14-059037 - MARICOPA COUNTY DEPARTMENT OF PUBLIC HLTH AMD 3.PDF

ARIZONA DEPARTMENT
OF HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 1740 West Adams, Room 303
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 FAX
Procurement Officer:
Contract No.: ADHS14-059037 Amendment No.: 3
Delilah Gonzalez
STATEWIDE COMPREHENSIVE NEEDS ASSESSMENT
It is mutually agreed that the Intergovernmental Agreement referenced is amended as follows:
1. Pursuant to Terms and Conditions, Provision Six (6). Contract Changes, Item (6.1), Amendments, Purchase Orders
and Change Orders, the attached Budget is added to the Contract. All Budget items will be added to the ProcureAZ
“Items” tab upon execution of this Amendment.
(CONTINUED ON NEXT PAGE)
ALL OTHER PROVISIONS OF THIS AGREEMENT REMAIN UNCHANGED.
CONTRACTOR SIGNATURE
Contractor Name: Authorized Signature
MARICOPA COUNTY RYAN WHITE PART A PROGRAM
.
301 WEST JEFFERSON, #3200
Address: Print Name
PHOENIX ARIZONA 85003
City State Zip Title
CONTRACTOR ATTORNEY SIGNATURE This Intergovernmental Agreement Amendment shall be effective
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney has the date indicated. The Public Agency is hereby cautioned not to
determined that this Intergovernmental Agreement is in proper form and is within commence any billable work or provide any material, service or
the powers and authority granted under the laws of Arizona construction under this IGA until the IGA has been executed by
an authorized ADHS signatory.
State of Arizona
Signature Date
Signed this day of 2016.
Print Name Title
Procurement Officer
Attorney General Contract No.: P00120144000078 , which is an Agreement RESERVED FOR USE BY THE SECRETARY OF STATE
between public agencies, has been reviewed pursuant to A.R.S. § 11-952 by the
undersigned Assistant Attorney, who has determined that it is in proper form and is
within the powers and authority granted under the laws of the State of Arizona.
Signature Date
Assistant Attorney General
Print Name Title
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ARIZONA DEPARTMENT
OF HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 1740 West Adams, Room 303
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 FAX
Contract No.: ADHS14-059037 Amendment No.: 3 Procurement Officer:
Delilah Gonzalez
Budget
Maricopa
ADHS Part County
Phase Components Hours Rate Total B Portion Part A
(77%) Portion
(23%)
Meet with key stakeholders to develop the quality
1.1 50 $80 $4,000
improvement needs assessment. $3,080.00 $920.00
Conduct interviews and sample chart audits to
identify potential quality management
1.2 improvement areas/assess provider capacity for 950 $80 $76,000
adopting Arizona standards of care (16 Part B
providers; 10 Part A providers) $58,520.00 $17,480.00
Analyze findings, present recommendations for
1.3 100 $80 $8,000
each partnering agency. $6,160.00 $1,840.00
Technical Assistance to service providers based
1.4 100 $80 $8,000
on Needs Assessment findings $6,160.00 $1,840.00
Total 1200 $96,000 $73,920.00 $22,080.00
Conduct a statewide Needs Assessment
Meet with key stakeholders to develop the
consumer survey instrument in English and
2.1 50 80 $4,000
Spanish. Translate survey into Spanish. Create
databases for data entry/capture $3,080.00 $920.00
Conduct statewide consumer surveys (n=800);
2.2 960 80 $76,800
identify barriers/gaps in retention in care. $59,136.00 $17,664.00
Utilize CAREWare data, analyze client level data
to show identify any disparities in the dis-enrolled
2.3 250 80 $20,000
populations including those of may have dropped
out of care or in care at other providers $15,400.00 $4,600.00
2.4 Analyze survey data, present draft findings 125 80 $10,000 $7,700.00 $2,300.00
Complete 2016 Needs Assessment
2.5 40 80 $3,200
Document/Presentation to key stakeholders $2,464.00 $736.00
Total 1425 $80 $114,000 $87,780.00 $26,220.00
Grand Total 2625 $80 $210,000 $161,700.00 $48,300.00
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