A1e:2011'4.03 Ily 3r) by 09 Any .271-34 all. -Troy Brayo 3/30/2018 Signature of Director or DON Date Date received by ADHS: Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P I 602-542-1025 F I 602-542-1062 W I azhealth.gov Health and Wellness for all Arizonans ATTACHED TO AND A PART OF: Tuberculosis Control Incentive Program MCDPH, Clinical Services, Tuberculosis Program, for Redeemable Vouchers C-86-18- IN WITNESS WHEREOF, the parties agree to enter into this Agreement and its Amendments: FOR AND ON BEHALF OF MARICOPA COUNTY By Steve Chucri, Chairman, Board of Supervisors Date ATTEST: Clerk of the Board Date APPROVED AS TO FORM: Attorney for Maricopa County Date