ADHS INCENTIVE REQUEST - BASHAS GIFT CARDS FY22.PDF
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Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 F | 602-542-1062 W | azhealth.gov Health and Wellness for all Arizonans TUBERCULOSIS CONTROL – INCENTIVE PROGRAM – INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364-3267 or email kara.tarter@azdhs.gov. If you have any questions regarding this form, please call (602) 364- 4750. Bashas’ Walmart Chevron Total number of $10.00 vouchers requested Total value ($) of vouchers requested The vouchers will be used solely as incentives for clients receiving anti-TB treatment. Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. Initials of program representative: The program will keep a record (tracking log) of every voucher dispensed and record the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. Initials of program representative: The program will submit a monthly report to ADHS listing the number of vouchers distributed, the number of patients who received vouchers, and number of vouchers distributed YTD. Initials of program representative: Comments: Program Representative Contact Name, phone#, email Director or DON Contact Name, phone#, email Physical Address Where Cards Should be Sent (Cannot be a PO Box): _____________________________________________________ ________________________ Signature of Program Representative Date _____________________________________________________ ________________________ Signature of Director or DON Date Date received by ADHS: __________________ cvb cvhb cvhb Charlotte V. Hunter-Brown Corinne Velasquez 1645 E. Roosevelt Phoenix, AZ 85006 250 $2500 cvhb Corinne.Velasquez@Maricopa.gov 602 506-6657 charlotte.hunter-brown@maricopa.gov Charlotte V. Hunter-Brown 01/24/2022 01/20/22 ATTACHED TO AND A PART OF: Tuberculosis Control Incentive Program Acceptance And Use of Bashas' Grocery Vouchers IN WITNESS WHEREOF, the parties agree to enter into this Agreement: FOR AND ON BEHALF OF MARICOPA COUNTY By_____________________________ Bill Gates, Chairman, Board of Supervisors _______________________________ Date ATTEST: _______________________________ Clerk of the Board _______________________________ Date APPROVED AS TO FORM: _______________________________ Attorney for Maricopa County _______________________________ Date