AMD 7 RE REFUGEE MEDICAL ASST PRGM WITH ADES.PDF

Intergovernmental Agreement
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 7
4. THE PARTIES AGREE TO THE FOLLOWING AMENDMENT
Pursuant to Section 3.0, Term of Agreement, Paragraph 3.2, Extension, the above referenced contract is extended
for the period of July 1, 2015 to June 30, 2016. The Health Assessment service rate is not adjusted for the extension
period and shall remain the same as for the previous contract term.
Pursuant to Section 4.0, Amendments or Modifications, the contract reimbursement ceiling for the “Coordination-
Refugee Preventive Health” service for the period of July 1, 2015 through June 30, 2016 is $167,342.00.
The cumulative reimbursement ceiling is revised to $1,152,091.00.
Therefore, the Itemized Service Budget for the period of July 1, 2015 to June 30, 2016 is 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 through its Department of Public Health
SIGNATURE OF AUTHORIZED INDIVIDUAL SIGNATURE OF AUTHORIZED INDIVIDUAL
TYPED NAME TYPED NAME
Pam Giroux Steve Chucri
TITLE TITLE
Procurement Manager
Chairman, Maricopa County Board of Supervisors
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
_______________________________________

ITEMIZED SERVICE BUDGET
CONTRACT SERVICE: Refugee Medical Assistance Program
CONTRACT: DE101038001
PROVIDER NAME: Maricopa County Department of Public Health Services
Division of Public Health Clinical Services
CONTRACT PERIOD: 07/01/2015 to 6/30/2016
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 $53,891 5% + 95% = 100% 53,891 53,891
1 0.70 X-RAY Tech $37,271 5% + 95% = 100% 37,271 37,271
TOTAL: 91,162 91,162
*A = % Administrative Functions D = % Direct Service Functions
2. EMPLOYEE RELATED EXPENSES TOTAL DAAS
ITEM Fixed Variable 19.31% COST COST
1 1.00 Registered Nurse $10,032 5% + 95% = 100% 20,439 20,439
1 0.70 X-RAY Tech $10,032 5% + 95% = 100% 14,219 14,219
TOTAL: 34,658 34,658
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 1061 miles @.56per mile 594.00 $594
$0
TOTAL: 594.00 $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
$0
$0
18,095 18,095
TOTAL: 18,095 $18,095
9. INDIRECT COSTS TOTAL DAAS
ITEM BASIS COST COST
Allocated Indirect 15.8% 22,833 22,833
TOTAL: 22,833 $22,833
10 SUBTOTAL AMAIN COST 167,342 $167,342
11. VOUCHERS
TOTAL DAAS
TOTAL: $0
1 TOTAL SERVICE COST/DAAS TOTAL COST: 167,342 $167,342 H.