HomeMy WebLinkAboutAmendment ABCD DentalCONTRACT HCA Contract No.: K2747
AMENDMENT Amendment No.: 01
For
Wa shington State {\(ith --j
Healt h Care uth ority ABCD DENTAL SERVICES
Kittitas County
THIS AMENDMENT TO THE CONTRACT is between the Washington State Health Care Authority
and the pa rty whose na me appears below, and is effective as of the date set forth below.
CONTRACTOR NAM E CONTRACTOR doing business as (O BA)
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 2 nd 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 SIGNA'TURE
HCA Contract No. K27 4 7
Amendment #01
PRINTED NAME AND TITLE
·,V"'l ~&Y1 t-a VVl b
Administrator
PRINTED ~AME A2J;ND TITLE
..Ja.;:;es W. Oeylon r-111, ~#l::,.
Co~lloels Aeffli111i,,1 o'f ''
DATE SIGNED
Page 1 of 2
Exhibit A -ABCD Quarterly Outreach & Case Management Report
Year One 2018 -2019 • 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.Tad eo @HCA.W A.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
Performance Category
Contact at least 10%
of client list
Attend and participate
in ABCD
Coordinator /Program
Meeting
Community and
Provider Outreach
Coordinate Care
HCA Contract No. K2747
Amendment #01
available for staff assignments, provide name and title) -no more than 100
this words (complete Exhibit A and attach supporting document if
Yes/No deliverable providing additional detail)
$450 Complete Exhibit B
$500
$960 Complete Exhibit B
$465 Complete Exhibit B
Page 2 of 2
1 1
Today's Date
03/13/2019
Fund/Department
116-Public Health
Kittitas County
Review Form
Grants & Contract Agreement
Agenda Date
Contract/Grant Information
Contract /Grant Age ncy : HCA Amendment for ABCD Kittitas Count y
"I f~ I
\ C)
Period Begin Date: 10/01/2018 I I Period End Date: 12/31/2018
Total Grant/Contract Amount: $2375.00
Grant/Contract Number: K2747 Amendment 1
Contract/Grant Summary:
The HCA amendment amends the contract to provide clarification of the 2nd quarter for year one 2018-
2019 Exhibit A, titled ABCD Quarterly Outreach and Case Management Contract Report, by replacing
Exhibit A for 2nd Quarter contract period.
Recommendation for Board of Health and Board of Health Review on
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPR -DAS TO FORM :
Date
Date
Signature of Board of Health member Date
Financial Information
Total Amount$ 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 hirin g -rep o rti ng re q uirements
Future impacts or liability to Kittitas County:
Budg et Information
Budget Amendment Needed? Yes D attach budget form No D Why not
New Division Created?
Revenue Code 116.612.24.1.334.06.901 State Funds 10/01/18-12/31/18
2 nd Qtr Year One 2018-2019
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date :
Prosecutor Review
I Has the Prosecutor reviewed this agree ment? l ves D No D
Cou nty Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature:
Department:
I Date:
Assignment of Tracking Information
Auditor's Office
-
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date
Grant/Contract Review Page 2