COMP IMP CONTRACT RE DENTAL SVCS WITH CENTRAL AZ SHELTER SVCS.PDF

CONTRACT FOR SERVICES
MARICOPA COUNTY
by and through the
DEPARTMENT OF PUBLIC HEALTH
4041 N. Central, Suite 600, Phoenix, Arizona 85012
1. Contract No: C-86-15-045-3-00 2. Contract Type: Unit Cost
3. Contract Amount: $ 132,558 4. Purpose: Homeless Dental Services
(Maximum Reimbursable Amount)
5. Start Date: 11/1/2014 6. Expiration Date: _10/31/2015
This Contract is entered into by and between Central Arizona Shelter Services, Inc. (CASS) referred to
hereinafter as the “Contractor,” and Maricopa County, by and through the Department of Public Health,
referred to hereinafter as the “County.” The Contractor and the County are collectively referred to as the
“Parties” and individually as a “Party.” The Parties, for and in consideration of the covenants and conditions
set forth herein, shall provide and perform the services as set forth below. All rights and obligations of the
Parties shall be governed by the terms of this Contract, including its Exhibits, Attachments, Appendices, and
any Subcontracts or Amendments as set forth herein and in:
Section I - General Provisions Section III - Work Statement
Section II - Special Provisions Section IV - Compensation
This Contract contains all the terms and conditions agreed to by the Parties. No other understanding,
oral or otherwise, regarding the subject matter of this Contract shall be deemed to exist or to bind the
Parties. Nothing in this Contract shall be construed as consent to any lawsuit or waiver of any defense
in any lawsuit brought against the State of Arizona, the County, or the Contractor, in any State or
Federal Court.
Legal notice under this Contract shall be given by personal delivery or by registered or certified mail, postage
prepaid and return receipt requested, to the addresses set forth below. If the legal notice is personally
delivered, it is deemed given and effective upon receipt by the Party to whom it is addressed. If the legal
notice is mailed, it is deemed given and effective three (3) days after it is mailed by registered or certified mail.
Notice to Contractor: Kris Volcheck, DDS ______________ Phone:__602-256-6945_____
Address: 230 South 12th Avenue, Phoenix, AZ 85007______________________________
Notice to Department: MCDPH Grants/Contracts Unit Phone: (602) 506-1829
Address: 4041 N. Central Ave., Suite 1400, Phoenix, AZ 85007
IN WITNESS WHEREOF, the Parties enter into this Contract:
FOR AND ON BEHALF OF
CONTRACTOR : MARICOPA COUNTY
BY: BY:
Signature Chairman, Board of Supervisors
Mark Holleran, CEO
Type Name and Title ATTEST
Date Clerk of the Board
Date
APPROVED AS TO FORM: APPROVED AS TO FORM:
Attorney for Maricopa County
Date Date

SECTION I GENERAL PROVISIONS
1. EFFECT
To the extent the Special Provisions are in conflict with the General Provisions, the
Special Provisions shall control. To the extent the Work Statement(s) and the Special or
General Provisions are in conflict, the Work Statement(s) shall control.
2. DEFINITIONS
As used throughout this Contract, the following terms shall have the following meanings:
A. Contract means this document and all exhibits, attachments, appendices, and
amendments to this Contract.
B. Contractor means the person, firm, or organization listed on the Cover Page of
this Contract.
C. County means Maricopa County, Arizona.
D. Department means the Maricopa County Department of Public Health
(MCDPH).
E. Director means the Director of the Department.
F. Funding Source means any Federal, State, or Private Agency funding source
that may impose conditions on the funding that will be passed on to the
Contractor.
3. GENERAL REQUIREMENTS
A. The terms of this Contract shall be construed in accordance with Arizona law.
Any lawsuit arising out of this Contract shall be brought in the appropriate court in
Maricopa County, Arizona.
B. The Contractor shall, without limitation, obtain and maintain all licenses, permits,
and authority necessary to do business, render services, and perform work under
this Contract, and shall comply with all laws regarding Unemployment Insurance,
Disability Insurance, and Workers’ Compensation.
C. The Contractor is an independent Contractor in the performance of work and the
provision of services under this Contract and is not to be considered an officer,
employee, or agent of the County.
4. AMENDMENTS
All Amendments to this Contract shall be in writing and signed by the Parties.
5. ADEQUACY OF RECORDS
If the Contractor's books, records, and other documents relevant to this Contract are not
sufficient to support and document that allowable services were provided to eligible
persons, the Contractor shall reimburse the County for the services not sufficiently
supported and documented.
2

SECTION I GENERAL PROVISIONS
6. RETENTION OF RECORDS
A. This provision applies to all financial and programmatic records, supporting
documents, statistical records, and other records of the Contractor, which are
reasonably considered as relevant to this Contract.
B. The Contractor shall retain all financial books, records, and other documents
relevant to this Contract for five (5) years after final payment or until after the
resolution of any audit questions, which could take more than five (5) years,
whichever is longer. The County, Federal, or State auditors, and any other
persons duly authorized by the County, shall have full access to, and the right to
examine, copy, and make use of any and all such materials.
7. ASSIGNMENT / SUBCONTRACTING
No rights, liability, obligations, or duties under this Contract may be assigned, delegated,
or subcontracted without the prior written approval of the County.
8. AUDIT DISALLOWANCES
A. The Contractor shall, upon written demand therefore, reimburse the County for
any payments made under this Contract that are disallowed by a Federal, State,
or Maricopa County audit in the amount of the disallowance, as well as all
expenses, court costs, and attorney fees the County incurs in connection with
any legal action relating to such disallowance.
B. If, at any time, the County determines that a cost for which payment has been
made is a disallowed cost, the County shall notify the Contractor in writing of the
disallowance and the required course of action, which may be, at the option of
the County, either to adjust any future claim submitted by the Contractor by the
amount of the disallowance or to require repayment of the disallowed amount by
the Contractor.
9. CONTRACT COMPLIANCE MONITORING
The County shall monitor the Contractor's compliance with, and performance under, the
terms and conditions of this Contract. Announced or unannounced on-site visits for
Contract compliance monitoring may be made by the County and its grantor agencies at
any time during the Contractor's normal business hours. During the visit, the Contractor
shall make available for inspection and copying by the County, all records and accounts
relating to the work performed or the services provided under this Contract, or for similar
work and service provided under other grants and contracts.
10. AVAILABILITY OF FUNDS
A. The provisions of this Contract relating to payment for services shall become
effective when funds assigned for the purpose of compensating the Contractor,
as herein provided, are actually available to the County for disbursement. The
Director shall be the sole judge and authority in determining the availability of
funds under this Contract and the County shall keep the Contractor fully informed
as to the availability of funds.
3

SECTION I GENERAL PROVISIONS
B. If any action is taken by any State Agency, Federal Department, or any other
agency or instrumentality to suspend, decrease, or terminate its fiscal obligations
under or in connection with this Contract, the County may amend, suspend,
decrease, or terminate its obligations under or in connection with this Contract.
In the event of termination, the County shall be liable for payment only for
services rendered prior to the effective date of the termination, provided such
services are performed in accordance with the provisions of this Contract. The
County shall give at least ten (10) days prior written notice of the effective date of
any suspension, amendment, or termination under this section.
11. CONTINGENCY RELATING TO OTHER CONTRACTS AND GRANTS
A. The Contractor shall, during the term of this Contract, immediately inform the
County in writing of the award of any other contract or grant where the award of
such contract or grant may affect either the direct or indirect costs being paid or
reimbursed under this Contract. Failure by the Contractor to notify the County of
such award shall be considered a material breach of this Contract and the
County shall have the right to terminate this Contract without liability.
B. The County may request, and the Contractor shall provide within a reasonable
time, a copy of any other contract or grant when, in the opinion of the Director,
the award of the other contract or grant may affect the costs being paid or
reimbursed under this Contract.
C. If the County determines that the award to the Contractor of such other Federal
or State contract or grant has affected the costs being paid or reimbursed under
this Contract, the County shall prepare a Contract Amendment effecting a cost
adjustment. If the Contractor protests the proposed cost adjustment, the protest
shall be considered a dispute within the meaning of the "Disputes" clause
contained herein.
12. NON-APPROPRIATION OF FUNDS
Notwithstanding any other provision herein, this Contract may be terminated without
liability if the Maricopa County Board of Supervisors does not appropriate sufficient
monies for the purpose of maintaining this Contract.
13. DEFAULT
The County may suspend, modify, or terminate this Contract immediately upon written
notice to the Contractor in the event of a non-performance of stated objectives or other
material breach of contractual obligations; or upon the happening of any event that may
jeopardize the ability of the Contractor to perform any of its contractual obligations.
14. TERMINATION
A. The County or the Contractor may terminate this Contract at any time with at
least thirty (30) days prior written notice to the other Party. Such notice shall be
given by personal delivery or by Registered or Certified Mail, postage prepaid
and return receipt requested.
4

SECTION I GENERAL PROVISIONS
B. This Contract may be terminated by mutual written agreement of the Parties
specifying the termination date therein.
C. The County may terminate this Contract upon twenty-four (24) hours notice when
the County deems the health or welfare of any person is endangered or the
Contractor’s non-compliance jeopardizes funding source financial participation. If
not terminated by one of the methods stated above, this Contract shall terminate
on the expiration date of this Contract as stated on the Cover Page.
15. TERMINATION FOR BREACH
If either Party defaults under this Contract and the default continues for more than ten
(10) days after the effective date of the other Party’s written notice stating the specific
nature of the default, then the noticing Party may treat the default as a breach of this
Contract. Upon a breach, the aggrieved Party may exercise any remedy available under
the law, including the termination of this Contract.
16. SEVERABILITY
Any provision of this Contract that is determined by a court of competent jurisdiction to
be invalid, void, or illegal shall not affect, impair, or invalidate any other provision hereof,
and the remaining provisions shall remain in full force and effect.
17. STRICT COMPLIANCE
Acceptance by the County of performance not in strict compliance with the terms of this
Contract shall not be construed as a waiver of the requirement of strict compliance for all
future performance obligations. All changes in performance obligations under this
Contract shall be in writing.
18. NON-LIABILITY
The County and its officers and employees shall not be liable for any act or omission by
the Contractor or any subcontractor, employee, officer, agent, or representative of the
Contractor or subcontractors that occurs during the performance of this Contract, nor
shall they be liable for any purchases, debts, or agreements made by the Contractor in
anticipation of funding hereunder.
19. INDEMNITY
The Contractor agrees to indemnify, hold harmless, and defend the County, its officers,
employees, boards, and commissions, from and against any and all claims, damages,
lawsuits, and proceedings, regardless of the merits, and from any liability, punitive
damages, costs, and expense of every type, arising in whole or in part out of or in
connection with or by reason of any act or omission of the Contractor or any
subcontractors or anyone directly or indirectly employed by either the Contractor or any
subcontractors. Contractor and its Subcontractors shall reimburse the County for all
expenses, costs, and attorney's fees incurred for the defense of any litigation arising
from such claims. The Contractor shall include a clause to this effect in all subcontracts
inuring to the benefit of the Contractor or the County.
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SECTION I GENERAL PROVISIONS
20. COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or selling agency has been employed or
retained to solicit or secure this Contract upon an agreement or understanding for a
commission, percentage, brokerage, or contingent fee. For breach or violation of this
warranty, the County may terminate this Contract without liability.
21. SAFEGUARDING CLIENT INFORMATION
The use or disclosure by any Party of any information concerning an eligible person
served under this Contract is directly limited to the performance of this Contract.
22. RIGHTS IN DATA
The Parties shall have the use of data and reports resulting from this Contract without
cost or other restriction, except as may otherwise be provided herein or by law or
applicable regulation. Each Party shall supply to the other Party, upon request, any
available information known to the supplying Party that is relevant to this Contract and to
the performance hereunder.
23. NON-DISCRIMINATION
The Contractor, in connection with any service or other activity under this Contract, shall
not in any way discriminate against any person on the grounds of race, color, religion,
sex, national origin, age, or disability. The Contractor shall include a clause to this effect
in all Subcontracts inuring to the benefit of the Contractor or the County.
24. EQUAL EMPLOYMENT OPPORTUNITY
The Contractor shall not discriminate against any employee or applicant for employment
because of race, age, disability, color, religion, sex, or national origin. The Contractor
shall take affirmative action to ensure that applicants are employed and that employees
are treated during employment without regard to their race, age, disability, color, religion,
sex, or national origin. Such action shall include, but is not limited to, the following:
employment, upgrading, demotion or transfer, recruitment or recruitment advertising, lay-
off or termination, rates of pay or other forms of compensation, and selection for training,
including apprenticeship. The Contractor shall, to the extent such provisions apply,
comply with Titles VI and VII of the Federal Civil Rights Act; the Federal Rehabilitation
Act; the Age Discrimination in Employment Act; the Immigration Reform and Control Act
of 1986 (IRCA); and Arizona Executive Order 2009-09, which mandates that all persons
shall have equal access to employment opportunities. The Contractor shall also comply
with all applicable provisions of the Americans with Disabilities Act of 1990.
25. RIGHT OF PARTIAL CANCELLATION
If more than one activity is funded by this Contract, the County reserves the right to
terminate this Contract or any part thereof based on the Contractor's failure to
perform any part of this Contract without impairing, invalidating, or canceling the
remaining Work Statement obligations.
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SECTION I GENERAL PROVISIONS
26. RIGHT TO EXTEND CONTRACT
Subject to the availability of funds and acceptable Contractor performance, the
Contractor hereby acknowledges and agrees that the County shall have the right to
extend this Contract for additional one-year periods, not to exceed a total extended term
of five (5) years, except that the cost will be subject to renegotiation. Any extension of
this Contract shall be in a writing mutually acceptable to the Department and the
Contractor and signed by both Parties.
27. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
A. The undersigned (an authorized official signing for the Contractor) certifies to the
best of his or her knowledge and belief, that the Contractor, defined as the
primary participant in accordance with 45 CFR Part 76, and its principals:
1) are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered transactions by
any Federal Department or agency;
2) have not, within the 3-year period preceding this Contract, been convicted
of or had a civil judgment rendered against them for the commission of
fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (Federal, State, or local) transaction or
contract under a public transaction; or violated any Federal or State
antitrust statues; or committed embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or
receiving stolen property;
3) are not presently indicted or otherwise criminally or civilly charged by a
government entity (Federal, State, or local) with the commission of any of
the offenses enumerated in paragraph (2) of this certification; and
4) have not, within the 3-year period preceding this Contract, had one or
more public transactions (Federal, State, or local) terminated for cause of
or default.
B. If the Contractor is not able to provide this certification, an explanation as to why
shall be attached to this Contact.
C. The Contractor shall include, without modification, this clause in all lower tier
covered transactions (i.e. transactions with subcontractors) and in all solicitations
for lower tier covered transactions related to this Contract.
28. E-VERIFICATION OF EMPLOYEES
The Contractor warrants that it is in compliance with A.R.S. § 41-4401 and further
acknowledges:
A. That the Contractor and its subcontractors, if any, warrant their compliance with
all federal immigration laws and regulations that relate to their employees and
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SECTION I GENERAL PROVISIONS
their compliance with A.R.S. § 23-214, subsection A: after December 31, 2007,
every employer, after hiring an employee, shall verify the employment eligibility of
the employee through the e-verify program and shall keep a record of the
verification for the duration of the employee's employment or at least three years,
whichever is longer.;
B. That a breach of a warranty under subsection A above shall be deemed a
material breach of this Contract that entitles the County to, among other things,
terminate this Contract without liability;
C. That the County retains the right to inspect the papers of the Contractor and any
subcontractor employee who works on this Contract to ensure that the Contractor
and all subcontractors are complying with the warranty provided under
subsection A above, and that the Contractor shall make all papers and
employment records of said employee(s) available during normal working hours
in order to facilitate such an inspection.
D. That nothing herein shall make the Contractor or any subcontractor an agent or
employee of the County.
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SECTION II SPECIAL PROVISIONS
1. MEDIATION/ARBITRATION
In the event that any dispute arises out of this Contract or involves a recipient of services
under the terms of this Contract, the Parties shall meet and confer in an effort to resolve
the dispute. In the event that such efforts to resolve the dispute are unsuccessful, the
Parties shall resolve the dispute by arbitration pursuant to A.R.S. § 12-1518(A).
2. CHANGES
A. The Director may, at any time, by written order, make changes within the scope
of this Contract in any one or more of the following areas:
1). Work Statement activities reflecting changes in the scope of services,
Funding Source, or County regulations, policies, or requirements.
2). Administrative requirements, such as changes in reporting periods,
frequency of reports, or report formats required by funding source, or
County regulations, policies, or requirements.
3). Contractor reimbursement schedules and program budgets
B. The Director shall not increase or decrease the maximum reimbursable amount
to be paid the Contractor without an official amendment to this Contract.
Additionally, the Director shall not direct substantive changes in services to be
rendered by the Contractor.
C. Any dispute or disagreement caused by such written order shall constitute a
"Dispute" within the meaning of the Disputes Clause of the Special Provisions of
this Contract and shall be administered accordingly.
3. SPECIAL REQUIREMENTS
A. If the use of subcontractors is approved by County, the Contractor shall use
written subcontracts or consultant agreements that conform to Federal and State
laws and regulations, and to the requirements of this Contract appropriate to the
service or activity covered by the subcontract. These provisions apply with equal
force to the subcontract as if the subcontractor were the Contractor referenced
herein. The Contractor is responsible for performing under this Contract whether
or not Subcontractors are used. The Contractor shall submit a copy of each
Subcontract to the County within fifteen (15) days of its effective date.
B. The Contractor shall include in any subcontracts a provision to the effect that the
subcontractor agrees that the County shall have access to the subcontractor’s
facilities and the right to examine any books, documents, and records of the
subcontractor, involving transactions related to the subcontract and that such
books, documents, and records shall not be disposed of except as provided
herein.
4. INSURANCE
A. The Contractor shall have in effect at all times during the term of this Contract
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SECTION II SPECIAL PROVISIONS
insurance that is adequate to protect the County, its officers, employees,
participants, and equipment funded under this Contract against such losses as
are set forth below. The Contractor shall provide the County with current
documentation of insurance coverage by furnishing a Certificate of Insurance or
a certified copy of the insurance policy naming the County as an additional
insured.
B. The following types and amounts of insurance are required as minimums:
1.) Workers’ Compensation and Unemployment Insurance as required by
law.
2.) Unemployment Insurance as required by Arizona Law.
3.) Public liability, bodily injury, and property damage policies that insure
against claims for liability for the Contractor’s negligence or maintenance
of unsafe vehicles, facilities, or equipment brought by clients receiving
services pursuant to this Agreement and by lawful visitors of such clients.
The limits of the policies shall not be less than $2,000,000 per occurrence
and $4,000,000 aggregate.
C. Automobile and Truck Liability, Bodily Injury and Property Damages:
1.) General Liability, each occurrence; $1,000,000.00
2.) Property Damage; $1,000,000.00
3.) Combined single limit; $1,000,000.00
D. Standard minimum deductible amounts are allowable. Any losses applied
against insurance deductible are the sole responsibility of the Contractor.
E. Professional Liability:
1.) Insurance for the Contractor and its Agents, Employees, and other
Contractor Staff shall be maintained with coverage limits of one million
dollars ($1,000,000) per person, three million dollars ($3,000,000) per
occurrence.
2.) The Contractor agrees that in the event it, or any of its Agents,
Employees, or other Contractor Staff working under this Contract, is
named as a defendant in litigation, or is identified in a written notice of
claim wherein professional misconduct is alleged, the Contractor shall
promptly notify the Director in writing. The duty to notify under this
paragraph applies whether or not the County is claimed to be involved, is
named as a party to the matter, or could be potentially liable as a party.
F. The Contractor shall immediately inform the Director in writing of any cancellation
or its insurance or any decrease in its lines of coverage at least thirty (30) days
before such action takes place.
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SECTION II SPECIAL PROVISIONS
5. STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST
Notice is given that pursuant to A.R.S. § 38-511, the County may cancel this Contract
without penalty or further obligation within three years after execution of this Contract, if
any person significantly involved in initiating, negotiating, securing, drafting, or creating
this Contract on behalf of the County is at any time while this Contract or any extension
of this Contract is in effect, an employee or agent of any other Party to this Contract in
any capacity or consultant to any other Party of this Contract with respect to the subject
matter of this Contract. Additionally, pursuant to A.R.S. § 38-511, the County may
recoup any fee or commission paid or due to any person significantly involved in
initiating, negotiating, securing, drafting, or creating this Contract on behalf of the County
from any other Party to this Contract arising as the result of this Contract.
This Contract may be cancelled pursuant to A.R.S. § 38-511.
6. LAWS, RULES, AND REGULATIONS
The Contractor and the County understand and agree that this Contract is subject to all
applicable State and Federal laws, rules, and regulations.
A. Neither this Contract, nor any portion thereof, may be assigned to another person
by the Department without the written consent of the Contractor’s designated
representative. Any attempt by the Department to assign any portion of this
Contract without the written consent of the Contractor shall constitute a breach of
this Contract.
B. No assignment shall alter the Department’s responsibility to the Contractor to
assure that all of the provisions under this Contract are carried out by its
assignee. All terms and conditions in this Contract shall be included in the
Department’s assignments.
11

SECTION III WORK STATEMENT
CENTRAL ARIZONA SHELTER SYSTEMS
Homeless Dental Services
1. BACKGROUND
The Health Care for the Homeless (HCH) Program, located at 220 South 12th Avenue, Phoenix,
Arizona 85007, has been providing medical, behavioral and dental care to homeless individuals
since 1985. The HCH Program is funded by a grant from the Federal Health Services Resource
Administrations, Health and Human Services Division.
Homeless have several barriers to receiving dental care. They do not have a regular residence,
telephone, watches or transportation that assist other individuals in keeping appointments. In
addition, the homeless population often is not well groomed or bathed, which makes them less
desirable in a private dental setting. All of these factors limit the availability of dental services to
the homeless population,
Central Arizona Shelter Systems (CASS) operates a dental facility on the Human Services
Campus located at 230 South 12th Avenue, Phoenix, Arizona 85007. This facility operates
during the same hours of business as the HCH clinic, as well as a few evenings per week. The
clients served at the HCH clinic will be able to get service on a referral only basis because of the
close proximity of the two facilities.
2. OBJECTIVE
Eligible HCH clients will be assessed and referred for routine, extensive and emergency dental
services as funding permits. Dental services are valid for six months from the referral date.
3. SCOPE OF WORK
To provide a full array of routine dental services including dental examinations, dental x-rays,
dental cleanings, fluoride treatments, and restorative procedures such as amalgams and resin
fillings, space maintainers, routine extractions, stainless steel crowns, dentures and emergency
treatment for relief of pain and infection. Extensive dental treatment must be pre-authorized by
HCH.
4. TASKS
A. HCH shall perform the following:
1. HCH Case Managers will determine eligibility to receive dental services:
a. Client must be homeless.
b. Client must be currently receiving medical services from HCH
(extenuating cases can be submitted to the HCH for
consideration).
c. Client needs to have been screened for TB in last 6 months.
2. Clients who require PPD or Chest x-ray will be referred to an HCH nurse.
3. After determining eligibility, HCH Case Manager will refer client name to
the HCH Case Management Supervisor for appointment scheduling.
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SECTION III WORK STATEMENT
4. HCH Case Management Supervisor will contact CASS for a dental
appointment.
B. Contractor shall perform the following tasks within the acceptable scope of
practice permitted by law, utilizing established professional standards and clinic
policies, procedures and protocols:
1. Provide X-ray and routine examination of client at initial visit.
2. Prepare a treatment plan for the client, outlining the extent and cost of all
treatment including preventative care.
3. Submit a treatment plan to HCH for approval of treatment (prior to any
work being done on the patient).
4. Perform all approved procedures on the client, as evidenced by the HCH
approved treatment plan.
5. Present to HCH for payment an invoice of all procedures completed.
5. REPORTS
The Contractor shall:
A. Provide a copy of the treatment plan for each client within 2 working days of the
initial visit.
B. Provide a copy of the monthly appointment schedule for each client who was
seen during that month annotating what procedures were completed during the
month.
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SECTION IV COMPENSATION
1. COMPENSATION
A Subject to the availability of funds, HCH will reimburse Contractor for any
procedure approved and completed on treatment plans. Contractor will make
available to HCH 10 new patient appointments, weekly, up to the contract
maximum of $132,558 for the period 11/01/2014 to 10/31/15.
B. CASS shall charge HCH for each procedure based on the schedule of fees
attached to this contract.
C. CASS shall charge HCH for only those restorative procedures itemized on the
approved treatment plan.
2. METHOD OF PAYMENT
A. Contractor will submit an Expenditure Report for services performed at least
once a year before October 1st of the end of the contract period.
B. Subject to the availability of funds, County will, within sixty (60) working days
from the date of receipt of the documents enumerated herein, process and remit
to the Contractor a warrant for payment up to the maximum total allowable for
services provided or work performed during the contract period. Should County
make a disallowance in the claim, the claim shall be processed for the reduced
amount. If the Contractor protests the amount or the reason for a disallowance,
the protest shall be construed a dispute concerning a question of fact within the
meaning of the “Disputes” clause of the Special Provisions of this Contract.
C. The Contractor understands and agrees that County will not honor any claim for
payment submitted six months after date of service. The Contractor understands
and agrees that County will not process any claim for payment for services
rendered prior to the expiration date which are submitted sixty (60) days after the
expiration date without approval of County. For claims that are subject to
AHCCCS Regulation R9-22703.B1, County will not honor any claim for payment
submitted nine months after date of service.
D. Payments made by County to the Contractor are conditioned upon the timely
receipt of applicable, accurate and complete reports to be submitted by the
Contractor. All monthly expenditure reports must be supported by auditable
documentation that is determined to be sufficient, competent evidential matter
defined by the County.
E. Submit monthly invoice by hard copy or electronically to:
Heather Callies, HCH Supervisor
Healthcare for the Homeless
220 South 12th Avenue
Phoenix, AZ 85007
Telephone: 602-372-2101
Fax: 602-372-2107
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ATTACHEMENT A
CASS DENTAL CLINIC
DENTAL LICENSURE INFORMATION
Community Clinic Provider
Kris Volcheck Arizona Dental License #D3480

FEE SCHEDULE
Central AZ Shelter Services
Date: 09130/2014 Page: 1
CODE DESCRIPTION FEE 1 LAB EXPENSE MATERIAL
Cancelled Cancelled Appointment 0.00 0.00 0.00
0001 Photo / Phone Call to Lab 0.00 0.00 0.00
d0002 RE -treatment plan 60.00 0.00 0.00
D0003 Tx Plan Synopsis 0.00 0.00 0.00
00120 Pedo Exam 42.00 0.00 0.00
00140 Emergency Exam 66.00 0.00 0.00
O0145 Child Exam - under 3 years old 44.00 0.00 0.00
D0150 Comprehensive Exam 76.00 0.00 0.00
D0151 Pedo Exam 65.00 0.00 0.00
D0170 Limited re-evaluation estab pat 67.00 0.00 0.00
D0180 Peri° Evaluation 100.00 0.00 0.00
D0210 FMX - Complete Set 107.00 0.00 0.00
D0220 1 PA X-ray 24.00 0.00 0.00
D0230 Additional PAX-ray 21.00 0.00 0.00
D0240 Intraoral-occlusal film 37.00 0.00 0.00
D0250 Extraoral-first film 22.00 0.00 0.00
O0270 1 Bitewing 24.00 0.00 0.00
00272 2 Bitewing X-rays 39.00 0.00 0.00
D0273 3 Bitewings 48.00 0.00 0.00
D0274 4 Bitewing X-rays 57.00 0.00 0.00
00277 Vertical Bitewings 87.00 0.00 0.00
D0330 Panoramic X-ray 99.00 0.00 0.00
D0460 Pulp vitality tests 65.00 0.00 0.00
D0470 Diagnostic casts 60.00 0.00 0.00
D1110 Adult Cleaning 77.00 0.00 0.00
01120 Child Cleaning (under 12) 58.00 0.00 0.00
01201 Prophylaxis with fluoride-child 80.00 0.00 0.00
01203 Fluoride - Child 29.00 0.00 0.00
01204 Fluoride- Adult 29.00 0.00 0.00
01205 Prophylaxis with fluoride-adult 101.00 0.00 0.00
D1206 Fluoride Varnish 29.00 0.00 0.00
D1310 Nutritional counseling 35.00 0.00 0.00
D1330 Oral hygiene instruction 48.00 0.00 0.00
D1351 Sealant 45.00 0.00 0.00
D1352 Preventive Restoration, Perm Th 0.00 0.00 0.00
D1510 Space maint-fixed-unilateral 275.00 0.00 0.00
D1515 Space maint-fixed-bilateral 385.00 0.00 0.00
D2100 Final Impression 0.00 0.00 0.00
D2101 Seat Crown 0.00 0.00 0.00
02140 Amalgam- 1 Surface 108.00 0.00 0.00
02150 Amalgam -2 surface 142.00 0.00 0.00
02160 Amalgam -3 surface 168.00 0.00 0.00
D2161 Amalgam 4+ surface 204.00 0.00 0.00
D2330 Composite - Anterior 1 surface 150.00 0.00 0.00
D2331 Composite - Anterior 2 surface 185.00 0.00 0.00
O2332 Composite - Anterior 3 surface 240.00 0.00 0.00
02335 Composite - Anterior 4 surface 290.00 0.00 0.00
D2390 Resin composite crown, anterior 288.00 0.00 0.00
D2391 Composite -Posterior 1 surface 150.00 0.00 0.00
D2392 Composite -Posterior 2 surface 185.00 0.00 0.00
D2393 Composite -Posterior 3 surface 240.00 0.00 0.00
02394 Composite -Posterior 4 surface 290.00 0.00 0.00
D2544 Onlay-metallic-four + surfaces 1100.00 0.00 0.00
D2740 Crown-Zirconia/eMax 1200.00 0.00 0.00
02750 Crown -Porcelain Fused to Metal 925.00 150.00 0.00
02180 3/4 Gold Crown 970.00 0.00 0.00
02783 3/4 Porcelain Crown 1025.00 0.00 0.00
02790 Gold Crown 925.00 150.00 0.00
02791 Crown-full cast base metal 1200.00 0.00 0.00
O2910 Recement inlay/onlay/partial 92.00 0.00 0.00
02920 Recement Crown 92.00 0.00 0.00

FEE SCHEDULE
Central AZ Shelter Services
Date: 09/30/2014 Page: 2
CODE DESCRIPTION FEE 1 LAB EXPENSE MATERIAL
02930 Stainless Steel Crown- Baby Th 240.00 0.00 0.00
D2931 Stainless Steel Crown -Adult 284.00 0.00 0.00
D2932 Prefabricated resin crown 300.00 0.00 0.00
D2940 Sedative filling 110.00 0.00 0.00
D2950 Core Build Up 240.00 0.00 0.00
02951 Pin retention-/tooth, (+ rest) 60.00 0.00 0.00
02952 Cast post &core in add to crown 384_00 0.00 0.00
02954 Prefab Post & Core 285.00 0.00 0.00
D2955 Post removal (not with endo) 275.00 0.00 0.00
D2962 Veneer 1025.00 0.00 0.00
D2970 Temporary crown (fractured th) 300.00 0.00 0.00
D2980 Crown repair, by report 500.00 0.00 0.00
D3110 Pulp cap-direct, (+rest) 55.00 0.00 0.00
D3120 Pulp cap-indirect, (+ rest) 74.00 0.00 0.00
03220 Pulpotomy 165.00 0.00 0.00
03221 Pulp Debridement (Start RCT) 175.00 0.00 0.00
D3230 Pulpectomy - Front, Baby Tooth 350.00 0.00 0.00
D3240 Pulpectomy - Molar, Baby Tooth 350.00 0.00 0.00
03310 Finish Root Canal -Anterior 855.00 0.00 0.00
03320 Finish Root Canal - Bicuspid 855.00 0.00 0.00
03330 Finish Root Canal - Molar 855.00 0.00 0.00
D3333 Int root repair of perf defects 345.00 0.00 0.00
D3346 Retreat, prey RCT - anterior 707.00 0.00 0.00
D3347 Retreat, prey RCT - bicuspid 792_00 0.00 0.00
D3348 Retreat, prey RCT - molar 974.00 0.00 0.00
D3351 Apexification/recalcif, initial 90.00 0.00 0.00
D3354 Pulpal Regeneration-child-12 150.00 0.00 0.00
O3410 Apicoectomy/Periradic surg-ant 600.00 0.00 0.00
D3421 Apicoect/Perirad-bicus/1st root 600.00 0.00 0.00
D3425 Apicoect/Perirad-molaill St root 600.00 0.00 0.00
O3425 Apicoect/Perirad (each + root) 300.00 0_00 0.00
03430 Retrograde filling-per root 200.00 0.00 0.00
03450 Root amputation-per root 225.00 0.00 0.00
D3920 Hemisection, no root can ther 200.00 0.00 0_00
04210 Gingivectomy-4+ per quadrant 500.00 0.00 0.00
D4211 Gingivectomy-1-3 contig th/quad 167.00 0.00 0.00
D4220 Subgingiyal curettage-per quad 175.00 0.00 0_00
D4230 Anatomical crwn exp,4+teeth/qu 494_00 0.00 0.00
D4231 Anatomical crwn exp,1-3 thiquad 247.00 0.00 0.00
04240 Ging flap root pin, 4+ per quad 650.00 0.00 0.00
D4241 Ging flap it pin 1-3 cntg th/qu 217.00 0.00 0.00
D4242 Gingival Flap 2-3 Teeth 325.00 0.00 0.00
04249 Crown Lengthening 947.00 0.00 0.00
D4260 Osseous Surgery Per/Tooth 1400.00 0.00 0.00
D4261 Osseous surg- 1-3 contg th/quad 900.00 0.00 0.00
O4263 Bone Grafting 800.00 0.00 0.00
D4264 Bone replace graft-each add/qu 115.00 0.00 0.00
D4265 Bio mat, sft&osseous liss regen 450.00 0.00 0.00
D4266 Guided tiss regen-resorb-per 500.00 0.00 0.00
D4267 Guided tiss regen-nonresorb-per 500.00 0.00 0.00
O4268 Surg revision proc, per tooth 450.00 0.00 0.00
04270 Pedicle soft tissue graft proc 800.00 0.00 0.00
04271 Free soft tissue graft proced 800.00 0.00 0.00
04273 Subepithelial con tis graft/th 850.00 0.00 0.00
D4274 Distal/proximal wedge procedure 300.00 0_00 0.00
04341 SRP - per Quadrant 225.00 0.00 0.00
04342 SRP - 1-3 teeth 125.00 0.00 0.00
D4355 Full Mouth Debridemnt 175.00 0.00 0_00
D4910 Periodontal Maintenance 118.00 0.00 0.00
D5104 Overdenture Amalgam Cap 216.00 0.00 0.00
05105 Wax Bite Rims / Metal Framework 0.00 0.00 0.00

FEE SCHEDULE
Central AZ Shelter Services
Date: 09/30/2014 Page: 3
CODE DESCRIPTION FEE 1 LAB EXPENSE MATERIAL
05106 Wax Try-in 0.00 0.00 0.00
D5107 Deliver Denture 0.00 0.00 0.00
D5108 Deliver Partial 0.00 0.00 0.00
05110 Upper Denture - Initial Imp. 1500.00 250.00 0.00
D5120 Lower Denture - Initial Imp. 1500.00 250.00 0.00
D5130 Immediate Upper Denture /imp 2000.00 250.00 0.00
D5140 Immediate Lower Denture / Imp 2000.00 250.00 0.00
05211 Maxillary partial - Impression 1500.00 350.00 0.00
D5212 Mandibular partial - Impression 1500.00 350.00 0.00
D5213 Upper Partial Denture - Imp 1525.00 350.00 0.00
D5214 Lower Partial Denture - Imp 1525.00 350.00 0.00
05225 Upper Valplast 1500.00 0.00 0.00
05226 Valplast Lower 1500.00 0.00 0.00
D5410 Adjust Upper Denture 80.00 0.00 0.00
05411 Adjust Lower Denture 80.00 0.00 0.00
D5421 Adjust Upper Partial 80.00 0.00 0.00
D5422 Adjust Lower Partial 80.00 0.00 0.00
05510 Repair Broken Denture 500.00 100.00 0.00
05520 Replace Tooth on Denture 154.00 100.00 0.00
D5610 Repair Chipped Denture 350.00 100.00 0.00
D5620 Repair cast framework 252.00 100.00 0.00
D5630 Repair Broken Clasp on Partial 228.00 100.00 0.00
05640 Replace tooth on Partial 156.00 100.00 0.00
05650 Add tooth to exist part denture 198.00 100.00 0.00
D5660 Add clasp, exist part denture 240.00 100.00 0.00
D5710 Rebase complete maxil denture 499.00 100.00 0.00
D5711 Rebase complete mand denture 500.00 100.00 0.00
05720 Rebase maxil partial denture 481.00 100.00 0.00
D5721 Rebase mand partial denture 481.00 100.00 0.00
05730 Reline Upper Soft 250.00 0.00 0.00
05731 Reline Lower Soft 250.00 0.00 0.00
05740 Reline maxil partial-chairside 330.00 0.00 0.00
D5741 Reline nnand partial-chairside 330.00 0.00 0.00
05750 Reline Upper Denture-Lab 500.00 100.00 0.00
05751 Reline Lower Denture-Lab 400.00 100.00 0.00
05760 Reline Upper Partial 419.00 0.00 0.00
05761 Reline Lower Partial 419.00 100.00 0.00
D5810 Interim comp denture (maxil) 721.00 100.00 0.00
05811 Interim comp denture (mand) 754.00 100.00 0.00
D5820 Upper Flipper 601.00 100.00 0.00
D5821 Lower Flipper 601.00 100.00 0.00
05850 Tissue condition - Upper 85.00 0.00 0.00
D5851 Tissue condition - Lower 85.00 0.00 0.00
D5860 Overdenture- initial impression 1900.00 350.00 0.00
D5861 Over - Partial 1900.00 0.00 0.00
D5862 Implant Attachment 550.00 100.00 0.00
05867 ERA/Zest Replacement 450.00 0.00 0.00
D5992 Adj Max'facial Prosth, Report 0.00 0.00 0.00
D5993 Maint Max'facial Prosth, Report 0.00 0.00 0.00
D6000 Seat Bridge 0.00 0.00 0.00
D6010 Implant 2000.00 0.00 0.00
06053 Implant Overdenture 2500.00 0.00 0.00
D6056 Abutment - Prefabricated Stock 650.00 0.00 0.00
D6058 Implant Crown - Porcelain 1400.00 0.00 0.00
D6059 Implant Crown - PFM 1350.00 0.00 0.00
D6062 Implant Crown - Gold 1350.00 0.00 0.00
06080 Implant Maintenance 150.00 0.00 0.00
D6091 Rpl Overdenture lnsert/Attchmnt 260.00 0.00 0.00
D6190 CT scan for implants 250.00 0.00 0.00
06195 Healing Abutment 300.00 0.00 0.00
D6210 Pontic - Gold 925.00 150.00 0.00

FEE SCHEDULE
Central AZ Shelter Services
Date: 09/30/2014 Page: 4
CODE DESCRIPTION FEE 1 LAB EXPENSE MATERIAL
D6240 Pontic - PFM 925.00 150.00 0.00
D6241 Pontic-porcelain fused to base 600.00 0.00 0.00
D6245 Pontic - Zirconia/eMAx 1200.00 0.00 0.00
06254 Interim Pontic 0.00 0.00 0.00
06545 MARYLAND BRIDGE(metal wings) 520.00 0.00 0.00
06548 MARYLAND BRIDGE(pontic) 950.00 0.00 0.00
06740 Bridge Abutment Zirconia/eMax 1200.00 0.00 0.00
06750 Bridge Abutment/Retainer - PFM 925.00 150.00 0.00
D6790 Bridge Abutment/Retainer - Gold 925.00 150.00 0.00
06795 Interim Retainer Crown 0.00 0.00 0.00
06930 Recement Bridge 400.00 0.00 0.00
06950 Precision attachment 620.00 150.00 0.00
D6972 Prefab Post under Bridge 285.00 0.00 0.00
D6973 Core Buildup Under Bridge 240.00 0.00 0,00
D7140 Extraction 145.00 0.00 0.00
D7210 Extraction - Surgical 235.00 0.00 0.00
D7220 Extraction - Soft Tissue Impact 275.00 0.00 0.00
D7230 Extraction - Part Bony 350.00 0.00 0.00
D7240 Extraction - Full Bony 450.00 0.00 0.00
07241 Extraction - Impacted/Complex 525.00 0.00 0.00
07250 Extraction - Root Tip 200.00 0.00 0.00
07251 Coronectomy-part tooth removal 0.00 0.00 0.00
07257 Post-op 0.00 0.00 0.00
D7260 Oral antral fistula closure 1300.00 0.00 0.00
D7261 Prim closure sinus perforation 1300.00 0.00 0.00
D7286 Biopsy of Soft Tissue 250.00 0.00 0,00
07310 Alveoloplasty w/ Extractions 260.00 0.00 0.00
D7311 Alveoloplasty w/ext 1-3 th/quad 150.00 0.00 0.00
D7320 Alveoloplasty without Exts 390.00 0.00 0.00
D7321 Alveoloplsty w/o ex 1-3 th/quad 550.00 0.00 0,00
07350 Vestiplasty-ridge ext (inc) 638.00 0.00 0.00
07472 Removal of torus palatinus 473.00 0.00 0.00
D7473 Removal of torus mandibularis 473.00 0.00 0.00
D7510 Incise & Drain - Intraoral 200.00 0.00 0.00
D7530 Removal of Foreign Body -Tissue 325.00 0.00 0.00
D7960 Frenulectomy-separate procedur 218.00 0.00 0.00
08090 Orthodontics/Braces - Adult 5600.00 0.00 0.00
08680 Orthodontic Retention/Retainer 450.00 0.00 0.00
09110 Emergency Pallative Treatment 110.00 0.00 0.00
09230 Nitrous Oxide 100.00 0.00 0.00
09248 Non IV conscious sedation 0.00 0.00 0.00
09310 Consultation 110.00 0.00 0.00
D9311 Consult with Dr. V 110.00 0,00 0.00
d9312 Implant Consult 150.00 0.00 0.00
09313 Consult with Harold/Dr. Scafaru 110.00 0.00 0.00
09315 Consult with Dr. Rushlo 110.00 0.00 0.00
09430 Office Visit 40.00 0.00 0.00
09440 Office visit-after regular hrs 144.00 0,00 0.00
09450 Treatment Plan Presentation 50.00 0.00 0.00
D9910 Application of desensitize med 12.00 0.00 0.00
09911 Apply desensitiz resin, per th 35.00 0.00 0.00
09920 Behavior management, by report 60.00 0.00 0.00
09940 Night Guard 420.00 0.00 0.00
09941 Fabricate athletic mouthguards 216.00 0.00 0.00
09943 Deliver Night Guard 0.00 0.00 0.00
D9951 Occlusal adjustment-limited 155.00 0.00 0.00
D9952 Occlusal adjustment-complete 617.00 0.00 0.00
09971 Odontoplasty 1-2 teeth-rmv enann 60.00 0.00 0.00
09972 Custom Tray/Bleach Tray 150.00 0.00 0.00
09991 Oral Cancer ScreeningNelscope 60.00 0.00 0.00
Missed Missed Appointment 0.00 0.00 0.00

FEE SCHEDULE
Central AZ Shelter Services
Date: 09/30/2014 Page: 5
CODE DESCRIPTION FEE 1 LAB EXPENSE MATERIAL
Reschedul Rescheduled Appointment 0.00 0.00 0.00
werkyqs,. Qw3rkyuq 87.00 0.00 0.00
07110 Suture Removal 0.00 0.00 0.00
07120 Extraction Additional 120.00 0.00 0.00
15000 Drifting - Mesial 0.00 0.00 0.00
15001 Drifting - Distal 0.00 0.00 0.00
15002 Impacted - Distal 0.00 0.00 0.00
15003 Impacted - Mesial 0.00 0.00 0.00
15004 Bleeding 0.00 0.00 0.00
15006 Gum Abscess 0.00 0.00 0.00
15009 Watch Tooth 0.00 0.00 0.00
15011 Hypersensitivity 0.00 0.00 0.00
15012 Recession 0.00 0.00 0.00
15101 Missing tooth 0.00 0.00 0.00
15104 Cavity 0.00 0.00 0.00
15108 Failing Filling 0.00 0.00 0.00
15110 Fractured Tooth 0.00 0.00 0.00
15111 Residual Root Tip 0.00 0.00 0.00
15114 Unerupted tooth 0.00 0.00 0.00
15115 Root Abscess 0.00 0.00 0.00
15116 Supereruption 0.00 0.00 0.00