AMENDMENT 5 RE COMMUNITY HEALTH GRANT WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 1740 W. Adams, Room 303
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS12-010921 Amendment No. 3
Sue-Anne Tan
Community Health Grant
Effective January 1, 2015, it is mutually agreed that the IGA referenced is amended as follows:
1. The Price Sheet of Amendment Two (2) is replaced with the revised Price Sheet of this Amendment Three (3).
The IGA Item Pricing shall be revised in ProcureAZ to align with available funding upon execution of this
Amendment Three (3). The IGA budget total remains the same at $300,000.00 based on the following line
item changes:
1.1 Personnel increased by $1,477.68 for a total of $181,624.68 due to salaries increased by 2.5%;
1.2 ERE increased by $2,191.73 for a total of $68,461.73 due to increase in salaries;
All other provisions of this agreement remain unchanged
CONTRACTOR SIGNATURE
In accordance with A.R.S. 35-391.06 and A.R.S. 35-393.06, the Contractor
hereby certifies that the Contractor does not have scrutinized business
operations in Sudan or Iran.
Maricopa County Department of Public Health
Contractor Name Contractor Authorized Signature Date
4041 North Central Avenue, Suite #1400
Address Printed Name
Phoenix AZ 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. P0012014000078, which is an RESERVED FOR USE BY THE SECRETARY OF STATE
Agreement between public agencies, has been reviewed pursuant to
A.R.S. § 11-952 by the undersigned Assistant Attorney General, who Under House Bill 2011, A.R.S. § 11-952 was amended to
has determined that it is in proper form and is within the powers and remove the requirement that Intergovernmental Agreements
authority granted under the laws of the State of Arizona. be filed with the Secretary of State.
Signature Date
Assistant Attorney General
Printed Name:
1

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 1740 W. Adams, Room 303
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS12-010921 Amendment No. 3
Sue-Anne Tan
1.3 Other decreased by $3,600.00 to $0.00. The budget amount of this line item is moved to Other
Operating Expenses;
1.4 Indirect (if authorized) decreased by $4,255.04 for a total amount of $38,675.96 due to Indirect for 2015
is projected to increase to 14.80%; and
1.5 Other Operating Expense is increased by $4,185.63 for a total amount of $8,237.63 as the budget
amount for Other has been moved to this line item.
2. Pursuant to Terms and Conditions, Provision Seven (7), Risk and Liability, Section 7.3 Indemnification –
Patent and Copyright, is hereby deleted in its entirety.
3. Pursuant to Terms and Conditions, Provision Eighteen (18), Health Insurance Portability and Accountability
Act of 1996 (HIPAA) is revised to read as follows:
18. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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.
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.
2

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 1740 W. Adams, Room 303
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS12-010921 Amendment No. 3
Sue-Anne Tan
MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH
As of January 1, 2015
Cost Reimbursement Line Item Budget
ACCOUNT CLASSIFICATION AMOUNT
Personnel $181,624.68
ERE $68,461.73
Professional & Outside Services $1,000.00
Travel Expense $2,000.00
Out of State Travel $0.00
Operating Expense $0.00
Other $0.00
Indirect (if authorized) $38,675.96
Other Operating Expense $8,237.63
Capital Outlay $0.00
TOTAL $300,000.00
With prior written approval from the Program Manager, the Contractor is authorized to transfer up to a maximum of
ten percent (10%) of the total budget amount between line items. Transfers of funds are only allowed between
funded line items. Transfers exceeding ten percent (10%) or to a non-funded line item shall require a Contract
amendment.
3