AMENDMENT RE TUBERCULOSIS CONTROL PROGRAM WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS13-042100 Amendment No. I
Jacqueline Ortega-Avila
TUBERCULOSIS CONTROL
Effective January 1, 2014, it is mutually agreed that the Intergovernmental Agreement referenced is amended as
follows:
1. Pursuant to Page Three (3), Terms and Conditions, Provision Four (4), Contract Administration and Operation, Item
(4.12), Scrutinized Businesses, is deleted in its entirety.
2. Pursuant to Page Seven (7), Terms and Conditions, Provision Six (6), Contract Changes, Item (6.1), Amendments,
Purchase Orders and Change Orders; the Contract Price Sheet Effective January 1, 2013 is replaced with the
Revised Price Sheet January 1, 2014 of this Amendment. Pricing will be updated in the ProcureAZ 'Items Tab" to
reflect the pricing upon execution of this Amendment,
(CONTINUED ON NEXT PAGE)
ALL OTHER PROVISIONS OF THIS AGREEMENT REMAIN UNCHANGED.
CONTRACTOR SIGNATURE
Maricopa County Department of Public Health
Contractor Name Contractor Authorized Signature
4041 North Central Avenue, Suite #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.& § 11-952, the undersigned public agency attorney has date indicated. The Public Agency is hereby cautioned not to commence
determined that this Intergovernmental Agreement is in proper form and is any billable work or provide any material, service or construction under
within the powers and authority granted under the laws of the State of this IGA until the IGA has been executed by an authorized ADHS
Arizona. signatory.
State of Arizona
Signed this day of 2013
Signature Date
Printed Name Procurement Officer
RESERVED FOR USE BY THE SECRETARY OF STATE
Attorney General Contract No. P0012012000033, 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 authority was amended to remove the requirement
granted under the laws of the State of Arizona. that Intergovernmental Agreements be tiled
with the Secretary of State.
Signature Date
Assistant Attorney General
Printed Name:
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
4111111116, 1740W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT Phoenix, Arizona 85007
(602) 5424040
(602) 542-1741 Fax
Contract No: ADHS13-042100 Amendment No. 1 Procurement Specialist
Jacqueline Ortega-Avila
2.1 Personnel Services and ERE shall increase by $26,706.00 to reflect the new total amount of $265,969.00.
2.2 Professional and Outside Services shall remain the same.
2.3 Travel Expenses shall decrease by $1,979.00 to reflect the new total amount of $35,088.00.
2.4 Other Operating Expenses shall increase by $8,499.00 to reflect the new total amount of $8,500.00.
2.5. Capital Outlay Expenses shall remain the same.
2.6 Other shall increase by $2,774.00 to reflect the new total amount of $46,434.00.
2.7 The new Contract total is $355,991.00
3. Pursuant to Page Twelve (12), Terms and Conditions, Provision Fifteen (15), Fingerprint and Certification
Requirements/Juvenile Services, is deleted in its entirety.
4. Pursuant to Page Twelve (12), Terms and Conditions, Provision Eighteen (18), Health Insurance Portability and
Accountability Act of 1996 (HPAA) 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 Strategic
Enterprise Technology (ASET) Office, Statewide Information Security and Privacy Office (SISPO) Chief
Privacy 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 ASET /SISPO Chief
Privacy Officer and HIPAA Coordinator.
5. Pursuant to Page Thirteen (13), Terms and Conditions, Provision Twenty (20) is added as follows:
20. Data Universal Numbering System (DUNS) Number Requirement
Pursuant to 2 CFR 25.100 et seq., no entity (defined as a Governmental organization, which is a State, local
government, or Indian tribe; foreign public entity; domestic or foreign nonprofit organization; domestic or
foreign for-profit organization; or Federal agency, but only as a subrecipient under an award or subaward to a
non-Federal entity) may receive a subaward from ADHS unless the entity provides its DUNS Number to
ADHS.
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ARIZONA DEPARTMENT OF
to =le HEALTH SERVICES
1740W. Adams, Room 303
0 RT 0EUS INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT Phoenix, Arizona 85007
(602) 542-1040
. (602) 542-1741 Fax
Contract No: ADHS13-042100 Amendment No. 1 Procurement Specialist
Jacqueline Ortega-Avila
TUBERCULOSIS CONTROL
REVISED PRICE SHEET
EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014
ACCOUNT CLASSIFICATION AMOUNT
1. Personnel Services and ERE $265,969.00
2. Professional and Outside Services $0.00
3. Travel Expenses $35,088.00
4. Other Operating Expenses $8,500.00
5. Capital Outlay Expenses $0.00
6. Other $46,434.00
TOTAL $355,991.00
LINE ITEM BUDGET TRANSFERS
With prior approval from the ADHS TB Program Manager, the contractor is authorized to transfer up to a
maximum of 35% of the total budget amount between line items. Transfers of funds are only allowed
between funded line items. Transfers exceeding 35% or to a non-funded item shall require an
amendment.
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