TB PROGRAM INCENTIVE REQUEST.PDF

I 111•1111
ARIZONA DEPARTMENT
OF HEALTH SERVICES
1111 P 11111 -1 1 iiiiHrit
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 Marv.Gullicm@azdhs.gov . if you have any questions regarding this form, please call
(602) 364-4750.
Bashas' Walmart Chevron
Total number of $10.00 vouchers requested 200
Total value ($) of vouchers requested 2000
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
Director or DON Contact
Name, phone#, email Angelito Bravo 602-372-1013 AngelitoBravo@mail.maricopa.gov
Signature of Program Representative Date
Angelito Bravo 7/25/2017
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 WI azhealth.gov
Health and Wellness for all Arizonans

ATTACHED TO AND A PART OF:
Tuberculosis Control Incentive Program
IV1CDPH, 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
Denny Barney, Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date