PROVIDER PARTICIPATION AGREEMENT WITH AHCCCS.PDF

PROVIDER PARTICIPATION AGREEMENT
Between
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ("AtICCCS")
and
Provider Name: hlarteopa County Department a Public Health. blea Intaricupu County ()apartment of Health Services dbe Public Health Clinical (Laboratory)
SSN/Tax ID# : 86600472
Business Address: 1645 E Roosevelt Street
City/State/Zip: Phoenix, Arizona 85006
Email Address: FrancesDelgado@mail,mancopa,gov
(Correspondence)
A. PURPOSE:
This Agreement between AHCCCS and the Provider is made pursuant to Title XIX and Title XXI of the Social
Security Act and A.R.S. §36-290I et seq. to govern: (I) the registration and payment for the health care
services provided by the Provider to fee-for service eligible persons who are not enrolled with a Contractor
under contract with AF1CCCS ("Contractor") or who receive emergency services only, (2) the registration for a
Provider to participate and deliver health care services to eligible persons who are enrolled with a Contractor,
and (3) the registration of a Provider who wishes to participate and qualify under the one-time only waiver
option.
Therefore, in consideration of the covenants contained in this Agreement:
B. GENERAL TERMS AND CONDITIONS:
1. Pursuant to 42 C.F.R. §431.107, Provider is prohibited from participation in the AHCCCS system
unless a provider agreement with the Administration is in effect. Provider may not enter into or
continue any contracts for the delivery of health care services to any AHCCCS eligible person with
any Contractor if this Agreement is terminated. Furthermore, AHCCCS will not pay the Provider
for any services rendered if there is no Agreement in effect at the time a claim is submitted.
2. When AHCCCS issues an amendment to modify this Agreement or to modify documents
incorporated by reference as part of this Agreement, the provisions of such amendment will be
deemed to have been accepted thirty (30) days after the date AHCCCS provides notice to the
Provider, even if the amendment has not been signed by the Provider. If the Provider gives written
notice of refusal of the amendment to AHCCCS prior to the end of the (thirty) 30 days stated above,
this Agreement shall terminate.
3. Pursuant to 42 C.F.R §447.10, payment for any service furnished to an AHCCCS eligible person by
Provider will not be made to or through a factor, either directly or by power of attorney.
4. The Provider shall maintain all records relating to performance of this Agreement in compliance
with all specifications for record-keeping established by AHCCCS. All books and records shall be
maintained in such detail as to reflect each service provided and all other costs and expenses of
whatever nature for which payment is made to the Provider. Such material shall be subject to
inspection, audit or copying by the state, AHCCCS, the U.S. Department of Health and Human
Services, and any other duly authorized representative of the state or federal governments during
normal business hours at the Provider's place of business. The ABCCCS Office of Inspector
General ("AHCCCS-OIG") reserves the right to request and secure original records from Provider at
Provider's expense. The AHCCCS-01G shall be responsible for maintaining and safeguarding the
integrity of these records, and will provide Provider with sufficient time to copy records for
Provider's use.

5. The Provider shall preserve and make available the records described in Paragraph 4 above for a
period of five (5) years from the date of payment under this Agreement, except: (a) if this
Agreement is terminated, the records shall be preserved and made available for a period of five (5)
years from the date of any such termination; (b) records which relate to disputes, appeals, litigation
or the settlement of claims arising out of this Agreement, or costs and expenses of this Agreement to
which exception has been taken by the state, shall be retained by the Provider until such disputes,
appeals, litigation, claims or exceptions have been fully and completely resolved. The Provider shall
comply with all applicable AHCCCS rules and policies relating to the audit of the Provider's records
and the inspection of the Provider's facilities. If the Provider is an inpatient facility, the Provider
shall file uniform reports and Title XVIII and XIX cost reports with AHCCCS.
6. The Provider shall comply with all federal, state and local laws, rules, regulations, standards, and
executive orders governing performance of duties under this Agreement, without limitation to those
designated within this Agreement.
7. The Provider shall comply with all AHCCCS and/or Contractor Provider Manuals and Policy
Guidelines, including the AHCCCS Minimum Subcontract provisions found on the AHCCCS public
website, and any amendments thereto, all of which are incorporated by reference into this
Agreement.
8. The Provider, by execution of this Agreement, warrants that it has the ability, authority, skill,
expertise and capacity to perform the services specified in this contract. The Provider shall obtain
and maintain all licenses, permits and certifications necessary to do business and render services
under this Agreement and, where applicable, shall comply with all laws regarding safety,
unemployment insurance, disability insurance and worker's compensation. The Provider shall notify
the AHCCCS Administration within twenty-four (24) hours of a termination or suspension of its
license.
9. The Provider agrees to hold harmless the state, all state officers and employees, AHCCCS, and any
other applicable state agencies, and all officers and employees of AHCCCS against all injuries,
deaths, losses, damages, claims, suits, liabilities, judgments, costs and expenses which may, in any
manner, accrue against the State, AHCCCS, its agents, officers, or employees or AHCCCS
Contractors, through the intentional conduct, negligence or omission of the Provider and its agents,
officers or employees.
10. The Provider expressly acknowledges and agrees that AHCCCS is in no way establishing any sort of
employment relationship with Provider through this Agreement. The Provider is not the employee
of AHCCCS. AHCCCS bears no responsibility for taxes, unemployment insurance, or workers
compensation on behalf of the Provider.
11. The Provider shall maintain for the duration of this Agreement all necessary policies of professional
liability insurance, comprehensive general liability insurance and automobile liability insurance.
The Provider agrees that any insurance protection required by the Agreement, or otherwise obtained
by the Provider, shall not limit the responsibility of Provider to indemnify, hold harmless and defend
the State and AHCCCS, and their agents, officers and employees as provided herein. The Provider
bears all responsibility for taxes, worker's compensation insurance, unemployment insurance, and
any other applicable insurance coverage for itself and its employees.
12. Confidential and protected health information shall be safeguarded pursuant to all federal and state
laws and regulations,
13. Any appeals or claim disputes filed by the Provider shall be adjudicated in accordance with
AHCCCS rules as published in the Arizona Administrative Code. The Provider agrees to waive
attorneys' fees in any dispute concerning this Agreement.
2

14. For Fee-For-Service Providers, AHCCCS agrees to make payments to the Provider, consistent with
State and Federal Law, the terms of this Agreement, and the AHCCCS Capped Fee-For-Service
Payment Schedule (including amendments thereto and as hereby incorporated by reference) for
services provided by the Provider to fee-for-service eligible persons. With respect to fee-for-service
eligible persons, the Provider agrees to bill and accept payment in accordance with the terms of this
Agreement, state and federal law, and the following documents, including amendments thereto and
hereby incorporated by reference: the AHCCCS Fee-for-Service Manuals, the AHCCCS Medical
Policy Manual, AHCCCS Claims Clues and other written directives provided by AHCCCS to the
Provider. These documents are made available to the provider via the AHCCCS Internet website
(www.azahcccs.gov) or in hard copy form.
15. With respect to any services furnished by the Provider to an AHCCCS eligible person enrolled with
a Contractor, the terms and conditions of payment shall be as set forth in the contract between the
Provider and the Contractor notwithstanding any inconsistent provisions as set forth in Paragraph 14,
above. The Provider agrees to hold AHCCCS harmless, and agrees not to seek reimbursement from
AHCCCS, for services rendered to an enrolled member pursuant to a contract between the Provider
and a Contractor. If the contract is silent on a claims issue, the AHCCCS Fee-For-Service
provisions will govern.
16. Provider shall conform its billing practices to ICD9 or ICD 10, whichever is in effect on date of
service, CPT, HCPCS, CDT and H1PAA TCS compliance standards. Upon request, Provider shall
disclose to AHCCCS which CPT and/or CDT coding guidelines Provider uses prior to any audit of
Provider. Any Provider changes to its methodology shall be documented with the date of change.
17. Provider shall ensure that its Electronic Health Records System (EHR) is programmed to track and
capture any changes or modifications to the electronic health record.
18. The Provider agrees to bill AHCCCS only after a potential third party payer has been billed. After
payment from any potential third party payer, the Provider agrees to bill AHCCCS the balance due
only up to the limit of the member's responsibility.
19. No Provider may bill with another Provider's ID number, except in locum tenens situations.
20. No Provider may use the AHCCCS/ALTCS/KidsCare or any other AHCCCS program logo or
design on any written materials disseminated by Provider, absent written approval by AHCCCS.
21. In addition to any other remedies available under this Agreement, AHCCCS shall be entitled to
offset against any amounts due the Provider any overpayments, expenses or costs incurred by
AHCCCS concerning the Provider's non-compliance with this Agreement. AHCCCS also retains
the right to offset for Medicare sanctions. Provider may be held financially liable for acts committed
by its independent contractors that would constitute non-compliance with this Agreement. The rights
and remedies of AHCCCS under this Agreement are not exclusive.
22. The Provider shall not bill, nor attempt to collect payment directly or through a collection agency
from a person claiming to be AHCCCS eligible without first receiving verification from AHCCCS
that the person was ineligible for AHCCCS on the date of service, or that services provided were not
AHCCCS-covered services. The Provider agrees to comply with A.R.S. §36-2903.01 and A.A.C.
R9-22-702, which prohibits the Provider from charging, collecting or attempting to collect payment
from an AHCCCS eligible person or the financially responsible relative or representative. AHCCCS
retains the right to offset against any amounts due the Provider, if Provider fails to comply with the
rules and regulations governing the billing of AHCCCS eligible persons.
23. Pursuant to the Federal Fraud Enforcement and Recovery Act of 2009 (FERA), AHCCCS defines a
"claim" for purposes of fraud enforcement and recovery to mean "a request or demand for money or
property that is presented to the government, state, contractor, grantee or other recipient, if the
money or property is to be spent or used on the government's behalf or to advance the government's
interest".
24. Any Provider who receives or makes annual Medicaid payments under the State Plan of at least $5
million dollars must certify its compliance with Public Law (PL) 109-171 Section 6032 of the 2005
Deficit Reduction Act (DRA) [42 U.S.C. §I396a(a)(68)].
3

25. If Provider or any employee or contractor of Provider discovers, or is made aware, that an incident
of potential fraud or abuse has occurred, the Provider shall report the incident to the AHCCCS
Office of Inspector General (AHCCCS OIG) in accordance with state statutes and AHCCCS policy.
26. By signing this Agreement, Provider certifies that it is in compliance with State Medicaid Director
Letter (SMDL) 09-001 and has screened all its employees and contractors for persons that have been
excluded from participation in Federal health care programs.
27. Pursuant to Section 6505 of the Affordable Care Act of 2010 [42 U.S.C. §1396a(a)(80)1, AHCCCS
shall not make any payments for items or services provided under the State Plan or under a waiver to
any financial institution or entity located outside of the United States (U.S.).
28. Pursuant to Section 6402 of the Affordable Care Act of 2010, if Provider has received an
overpayment, Provider shall report and return the overpayment to AF1CCCS or the Contractor within
60 days of the date the overpayment was identified.
29. AFICCCS may require Provider or any employees or contractors of Provider to verify United States
citizenship or lawful permanent resident status prior to the signing of this Agreement. AHCCCS
may, at its sole discretion, conduct criminal background cheeks and/or fingerprint checks on
Provider or any employees or contractors of Provider.
30. Provider agrees to submit, upon request by AHCCCS or the federal government, full and complete
information as to ownership, business transactions, and criminal activity, all in accordance with 42
C.F.R. 455 Subpart B and State law. Provider further agrees to report to AHCCCS immediately any
debarment or suspension of any its owners, managers, licensed professionals, or any other
employees.
31. Upon thirty (30) days written notice, either Party may voluntarily terminate this Agreement.
AHCCCS has the right to terminate or suspend this Agreement upon twenty-four (24) hours written
notice when AHCCCS deems the health or welfare of a member is endangered; the Provider fails to
comply with this Agreement or with Federal and State laws and regulations; or there is a
cancellation, termination or material modification in the Provider's qualifications to provide.
AFICCCS may also terminate this Agreement if it is found that gratuities in the form of
entertainment, gifts, or otherwise, were offered or given by Provider or any agent or representative
of Provider to any officer or employee of the State with a view towards securing a contract or
securing favorable treatment with respect to a contract.
32. Upon any termination of this Agreement, Provider shall assist in providing for the orderly transition
of care for members assigned to the Provider.
I have read, understand, and agree to abide by all the terms and conditions set forth in this Agreement.
FOR AND ON BEHALF OF AHCCCSA
2 1,7//:,
Signature Date Authorization
Max Porter
Typed Name Date
Deputy Director Of Public Health
Title Provider Number Assigned.
2011
4

Provider Participation Agreement Arizona Health Care Cost Containment System (AHCCCS)
IN WITNESS WHEREOF, the parties agree to enter into this Agreement:
FOR AND ON BEHALF OF
MAR1COPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
C1erk of the Board
Date
APPROVED AS TO FORM:
Deputy Attorney for Maricopa County
Date

W-9 Request for Taxpayer Give Form to the
Form
requester. Do riot
(Rev. August 2013) Identification Number and Certification
Department of the Treasury send to the IRS.
Internal Revenue Service
I
Name (as shown on your income tax return)
Maricopa County, D.B.A. Maricopa County Department Of Public Health D.B.A Public Health Clinical Services (Laborator
Business name/disregarded entity name, if different from above
2.
page
Check appropriate box for federal tax classification: Exemptions (see instructions):
on [1] individual/sole proprietor El G Corporation El S Corporation LII Partnership 1111 Trust/estate
type Exempt payee code (if any)
Instructions • Limited liability company. Enter the tax classification (C=C corporation, S'S corporation, P=partnership) fi• Exemption from FATCA reporting
or
code (if any)
Print ea Other (see instructions) IP: GOVERMENT AGENCY
Address (number, street, and apt. or suite no.) Requester's name and address (optional)
Specific
1645 E ROOSEVELT STREET
City, state, and ZIP code
See
PHOENIX ARIZONA 85006.3638
List account number(s) here (optional)
Taxpayer Identification Numbe (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line Social security number
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other •••I
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
8 6 6 0 0 0 4 1 7 2
FM Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below), and
4, The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured 7perty, 3 cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividen u are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign Signature of
Here U.S. person kb- /7/471 2, Date lb /2-2- /3
General Instructions withholding tax an foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
Section references are to the Internal Revenue Code unless otherwise noted. exempt from the FATCA reporting, is correct.
Future developments. The IRS has created a page on IRS.gov for information Note. If you are a U.S. person and a requester gives you a form other than Form
about Form W-9, at www.irs,gov/w9. Information about any future developments W-9 to request your TIN, you must use the requester's form if it is substantially
affecting Form W-9 (such as legislation enacted after we release it) will be posted similar to this Form W-9.
on that page. Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
Purpose of Form person if you are:
• Art individual who is a U.S. citizen or U.S. resident alien,
A person who is required to file an information return with the IRS must obtain your
correct taxpayer identification number (TIN) to report, for example, income paid to • A partnership, corporation, company, or association created or organized in the
you, payments made to you in settlement of payment card and third party network United States or under the laws of the United States,
transactions, real estate transactions, mortgage interest you paid, acquisition or • An estate (other than a foreign estate), or
abandonment of secured property, cancellation of debt. or contributions you made
• A domestic trust (as defined in Regulations section 301.7701-7).
to an IRA.
Special rules for partnerships. Partnerships that conduct a trade or business in
Use Form W-9 only if you are a U.S. person (including a resident alien), to the United States are generally required to pay a withholding tax under section
provide your correct TIN to the person requesting it (the requester) and, when 1446 On any foreign partners' share of effectively connected taxable income from
applicable, to: such business. Further, in certain cases where a Form W-9 has not been received,
1. Certify that the TIN you are giving is correct (or you are waiting for a number the rules under section 1446 require a partnership to presume that a partner is a
to be issued) ; foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
2. Certify that you are not subject to backup withholding, or U.S. person that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If and avoid section 1446 withholding on your share of partnership income.
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
Cat. No. 10231X Form W-9 (Rev. 8-2013)

DISCLOSURE OF OWNERSHIP/CONTROL
AND
A: CC. CRIMINAL OFFENSES STATEMENTS
Item I. Identifying Information
(a) Name of Individual, Facility or Organization: M'c'Pa County, D.B.A. Maricopa County Cepartment 01 Public Health 1J -.13.A Public H-ealth Clinical Sor.6ces i_aboratoryl
(b) DNA Name: Makopa County, D.B.A. Makopa County Department Of Pubilc Health D.B.A Public HealthClinical Services (Laboratory)
(c) Federal Tax Identification Number (TIN) or Social Security Number (SSN): 866000472
(d) Check the entity type that best describes the structure of the enrolling provider entity. Check only one box.
_
— For-Profit Corporation Li Non-Profit Corporation Partnership >< Government Owned Sole- Proprietorship
(e) Is this entity chain affiliated? 1-7No Yes
As requited by 42 CFR Part 455, Subpart B which implements Section 1124, 1126, 1902(a) (38), 1903( .0(2) and 1903(n) of the Social Security Act and sets
forth State Plan requirements regarding Full Disclosure of Ownership and Control and Related Party Transactions, the following information must be
submitted to AHCCCS prior to registration and upon each renewal of certification or licensure in order to participate as an AHCCCS provider.
AHCCCS may refuse to enter into or renew an agreement with a provider if the provider fails to disclose ownership and control interest information,
information related to business transactions and information on persons convicted of crimes, or if the provider did not fully and accurately make the disclosures
as re.uired.
Item II. Ownership and Control Interest Information (Reference-42CFR, Part 455.104 and SSA 1124)
(a) List the name, title, address, SSN and DOB for each officer and/or individual who has direct or indirect ownership or control interest, separately or in
combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, TIN, and address of any organization, corporation, or
entity having direct or indirect ownership or control interest, separately or in combination, amounting o an ownership interest of 5% Or more in the
provider entity. Also, list below all officers, owners, managing employees and ownership entities. Use attachment A if additional space is needed.
Name Address 1J Date of Birth
MARICOPA COUNTY 551W JEFFERSON STREET # 105 PHODPX, ARf7.135006-3638 866000472 100%
IIIIIIIIIIIIIIIIIII.==IIIIIIIIIIII ME
(e) For any corporate entity, listed in (a), that has an ownership or control interest of 5% or more, list the following information for that entity: Include all
business addresses, both service addresses and P.O. boxes. Use attachment A if additional s.ace is needed.
IMal .. .... ...._ Address MEM Percentage
NA
(c) List the name, title, address and SSN of each person with an ownership or control interest in any subcontractor in which the disclosing entity has director
indirect ownership of 5 percent or more.
iani Title Address Percentage
NA IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMII
1111111111111111111111111.1111111111111111.1.11111111111111.111111111111111111111111111111
IIIIIIIIIIIIII
(d , List those iersons named in Item 11 (a), c that are related to each other s.ouse, •arent, child, or siblin! .
111=211111111111111111111111111111111111111.111 Iel`ltionshil) SSN Date of Birth
NA IIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIII
Min
IIIIIIIIIIIIIIIIIIIIIIIIIIIII
(e) List the name, address and TIN of any other disclosing entity in which a person with an ownership or control interest in the disclosing entity also has
ownershi or control interest of a t least 5% or more.
IIIIIIEEIMIIIIIIIIIIIIIIIIIIIIIIIIII Address TIN Percentage
-+ IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIMM
M.lcupa Ocemy. 8.8 A. 85s1wpa CourAy Depmrtmant 01Put4ic Hae. 8 8 A Pubtic.Fles 88 Mirka, Sew
1 of 3 Disclosure of Ownership.duc

DISCLOSURE OF OWNERSHIP/CONTROL
AND
At' CCS CRIMINAL OFFENSES STATEMENTS
Item III. Criminal Offenses (Reference-42CFR, Pan 455.106 and SSA 1124)
(a) List the name, title, SSN and address of each officer and/or individual who has ownership or control interest in the disclosing entity, or is an agent or
managing employee of the disclosing entity and has been convicted of a criminal offense related to that person's involvement in any program under
Medicare, Medicaid or the Title XX services program since the inception of those pro:rams.
Name Title Address SSN (or TIN in organization)
NA
(b) List the name, title, SSN and address of any individual who has an ownership or control interest in the disclosing entity an has been suspended or debarred
from •articigation in Medicare, Medicaid or Title XX program at any time since the ince tion of those p o arns
Name Title Address SSN
NA
Item V. Bo. rd of Directors
List the name, title and address of each member of the Board of Directors of the disciosiof entity.
Name Title Address
Denny Barney Dist 1 Supervisor 301 w Jefferson 10 Floor
Steve Chucri Dist 2 Supervisor 301 w Jefferson 10 Floor
Andy Kunasek Dist 3 Supervisor 301 w Jefferson 10 Floor
Clint L. Hickman Dist 4 Supervisor 301 w Jefferson 10 Floor
Mary Rose Wilcox Dist 5 Supervisor 301 w Jefferson 10 Floor
I affirm under penalty of law that the Information I have provided for this f onn is true, accurate and complete to the best of my knowledge.
Max Porter Deputy Deputy Director of public Health
Print N i e of A zed Repress. lit, Title
/2-1-1 - /3
Signature of Authorized Representative Date
Revised 0612012
2 of 3 Disclosure of OwneishLp.doe

DISCLOSURE OF OWNERSHIP/CONTROL
AND
AHCCCS CRIMINAL OFFENSES STATEMENTS
ATTACHMENT A
Use the additional space provided below for Item II (a). Ownership and Control Interest Information
(Reference-42CFR, Part 455.104 and SSA 1124)
Nam Title Address SSN/TIN I Date of Birth I Per ge
Use the additional space provided below for Item II (b). Ownership and Control Interest Information
(Reference-42CFR, Part 455.104 and SSA 1124)
1 TIN
06/201
3 of 3 Disclosure or Ownership. doe

ATTESTATION OF COMPLIANCE WITH A.R.S. 35-196.05
On behalf of the Provider identified below my signature, I hereby attest to the
following:
1. As of August 2, 2012, and thereafter, the Provider will not perform any abortions
for any member of the public or maintain or operate a facility where any abortion
is performed for any member of the public unless one of the following conditions
is present:
a. A licensed physician has certified that the pregnant woman suffers from a
physical disorder, physical injury, or physical illness (including a life-
endangering physical condition caused by or arising from the pregnancy
itself) that places the member in danger of death unless the pregnancy is
terminated.
b. The pregnancy is a result of rape or incest.
c. A licensed physician has attested that the pregnancy termination is
medically necessary for an AHCCCS eligible woman because
continuation of the pregnancy could reasonably be expected to pose a
serious physical or mental health problem for the pregnant woman by:
i. Creating a serious physical or mental health problem for the
pregnant member,
ii. Seriously impairing a bodily function of the pregnant member,
iii. Causing dysfunction of a bodily organ or part of the pregnant
member,
iv. Exacerbating a health problem of the pregnant member, or
v. Preventing the pregnant member from obtaining treatment for a
health problem.
d. Other circumstances where, under A.R.S. 35-196.05(B), a medical
condition exists such that the abortion is performed for a treatment of a
medical condition and is not performed for the provision of family
planning services. Describe the circumstances and medical condition
here:
2. The Provider will inform the AHCCCS Administration within 48 hours if the
Provider fails to comply at any time with these attestations by providing written
notice sent to:
AHCCCS Provider Registration
P.O. Box 25520, Mail Drop 8100
Phoenix, AZ 85002
authorized to make these attestations on behalf of the Provider.
Signature Date
Printed Name Provider Name
Title Provider ID number

GROUP BILLER PARTICIPATION AGREEMENT
Between
ARIZONA HEALTH CARE
COST CONTAINMENT SYSTEM ADMINISTRATION (AHCCCSA)
and
Maricopa County, D.B.A. Maricopa County Department Of Public Health D.B.A 866000472
Group Biller Name SSN/Tax ID g
Located at
1645 E. Roosevelt Street Phoenix, Arizona 85006-3638
Business Address City, County, State, Zip Code
This Agreement between AHCCCSA and the Group Biller is made pursuant to Title XIX of the Social Security Act and
A.R.S. Title 36, Chapter 29 to govern: (1) registration of and payment to the Group Biller on behalf of Affiliated
Providers of health care services provided by the Affiliated Providers to eligible persons who are not enrolled with a
program contractor or health plan under contract with AHCCCSA ("Contractors") and (2) registration for the Group Biller
to participate in the Arizona Health Care Cost Containment System through a Contractor.
As used in this Agreement:
"Group Biller" means an organization acting as the financial representative of any Provider or group of Providers who
have authorized the organization to act on the Provider(s) behalf.
-Affiliated Provider" means a provider of health care of medical serivces who has authorized the Group Biller to act as its
finanicial representative.
In consideration of the covenants contained in this Agreement:
I. Fee-for-Service Patients
1. AHCCCSA agrees to make payments to the Group Biller on behalf of Affiliated Providers, consistent with State
and Federal law, the terms of this Agreement, and the AHCCCSA Capped Fee-For-Service Payment Schedule (including
amendments thereto and as hereby incorporated by reference), for health care services provided by Affiliated Provieders
to fee-for-service patients.
2. For health care or medical services provided by Affiliated Providers to fee-for-service patients,
the Group Biller agrees to bill AHCCCSA in accordance with the terms of this Agreement, State and Federal law, and the
following documents, including amendments thereto, hereby incorporated by reference: the AHCCCS Fee-For-Service
Billing Manuals, the AHCCCS Medical Policy Manual, AHCCCS Claims Clues and other written directives provided by
the AHCCCSA to the Provider. These documents shall be made available to the Group Biller either in hard copy or via
AHCCCS Internet Website at www.ahcccs.state.az.us . The Group Biller shall conform its billing practices to ICD9, CPT
and HCPCS compliance standards except when those standards conflict with AHCCCS policies defined listed above.
II. Participation through a Program Contractor or Health Plan
1. Pursuant to 42 CFR 431.107, an Affiliated Provider is prohibited from participation in the Arizona Health Care
Cost Containment System unless a provider agreement with the Administration is in effect. The Group Billing shall not
provide group billing services to any provider who does not have in effect a Provider Agreement with AHCCCSA at the
time services are rendered.
2. With respect to any services furnished by an Affiliated Provider to an AHCCCS eligible person enrolled with a
Contractor, the terms and conditions of payment shall be as set forth in the contract between the Provider and the
Contractor notwithstanding any inconsistent provisions of Section I of this Agreement.
3. The Provider agrees to bold the AHCCCSA harmless, and agrees not to seek reimbursement from AHCCCSA, for
services rendered, pursuant to a contract between the provider and a Contractor, to AHCCCS eligible persons enrolled
with a Contractor.
General Terms and Conditions

The following terms and conditions apply both to services provided on a fee-for-service basis and services
provided through a Program Contractor or Health Plan:
1. Pursuant to 42 CFR 431107, an Affliated Provider is prohibited from participation in the Arizona Health Care
Cost Containment System unless a provider agreement with the Administration is in effect The Group Billing shall not
provide group billing services to any provider who does not have in effect a Provider Agreement with AHCCCSA at the
time services are rendered.
2. The Group Biller shall ensure that every Affiliated Provider has completed an AHCCCSA Provider Participation
Agreement, is registered with AHCCCSA, and has signed an AHCCCSA Group Billing Authorization form. Each
Affiliated Provider shall be considered part of the billing group unitl the Provider furnishes written notification of its
termination of the group billing arrangement to the AHCCCSA Provider Registration Unit.
3. The Group Biller shall include the individual Affiliate Provider's AHCCCS Provider ID number on each claim
submitted by the Group Biller on behalf of the Affiliated Provider.
4. When AHCCCSA issues an amendment to modify this Agreement or to modify documents incorporated by
references as part of this Agreement, the provisions of such amendment will be deemed to have been accepted 30 days
after the date AHCCCSA provides notice to the Group Biller, even if the amendment has not been signed by the Group
Biller, unless within that time the Group Biller notifies AHCCCSA in writing that it refuses to sign the amendment. If the
Group Biller provides such notification, this Agreement terminates.
5. The Group Biller shall not bill, nor attempt to collect payment directly or through a collection agency from a person
claiming to be AHCCCS eligible without first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered services. The Group Biller agrees to
abide by Arizona Administrative Code R9-22-702 prohibiting the Group Biller from charging, collecting, or attempting to
collect payment from an AHCCCS eligible person.
6. The Group Biller agrees to bill the AHCCCSA only after a potential third party payer has been billed and, after
payment has been received, to bill AHCCCSA the balance due only up to the limit of the member's responsibility.
7. In addition to other remedies available under this Agreement, AHCCCS shall be entitled to offset against any
amounts due the Group Biller any overpayments, or expenses or costs incurred by AHCCCSA concerning the Group
Biller's non-compliance with this Agreement. The rights and remedies of AHCCCSA under this contract are not
exclusive.
8. The Group Biller shall maintain all records relating to performance of this Agreement in compliance with all
specifications for record keeping established by AHCCCSA. All books and records shall be maintained in such detail as shall
reflect each service provided and all other costs and expenses of whatever nature for which payment is made to the Group
Biller. Such material shall be subject to inspection, audit or copying by the state, AHCCCSA, the U.S. Department of Health
and Human Services, any other authorized representative of the state or federal governments during normal business hours at
the Group Biller's place of business. The Group Biller shall preserve and make available records for a period of five years
from the date of payment under this Agreement except: (1) if this Agreement is completely or partially terminated, the
records relating to the work terminated shall be preserved and made available for a period of five years from the date of any
such termination; and (2) records which relate to disputes, litigation or the settlement of claims arising out of this Agreement,
or costs and expenses of this Agreement to which exception has been taken by the state, shall be retained by the Group Biller
until such disputes, litigation, claims or exceptions have been disposed of. The Group Biller shall comply with all applicable
AHCCCS Rules and Audit Guide relating to the audit of the Group Biller's records and the inspection of the Group Biller's
facilities.
9. The Group Biller agrees to hold harmless the state, all state officers and employees, AHCCCSA and other
appropriate state agencies, and all officers and employees of AHCCCSA against all injuries, deaths, losses, damages, claims,
suits, liabilities, judgments, costs and expenses which may, in any manner, accrue against the State, AHCCCSA or its agents,
officers or employees, or AFICCCS contractors, through any breach of contract (including, but not limited to, the Group
Billing Agreement with Affiliated Providers), intentional conduct, negligence or omission of the Group Biller, its agent,
officers or employees.
10. The Group Biller shall comply with all federal, State and local laws, rules, regulations, standards and executive
orders governing performance of duties under this Agreement, without limitation to those designated within this Agreement.
11. Confidential information shall be safeguarded pursuant to 42 CFR Part 431, Subpart F, ARS §36-107, 36-2903, 41-
1959 and 46-135, any other applicable State and Federal laws, and AHCCCS and/or ALTCS Rules.
12. Any grievances filed by the Group Biller on behalf of Affiliate Providers shall be adjudicated in accordance with
AHCCCS Rules as published in the Arizona Administrative Code. The Group Biller agrees to waive attorneys' fees in any
disputes concerning this Agreement.

13. Upon thirty (30) days written notice, either party may voluntarily terminate this Agreement. AHCCCSA has the
right to terminate this Agreement, in whole or part, upon twenty-four (24) hours written notice when AHCCCSA deems
the health or welfare of a member is endangered; the Group Biller fails to comply with Federal and State laws and
regulations; or there is a cancellation, termination or material modification in any Affiliated Provider's qualifications to
provide.
14. AHCCCSA may, by written notice to the Group Biller, terminate this Agreement if it is found, after notice and
hearing by the State, that gratuities in the form of entertainment, gifts, or otherwise were offered or given by the Group Biller,
or any agent or representative of the Group Biller, to any officer or employee of the State with a view towards securing a
contract or securing favorable treatment with respect to the awarding, amending or the making of any determinations with
respect to the performance of the Group Biller; provided, that the existence of the facts upon which the state makes such
findings shall be in issue and may be reviewed in any competent court. If the Agreement is terminated under this section,
AHCCCSA shall be entitled to a penalty, in addition to any other damages to which it may be entitled by law, and to
exemplary damages in the amount of three times the cost incurred by the Group Biller in providing any such gratuities to any
such officer or employee.
15. The Group Biller shall comply with State Executive Order 99-4, incorporated by reference as part of this
Agreement, and Federal Order 11246 which prohibit discrimination based on of race, color, religion, sex, age, national
origin or political affiliation.
16, By signing this Agreement, the Group Biller certifies that it has not engaged in any violation of the Medicare Anti-
Kickback statute (42 USC §5S1320a-7b) or the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom.
17. The Group Biller shall maintain for the duration of this Agreement a policy or policies of errors and ommissions
liability insurance and comprehensive general liability insurance. The Group Biller agrees that any insurance protection
required by this Agreement, or otherwise obtained by the Group Biller, shall not limit the responsibility of the Group Biller
to indemnify, keep and save harmless and defend the State and AHCCCSA, their agents, officers and employees as provided
herein. Furthermore, the Group Biller shall be fully responsible for all tax obligations, Worker's Compensation Insurance,
and all other applicable insurance coverage, for itself and its employees, and AHCCCSA shall have no responsibility or
liability for any such taxes or insurance coverage.
18. If the Group Biller discovers, or is made aware, that an incident of potential fraud or abuse has occurred, the Group
Biller shall report the incident to the Health Plan, Program Contractor, or the Administration who shall proceed in accordance
with the AHCCCS Health Plans and Program Contractors Policy for Prevention, Detection and Reporting of Fraud and
Abuse. Incidents involving potential member eligibility fraud should be reported to AHCCCSA, Office of Managed Care,
Member Fraud Unit. All other incidents of potential fraud should be reported to AHCCCSA, Office of the Director, Office of
Program Integrity.
19. The Provider agrees to submit, within thirty-five (35) days after the date of request by AHCCCSA or the U.S.
Department of Health and Human Services, full and complete information as to ownership, business transactions, and
criminal activity in accordance with 42 C.F.R. 455 Subpart B and State law.
FOR AND ON BEHALF OF THE GROUP BILLER FOR AND ON BEHALF OF AHCCCSA
Signature Date Authorization
Max Porter
Typed Name Date
Deputy Director Of Public Health
Title Provider Number Assigned
PROVAGR/4-96

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
PROVIDER REGISTRATION FORM
SHADED FIELDS FOR AHCCCS PROVIDER REGISTRATION STAFF ONLY Please Tyne or Print in Ink
SECTION I
la) PROVIDER AHCCCS ID NUMBER (Complete Only if you are currently 1b) PROVIDER NP1 (NATIONAL PROVIDER IDENTIFIER) NUMBER (if
registered and have a Provider No) 099267 applicable) 1417204157
2) PROVIDER NAME(Last Name/First Name/Middle Initial or business/facility name)
Maricopa County, D.B.A. Maricopa County Department Of Public Health D.B.A Public Health Clinical Services (Laboratory)
3) SOCIAL SECURITY NUMBER 4) DATE OF BIRTH 5) GENDER 6) DEGREE
7) PROVIDER TYPE 8) FFS TYPE 9) IHS INDICATOR
01
10) APPLICATION DATE 11) FIRST DATE OF SERVICE FOR WHICH A CLAIM WILL BE SUBMITTED
Month 11 Day 14 Year 13 Mortill Day Year
SECTION II ADDRESS INFORMATION
CORRESPONDENCE ADDRESS
ADDR SITE 1645 E Roosevelt Street
• 01 12) STREET LINE 1
13) STREET LINE 2
14) CITY/STATE/ZIP Phoenix , Arizona 85006-3638
- ----.-----
15) COUNTY CODE: 13 1 16) COUNTRY CODE:
17) BUSINESS PHONE: ( 602 ) 372 _ 1013 18) EMERGENCY PHONE ( 602 ) 506 - 6657
19) ATTENTION TO' Angelinto Bravo
PAY-TO ADDRESS
ADDR SITE 1645 E Roosevelt Street
• 01 12) STREET LINE 1:
13) STREET LINE 2: ADMINISTRATION
14) CITY/STATE/ZIP: Phoenix , Arizona 85006-3638
15) COUNTY CODE: 13 [16) COUNTRY CODE -
17) BUSINESS PHONE: ( 602 ) 506 - 6660 18) EMERGENCY PHONE ( 6°2 ) 506 - 6657
19) ATTENTION TO ISSMENE QUINTANILA
ADDITIONAL PAY-TO INFORMATION 21) END DATE: 22) EMPLOYER TAX ID: 866000472ADM
SERVICE ADDRESS
ADDR SITE 1645 E Roosevelt Street
• 01 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP: Phoenix , Arizona 85006-3638
15) COUNTY CODE: 13 16) COUNTRY CODE'
17) BUSINESS PHONE . ( 6°2 ) 506 _ 6660 18) EMERGENCY PHONE ( 602 ) 606 _ 6657
19) ATTENTION TO ISSMENE QUINTANILA
20) BEGIN DATE: 21) END DATE"
ADDITIONAL SERVICE INFORMATION: 23) PAY-TO LOCATION CODE:
Page 1

PAY-TO ADDRESS
ADDR SITE NA
02 12) STREET LINE 1:
13) STREET LINE 2.
14) CITY/STATE/ZIP.
15) COUNTY CODE: [16) COUNTRY CODE -
17) BUSINESS PHONE: ( 18) EMERGENCY PHONE {
19) ATTENTION TO
ADDITIONAL PAY-TO INFORMATION 21) END DATE: 22) EMPLOYER TAX ID:
SERVICE ADDRESS
ADDR SITE NA
02 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE
17) BUSINESS PHONE: { 18) EMERGENCY PHONE
19) ATTENTION TO:
20) BEGIN DATE: 21) END DATE:
ADDITIONAL SERVICE INFORMATION: 23) PAY-TO LOCATION COD
PAY-TO ADDRESS
ADDR SITE NA
03 12) STREET LINE 1
13) STREET LINE 2
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( 18) EMERGENCY PHONE {_.)
19) ATTENTION TO
ADDITIONAL PAY-TO INFORMATION 21) END DATE: 22) EMPLOYER TAX ID:
SERVICE ADDRESS
ADDR SITE NA
S 03 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( 18) EMERGENCY PHONE)
19) ATTENTION TO:
20) BEGIN DATE: 21) END DATE:
ADDITIONAL SERVICE INFORMATION: 23) PAY-TO LOCATION CODE:
Page 2

LICENSING *
24) LICENSE NUMBER 25) ISSUE DATE (mmlopiyrrY) 26) EXPIRATION DATE 27) NEXT RENEWAL DATE
03D0057138 7/27/2012 7/26/2014 7/2612014
ADHS AZ 0169 10/01/2013 09130/2014
AZ Radiation Reg 7 -M -137 05/18/2005 05/31/2015 05/31/2015
* A COPY OF THE LICENSE MUST BE ATTACHED
PROVIDER SPECIALTY INFORMATION- MANDATORY FOR PHYSICIAN, DENTISTS, PODIATRISTS,
OSTEOPATHS, AND REGISTERED NURSE
PRACTITIONERS
26) SPECIALTY 29) BEGIN DATE (MMJDONYYY) 30) END DATE
Laboratory
BED COUNT INFORMATION - HOSPITALS, NURSING HOMES, AND HOSPICES ONLY
31) BED TYPE 32) STATE CERTIFIED 33) MEDICARE 34) MEDICAID 35) BEGIN DATE 36) END DATE
COUNT CERTIFIED COUNT CERTIFIED COUNT (MMOIDNYYY)
NA
SECTION IV
AUTHORIZED SIGNATURE
37) SIGNATURE 35) PRINT NAME 39) BEGIN DATE /mmioDivr(Y)
MAX PORTER
Page 3

GROUP BILLING AUTHORIZATION
40) GROUP NAME/AHCCCS ID NUMBER AND/OR NPI NUMBER 41) ASSOCIATION BEGIN DATE 42) ASSOCIATION END DATE
(MWODNYYY)
Mancopa County, D.B.A. Marinopo C000ly Dupartnnent 01 Patio Health D.B.A Public Health ClInIcal Seroces (Laberatefy) Mill=
097451 1447410048
MI=
IIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
MEDICARE INFORMATION (Mandatory for all providers. If not a Medicare provider indicate by placing N/A in block #42)
43) MEDICARE 44) MEDICARE 45) INTERMEDIARY 46) CARRIER 47) BEGIN DATE 48) END DATE
ID NO COVERAGE NUMERIC CODE NUMERIC CODE (MMIDDYYYY)
NA
Has the practice/organization that you represent or any of the signatories listed in (37) ever applied for or received an AHCCCS provider
identification number under any other name than noted on this form?
NO
YES (Please explain)
Maric,opa County, D.B.A. Maricopa County Department Of Public Health D.B.A Public Health Clinical Services (Laboratory)
097451 1447410048
Have you or the practice/organization that you represent or any of the signatories listed in (37) ever been terminated, suspended, advised of
any deficiencies or otherwise subject to any corrective or disciplinary action by a governmental body? This includes a professional licensing
or certification board and any city, state, county or federal entities. If yes, include documentation from issuing entity.
NO
YES (Please explain)
Ihereby authorize the groups listed in to bill on my behalf and receive payment for services provided to AHCCCS members.
I affirm undc 7,7 It f law that the . or ation I have provided on this form is true, accurate and complete to the best of my knowledge.
49) 50)
PROVIDER SIGNATURE (ONLY) DATE
51) MAX PORTER
PROVIDER NAME (PLEASE TYPE OR PRINT)
12/2011
Page 4

CE R71 IPC OF CO,=-11=1_ NCE
ADDRESS CL1A iD NUIVI.UR
MARICOPA COUNTY PUBLIC HEALTH LAB 03D0057138
1645 EAST ROOSEVELT STREET
PHOENV, AZ EFFECTIVE DATE
07/27/2012
LABORATORY r.COR ,:i'xi.i,Y .P.aATION DATE
RENUKA KHUR•NA, MD 07/26/2014
Pumezaw.
YSE
Cr (5/1-ter
- uf a list of the k`aborataty
Ce • ..;.:petfc.4..!
:
BACTERKILOGY (110) 07/27/1994
MYCOBACTERIOLOGY (115) 07/27/1994
MYCOLOGY (120) 07/2711g94
PARASITOLOGY (1m) 07/27/1994
SYPMLIS SEROLOGY (210) 07/27/1994
GENERAL MMUNOLOGY (220) 07/27/1996
URINALYSS (320) 07/27/1994
PI,EASIL CONE:

MARICOPA COUNTY
RISK MANAGEMENT
CERTIFICATE OF INSURANCE ,
This certifies that Maricopa County, Arizona, maintains for all its departments, boards, committees and employees insurance and self-insurance of the
types and amounts specified below in accordance with the Declaration of Trust for Maricopa County, Arizona Self-Insured Trust Fund and ARS I 1 ,-
981. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. It neither affirmatively amends,
extends, nor alters the self insurance or coverage cited below. This certificate supersedes any previously issued certificates, This certificate is issued
by the Maricopa County, Arizona, Risk Management Department.
COVERAGE LIMITS OF COVERAGE
Public Entity Liability including: Bodily Injury and Property
1. Premises/Operations Liability Damage $5,000,000 per
2. Products/Completed Operations occurrence, no aggregate limit
3. Blanket Contractual
4. Personal Injury
— 5. Broad Form Property Damage
Automobile Liability including: Bodily Injury and Property
1. Owned Autos Damage $5,000,000 per
2. Non-Owned Autos combined single limit
3. Hired Autos
Workers Compensation: S2,000,000
Employer's Liability: each accident, disease each
employee, disease-policy limit
All Risk Real Property, Replacement Cost
All Risk Personal Property, Actual Cash Value
Medical Malpractice Liability: $5,000,000
Other: Professional Liability $5,000,000
Description of Event/Property/Contract: Proof of Coverage
Effective Dates: 03/01/2013 — 3/1/2014
Location:
Special Provisions:
Any liability by Maricopa County in the event of a claim for loss, damage or injury is limited to its solo negligence.
Maricopa County Dept of Public Health
DATE ISSUED 11/18/2013
CERTIFICATE HOLDER Christine Nobles, Insurance Manager (coi)