AMD 2 RE HCH WITH FALCON PRACTICE MGMT.PDF

CONTRACT NO: C-86-15-029-3-02 AMENDMENT NO: 2
AMENDMENT No 2 TO
RFP CONTRACT BETWEEN MARICOPA COUNTY
by and through the
DEPARTMENT OF PUBLIC HEALTH
AND
FALCON PRACTICE MANAGEMENT, LLC
The above named contract is hereby amended as specified below:
A. Exhibit A, Pricing Sheet, replace with a new pricing sheet to allow for
Consultation Services;
B. Exhibit B, 2.0 Scope of Work, add the following:
2.0, 2.1, 2.1,22 - Contractor consultation may be utilized for insurance and
billing questions for the Division of Clinical Services.
C. The Business Associate Agreement is made a part of this contract.
All other terms and conditions of the original contract and all amendments
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 THE CONTRACTOR
By By
Chairman, Board of Supervisors President/CEO
Date Date
ATTEST: ATTEST:
Clerk of the Board Signature
Date Date
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APPROVED AS TO FORM: APPROVED AS TO FORM:
Attorney for Maricopa County Signature
DATE: DATE:
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EXHIBIT A
Contract #: 860-15-003 / PH RFP 15-003
PRICING SHEET
ro, (40 Praoh'ce, e,M e 11-
BIDDER NAME:
F.I.D.NENDOR #:
BIDDER ADDRESS: La ey Rd E-- rov-ke d fr.?)vcv J OF 73/
P,O. ADDRESS; FO. ft)( KLIF og
BIDDER PHONE #: So
BIDDER FAX L2 6 I 6i
COMPANY WEB SITE: \i'V \A.Wi-f6i,LOOpirOdlLe. 61(301a Co (72
COMPANY CONTACT (REP); ,1\\A(eice- ,L0)5-4'01 ,
E-MAIL ADDRESS (REP); die! C- 0 (1) OC° fice, cv
PAYMENT TERMS; BIDDER IS REQUIRED TO SELECT ONE OF THE FOLLOWING.
TERMS WILL BE CONSIDERED IN DETERMINING LOW BID,
FAILURE TO CHOOSE A TERM WILL RESULT IN A DEFAULT TO NET 30.
BIDDER MUST INITIAL THE SELECTION BELOW.
NET 10
NET 15
NET 20
NET 30
NET 45
NET 60
NET 90
2% 10 DAYS NET 30
1 04110 DAYS NET 30
2%30 DAYS NET 31
1% 30 DAYS NET 31
5%30 DAYS NET 31
DESCRIPTION OF SERVICES; FEE/HOURLY RATE
Medical Billing Outso cing 8% of Revenues collected
Consultation $125/Hour
Respondent's signature (4619 ) indicates understanding and agreement with the predetermined hourly
compensation/fees rate lift!' ated above.
///)/
Date
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