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Home My WebLink AboutHCA Amendment for ABCD Kittitas County (K2747 Amendment 1)Kittitas County AAA Review Form rrrr. s •ui n rr Grants & Contract Agreement *451,39 Today's Date Agenda Date 03/13/2019 Fund/Department 116 -Public Health Contract/Grant Information Contract /Grant Agency: HCA Amendment for ABCD Kittitas County Period Begin Date: 10/01/2018 Period End Date: 12/31/2018 Total Grant/Contract Amount: $2375.00 Grant/Contract Number: K2747 Amendment 1 Contract/Grant Summary: The HCA amendment amends the contract to provide clarification of the 2nd quarter for year one 2018- 2019 Exhibit A, titled ABCD Quarterly Outreach and Case Management Contract Report, by replacing Exhibit A for 2nd Quarter contract 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: ighiat re of Prose utor's Obqce Date Sign tux of uditor's Office Date Signature of Board of Health member Date Financial Information Total Amount $ 2,375 State Funds $ 2,375 Federal Funds $ Percentage County Funds Matching Funds $ CFDA# In -Kind $ Explain Grant/Contract Review Page 1 Is Equipment being purchased? Who owns equipment? New Personnel being hired? Contact HR hiring — reporting requirements Future impacts or liability to Kittitas County: Budget Information Budget Amendment Needed? Yes ❑ attach budget form No [:]why not New Division Created? Revenue Code 116.612.24.1.334.06.901 State Funds 10/01/18-12/31/18 Prosecutor 2nd Qtr Year One 2018-2019 Pass Through Information Agency to Pass Through Amount to Pass Through $ Sub -Contract Approved Date: Prosecutor Review Has the Prosecutor reviewed this agreement? Yes ❑ No ❑ County Departments Impacted 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 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 WHEREAS, HCA and Contractor previously entered into a Contract to provide 'Access to Baby and Child Dentistry' services to detect and prevent early childhood dental decay by engaging dentists in seeing birth to six (6) year old Medicaid eligible children and engaging local public health departments in outreach and case management, and; WHEREAS, HCA and Contractor wish to amend the Contract to provide clarification of 2nd Quarter for Year One 2018-2019 Exhibit A, titled ABCD Quarterly Outreach and Case Management Contract Report, by replacing in its entirety, the Exhibit A for 2nd Quarter contract period; NOW THEREFORE, the parties agree the Contract is amended as follows: 1. Exhibit A. Titled ABCD Quarterly Outreach and Case Management Contract Report. Replace in its entirety, the below revised 2nd Quarter for Year One 2018-2019 Exhibit A form, for the 10/1/18 through 12/31/18 time period. There are no fiscal allocation changes for this amendment. 2. This Amendment will be effective as of the last date of signature shown below ("Effective Date"). 3. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the Contract. 4. 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 CONTRACT HCA Contract No.: U747 Washington State AMENDMENT Amendment No.: 01 Health Care HCA SIGNATURE For DATE SIGNED uthority ABCD DENTAL SERVICES Contracts Administrator 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 CONTRACTOR doing business as (DBA) Kittitas County Public Health Network CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS IDENTIFIER 507 North Nanum Street, Suite 201 (UBI) Ellensburg, WA 98926 WHEREAS, HCA and Contractor previously entered into a Contract to provide 'Access to Baby and Child Dentistry' services to detect and prevent early childhood dental decay by engaging dentists in seeing birth to six (6) year old Medicaid eligible children and engaging local public health departments in outreach and case management, and; WHEREAS, HCA and Contractor wish to amend the Contract to provide clarification of 2nd Quarter for Year One 2018-2019 Exhibit A, titled ABCD Quarterly Outreach and Case Management Contract Report, by replacing in its entirety, the Exhibit A for 2nd Quarter contract period; NOW THEREFORE, the parties agree the Contract is amended as follows: 1. Exhibit A. Titled ABCD Quarterly Outreach and Case Management Contract Report. Replace in its entirety, the below revised 2nd Quarter for Year One 2018-2019 Exhibit A form, for the 10/1/18 through 12/31/18 time period. There are no fiscal allocation changes for this amendment. 2. This Amendment will be effective as of the last date of signature shown below ("Effective Date"). 3. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the Contract. 4. 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 zv; S+�v► Lit w► b Administrator HCA SIGNATURE PRINTED NAME AND TITLE DATE SIGNED James W. Gayton Contracts Administrator HCA Contract No. K2747 Page 1 of 2 Amendment #01 Exhibit A — ABCD Quarterly Outreach & Case Management Report Year One 2018 — 2019 s 2nd Quarter Report Please complete and submit report electronically to: Janice Tadeo, Dental Program Administrator Division of Health Care Services, Washington State Health Care Authority PO Box 45506, Olympia, WA 98504-5506 Phone: (360) 725-1583 Email: Janice.Tadeo HCA.WA.GOV Organization: Kittitas County Public Health Network ABCD Contact Person: Kasey Knutson kasey.knutson@co.kittitas.wa.us Phone: 509/962-7029 2nd Quarter Report Due: 10/1/18- 01/31/2019 12/31/18 Maximum $$ Brief description (for events, provide date held/attended/ for available for staff assignments, provide name and title) - no more than 100 this words (complete Exhibit A and attach supporting document if Performance Category Yes/No deliverable providing additional detail) Contact at least 10% of client list $450 Complete Exhibit B Attend and participate _ in ABCD Coordinator/Program i Meeting $500 Community and Provider Outreach_ $960 Complete Exhibit B Coordinate Care $465 Complete Exhibit B HCA Contract No. K2747 Page 2 of 2 Amendment #01