AMENDMENT 2 RE CHRONIC DISEASE HEALTH POLICY 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: ADHS12-015902 Amendment No. 2
Lorraine Ball-Schwarzwald
Chronic Disease Health Policy
It is mutually agreed that the Intergovernmental Agreement (IGA) referenced above is amended, effective April
1, 2015, as follows:
1. Pursuant to Terms and Conditions, Provision 4. Contract Administration and Operation of this Agreement, Section
4.2 Contract Renewal, this Agreement is extended to June 30, 2015.
2. Price Sheet is replaced with the “Price Sheet”, of this Amendment for the increase of $75,000.00, due to a grant
extension of April through June 2015.
3. Terms and Conditions, Provision 18. Health Insurance Portability and Accountability Act of 1996 (HIPAA), is
deleted in its entirety and replace it with the following:
ALL OTHER PROVISIONS OF THIS AGREEMENT REMAIN UNCHANGED.
CONTRACTOR SIGNATURE
Maricopa County Health Department
Contractor Name Contractor Authorized Signature
4041 North Central Avenue, #1400
Address Printed Name
Phoenix Arizona 85012
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. PIGA2012000344, 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:
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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: ADHS12-015902 Amendment No. 2
Lorraine Ball-Schwarzwald
18. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
18.1 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.
18.2 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.
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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: ADHS12-015902 Amendment No. 2
Lorraine Ball-Schwarzwald
Price Sheet
Effective April 1, 2015 – June 30, 2015
Current
Proposed New Budget
Cost Reimbursement Line Items Budget
Amount Amount
Amount
1. Personnel Services / ERE $91,403.00 $22,809.00 $114,212.00
2. Professional and Outside Services $185,369.00 $44,760.00 $230,129.00
3. Travel Expenses $6,000.00 $1,505.00 $7,505.00
4. Other Operating Expenses $2,518.00 $2,505.00 $5,023.00
5. Capital Outlay Expenses NOT ALLOWED NOT ALLOWED NOT ALLOWED
6. Other (Indirect Costs) $13,710.00 $3,421.00 $17,131.00
Total Contract Amount
$299,000.00 $75,000.00 $374,000.00
(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 percent (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.
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