HomeMy WebLinkAboutC2005-022 - 1/18/2005 - ApprovedDEPARTMENT OF STATE HEALTH SERVICES
1100 WEST 49TH STREET
AUSTIN, TEXAS 78756-3199
STATE OF TEXAS
COUNTY OF TRAVIS
DSHS Document No. 7460005741A2005
Contract Change Notice No. 0~5
The Deparlment of State Health Services, hereinafter ret~:rred to as RECEIVING AGENCY, did heretofore enter into a contract in
writing with CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT (CITY) hereinafter referred to as
PERFORMLNG AGENCY. The parties thereto now desire to amend such contract attachment(s) as follows:
SUMMARY OF TRANSACTION: ATT NO. 04A CHS - TITLE XX
Revised Contract Total: 20,000.00
Revised Number to be Served/Units or' Service: 143
All terms and conditions not hereby amended remain in full lbrce and effect.
EXECUTED 1N DUPLICATE ORIGINALS ON THE DATES SHOWN.
CORPUS CItRIST1 (CITY OF)
Authorized Contracting Entity (type above if diftbrent
from PERFORMING AGENCY) for and in behalf of:
PERFORMING AGENCY:
RECEIVING AGENCY:
CORPUS CHRISTI-NUECES COUNTY PUBLIC
HEALTH D~R1CT (CITY)
By: I) ZL<
(Sigg~du~of person authorized to sign)
(Name'and Tithe) ~ i
~COMMENDED:
(~E~FORMING AGEN~ ~i~ctor, if different
from person authoriz~ to sign contract)
DEPARTMENT OF STATE HEALTH SERVICES
By:
(Signature of person authorized to sign)
Bob Burnette, Director
Procurement and Contractine Services Division
(Name and Title)
Da,e: 2-I'o
DSHS
CC PCSD Rev. 6/04
200~022
01/18/05 ........... ~
Res026105 s [el'~'7,~l~ -Fy c--
DETAILS OF ATTACHMENTS
A~tJ DSHS Program ID/ Term Financial Assistance Direct Total Amount
Amd DSHS Purchase Assistance (DSHS Share)
No Order Number Begin End Source of Amount
Funds*
01 SEAFOOD 09/01/04 08/31/05 State 22,500.00 0.00 22,500.00
C038580000
02A CHS/FEE 09/01/04 08/31/05 State 93.994 162.305.00 0.00 162,305.00
C038877000
03A ACFHJb~E FP 09/01/04 08/31/05 State 93.994 306,274.00 0.00 306,274.00
04A CHSFFTLXX 09/01/04 08/31/05 93.667 20,000.00 0.00 20,000.00
DSHS Document No.7460005741A2005 Totals
$511,079.00 $ 0.00 $511,079.00
Change No. 05
*Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO
BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS.
Cover Page 2
DOCUMENT NO. 7460005741A-2005
ATTACHMENT NO. 04A
PERFORMING AGENCY: CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH
DISTRICT (CITY)
RECEIVING AGENCY PROGRAM: COMMUNITY HEALTH SERVICES SECTION
TERM: September01, 2004 THRU: August 31, 2005
It is mutually agreed by and between the contracting parties to amend the conditions of
Document No. 7460005741A2005 -04 as written below. All other conditions not hereby
amended are to remain in full force and effect.
SECTION I. SCOPE OF WORK, fifth paragraph with heading PERFORMANCE MEASURES,
is replaced with the following:
PERFORMANCE MEASURES
The following performance measures will be used to assess in part the PERFORMING
AGENCY'S effectiveness in providing the services described in this contract Attachment,
without waiving the enforceability of any of the other terms of the contract.
PERFORMING AGENCY shall provide medical services to 143 unduplicated clients who live
or receive services in the following county(ies)/area: Nueces. The services shall be provided to
the clients in the following population categories and in the following numbers:
Category Number of Clients
Women 19 and Under 31
Women 20 to 34 99
Women 35 and Over 11
Males 2
Total Medical Clients 143
SECTION II. SPECIAL PROVISIONS, sixth paragraph with heading, COPAYMENT. is
replaced with the following:
COPAYMENT
PERFORMING AGENCY may assess a copayment from clients provided services by
RECEIVING AGENCY under this Attachment if the copayment is assessed according to
ATFACHMENT Page I
a sliding fee schedule adjusted for family size and income, approved in advance by
RECEIVING AGENCY'S Family Planning Division. PERFORMING AGENCIES that
are Local Health Departments shall assess a copayment according to the criteria outlined
above. A copayment assessment may not exceed 25% of the amount RECEiVING
AGENCY pays PERFORMING AGENCY for the provision of a given service. A
copayment shall not be assessed to clients with zero income or to adolescents age 19 and
younger receiving group outreach and education services. A client may not be denied
services due to inability to pay. Local Health Departments must also comply with
RECEIVING AGENCY fee collection policies detailed in 25 TAC {}1.91.
SECTION III. BUDGET is replaced with the following:
SECTION 111. BUDGET:
PERFORMING AGENCY shall adhere to the current schedule of allowable services and rates as
referenced in SECTION 1I. SPECIAL PROVISIONS, as amended and approved by the
RECEIVING AGENCY.
Total payments will not exceed $20,000.00.
ATI'ACHMENT Page 2