AMENDMENT 2 RE HYPERTENSION AND DIABETES WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) 1740 W. Adams ST, RM 303
AMENDMENT Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS14-072293 Amendment No. 2
Lorraine Ball-Schwarzwald
HYPERTENSION AND DIABETES SYSTEM OF CARE
It is mutually agreed that the Intergovernmental Agreement (IGA) Amendment referenced above is amended,
effective March 1, 2015 as follows:
1. Scope of Services, Provision 4. Tasks, is amended to add the following:
4.14 Conduct needs assessment and site reviews of other area clinics for future program expansion.
2. Scope of Services, Provision 5. Deliverables and Delivery Schedule, is amended to add the following:
5.3.6 Written needs assessment review of other local clinics and recommendations for future program
expansion due by June 29, 2015.
All other provisions of this agreement remain unchanged.
CONTRACTOR SIGNATURE
Maricopa County through the Department of Public
Health
Contractor Name Contractor Authorized Signature
4041 North Central Avenue
Address Printed Name
Phoenix Arizona 86012
City State Zip Title
CONTRACTOR ATTORNEY SIGNATURE This Intergovernmental Agreement Amendment shall be effective the
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney date indicated. The Public Agency is hereby cautioned not to commence
has determined that this Intergovernmental Agreement is in proper any billable work or provide any material, service or construction under
form and is within the powers and authority granted under the laws of this IGA until the IGA has been executed by an authorized ADHS
the State of Arizona. signatory.
State of Arizona
Signed this __________ day of __________________________ 2015
Signature Date
Printed Name Procurement Officer
Attorney General Contract No. P0012014000078, which is an
Agreement between public agencies, has been reviewed pursuant to
A.R.S. § 11-952 by the undersigned Assistant Attorney General, 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
Printed Name:
Page 1 of 3

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) 1740 W. Adams ST, RM 303
AMENDMENT Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS14-072293 Amendment No. 2
Lorraine Ball-Schwarzwald
3. The Price Sheet is replaced with the “Price Sheet”, of this Amendment. The additional funding is for conducting
assessments, site reviews and developing recommendations for future program expansion.
4. Terms and Conditions, Provision 17. Health Insurance Portability and Accountability Act of 1996 (HIPAA), delete
Sections 17.1 and 17.2, and replace it with the following:
17.1 The Contractor warrants that it is familiar with the requirements of HIPAA, as amended by the Health
Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009, and accompanying
regulations and will comply with all applicable HIPAA requirements in the course of this Contract.
Contractor warrants that it will cooperate with the Arizona Department of Health Services (ADHS) in the
course of performance of the Contract so that both ADHS and Contractor will be in compliance with
HIPAA, including cooperation and coordination with the Arizona Department of Administration-Arizona
Strategic Enterprise Technology (ADOA-ASET) Office, the ADOA-ASET Arizona State Chief Information
Security Officer and HIPAA Coordinator and other compliance officials required by HIPAA and its
regulations. Contractor will sign any documents that are reasonably necessary to keep ADHS and
Contractor in compliance with HIPAA, including, but not limited to, business associate agreements.
17.2 If requested by the ADHS Procurement Office, Contractor agrees to sign a “Pledge To Protect
Confidential Information” and to abide by the statements addressing the creation, use and disclosure of
confidential information, including information designated as protected health information and all other
confidential or sensitive information as defined in policy. In addition, if requested, Contractor agrees to
attend or participate in HIPAA training offered by ADHS or to provide written verification that the
Contractor has attended or participated in job related HIPAA training that is: (1) intended to make the
Contractor proficient in HIPAA for purposes of performing the services required and (2) presented by a
HIPAA Privacy Officer or other person or program knowledgeable and experienced in HIPAA and who
has been approved by the ADOA-ASET Arizona State Chief Information Security Officer and HIPAA
Coordinator.
Page 2 of 3

INTERGOVERNMENTAL AGREEMENT (IGA) ARIZONA DEPARTMENT OF
HEALTH SERVICES
AMENDMENT
1740 W. Adams, Room 303
Phoenix, Arizona 85007
PRICE SHEET (602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS14-072293 Amendment No. 2 Lorraine Ball-Schwarzwald
PRICE SHEET
Effective March 1, 2015 – June 29, 2015
COST REIMBURSEMENT Jan 01, 2015 – Additional Amount
New Adjusted Amount
LINE ITEMS Jun 29, 2015 to be Added
1. Personnel Services / ERE $3,732.58 $13,503.58 $17,236.16
2. Professional & Outside Services $74,401.00 $0.00 $74,401.00
3. Travel Expenses $0.00 $1,000.00 $1,000.00
4. Other Operating Expense $5,500.00 $0.00 $5,500.00
5. Supplies $0.00 $0.00 $0.00
6. Capital Outlay Expense NOT ALLOWED NOT ALLOWED NOT ALLOWED
7. Other (Indirect Costs) $1,366.42 $1,434.42 $2,800.84
Total Contract Amount *
$85,000.00 $15,938.00 $100,938.00
(not to exceed)
1. ITEMIZED SERVICE BUDGET (ISB) RESTRICTIONS:
1.1. The Contractor is authorized to transfer up to a maximum of ten percent (10%) of the total Contract
amount among the categorical line items. Transfers of funds are only allowed among funded line items
as detailed in the original ISB. Transfers exceeding ten percent (10%) of the Contracted amount, or to a
non-funded line item, shall require a Contract Amendment.
1.2. Indirect Costs shall not exceed fifteen (15%) of the combined total of Personnel Services and Employee
Related Expenses as listed on the ISB. For more detailed information regarding indirect costs, refer to
the ADHS Accounting and Auditing Procedures Manual for Contractors of ADHS Funded Programs.
This manual is incorporated into this Contract by reference herein.