HomeMy WebLinkAboutHCA and KCPHD Amendment 3Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
12/19/2017
Fund/Department
116 -Public Health
Contract/Grant Information
IAgenda Date
-„
r'
1-1'1--11 i P"Y
Contract /Grant Agency: HCA and KCPHD Amendment 3
Period Begin Date: 01/01/2018 Period End Date: 06/30/2018
Total Grant/Contract Amount: $4750.00
Grant/Contract Number: K763
Contract/Grant Summary:
The HCA and KCPHD Amendment 3 to extend the term of the agreement from January 1, 2018- June 30,
2018 and add funding for that period.
Recommendation for Board of Health and Board of Health Review on
Department Head Signature: , Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office Date
Signature of Auditor's Office
Signature of Board of Health member
Date
Date
Financial Information
Total Amount $4,750 State Funds $2,375 Federal Funds $2,375
Percentage County Funds Matching Funds $ CFDA#93.778
In -Kind $
Explain
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring — reporting requirements
Grant/Contract Review Page 1
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed?
New Division Created?
Revenue Code
Yes ❑ attach budget form x D,Nhy not
116.612.24.1.333.93.778 - $2,375
116.612.24.1.334.06.901- $2,3175
Pass Through Information
ncy to Pass Th
Amount to Pass Through $
Sub -Contract Approved Date:
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes ❑ No
already budgeted
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
Signature: Date:
Department:
Assignment of Tracking Information
..........
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer I Date
Grant/Contract Review Page 2
Washington StateCONTRACT HCA Contract No.: K763
Health CareAljf�ho'rityAMENDMENT Amendment No.: 03
For
ABCD Dental Services
Kittitas County
THIS AMENDMENT TO THE CONTRACT is between the Washington State Health Care Authority
and the party whose name appears below, and is effective as of the date set forth below.
CONTRACTOR NAME
Kittitas County Public Health Network
CONTRACTOR ADDRESS
507 North Nanum Street, Suite 201,
Ellensburg, WA 98926
CONTRACTOR CONTACT
Kasey Knutson
CONTRACTOR CONTACT EMAIL ADDRESS
kasey.knutson@co.kittitas.wa.us
WHEREAS, HCA and Contractor previously entered into a Contract for utilization of dental services
early in life, improved oral health, and Apple Health/Medicaid cost savings, and;
WHEREAS, HCA and Contractor wish to amend the Contract pursuant to Section 4 Consideration and
Section 5 Term, and;
NOW THEREFORE, the parties agree the Contract is amended as follows:
1. Section 4. Special Terms and Conditions. Consideration. The consideration is increased by the
same amount allocated from the previous contract period. Maximum consideration is hereby
increased for this amendment by $4,750.
2. Section 5. Special Terms and Conditions. Term. The period of performance is hereby
extended from January 1, 2018 through June 30, 2018.
3. This Amendment will be effective January 1, 2018 ("Effective Date").
4. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the
Contract.
5. All other terms and conditions of the Contract remain unchanged and in full force and effect.
The parties signing below warrant that they have read and understand this Amendment and have
authority to execute the Amendment. This Amendment will be binding on HCA only upon signature by
HCA.
CONTRACTOR SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
HCA SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
James W. Gayton
Contracts Administrator
HCA Contract No.«Contract—Number)) Page 1 of 1