AMENDMENT RE POPULATION HEALTH POLICY 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: ADHS12-021145 Amendment No. 1
Manuel Gonzales
Population Health Policy Initiative
It is mutually agreed that the Intergovernmental Agreement referenced is amended, effective upon final signature, as follows:
1. Pursuant to Terms and Conditions, Provision Four (4) Contract Administration and Operation 4.2, Contract
Renewal, the Contract is hereby extended through June 30, 2015.
2. Replace Price Sheet of the original Agreement, with the revised Price Sheet Page Three (3), of this Amendment
One (1).
3. Delete in its entirety, Terms and Conditions, Provision Four (4), item 4.12 Scrutinized Businesses In accordance
with A.R.S. § 35-391 and A.R.S. § 35-393, Contractor certifies that the Contractor does not have scrutinized
business operations in Sudan or Iran.
All other provisions of this agreement remain unchanged.
CONTRACTOR SIGNATURE
Maricopa County Department of Public Health
Contractor Name Contractor Authorized Signature
4041 N. Central Ave, Suite 700
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. 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:
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ARIZONA DEPARTMENT OF
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT HEALTH SERVICES
1740 W. Adams, Room 303
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS12-021145 Amendment No. 1
Manuel Gonzales
4. Pursuant to Terms and Conditions, Provision Eighteen (18), Health Insurance Portability and Accountability Act of
1996 (HIPAA) is revised with the following:
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.
5. Revise and replace Scope of Work, Provision F, section one (1), Notices, Correspondence and Reports from the
Contractor to ADHS shall be sent to:, with the following updated information:
1. Arizona Department of Health Services
Bureau of Health Systems Development
Attn: MPA Health Policy Program Manager
150 N 18th Ave., Suite 300
Phoenix, AZ 85007
Telephone: (602)-364-0606
Facsimile: (602)-542-2011
Email: sherry.haskins@azdhs.gov
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ARIZONA DEPARTMENT OF
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT HEALTH SERVICES
1740 W. Adams, Room 303
Price Sheet Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Contract No: ADHS12-021145 Amendment No. 1 Procurement Specialist
Manuel Gonzales
Revised
Quarterly Fixed Price
Number Per
Account Classification Budget Unit Rate Total Cost
Period
Procurement 5 $19,945.00 $99,725.00
School Health 5 $19,945.00 $99,725.00
Worksite Wellness 5 $19,945.00 $99,725.00
Healthy Community Design 5 $19,945.00 $99,725.00
Clinical Care 5 $19,945.00 $99,725.00
Total $498,625.00
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