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HomeMy WebLinkAbout081516_ca03615 Sheridan Street Port Townsend, WA 98368 tArsoi✓e www.JeffersonCountyPublicnensi�hit ftnda July 6, 2016 Health JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Vicki Kirkpatrick, Director DATE: (� SUBJECT: Agenda Item — Contract Agreement with Public Health of King County for Breast Cervical & Colon Health Program Services; July 1, 2016— June 14, 2017; $500.00 STATEMENT OF ISSUE: Jefferson County Public Health, Community Health, requests Board approval of the Contract Agreement with Public Health of King County for Breast Cervical & Colon Health Program Services; July 1, 2016 — June 14, 2017; $500.00 ANALYSIS/ STRATEGIC GOALS/PRO'S and CON'S: This is an ongoing agreement between Jefferson County and Public Health Seattle & King County to provide Breast and Cervical Health Care, (Screening & Referral Services) to a specific segment of the population, uninsured or underinsured women. Services are available to eligible clients to pay for preventive services such as health exams, mammograms and pap tests. This includes breast screening and annual exam for women age 40-64 with incomes at or below 250% of Federal Poverty Level and mammography and breast diagnostics available to women below 300% of FPL. These services will also be available to women who may not be eligible for apple Health (Medicaid). This contract provides for colon health services to certain counties that contract with Public Health of Seattle & King County, Jefferson County is not one of those counties. JCPH will continue to do outreach. FISCAL IMPACT/COST BENEFIT ANALYSIS: The agreement provides $500.00 in State and Federal funding. No general fund dollars support this program. The agreement provides: $500.00 in funds for one or more of the following: annual exam, clinical breast exam, problem -focused visit, Pap tests, HPV tests. RECOMMENDATION: JCPH management request approval of the Contract Agreement with Public Health of King County for Breast Cerv' - I & Colon Healt ogram Services; July 1, 2016 — June 14, 2017; $500.00 i W ilip Morl y, ounty Admi 'str Date Community Health Environmental Health Developmental Disabilities Water Quality 360-385-9400 360-385-9444 360-385-9401 (f) Always working for a safer and healthier community (f) 360-379-4487 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 --- . . . . ......... Public Health COMMUNITY SERVICES PHSKC Agreement # Seattle & King County L19 AGREEMENT CDIP4197 ....... . ..... . ......... This Agreement is between King County and the Recipient identified below. The County department overseeing the work to be performed in this Agreement is the Department of Public Health (PHSKC), RECIPIENT NAME RECIPIENT FEDERAL TAX ID # Jefferson County Public Health 91-6001322 . .. . . . . ............. . ............................ . . .. . ......... . . ....... . . . . . . ................ --- - ------- . ......... . . ............ .... . . .... RECIPIENT ADDRESS RECIPIENT CONTACT & EMAIL ADDRE. SS 615 Sheridan Veronica K. Shaw Port Townsend, WA 98368 veronica@co.jefferson.wa.us PHSKC DIVISION PROJECT TITLE Chronic Disease & Injury Prevention Breast, Cervical and Colon Health Program (BCCHP) AGREEMENT END DATE AGREEMENT MAXIMUM AMOUNT 7/1/2016 6/14/2017 $500.00 AGREEMENT START DATE FUNDING DETAILS Fundin Source PHSKC Contract # Amount Effective Dates Fr i - GFDA No.93,752 C17123 $500,00 71112016-611412017 ...... . .. . FUNDING SUMMARY COUNTY: $0 S TE: $0 OTHER: $0 FEDERA $50 0.00 T— IS THE RECIPIENT A SUBRECIPIENT FOR PURPOSES OF THIS AGREEMENT? [:1 YES X NO EXHIBITS. The following Exhibits are attached and are incorporated into this Agreement by reference: Exhibit A - Special Terms & Conditions Exhibit B - Scope of Work Exhibit C - Budget Exhibit D - Invoice Exhibit E - Service Authorization Form Exhibit F - Certificate of Insurance & Additional Endorsement In consideration of payments, covenants, and agreements hereinafter mentioned, to be made and performed by the parties hereto, the parties mutually agree that the Recipient shall provide services and comply with the requirements set forth in this Agreement. The parties signing below represent that they have read and understand this Agreement, and have the authority to execute this Agreement. Furthermore, in addition to agreeing to the terms and conditions provided herein, by signing this Agreement, the Recipient certifies that it has read and understands the Agreement requirements on the PHSKC website (hftp://www.kingcounty.gov/health/contracts), and agrees to comply with all of the Agreement terms and conditions detailed on that site, including EEO/Nondiscrimination, HIPAA, Insurance, and Credentialing, as applicable. RECIPIENT SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Veronica Shaw PHSKC SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Approved as to Form: OFFICE OF THE KING COUNTY PROSECUTING ATTORNEY (This form is available in alternate formats for people with disabilities upon request.) tt� + . 0 KING COUNTY TERMS AND CONDITIONS Agreement Term and Termination A. This Agreement shall commence on the Agreement Start Date and shall terminate on the Agreement End Date as specified on page 1 of this Agreement, unless extended or terminated earlier, pursuant to the terms and conditions of the Agreement. B. This Agreement may be terminated by the County or the Recipient without cause, in whole or in part, prior to the Agreement End Date, by providing the other party thirty (30) days advance written notice of the termination. The Agreement may be suspended by the County without cause, in whole or in part, prior to the date specified in Subsection 1.A. above, by providing the Recipient thirty (30) days advance written notice of the suspension. C. The County may terminate or suspend this Agreement, in whole or in part, upon seven (7) days advance written notice in the event: (1) the Recipient materially breaches any duty, obligation, or service required pursuant to this Agreement, or (2) the duties, obligations, or services required herein become impossible, illegal, or not feasible. If the Agreement is terminated by the County pursuant to this Subsection 1.C. (1), the Recipient shall be liable for damages, including any additional costs of procurement of similar services from another source. If the termination results from acts or omissions of the Recipient, including but not limited to misappropriation, nonperformance of required services, or fiscal mismanagement, the Recipient shall return to the County immediately any funds, misappropriated or unexpended, which have been paid to the Recipient by the County. D. If County or other expected or actual funding is withdrawn, reduced, or limited in any way prior to the termination date set forth above in Subsection 1.A., the County may, upon written notification to the Recipient, terminate or suspend this Agreement in whole or in part. If the Agreement is terminated or suspended as provided in this Section: (1) the County will be liable only for payment in accordance with the terms of this Agreement for services rendered prior to the effective date of termination or suspension; and (2) in the case of termination the Recipient shall be released from any obligation to provide such further services pursuant to the Agreement ; and (3) in the case of suspension the Recipient shall be released from any obligation to provide services during the period of suspension and until such time as the County provides written authorization to resume services.. Funding or obligation under this Agreement beyond the current appropriation year is conditional upon appropriation by the County Council of sufficient funds to support the activities described in the Agreement. Should such appropriation not be approved, this Agreement will terminate at the close of the current appropriation year. E. Nothing herein shall limit, waive, or extinguish any right or remedy provided by this Agreement or law that either party may have in the event that the obligations, terms, and conditions set forth in this Agreement are breached by the other party. 2. Compensation and Method of Payment A. The County shall reimburse the Recipient for satisfactory completion of the services and requirements specified in this Agreement, payable upon receipt and approval by the County of a signed invoice in substantially the form of the attached Invoice Exhibit, which complies with the attached Budget Exhibit. B. The Recipient shall submit an invoice and all accompanying reports as specified in the attached exhibits not more than 15 working days after the close of each indicated reporting period. The County shall make payment to the Recipient not more than 30 days after a complete and accurate invoice is received. DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 C. The Recipient shall submit its final invoice and all outstanding reports within 30 days of the date this Agreement terminates. If the Recipient's final invoice and reports are not submitted by the day specified in this subsection, the County will be relieved of all liability for payment to the Recipient of the amounts set forth in said invoice or any subsequent invoice. D. When a budget is attached hereto as an exhibit, the Recipient shall apply the funds received from the County under this Agreement in accordance with said budget. The Agreement may contain separate budgets for separate program components. The Recipient shall request prior approval from the County for an amendment to this Agreement when the cumulative amount of transfers among the budget categories is expected to exceed 10% of the Agreement amount in any Agreement budget. Supporting documents necessary to explain fully the nature and purpose of the amendment must accompany each request for an amendment. Cumulative transfers between budget categories of 10% or less need not be incorporated by written amendment; however, the County must be informed immediately in writing of each such change. E. Should, in the sole discretion of the County, the Recipient not timely expend funds allocated under this Agreement, the County may recapture and reprogram any such under -expenditures unilaterally and without the need for further amendment of this Agreement. The County may unilaterally make changes to the funding source without the need for an amendment. The Recipient shall be notified in writing of any changes in the fund source or the recapturing or reprograming of under expenditures. F. If travel costs are contained in the attached budget, reimbursement of Recipient travel, lodging, and meal expenses are limited to the eligible costs based on the following rates and criteria. 1. The mileage rage allowed by King County shall not exceed the current Internal Revenue Service (IRS) rates per mile as allowed for business related travel. The IRS mileage rate shall be paid for the operation, maintenance and depreciation of individually owned vehicles for that time which the vehicle is used during work hours. Parking shall be the actual cost. When rental vehicles are authorized, government rates shall be requested. If the Recipient does not request government rates, the Recipient shall be personally responsible for the difference. Please reference the federal web site for current rates: http://www.gsa.gov. 2. Reimbursement for meals shall be limited to the per diem rates established by federal travel requisitions for the host city in the Code of Federal Regulations, 41 CFR § 301, App.A. Please reference l utt;/iwww. sa.ov for the current host city per diem rates. 3. Accommodation rates shall not exceed the federal lodging limit plus host city taxes. The Recipient shall always request government rates. 4. Air travel shall be by coach class at the lowest possible price available at the time the County requests a particular trip. In general, a trip is associated with a particular work activity of limited duration and only one round-trip ticket, per person, shall be billed per trip. Any air travel occurring as part of a federal grant must be in accordance with the Fly America Act. 3. Internal Control and Accounting S stem, The Recipient shall establish and maintain a system of accounting and internal controls which complies with generally accepted accounting principles promulgated by the Financial Accounting Standards Board (FASB), the Governmental Accounting Standards Board (GASB), or both as is applicable to the Recipient's form of incorporation. 4. Debarment and Suspension Certification Entities that are debarred, suspended, or proposed for debarment by the U.S. Government are excluded from receiving federal funds and contracting with the County. The Recipient, by signature FROWNWITIVARMONTai to this Agreement, certifies that the Recipient is not presently debarred, suspended, or proposed for debarment by any Federal department or agency. The Recipient also agrees that it will not enter into a sub -agreement with a Recipient that is debarred, suspended, or proposed for debarment. The Recipient agrees to notify King County in the event it, or a sub-awardee, is debarred, suspended, or proposed for debarment by any Federal department or agency. 5. Maintenance of Records/Evaluations and Inspections A. The Recipient shall maintain accounts and records, including personnel, property, financial, and programmatic records and other such records as may be deemed necessary by the County to ensure proper accounting for all Agreement funds and compliance with this Agreement. B. In accordance with the nondiscrimination and equal employment opportunity requirements set forth in Section 13. below, the Recipient shall maintain the following: 1. Records of employment, employment advertisements, application forms, and other pertinent data, records and information related to employment, applications for employment or the administration or delivery of services or any other benefits under this Agreement; and 2. Records, including written quotes, bids, estimates or proposals submitted to the Recipient by all businesses seeking to participate on this Agreement, and any other information necessary to document the actual use of and payments to sub-awardees and suppliers in this Agreement, including employment records. The County may visit the site of the work and the Recipient's office to review the foregoing records. The Recipient shall provide every assistance requested by the County during such visits and make the foregoing records available to the County for inspection and copying upon request. The Recipient shall provide right of access to its facilities—including those of any sub-awardee assigned any portion of this Agreement pursuant to Section 12—to the County, the state, and/or federal agencies or officials at all reasonable times in order to monitor and evaluate the services provided under this Agreement. The County will give advance notice to the Recipient in the case of fiscal audits to be conducted by the County. The Recipient shall comply with all record keeping requirements set forth in any federal rules, regulations or statutes included or referenced in the Agreement documents. The Recipient shall inform the County in writing of the location, if different from the Recipient address listed on page one of this Agreement, of the aforesaid books, records, documents, and other evidence and shall notify the County in writing of any changes in location within ten (10) working days of any such relocation. C. The records listed in A and B above shall be maintained for a period of six (6) years after termination of this Agreement. The records and documents with respect to all matters covered by this Agreement shall be subject at all time to inspection, review, or audit by the County and/or federal/state officials so authorized by law during the performance of this Agreement and six (6) years after termination hereof, unless a longer retention period is required by law. D. Medical records shall be maintained and preserved by the Recipient in accordance with state and federal medical records statutes, including but not limited to RCW 70.41.190, 70.02.160, and standard medical records practice. If the Recipient ceases operations under this Agreement, the Recipient shall be responsible for the disposition and maintenance of such medical records. E. The Recipient agrees to cooperate with the County or its agent in the evaluation of the Recipient's performance under this Agreement and to make available all information reasonably required by any such evaluation process. The results and records of said evaluations shall be maintained and disclosed in accordance with RCW Chapter 42.56. 4 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 F, The Recipient agrees that all information, records, and data collected in connection with this Agreement shall be protected from unauthorized disclosure in accordance with applicable state and federal law. 6. Compliance with the Health Insurance Portability and Accountabilit Ar_.t of 1996 (HIPAAI The Recipient shall not use protected health information created or shared under this Agreement in any manner that would constitute a violation of HIPAA and any regulations enacted pursuant to its provisions. Recipient shall read and certify compliance with all HIPAA requirements at http://www.kingcounty.gov/healthservices/health/partnerships/contracts 7. Audits A. If the Recipient, for-profit or non-profit, receives in excess of $100,000 in funds during its fiscal year from the County, it shall provide a fiscal year financial statement prepared by an independent Certified Public Accountant or Accounting Firm within six (6) months subsequent to the close of the Recipient's fiscal year. B. Additional audit or review requirements which may be imposed on the County will be passed on to the Recipient and the Recipient will be required to comply with any such requirements. 8. Corrective Action If the County determines that a breach of Agreement has occurred, that is, the Recipient has failed to comply with any terms or conditions of this Agreement or the Recipient has failed to provide in any manner the work or services agreed to herein, and if the County deems said breach to warrant corrective action, the following sequential procedure will apply: A. The County will notify the Recipient in writing of the nature of the breach; The Recipient shall respond in writing within three (3) working days of its receipt of such notification, which response shall indicate the steps being taken to correct the specified deficiencies. The corrective action plan shall specify the proposed completion date for bringing the Agreement into compliance, which date shall not be more than ten (10) days from the date of the Recipient's response, unless the County, at its sole discretion, specifies in writing an extension in the number of days to complete the corrective actions; B. The County will notify the Recipient in wrl#ing of the County's determination as to the sufficiency of the Recipient's corrective action plan. The determination of sufficiency of the Recipient's corrective action plan shall be at the sole discretion of the County; C. In the event that the Recipient does not respond within the appropriate time with a corrective action plan, or the Recipient's corrective action plan is determined by the County to be insufficient, the County may commence termination or suspension of this Agreement in whole or in part pursuant to Section 1.C.; D. In addition, the County may withhold any payment owed the Recipient or prohibit the Recipient from incurring additional obligations of funds until the County is satisfied that corrective action has been taken or completed; and E. Nothing herein shall be deemed to affect or waive any rights the parties may have pursuant to Section 1., Subsections B, C, D, and E. The parties shall use their best, good -faith efforts to cooperatively resolve disputes and problems that arise in connection with this Agreement. Both parties will make a good faith effort to continue without delay to carry out their respective responsibilities under this Agreement while attempting to resolve the dispute under this section. DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 10. LiabiliNforNecall ence Each party will be responsible for damages to the extent caused by the negligence of its officers, agents and employees arising from the performance of this agreement. Insurance Requirements By the date of execution of this Agreement, the Recipient shall procure and maintain for the duration of this Agreement, insurance against claims for injuries to persons or damages to property which may arise from, or in connection with, the performance of work hereunder by the Recipient, its agents, representatives, employees, and/or sub-awardees. The costs of such insurance shall be paid by the Recipient or sub-awardee. The Recipient may furnish separate certificates of insurance and policy endorsements for each sub-awardee as evidence of compliance with the insurance requirements of this Agreement. The Recipient is responsible for ensuring compliance with all of the insurance requirements stated herein. f=ailure by the Recipient, its agents, employees, officers, sub- awardee, providers, and/or provider sub-awardees to comply with the insurance requirements stated herein shall constitute a material breach of this Agreement. Specific coverages and requirements are at http://www.kingcounty.gov/healthservices/health/partnerships/contracts; Recipients shall read and provide required insurance documentation prior to the signing of this Agreement. Assignment/Sub-agreements A. The Recipient shall not assign or sub -award any portion of this Agreement or transfer or assign any claim arising pursuant to this Agreement without the written consent of the County. Said consent must be sought in writing by the Recipient not less than fifteen (15) days prior to the date of any proposed assignment. B. "Sub -agreement" shall mean any agreement between the Recipient and a sub-awardee or between sub-awardees that is based on this Agreement, fjroyided that the term a"sub-- awardee" does not include the purchase of (1) support services not related to the subject matter of this Agreement, or (2) supplies. C. The Recipient shall include Sections 2.D., 2.E., 3, 4, 5, 6, 10.A., 10.B., 10.G., 12, 13, 14, 15, 16, 17, 23, 24, 25, and the Funder's Special Terms and Conditions, if attached, in every sub - agreement or purchase agreement for services that relate to the subject matter of this Agreement. D. The Recipient agrees to include the following language verbatim in every sub -agreement for services which relate to the subject matter of this Agreement: "Sut awardee shall protect, defend, indemnify, and hold harmless King Cou11ty, its officers, employees and agents from any and all costs, claims, judgments, and/or awards of damages arising out of, or in any way resulting from the negligent act or omissions of sub-awardee, its officers, employees, and/or agents in connection with or in support of this Agreement. Sub- awardee expressly agrees and understands that King County is a third party beneficiary to this Agreement and shall have the right to bring an action against sub-awardee to enforce the provisions of this paragraph." 11. Nondiscrimination; Eaual Emoloyment onnortunity: Pavment of a Livina Waae The Recipient shall comply with all applicable federal, state and local laws regarding discrimination, including those set forth in this Section. A. During performance of the Agreement, the Recipient agrees that it will not discriminate against any employee or applicant for employment because of the employee or applicant's sex, race, color, marital status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or age except by minimum age and retirement provisions, unless based upon a bona fide occupational qualification. The Recipient will make equal employment DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 opportunity efforts to ensure that applicants and employees are treated, without regard to their sex, race, color, marital status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or age. Additional requirements are at http://www.kingcounty.gov/healthservices/health/partnerships/contracts; Recipients shall read and certify compliance. B. Requirements of King County Living Wage Ordinance In accordance with King County Ordinance 17909, as a condition of award for agreements beginning on or after April 1, 2015, for services with an initial or amended value of $100,000 or more, the Recipient agrees that it shall pay and require all sub-awardees and subcontractors to pay a living wage as described in the ordinance to employees for each hour the employee performs a Measurable Amount of Work on this Agreement. The requirements of the ordinance, including payment schedules, are detailed at http://www. kingcounty.gov/operations/procurement/Resources/ordinance-17909.aspx. Violations of this requirement may result in disqualification of the Recipient from bidding on or being awarded a County agreement or contract for up to two years; contractual remedies including, but not limited to, liquidated damages and/or termination of the Agreement; remedial action as set forth in public rule; and other civil remedies and sanctions allowed by law. For purposes of this Section, a "Measurable Amount of Work" is defined as a definitive allocation of an employee's time that can be attributed to work performed under this Agreement, but that is not less than a total of one hour in any one week period. 12. Conflict of Interest A. The Recipient agrees to comply with applicable provisions of K.C.C. 3.04. Failure to comply with such requirements shall be a material breach of this Agreement, and may result in termination of this Agreement pursuant to Section II and subject the Recipient to the remedies stated therein, or otherwise available to the County at law or in equity. B. The Recipient agrees, pursuant to KCC 3.04.060, that it will not willfully attempt to secure preferential treatment in its dealings with the County by offering any valuable consideration, thing of value or gift, whether in the form of services, loan, thing or promise, in any form to any county official or employee. The recipient acknowledges that if it is found to have violated the prohibition found in this paragraph, its current Agreements with the county will be cancelled and it shall not be able to bid on any county Agreement for a period of two years. C. The Recipient acknowledges that for one year after leaving County employment, a former County employee may not have a financial or beneficial interest in an agreement or grant that was planned, authorized, or funded by a County action in which the former County employee participated during County employment. Recipient shall identify at the time of offer current or former County employees involved in the preparation of proposals or the anticipated performance of Work if awarded the Agreement. Failure to identify current or former County employees involved in this transaction may result in the County's denying or terminating this Agreement. After Agreement award, the Recipient is responsible for notifying the County's Protect Manager of current or former County employees who may become involved in the Agreement any time during the term of the Agreement. 13. Equipment Purchase Maintenance. and Ownership A. The Recipient agrees that any equipment purchased, in whole or in part, with Agreement funds at a cost of $5,000 per item or more, when the purchase of such equipment is reimbursable as an Agreement budget item, is upon its purchase or receipt the property of the County and/or federal/state government. The Recipient shall be responsible for all such property, including the proper care and maintenance of the equipment. DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 B. The Recipient shall ensure that all such equipment will be returned to the County or federal/state government upon termination of this Agreement unless otherwise agreed upon by the parties. 14. Proprietary Riqhts The parties to this Agreement hereby mutually agree that if any patentable or copyrightable material or article should result from the work described herein, all rights accruing from such material or article shall be the sole property of the County. The County agrees to and does hereby grant to the Recipient, irrevocable, nonexclusive, and royalty -free license to use, according to law, any material or article and use any method that may be developed as part of the work under this Agreement. The foregoing products license shall not apply to existing training materials, consulting aids, checklists, and other materials and documents of the Recipient which are modified for use in the performance of this Agreement. The foregoing provisions of this section shall not apply to existing training materials, consulting aids, checklists, and other materials and documents of the Recipient that are not modified for use in the performance of this Agreement. 15. Political Agj vitt' Prohibited None of the funds, materials, property, or services provided directly or indirectly under this Agreement shall be used for any partisan political activity or to further the election or, defeat of any candidate for public office. 16. King County Recycled Product Procurement Policy In accordance with King County Code 18.20, the Recipient shall use recycled paper, and both sides of sheets of paper whenever practicable, when submitting proposals, reports, and invoices, if paper copies are required. 17. Future Support The County makes no commitment to support the services awarded for herein and assumes no obligation for future support of the activity awarded herein except as expressly set forth in this Agreement. 18. EntireACtreernentlWaiver of Default The parties agree that this Agreement is the complete expression of the terms hereto and any oral or written representations or understandings not incorporated herein are excluded. Both parties recognize that time is of the essence in the performance of the provisions of this Agreement. Waiver of any default shall not be deemed to be a waiver of any subsequent default. Waiver or breach of any provision of the Agreement shall not be deemed to be a waiver of any other or subsequent breach and shall not be construed to be a modification of the terms of the Agreement unless stated to be such through written approval by the County, which shall be attached to the original Agreement. 19. Amendments Either party may request changes to this Agreement. Proposed changes which are mutually agreed upon shall be incorporated by written amendments to this Agreement. Changes to the County's Agreement numbering system or fund source may be made unilaterally by the County and without the need for amendment of this Agreement. The Recipient shall be notified in writing of any changes in the Agreement number or fund source assigned by the County; provided, however, that the total compensation allocated by the County through this Agreement does not change. 20. Notices Whenever this Agreement provides for notice to be provided by one party to another, such notice shall be in writing and directed to the chief executive office of the Recipient and the project representative of the County department specified on page one of this Agreement. Any time within 8 which a party must take some action shall be computed from the date that the notice is received by said party. 21. Services Provided in Accordance with Law and Rule and Rec ulatton The Recipient and any sub-awardee agree to abide by the laws of the state of Washington, rules and regulations promulgated thereunder, and regulations of the state and federal governments, as applicable, which control disposition of funds granted under this Agreement, all of which are incorporated herein by reference. In the event that there is a conflict between any of the language contained in any exhibit or attachment to this Agreement, the language in the Agreement shall have control over the language contained in the exhibit or the attachment, unless the parties affirmatively agree in writing to the contrary. 22. Applicable Law This Agreement shall be construed and interpreted in accordance with the laws of the State of Washington. The venue for any action hereunder shall be in the Superior Court for King County, Washington. 23. Electronic Processinq and Siqnatures The parties agree that this Agreement may be processed and signed electronically, which if done so, will be subject to additional terms and conditions found at hUps ` /www.docusr n.corn/corn pan It rrn of -use. The parties acknowledge that they have consulted with their respective attorneys and have had the opportunity to review this Agreement. Therefore, the parties expressly agree that this Agreement shall be given full force and effect according to each and all of its express terms and provisions and the rule of construction that any ambiguities are to be resolved against the drafting party shall not be employed in the interpretation of this Agreement. The parties executing this Agreement electronically have authority to sign and bind its represented party to this Agreement. 24. No ThirdParty Beneficiaries Except for the parties to whom this Agreement is assigned in compliance with the terms of this Agreement, there are no third party beneficiaries to this Agreement, and this Agreement shall not impart any rights enforceable by any person or entity that is not a party hereto. END OF COUNTY TERMS AND CONDITIONS DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions This Agreement is funded in whole or in part by the US Government Department of Health and Human Services, through the Washington State Department of Health Contract No. C17123 with PHSKC, CFDA No. 93.994. In addition to King County's general terms and conditions, the Recipient shall also comply with the terms and conditions of the funder in this Exhibit. 1. Subrecipients shall comply with Title 2 CFR Part 200 — Uniform Administrative Requirements, Cost Principles, and Audit Requirements as appropriate for the subrecipient's organization type. 2. 2 CFR Part 200 Subpart F —Audit Requirements A. If the Recipient or subrecipient is a non-profit organization as defined in 2 CFR Part 200, and expends a total of $750,000 or more in federal financial assistance and has received federal financial assistance from the County during its fiscal year, then the Recipient or subrecipient shall meet the respective audit requirements described herein as applicable. B. If the Recipient is a non-profit organization, it shall have an independent audit conducted of its financial statement and condition, which shall comply with the requirements of GAAS (generally accepted auditing standards); GAO's Standards for Audits of Governmental Organizations, Programs, Activities, and Functions; and 2 CFR Part 200 Subpart F, as amended, and as applicable. The Recipient shall provide a copy of the audit report to each County division providing financial assistance to the Recipient no later than nine (9) months subsequent to the end of the Recipient's fiscal year. The Recipient shall provide to the County its response and corrective action plan for all findings and reportable conditions contained in its audit. When reference is made in its audit to a "Management Letter" or other correspondence made by the auditor, the Recipient shall provide copies of those communications and the Recipient's response and corrective action plan. Submittal of these documents shall constitute compliance with this requirement. C. If the Recipient is a Washington state municipal entity or other government institution or jurisdiction, it shall submit to the County a copy of its annual report of examination/audit, conducted by the Washington State Auditor, within thirty (30) days of receipt, which submittal shall constitute compliance with this requirement. U.S. Department of Health and Human Services (HHS) Requirements This Agreement is subject to the requirements of the HHS Grants Policy Statement (HHS GPS) that are applicable (any references in the GPS to 45 CFR 74 or 92 are now replaced by 2 CFR 200 and 45 CFR Part 75), and requirements imposed by program statutes and regulations, Executive Orders, and HHS grant administration regulations, as applicable; as well as any requirements or limitations in any applicable appropriations acts. The HHS GPS is available at htlm//www�P�k�.�ov0a�i'rb1/b �wor�19�1_sgP,LO .pll'w Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS awards are at 45 CFR Part 75 effective December 26, 2014. 4. Division G, Title II of the Consolidated and Further Continuing Appropriations Act, 2015 (Public Law 113-235) limits the use of federal funds from the HHS Office of the Assistant Secretary for Health (OASH) on all grant or cooperative agreements henceforth including the current budget period. (1) Restriction on Distribution of Sterile Needles (Section 521) DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions "Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drug." (2) Salary Limitation (Section 203) "None of the funds appropriated in this title shall be used to pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of Executive Level II." Effective January 11, 2015, the Salary Limitation is based upon the Executive Level 11 of the Federal Executive Pay Scale. That amount is $183,300. For the purposes of the salary limitation, the direct salary is exclusive of fringe benefits and indirect costs. An individual's direct salary is not constrained by the legislative provision for a limitation of salary. The rate limitation simply limits the amount that may be awarded and charged to the grant. A recipient may pay an individual's salary amount in excess of the salary cap with non-federal funds. 5. CERTIFICATION REGARDING LOBBYING Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain 1edcral contracting and Imancial transactions," generally prohibits recipients of Federal grants and cooperative agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of' the Federal Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying undertaken with non -Federal (nonappropriated) funds, These requirements aplDly to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93). The Contractor certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the Contractor, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a. Member of Cmigress in connection with this Federal contract, grant, loan, or cooperative agreement, the Contractor shall complete and submit Standard Form -LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Form -LLL, "Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this application form.) (3) The Contractor shall require that the language of this certification be included in the award documents for all subcontracts at all tiers (including subcontracts, subcontracts, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, U.S. Code. Any person who fails to file the W DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. (b) No part of any appropriation contained in this Act or transferred pursuant to section 4002 of Public Law 111-148 shall be used to pay the salary or expenses of any grant or contract recipient, or agent acting for such recipient, related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or Executive order proposed or pending before the Congress or any State government, State legislature or local legislature or legislative body, other than for normal and recognized executive -legislative relationships or participation by an agency or officer of a State, local or tribal government in policymaking and administrative processes within the executive branch of that government. (c) The prohibitions in subsections (a) and (b) shall include any activity to advocate or promote any proposed, pending or future Federal, State or local tax increase, or any proposed, pending, or future requirement or restriction on any legal consumer product, including its sale or marketing, including but not limited to the advocacy or promotion of gun control." (4) Gun Control (Section 217) "None of the funds made available in this title may be used, in whole or in part, to advocate or promote gun control." 6. Trafficking in Persons This award is subject to the requirements of Section 106 (g) of the Trafficking Victims Protection Act of 2000, as amended (22 U.S.C. 7104) a. Provisions applicable to a recipient that is a private entity. 1. You as the recipient, your employees, subrecipients under this award, and subrecipients' employees may not — i. Engage in severe forms of trafficking in persons during the period of time that the award is in effect; ii. Procure a commercial sex act during the period of time that the award is in effect; or iii. Use forced labor in the performance of the award or subawards under the award. 2. We as the Federal awarding agency may unilaterally terminate this award, without penalty, if you or a subrecipient that is a private entity — i. Is determined to have violated a prohibition in paragraph a.I of this award term; or ii. Has an employee who is determined by the agency official authorized to terminate the award to have violated a prohibition in paragraph a. I of this award term through conduct that is either — A. Associated with performance under this award; or DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions B. Imputed to you or the subrecipient using the standards and due process for imputing the conduct of an individual to an organization that are provided in 2 CFR part 180, "OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurernent)," as implemented by our agency at 2 CFR part 376. b. Provision applicable to a recipient other than a private entity. We as the Federal awarding agency may unilaterally terminate this award, without penalty, if a subrecipient that is a private entity — 1. Is determined to have violated an applicable prohibition in paragraph a.1 of this award term; or 2. Has an employee who is determined by the agency official authorized to terminate the award to have violated an applicable prohibition in paragraph a. l of this award term through conduct that is either — i. Associated with performance under this award; or ii. Imputed to the subrecipient using the standards and due process for imputing the conduct of an individual to an organization that are provided in 2 CFR part 180, "OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement)," as implemented by our agency at 2 CFR part 376. c. Provisions applicable to any recipient. 1. You must inform us immediately of any information you receive from any source alleging a violation of a prohibition in paragraph a.1 of this award term 2. Our right to terminate unilaterally that is described in paragraph a.2 or b of this section: i. Implements section 106(g) of the Trafficking Victims Protection Act of 2000 (TVPA), as amended (22 U.S.C. 7104(g)), and ii. Is in addition to all other remedies for noncompliance that are available to us under this award. 3. You must include the requirements of paragraph a.1 of this award term in any subaward you make to a private entity. d. Definitions. For purposes of this award term: 1. "Employee" means either: i. An individual employed by you or a subrecipient who is engaged in the performance of the project or program under this award; or 12 Exhibit A — Special Terms and Conditions ii. Another person engaged in the performance of the project or program under this award and not compensated by you including, but not limited to, a volunteer or individual whose services are contributed by a third party as an in-kind contribution toward cost sharing or matching requirements. 2. "Forced labor" means labor obtained by any of the following methods: the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. 3. "Private entity": i. Means any entity other than a State, local government, Indian tribe, or foreign public entity, as those terms are defined in 2 CFR 175.25. ii. Includes: A. A nonprofit organization, including any nonprofit institution of higher education, hospital, or tribal organization other than one included in the definition of Indian tribe at 2 CFR 175.25(b). B. A for-profit organization. 4. "Severe forms of trafficking in persons," "commercial sex act," and "coercion" have the meanings given at section 103 of the TVPA, as amended (22 U.S.C. 7102) 7. Grantee is hereby given notice that the 48 CFR section 3.908, implementing section 828, entitled "Pilot Program for Enhancement of Contractor Employee Whistleblower protections," of the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2013 (Pub. L. 112-239, enacted January 2, 2013) applies to this award. In any grant -related activity in which family, marital, or household considerations are, by statute or regulation, relevant for purposes of determining beneficiary eligibility or participation, grantees must treat same-sex spouses, marriages, and households on the same terms as opposite -sex spouses, marriages, and households, respectively. By "same-sex spouses," HHS means individuals of the same sex who have entered into marriages that are valid in the jurisdiction where performed, including any of the 50 states, the District of Columbia, or a U.S. territory or in a foreign country, regardless of whether or not the couple resides in a jurisdiction that recognizes same-sex marriage. By "same-sex marriages," HHS means marriages between two individuals validly entered into in the jurisdiction where performed, including any of the 50 states, the District of Columbia, or a U.S. territory or in a foreign country, regardless of whether or not the couple resides in a jurisdiction that recognizes same-sex marriage. By "marriage," HHS does not mean registered domestic partnerships, civil unions or similar formal relationships recognized under the law of the jurisdiction of celebration as something other than a marriage. ASSURANCES — NON CONSTRUCTION PROGRAMS Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503 PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the Recipient, I certify that the Recipient: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non -Federal share of project cost) to ensure proper planning, management, and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4, Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728-4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is 6 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions being made; and 0) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. 1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis -Bacon Act (40 U.S.C. 276a to 276a-7), the Copeland Act (40 U.S.C. 276c and 18 U.S.C. 874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333), regarding labor standards for federally assisted construction subagreements. 10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93- 205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1721 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a -I et seq.). 14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 7 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit A — Special Terms and Conditions 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.) which prohibits the use of lead- based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, Audits of States, Local Governments, and Non -Profit Organizations. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program. 8 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit B: Scope of Work CDIP4197 JEFFERSON COUNTY PUBLIC HEALTH CLINICAL and CLIENT SUPPORT SERVICES, OUTREACH & RECRUITMENT July 1, 2016 through June 14, 2017 BACKGROUND The Breast, Cervical, and Colon Health Program (BCCHP) helps eligible clients get screened for breast, cervical, and colorectal cancers, and connects clients with diagnostic services and treatment when needed. The program serves clients with low incomes and who lack health insurance coverage for cancer screening. BCCHP improves access to services, especially for people who face extra barriers to getting health care. PURPOSE Jefferson County Public Health will enroll BCCHP eligible clients and provide recommended cancer screening services. They will refer BCCHP enrolled clients with abnormal cancer screening results to other BCCHP contracted providers for appropriate follow-up services. They will also use outreach activities outlined below to recruit clients for the BCCHP. SERVICES Enrollment Site: Annual exam with Clinical Breast Exam (CBE) Problem -focused visit Pap tests HPV tests ELIGIBLE POPULATION Women — all services; Breast screening & annual exam Cervical^ 40-64, or If last pap normal & > 3 years or co - 35 -39, if being seen for breast testing (Pap normal and HPV symptoms, or negative) > 5 years: 64+ if ineligible for Medicare • 40-64 • 35-39, if being seen for breast Priorit for Mammo rah symptoms • Ages 50 or older, and last mammogram > 2 years ^As per USPSTF 2012 Cervical Cancer • Suspicious breast findings Screening Guidelines. If not eligible for Pap Strong family history or other Test, pelvic exam paid only if done as part of ' g y y visit for breast screening/annual exam high risk At or below 250% of Federal' Poverty Level (FPL)*, Uninsured or Underinsured (deductible over,$500) Ineligible for Apple Health (Medicaid) —'documentation" required _ �Washingto6State,Residents "mammographv and breast diagnostics available to clients at or below 300% FPL CDIP4197 Jefferson County Public Health Page 1 of 4 DocuSign Envelope ID: 796CC24A-67F2-4421-86AD-AACA5F704821 ENROLLMENT Some populations have lower screening and/or higher morbidity or mortality rates. Jefferson will focus enrollment efforts on clients who: • Have never or rarely received breast or cervical services • Are ages 50 or older (breast services) or 40-49 (cervical services) • Are new to BCCHP • Are from a racial or ethnic minority population, including African American, Asian, Pacific Islander, American Indian/Alaskan Native, and Hispanic/Latina • Are lesbian, gay, bisexual, or transgender • Have a disability (as defined by the client) • Have a strong family history or other high risk, including ages 40-49 for breast services The contractor will obtain informed consent before performing services, and mail completed enrollment and consent forms to BCCHP (within the timeframe listed below under "reimbursement process"). PERFORMANCE REQUIREMENTS Clinical Services The Contractor will: • Make best efforts to comply with CDC and DOH Performance Indicators: o Assist the client to complete the diagnostic work-up within 60 days of a documented abnormal breast finding. o Assist the client to start breast cancer treatment within 60 days of a documented diagnosis of breast cancer or breast pre -cancer. o Assist the client to start cervical cancer treatment within 90 days of a documented diagnosis of cervical cancer or pre -cancer. • Document attempts to contact each client for follow-up services per BCCHP protocol. It is thecontractor's responsibilit to get clients in for timely follow-up. • Review and follow instructions in the Contractor's Procedure Manual, available at: htt ://www.{<ion court . ovlhealthserviceslhealthlchronic/bch /down load .a • Document that administrative and health bare personnel who work with BCCHP clients review the DOH online BCCHP training modules that correspond to their work. See: Ihfitp1/dohmedia doh.w�cr • Maintain HIPAA regulated confidentiality of all BCCHP client data and medical records. • Provide effective, understandable, and respectful care to clients in their preferred language, Make reasonable efforts to provide care that is compatible with clients' cultural health beliefs and practices. • Maintain documentation of current WA State licensure and/or certification for all health care professionals who perform medical procedures under this contract. Present documentation to BCCHP staff upon request. • Send a representative to the annual BCCHP mandatory meeting and a minimum of two other meetings and/or trainings as scheduled by the DOH or Public Health. • Work with BCCHP staff to distribute educational materials, upon request. CDIP4197 Jefferson County Public Health Page 2 of 4 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Client Support Services at Jefferson The contractor will: 1.. Track BCCHP clients to make sure they receive timely follow-up after abnormal breast or cervical cancer findings. Monitor clients until they receive a diagnosis. 2. Implement a re -screening reminder system for BCCHP clients. 3. Document scheduling for appropriate follow-up tests and return appointments. 4. Review and give test results to clients in a timely manner. 5. Document all findings and send to Public Health. REIMBURSEMENT PROCESS: The Contractor will: • Complete program reimbursement forms and, if applicable, diagnostic forms. If available, include U1390s or Health Insurance Claim Forms with reports attached. Program forms are available online at: lett /l rww.k4r gc LwL _.gov/h alth ervicos/health/rl�ro.niclb owr Noads,a • Make best efforts to submit reimbursement forms to BCCHP at Public Health within 10 business dais from the date of service. • Accept the amounts for CPT -coded services listed on the current BCCHP Fee Schedule. • Certify that work to be performed under this contract does not duplicate any work to be charged against any other contract, subcontract, or other funding source. • Monitor funds spent and clients scheduled, to stay within the total budget. • In the case of any overpayment, contact BCCHP staff before takin an action to discuss how to correct the error. Review BCCHP-generated invoices promptly, and approve by mailing a signed original to BCCHP. BCCHP will not pay for services if we receive reimbursement forms later than 45 days from the service date. We will evaluate exceptions on a case-by-case basis. We may impose an earlier deadline to submit forms for June services, to achieve timely fiscal year-end close out. REIMBURSEMENT LIMITS: Pavment will not exceed the total budgeted contract amounit (Exhibit Cl_._ Exhibit C shows the "anticipated number of clients" (sometimes called "slots") that the clinical funding may cover for each type of service. These are estimates based on average historical costs per type of clinical service. Since costs may vary, these estimates are only gudeline to show a possible mix of services that the Contractor could provide with total available funds. Please carefully review Exhibit C. CDIP4197 Jefferson County Public Health Page 3 of 4 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 REIMBURSEMENT PROCEDURES BCCHP at Public Health will: • Pay for services provided within the corresponding contract period. • Send the current Fee Schedules for Breast and Cervical Cancer Screening to the Contractor, as well as any subsequent revisions. Revisions will replace earlier versions. • Pay for CPT -coded services at rates listed on the Fee Schedule. When applicable, payment will include facility fee costs, as described on the Fee Schedule. We reimburse clinic services at "Professional non -facility office" rates. • Monitor contracted funds. • Generate monthly clinical services billing reports for the contractor, based on forms the contractor submits. The reports will detail client names, dates of service, CPT codes, and fees. • Create a monthly invoice from the billing reports and send to the Contractor to review and approve. • Pay the Contractor based on the approved invoice. The Contractor will not bill BCCHP clients for any differences between service charges and BCCHP reimbursement. CDIP4197 Jefferson County Public Health Page 4 of 4 Exhibit C: Budget Jefferson County Public Health 615 Sheridan St Port Townsend, WA 98368 July 1, 2016 - June 14, 2017 BUDGET DETAIL Breast and Cervical Health Services Includes one or more of the following: annual exam with Clinical Breast Exam (CBE), problem -focused visit, Pap tests, HPV tests. Total Fundina M. TOTALFUNDS ALLOCATED 500.00 500.00 Services will -Be paid by CPT code actor ing to the rates listed on the Most GUrreni breast, Cervical, and Colon Health Program Fee Schedule. The fee schedule changes annually on JUN 1. Anticipated #s BCHP 4 CDIP4197 - Jefferson County Public Health BCHP Services averaae $125/client III Jefferson County Public Health 6ISSheridan St Port Townsend, VVA9836O ]uUaDanskin (360) 385-9420 Submit signed hardcopy invoice to: Amber Roche King County Accounts Payable Information Purchase Order If Supp|iexNanme JEFFERSON COUNTY Supplier 11 6649 Supplier, pay site PUBLIC HEALTH Remit Address 615 Sheridan Port Townsend, WA 98368 Invoice Date Invoice AmmumttmbePaid Note tmAP Pay Immediately RenmitQmocriptiou BCCHP internal contact & phone ArnberRmche782Q5 Public Health -Seattle & King County Breast, Cervical, and Colon Health Program 4O1Fifth Avenue, Suite 1110 Semtt|e/VVA981O4 Project Manager Phone: 206'262'8205 Contract Number: CD|P4197 Exhibit # (if app|icab|e): 0 PnojectName(if opp|icob|e): BC[H9 invoice for services rendered under this contract for the period of: [] Check this box ifthis ixthe final reimbursement request for this contract Fund Source Project Org Expend. Type Task Award Cost Total This Cumulative Budget Request to Date Balance Total Request $ 1,the undersigned, u^hereby certify under penalty ovperjury, that this matrue and correct claim for reimbursement services rendered. /unmerstanmthat any Taoeclaims, statements, documents, mconcealment mmaterial fact may be prosecuted under applicable Federal and State laws. This certlficatlon includes any attachments which serve assupporting documentation oothis reimbursement request. DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 Exhibit E Service Authorization Form BCCHP Program Contract #CDIP4197 Contractor: Jefferson County Public Health 615 Sheridan Port Townsend, WA 98368 Service Authorization Effective Date: Public Health Seattle & King County hereby amends the not to exceed arnount and authorizes the following not -to - exceed amount for the set -vices provided in the Scope of Work Exhibit under the above referenced contract at the rates set forth in the Budget Exhibit: .... . ..... . ..... . . Description Original not Amended additional Total to exceed amount reimbursable amount amount Breast and Cervical Services: Annual exam with Clinical Breast $500 Exam (CBE), problem -focused visit, Pap tests, HPV tests. .......... . . . . ........ . Total reimbursable Contract $500 $ Amount The total reimbursement shall not exceed the amount set forth in this Service Authorization Form —FUNDING 60k-dit–s- ORIGINAL ADDITIONAL_ TOTAL—" EFFECTIVE"' FUNDING FUNDING FUNDING DATES LEVELS LEVELS FEDERAL Federal Catalogue No. $500 $ $ 7/1/16 – 6/14/17 93.752 TOTAL " .. ...... . . $500 Public Health Signature Date Name 7/2016 DocuSign Envelope ID: 796CC24A-67F2-4421-86A0-AACA5F704821 EXHIBIT F k^lltC+1("'t?liW1�il''�l' t';fi''dC71tCCle,'R�tD� CERTIFICATE ISSUED A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDERTHIS CERTIFICATE DOESNOT AMEND, EXTEND OR ALTER THE JOINT SELF-INSURANCE LIA13Il..rry COVERAGE AFFORDED BY THE WASHINGTON COUNTIES RISK POOL Ml SVSIolm COUNTY: I.latopMy Coverage Afforded by the: JetUrso!u. County, Washington W'anhinplton Counties RislcPool Ai ii; Philip Morley, County Administrator 2558 R W Johnson Rd SW, Suite 106 1't'1 Box 1220 "1wnwwa, WA 985124103 Port TowtiSEnd, WA 98368 j3 ,ffeNq n County (the "County") is a member of the Washington Counties Risk Pool (the "Pool"), as authorized by RCW 48.62.03 1, and the County is covered by the Pool's Joint Self -Insurance Liability Program. The Pool's Joint Self -Insurance Liability Program was created by interlocal cooperative agreement amongst the Pool's member counties to share risks by "jointly, self-insuring" certain tturd- party liabilities. The Pool is NOT an insurance company. Claims that are covered under a Memorandum of Liability Coverage (11MLC'11) from the Pool and were submitted under Chapter 4.96 RCW ("Actions against political subdivisions, municipal and quasi- riiun cipal corporations") against the County, its employees, officers, volunteers and agents and/or actions in connection with or incWe tal to the performance of an agreement/contract which the County and/or its officers, employees or volunteers are found to be IGable for will be paid by the Pool and/or the County, Nfl,C NUMBER; 201 �i241StRItIial4.IM{1OL II+tM°O MLC EFFECTIVE DATE: t' 010hu, 1, 2015 NILC EXPIRATION DATE: ootobo 1, 2016 I,l'MJ.1'S OF LIABLITY EACIi OCCURRENCE LSI AND W) CONIl11pl1t17: It1 OOU 000 TYPES OF LIABILITY CO ?EItAf;E AFFORDED: Gerl.vtl l.,lnbil'liv, Includurg: Bodily Injury Personal Injury Property Damage Errors and Omissions/Professional Advertising Injury i�ulorwtola,llis I'Jfal�llltt, l�Il,°dC"llll'1°Ii31� Q�lr I�J`ItillttL"ltLN4/I 17C'A"I"II,II'tri!YI"`LIIIa�gI' t"'r�1sIC ItlyJ.,;ATIt��a' SIH{)IpI,IJ THE ABOVE DESCRIBED MLC BE CANCELLED BEFORE TNG EXPIRATION DATE THEREOF, THE ISSUER A, n lutlne the genoral public to enroll in affordable WILL ENDEAVOR TO PROVIDE THIRTY (30) DAYS WRITTEN Eiaaltpt we under the new regulations NO]'ICI1 TO THE CERTIFICATE HOLDER, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION NOR LIABILITY OF ANY I,,IND UPON THE ISSUER OR ITS AGENTS OR During the MLC l'erlod 10/1/15 - 10/1/16 REPRESENTATIVES. IITIi"Jf"A9 l IIOI:,tlJJilt JSgI1J', JJA fJt,: 4i+,ltirlwtrfl'a (',1101Ctt Begion,il Health Nd worts Claims Assistant