IGA AMD RE FLUORIDE VARNISH WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT (602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS13-031613 Amendment No. 2
Sue-Anne Tan
Fluoride Varnish Services
Effective August 1, 2014, it is mutually agreed that the IGA referenced is amended as follows:
1. The current Price Sheet of the IGA is replaced with the attached revised Price Sheet of this Amendment Two (2).
The IGA Item Pricing shall be revised in ProcureAZ to align with available funding upon execution of this
Amendment Two (2). The IGA budget total increased from $179,749.00 to $257,429.00 based on the following
line item changes:
1.1 Personnel increased by $124,228.00 for a total of $156,993.00 due to transitioned all of the contracted
dental staff previously under "professional and outside services" to temporary Maricopa County
employees. Additional 2 hygienists and 2 site assistants;
1.2 ERE increased by $24,135.00 for a total $39,219.00 due to additional employees;
1.3 Professional & Outside Services decreased by $78,140.00 for a total of $2,500.00 due to previously
contracted employees are now Maricopa County employees.
All other provisions of this agreement remain unchanged.
CONTRACTOR SIGNATURE
Maricopa County Health Department
Contractor Name Contractor Authorized Signature
4041 North Central Avenue, Suite 600
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 _______________________ 2014
Signature Date
Printed Name Procurement Officer
RESERVED FOR USE BY THE SECRETARY OF STATE
Attorney General Contract No. P0012014000078, which is an
Agreement between public agencies, has been reviewed pursuant to Under House Bill 2011, A.R.S. § 11-952
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 was amended to remove the requirement
authority granted under the laws of the State of Arizona. that Intergovernmental Agreements be filed
with the Secretary of State.
Signature Date
Assistant Attorney General
Printed Name:
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT (602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS13-031613 Amendment No. 2
Sue-Anne Tan
1.4 Travel Expenses increased by $543.00 for a total of $1,344.00 due to increase in traveling;
1.5 Operating Expenses increased by $3,452.00 for a total of $33,970.00 due to additional rent and program
supplies are needed to provide services;
1.6 Other Expenses decreased by $3,600 to $0.00 due to no equipment will be purchased during FY15; and
1.7 Indirect (if authorized) increased by $7,062.00 for total of $23,403.00 due to budget changes.
2. Delete in its entirety, Terms and Conditions, Provision Eighteen (18), and replaced with the following:
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
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT (602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS13-031613 Amendment No. 2
Sue-Anne Tan
PRICE SHEET
As of August 1, 2014
Maricopa County Public Health
Cost Reimbursement Line Item Budget
ACCOUNT CLASSIFICATION AMOUNT
Personnel Services $156,993.00
ERE $39,219.00
Professional & Outside Services $2,500.00
Travel Expenses (In state) $1,344.00
Operating Expenses $33,970.00
Other $0.00
Indirect (If authorized) 10% $23,403.00
Total Contract Amount $257,429.00
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 an Amendment.
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