AGREEMENT RE SUBSCRIPTION AGREEMENT WITH AHCCCS.PDF

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
1. AMENDMENT #: 2. CONTRACT #: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
1 YH14-0005-036 December 5, 2013 DMS
5. CONTRACTOR/PROVIDER NAME AND ADDRESS:
Maricopa County
301 W. Jefferson, 10 th Floor
Phoenix, AZ 85003
6. PURPOSE:
To modify the contact information, address, signatory, user seats and fees.
7. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:
The subscriber specific information listed on the first page of the agreement is hereby removed and replaced with
the following:
1. SUBSCRIBER SPECIFIC INFORMATION
Subscriber Name: Maricopa County
Subscriber Address: 301 W. Jefferson, 10th Floor
Phoenix, AZ 85003
Agreement Contact Person, Phone and Email: Jennifer Hawkins (same address as above)
602-506-1968
hawkinsi002@mail.maricopa.gov
Billing Contact Person, Phone and Email: Jane E. Cochrane
(same address as above)
602-372-2109
janecochrane@mail.maricopa.gov
Set up Fee: $0.00
Subscription and Maintenance Fee: $200.00 per month for # 21-30 user seats
(Includes Transaction Fees)
Plan A / Plan B Plan A
Organization type: AHCCCS Registered Medical Provider or Contractor (RBHA, Health
Plan, FQHC, Hospital, other clinic or medical provider).
Subscription Restrictions: The subscriber understands that this subscription is for:
Subscriber's client services at all locations and for use in eligibility
screening at Maricopa County Public Health, Sheriff's Office,
Correctional Health Services and Adult Probation facilities
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NOTE: Please sign, date and return one scanned copy to: Jennifer Roberts
Jennifer.Robertspazahcccs.aov
Electronic Submission: An electronic or portable document file (PDF) copy of this amendment shall serve as the original.
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL AGREEMENT NOT HERETOFORE CHANGED AND/OR
AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.
9. NAME OF CONTRACTOR/PROVIDER: 10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
Maricopa County
SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
TYPED NAME: TYPED NAME:
Jennifer Hawkins ggan Harley, CPPO, MSW
TITLE: TITLE:
Health Care Services Integration Administrator Procurement and Contracts Manager
DATE: DATE: g /3
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