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pg 1 Intergovernmental Agreement C-86-10-007-3-12 CONTRACT AMENDMENT 1. CONTRACTOR (Name and address) 2. CONTRACT ID NUMBER DE101038-001 Maricopa County Department of Public Health 4041 N. Central Ave., Suite 1400 3. AMENDMENT NUMBER Phoenix, AZ 85012 10 4. THE PARTIES AGREE TO THE FOLLOWING AMENDMENT Pursuant to Section 4.0, Amendments or Modifications, the contract reimbursement ceiling for “Coordination- Refugee Preventive Health” services is increased by $1,585,262 to add funding for the reimbursement of initial medical screenings for the period of July 1, 2016 through June 30, 2017. Funds for initial medical screenings will be used to reimburse the Contractor for the provision of federally required medical screenings for new Refugee arrivals. Contractor will only be reimbursed for initial medical screenings provided to refugees who are not covered by AHCCCS and which are performed within 90 days of the Refugees’ US entry. The funding in the amount of $1,585,262 for initial medical screening reimbursement represents an estimate of the amount of funds necessary to provide all such medical screenings. ADES may increase or decrease the estimate based on actual Refugee arrivals. Pursuant to section 9.0, Reporting Requirements, to be reimbursed for initial medical screenings; the Contractor shall submit through secure email a monthly report which includes the following: Name of service recipient, date of birth, gender, date of referral for the domestic medical screening, date of service(s), alien number, procedure code, and the total charge. The contract reimbursement ceiling for the period of July 1, 2016 through June 30, 2017 is revised from $210,812 to $1,796,074. Therefore, the Service Budget for the period of July 1, 2016 through June 30, 2017 is revised and attached. 5. EXCEPT AS PROVIDED HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT AS HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL FORCE AND EFFECT. THE AMENDMENT SHALL BECOME EFFECTIVE ON THE DATE OF LAST SIGNATURE UNLESS OTHERWISE SPECIFIED HEREIN. BY SIGNING THIS FORM ON BEHALF OF THE CONTRACTOR, THE SIGNATORY CERTIFIES HE/SHE HAS THE AUTHORITY TO BIND THE CONTRACTOR TO THIS CONTRACT. 6. 7. NAME OF CONTRACTOR ARIZONA DEPARTMENT OF ECONOMIC SECURITY Maricopa County Department of Public Health SIGNATURE OF AUTHORIZED INDIVIDUAL SIGNATURE OF AUTHORIZED INDIVIDUAL TYPED NAME TYPED NAME Cynthia Pullen TITLE TITLE Procurement Manager DATE DATE IN ACCORDANCE WITH ARS §11-952 THIS CONTRACT AMENDMENT HAS BEEN REVIEWED BY THE UNDERSIGNED WHO HAVE DETERMINED THAT THIS CONTRACT AMENDMENT IS IN APPROPRIATE FORM AND WITHIN THE POWERS AND AUTHORITY GRANTED TO EACH RESPECTIVE PUBLIC BODY. ARIZONA ATTORNEY GENERAL’S OFFICE APPROVED AS TO FORM By: _________________________________________ By: ____________________________________ Assistant Attorney General Public Agency Legal Counsel Date: _______________________________________ Date: __________________________________ ATTEST: Clerk of the Board Date _______________________________________ pg 2 ITEMIZED SERVICE BUDGET CONTRACT SERVICE: Coordination - Refugee Preventiv Health CONTRACT: DE101038001 PROVIDER NAME: Maricopa County Department of Public Health Services Division of Public Health Clinical Services CONTRACT PERIOD: 07/01/2016 to 6/30/2017 1. PERSONNEL TOTAL Number of FTE Total Salary for the % Allocated Service SERVICE DAAS Positions Level Position Title Contract Period *A + D = Total COST COST 1 1.00 Registered Nurse $53,892 5% + 95% = 100% $53,892 53,892 1 0.60 Client Service Coordinator $28,000 5% + 95% = 100% $28,000 28,000 1 0.70 X-RAY Tech $38,179 5% + 95% = 100% $38,179 38,179 TOTAL: 120,071 120,071 *A = % Administrative Functions D = % Direct Service Functions 2. EMPLOYEE RELATED EXPENSES TOTAL DAAS ITEM Fixed Variable 19.21% COST COST 1 1.00 Registered Nurse $11,400 5% + 95% = 100% $ 21,753 $ 21,753 1 0.60 Client Service Coordinator $11,400 5% + 95% = 100% $ 12,219 $ 12,219 1 0.70 X-RAY Tech $11,400 5% + 95% = 100% $ 15,314 $ 15,314 TOTAL: 49,286 49,286 3. PROFESSIONAL AND OUTSIDE SERVICES TOTAL DAAS ITEM BASIS COST COST - - TOTAL: - $0 4.TRAVEL TOTAL DAAS ITEM BASIS COST COST Staff Owned Vehicle Mileage Field visits 2846 miles @.56per mile $ 1,594 $ 1,594 TOTAL: 1,594.00 $1,594 5.SPACE TOTAL DAAS ITEM BASIS COST COST $0 TOTAL: - $0 6. EQUIPMENT TOTAL DAAS ITEM BASIS COST COST $0 TOTAL: - $0 7. MATERIALS AND SUPPLIES TOTAL DAAS ITEM BASIS COST COST $0 TOTAL: - $0 8. OPERATING SERVICES TOTAL DAAS ITEM BASIS COST COST Translation Services $ 12,205 $ 12,205 TOTAL: 12,205 $12,205 9. INDIRECT COSTS TOTAL DAAS ITEM BASIS COST COST Allocated Indirect 15.1% 27,656 27,656 TOTAL: 27,656 $27,656 10 SUBTOTAL ADMIN COST 210,812 210,812 11. VOUCHERS TOTAL DAAS $ 1,585,262 $ 1,585,262 TOTAL: 1,585,262 $ 1,585,262 12. TOTAL SERVICE COST/DAAS TOTAL COST: 1,796,074 1,796,074