AMD 1 TO ADHS 3RD PARTY BILLING 02.PDF

C-86-16-080-3-02
ADHS16-123017 AMENDMENT 1 TO INTERGOVERNMENTAL AGREEMENT
Between MARICOPA COUNTY By and Through its
DEPARTMENT OF PUBLIC HEALTH, Office of Oral Health,
And the ARIZONA DEPARTMENT OF HEALTH SERVICES for
Third Party Reimbursement for Fluoride Varnish Services
I. The above named contract is hereby amended as specified below:
Section III
4. Tasks
L. Provide Maricopa Department of Public Health (MCDPH) with funds from
Arizona Department of Health Services (ADHS) (administration fees and/or
billing and reimbursement fees) for services appropriately billed to insured
clients, along with quarterly reports, on the 15th of the month following the
close of each quarter. Generated revenue for MCDPH is estimated not to exceed
$200,000 for the budget period July 1, 2015 through June 30, 2016.
II. All other terms and conditions of the original contract shall remain in full force and effect.
IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AND ON BEHALF OF FOR AND ON BEHALF OF
MARICOPA COUNTY Arizona Department of Health Services
By: By:
Chairman, Board of Supervisors
Date Date
ATTEST ATTEST
Clerk of the Board
Date Date
APPROVED AS TO FORM APPROVED AS TO FORM
Attorney for Maricopa County
Date Date
1