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October 27, 2016 C-86-17- Angelito Bravo Maricopa County Health Department 1645 E. Roosevelt Street Phoenix, AZ 85006 Dear Mr. Bravo: The Arizona Department of Health Services’ (ADHS) Tuberculosis (TB) Control Program has $10 grocery vouchers available. These were purchased to assist local TB programs address some of the challenges associated with completion of therapy for TB and latent TB infection (LTBI) cases, and for compliance of TB related services. Funding for these vouchers is made available through the American Lung Association of Arizona. We would like to offer a maximum of 200 $10 vouchers (total monetary value of $2,000) that may be requested by Maricopa County at one time. Replenishment requests can be made as vouchers are used. 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 1st 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, Kristen Herrick, TB Program Manager Arizona Department of Health Services Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 F | 602-542-1062 W | azhealth.gov Health and Wellness for all Arizonans 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. Number of $10.00 vouchers requested from the ADHS TB Control Program 200 The total value ($) of vouchers requested is $2,000 The vouchers will be used solely as incentives for clients receiving anti-TB Initials of program treatment. Active cases of TB will have the highest priority; however, if representative: warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. The program will keep a record (tracking log) of every voucher dispensed and Initials of program record the name of recipient, DOB, TB case/infected contact/high risk person representative: with LTBI, contact information, date. The program will submit a monthly report to ADHS listing the number of Initials of program vouchers distributed, the number of patients who received vouchers, and representative: number of vouchers distributed YTD. Comments: Program Representative Contact Name, phone#, email Director or DON Contact Name, phone#, email _____________________________________________________ SIGN ________________________ Signature of Program Representative Date _____________________________________________________ SIGN ________________________ Signature of Director or DON Date Date received by ADHS: __________________ Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 F | 602-542-1062 W | azhealth.gov Health and Wellness for all Arizonans TUBERCULOSIS CONTROL – INCENTIVE PROGRAM – MONTHLY REPORT 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. Please submit this report on the first of every month to indicate the number of TB patient treatment incentives that were given out in the previous month (i.e., please fax on 2/1/2016 for the number of incentives given out in January of 2016). In addition, please keep a tracking log including information regarding who received an incentive, the date they received it, why they received it and the serial number of the incentive card. County Report Month Report Year Type of Incentive Bashas Number of patients who received incentives this month Number of incentives distributed this month Total number of incentives distributed this year I, _________________________________(please print), verify that the above information regarding TB patient incentive distribution is correct and that the incentives were only distributed to individuals who are/were TB cases, TB suspects, contacts to TB cases, or LTBI patients. Signature: _______________________________________________ SIGN Title: ___________________________________________________ Date: ___________________________________________________ Date received by ADHS: __________________ Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 F | 602-542-1062 W | azhealth.gov Health and Wellness for all Arizonans TUBERCULOSIS CONTROL – INCENTIVE PROGRAM – TRACKING LOG RECIPIENT IDENTIFICATION DATE ISSUED INCENTIVE SERIAL NUMBER CODE* (ID NUMBER OR NAME) *CODE: TB case = 3, TB suspect = 5, infected contact = 2.a, infected (high risk), not known contact = 2.b Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 F | 602-542-1062 W | azhealth.gov Health and Wellness for all Arizonans ATTACHED TO AND A PART OF: Tuberculosis Control Incentive Program MCDPH, Clinical Services, Tuberculosis, for Bashas' Gift Vouchers from ADHS and the American Lung Association of Arizona C-86-17-_________________ IN WITNESS WHEREOF, the parties agree to enter into this Agreement and its Amendments: FOR AND ON BEHALF OF MARICOPA COUNTY (“The Group”) By_____________________________ Clint Hickman, Chairman, Board of Supervisors _______________________________ Date ATTEST: _______________________________ Clerk of the Board _______________________________ Date APPROVED AS TO FORM: _______________________________ Attorney for Maricopa County _______________________________ Date