HomeMy WebLinkAboutFully Executed AgreementKITTITAS COUNTY
AGREEMENT FOR SERVICES
This Agreement for Services (fiereinafter "Agreement") ls entered lnto by and between Kittitas County
{hereinafter "County"}, a political subdivislon of the State of Washington, and Apple Valley Counseling Servlces,
LLC d/b/a Valley Health and CounseIing (hereinafter "Contracto/').
The purpose of this Agreement is as follows; To provide up to full-time, on-site mental health counseling
and substance use disorder professional servlces, as requested and scheduled by mutual written agreement, and
qualified practitlonef s€rvices for behavioral-health assessment, medlcation management, care coordination, ancl
ieferral foi indivlduals incarceratejd at the Kittltas County Jail.
The term gf this Agreement beglns on the date of the last signatuie and continues for one (1) year,
unless sooner [ermlnated under thls Agreemertt. This contract may continue from year-to-year upon mutual
agreement between the two parties and is based on muttlal adjustments to the appropriate.Medicaid rates,
Thp parties' addresses and points of contact for the adrhinlstration of this Agteement are as follows:
COUNTY CONTRACTOR
205 W 5th Avenue, Suite 108
Ellensburg, WA 98926
Steve Panattonl
Superintendent
Kittitas County Sher:iff s Offlce-Jail
steve.panattonl @co.klttitas.wa,us
509-962:7527
Kltt ltas Cou nty- Agteem en t for Se rvl ces lr ev : 5 | 74 | 251,
Fage I of zr
1425 Lakeside Court
Yakima, WA98902
T.anner Rapp
owner / ciinical Director
T.Rapp@ValleyHC.org
s09-961-6336
Thls Agreement lncludes the followlng whlch are attached hereto and hereby lncorporated by thls reference:
Attachment "A":
Attachment "8":
Attachment "C":
Attachment "D":
Attachment "F':
Attachment "F":
Kittitas County Agreement for Servlces (rev'5/t4l25l
Page 2 of 23
Scope of Work
Cornpensation
lnsurance Requlrements
General Terms and Co nditions
W-9 (Contractor must complete and return to the County for payment)
Retirement Status Folm (Contractor must complete and return to the County
for payment r/Contractor ls an lndivldual, as opposed to a corporate buslness
entltyl
lN WITNESS WHEREOF, this Agreement has been executed by and on behalf of the parties through thelr
authorized representatives, effective as of the latest date written below.
Klttitas County Agreement for Services lrev, 5l74l2sl
Page 3 of 23
Title
L4.GDatel
CONTRACTOR
cffi
fr,rt
Printed Name.
KIITITAS COUNTY SHERIFF,S OFFICE
KITTITAS COUNTY
BOARD OF COUNTY
Commissloner
Sheriff
MI
Brett
r
ABSENT
Date:
ClaY
Chair
L)
Date: g" /s-,24
ATTACHMENT.JA,,
SCOPE OF WORI(
CONTRACT PROVISIONS RELATED TO MENTAT HEALTH COUNSETOR
a, Provide appropriately licensed mental health counselor services up to five (5) days and forty
(40) hotus per rveek, subjeot to mutually egeed wlitten staffing schedtrles, County seryice
demand, safo facility acoess, and Contractor wot*force availability. Any minirnutn staffing
commitment or naterial schedule chauge must be approved in writing by both parties.
b. provide screening of incarcerated iudividuals within 72 horu's of booking, most ofteu within
24 houns of booking. If an irulividual is booked over the weelcend or on & holiday, the
individual will be screened on the following business day. Any screoning timeframe begins
when the County provides accurate booking aud refeffal information and safe, tirnely access
to the inclividual,
c. Provide assessments on incarcerated individuals that screen positive for mental health
heatrnsnt needs,
d. Provide group treatment as appropriate.
e, Assist and collaborate with medical providers when assessing and tteating irunatos at KCJ.
f. Evaluate any inoarcerated individual presenting with a mental health or zubstance use
disorcler: clisis and coordinate with Cornprehensive's Dosignated Crisis Respondots as
necossaly'
g, Cornmnnicate with coults, prosecutors, ancl defenss counsel only as permitted by FIIPAA' 42
C,F,R. Part2,chaptor 70,02 RCW, applioable privilege, a valid authorization or court otder,
nnd the rninimttm+recessal'y standard.
h. Provicle tr.aining to I(CJ personnel in coordination with l(CJ administration.
i. Make reforrals to community proviclers for incarcerated indivldual's needs to prornote a
te<luced lisk of tecidivism.
CONTRACT PROVISIONS RETATED TO SUBSTANCE USE DISORDER PROFESSIONAT
a, Provide assessments on incarcerated individuals that screen positive for substance ttse
treahnent needs.
b, Make referals to the appropriate conh'acted provider with l(CJ for rnedication treatmetrt for
substance use disotdels.
c, Make refenals to comrnunity providers for incarcerated indivitlttal's needs to pronrote a
reducetl rislc of recidivism.
cl, Make rofenals to providers iu the incarcerated individual's community of residence,
e. Provide warm hatrdoff referrals when possible.
f, Coordinats rofenals with other providers seling those incaroerated in KCJ,
g, Plovide counseling sslices to incarceratecl individuals who qualify as having a substance
use disorder,
CONTRACI PROVISIONS RETATED TO PRACTITIONER
Def lnltlons:
Praclitioner mesns o Washington-licensed advatrced registered nurse practitioner, physicinn, physician
assistant, or other rnedioal plot'essional whose license, competence, and prescdptive authority are
Klttitas County Agreement for Servlces (rev. 5/14/25)
Page 4 of 23
sufficient for the assignecl servises anrl whom the parties nrutually approve. Contractor may sttbstitute nn
equally ol.mol'e qualiliecl pmqtitlonef upon reasonable adVance notice,
a, Contractor will supply a qualified Practitioner to provide behavioral'health assessment and
treatment lncl behivioral..health rnedication evaluation and management at KCJ. Services
nray includo olinicaliy apptopriate evaluation, prescribing, monitoring, andcoordination or
refigal within the Practitionor's license, competence, credentialing, and intlependent
professional jlclgment, Contraotor will refer ptifirary caro, family medicine, general medical
colditiorrs, drgent care, clu'onlc-disease man&gsment, and other non'behavioral-health
ntedical needs to I(CJ's designated medical providor. Contractor will not ahor or aesurne
mallagement of general rneclical treatnrent being plovided by I(CJ's designated medical
provider, except for clinically nec€ssary coordination within the Praciitioner's scope to
acldress llehavior.al-health rnedication safety. The Praotitioner shall provide selices during
rnutually ngreed schedtrled hours and such additional clinically necessary time as Conhactor
accepts. This Agreerneirt does not cfeate continuous covel'age or guarantee accEss to a
particular practiiioner. All clinical deoisions remain within Contmctor personnel's
independent professional juclgment, licensure, and applicable standarcls of care, and no
particulat clinical outcome is guaranteed,
b, No incarceratecl individual shall be denied accsss tomental health cale. Contractor's obliga?ion
is to provide the contracted service.s within the scope, soheduled houts, and staffing of this
Agreement; the County retains its indeperrdent legal responsibility to ensure incarcerated
individuals have access to necessary health cate, including when Contraotor services are
unavailable. Mental health care oan be requested by the indiviclual antl/or Jnil staff. Those
Requests for Mental health care that do not requirre the services of the VALLEY HEALTH
AND COUNSELING shatl be refEtted to the appropriate service.
a, The Proctitioner shall be rosporrsible for documenting all patients seen and treattnent they
polfonned in the IGtlitas County Jail's Electronio Health Records. The Practitioner shall
provide rnedical referuals and obtain nredical consultation as necessary'
c1. Contractolmay provide tolephonic sonsultatiou between 8:00 a,m, and 9:00 p,m, when an
appropriatoly licensed practitioner is available, This is not guaranteed on.call or emel'genoy-
lesponse covelage. The County muains responsible fot emergency response and shall use 91 1 ,
the local omergency clepa*ment, ol a designated olisis resporrcler as appropriate. Consultatiott
tirne will be bilted in fifteen-minnte inorements at the practitioner rate statecl in Attachmsnt
r(B.rt
I(CJ ngt'ees to
a. Rofer incarcerated indivicluals to theVALLEY HBALTH AND COUNSELING selices
relatigg to the indiviclual's overnll behavior based upon observatious of thoir concluct and the
training of KCJ staff as describecl herein,
b, Plovidl appropriate arrd accutate information onrefet:recl incarcslnte<l individuals,
c. Provide appropriate snpport for VALLEY HDALTH AND COUNSELING MHC to
nccomplish the services needed.
Klttitas County Agreement for Servlces $ev.5/14125,
Page 5 of 23
d. Designate Slperintendont Steve Pansttoni, his designee, or other individual assigned as such
by tG Sher.iff as contact pel'$on and liaison with VALLEY HBALTH AND COUNSELING.
o. pay Contractor invoices consistent with Attachment "B" arrd Attaohmerlt "Dr" Section 2
(Accounting ancl Payrnent), with undisputed nmounts due withirr thfuty (30) oalendar days of
teceiPt of invoioe.
f. provide access to tlre appropriate and necessary electrotilc pfograms used at KCJ to complete
your sorvices'
E. itrovide workspaoe for contracted petsonnel.
I provide atrd rnaintain technology needed to accoss electronic ploglrms rtsed at KCJ' The
County shnll also provide tirnely fncility and patient Bccessr appropriate con'ectional staffing
nnd estofis, emergency response, nutl operation and sesurity of County systoms' Subject to a
mutually approved written implementation plan, the parties may pemit teasonable use of
existilg spaie, power, and conneotivity for applwed tolehealth, electronic'1'efoffal, or care'
coordination equipmont. Neither party is required to purohase equipment, provide rnatchiug
funds, adrninister a grant, or incui no'rv oosts nnlsss separately agt'eecl in writing. Contractor
persolnel will not perform custody, hansport, restraint, or other conectioual'security tluties.
VALLEY HEALTII AND COUNSELING agrce to:
il, Designate Tanner Rapp or designee as Coutractor's liaison with KCJ and Tanner Rapp or
designee as the billing and corrtract contaot.
b, Provide the listed services presenied in this exhibit,
c. Provide a lrontlrly, de-iclentitiecl aggregate report for I(CJ leadership statilg the uumber of
assessrnents completr.l by selice, the number of uniquo inclividtlals served by service
category an<l the nunbei of refenals made, \Mhere reasonably available ftom oxisting
systJms,-the repofi may nlso include seruice limeliness, telehealth utilization, referral status
or.closure, and-ilischarge or reerilry referrals, Neither pafty must orEate a new repoiling
systern orperform matirial ctrstom analytics without a separately approved scope and price,
ieports will not include plotected health informatiou, psychothelapy no!e.s' or identifiable
pait Z infonnation unlesJ disolosure is specifically authorized by law aud the applicable
privacy ngreement,
d, euamect SuUstitute: VALLEY HBALTH AND COUNSELING rnay, with advance notice to
liCJ, if th* rlesignated Practitioner i.s not nvailabie for any re,Lsoll, ptovide a substitute for the
Practitioner of iqual or gloatet qualifioations, The poriod of notice shall be as muoh as
reasonably possibie, consistent with the circumstatrces that te<1uire the substitution. It is the
iqtent of ihe parties that a specific, substihrte bo clesignated an<l utilized to the greatest oxte[t
possible so that continuity of sare is maintained.
VALLEYIIEALTH AND COUNSELING nrrd I(CJ mutunlly sgree3
0. To maintain an open line of communication between KCJ staff arrd VALLEY HEALTH
AND CO1INSBLnIC stafffor sharing peltinent infonnation about incarceratecl individuals'
behavior,
b, To have a soheclule that is flexible and consistent withKCJ operations and mair*ain their
cretlential status,
c, Contraotor alcl KCJ shall comply with HIPAA,42 C.F.R. Part?, ohapter70.02 RCW, and
other applicable confrrdentiality [aws, Before any exohange of protecteel health infotmation or
part 2 reeotds, the parties shali execute ancl incotporate a Business Assooiate Agreemont and
Kittltas county Agfeement for Servlces lrev'5lt4l25l
Page 6 of 23
any requirecl Partl provisions, Those privacy torms conhol over any conflicting ptovision of
this Agreement.
d. To acknorvledge thatincarcerated individuals may refuse VALLEY HEALTH AND
COTINSELING services exoept to any extentmandatecl by law including court order'
e. That the VALLEY HEALTH AND COUNSELING MIIC's aotivities will not go beyond
those dgties as approved by I(CJ and VALLEY HBALTH AND COUNSBLING except as
othervise provided by la'w,
f. vALLEy HEALTH AND COIJNSELTNG egree to femovo any MHC provided to KCJ
irnrnediately upon written requestby KCJ.
g. Contractor wiil Uilt an eligible tliirdjarty payer only when coverage is active on the date of
se1ice, tho service is lawfillly covered in the cortectional settirig, and Conhactor is emolletl
ald authorized to bill, If coverage is inaotive ot cannot be verified at the tirne of sericg
incarceration makes the selvics irreligible tor third-party payment, or n claim is denied for a
reason other than Contractor billing enor, the County lvill reimbtrrse Contractor ot the
Medicaicl-equivalent rate defined in Attachment "B." Contmctor will not balance'bill
incarcetated iudividuaLs-
h. Specific services maybe cancelled or rescheduled for good causeby eithelparty. "Q_ood cause"
igcludes docnmented security, safety, clinical, or unfoteseen staffing coilcellls affecting safe
operations, Except for a dosumented omergency, County oancellntions made less tltatt twenty-
four (24) lroursbeforereseled oliniciantimemaybobilled atthe applicablerate inAttaohment
.B.tt
Klttltas County Agreement for Services lrev'51141251
PageT of2!
ATT/4CHMENT,,B'
coMPENSAUQN
THE COUNTY WILL NOT PROCESS PAYMENT FOR SERVICES RENDERED UNDER THIS AGREEMENT UNTIL
CoNTRACTOR SUBMITS A COMPLTTED W'9 (SEE ATTACHMEN'f uEnl.
As full compensation for covered cllnical services under Attachment "A," the County shall pay Contractor
ono hundred percent (100%) of the Washlngton Apple Health (Medicald) fee-for-service maximum allowable
amount effectlve on the date of servlce for the correctly documentecl code, modifier, unit, provlder type, age,
place of service, and facilliy or non-facllity designatlon. "Medicaid-equivalent rate[ means that amount, includlng
any generaly appllcable HCA enhancement or reductlon for whlch the servlce and renderlng provlder qualify,
wlthout requlring the client or serylce to be payable by Medicald'
The controlling schedules are: (a) mental health and psychology services, the HCA Mental Health and
psychology Services Fee Schedule; (b) substance use dlsorder serulces, the HCA Substance use Dlsorder Fee
sciredule and applicable servlce Encounter Reporting lnstructlons (sERl); and (c) behavioral-health practitioner
and medlcatlon-managernent services, the HCA Physlclan-Related Services/nealth Care Professional Services Fee
Schedule. HCA,s billing guldes and coverage rules determlne the correct code and rate. The cornpanlon Clinical
operations MOU contalns a rate-verification table uslng the July !,2026, schedules. lf HCA publishes no rate for
a iequested servlcer lncludlng court, tralnlng, meetlng, or admittistrative time, the parties must aBree to a written
rate before the service ls performed.
Contractor will invoice monthly, Each lnvolce will identifli the service date, categorr/, code, modifier, unlts,
renderlng provlder type, appllcable HCA schedule and effective date, lnsurance status or payer dlsposltion, and
calculated amount, Undisputed amounts are due within thlrty (30) calendar days. The county must identlfy
disputed ttems ln writlng withln fifteen (15) calendar days and tlmely pay all undlsputed portions' Undlsputed
amounts not paid within thirty (30) calendar days accrue lnterest as provided by chapter 39,76 RCW.
Contractor will flrst blll Medicaid, Medicare, or prlvate lnsurance only when coverage ls actlve on the date
of service, the lndividual and service are etigible, the servlce ls lawfully payable ln the corlectional setting, and
Con$actor ls authorized to bill, The County will reimburse contractor at the Medicaid-equivalent rate in
Attachment .'B', when the client lacks actlve lnsurance at the time of the vlslt, coverage cannot be verified,
lncarceratlon or payer policy prevents payrnent, or the claim is denied for a reason other than Contractor billing
error. Contractor need not wait for a denial when ellgibility records establish that no payer ls available. The county
wlll not condition payment on collection from the cllent, and Contractor will not billthe cllent.
Unless otherwise provlded herein, Contractor shall be solely responslble for Contractotrs travel and
related expenses.
Klttltas County Agreement for Setvices (rev' s/fq/ZS)
Page B of 23
ATTACHMENT NC,,
rNsu RA[,l.cE REQU I REM ENTs
Contractor shall secure and malntain in effect at all tlmes durlng performance of work under this
Agreement such insurance as wlll protect Contractor, iis employees, and agents from all claims, losses, harrn,
.Jrtr, llrnllttles, damages and expenses arlslng out of Contractor's performance under thls Agreement,lncludlng
but not limlted to personal lnJury (including death) or property damage.
All insurance shall be issued by companles admltted to do buslness in the state of Washington and have
a railngof A-, class Vll or better ln the most recently publlshed edltlon of Best's Reports unless otherwise approved
bytheiounty. lfaninsurerisnotadmltted,allinsurancepoliciesandproceduresforlssulngthelnsurancepolicies
must comply with Chapter 48.15 RcW and 284-15 WAC.
At a mlnlrnurn, Contractor shall maintaln and provide proof of the following selected optionsl
Corn rnercla I General Lia bll itv. I nsurance
' Coverage llmlts not less than:
r $21000,000 per occurrence, for allcovered losses
. 54,000,000general aggregate
r $4,000,000 products & completed operations aggregate
r $2,000,000 personal and advertlslng injury, each offense
r The pollcy must be endorsecl to include the County and its officials, employees and agents
as addltlonal lnsureds.
Commerclal AutoFqbile LlabllitY lnsufance
r Automobile Liability for owned vehicles used in contract performance and hired and non-
owned vehlcles, wlth llmlts stated below, Transportatlon of incarcerated lndividuals or
pollutants ls not contemplated; MCS 90 and CA 9948 endorsements are not required
unless the parties add such transportation by written amendment,
r Coverage limlts not less than:
. $1,00Q000 comblned slngle limlt
m Exceq,s or Umbrella Liabilitv-_; Contractor shall provide Excess or Urnbrella Liabtlity coverage of $X.,000,000 per
occqrrence and $1p00,00O aggregate applying at least to Commerclal General Llablllty.
Any higher llmit or application to acldltlonal underlylng coverage requlres a written
arnenclment and an equitable adjustment for the lncremental premlum.
' Thls requirement rnay alternatively be satisfied through Contractor's prirnary Cornmerclal
General and AUtomoblle Llablllty covefage, oI any combination thereof.
r The poliry must be endorsed to include the County and its offlcials, ernployees and agents
as additional lnsureds., Coverage shall be "pay on behalf", with defense costs payable in addition to pollcy llmits.
. There shall be no cross liability excluslon precludlng coverage for clalms or suits by one
insured agai nst another.
E Wor.kerq'Comnenqatlon&Emplovefs.Lla.bilitY
Klttitas County Agreement for Servlces (rev. 5/14/25)
Page 9 of 23
I
tr
Contractor shall provide Workers Compensatlon and Emptoye/s Llability lnsurance on a
state-approved policy form providlng benefits as requtred by law wlth ernployer's liablllty
llmlts no less than $1,000,000 per accldent or dlsease.
X
r $1,000,000 each clalm and $61000,000 aggregate
Contractor must provlde evldence of this coverage on a policy form approprlate to
Contractot's Professlon'
n IOther lnsurance coverage as deemed approprlate by elther the County Risk Manager or the
assigned Deputt prosecuting Attorney, Addltional lnsurance types which the county may need to require (non'
exhlustlve list)icyber, pollutlon, Aircraft, watermaft, Llquor, crlme/Fidellty, sexualAbuse & Molestatlon, Jones
Act, Longshoremen/Harborworkers, Marlne. I
Contractor shallfurnlsh to the County a Certiflcate of lnsurance, !U!th endorsement where requlred above,
as evidence that pollcles provldlng insurance requlred by this Agreement are ln full force and effect' Contractor's
lnsurance policles requiied above must apply on a primary non-contrlbuting basls ln relatlon to any other
insurance or self{nsurance available to the County.
contractor will provide the county prompt wrltten notlce after contractor recelves notlce from an lnsurer
of cancellation, material reductlon, or non-fenewal of required coverage, and will use commerclally reasonable
efforts to provide at least thlrty (30) days'advance notice when avallable,
Contractor shall assume full responsibillty for all loss or damage from any cause whatsoever to any tools,
machlnery, equipment, or motor vehicles owned or utllized by Contractor, or Contfactor's agents, employees,
suppliers or contractors, as well as to any temporary structures, scaffolding and/or protectlve fences'
Contractor shall have sole responsibility for ensuring the insurance coverage and lirnlts required herein
are also obtalned by any subconlractors.
NoTE: Notrryithstandlng any other provlsion(s) of this ABreement, no contract shall form under this Agreement
until and unless the foitowlng are provided to the county: {1} a copy of the certificate(s) of ltrsurance with all
requirecl endorsernents, properly cornpleted and in the amounts required, and {2}where requested by the County,
a copy of the required lnsurance pollcles, lncludtng all required endcrsements.
Klttltas County Agreement for Servlces lrev,5lt4l25l
Page 10 of 23
ATTACHMENT,,D"
G ENFFAT TERMS AND CONDITIONS
I. Scope otContraelo{g_SefVlces: Contractor agrees to proVlde to the County servlces as set forth in
Attachment "N,. No *at.rtltr, labor, or facllities will be furnished by the county, unless otherwise provided
herein, All work perforrned under thls Agreement shall comply wlth appllcable laws and regulations'
Z, Ac_c_ountlnq and Pavmen!: Cornpensatlon to Contractor for servlces rendered under thls Agreemeni
shall be ffi r"tiortt in Attachment ',8',, Where Attachment "8" requlres payment(s) by the county, payment shall
be based upon blllings, supported unless provlded otherwlse ln Attachment'r8", by documentation of unlts of
work actuaily perforrned and amounts earned, includlng, where approprlate, the total number of hours for the
month and tire total dollar payment requested. Unless specifically stated ln Attachment'rBr', the County will not
relrnburse Contractorfor any costs or expenses lncurred by Contractor ln performance of thls Agreernent' Where
requirecl, the County shall, upon receipt of appropriate documentatlon, compensate Contractpr' no more often
than monthly, through the County voucher system, for Contractor's servlces pursuant to the fee schedule set forth
inAttachment',8", lntheeventiontractorfailstoperformanyofltsobligationsunderthlsAgreementwlthlnthe
time specifiecl herein, the County may wlthhold only the amounts reasonably attrlbutable to the nonconformlng
services, after wrltten notice identlfying the failure and consistent wlth the dispute process in Attachment "8,"
untilthefailureiscuredorresolvecl;allundisprrtedamountsremaindueandpayable, TheCountywillnotprocess
payment for services rendered under thls Agreement untll Contractor submits a completed W-9 (See Attachrnent
uE'l',
3. Taxes: Contractor understands and acknowledges that the county will not wlthhold Federal or state
income taxei from payments made to contractor, where required by state or Federal law, contractor authorizes
thecountytomakswithholdingforanytaxesotherthanincometaxes(e.g.,Medlcare). Allcompensationreceived
by contra;tor will be reportedio the lnternal Revenue Servlce at the end of the calendal year in accordance with
appllcable IRS regulations. lt is the responsibillty of Contractor to make lts necessary estlmated tax payments
thioughout the year, if any, and contractor is solely liable for any tax obllgation arising from Contractor's
performance of thls Agreement.
The County will pay sales and use taxes imposed on goods or services acqulred hereunder as reqttlred by
law, contractor must pay all other taxes, Includlng but not limited to: business and occupatlon tax; or taxes based
on (1) Contractot s gross or net income, or (2) personal property to which the County does not hold title' The
County ls exempt from federal excise tax'
4, lndependent JqXlfqglpl: Contractor's services shall be furnished by Contractor as an lndependent
c0ntr".tor,-"ncl nottring;trt*d heretn shall be construed to create a relationship of employer-employee or a
guarantee of future employment. contractor acknowledges that its entire compensation under this Agreement
L speclfied in Attachrnent',8", and that Contractor ls not entitled to any County benefits, lncluding but not llrnlted
to: vacatlon pay, holiday pay, sick leave pay, medical, dental, or other insurance benefits, or any other rights or
privlleges afforded to Kittitas County employees.
S. Asqien$ent and Subcontla,cting: Thls Agreement may not be assigned ln whole or materlally
subcontracteu witt out the co,rntyir piior written approval, which will not be unreasonably wlthheld or delayed.
Use of Conlactor employees and quallfied substitutes under Attachment "A" is not an assignment or subconttact
and requlres notlce ratherthan prior approval.
6, Rlsht to Rgvlew; Maintpnance of : Thls Agreernent ls subject to revlew by any Federal or State
auditor. th, County or ltr designee shall have the right to review and monitor the flnancial and servlce
Kittltas county Agreement for Servlces {rev. 5/14125)
Page 11 of 23
components of the work performecl under this Agreement by r,vhatever means are deemed expedlent by the
county. Except for a documented emergency or legally requlred audlt, review will occur on reasonable advance
notlce clurlng buslness hours and will be limlted to noncllnlcal flnanclal, credentiallng, staffing, and performance
records reasinably related to thls Agreement. Access to protected health lnformatlon, psychotherapy notes, Part
2 records, prlvileged communlcatlons, or dlrect contact with service reclpients requlres a lawful basls, mlnlmum'
necessary limltagon, ancl compliance wlth the Business Assoclate Agreement and Part 2; de-identlfied records wlll
be usdcl whenever sufficient. Contractor shall preserve and malntaln all records relatlng to thls Agreement for six
(E) years after terrnlnatlon or explration of the Agreement, and upon request shall make them avallable for revlew
by any Federal or State auditor, the County, and/or any persons authorized by the County'
7. Medlfleatlatr
7,1. Thls Agreement may be anrcnded by mutual agreement of the parties. Any such amenclment
shatl be in writing and slgned by both parties'
?,2 Neither party may unllaterally change clinicalscope, staffing levels, schedules, deliverables, rates,
or material performance obllgations, Any material change requlres a written amendment signed by both parties,
lncludlng anequltable ad1ustment to compensation and tlme, contractor is not requlred to perform changed work
before the amendment is effective, except for a short-terrn emergency measQre that Contractor accepts ln writing
and that is conslstent with licensure and patient safety.
8, Termlnatlon
8.1 This Agreetnent may be terminated at any time by mutual wrltten agreeme nt of the partles.
8,2 Either party may termlnate thls Agreement wlthout cause upon thirty (30) days' written notice.
The county may require an earlier cessation only for a documented immediate safety, licensure, confidentlality,
or fundlng lssue. The county wlll pay for all conformlng servlces performed, reserved cancellatlon time properly
chargeable underAttachment "A," and approved noncancelable commitments through the effectlve date,
g,3 lf Contractor materia lly defaults, the County will provide written notice describing the default and
ten t10) buslness days to cure, except where an immediate safety, llcensure, or confidentiality threat cannot
reasonably be cured, lf the default remalns uncured, the County may termlnate and obtain substitute
performance, Contractor relnalns entltted to payment for conformlng services already performed. Any offset is
ii*it.a to documented, direct, and reasonable costs caused by the uncured default; neither party is llable under
this paragraph for consequential, speclal, exemplary, or punitlve darnages.
g.4 Termtnation of this Agreement by any rneans provided hereln shall not excuse any party's
performance of lts obligations hereunder through the effectlve date of termlnation, except that the county shall
not be obligated to payfor servlces that have not been performed or deliverables that have not been provided.
9. Indemnlt!.c,?tlon
9.1 To the fullest extent permitted by law, each party will indemnify, defend, and hold harmless the
other party and lts officials, employees, and agents from thlrd-party clalms, damages. losses, and reasonable
defense costs, but only to the extent caused by the lndemnlfylng party's negllge nt or wrongful acts or omlsslons,
material hreach, or willful misconcluct in performing this Agreement. Neither party will indemnlfo the other for
the other party,s negligence or wlllful rnlsconduct. Contractor's obllgation does not extend to County custody or
securlty operations, premlses conditlons, County systems, or acts of County personnet. Any waiver of lmmunity
under iCW ritle sr is limited to claims by contractor personnel and to the extent of Contractor's fault, and the
Klttitas County Agreement for Servlces lrev, s/t4l25l
Page 12 of 2a
parties acknowledge that this limited walver was mutually negotiated. Except for the partles' indemnificatlon
obllgations for third-party claims under this Sectlon 9, nelther party wlll be llable to the other for consequential,
special, lncldental, exemplary, or punitive damages arising out of or relatlng to this Agreernent.
g,Z The County reserves the rlght, but not the obllgatlon, to partlcipate in the defense of any clalm
for damages, losses or expenses, and such particlpatlon shall not constltute a walver of Contractor's lndemnlty
obllgatlons contained in any sectlon of this Agreement'
g.3 ln the event Contractor enters lnto subcontracts to the extent allowed under thls Agreement,
each such subcontractor shall lndemnlfy the County on a basls equal to or exceedlng Contracto/s lndemnlty
obligatlons to the CountY.
1.0. Venu_es,nd Choice qf [aw: ln the event that any litigatlon should arise concerning thls Agreement,
tlrc venue for such action shall be ln the Superlor Court of the state of Washlngton in and for the county of Klttltas,
This Agreement shall be governed by the laws of the State of Washlngton.
11. Non.Appropr:iA_tio!gfFunds: lftheCountydoesnotappropriatesufflclentfundingforthisAgreement
for any future flscal p.tfod, the County wlll not be obligated to make payments for seruices performed after the
end of the last fiscal period for which sufficient fundlng was appropriated. The countY wlll provlde Contractor
prompt written nogce upon learnlng that sufficient funding wllt not be approprlated, and Conffactor's obligatlon
io p*ifor* ends on the date funding ends. No penalty or expense slrall accrue to the county in the event this
provision applies, provlclecl the County pays for conforming sewlces perforrned through that date.
j.Z, Contractar Comrnitmentsl Warran{e.$, an$l Representatlons: Contractor represents and warrants as
follows:
];z.l Contractor is a limited liability company duly organlzed, valldty exlstlng and in good standing
uncler tho laws of the State of Washington, and has all requislte company power and authority to enter inio and
to perform its obligatlons uncler this Agreement'
LZ,z Contractor has the authority to execute this Agreement, to mako the representatlons and
warranties set forth herein, and to perform its obligations hereunder.
IZ,3 This Agreement has been validly executed by an authorized representatlve of Contractor and
constitutes a valld and legally binding and enforceable obligatiOn of Contractor.
12,4 Contractor holds, or wlll obtain prior to commenclng work under this Agreement, such licenses,
permits and other authorlzations from federal, state and local governmental authorlties, or from any applicable
industrial or professional certification oI llcenslng bodies, as are necessary for the lawful performance of its
obllgations under thls Agreement, and will maintain such throughout the term of this. Agreernent.
12.5 Contractor is not in violation of any applicable law ordinance or regulation the consequence of
whichwlllolylaymateriallyaffectContractor'sabllitytoperformltsobligationsunderthlsAgreernent. Contractor
is not subJect to any order or Judgment of any court, trlbunal or governmental agency whlch materially and
adversely affects lts operations or assets in the State of Washlngton, or its ability to perform its obli8atlons under
this Agreernent,
tZ,6 Contractor is not preserrtly debarred, suspended, proposed for debarment, declared lneliglble or
voluntarlly excluded from covered transactlons by any Federal or State department or agency'
Klttltas CountyAgreement for Services (rev. 5/X4/251
Page 13 of 23
12; None of the representatlons or warranties ln this Agreement, and none of the documents,
statements, certificates or schedules furnlshed by contractor ln connectlon wlth the performance of the
obligatlons contemplated under thls Agreement, contalns or will contain any untrue statement of a material fact
or omlts or will omit a materlal fact necessary to make the statements of fact contained therein not rnisleading.
13, owngtshl! lfl.lcng_ryodgged: The County owns final adminlstratlve reports and other deliverables
specifically .reat.O for ancl pald for by the County under thls Agreement, contractor retalns ownership of
preexlstlng materials, clinlcal methods, forms, ternplates, software, know'how, and improvements, subject to a
nonexclusive llcense for the County to use pald deliverables for its governmental purposes, Medical and clinlcal
records, protected health lnformailon, psychotherapy notes, and Part 2 records are not work product or county-
owned intellectual property and remaln governed by applicable law, professlonal dutles, the County tHR
arranSement, and the partles' privac! agreements.
14. lnJellectupl prop_grtv lnfrlneement: Contractor will defend and indemnlfl the County from any
claimed action, .rure o, d"rnrnd brought against the Counly, to the extent such action is based on the claim that
lnformatlon and/or materials supplied by contractor lnfringe any intellectual property rlghts of any third
party(ies). contractor will pay all costs and damages attrlbutable to any such claims flnallyawarded agalnst the
bouni.,, ln any actlon. such defense and payments are conditioned upon the following: (1) contractor shall be
notified promptly ln wriung by the County of any notice of such claim; and (2) contractor shall have the rtght
hereunder, atits option und .xp.nr", to obtain for the County the rlght to contlnue uslng the information and/or
materlals that are the subject of such claim, providecl no reduction ln performance or loss results to the County,
15. U$e Qf Countv Nam€ and Logo: Contractor may not use the County's natne, logo(s), trademark(sl, or
other identifying lntormation, or ldentify the County as a current or former client, on its webslte or in any
marketing or prornotlonal materlals wlthout the prlor written consent of the County,
16. Dlsp$tq.s,: The parties will first atternpt in good falth to resolve disputes through their deslgnated
contract representatives, foliowed by executive-level negotiation, lf unresolved after thirty (3o) days, either party
m.y r.qu"it nonbinding mediation, wlth costs shared equally. Either party may then pur$ue rernedies in the court
identifiecl ln Section ro. Rrbitration ls permitted only by a separato written agreement signed after the dispute
arlses,
17. te$LdenfiAlilyl Each party and its personnel wlll protect the other party's confidential lnfonnatlon
and use it onrv roiihii Agr."rnent, except as authorlzed ln writing or requlred by law' Health lnformatlon and
substance use disorder reiords are governed by HIPAA, 42 c.F.R. Part 2, chapter70,02 RcW, professional privilege,
antl will be protected as required by these authorities and the parties separate Data Protection Agreement'
colltfactor agrees to conspicuousty mark any non-health related record contractor believes to be proprietary or
otherwise confidentialwlth ,,coNFlDENTIAL- DO NOT DISCLOSE" at the top of the page, when legally permltted,
the County will provlde prompt notlce of a public records or legal request for any appropriately marked contractor
record reviewed by County staff responding to such request,
1g, Noilces: Written rrotices requlred or permitted to be provided by one party to the other party under
thls agr".m.nt rnay be provided by personal delivery, legal courier servlce, or certlfled mail, postage prepald and
return recelpt requested. Notice may be provided by email to the listed contacts, effective upon acknowledgment
of receipt, or by iegular first-class rnail if sirnultaneous notlce ls provlded by email. Notlces given by contractor
shall be piovided tJ the county's point of contact llsted on page 1 of thls Agreement, at the address there listed,
and to tire department heacl of the county department for which seruices under this Agreement are renclered.
Noilces given by the county shall be provlded to contractor at contracto/s address listed on page x' of this
Agreement.
Klttltas County Agreement for Servlces ltev.5lt4l25l
Page 14 of 23
L9. Standard of Care: Contractor shall perform lts duties hereunder in a manner conslstent wlth that
degree otcaI inO sklllorclinarily exercised by members of the same professlon or lndustry as Contractor currently
prictlcing or working under slmllar clrcurnstances. Where reasonably curable, Contractor wlll correct a deflcient
admlnlstaflve dellverable without addltlonal cornpensation. This remedy does not requlre alteration of an
accurate cllnlcal record, overricle lndependent clinicaljudgment, or guarantee a cllnical outcome.
20. Nondlscrimlnatlon
20,1 ln the performance of this Agreement, Contractor wlll not dlscrlminate against any employee or
applicant for employment on the grounds of age, race, creed, color, natlonal orlgln, cltlzenship or immiSration
status, sex, pregnancy, sexual orlentatlon, gender ldentity or expresslon, marital status, honorably discharged
veteran or military status, or the presence of any sensory, mental or phystcal disabllity or the use of a trained
dog guide or servlce anlmal by a person lvlth a dlsablllty; provlded that the prohlhltlon against discrlmlnation
beiuirse of such disability shall not apply lf the partlcular dlsablllty prevents the proper performance of the
partlcular worker Invofued. contractor shall ensure that applicants are employed, and that employees are treated
during employment, without discrimination because of their age, race, creed, color, national origin, citizenshlp
or lmmigration status, sex, pregnancy, sexrral orientatlon, gender identity or expression, marltal status, honorably '
<lischargedveteran ormilitarystatus, orthepresence of any sensoly, mentalorphyslcaldlsabilltyorthe useof
a rrained dog guide or servlce animal by a person wlth a dlsability. Such requlrernents apply, without limltatlon,
to the followlng: employment, promotion, demotion, transfer, recruitment or recruitment advertlsing, layoff or
terrninatlon, rates of pay or other forms of compensatlon, and programs for training, lncluding apprenticeships.
Contractor shall take such action with respect to this Agreement as may be requlred to ensttre full compliance
wlth local, state and federal taws prohibiting discrlmlnation in employment.
20,2 Contractor will not discrlmlnate agalnst any reclplent of any services or benefits provided for
under this Agreement on the grounds of age, race, creed, color, national origin, cltlzenshlp or lmrnigration status,
,**, prug,,un.y, sexualorlentatlon, gender ideniity or expression, marltal status, honorably discharged veteran or
mllitaryitatus, or the presence of any sensory, mental or physlcal disabllity or the use of a trained dog guide or
servlce anlmal by a person wlth a disability.
20.3 tf any assignment and/or subcontracting has been authorlzed by the County, said assignment or
suhcontract shal I lnclude appropriate safeguards against dlscrimination.
21, lrllalv_er: The waiver of any default or breach of this Agreement, or the fallure of a party to enforce
any provision hJreof or to exercise any right or prlvllege hereunder, shall not be deented to waive atry prior or
subsequent default or breach, the enforcement of any provislon hereof, or the exerclse of any right or prlvllege
hereunder, unless otherwlse stated in a wrltlng, signed by the partles hereto.
22, Headlnqs: The heacllngs of sectlons and paragraphs of thls Agreement are for convenience of
reference onty unA are not lntended to restrict, affect, or be of any weight in the interpretation or construction of
the provlslons ofsuch sections or paragraphs.
23, SUrvlval: TheprovisionsOf paragraphs2,31 4,6,8,9,10,13, 1'4,L5,L6,L7,19,20,22,24,and28of
tlrese General Terms and conditions shall survive the completion, expiration, termination or cancellation of thls
Agreement for anY reason.
24. Comolete Agreeruenl: This Agreement constitutes the entire agreement between the parties and
supersedes iny and allother agreements, understandings, negotlations and discussions, oral or wrltten, express
or lmplied, regardlng the work to be performed hereunder. The parties agree that no other representatlont
lnducements, ptomises, agreements, or warrantles relating to this Agreement, oral or otherwise, have been made
Klttltas county Agreement for servlces {rev,511'4125\
Page 1s of 23
between the parties. Except as provicled elsewhere ln thls Agreement, no modlficatlon or walver is valld unless ln
wrlttng and slgned by the partles. lf this Agreement confllcts wlth the Business Associate Agreement or appllcable
part 2 terms concernlng protected lnformatlon, the more protectlve privacy requlrement controls.
25. Sever_abllityl lf any term or condition of this Agreement or the application thereof to any person(s)
or circumstances ls held lnvalld, such lnvalidity shall not affect other terms, condltlons or applicatlons which can
be glven effect wlthout the lnvalid term, condltlon or applicatlon, To thls end, the lerms and condltlons of thls
Agreement are declared to be severable.
26. Tlme: Time ls of the essence ln the perforrnance of this Agreement unless otherwise agreed between
the partles ln a signed writing.
27. Constructlon: Thls Agreement has been rnutually revlewed and negotlated by the partles, and should
not be construed against the drafter.
28, Asreement Not for Beneflt of Thlrd Pafties: This Agreement is entered into solely for the benefit of
the parties hereto and vests no rlghts ln, nor is it enforceable by, any thlrd partles.
Klttltas County Agreement for Servlces (rev. 5/14/25)
Page 16 of 23
,o,,n lllf'$
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of t6lovr.
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Klttltas County Agreernent for Serulces f ev' sh4/251
Page 17 of 23
forn W-g 0bv. c.tm,[
F rnr $/.9 {na% l,!02.11 Plr.e2
must obtain 'rour cotrect larpayer idenlilication nthber filt'l)' whir;h
nrav be vour's.cial secudt'r nurhber (SSltl. hdividual iaxpayer
ideitificitiorr numuer (lTlFli, adoptiod laxpayor ldentilicaiion nunrber
{ATll.l}, or employer idenlificatioo numbor lElN), lo tepotl on an
illonrution r6tuitr tha arnount paid to Iou. o. olher Itncunt teFoitable
on an lnlormalion retum, Exaniples ol inlomralion ralurns includa, bul
are noi tlmited to, the follovring.
r Form l099lNT (intarest eamed or paid),
r Form losg-DlV (dividends, inchrdiry lhoge trom stocks D. mutual
luods).
. Form 1099-lvllS0 (valous typer of.incomet Prizes. avards' orgtoss
proceedsl.
. fom i099'llEC (rronenrployee compsnsation).
. Fom 1099.8 (slock or mulual fund sales and certain other
lransactioirs by brokers).
r Form 1099.9 lproceeds from redl eslate lransactions).
. Form 1099-K {nerchdnl catd and thitd-patq nolrvork lransaclionsl,
. Form 1099 (horno nlo.lgBge lnte.4stl, tOSS-E (sludeot loan intares$,
and 1098'T(tuilioo),
. Form logg-C (cailceled debl).
. Form 1099-A (acquisition or abandonmen! ol secutd prop*rryl.
tho Fc{m tV-g only il you are a U.S. parson $ncluding e tesideol
alien), to provide you. conect TIN:
Cautlon: lf vou don'l .etutn Form !il'9 lo lhe requaster vrith a Tlll' you
m'rght bo subiecl to backuPv/ithholding, See lYiat is bac,lvp
wilhholdhg. lal?t.
By sigaiirg the lillcd.out lornt, you:
l. Cerlifu thal lhe Tll'l you are gi'rlng is correol (or you are waiting lor a
ounlbet to be issuedl;
2. CatiFT lhat you are not su$ecl (o baekup vrithholding; or
3. Claim exentplion fiom bAckup r'rithholdirrg il you are a U.S. exentpl
payeei and
4. Cerli{'r to yorrr non-loreign slalus fot purposes of vrirhhcldirtg trnder
chiptar g bi a bl tl€ Code ftl applicable); ard
5, C€rtifv lhat FATCA ccde(s) entetqd on lhis totm {if any} lndlcaling
lhst you aib aximpt kom lh4 FATCA reportrog ls conecl. $ee lVnal ls
FArCA Rcport ng, laler, for furthar infonrration.
Noto; ll you als a U,S. peison and a requester gives you a form oll'.er
ihsn Fo;n !'r-g io (equist your llll you musl use lha requester's fomr il
tt ls subslantlally slmilar to this Form lV'9.
Delinition of a U,S. purson. For fedstal tax putposas, fou aro
cbnsldered a U.S. pdrson if Yor aie:
. An individual vrho is a U.S. cidzen or U,S, residerrl alien;
. A oarlnerahio cerf,oratiort, company. or associalion crbaled or
orginhed in the Uniied Sla(es cr under lhe lavts o-f the Unittd Siale$;
i &r Eslite (oilita lltan a loreign aslale): or
r Adomislig lrust{as define{ in Fegulalions secl;on.30l.7tol-7}.
Establishhrg U.S, slattts tor ltur;roses o-l chapler 3 anil chapter 4
viithhoftJhur. Pavments nrada lo fo.eign petsonS. including certar-n
cliilribotioni, aildcaiions ot irtconre. o/ lrinsfsrs of sar€s PtctaEde, trtily
be subiit to nithholding undx chapter 3 or chapte{ .l ollha Code
(secliois l4a I -1i174). U;ldEr those rules, il a Form 1V'9 or olher
iertilication of non-fireiqn slalus has nol been received, 'r t'rhhhol{ing
aqaii, iransfereE, or paflrieiship tpat'od g*nerally app]es.pesumption
njies that o:ay requile lhe payor toivithhbld apflicable.l+t ltom tha
recirrienl, ovriec iraf€femr, or pa4ner {payee). S€e ftrb. 515,
ttihholdrog otTax on Nonresident Aliens ard Foreign Enlities.
Ihh folloyrins parsons must provide Fonh VJ'g lo lhE Pa?ot for
pwposes ol establishing ils non.loreign slalus.
, ln the case of a disregarded inlily rvith a U.S. ovner, the U'S. or';ner
bl lhe disregarded enlity aird not lho disr€gudad entity
. ln lhs c6ss of a qranlor lrusl trilh a U,S, granlor or olilgr U.S. o'sner,
grnerally,ihi U.S:g.anlotoi olher U.S. ovzngrof lh€ grantor vust and
0ol lha gtsntor lrusl
, ln tha case of a U.S, lru9t (olher thao a granlor truslf. lhe U.S, itusl
end not the bon€ficiatiss ol the lrusl.
SEe Pub. 516 tor mora infomlat-on on p(oviding I Form !r/-9 o{ q
cerirfrcation ol non-loreigh status to avord v/iihhotding'
Klttitas county Agreement for services {rev .5t14/251
Page 18 of 23
Foreiun oerson, ll vou are a foreiqn pgrson or the U.S. branch ol f,
loreiqi b'enk lhat hiE elecled to bi kbated os a U.S, peaon (under
iesu-lations seclion l,l44I -ttbl(2)$v) o/ olher apPlicable seclion tor
chipisr 3 or rl purpos6), do nol use Fonn W'9. lnstead, use lhe
sppropdate Fohr i{"8 ot Fomr s233 (seo Pub, 6lS)' ll you are a
ou-afrfiid foreiqn cension lund under Regolations seclton l.sg?tll- l(d). or
a'partnErshipihai is.wholly or.rnad by qwlrlied foreign pensiotr lunds,
lhat is lreated as a nbn.foteign person lor purposei <if section 14'15
withholding, do nol use Fonn Vr-g. lnst4ad, u36 Form lir-8EXP (ot othe,
certilication of non.loreign slatus!.
Nonresidsnt allsn who liecotttas n resldent nllett. Generally, only a
nqn,Esldent alien irrdividual may uss iho terms ol e tar treaty lo redreo
or eliminale U.$. lax on cerlain types ol incorrre. l{oweYe(, nlost lax
traatiee canlain a ptovision knotrn as a $avind clause. Erceplions
soe cilied ln lhe sa|ino clause mav petmit an exemptioo ftom lax to
cbntjnuo for oerlain tipes ol incoirb aven afier lhe'payae has qthirtlse
become a U.S, residgnt a.lien lor lax purPog€3,
lf you are a U.$. residant alien who is re!7ing on an axception
contiined in the sa,ring claus€ ol a lax lreaty to claim sn et(emplion
frorn U,S, lax on cerlain lypes of incontl. you musl atlach a slaltmenl
to Form W.g thai specilieC tlre lollorving five ilems'
l. The ltoaty counhT. Generally, lhis nrust be lhe sa.he treaty undel
which you cfaimed exemplion trom tax as a nonlesidonl alien'
?, Th6 trtaty..rlicla addrassing tha lncome.
0, the erlicle nunrber (or lccation) in lhs td,( l,trly thrt conlains tha
sailng clause and ils exc€ptions.
.1. Tha t.Jpe and anrount of ific6nio thal qu.{ifiet for he exemFtlon
frbrn lar -
5. Sufficiont tactc to iuslify lhe exenrption fiont tax under lha lerms ol
the keaiy arllcl€.
Exarnple. Arllcle 20 ol ths U,S..China income lax lr€ah/ allores arl
eiemolibn fronr Ior lor scholdrship income recei'ed by a Ohinese
Etudeht tErnoffarilv presant ln lhe Unihd Slates: Under U.S. fag, this
studenl viil beconiE a iesidml alien for'lar purposas il lheir slay in lhe
UnilEd Slales exce;ds $ calendar teare: llowev€t' paraEiaPh a D{ tha
fl(st Protocol !o lhs U.S,-Chlno treatv (dated ADnl 90, 19e'l) allows lhe
prbvisions of Adicle ?0 to continue tb ipply even after lhe Chinese
itudent becoilrcs a resident alieh ol the United Slates. A Chhasg
student who qualifies fgr lhlq exception (under Paragraph 2 of lir€ firsl
Protoccll and is ielvinq on lhis exc€ption to claim an exemrjlion from tat
on U$ir ichotarshif oirrtlowehip irtionte tlould anach lo Fotil vr-g a
statement lhal ir*ludes lhe infoinration described sbo're to suFpott lhat
exehipliori.'
.ll lou ars a nontesidenl alien or a fQrsign anlily. gli€ lhs reguoslet lhe
approFriala complsted Fonrl ll/-0 or Foml 8233.
Backup Withholding
Whal is bncktrp rvithholdino? Persoos ntaking cetlain paymEnts to lau
olust und*i ceriaio ionditions 'rdthhold and pay lo ft; IR$ ?.lYc ol such
paynrenls. This is called obaclup trirtrholdin!.rPayments thal may'oe '
iubiect lo ba':kup r,,rlhhqlding irclude. but ale nol limiled to, int€re3l,
ta:r-erernbi interesl, di'Jdends. broker arld barl€t eichange
lransaclions. ierrts, lovaltles, nortelnployee pay, payments ntnde in
selltenltnl.oi paym€ni card and lhird'party nehvblk lrar'saclions. and
i+*ein palrndnti trom lishing boot operaiots' Re6l islale lransaclions
aro nol'wbjecl to.baekup raiilrholding.
Yan will nol b4 subjecr to bachup withholding on Paynrerll$ yo-u tecerv€
if you Eive the requesiw your cottdct TlN, mak; lhe'priper cerlificaricni'
arid rebort all yqur laxable inlerest ond dMdends on your lar ralurn.
Piiymenls you receive vrill.be eubiect io }dckup tdlhhokling il:
l, You do nol-turnish yout TIN to the requeet€ri
?. Y. o! do nol c€.rliS; your TIN r,rhert tequked {sea the inslruclions lor
Pari ll fordeiailsli
3. the IRS leils lhe requesier lhdl yoo lumished an inconecl Tlfli
.1. th€ IRS tells you that you aie subiect to backup wilhholdng
because ybu did nol reFoi all yourinlbresl and dividedds on y6ut lar
retum (fol reporlabfe inlerest and dividends onty[ or
6. You do not cerlify lo th€ requdsler lhal you drq nol subpcl lo
b'ackup nithholding, 6s desodbed in ilem 4 dndei "8ystgning lha filleil-
ou, forhr abova {fCr reporlabla interest and dividend accouts op€ned
atler 1983 only),
Form lV.9 lR6v. 3.2'P.1,Pts6 3
e,€dairi payeoo and paym6nts aro sxempt ftom backup wilhholding.
See Eremll i'ayee code, laler, and lhe sepa.ate lnslruclions for lhe
Requestel ol Form VI.9 lor mora lnformalion,
See atso Eslablishing U.$. stalus /or pwposes pl chapaet 3 and
chapter .I wi lhlnkli ng. eorlier.
What ls FATCA Beporting?
Ihe Foreign Accounl Tax Conlplinnee Aot IFATCA) r€quiris e
podicipaling forelgn linancial irtslilulio,r to teporl all U.$. accounl
holderi lhdi are sfocified U.S. p+rsons. Cerlan payees ue exempl fiorn
FATGA rspoding.'See Exemption hom FAICA ieprling coda. lalel and
lhe lnslruclions for lhe Rlque.sler of Form W-9 lor more infonnalion'
Updating Your lnformation
You nlusl provide updatedinlomration lo any porson lo vrhorir you
claimed to be an exempl payea il you are no longet an exempt payee
and anlicioaie receivinn reoodable oa,rrnenlg in lhd lutule trom lhiS
peoon. F6r oxample, yitr rnay need tti prodde updated inlormalioo il
you are a C corpodlion thal elecls lo be an S corporation, or if you ate
io longer tax eiernpl In addition, you musl (unlish a nev/ Form W-g il
lhe name or TIN chnngeS for the account, for example, if lhe grantor ol a
granlo, lrust dies.
Penalties
Faihrre to funrislr TlN. ll you tail lo lumish your conect Tlll lo a
rpquester,,/ou arg subiecl to a penally ol $:0 for each sttch failure
unlbsi youi lailure ls due to reasonable cause and nol lo willfut nagleot.
civit nenalV lor talse irriorrualiort wilh rbsp€cl lo willrhotrlirrg. lf you
rnaks a false statement rvith no n'asonable ba$is lhal tesulle in no
backup'.vithholdidg, yiru aie sublecl tci a Ss0o panalty.
Crhnlnal penalty for falsifying hrtonrrrillon. lr/illhrlly falsi{ylng
cedilicalrbns or afiirmalion3 may subiect you to c.iminal Penaltigs
including fi nes and&r intpri3onrllsrlt'
MlsusE pl flNs. lf the requester dieclos€s or usas Tlfls lil vio{ation ol
iederal larz, lha rqqrtesler nray be suhiact to civil and crirninal penallies.
Specific lnstructions
Llne 1
You nlusl enler o4e ol ltrg follovring on this linE; do tlot leeve lhis line
blank The nanre should maich lhe narno on your lax retutn.
ll tris Form \ri;g is for a ioint account (other lhan an account
majnlained by a foreigrt fnancial institulion (FF[], lisl lirsl, and then
circld, the name ol lho person or enlity vrhot6 nuntber you entered in
Parl I of Fom t'J"9. ll !rcu are pr6'iiding Fontr VJ-9 to an FFI lo documEnt
a joini accounl, each holder ol Uls accaunl lhal is a U.3. person must
provide a Form lV-9.
r lndividual. Generally, entir lhg neme shovrn on yout lax roturn, lt you
have chqnged ;our lasl nante viilrout futforming l}i6 Social Secudty
Administraiion {SSA) ol the nanre chanoe, entel you. first name, lhe lasl
narne as shor.rri on your soci{l sEcurlty card, and yottr ne'.'/ last nanrc.
Nots ior IIIN llrplicnnl: Enter totrr irrdividual nanre a$ il vlas enlered
on youi Fomr !V.7 application, lrrre Ia. This sho{l(J also bi lhe same bs
lhe.name you entered on thE Form t040 you filec{ rvith your applicalion.
. Sole proPaiotor. Enler yout indiuidual name as shorcn on your Folm
to{o oi tirie l. Enler ,pur business. kade. cir 'ldolng business as' {DBAI
na.ma on line 2.
. Pbrlnership. C corpor.rlion, S col;toraliol, or LLC, olher llran o
disrgrJaidgtlenlily. €nter lha onrity's harne as 6horin on lhe enlit'/'s tai
ratum on line I and ariy business, tradq or DBA name on line 2.
' Othsr etilities, Entwyour name as thortn od iequked U.S..ledenf tar
documehld on line 1. This nami shorild mstch lhE name shovrn onihe
chader or olher legal docunrenl cteating lhe entity. Entarany businrss,
lrade, or OBA name on lire ?.
r Disregarddd enlity, ln g6ne.al, a businoss €ntily that hae a singl?
or,rner, including dn LLC, and iq nol a corPotalion, is distegarded.as an
enlity #parale fion ils owner [a disregarded enlity). See flggula(gns
section iot,770t-z(cxzl. A disregarded enlity should check the
appropdate bor lor lhe tax classification ofils owner. Enter lhe orsner's
nime on line L The naua oJ the owner enlere<Jon litte .1 shouH ne'rer
bd a disreoarded enlilv. The nante on line I should be the aama sliown
on the lnc6mE hr retrim on vrhhh the inqome should be repbrtid. For
lF lho entig/irxlividual on lirre I
iea(ttl.,.
IHEN check the box lor
. Corporatiorl Corooration.
r Individualor
. Solo prciprielorship
lndivldual/sole proprietor.
r LLOclassilied as a padnership
tor U.S, lederal lax purposee or
r LLG thal has frled FormssSzqr
2553 elecUig to be taxed a5 a
corporalion
Lintited liabtrity company and
enter lhe appropdrte lax
cla$ificati06:
P - Parlnership,
C=Ccorpomtion,oi
S = S corpc,ration,
r Partnership Parlnership.
. TrulYeslite TrusVestbte.
oxemple. if a loreiqn LLO lhat is traoled as d dis.eqarded anlity lor U.S.
feaeril tii purposis has a singls orynrr that is a U.S. porson, ine u.S,
or,rner's name ia required to be providod on lina L lf lhe ditect owner ol
the enlity is also a disregaided entitT. enler lhe first ovrnet that ls not
disregardad lor ledoral laK purpose3, €nter the disragarded cnlily's
namC on linq 2. ll lhe ovrner ol the disregatded entity is a toreign p€rson,
lhe o.oner musl complele an appropriatb Form W'8 hstead oli Form
tl/-g. ftis is lhe casd even il th€ foreign parson has a U.S, Tll.l.
Llne 2
lf you have a buginass nam*, trado narne, DBA name, or distegarded
endt'/ nam€, eoter il on lins 2.
Ltne 3a
Check lha approprilt€ bor of lirls 3a lor lho U'S. led€tal tax
clasrificalion of lho person nhosg nanre is anlsred on line L Check only
one bor on line 3a,
Line 3b
Check this bor il you are a partnetsttip (including an LLC olassilied as a
partnership lcr U.$. fEderal ta:< purposes), lrusl, ot aslale lhal ha$ iny
foreign Farlnsrs, owngrs, ot bansfciades, and yort are providing this
lorm to-a parlnership, lrusl, or estale, in t{hkh ycu ha'ru an ovnlership
lnter€sl. 'lou rnrBl check lh6 box on lina 3b il you receivg I Form Ul8
(otdoculnenlar/ evidence) ftom any partner, ovrner. or beneliciary
establishing loieign status or if you n*ei're a Folnl y,l-9 lrant any
parlner. oVoer. oi beneficiary Ural has chetked ths box on line 3b.
Nols: A pannershlp lhat pro'rides a Form !V-9 and checks box 3b may
be requiied lo coniplete Schedules K"2 afld K-3 lFerm 1065). For more
inlorntation, ses lhs Padnemhip lnstnrcdons lot Schedufes K-? and K-S
(Form J065!:
It you ar€ .equired lo complele line 0b but fail to do so, you may nol
receiva the information recessonJ to filt a conecl inforrnaiion rahlm {'/ilh
lhe IRS or ftimish a corrdcl payae Blalsm€nl lo yourpadrle6 or
benenciaries..See. (or example, seclioos 6698, 6722, a|ld 672.1 lor
penallies thal nray apply,
Line 4 Exemptions
It iou 6re erenrpl kom backup r';ilhholding and/or FATCA repodin$.
eriter in llre appiopdate spacd on lina ,l any code(s) lhdl nlay epply to
l/ou,
Exernpl grayee rbde.
' Generaliy, individualg 0ncludirg sole propd*lors) are not exempl lrom
backup rvitNroltling.
. F.:*cepl as provided belovr, corpotslioris ars exempt ftom backuP
viithholiling lbr cerlaln payrn*nls, includicg lnletesl and dividends.
r Corpoiations er€ not e:(ernpl tionr backup wilhholtiing foi ppymanis
meds r'n sElllenlenl ol paymehl card or thirai'party netrara'k lraniaaions''
. Corporalions are nol erernpl lronr backup wilhholding vrilh respect to
altombys' le*3 or gross proceeds paid io atlomeys. and corporations
Itiai proyide medcal or heallh care seilices er€ not axempt vrith tespect
to payments reporlable on Form 10E9-fullSC'
The folloeiing codes idenlity paye$ lhal are exbmpl kool backup
wilhholding. Enlerthe appropriate ccde in the space on line ,1,
I -An organizalrbn e,(empl from tar under section 5o1(el, sny lFA, ar
a cuslodht account uMer seclion 403tblf/) if the sicounl satisfies lha
raquirements ol section .101(fX2).
Klttltas County Agreement for Services (rev.5lt4l25l
Page 19 of 23
Pas+ 4Form tV-9 {Fcv, 3'?d2{l
2-Tho Uniled States or ony of ils agetlcl€s of inskunenlalitiaS.
3-A glate. ih€ Oislrict ol Colunrbia, a U.S, commgnr/e3lth or lerntory'
or any of ih€ir polifcal subdivisions 6r idstruInertaliug3;
4-A forelgn gov.emmtol or any 4l its folitical subdi'rislons, agencias'
or lnshurnenlalilies.
5-A corpontton.
6-A daaler in gecurilies or comnrodilias requked lo (eglBl€t itl th€
United Slalss, lha 0islriit ol Golumbla, or a U.S- commonrvealth or
leiri{ory.
7-A tutures conlmlss,oo merchant regisilred vlith lhe Commodily
Futures Trading Cofititission'
8-A real esteld inTestment trust.
9-An €ntitt r€gister# at atl times dudng th* tax year undar lhe
lnveslnrent Conrpany Acl ol l0'10.
10-A common |tuel lund operaled b7 a bank under section 584(a!.
I I *A linancial inslitulion as d€lined undNr Secuon 5sl'
'12-A middleman knorvn in the invBslmeot contnunityes a nominee or
oilsl6dian.
l3-A lrusl exempl frprn tax under seclion .66'l or descdbed in secliori
F-A deale/ in g6cudlies. coilmodities, ot deri'rati'/e linancial
instnrntenls {ncluding noliooal principal conlracts, tututes, lornatds,
and opllorrg)'lhatis ri{istered as srrch ultler the lavrs of lha United
SlatEe or any!lat€.
G-A rEal estato inveslngnl trtlst.
H-A regulaled inveslntenl conrpdoy as defned irt seclion 851 or an
entity regiatored flt all tinres durirrg lh8 tax /ear und€r the lnvestnenl
Gornpany Aci of lolo.
l-A common trust lund a$ dalined in s4ctron 58'l(a)'
J-A bank as defined in 5€ction 581,
R-A broker,
L-A trusl exernpl flonr tdx trnde, s€ctiDn 66{ or dE$cribed ln section
de{7(a)(1).
lv[-A tor'axempt tiust undera section {031b} plan or section {57{gl
plan,
Nots: You may vrish to comult'Jrilh lho linancial institution tcquestlng
thig lorm lo det+rmine whelher lha FATCA cod6 afld/or €xempl paye€
code should he compleled,
Llne 5
Enler your address {alumbgr, slte6l, and apartment or suila nuntbed.
This id vrhere lhe reqtr+sttr ol thls Fom l'1-9 will nrail your inlormotion
retums, lf this addrEss dif{ers lrom the one llte requesler already has on
lil€, €nlei'NE/1" at the iop. lf a ne}r address is provided, hEre is still o
chancE the otd qddioss r',ill bq used tlntil lho Fayo. chang$ your
addllss in thela recotdg.
Line 6
€nleryour city, sl5te. end zlP cods.
Part l. Taxpayer ldentification Number (TlN)
Entsryour TIN itr dre alrpropriate hox. ll you are a rasldent alien and
.you do nol haye, and arjhot-eligibla to g.tt, an SSil, your TIN is your
iHS lTlll. Enter il in he ent{y space tor lh-" Social securily nuorber, lf you
do rlat have ari tTlll, srea Hor'l lo gdl a llll bel6rv,
ll you are a sole p*oprielor and yott have an €li'|, you nrsy €nl€r either
lour SSll ot Elll,
lf vou arE a sinob-0.renrbet LLC lhat is disregarded as an enlity
seoinla fiom ils-oYiner, snter the ovrne/s SSI'I (or Elll, i{ lha ovrnet has
orla). lt the LLC is classilied as a corpotation or partnetship. enter the
enlity's ElN,
Nolej See l9flal llante and NunberToGiva lhe fiequester. laler, lor
lurlhei iladfiCalion ol nanle and flll conrbinalicn$.
How lo qet a TlN, ll you do noi have a Tlll,:apply for one inrmediately.
fo appt./lor an SStl. get Fornr $S-5, Applichtion for a Social SecuritT
Caoj.'{rirm vcur hcal SSA olfice or get lhi3 lotm p.nline al
rnzHi.SSAdon Ycu may elso get this lorm by calling 800'7?2't?t3. Use
Fom trV.7.-Ar:olication for IRS-lndividual Taxpafer ldenlifi callon
Numter. t6 a'pbty foi an lllll, cr Fdm SS'.1, Apdication lor Enrployar
ldentilicalion-l'iuhb+r. to apply br art Elll. You can apply tot an EIN
6nline by accessrjg ihe IRS vr;bsite at r',lrv.ri'c.govlEliV. Go lo
r,l'th,i.i9.r,f;vlFoffii to visrv, doitnload, or p*int Form tril'7 i4dlor Foffil
5s-i. ci]vou ian go lo r',r;'t irs.go'lo.dP;Fblms lo placo ao order ahd
have Ford Ur-7 aniVor.Fonu SS-.1 ntailed lo yntt rvith;n l5 buslnesg
da1s.
ll vou ara asked to comolete totm I'J'g btn do nol hs're ATll.l, apply
lor a'Tll.l and enter "Apoli;d Fot'in tl'e tpace fot he TlN, sign and date
the form. and qii'a it lri ihe request:r. For.interasl and dividend
paymeolg, andc*rtain paynrahts mada t'tilh r*spect to read'ly Itadrble
inriru-"nis, you vritt q6nerally have eO da'/s to gel a Thl snd give il to
the ienuesteikiford tou arg iubiecl to backtrp v,ithholding on
oavmehls, Tho 60.div da iloes nbt bpply tb olhet types ol piymenls.
Voir vdl{ be subiecl to backup vrithlsldng on all such paymenls unlil
you prorida your Tll'l to lhe request€r'
Notel Entering 'Apllied For" neans thal You have alte6{y applled fot a
Tltt or th"l vd inieird to aoplv for ona so6n. See also Esaab/tsh,hg U.S.
status loi oitiposes ot chalpiei g and chapter 4 tti|/*,olding' barllet, fot
when you'may iostead be Subiect to vrithholding under chaplgr 3 oi 4 ol
lhs Cod?.
cstrtion; Adisregarded U.$. eotity lhat lias a lo.reign ovrner musl use
lhe App.opriale Form lv-8.
and
4947.
The chart
lF lha payrlettl is for ...THEN ths payrrltrtt i3 6xanrPt
for .., .
. lnleresl ald PaynlentS exemPl payEss excepl
for 7
lo ?012,
paye€s I lhrouglr.l.
to
be repoaed
s5000r
ol Etenrpt payees 1 lhtough 4,
I Sep Fotnr hliscellane-qus ln{bmtalioo, and its instrucllons.
.Klttitas County Agreement for Servlces (rsv. 5/14/25)
Page2O oi,t23
iHor,/ever. lhe fotlovrinq paymbhls meCe to a corpo.ntidn and
reoorteblson Form 109-Il'{lSQ are not ex:mpl from backup
itithrrolOirio: meiical and heahh care pilynlanl!, attoine'F' lees, grobs
proceeds iaid lo an aHorney reporteble'urdei eection 60'15{0. dnd
bayments for serices paid by a feCetal ex€4utive agency.
Exenrotion lrorir FATCA reporting code, Tha lolloiling ccdes idonlity
oaveei lhat arE r*ernpl ttoft t€potling und*r FATCA. These codes
'rrtlh to rieoons subirittino thli ionn-{ol accounls mainlalned oulslde
"?iiri u,iitea smtes bv cerliin loreibn financial institulions. Thetelore; il
voi.r i'a onlv cubmillinh this iomi loian account you hold in thb Unitki
6lates. vou ma'rleave-ihis lield btank' Corsult v;ih the peruon
imrieitino this iomr lf vou are unceiiain if lhe frnanclal lnslihrtion is
su[leci tith*se reouiimenb. A redueslet moy indicele that a codEis
noikorrireil bv oroiidino vou l'rhh aFomr !il-g r'rith .No! Applicablel tor
iny ainltar intricatirnl eritrirird on tht lin* for a FATCA exqmption c4d*.
A-Ar oioanizliticn exempt lnom lax undEr geclioh Sot(a) or any
individual re'tirement plan ad C+lined in section ??01{3}1371.
.B*Tha United Slates ot sny of iB agencles or lnslrum?ntalillee'
c*A sl3le. lhe Disltrot ol.colunrbia, a u's' comnon"'reallh ol
lenitqry, qr any.ol thelr political subdivisjons qt inslrumenlalitiee'
O-A cqrpo.drion lh€ slo-ch of whichisregularly traded ofi one o.
mors eslablished sEcu.ities markels. ds desoi'ibad in Regulations
section l, 1 a7P-l(cltl)(il;
E-A corooration lhal is a m;nib€iol the samd erpanded qtliiiated
group bs a torporalion dgscdbed in Regulations:section f'1d72-1(cllUf'1,
ovet
6+narally, e:<,:ntpt paYe*s
1 through 5.r
Pc!t+ 5Fom W.9 (Riv. +202.11
Part ll, Cettificatlon
To eslablish to lhe vri&holding agent thal you are e U'S, pbrson. or
iesidenl alien. slqn Form W-0. Ygu may be requested to sign by lh€
vrithholding agedt eeen il ilern l, 4, or i belov, indicalas oth€c'ris6.
For a loinl accounl. onV lhe persdn lvhose Tll'l is shovrn in Parl I
.h";iJiid'(rri,;n teiruirear' ln'the caee ol b disregarded enlitT, ihe
pe.rson idintifiea on li'ne I rirust slgn. Exempl payees. se" Exampl payee
code, earlisr,
Signnluro requilsnionts, Complele the cerlification ag indicaled in
itemqllhrough5below.
{. hrieresl, (livklend, and barter exchange accoonts opetred
before 1984 bnd brokot rccouhls considered active durillg t983'
You nlusl givg your correct Tlfil, bvt you do nol have to sigrl the
cerlilicalion.
8. Obr.glrded enliv nol
indildud
9, Arolid twgl, t3lstc, or p!drloo t{u9t
10, Corroralion or LLC ehc$ng corpcrole
rtJIilf on Fornr 8gl? ot Fr,tm 25s
I !, As.rociilicrl. club. religiooc, chgiiabll.
€ducn$dodl or 6ther iaf,.ixemPl
ctganiathn
12. P4de,ship or nulli.mtmbrt LLC
t3. A trok$! or (itiElered nonin6t
Give ilartre
art Tha oyir*r
L€961 cntiVr
The cc{t€rrlion
Ihe olgrnization
Iha prdncrchip
fha broker or nomhca
The publlt *htily
lhis
1,1. Accounl v/ih th+ otporirnenl sl
Agdwltwc h lhc nqrur ol o Public
eotit/ (such d3 a ihlt ot l€cd
qov;ritnenl, sahool dietricl. ot pdscol
thot r*eitts oqrieultu tolgrogrttt
piyfi.nt!
t5. G6ntor kutl filjng Fc{m 10.11 c.
undtr lhe Opliooal Frlinq il6ttod 2,
requirinE Form I 09tl {6ra Rcqul.ll:cn3
€icliqn 1.6? 1.4{b){?i{i)(BD"
The t uqt
3. Rdal e3lato lratrsaclions. You nlusl sign tha g4rlilication' You nay
cross out ;tefit 2 ol lhe ceriificalion.
4. Olher oavrnsnts. You must gi're your cofiect Tl]1, bul you do nol
have to sioi tfie certilication unless you hdve been nolified lhat you
hava orEviouslv oiverl an Incorrect T[N' 'Olhar paymenls" includg
ii']minls rnaaiTn lhe cou.ss of lhe requester'-s l;ad€ or husiness for
ierite. ro'/alties. goods (olhet lhah bills fcr tneichand'se)' medical and
health cire serviles fniluding paynlents lo corPctalions)' pa'ltnents to
a nonemployee lot s;dces, paymsnts made ln settlemenl ot-painlonl
ciiJ lnii'ttrlia.oarlv natr';ork'trinsaciions. parm€n13 lo cerrain lishing
boat cre'a meniberi and lishenrren, and g/o33 proceeds paid to
ailomgys {t-}cluding PilynEnts to coForalions}.
5. Modoaos itlleresl paid by you, acqtrisition oI altattqlottntenl of
secrrrerl irbirertv. canc-eliatioir bl debl, qrralilied luilion Progr.lltr
t""iiJ,rrliuir,tei'secrion 529h ABLE aicbrrnts {under seclion 520A1'
inl, Coverctetl ESA, fucher MSA or HSA contrihutlonq or
disidbulione,'and pension diskibulions' You thust gi're your conecl
Tlll, but you do noihava lo sigo the ce,lillcslion.
What Narne and Number To Give the
For of 6ccounl:Give rtarne and SSN
Th'r
tLlst lirst and circle lhe name of the person
ll only one penon on a joht accounl has an
must be fumighod.
rCircle lhe minols name and lumirh tho mino/s SSll'
!You musl shov, voui indi'ridual name on line 1. and enteryour business
oi b'baiiiiriJ. iieirrv. on tine z, You mav use eilher vour $S't{ or El}l 1if
you have onei, but the IHS encourages you to use your SSI'1.
{ List lirsi and circlE lhe name of the lrusl. ellala, or pension lrust. (0o
not fumish the TIN ol tho Detsonat repregtntaliib or lruslee uille3s lho
le€at €ndty ilsEli 15 0ol dtilgaaled in lhe sccount tille')
'Note: The grantor must.also p/ovidt a For$ li/'g lo lho trustee ol thr
lrust.
't Fot more information on optiorlel filirrg nelhods lor g.anlor trrsls, se€
the lnswdlions tor Fo.m l0.ll.
Nole: ll no ilama ls ckcled $rhen morg lhan ons ndme 16 llslid. tho
number ryill ba consldered lo bg lhat of rhe fif$l natne listed.
Secure Your Tax Becords From ldentity Theft
ldentitv th€R irccurs wben someons (lses your Pdrgonal inlormation'
such a! vour narne, SSll, or oihea identi!ing inlormalion' v/ilhoul your
oernrissi6n lo contrnil lraud or other crimes. An idenlity lhial tnay usa
iorlr SSN to get a iob or may lil€ a taq rslurn using your SSI'' to taceiYs
a refund,
To reduce your rirlt:
. Piotect yo.tit $sll,
. Ensure your ernployer i5 protecung }'our S$ll, and
. Be carelul vrhen choosing a tax retunr preparer.
l{ vbur tax records are attecled by iCentity theh.ancl you recefua a
notiie fionr ihe lRS, respond right i'.v;ay lo lhe name a4d phone number
pdnted pn lhe lB9 nolicb oi'letttr
It vour le.t r*cords are mt curenily atfEcled by idenliv lhelt bul you
lhinli vou are al dsk due to a lost or ito{en purse or vtallel, qug3tionable
credifcanJ aclivrty, oi a questionable c.edit r6pod, contaot tha lFlS
ldentity Theft HotiinE al 00o'9o&'t'190 or subfiil Fom t 'i039'
For mqre informelion. s:e Pub' 502?, lclenlity Theft lnfonnalion for
Taxpaye'3,
r,uho-.e nunrber you fumish.
SSfl, that perion's number
2. Tvro cr mcru hdiviJsils Ednl acttuml
olher lhrn u occaunl rhdrntdlc€d by
on FFI
3, Tso or mote U.$, p:mnr
fainl aeouni mrhhhtd by an FFl.}
.t. Cuntcdi:l accouni cl o hioci
tUniforn Gitt lo t'{h+rc$:t}
5. a, Th+. o*it r:vocittie 3rringi lrusl
(gr8lcr b orso trdgtal)
b, Socrllrd trurtofcwnt lhrl FJ nol
rr bgJ or rrJiC ttuet unds chtt bz
O, Sogt proFd.tOr9fdp a di*ragord#
ea,tilf ovined by m hdifidurl
7. G6niq. busr .f&o? unde, Optbnil
Fttne l'lrlhcd 1 lg+: F;gslalioc:
sec$on l.67 t.rtbPXil',lJ)"
th* iclual os?!?( of lha lcccqnl or,
it combh€d ,rvnds, tha fir*l individuol
co ihr a€caunlt
E{ch holdrr cllhe occcunt
Thr minorl
fhg. gra'ltotjtru6!}il
th* octust ov,n:rl
fle ormrrr
'Ih: groalorr
Kittltas county Agreement for Services (iev, 5/14/25)
PageZL of ztr
irccouiltl
Paqa 6Fo.m YI.g (fuv,3-?o2{)
Victims of identitv theft vJho ara experi4ncing econonlic harm or a
svsiemic oroblem, 'or are seekinq helb in resoliing tar ptoblen3 lhal
hiva not 6een resolved lhrough norrrtal channals. nray be eligible lor
Taxoaver Advocalo Serr/ice (irASl issistance. You can ieach TAS by
caitiirrg the TAS toll.free caso irrtake lirl€ alafT'777'{77s or Tfi/TDD
800'029-4059,
Prolecl vottrsell lront stlsplciorts pnl0ilq or phishiltg schantos'
Phishins'is lhe creation and us€ of Entail and iirsbeiles dasigned lo
nrinric lJoitimale business entails and vlebsites, The nrost -contmon act
is sendin-g an enrail lo a user falsely claiming lo be an eslablished .
leoiumate enteoi'iso in an attempl lo scam the u3el lnlo sutrenoarrng
private informatiolr lhal viill b€ u;ed for Usnlily lhefl.
Iha IRS doss nol lnhlate conlacls with laxpayers'ria emails' Also. tha
IRS does not requesl personal detailed inhrmaiion-through entail.or ask
taxoavers for the Plll itunrber$, passuotds, or similar gect€l accebs
lnfdmiation lor their credit card,'bank, or olhet linancial accounts,
lf vou raceive an unsolicited email olainring to be from ths lFS,
lonvird thig mossagilophishing'4rh'gor'. You may also report misusa
oi the IFS nanre, loiro. oi olher IRS p(operly to tha T/easury lnspector
General lor Tax Adnrinislralion (IlGTAl 8l sc0-3€8-448't. You can
lor,lard suspicbps emaifs lo lhe Fed9ralTnda Commission at
soam9uce.iov or rep,irl them ot lngw. ftc.go'tlcomplainL You can
iontact thaFf C a t v|nv.ftc,qovtidthett or 677-IDTHEFT (817-'t38"1338).
li you hive Ueen the victirn o'f id,nlity theft. 6.e tzwlt 'rdentilyThelt.gor
and Pub.5g27.
Go to rww.ris.go vttdentiryf haft lo ldain mote aboul identity theit and
hosr to redvce yogr dsk.
Privacy Act Notice
Klttltas County Agreernent for Services lrev'5lL4l25l
Page2Z of 23
ATTACHMENT I'F"
nETTREMENTSTATUS FORM
** All contractors who are lndlvlduals must complete and slgn **
SECTION 1: CONTRACTOR COMPTETES THIS SECTION:
Did you retlre from one of the State of Washlngton Retlrement Systems?
Dld you retlre before age 65 using the 2008 early retlrement factors (ERF)?
Willyou be recelvlng dlrect compensatlon for these servlces?
Willyou be lndirect compensation for these services?
Yes fl. ruo
Yes i[ ruo{v.r T No
9A.Yes _ No
ntractor as ln DRS flllngs-Please Prl
Signatu Last Four Digits of Soclal Security
Date
sECTloN 1: COUNTY COMPLETES THIS SECTION:
[Use Member ReportlngVerlflcatlon (MRV) lo verlfythe past retlrement membershlp and document belowl
1. Has Contractor been a member of a Washington State Retirement System? - Yes -
No
lf yes, which system and plan?
-
Teachers' Retirement System {TRS) -. Plan 1
- Plan 2 -
Plan 3
-
School Employees' Retlrement Systern (SERS) * Plan 2 - Plan 3
_ Public Employees' Retlrement Systerns (PERS)
-
Plan 1
- Plan 2
-
Plan 3
_ Public Safety Employees' Retlrernent System (PSERSI -- Plan 2
_ Law Enforcement Officers'& Fire Fighters' Retlrement System (LEOFF) -_ Plan 1
-
Plan 2
_ Washlngton State Patrol Retirement System (WSPRSI
-
Plan 1
- Plan 2
* Judicial Retirement System (lRS)
2, ls Contractor a retlree of a Washington State Retirement System?
3. Did Contractor retire before age 65 usingthe 2008 ERF?
I have verified the information above using MRV or by contacting DRS.
COUNTY REPRESENTATIVE {Please Pri
Slgnature:- Date:-
COUNTV RETAINS THIS FORM
l(lttltas County Agreement for Services Fev,5174125,
Page 23 of 23
.V LA,LJ,L|^L
_Yes -. No
__Yes _ No
me
CLINICAL OPERATIONS MOU
MEMORANDU M OF UNDER$TANDING
CLINICAL OPERATION$
Klttltas County / Kltlltas County Jall and Gonlractor I Auguat 2026
1. PURPOSE AND RELATIONSHIP TO SERVICE AGREEMENT
Thls MOU establlshes the day-to-day operallng model botween Klttltas County, actlng through Klltitas County Jall'
anJ nppu Valley counsellng servlc6s,'LLC, a Washlngton llmltod llabillty-company doing buslness as Valley Health
and Cbunseltngicontractorl, for menlal health, substance use disorder (SUD), behavloral'health.practllloner, and
nerravtorat-neaith medloailon.manugrmenl services at Kltlltas County Jatl (KCJ). lt supplemonts lhe partles'serylce
,gr"ilent and BAA, lt dqes not exfand custody dulles, walve legal regulrements, Qr overrlde the servlce
agreements payment, insurance' lndemnlty, or termlnallon terms.
2. SERVICES
r Mental health; screenlng, assessment, indlvlclual or group treatment lvhen clinically appropriate' crlsls evalualion
and coordinatlon, cllschirge or reentry referral, and cllnlcally necessary care coordlnatlon'
r SUD: soreenlng and asseisment, counsellng, cass manag€ment, medlcatlon-treatment referral and coordination,
communlty referral, and warrn handoff when feaslble'
. Behavloral-hsalth pracllfloner servlces: behavlorat-heallh assessrnent, medicatlon evaluatlon and management,
monitorlng, prercriblng, consultatlon, and coordinatlon or reforral wiihln the rendoring cllnlclan's scope and
credenlailng, Generaimecllcal, primary-care, famlly-medicine, urgent.care, and chronlc'dlsease needs remaln
with KCJ,s designated medical provlder, Contraclorwill not alter or assume rnanagemenl of medlcal treatment
already undor tliat providor's care, except for olinlcally necessary coordlnatlon withln the practtlloner's scope to
address behavioral'health medlcatlon safety'
. Tralnlng, court parlicipation, meetlng$, reporling, and noncllnlcal admlnlsBatlve work only when requested and
prlced ln wriling.
3. REFERRAL, TRIAGE, AND SC}IEDUIING
r KCJ will submlt referrals thlough the approved melhod wilh accurate booklng, ollnloal, safety, custody, language,
accesslbillty, and insurance lnformation available to lt.
r Conlractor will klage refenals by cllnlcal urgency and avallable scope. Emergencles lemaln_ the Counly's
responsibillty lhrotigh 9f 1 , lhe emergonoy deparlment, crlsls response, or other establlshed emergenoy
pathwaYs.
. The paities will malntain a wrltten stafllng schedule. Reserved tlme cancolled by the County with loss {han
f*"rfy-tou1. hours' notlce may be bllled under the servloe agroement, except for a documented emergency,
r Nelther the MOU nor a referral guarantees a spoclflc trealment, proscdption, dlagnosis, provlder' outcomo, or
contlnuous on-call coverage.
4. FACILITY ACCESS AND SAFETY
. KCJ supplies secure workspace, reasonable privacy, connectlvlty, approved system access, e$corts, correctional
stafflng, emergsncy responss, and tlmely access to referred patients.
, Contractor personnel foilolv reasonable faclllty safety rules that do no( confllct wlth llcensure, clinical
lndependenco, confldentlallty, or patienl safety.
r Contraclor personnel do not porform cuslody, seafch, lransport, restralnt, classiflcallon, discipllne' or evidence'
gatherlng dutles.
5, CLINICAL INDEPENDENCE AND CONTINUITY
Cllnioal deolslons remaln wlth the llcensed renderlng professional. KCJ may provlde relevatrt observations and safety
lnioir*1on Uut may not dlrect dlagnosis, prosoriblng, dooumentatlon, treatrnenl, dlscharge, or dlsclosuro contrary to
i"w or piof"t"lonal standards. Coitractor wlll coordinate cllnlcally approprlate continuity' referral, medlcatlon
reconcillallon, and reentry handoffs when lnlormatlon and oommunif r€sources permit'
6. DOCUMENTATION AND RECORDS
r Contractor documents soryices ln the approved EHR or agreed record system wlthln cllnically reasonable
tlmeframes.
KITTITAS coUNTY / VALLEY HEALTH AND CoUNsELING I Page 1
CLINICAL OFERATIONS MOU
. Correcllons to cllnlcal recorcls follow professlonal and logal standards; nellher party wlll requlre alteratlon of an
accurate cllnlcal record.. KCJ roceives operailonal and de^ldenllfled aggregate reports. Whe_ra reasonably avallable from existlng systems,
aggregate measures ruy fnrfuOu servloe ttniettness, tel6health utlllzation, referral status or closure, dlocharge or
L"*fri r"f"nrts, anC boliavloral-hoalth medication-management contlnulty' Nelther party must create a new
reporling system or perlorm materlal cuslom analyllos wlthout a separately qpproved sry99 a1d prlce, Access to
tdentlflable records requires a lawful purpose and mlnimum-necessary basls under the BAA, Parl 2, chaptet 70'02
RCW, prlvllege, and other applloable law'
7. PRIVACY AND COMMUNICATION
The partles will execute the BAA and appllcable Part 2 terms bsforo exchanglng PHI or SU-D rosords. Clinical
lnformation wil be communlcated ttrrodg'h approved securo channels. Gommunicatlons wlth courts, prosecutors,
;;f;;;;;"d;"1, famtly, oi ort*f Or provioer'o r"qulre lhe authorlzatlon, court order, troatment exceptlon, or o{her legal
basls applicable to the lnformatlon.
8, INSURANCE VERIFICATION AND BILLING
. KCJ provldes avallable coverago lnformation at relerral and.promptly supplles updates, Conkactor per{orms
reasdnable verlllcatlon but does not guarantee payer ellgiblllty or payment.
r Contractor bllls an actirre thlrd-party fayer first only when the cllent, servlce, setling' provlder, and clalm are
lawfully payable and Contractor ls aulhorlzed to blll.
, lf lnsurance ls lnactive or cannot be verllled at lhe vislt, lncarceratlon or payor policy prwenfg payment, or a clalm
ls denled for a reason other than Contraotor bltllng error, KCJ relmburses Contractor at the Medlcald-equlvalent
rate. Contraclor need nol awall a denlatwhen eliglbllity records establlsh that no payer ls avallable'
. Contraotor w1l not blll or balance-blll the lncarcerited client. No servlce may be blle.d to. P-olh a payer and KCJ
n"VonJrty lavufut iesldual amoun$ later payer recovery wlll be credited or refunded to KGJ'
, lnvolces will lden$fy seryice date, category, code, modifier, unlts, provider type, HCA schedule/effactive date'
lnsurance status or payei Oirpouitton, ind anrount. KCJ wlil pay undispuled amounts wlthln thlrty days and
io.nirry oirput"s wf tfiilfiireeri days. [tndlsputed amounts not pald when duo accrue lnterest as provlded by
chapter 39,70 RCW, conslstent wlth lhe service agreement'
9. MEDICAID-EqUIVAIENT RATE METHOD
Mentqlheallh uses the HCA Mentat Heatth and psychology sorvlces Fee schodule. SUD uses the HCA Substance
Use Disorcler Fee Schedulo-ana afpftcaole SERI r6qulrem'ents, Behavloral-health practltloner and medlcatlon-
managernent servlces ,ru ini HcA'physlclan-Related servlceslHealth care Professlonal servlces Fee sohedule'
The schedule effecflvs on tnJs"rtoe clate controls for the correctly docurnented code, modlfler, unit, providor lypo,
age, ptucu of servleo, and iactltty cleslgnation. Where no HCA rate exists, the parlles must approve a wrltten rate
before servlce.
preapprovod buslness mlleage ls relmbursed at the Washlnglon Offico of Flnanclal Managemenl prlvately owned
ventcti rate effeclivo on the t"ravet clate ($0.725 por mlle effettlve January 1, 2026). Travel tlme and other expenses
are not separately payable untess approved in wrltlng beforo travel'
10. TECHNOLOGY AND FUNDIN6 COOPERATION
r Subject to available funding, appllcable app.rovals, and a mutually approved wrltton lmplomentalion plan, the
parles may u.. r.rrl" iui6it.bitn, electrinlc refsrral, behavioral'health medlcatlon follow'up, and transition-
support teihnology to lmprove access lo the contractsd servlces'
. Before deployment, the lmplementation plan wlll address ownership, apgroved
f ":,"tP.L:9.i":-'
powef
'
connecllvity, "ytt"r'uaa"is,
prlvacy, securlty, accesslbllity, cllnlcai safety, support, custody, lncldent reporling,
anO ,"*ouii, Crant tunCs wlll'not clupllcate technology the iounty already provldes under lhe servlcs agreement'
. Upon reasonable request, the County m.ay provide factual conflrmatlon of the servlce relallonshlp, identllled
oierarnnat neec, tn6na'ed locaflon, ina ip'proved workflows for a funcllng appllcatlon. Thls does nol require tho
County lo sponsor oianOotr"
"n
apptlcatlon, provlda rnatchlng funds., guaranlee an award,,purchase equipment,
aOmtnirtur a grant, accept grant-compllance dutles, or lncur costs not separately approved ln writing'
11. INCIDENTS, COMPLAINTS, AND ESCATATION
. lmmedlato clinlcal or safoty threats follov,r KCJ emergency procedures flrsl, followed by prompt notlce to
Contractor leadershiP.
KITTITAS OoUNTY / VALLEY HEALTH AND COUNSELING I Page 2
CLINICAL OPERATIONS MOU
r prlvacy or sscurity events fo1ow the BAA, cllnlcel-quallty complalnts are routed to Conlrastor; custody or faclllty
complalnls ale routed to KCJ.. opeiatlonal dlsputes escalate from deslgnatod lialsons to exeoutlve tepresentallvee. Patlent care wlll not be
OdlaVeO for an admlnlstratlve dlspute when safe lawful care can proceed.
12. CONTACTS AND REVIEW
partles wlll review oPe rations al least ng llrst year contacts,and wrllten
rate exceptlons as needed.Materlal scope or compensation ohanges requ iro a slgned servlce-agreoment
amendment.
ContractorKCJFunction
Tanner Rapp
T.Rapp@VatloyHC.org
509-901 -6336
Stevo Panattonl, SuPetlnlendent
steve,panattonl@co.klttltas.wa'us
609-902;7527
(proposed; CounlY to confitm)
Cllnlcal oporatlons
Tannor RapP
T.Rapp@ValleYHC.org
609-961-6336
Steve Panattonl, SuPorlnlendont
steve.panattonl@co.kittitas.wa'us
609-962-7527
(proposed; CountY to conflrm)
Schedullng / refertals
Tanner RaPP
T.Rapp@ValleYHC.org
s09-961-6336
Steve Panaltonl, SuPellntendent
steve.panattonl@co.kittitas.wa. us
509-962-7627
(proposed; Gounty to confirm)
Bllllng
Tanner Rapp
T,Rapp@ValleYHC.ots
509-961-6336
Steve Panattonl, Supellntendont
steve.panaltonl@co,kittitas.wa'us
509.962-7527
(proposed; County to conflrm)
Privacy / socurity
Tanner Rapp
T,Rapp@ValleyHC.org
509-961-6336
Steve Panattonl, SuPerlntendent
steve.panattoni@oo,kltlllas'wa'us
509-962-7527
(proposed; CountY to oonfirm)
Exeoutlve escalallon
KITTITAS COUNTY /VALLEY HEALTH AND COUNSELING I PAgC 3
CLINICAL OPERATIONS MOU
EXHIBIT 1 . M EDICAID-EQUIVATENT RATE REFERENCE
The controlllng amount ls the washlngton HcA fee-for-servlce maxlmum allowable amount effectlve on the servlce
date for the correct coOe, modltler, unit, provlder type, age, place of servic€, and faclllty deslgnatlon. The examples
below verifu the July 1, 2020 schsdulos; thsy are not a frozon rate card,
Doscrlpllon I notoNFSFSModlflerCodeCat6gory
Psychlatrlc dlagnosllc
ovaluatlon090,23Nonei127,40s0791Menlal health
Pgychothelapy, 46
nlnulss$06.31$03.48None90834Mentat hoallh
60P$ychoiherapy,
mlnutos$s7,82i12?.,61None90837Menlal heallh
SUD asssssmenlSams$101.50HFl-t0001SUD
lndMdualsUD
therapy, par {5
mlnutes (HCPCS
unlt)
Same$31.07HFH0004SUD
Case managomenl,
each 15 mlnutesSamg$14,20HFT{017SUD
Establlshed pallenl
ErM; bohavlomt-
healih madhallon
managsmenl only
$25,08$42.65None99213Bohavloaal-healh
praclllloner E/M
Establlshed patl€nl
EIM; behavloral'
heallh medlcatlon
management only
$30.70$60.65Nono99214Behavloral-health
praciltloner F/M
settlng; Fs =$ettlng. HCA
spocilic, telehoalth' or olhet HCA rules may change the payable amount.
amount age.
KITTITAS coUNTY / VALLEY HEAI"TH AND COUNSELING I Paso 4
CLINICAL OPERATIOI.IS I,/IOU
EXHIBIT 2. CURRENT SOURCE REFERENCES
. Washington HOA provider bllling guides and lee schedulesl httpsl/Ww.hca.wa.gov/blllers-providers-
parherJ/prlor-authorization-clalms-and-blllln0/provider-bllllng-guides-and-fee-schedules
. Mental health feo schedule effective Jily 1,2O26: mental"health-services-20260701.x|sx. Substance use dlsorder fee schedule effeclive July 1 , 2026: substance-use<llsorder?0260701 .xlsx
. Physician-related services fee schedule effective July 1, 2026: physician-20260701,x|sx
r Washington OFM travel rates: https://ofm.wa,Eov/accountlng/travel/per-dlem-rate-tables/
SIGNATURES
KITTITAS COUNTY
CONTRACTOR
Apple Valley Gounseling Seruices, LLC
Date:c . )J .,tz
d/b/a Counseling
J By:
Dale;
KITTITAS,GaUNTY / VALLEY HEALTH AND COUNSFL|f{G I Page 5